Lean is a quality management system that focuses on removing “waste” from a system or process to make it as efficient and effective as possible, thereby maximising value for the customer (which is generally the patient). Lean is driven by the identification of customer needs and aims to improve processes by removing activities that are non-value-added (a.k.a. waste). Basically, it is doing more with less by cutting out anything that is unnecessary.
The foundations of Lean were developed by Toyota in the 1950’s, who called it the Toyota Production System (or TPS). The success they demonstrated, led to the technique being adopted by other manufacturers, and to widespread application of similar tools and techniques to other industries, including healthcare, in the 1990’s. This is also when the approach became formally known as Lean.
Lean Six Sigma and other adaptations
Lean methods are often used in combination with Six Sigma, in a process called Lean Six Sigma. These are considered complimentary techniques in that Lean deals with eliminating waste from a process, whilst Six Sigma focused on reducing the rate of defects in the output.
Many organisations have adapted the Lean approach to address specific goals of industries. In healthcare, one of the most well-known examples is the Virgnia Mason Production System (VMPS), which has been applied in numerous healthcare organisations with great results.
Key Principles of Lean
At its heart, Lean is a set of principles, arranged into a 5-step thought process…
Specify Value: Value should always be considered from the customers perspective - in healthcare this is normally the patient! The start of the process is to determine what it is important to them.
Identify the value stream: This is where the value defined in the first step is used as a reference point to identify all the activities that contribute to this. Any steps in the process that do not contribute to that value are considered waste and should be eliminated or minimized.
Create flow: Value creating steps should occur in a tight sequence so that the process runs effectively and flows continuously.
Establish pull: This ensures that customers (patients), are driving (pulling) demand on the system and that this is tracked back through the entire process. This avoids work or supplies being ‘pushed’ to the next process or department.
Pursue perfection: This is the iterative element to Lean – once all the previous steps are completed it is important to go back through the process until a state of perfection is reached.
So, what is waste in healthcare processes?
In Lean, waste is any action or step in a process that does not add value to “the customer”. The original method defined 7 types of waste, although over time, this has become 8:
- Defects: waste derived from doing something incorrectly, inspecting for errors, or fixing errors. E.g. Healthcare Acquired Conditions/Infections, medication errors or avoidable readmissions.
- Overproduction: doing more work that is required or doing it sooner than needed. E.g. unnecessary or duplicated tests, extending hospital stays longer than required or preparing excess medication.
- Transport: wasted time, resources and costs of unnecessarily moving things (supplies, or even patients!). E.g. transfer of patients between departments and poor hospital layout.
- Waiting: time spent waiting for the next event or work activity – this could be by patients or employees. E.g. patients waiting for their appointment and staff waiting for required equipment
- Inventory: excess cost of unneeded product or materials. E.g. surplus supplies, superfluous equipment, expired medications.
- Motion: wasted time (and energy) of staff movement. E.g. staff walking unnecessarily far, poor layout of commonly required supplies or equipment.
- Over-processing: Doing work that does not add value for the customer (the patient), or maintaining a quality that is not required. E.g. recording information that is never used, redundant tests, duplication of data entry.
- Skills: waste due to under-utilization of peoples skills and knowledge, or not properly engaging staff. E.g. admin tasks carried out by consultants when they could be completed by more junior staff.
Lean terminology & tools
The world of Lean is filled with expressions, acronyms and unfamiliar words that don’t seem easy to understand at first. Many terms such as Muda (“Waste”), Kaizen (“continuous development”) and Kanban (“Signboard”) are derived from the Japanese origins of Lean. Whilst daunting at first, this unique vocabulary provides an effective communication tool and is often seen as central to the lean process. There are some great guides to lean terminology, such as this one from the Virginia Mason Institute.
Some improvement tools are fundamental to the Lean improvement approach, and are often just referred to as “Lean tools”. Each tool is designed to address the improvement of flow or the elimination of waste. Some of the most commonly used lean tools include Value Stream Mapping, A3 Diagrams, PDCA, Kanban Boards, 5s, 5 Whys and Ishikawa (Fishbone) diagrams. Whilst many of these tools have their origins in Lean, over time some of the tools have been more regularly incorporated in projects run using different methodologies (e.g. the Model for Improvement).
Should I use Lean?
Lean offers a structured way of thinking and delivering improvement. At its heart is a focus on the patient and developing a real understanding of what value means to them. Although this is incorporated in other improvement approaches, lean is the only one that is structured around this. It is also very adaptable in terms of the types and scale of problems to which it can be applied – this is partly due to the fact that is it more of a way of thinking, rather than a project-by-project approach.
Organisation who are most successful in using Lean have instilled the approach and culture across the organisation. The terms “Lean thinking” and “Lean culture” are common and getting to this state can take significant effort.
Some also argue that Lean is not quantitative enough due to the fact that many of the core tools, like Value Stream Maps are qualitative in nature. This is in contract to other improvement approaches like The Model for Improvement or Six Sigma where much of the process is structured around quantification and measurement. The tools and terminology in the Lean process are numerous and varied which can be off-putting at first, however this variety really just speaks to the adaptability of the process to different problems.
Lean focuses on reducing waste and improving flow, which are important to improve any system. However, this focus could in some cases be at the detriment to reducing variability and errors – this is one of the reasons Lean is often combined with Six Sigma methodologies.