Radiology and Lean Leadership

Howard B. Fleishon, MD, FACR, MMMMedical Director

Department of RadiologyJohn C. Lincoln North Mountain Hospital

Disclosure:

Council Vice SpeakerAmerican College of Radiology

Learning Objectives:

1. Introduction to concepts of “Lean”process engineering.

2. Applications of Lean principles in Healthcare

3. Present pros and cons of “Lean”

“The future ain’t what it used to be.”

Yogi Berra

“Make no mistake: The cost of our health care is a threat to our economy. It’s an escalating burden on our families and

businesses. It’s a ticking time bomb for the federal budget. And it is unsustainable

for the United States of America.”

President Obama speech to the AMA, June 15, 2009

Bending the Cost Curve - Medicare Costs as % GDP

Redefining Health Care

“The patient's medical condition is the unit of value creation in health care delivery”

Michael Porter“Redefining Health Care”

Institute of Medicine

An epidemic of waste blights the US health care delivery system. Despite a huge dedication of resources to health care in the United States, the medical system does not deliver safe, effective, efficient, patient-centered, timely, and equitable care as recommended by the Institute of Medicine.1

http://jama.ama-assn.org/cgi/content/extract/297/8/871

Institute of Healthcare Innovation

“All organizations, including health care and Radiology organizations, are composed of a series of processes, or sets of actions intended to create value for those who use or depend on them”

Institute of Healthcare Innovation

“Agreement is growing among health care leaders that lean principles can reduce the waste that is pervasive in the US health care system. The Institute for Healthcare Innovation believes that adoption of lean management strategies, while not a simple task, can help health care organizations improve processes and outcomes, reduce cost, and increase satisfaction among patients, providers and staff.”

"We need health care that is sustainable and excellent – both. That will require rethinking our work and redesigning our systems of care boldly and guided by proper theory. Lean thinking and true patient-centeredness are not just compatible; they are, at heart, the very same thing.“

Donald Berwick, MD, MPP, FRCP, founder and former President and CEO of the Institute for Healthcare Improvement

What is “Lean”• Management strategy to improve processes.• In any given process, distinguish value added steps

from non-value-added steps. • Eliminate waste so that ultimately every step adds

value to the process.• Evaluate processes by accurately specifying the

value desired by the end user.• Making value flow from beginning to end of a

process based on the expressed needs of the customer/patient.

What is “Lean”

“Lean” is the identification and steady elimination of waste through:

The implementation of first time quality approaches to work.

Standardization of processes Smoothing of flow Flexibility of work Long term relationships with customers and vendors Reduction in time leading to cost reduction and business

improvement

“Lean” Companies

AbbottBoeing CompanyCarlo Scodanibbio

Industrial ConsultantDanaherDanaher CPDeere CompanyDjiaFordGlaxoHillenbrand Inc.HospiraIBM

Tool Works IndustriesIntel CorporationJohnson and JohnsNASDAQNewell RubbermaidNike Inc. CL BParker Parker Hannifin CPentair, Inc.PfizerPinnacle West CapitolRajvir Industries

Ravalg Sug FS&P 500 Index, RTH

SSE Composite IndexStanley Works

Steelcase Inc. Tesco PLCTextron Inc.

ToyotaVolkswagenWabtec Corporation

WabtechWyeth

Lean Industries:Validated Industry Averages

• Direct Labor/Productivity Improved 45–75%• Cost Reduced 25–55%• Throughput/Flow Increased 60–90%• Quality (Defects/Scrap) Reduced 50–90%• Inventory Reduced 60–90%• Space Reduced 35–50%• Lead Time Reduced 50–90%

*Summarized results, subsequent to a five-year evaluation, from numerous companies (more than 15 aerospace-related). Companies ranged from 1 to >7 years in lean principles application/ execution. Source: Virginia Mason Medical Center

Source: www.LeanMaps.com -- Mark Graban

Virginia Mason Production System

Reduced lab reporting times by more than 85% Improved time nurses spend in direct patient care from 35

% to 90 %. Reduced bedsores from 8% to less than 2% Saved $1 million in supply expense in 2009. Reduced professional liability insurance 48.9 percent from

2004 to 2009. Pharmacy improved medication from 2.5 hours to 10

minutes, reduced incomplete inpatient medication orders from 20 to 40 percent to less than 0.2 percent

Saved $8 million in planned expansion projects since 2002

Seattle Children’s HospitalContinuous Performance Improvement

• Cut costs per patient by 3.7 percent for a total savings of $23 million.

• Avoided spending $180 million on capital projects by using its facilities more efficiently.

• Served 38,000 patients, up from 27,000, without expansion or adding beds.

• Reduced the average waiting time for non-emergency M.R.I.’s from 25 days to 1.5 days.

http://www.nytimes.com/2010/07/11/business/11seattle.html

University of PittsburghPittsburgh Regional Healthcare Initiative

• Reduced catheter related infection rates dramatically.

• Pathology decreased staff by 28% through attrition. • Time needed to order inventory was cut from eight

hours weekly to minutes daily.

• Stock levels were reduced by 50%.

• Overstocking and rush orders due to stock outs were virtually eliminated.

http://www.ihi.org/NR/rdonlyres/B6EA145C-BA93-429B-9BDF 46ACE63F1B1C/0/ ShadysideSuccessStory.pdf

ThedaCare Improvement SystemCollaborative Care Units

• Patient Satisfaction- from 68% to 90%

• Quality of Care- Pneumonia: 38% to 95%

• 30% reduction in costs

• Projected improvement in NPV when disseminated throughout the system: 63% or more than $23 million

University of MichiganMichigan Quality System Projects

• 2 day reduction in LOS for uncomplicated cardiac patients

• Over 30 minute per patient decrease in time spent in ER waiting room

• 4 hour decrease (from 7 hours to 3 hours) in time from ER MRI requisition to scan started

• 34% improvement in payments posted within 3 days of receipt

• Interventional Radiology on-time starts improved from 13% at baseline in July 2007 to 58% in January, 2010

Ontario Wait Time Information Program

• CT avg wait time: 42% improvement

• MRI avg wait time: 12% improvement

The Application of Lean Thinking to the Care of Patients With Bone and Brain Metastasis With

Radiation Therapy

Results and Conclusion: Reduced the number of individual steps to begin treatment

from 27 to 16

Percentage of new patients with brain or bone metastases receiving consultation, simulation, and treatment within the same day rose from 43% to nearly 95%.

“By implementing the ideas of lean thinking, we improved the delivery of clinical care for our patients with bone or brain metastases.”

http://jop.ascopubs.org/content/3/4/189.abstract

Tra

nspo

rter

Tec

hT

rans

port

erT

ech

Clean, resupply room

Transport prev Pt to Unit

Get w/c, cart if needed

Transport Pt to MRI

Patient to Exam Table

Position, Instruct Patient

Before: Observed Cycle Time = 17.5 minutes includes 14.5 minutes waiting for patient

After: Observed Cycle Time = 4.1 minutes, includes 0 minutes waiting for patient

START

END

STARTClean, resupply room

Transport prev Pt to Unit

Get w/c, cart if needed

Transport Pt to MRI

Patient to Exam Table

Position, Instruct Patient

END

WAIT FOR PATIENT

MRI Room TurnoverProcess START: Previous patient off exam table. Process END: Current patient on table

Patient “ondeck” before procedure

TPS - Basis for Lean

The Toyota Production System (TPS) is a major part of the more generic "Lean

manufacturing". TPS is the philosophy which organizes manufacturing and logistics at

Toyota, including the interaction with suppliers and customers.

Learning to Lead at Toyota-4 Principles

• There is no substitute for direct observation

• Proposed changes should always be structured as experiments

• Workers and managers should experiment as frequently as possible

• Managers should coach, not fix

http://hbr.org/2004/05/learning-to-lead-at-toyota/ar/1

is a manufacturing philosophy which shortens the time between the customer order and the product build / shipment by eliminating sources of waste.

Lean Manufacturing

Business as Usual

PRODUCTPRODUCTBUILT & SHIPPEDBUILT & SHIPPED

CUSTOMERCUSTOMERORDERORDER

Time

Waste

PRODUCTPRODUCTBUILT & SHIPPEDBUILT & SHIPPED

CUSTOMERCUSTOMERORDERORDER

Time (Shorter)

Waste

Lean Manufacturing

“Waste” in TPSThe original seven wastes are:1. Transportation 2. Waiting 3. Inventory 4. Motion 5. Over Processing 6. Defects 7. Rework There has now been identified an 8th Waste8. Unused Human talent

“Lean” and Quality"It turns out--what we've learned," summarizes Kaplan, "is that the best way to improve quality is to eliminate non-value-added variation. This is a way, a method for that. And it's working!“

Gary Kaplan, MD

Chairman and CEO Virginia Mason

Lean Thinking as the Scientific Method Applied to Daily Work

Scientific Method• Observation• Hypothesis• Intervention• Results/reflection• Revise hypothesis• New intervention…• Structured abstract

Lean Thinking• Go see, ask why, respect• Plan P• Do D• Check/reflect C• Adjust A• Repeat PDCA cycle…• A3 report, Value Stream Map

35

MINDSET

MANAGEMENTSYSTEMS

METHODS

Culture Change

Culture ShiftTraditional Culture

• Function Silos• Managers direct• Benchmark to justify not

improving: “just as good”• Blame people• Rewards: individual• Supplier is enemy• Guard information• Volume lowers cost• Internal focus• Expert driven

Lean Culture

• Interdisciplinary teams• Managers teach/enable• Seek the ultimate performance,

the absence of waste• Root cause analysis• Rewards: group sharing• Supplier is ally • Share information • Removing waste lowers cost• Customer focus• Process driven

Applications in Radiology

• Standard WorkProtocolsPoliciesStructured reportingStandard Lexicon

• Streamline workflow in Billing and Collections

• Standardization versus patient variabilityhttp://online.wsj.com/article/SB10001424052748704913304575371210975895460.html

• Standard work flow and lack of inventory and may not be able to readily adapt to rapid changes in demand (i.e ER).

http://online.wsj.com/article/SB10001424052748703792704575367003265429096.html?mod=googlenews_wsj#articleTabs%3Darticle

• Reiteration of past methods- Six Sigma, CQI, etc.

Criticisms of Lean

• “Lean” is a method of process engineering based on the Toyota Production System.

• As Radiology group leaders we should be aware of “Lean’s” increasing profile in healthcare.

• Potential applications in Radiology

Summary

ASRT Code:VAD0110025

Books:• Womack, Jones. Lean Thinking. (An overview)• Liker. Toyota Way. Liker, Meier. Toyota Way Fieldbook. Liker, Hoseus. Toyota Culture.• Shook. Managing to Learn. (Best book on leadership in a lean organization and A3 use)• Sobek, Smalley. Understanding A3 Thinking. (Problem solving and A3 use)• Dennis. Getting the Right Things Done. (Strategy deployment or hoshin kanri)• Rother, Shook. Learning to See. (Value stream mapping)• Baker, Taylor. Making Hospitals Work (From Lean Enterprise Academy, UK)• Graban. Lean Hospitals. (Applies Lean principles to health examples) Articles:• Kim, Spahlinger, Kin, Billi. Lean health care: what can hospitals learn from a world-class automaker? J

Hosp Med. 2006;1:191.• Kim, Hayman, Billi, Lash, Lawrence. The Application of Lean Thinking to the Care of Patients With

Bone and Brain Metastasis With Radiation Therapy. J Oncology Practice. 2007;3:189.• Kim, Spahlinger, Kin, Coffey, Billi. Implementation of Lean Thinking: One Health System's Journey.

Joint Commission J Quality and Safety 2009;35:406.• Bush. Reducing Waste in the US Healthcare System. JAMA 2007;297:871.• Spear. (all Harvard Business Review) Fixing Health Care from the Inside, Today (9/05); Learning to

Lead at Toyota. (4/04); Decoding the DNA of Toyota Production System. (9/99)• IHI. Going Lean in Health Care

www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCareWeb: • Michigan Quality System at UMHS: med.umich.edu/mqs• Lean Enterprise Institute: www.lean.org webinars, books, meetings…• Lean Healthcare Value Leaders Network www.healthcarevalueleaders.org• Lean Enterprise Academy (UK): www.leanuk.org• Ideal Patient Care Experience at UMHS www.med.umich.edu/i/acs/ipe.htm

References