Process redesign – Lean Thinking

22 12 2011

photo creidt Alexander Svenssen

Lean Thinking is a way of thinking about the business or production processes to redesign them to be more efficient and effective. Based on processes developed in the Toyota production line the principles are now widely recognised in a variety of fields. It’s focus is on the elimination of any and all wastes. At the time it delivered for Toyota a faster production line with fewer parts required, higher quality (meaning fewer returns and recalls) – and hence growth as an organisation.

Lean Thinking first gained prominence in the non-manufacturing world through the book The Machine That Changed the World: The Story of Lean Production– Toyota’s Secret Weapon in the Global Car Wars That Is Now Revolutionizing World Industry by authors Womack and Jones.

I came across Lean Thinking in healthcare. The health industry, and most particularly the hospitals, are keen to eliminate waste, address quality, and speed up the system to address the waiting times at the “front door” (Emergency Departments, surgery waiting lists, outpatient waiting lists, etc). Here is a smattering of what I learned at a seminar called “Redesigning Care: Improving the Patient Journey”, presented by Dr David Ben Tovim, a psychiatrist from Flinders Medical Centre in Adelaide, South Australia. While the application to healthcare and to Toyota should be apparent, have a think about how it applies to your business.

Constantly stressed in Lean Thinking is the principle: Don’t start with the answers. Build up from staff knowledge. Often the staff know full-well where the problems are, but they have never been empowered to do anything about them.

Womack and Jones have five principles for Lean Thinking:

1. Value: a precise understanding of what the customer wants (or values). These are the aspects that need to be focussed upon, and non-value added processes may be eliminated. A silly example – if the customer values having fluffy dice hanging from the rear vision mirror, than this is a worthwhile process. If they don’t value it, then eliminate it. (Step One: Identify Value)

2. Value-stream mapping: The series of processes that lead to the production of value. (more on this later) (Step Two: Map your Value Stream)

3. Flow: processes should flow seamlessly on, one from another, rather than batching and stockpiling. (Step Three: Eliminate Waste)

4. Pull: the system should respond to customer demand rather than pushing products out in the hope they will be used. (again avoiding stockpiling – and example from healthcare later on). Don;t define customer too tightly – there are internal customers (downstream processes) as well as the end-customer. (Step Four: Allow the customer to pull products / services)

5. Perfection: A defined standardised output which is replicated every time. (Step Five: Improve the Process – start over)

photo credit Viêt Hoà DINH

These processes aim to eliminate waste in the process…..

The 8 Wastes

Eliminating wastes in the system is a strong principle in Lean Thinking. Wastes may be in product, resources, staff time or unnecessary processes. Here are the 8 wastes of Lean Thinking.

1. Waiting: waiting for information, people or equipment. (pauses in the process)

2. Queueing: people waiting for the next step in the process. (bottle-necks in the system)

3. Errors: requiring re-work or lacking something necessary (standardising output is an important factor in eliminating waste)

4. Transportation: of patients or equipment (wastes time, costs money and is an uneccessary variable)

5. Motion: of staff, having to travel around to get to meetings, the next stage of the process, etc

6. Over-processing: doing more in a process than is necessary (for instance double handling – why does the nurse write the information by hand for the admin officer to data-enter?)

7. Over-production: doing more than is needed right now (stockpiling is wasteful – however see also point 1 – what you need, needs to be there when you need it)

8. People: wasting the collective talents of people within your organisation. (People are not machines, and most of them are there to do a good job. Harness this.)

To identify wastes, Lean Thinking uses Value-Stream Mapping. This maps out the process, the staff, equipment and resources required at each step and shows where the “products” of each step go to. Each step is timed. (As a little light humour, here is a very poor value-stream map from Southpark – the Underpants Gnomes profit plan. The more complex and multi-stepped the process, the more possibility there is for waste and inefficient processes to creep in – so make your value-stream very detailed. (For a better Value-Stream map, see slide 7 of this PowerPoint by Prof Jones .

Once you have a detailed Value-Stream, you can look at each step in detail. Where are the branch points and commonalities between processes? Why does it take five minutes to do step 3? Perhaps the staff member has to walk down a corridor to get the piece of equipment they need. Moving it closer might make this a 2 minute job. Perhaps your process is held up by bits of paper that need to accompany products (or patients!) around the hospital. Electronic transfer of information might speed it up. Is there a particular step that has a lot of errors in it – that’s the area that needs to be focussed on – is it poor hand-writing? Are the tools not quite right?

(Want more on Value-Stream Mapping? Take a look at this book: Learning to See: Value Stream Mapping to Add Value and Eliminate MUDA)

David Ben Tovim told us a couple of stories that sped things up in the Emergency Department.

– The first was to split patients into two groups – likely to stay and likely to go home. The processes for each of these groups was significantly different, so once they had walked (or been wheeled) in the door and had the commonalities completed: been registered and triaged, they were split into two groups. This clarified priorities for staff and led to a more efficient system.

– Secondly was empowering the wards to “pull” for patients, rather than the ED having to “push” them into the wards. When a ward had a bed empty, they were able to look onto the ED system and identify which patients were waiting for space in their wards and they could then call down for them. This meant the ED spent less time seeking out beds, the beds in the wards were being used to the best possible capacity, and the patient time in ED was greatly reduced – which is a good thing for patient care and is one of the things hospital performance is measured on.

Want to know more? Here are some references:
Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction

Lean Thinking: Banish Waste and Create Wealth in Your Corporation, Revised and Updated

The Toyota Way: 14 Management Principles from the World’s Greatest Manufacturer

Web resources
Professor Daniel T Jones’ website

Introduction to Lean Thinking(check out the references and resources section at the bottom of the paper)




2 responses

30 12 2011
Janet (@Janet741)

One is tempted to say that Ben Tovim’s attraction to ‘lean’ thinking comes from his interest in eating disorders………………..

Seriously, though. There are some consumers of psychiatric services who are not ‘popular’ among many m h workrs and so I find the concept of psychiatric units cherry picking clients an intriguing one. I should add that I do not – at least try not to, adhere to such biases.

I would imagine there might also be pressures on busy medical units to also select, consciously or otherwise, those who might improve their OBDs, consultant outcomes and other clearance or separation rates or outcome measures.

30 12 2011

Haha! re Ben Tovim!

Good point – and not having worked at Flinders, I can’t answer the question but I would presume they must peel the psychiatric emergencies off somewhere in the process and deal with them separately.

Re the cherry-picking of patients to get better stats, this is probably worth a bit of research to see how it is overcome. Lean Thinking is big in the NHS as well so no doubt there is a solution that deals with all this. Ideally one would hope that the units all worked together for the betterment of the hospital’s overall stats, and by inference, the patients……but yes, internal competition no doubt comes into play. Perhaps additional weighting for patients who are more serious / complex or have been waiting for a period of time? The focus was on getting the bed filled as fast as possible and ensuring the wards were getting the right mix of cases (eg cardiac patients going to cardiac wards) and the wards were prepared for them.

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