Lean Hospital

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The term Lean Hospital (in German translations also Sleek Hospital ) describes a hospital , which has managed to achieve a better quality of treatment for patients on optimized processes and reduce costs by avoiding waste. The term is a further development of the lean management approach known from the automotive industry .

Derivation / history

The idea of ​​the lean philosophy originally came from the Japanese car manufacturer Toyota . US isolation policies in the 1930s and 1940s tightened available resources. An absolutely efficient production was essential for the carmaker's survival. The Toyota engineer Taiichi Ohno summarized the knowledge gained during this phase in 1978 under the name Toyota Production System (TPS) . To illustrate the complex matter, he formulated 14 management principles and developed the so-called Toyota house. This consists of two pillars, just-in-time and error elimination ( Jidoka ) as well as five guiding principles. The customer is always at the center of all processes. The term lean management was finally coined in the 1990s by James P. Womack and Daniel T. Jonas ("The Machine That Changed The World", "Lean Thinking"). In the meantime, Lean Management is being used successfully in almost all industries around the world and no longer only refers to manufacturing processes.

Following the pioneering Virginia Mason Medical Center (VMMC) in Seattle, hospitals in the northwestern United States and Singapore have been applying the Lean philosophy since 2001. Serious quality defects were successfully remedied. Finally, the Virginia Mason Medical Center (VMMC) in Seattle was voted “Hospital of the Decade” by the quality rating agency “Leapfrog” in 2010 and is thus asserting itself as the quality leader. The success of other imitators, such as the Everett Clinic at Smokey Point or the Seattle Children's Hospital, are examples of how “Lean” helps to achieve more patient orientation, better profitability and greater workplace attractiveness.

The news of the successful adaptation of the Lean philosophy for healthcare reached Europe in the mid-2000s. A few consulting firms and hospitals began to experiment with the implementation of lean principles in emergency rooms and wards. Lean is now perceived as a trend in healthcare that is likely to intensify in the next few years. The majority of the experts assume that this will lead to both increased cost efficiency and an improvement in quality.

Core idea

The Lean philosophy is based on two core principles, respect for the individual and continuous improvement. As a result, Lean is more than a toolbox. Rather, it's a long-term mindset that aims to get the best out of a system.

The term Lean Hospital refers to the application of the Lean philosophy to hospitals. This is challenging, since in most cases hospitals are expert organizations that have grown over the years. Lean Hospital aims to provide effective (doing the right thing) and efficient (doing it right) services as an organization and to continuously improve. Providing the right service requires a radical orientation towards patient needs. To a certain extent, the patient is assigned the role of a customer in the hospital, which must be taken into account in all considerations. To do it right, again, means eliminating anything that does not create value for the patient. In order for an effective further development to take place, clarity must be created about the overarching goal of an organization (True North).

Similar to the Toyota house, there is the Lean Hospital house for healthcare. It shows how the various elements of a lean system interlock. The basic requirement for a lean organization is to understand leadership as a daily process and as a service to employees and the overall system. The elimination of waste in processes, a leveling of the workload through planning and organization as well as the implementation of a system for continuous improvement (Kaizen) stabilize the overall system and form the basis for everything else. The combination of cycle times, the principle of one-piece flow and demand-driven (pulling) processes creates a flow of continuous added value. This should now be configured according to the two pillars of just-in-time and patient safety & quality. Services should therefore be provided "just in time" - that is, the right service in the right amount at the right time in the right place. Measures to ensure patient safety and quality are integrated into the processes. This means designing processes in such a way that it becomes difficult to do something wrong or to do something wrong. Errors can be noticed immediately.

A simple example of a “lean” service is the treatment of a patient from a “cast”, with the patient going through one treatment step after the other without unnecessary waiting times, errors occurring or unnecessary services being performed. Overall, such a system enables patients to be cared for in the best possible quality without unnecessary costs.

Principles

The specialist literature describes five guiding principles that must be followed in order to master the transformation to a lean hospital:

  1. Elimination of waste (muda)
    In the hospital, an activity must add value to the patient (e.g. treatment and diagnosis). In addition, there are non-value-adding but necessary activities (e.g. patient administration or accounting). It is important to reduce this to a minimum. Waste, i.e. unnecessary activities, must be eliminated (e.g. waiting times).
  2. Flowing processes (flow concept)
    Due to the goal of patient orientation, it is important to deliver all services to the patient as a continuous flow, such as the coupling of blood collection with the recording of vital signs.
  3. Balanced load (leveling)
    Load peaks should be avoided in order to reduce stress for employees and avoid mistakes.
  4. Standardization
    The introduction of standards, such as check lists, improves the quality of treatment for patients by increasing safety.
  5. Quality and continuous improvement
    It is important to involve employees in the improvement process through incentive systems in order to improve the quality of the suggestions.

implementation

During the entire transformation, it must always be ensured that the patient is the focus and that all process steps are aligned with him. The transformation takes place on three levels: “Ability” (Lean expertise), “Willing” (willingness to change) and “May” (management competence). A high-quality training program for all managers and employees is particularly important when introducing Lean. In this context, you will receive information on the concepts and tools, learn how to recognize waste and how to design value stream diagrams. The aim of the training and one of the most important aspects is to change the work culture and to integrate the Lean concept in the company. Employees should thus be motivated to independently incorporate suggestions for improvement and to want to bring about changes. Management learns that good leadership means developing new solutions together with employees.

Application tools

In order to be able to successfully implement the Lean philosophy, the areas of “Competence & Attitude”, “Management & Organization” and “Processes & Infrastructure” are to be optimized using a variety of instruments. In the following there is a list of all instruments and a brief description.

Competence & attitude

  • 5S: Five-step methodology to improve productivity through better design of the workplace and the environment.
  • 5 Whys method: By questioning five times, using the question “Why?”, A cause-effect relationship is determined for quality and process improvement.
  • Survey techniques: Precise definition of research questions in advance in order to ascertain preferences, attitudes, ideas and the quality of implementation.
  • Fishbone diagram: Used for the causality analysis of main problem sources. In the visual representation, problems are assigned to potential causes of errors.
  • Future-State-Diagram: Serves the analysis and optimization of defined process sections, which were visualized as part of a value stream analysis.
  • Service blueprint: arranges activities in the service process, depending on whether they run in the background (off-stage) or the patient is involved in the activities (on-stage).
  • Spaghetti diagram: Routes of nurses, patients or material are visualized as lines between points A and B in order to identify inefficient activities and thus to optimize workplace organization.
  • Swimlane diagram: Process representation that depicts the relationships between business processes and areas of responsibility.

Management and organization

  • Gemba: Systematic observation of value creation processes on the spot.
  • Skill-grade mix: Identifies and assesses the qualifications of employees. The distribution of tasks derived from this serves to relieve more highly qualified employees.

Processes and infrastructure

  • Hourly Safety Round: Restructuring of the work processes of the nursing staff to increase the quality of treatment.
  • Kanban (pull principle): method for demand-oriented control of the material flow.
  • Mobile care trolley: The caregiver's mobile workstation that contains a computer, medication and material.

Application in the Swiss healthcare system

Hospitals in Switzerland have also joined the lean trend and integrated the philosophy in some hospitals . Normally, a department starts with the transformation and then expanded to other areas. On the Leanhealth.ch page there is a map with an overview of Swiss hospitals that have introduced Lean in various departments. The table contains a brief description of the projects and the departments concerned. One of the first lean projects that was carried out in the Swiss healthcare system shows the special importance of lean as a mobilization of reflexivity in hospitals. In a practical example it becomes clear which role lean plays in the development of a reflection-friendly practice of leadership and cooperation in interdisciplinary everyday hospital life.

criticism

A large number of management consultants advise hospitals against orienting themselves towards Toyota, since the automotive and healthcare industries are very different and the principles must first be "translated". In addition, there are problems with the application insofar as productivity or changes are very difficult to measure through adapted processes. Overall, it can be said that many health care institutions are qualified to use Lean because they implement some guiding principles. However, the lean concept is not yet anchored as a work culture in the company. Therefore, a deeper understanding of Lean in general is required. Studies agree on the potential of lean, but there are only a few studies that critically examine it. Gaps in previous studies include the imprecise description of the entire transformation process for hospitals and the low external validity of case studies.

Individual evidence

  1. ↑ Simon Hehli: The slim model Toyota. NZZ, October 3, 2016, accessed on March 14, 2018 .
  2. ↑ a b Angerer, A. (2015). The Lean philosophy in practice. In D. Walker (Ed.), Lean Hospital - The Hospital of the Future (pp. 49-76). Berlin: MWV Medical Scientific Publishing Company.
  3. ^ Everett Clinic - About US. Accessed March 14, 2018 (English).
  4. ↑ Seattle Childrens - improvement and innovation SCII. Accessed March 14, 2018 (English).
  5. ↑ H + Lean Hospital Study Tour - Learning from the best. Retrieved March 14, 2018 .
  6. ↑ Daniel Walker, Miriam Alkalay, Micha Kämpfer, & Raphael Roth: More time for patients - Lean Hospital in use on the ward and in the department . Ed .: Daniel Walker. Medical Scientific Publishing Company, Berlin 2017, ISBN 978-3-95466-310-1 (188 pages).
  7. ^ Alfred Angerer, Eva Hollenstein & Florian Liberator: The Swiss Hospital System - A Management Perspective . An industry report by the Winterthur Institute for Health Economics. Ed .: ZHAW School of Management and Law. Edition 2016-2017, 2016, ISBN 978-3-03870-007-4 .
  8. ^ Liberatore, F. & Vetterli, C. (2018). Patient orientation. In A. Angerer (Ed.), LHT-BOK Lean Healthcare Transformation Body of Knowledge: Edition 2018–2019. Winterthur. Retrieved from www.leanhealth.ch
  9. ↑ Daniel Walker (Ed.): Lean Hospital: the hospital of the future . Medical Scientific Publishing Company, Berlin 2015, ISBN 978-3-95466-213-5 (180 pages, mwv-berlin.de ).
  10. ^ Hollenstein, E. & Angerer, A. (2018). Muda (waste). In A. Angerer (Ed.), LHT-BOK Lean Healthcare Transformation Body of Knowledge: Edition 2018–2019. Winterthur. Retrieved from www.leanhealth.ch
  11. ↑ Angerer, A. & Drews, T. (2018). Lean training: the basic principles. In A. Angerer (Ed.), LHT-BOK Lean Healthcare Transformation Body of Knowledge: Edition 2018–2019. Winterthur. Retrieved from www.leanhealth.ch
  12. ↑ Leanhealth.ch (2018). Retrieved from https://leanhealth.ch/
  13. ↑ Zurich University of Applied Sciences. (2016). Leanhealth case studies. URL: https://www.leanhealth.ch/praxis/fallstudien/
  14. ↑ S. Gutzan, H. Tucker man, J. Rüegg-Stürm & TS Müller: Lean Hospital - "Toolbox" or mobilization of reflexivity? In: Swiss Medical Journal . tape 99 , no. 05 , January 31, 2018, p. 159–161 , doi : 10.4414 / saez.2018.06361 ( saez.ch [accessed on January 8, 2019]).
  15. ↑ S. Gutzan, H. Tuckermann & J. Rüegg-Stürm: Lean Hospital as an orchestration of reflective design practices for handling complexity . In: Swiss Medical Journal . tape 99 , no. 18 , May 1, 2018, doi : 10.4414 / saez.2018.06363 ( saez.ch [accessed January 8, 2019]).
  16. ↑ S. Gutzan, H. Tuckermann, TS Müller & J. Rüegg-Stürm: Lean Hospital - a practical example . In: Swiss Medical Journal . tape 99 , no. 09 , February 28, 2018, p. 280–283 , doi : 10.4414 / saez.2018.06362 ( saez.ch [accessed on January 8, 2019]).
  17. ↑ Brandao de Souza, L. (2009). Trends and approaches in lean healthcare. Leadership in Health Services, 22 (2), 121–139.
  18. ↑ Angerer, A., Liberatore, F., & Brand, T. (2016). Still Lost in Transformation? : A Literature Review on the Scientific Support of Lean Health Care Transformations. European Academy of Management (EURAM) Conference. Paris: lecture