Lean thinking across a hospital: redesigning care at the: Flinders Medical Centre.By: Be n-Tovim, David I.,Bassham, Jane E.,Bolch, D enise,Martin, Mar garet A.,D ougherty , Melissa ,Szwarcbord, Michael Publica tion: Australian Health Rev iew Date: Thursday, February 1 2007 Abstra ct Lean thinking is a method for organising comple x produ ction processes so as to encourage flow and reduce waste. W hile the prin ciples of lean thinking were developed in the manufacturing sector, there is in creasing interest in its application in hea lth ca re. This case history do cuments the introd uction and development of Redesign ing C are, a lean thinking -based p rogra m to redesign ca re processes across a tea ching gene ral hospital. Redesigning Care has produ ced substantial benefits o ver the first two-and-a-half years of its imp lementation, making care both safe r and more a ccessible . Redesign ing C are has not been aimed at chang ing the spe cifics of clin ica l practice . Rathe r, it has been con cerned with imp roving the flow of patients throug h clin ical and other systems . C oncepts that emerged in the manufacturing sector have been readily translatab le into health care. Lean thinking ma y pla y an important role in the reform of health care in Austra lia and e lsewhere. Aust Health Re v 2007: 31(1): 10-15 ********** THIS PAPER DESCRIBE S the introdu ction and early results of the Redesign ing C are Program at the Flin ders Medical Centre. Redesign ing C are explicitly app lies lean th inking (1) to health ca re. Lean thinking is a codification of man ufacturing te chn iques pioneered b y the To yota Motor Compan y. Du ring a la rge scale this may mean prod ucing components in widely separated lo cations . re ified b y the authors as lean thin king. and by a voiding wasteful over-prod uction and over-processing. The issues have rema ined essentia lly un changed sin ce Henry Ford developed the mass production methodology in the 1920's. The inevitable hiccups in p roduction within and between production villages were managed b y mainta in ing large bu ffe rs of parts at every stage in prod uction. Variations in customer demand were managed by creating banks of finished goods that were forced on dealers (and w hich. Nowadays.analysis of motor manu fa cture rs. C osts are conta ined b y min imising buffer stocks. The costs o f holding large amoun ts of un finished goods w ere contained by reducing the cost per production step b y any means possible . Fo rd arranged his fabricatio n machinery into production villages dedicated to specific fu nctions. These . w ere moved by means of special p romotions ). by rapidly identifying and avoiding w asteful e rro rs in produ ction. when unsold . the buffer sto cks managing any resultant dela ys in produ ction . Lean thinking and redesigning care Lean thinking is an atte mpt to correct the delays and wasteful reduplications that chara cterise man y mass production processes. In orde r to produce large nu mbers of differing kinds o f vehicles. Lean thinking facilitates moving from mass to flow production. rapidly changing a machine's w orking p rocess to match changing process requirements so that goods can be made in response to customer de mand rather than to a p rearranged prod uction schedule . (2) the p rodu ctio n processes developed b y the To yota Motor Compan y were identified as being so different from those of other large car-ma kers as to constitute a new manufacturing methodo logy. Flow produ ction aims to d ramatically decrease the time taken to p roduce goods by arranging the re levant machinery in p rocess sequen ces. Redesig ning Care is using lean thin king to imp rove flow and redu ce waste in co re clin ica l and support services across a whole hospital. Interest is grow ing in the potential utility of lean th in king in health care. The key principles of lean thinking * Specify the value desired b y the customer * Identify the value stream for each produ ct or service providing that value. (3.latter steps also lead to dramatic impro vements in the quality o f the goods produ ced. It is not.4) where the need to improve the flow of patients throug h hospitals and health services is beco ming increasingly urgent. The basic p rincip les unde rlying the imp lementation o f lean thinking are laid out in the Box. however. That is deemed to be outside the scope o f the program. con cerned w ith attemptin g to influence the pro fessional co ntent o f clinical encounte rs. This case history may be of some interest to othe rs seeking to transform their hospital or health service using similar methods. which is primarily concerned with flow and logistics. and challenge all the wasted steps * Make the produ ct or service flow continuously * Introdu ce pull between all the steps where continuous flow is impossible * Manage towards perfection so that the n umbe r o f steps and the amount of time and in formation transfer needed to serve the custo mer continually fall . (5) but without sustained bene fit. S equence of events By mid 2003.S etting The Flinders Medica l Centre is a 500-bed teaching general hosp ital in the southern suburbs of Adelaide. The clin ical staff at the Flin ders Medical Centre a re energetic and well motivated and had adopted standard p ractices to dimin ish congestion . the Flinders Medical Centre Emergen cy Department had beco me so congested that patients were regu larly o verflowing into the nearb y re cove ry area o f the operating theatre suite. Cancellations of ele ctive work were pervasive. The Emergen cy Department is busy. disrupting the work of both the Eme rgency Department an d the Division of Surgery. o f whom around 40% require hospital admissio n. the sa fety of care in the Emergency Department was becoming compromised. Flinders w as struggling to fulfil the predictable de mands of the popu lation served. pro viding a co mplete range of secondary and tertiary services to a population o f a round 300 000. The Flinders Medical Centre is the prima ry regional provider of time urgent. Flinders is a " cradle-to-gra ve" institution. the e xact nature o f w hich was yet to be clarified. comp lex ca re of all kinds . nor were they a consequence of unusual leve ls of de mand. These difficu lties had not arisen suddenly. W hat w as needed was to do something that the staff d id no t yet know how to do. surgical training schemes were under scrutin y. It is the largest member of a de-facto consortiu m o f hospital and co mmunity health service providers that also includes a sma lle r general hospita l and a commun ity hospital. seeing some 50 000 patients per year. . and high levels of staff turnover were undermining the viability of key clin ical services. The then-hospital board agreed to p rovide non-operatio nal fu nds to support a program o f hospital redesign . Making little headway. The itinera ry included visits to a numbe r o f hosp itals. Seve ral sessions w ere needed to do cument the steps invo lved in the patien t journe y through the department. one of whom also spent severa l days in Adelaide advising the hosp ital on the structure of an improvement program.Redesigning emergency department flows Two of us (DBT and MD) had started working w ith the E mergen cy Department staff analysing why safe and sustainable care was so hard to provide. hosted b y the NHS Modern isation Agency (sin ce dissolved). or w ho needed admitting to hospital. and generated support to change p rocesses within the Emergen cy Department irrespective of what was being done elsewhere in the hospital. A small group of sen ior staff made a brief visit to London. W e gathered a large multid isciplina ry group of Emergency Department sta ff and started to work our way through the journeys of patients who were either discha rged directly fro m the Emergency Department. we came across a description of process mapping on a National Health Se rvice (NHS) Modernisation Agen cy website. . the process is the end-to-end sequen ce of steps required to transfo rm a raw material to a fin ished product (1) and process mapping is the name given to the creation o f an end -to -end flow diagram of the steps involved. How exactly to do th is w as still not clear. The mapping sessions had a profound impact on a ll invo lved. They created a shared aw areness of how chaotic the care pro cesses had become. w e resolved to map the steps involved in the patient journe y throug h the Emergency Department. and d iscussions with Modernisation Agency staff. and the search fo r an imp rovement model began in earnest. (6) In lean th inkin g te rms. The care processes involved were described as the staff saw them. Taking the patient's symptoms (1) at the point of presentation as the "raw material" and the patient's journe y from arriva l th rough to exit fro m the Emergency Department as the "produ ct". but subsequently. this w as only if they w ere likely to go home. Staff received brief orientation to "strea ming". In the absence of a threat to life and limb . Ad ho c and ha rd to manage strategies were being used to try to push patients th rough when the build -up o f " bumped" patients became e xcessive . The mapp ing had de monstrated that attempting to p rio ritise care by means of the Australasian Triage Scale . materially contributed to the co mp lexity of patient a llocations w ithin the department. The sta ff w ere continually attempting to respond to the d istress o f patients who were "bumped" out of order fro m the ir place in the notiona l q ueue when a patient w ho arrived after them was seen before them because the y were in a d ifferent triage category. patients w ere to be seen in order of a rrival. likely to be ad mitted) was to be aligned with a separate team of nurses and docto rs in specific areas of the department. Initially. Instead. patients would be assessed by a triage nu rse w ho. w hile a llocating a triage score . Modern isation Agency sta ff also exposed the Flinders group to the con cepts of lean th inking. a five point measure of patient a cu ity. Follow ing the trip to the U K. and it was initiated towards the end of November 2003. the Director of the Emergency Department proposed a radical restructuring of the w ay patients flow ed through the Emergen cy Department at the Flinders Medical C entre. The new flows involved brea kin g away from using the triage s core as a method fo r prioritising care w ithin the department. Each stream of patients (likely to be discha rged. w ould also indicate whether in h is or her judg ment the patient w as likely to be ad mitted to hospital or to return home dire ctly from the department. At the end o f the first . The impact was immediate . and that those changes could have a profound impact on congestion within those depa rtments . the p roposal was w idened to include a ll adult patients. as the new processes came to be described.The United Kingdom visit demonstrated that real changes cou ld be made to the o rganisation of care within emergency departments. Lean thinking across the hospital The concepts behind streaming de rive d ire ctly from lean th in king. The redesign began with the identification of "patient-care fa milies". The sum of the steps needed to complete the jou rne y o f each patient-care family is known. In this case. as the value stream. and "likely to be ad mitted to hospital". and this sense of increased control has continued. reduction o f w aste and improvement in . Mapping care processes fro m beginn ing to end allow ed us to "see" patient ca re families and their value streams and to identify w asteful delays and reduplication along the journey.day. it was further redu ced by 6 minu tes. Streaming has been well suppo rted b y the staff and has been mainta ined continuo usly since its introd uction. The next year saw a 10% increase in the nu mbers of patients attend ing the department. but the decrease in average time in the department was not only mainta ined. to be managed together. in lean thin king terms . Lean thinking is focused on imp ro ving flow by simplifying produ ction processes. Streaming also de creased congestion by de creasing the ove rall time patients spent in the department. Patient-care fa milies are g roups o f patients w hose care pro cesses overall a re sufficiently simila r to each other.7 hours down to 5 hours). "D id -not-waits" as a percentage of arrivals fell from 7% o f a ll arriva ls to just over 3% and have been mainta ined at that le vel. A clear indication of the in creased acceptability of the ca re provided was the immed iate halving of the nu mbers o f patients leaving the department without completing their care . the patient-care families w ere "like ly to go ho me". lining up the steps in a value stream so that a steady production rhythm can be achieved. In the Emergen cy Department. The average time that patients spend in the department was reduced by 48 minu tes in the first year after imp lementation (bring ing the a verage time spent in the depa rtmen t from 5. yet different from those required by other patient-care families . there was a disce rnib le lessening of the chaos w ithin the department. Redesign ing C are prog rams were aligned with three broad streams of work (emergency. each headed b y a senior clinician and each w ith a sponsor from the senior hospital executive. and the small team o f a part-time director and three fulltime clinical facilitators (all senio r nurses ). O ver time. Specific progra ms of w ork a re s coped as to the beginning and end of the patient (o r other pro cess) journeys involved. mental health . A series of "plan-do-study-a ct" cycles a re then initiated based on the imp rovement opportunities that "fall out" of the mapping pro cess. The p rogra m was called Redesign ing C are. Process flow mapping and tracking of real-life patien t journe ys are then used to create a detailed picture of how the work is done now (the cu rrent state) and to generate acceptance o f the need for change. Ea ch cell fo cused on a particu lar patient-ca re family and completed work as it arose rather than queu ing patients and then treating the m in batches. Formal evaluations at designated points set the scene fo r the most difficult challenge of all: ma king change susta inable in the long run--making the new way the "way we do it rou nd here". and a s coping document is ag reed to by the key stakeholders .flow w as achie ved b y creatin g produ ctio n "cells" aligned w ith value streams. with facilitator assistance. suppo rted b y the senior managers in the hospital. Ta rgets are deve loped by the groups and are mon itored continuously. Lean thinking con cepts en courage health care p roviders to think about the patient journey fro m arrival to d ischa rge as a co mp lete . Initially. The cycles a re de veloped an d u ndertaken by work groups of staff invo lved. the range e xpanded to in clu de support services. The early su ccess of th is intervention w as sufficient to con firm the value of testing the application of lean thinking to co re clin ica l and support services throughout the hospital. med ical and su rgica l). and transition to community ca re. set about increasing their knowledge of lean thin king and de velop ing a structured approach to the implementation of lean thin king across the hospital. A clear e xamp le was provided early on in our redesign a ctivities. W e were mapping ou t the mo vement of patients through a large inpatient service when it became clear that patients treated within this service co mmonly spend at least half a day longe r in hospital than necessary because they could not be discharged w ithout a date for a crucial fo llow-up test in a hospital clinical laboratory. By now. The net result was that appointments cou ld o nly be made when a laboratory staff member was free to pick u p messages left on an answering s ystem. However. A hospita l is su ch a diverse entity that it may be hard to know where to begin a program of redesign. That laboratory was under such p ressure to perform tests that it had put the fu nding for its re ceptionist against a new laboratory technician. The re is also a more intensive program of exposure to lean th inking of staff from designated areas who will be key participants in specific progra ms of w ork. Redesigning Care across the hospital Fro m its inception . Support for the program has been built by communicating the methodology and the results in many different ways. hundreds of staff across the hosp ital are invo lved in redesign activities o f one fo rm or another. w e tend to be "po int optimisers". Important elements ha ve been "lean thinking" days in which the basic con cepts ha ve been introduced to la rge numbe rs of staff. As staff in hospitals and health services. which in tu rn increased congestio n in the Emergen cy Depa rtment while newly arrived patients w aited for a bed . igno ring the impa ct that changes to a step may have on the steps on either side. Getting appoin tments was very difficult. the pressures generated by the emergency ca re of patients w ere such that they . focusing on do ing the work in fron t o f us as best w e can . Redesign ing C are was seen as a change progra m.care process rather than as a series of dis connected steps. leading to delays in discharg ing patients. Importantly. the rate of serious adverse even ts repo rted to the hospital insu rers has halved sin ce the Redesign ing Care prog ram began. The staff in the medical and su rgical wards no longer ha ve to split their attention between the comp lex ca re needs o f longer staying patients and the administrative and organisationa l tasks in volved in moving patients rap idly th rough the hospital. and those required by longer staying patients. The capacity ga ined by this de velop ment enab led the hospital's sma ll elective surgery progra m to return to fu ll fun ctioning . While it has not been the primary fo cus of the Redesign ing C are progra m. But a hospita l is a dynamic entity. building further support fo r the program. ha lving the time taken to p ro vide that med ication. and redesigning the flow of longer staying medical patients. This unit now accommodates around one in fou r patients admitted to the hospita l. Initial mapping w ithin the med ica l an d surgical strea ms indicated that care processes could commonly be separated out into those required by patients who would spend relatively short periods (up to 72 hou rs ) in the hospital. Other important Redesign ing C are in itiatives ha ve included : redesigning the p rovision of medication at discharge. A sho rt-stay medical-surgical ward of so me 20 beds was developed for the majo rity of patien ts admitted as an e mergency and pred icted to spend a short time in hospital. and the w idespread take-up of clinical imp rovement progra ms a cross key clinical divis ions has also been an important contributor to enhan ced safety across the hospital. substan tial changes to bed management pro cesses.had to be attended to. One patient cannot be ad mitted u nless a previous patient has been discha rged. in the current financial year the hospital is providing care sufficiently cost effe ctively to be able to dire ct modest savings from . The latter program has reduced the average length of stay in the la rge genera l medical service by around 1 day of stay. Surg ical train ing s che mes ceased to be under threat. bottom-up approach emp loyed by Redesig ning Care. rather than ma ke every decisio n. hea lth care managers are chosen fo r the ir p roblem solving s kills. see their ro le as co ming up with a so lution that front-line staff then have to imp lement. There is therefore a tension between the somew hat painstaking. But a basic maxim of lean thinking is not to start with a solution. In gene ral. Early closure a nd starting with a solution is not confined to hospital managers. Actin g as a fa cilitator to de cis ion making is not easy. and the te mptation to regress to knee-jerk proble m solving seems ever present. unde rstand how the work is done and look for root causes of delays and other impediments to flow.its operational budget into enhanced equip ment replace ment and staffing. Th is is the first time in many years that this has been possible. Acknowledging that. and the mo re usua l "command and control" p rocess adopted by health care managers who. Problems. It . and providing good clin ical care invo lves compassion and empathy as well as cognitive and organisatio nal skills. The most successful excel at " fire -fighting" and enjoy the drama involved. Lean thin king requires managers to ensure that a de cis ion gets made . One of the mo re thoug ht pro voking of these has been the cha llenge offered to e xisting middle and senior managers. It is pervasive at every le vel in the health syste m. but to go to the workpla ce. conflicts and constraints The Redesigning Care Program is a major change program and as such w ill ine vitab ly come up against a wide variety o f difficulties. it is still possib le to con ceptualise patient journe ys as lengthy sequences of specific trans formative steps strung along de-facto p rodu ction lines spread throug hout hospitals and health services. once a prob lem has been identified. Lean thinking is not abo ut influencing the content of those moments w hen patients and staff are in contact. Discussion Patients are not cars . at the righ t p lace. the s ize of the challenge and the potential benefits of success be come clear. each component e volvin g within its own niche or process village. health care p ro cesses are almost never designed end-to-end . As we do so. an d at the right time. on this important task. and making hard-to -pe rfo rm steps easier to get righ t. and it is only a start. by simplifying sequences . making w hat has to be do ne more transparent. Redesign ing C are has made a start. . re moving reduplicative and unne cessary steps. fo r the right patient. ma king them easier to perform and less prone to error.is about giving more time fo r those mo ments. At an operational level. The Flinders Medical C entre has been using lean thinking to ma ke a start on design ing w hole sequences of care--not s imply to provide the care that is rig ht. bu t right first time. and w ithout necessarily taking acco unt of the impact on steps up and down the line. The y e volve s low ly. (5) Bartlett J. 1996. Roos D. Cisera M. Jones D. . revised 4/09/06. 15: 156-8. (Received 3/07/06. Available at: www. (6) National and Primary Care Trust Developm ent Programme. London: Simon and Schuster.natpact. The Big W izard.uk/demand_managem ent/wizards/big_wizard/downloads. New York: Rawson Associates. Qual Saf Health Care 2006. 2006. The Victorian em ergency department collaboration. (2) Womack J.php (accessed Jun 2006).Com peting interests The authors declare that they have no com peting interests. The machine that changed the world. Int J Q ual Health Care 2002. accepted 1/10/06) References (1) Womack J. Banish w aste and create wealth in your corporation.nhs. London: NH S Confederation. 1990. Intervie w with Gary Kaplan. (3) Reinertsen JL. Jones D. NHS M odernisation Agency Dem and Management Group. 14: 463-70. M itchell A. Lean thinking. Cameron P. (4) Jones D. Lean thinking for the NHS. ben-tovim@fm c. while developed in the manufacturing sector. Adelaide. MBA. and General Manager Flinders Medical Centre. SA. Redesigning Care M ichael Szw rcbo rd. a Southern Adelaide Health Services. Clinical Epidem iology and Redesigning Care Units Jane E Bassham. DipAppSc( Nu rsing). Correspondence: Professor David I Ben-Tovim . What does this paper add? This paper provides a case study of the implementation of lean thinking. Redesigning Care Denise Bolch. M HSS. What are the implications for practitioners? Using the principles of lean thinking. initially in the Emergency Departm ent. Flinders Medical Centre.au . Director.gov. and then throughout Flinders M edical Centre. Division of Surgery and Specialty Services M elissa Dougherty. Clinical Facilitato r. the processes can then be streamlined to improve patient flow. David I Ben-Tovim. Deputy Di rector. FAIM. RM. Clinical Facilitator. MRCPsych. Using a participative approach. Acu te Servi ces. Redesigning Care M argaret A M artin. BN.What is k nown about the topic? Lean thinking.sa. RN. RN. david. RN. M B BS. BN. BN. appears to be a relevant technique for redesigning hospital care. Bedford Park. practitioners are encouraged to explore the value that process components provide to patients. BSc. Adelaide. BSocAdmin. Executive Director. BA(Hons) Psychology. FRACNZCP. SA 5042. Deputy Director. PhD.