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The Lean Hospital: What does it mean? Kristin Furfari, MD

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Page 1: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

The Lean Hospital:What does it mean?

Kristin Furfari, MD

Page 2: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Outline

• Waste in the US Health Care System

• Lean principles: The Toyota Method

• Application to hospital medicine

• Discharge throughput: A UH example

Page 3: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Disclaimers

Page 4: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

.$4,887

$3,322

$2,808 $2,792$2,561

$2,131 $1,992

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

Unite

d St

ates

Switz

erlan

d

Germ

any

Cana

da

Fran

ce

Japa

n Un

ited

Kingd

om

Per Capita Health Care Spending (US$PPP)

Source: Organization for Economic Cooperation and Development, OECD Health Data 2002

Page 5: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

National Health Expenditures (in billions)

$200

$400

$600

$800

$1,000

$1,200

$1,400

$1,600

$1,800

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

Inflation-adjusted (1)

Source: Centers for Medicare & Medicaid Services, Office of the Actuary(1)Expressed in 1980 dollars; adjusted using the overall Consumer Price Index for Urban Consumers

Page 6: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

10.9%

13.4% 13.2%14.9% 15.4% 16.0%

18.7%

13.1%

0%

2%

4%

6%

8%

10%12%

14%

16%

18%

20%

1988 1993 1996 1998 2002 2004* 2006* 2014*

*ProjectedSource: Heffler et al., “Health Spending Projections for 2004–2014,” Health Affairs (February23, 2005).

National Health Care Expenditures as a Percent

of GDP

Page 7: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Institute of Medicine Report on Medical Errors

50,000-100,000 deaths annually

950,000 patients injured annually

$15 billion-$30 billion in cost

Page 8: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand
Page 9: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Wasted Time for Hospitalists

Percentage Breakdown of Time

Direct PatientCareIndirect PatientCareProfessionalDevelopmentEducation

Travel

Personal

Indirect PatientCare 69%

Direct PatientCare18%

Page 10: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Waste in healthcare

“The national numbers for waste in healthcare are between 30% and 40% but the reality of what we’ve observed by minute-to-minute observation over the last three years is closer to 60%....It’s everywhere: patient care and non-patient care alike.”

Page 11: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

The Problem

• Too little efficiency

• Too much waste

Page 12: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Toyota Production System

• Largest manufacturer in the world• Eight times more profitable than the

industry average• Produced 40% of the “most reliable” car

models on the market in the last decade

Page 13: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Toyota Production System

• Taiichi Ohno: Father of the TPS• Developed his ideas from observing:

The Indianapolis 500The River Rouge plantAmerican supermarkets

Page 14: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand
Page 15: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Toyota in Healthcare

• Creating an environment of stability

• Elimination of waste

• Rapid identification and correction of errors

Page 16: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

What is Lean Thinking?

• A methodology to produce the highestquality product in the shortest amountof time, at the lowest possible cost by eliminating the “seven wastes.”

• Fosters a culture which encourages all employees to continually look for improvement

Page 17: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

The “Seven Wastes”

• Waste of Overproduction• Waste of Time (waiting)• Waste of Product Transport• Waste in Excess Processing• Waste in Inventory• Waste in Movement• Waste in Producing Defects

Page 18: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

The “Seven Wastes”

• Waste of overproductionSeparate intern, resident, attending, social

services rounding cyclesEntering repetitive information on multiple

documents or forms

Page 19: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

• Waste of time on hand (waiting)Primary team waiting for support servicesPatients waiting to make followup

appointmentDelays for bed assignments

Page 20: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

• Waste of processingMultiple computer programs to document

patient care informationOrdering more diagnostic tests than the

diagnosis warrantsRetesting

Page 21: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

• Waste of stock on hand (inventory)Duplicate medications and supplies in

excess of normal usageUnnecessary instruments in operating room

kitsObsolete charts, files, equipment, paperwork

Page 22: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

• Waste in transportationPrimary team traveling to different floors to

see patientsWaiting for transportation to arrive to take

patient to testing, surgery, discharge

Page 23: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

• Waste of movementNurses leaving patient rooms for common

suppliesSearching for charts, patients, medications

Page 24: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

• Waste of producing defectsIatrogenic illnessMedication errors

Page 25: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Understanding Value

• Understand value as defined by our customersPatients, families, payers, regulatorsPhysicians, nurses, hospitals

High-quality, safe, efficient, appropriate

Page 26: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Understanding Value: Lowry Clinic

• Check in at front desk• Wait in waiting room• Walk with nurse to

assessment room• Nurse takes vitals• Walk to exam room• Wait for physician• Physician exam

• Wait for physician to return

• Physician consult and treat

• Wait for nurse follow-up• Walk to laboratory

waiting room• Wait for labs• Get labs drawn• Check out

Page 27: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Toyota Production SystemUniversity of Colorado Hospital - As-is Credit Process Map

Payment postedto account

Is there acredit

balance?

Is the balanceover $1,000? END

No

Yes Print screen Give to creditanalyst

Credit analystwaits for EOB

Run weeklycredit balance

report(on Monday)

Download toexcel

Manipulate excelbased on criteria(if 2 adj - reverseif 2 pmts - refund

etc.)

Refundappropriate?

Process reverseadjustment

Research (*)

Yes

No

No

Complete excelform

(1 form perrefund)

Print excel formBatch with EOB

<$50K peraccount?

Yes

Create batch inHPA

(group of 25)Post transactions Print batch

header

Bundle up EOBs,batch header,

excel formDeliver to A/P

Yes

Paym

ent p

ostin

gR

efun

d C

lerk

A/P

25 refunds?Supervisor sign-off

Billing OfficeManager sign-off

No Yes

Write vendor# onexcel form, key

visit, $, date, G/Linto Lawson

Add vendor (insco) or temp#

(patient) on thefly

Vendor insystem?

Does batchbalance?

Audit batch / fix Release batch forprinting

Checks printed(next day)

Copy of 2nd copyof check made

for Billing Office

Man

agem

ent

Audit checks vs.paperwork

Scan checks andpaperwork

Checksdistributed

No

Yes Yes

No

- Non Value

- Value Add- Value Enabling

Page 28: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Toyota Production SystemUniversity of Colorado Hospital - To-Be Credit Process Map

Payment postedto account END

Run weeklycredit balance

report(on Monday)

Download toexcel

Refundappropriate?

Research (*)

No

Paym

ent p

ostin

gR

efun

d C

lerk

A/P

Write vendor# onexcel form, key

visit, $, date, G/Linto Lawson

Add vendor (insco) or temp#

(patient) on thefly

Vendor insystem?

Does batchbalance?

Audit batch / fix Release batch forprinting

Checks printed(next day)

Copy of 2nd copyof check made

for Billing Office

Man

agem

ent

Checksdistributed

No

Yes Yes

No

Research (*)

Billing OfficeManager sign-off

Billing OfficeManager sign-off

Billing OfficeManager sign-off

Refundappropriate?

NO

Billing OfficeManager sign-off Research (*)YES Download to

excelDownload to

excel

Download toexcel

- Non Value

- Value Add- Value Enabling

Page 29: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Process Improvement

Preparation

Current state

Future state

Implementation plan

Page 30: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Kaizen

Kai: “Take Apart”

Zen: “Make Good”

Page 31: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

The Lean WeekPre-Lean

FriThursWedTuesMonLearn tools

Develop solutions

Go-live

Lean Week

Identify, map and measure current process

Monitor, measure, control, closePost-Lean

Page 32: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Standardization

• Standardization is the basis for continuous improvement and quality– Repeatable, stable methods provide a

predictable, regular output– Creates a safe culture to point out

problems and a standard way to fix them

Page 33: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Standard Work

• The technique of achieving consistent performance by creating a consistently applied method of doing a task

• The creation of the method by the people doing the work

• Should lead to continual improvement

Page 34: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand
Page 35: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Standardization

“Today’s standardization…is the necessary foundation on which tomorrow’s improvements will be based. If you think of standardization as the best you know today but which is to be improved on tomorrow—you get somewhere. But if you think of standards as confining, then progress stops.”

Henry Ford, 1921

Page 36: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Virginia Mason Medical Center

• Ventilator-associated pneumonia

0

5

10

15

20

25

30

35

2002 20004

CasesDeaths

Page 37: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Pittsburgh Regional Healthcare Initiative

30

60

90

120

150

Central Line-AssociatedBloodstreamInfections

2001 2002 2003 2004

Page 38: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

University of Michigan

• PICC lines placed within 24 hours of request:– Initially: 50%-70%– After Lean: 90%-95%

Overall 36% decrease in average time to placement

Page 39: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

12 West Lean Outcome DataOctober 2008-April 2009

22%

44% 42%29%

50% 54%

72%84%

0%10%20%30%40%50%60%70%80%90%

100%

Baseline Oct Nov Dec Jan Feb Mar April

Percentage of Discharges by 2pm

Page 40: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Opportunities• Identify and reduce waste in the 7E discharge

process

• Identify hospital system throughput delays

• Recommend process improvements for hospital-wide discharge process barriers

• Understand how efficiency of the discharge process affects patient satisfaction

Page 41: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Goals• Reduced time from room empty to room occupied

• Double the percentage “clean to occupied bed time”in less than 60 minutes from 22% to 44%

• Improve daily median discharge time by 1 hour for Monday through Friday discharges

• Create a control plan to monitor and sustain improvements

Page 42: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Baseline DataMedian Discharge Time by Day of Week:

10/1/09-12/31-09

1200

1300

1400

1500

1600

M o nday T uesday Wednesday T hursday F riday

Median Time ofDischarge

Page 43: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Baseline DataClean to Occupied Bed Time:

10/1/09 – 12/31/09

Page 44: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand
Page 45: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Pha

rmac

ist

EV

SA

ttend

ing

Phy

sici

anP

rimar

y R

NTr

ansp

orte

rH

ome

Hea

lth C

oord

inat

orP

atie

nt S

ervi

ce C

oord

inat

orC

harg

e N

urse

Cas

e M

anag

erS

ocia

l Wor

ker

DC IV DC Home orders are

w ritten(note 1)

Put chart on rack

(note 2)Flag the chart

yellow

Put chart on desk

(note 3)

Stop

Notified of DC order

(note 4)

Discuss DC Plan w ith Patient(note 6)

Complete nursing tasks

(note 7)

Print instructions f rom MicroMedex

Take instructions to patient room

(note 8)

Complete patient

education(note 9)

Remove IV access Prescript

ion filled at UCH?

Give prescription

to patient

Tube prescription

to Atrium Pharmacy

No

YesNeed

transportto car

Let patient w alk to the

car

No

Order Transport

Stop

Yes Complete Charting

Remove patient from

Care M anager(Note 10)

Tell Charge RN patient has been

discharged

Ask C.N.A. to remove equipment f rom room

Hear sound of chart being put

in rack

Review DC order and

prescriptions

Page other disciplines to complete pt care w ith

priority for DC

Enter OBS charges in to

IDX

Write DC on large w hite

board

Call RN to let him/her know

about DC order

Highlight patient's room

number on assignment

sheet

Put confirmed DC in

Bedboard

Transcribe DC order into Care

Manager(note 11)

Place chart back on rack for RN to co-

sign

Record DC info in Census

Book(note 14)

Write DC in Medical

Records log(note 15)

File DC paperw ork

copy

Breakdow n chart

Photo copy DC paperw ork

Page other disciplines to complete pt care w ith

priority for DC

Notify Primary RN about DC

orders

Remove patient f rom

Care Manager(Note 10)

Assist Primary RN w ith DC if RN is too busy

Go to patient's room

Reschedule pt pick up in system

Receive page from Care

M anager that pt is ready for discharge

Take patient off unit

Take pt to car Enter job completed in

phone system

Will pt be ready in 5

mins

Does pt need to go

to pharmacy

Is wait at pharmacy less than 5

minutes

Reschedule pt pick up in system

Take patient to pharmacy

YesYes

Yes

No

No

No

Does pt need home health care

Stop

Review DC paperw ork (pink sheet) for medical

needs

Complete "home care

assessment"(Note 12)

Contact home care agencies

Compile paperw ork to

send to accepting agency

Send paperw ork to

agency Stop(16)

No

Yes

Does pt need home antibiotics

Stop

Review DC paperw ork (pink sheet) for medical

needs

Fax pink sheet to infusion

center

Call company to set up equipment delivery(note 13)

Stop(17)

No

YesDoes pt

need home equipment

No

Yes

Stop

Determine payor source

Get chart f rom rack

Talk to family about w hat they w ant

StopDoes pt

need SW services

No

Yes

Does pt need inpt

meds befo re DC

Expedite meds being

processed by inpt pharmacy

Stop

No

Yes

No

YesDoes pt

have prescriptions

to be filled

Counsel patient on use

of certain medications

Log into phone system ("in progress")

Clean room (45-60

mintues)

Receive page w ith room number("dirty")

Go to patient room

Find someone to remove medical supplies

Log out in phone system

("clean")

Notify Nursing

Staff of DC

Orders Complete?Accurate?

(5)

Call Doctor for clarification

Enter complete code in phone

system

Yes

Stop

Can pt affo rd prescriptions

Yes

Will patient qualify fo r

CICP

Notify Social Worker for assistance w ith CICP

registration

No

Yes

Does pt qualify fo r outpt

assistance program

Refer pt to outpt

pharmacy for assistance

Contact physician to recommend

cheaper therapy

No

Yes

No

Yes

No

Copy chartContact SNF about

placement

Arrange transportation

Call SNF to update about

departure time/needs

Fax orders to SNF

Page 46: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Phase II• Compare staff interview and observation process

maps

• Meet with 7E staff to identify wastes in the process and determine Kaizen events

• Implement solutions

• Monitor data compared to baseline/goals

• Create plan for sustainability of project

Page 47: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

References

• Berczuk, C. The Lean Hospital. The Hospitalist. 2008; June• Bush, RW. Reducing waste in US Health Care Systems. JAMA. 2007;

297(8): 871-874.• Kim CS, Spahlinger DA, Kin JM, Billi JE. Lean Health Care: What Can

Hospitals Learn from a World-Class Automaker? J Hosp Med. 2006; 1(3): 191-199.

• Liker JK. The Toyota Way: 14 Management Principles from the World’s Greatest Manufacturer. McGraw-Hill: 2004.

• O’Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006; 1(2): 88-93.

• Spear SJ. Fixing Healthcare from the Inside, Today. Harvard Business Review. 2005; Sept: 1-14.

• Spear SJ, Bowen HK. Decoding the DNA of the Toyota Production System. Harvard Business Review. 1999; Sept: 96-106.

Page 48: The Lean Hospital: What does it mean? - Medline€¦ · The Lean Hospital: What does it mean? Kristin Furfari, MD. Outline ... hospital-wide discharge process barriers • Understand

Questions?