Patient Safety Tip of the Week


May 1, 2012     More LEAN Successes



LEAN, borrowed largely from Taiichi Ohno and Kiichiro Toyoda and the Toyota Production System, is both a performance improvement tool and a unique culture. Our October 11, 2011 Patient Safety Tip of the Week “LEAN in the Lab” described how one organization used LEAN principles to improve lab safety and efficiency. That article nicely described most of the principles used in LEAN.


A new study (Hydes 2012) shows how LEAN principles helped improve efficiency in a GI endoscopy unit. The organization had been managing upper GI endoscopy patients who did not require sedation in the same manner they handled all their colonoscopy patients who did require sedation. They employed some key concepts from LEAN thinking to redesign their processes and workflows. Those principles included viewing the process from the patient’s value perspective, removing steps that did not add value from the patient perspective, value stream mapping, removal of bottlenecks or other rate-limited steps, and improved handoffs.


They began with a value stream map of the current state. In the article they actually show a picture of the handwritten flow diagram. That is an early step not only in LEAN projects but also in FMEA’s (failure mode and effects analyses) or many other performance improvement projects. Only by doing that do you get a good feel for where your opportunities to remove unnecessary or wasteful steps (“muda”) are. Part of that process includes determining movement of the patient and staff as they are going through the process. And don’t forget to begin your map well before arrival of the patient at the GI unit, since many of the wasteful parts of your process may involve pre-procedure paperwork or other things that take place in preparation for the visit. They identified 22 steps in their current state process, 19 after arrival of the patient. And they found that the total patient “journey” ranged from 52 to 375 minutes. They identified 5 bottlenecks in their process and 3 handoffs. Of those steps they identified only 9 that added value from the patient perspective. Cuttting out those steps that did not add value reduced the total time necessary considerably. Ultimately they were able to reduce the total number of steps from time of arrival to discharge from 19 to 11 steps. Importantly, they reduced the number of bottlenecks from 5 to 3 and eliminated all 3 handoffs. This resulted in considerable reduction of “wasted” time from the patient perspective and an increase in the amount of “valued” time (eg. time spent with the endoscopist).


Two of the bottlenecks they eliminated were pre-procedure checks in the recovery unit and findings discussed with the nurse. Both of those steps would have been necessary in cases with sedation but were no longer necessary in this patient population. Because the patients were not sedated, the need for a post-procedure recovery unit and its staffing were no longer needed. So the project resulted not only in an improved process from a patient satisfaction perspective but also resulted in economic savings from improved efficiency. Patient satisfaction with the new redesigned process was good and they piloted the redesigned process at another site with similar good results.


Emergency Departments have also had considerable experience with LEAN. One study (Dickson 2009) analyzed LEAN implementations in ED’s at 4 different hospitals. They found that the closer hospitals followed the original Toyota production system principles, the more successful they were in achieving improvements. Keys to success were active participation and ownership by frontline staff combined with continuous support and commitment to LEAN by leadership. They also noted that improvements in patient satisfaction typically lagged behind LEAN implementation by a year. That paper stresses that LEAN is a tool and that the culture of the organization and individual area are critical to the success or failure of any performance improvement project regardless of the tools used.


Another LEAN project improved turnaround times (TAT) for CT scans in the ED (Humphries 2011). That project reduced such TAT by 20 minutes. It involved allowing the CT technologists to actively “pull” patient through the ED, reduced use of oral contrast for abdominal CT scans, matched technologist working hours to ED volume surge, use of wireless devices to improve communication between the ED and the radiology department, and provided active feedback to technologists.


A critical review of ED LEAN projects (Holden 2011) identified 18 published articles from 15 ED LEAN implementations. It is an excellent review of the principles of LEAN and reiterates some of the success factors and barriers noted above. Though it concludes that all studies basically showed some improvement after implementation of LEAN projects, it points out that many of the outcome measures were more anecdotal rather than hard patient quality outcome measures or patient safety measures and that some degree of publication bias likely exists. It points out the real need to also have more formal measures of effects of LEAN on staff.


The accompanying editorial (Dart 2011) highlights the success of LEAN thinking at Denver Health. It stresses the disparity between the way the customer (patient) perceives the system and the way the healthcare system sees itself. “Muda”, the waste or non-value-adding steps in processes, both infuriates patients and frustrates healthcare workers. He stresses that the keys to success are the insights of frontline staff combined with the executive power to authorize change. Though LEAN is a “bottom-up revolution” it unites frontline staff, middle management, and executive leadership.


LEAN has also been used to improve efficiency and efficacy in systems for cataract surgery (van Vliet 2010) and Mark Graban in his book “Lean Hospitals” (Graban 2011) gives numerous examples of success stories of LEAN in healthcare.


We, of course, always caution you with any redesign project to anticipate possible unintended consequences and make sure your outcome measures include “hard” patient outcomes. Improved patient satisfaction could be easily offset by just a few significant avoidable complications. So make sure that you look at multiple quality measures as outcome variables, not just your satisfaction and financial variables. Our biggest criticism of studies on LEAN in healthcare has been the tendency to focus metrics on “soft” outcomes such as process measures and measures of satisfaction rather than on “hard” patient outcomes.


LEAN implementation is not always easy. William Millard, in a perspective on LEAN from an emergency department view (Millard 2011), notes the many barriers and facilitators important at some of the healthcare pioneers in LEAN such as Virginia Mason, University of Colorado, and Parkland/University of Texas Southwest. He ends with a description of how LEAN principles in CVS Pharmacy’s MinuteClinic chain have resulted in concepts that now represent challenges to traditional hospital ED’s.


For those of you new to the LEAN world, the Serrano article (Serrano 2010) highlighted in our October 11, 2011 Patient Safety Tip of the Week “LEAN in the Lab” and the Holden paper (Holden 2011) noted today provide a great introduction to basic concepts and principles of LEAN. For those of you who are looking for more detail on LEAN in healthcare the second edition of Mark Graban’s book “Lean Hospitals” is now available.







Hydes T, Hansi N, Trebble TM. Lean thinking transformation of the unsedated upper gastrointestinal endoscopy pathway improves efficiency and is associated with high levels of patient satisfaction. BMJ Qual Saf 2012; 21: 63-69 Published Online First: 13 September 2011 doi:10.1136/bmjqs-2011-000173



Dickson EW, Anguelov Z, Vetterick D, et al. Use of Lean in the Emergency Department: A Case Series of 4 Hospitals. Annals of Emergency Medicine 2009; 54(4): 504-510



Humphries R, Russell PM, Pennington RJ, Colwell KD. Utilizing Lean Management Techniques to Improve Emergency Department Radiology CT Turnaround Times (Abstract). Annals of Emergency Medicine 2011; 58(4): S248



Holden RJ. Lean Thinking in Emergency Departments: A Critical Review. Annals of Emergency Medicine 2011; 57(3): 265-278



Dart RC. Can Lean Thinking Transform American Health Care? Annals of Emergency Medicine 2011; 57(3): 279-281



van Vliet EJ, Sermeus W, van Gaalen CM, et al. Efficacy and efficiency of a lean cataract pathway: a comparative study. Qual Saf Health Care 2010; 19: 1-6 Published Online First: 22 April 2010 doi:10.1136/qshc.2008.02873



Graban M. Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement. Second Edition. Productivity Press 2011



Millard WB. If Toyota Ran the ED: What Lean Management Can and Can't Do. Annals of Emergency Medicine 2011; 57(6): A13-A17



Serrano L, Hegge P, Sato B, et al. Using LEAN Principles to Improve Quality, Patient Safety, and Workflow in Histology and Anatomic Pathology. Advances in Anatomic Pathology 2010; 17(3): 215-221,_Patient.7.aspx




















Tip of the Week Archive


What’s New in the Patient Safety World Archive