Lean in Healthcare

Bohdan „Bo” W. Oppenheim, PhDProfessor of Systems Engineering, LMU

American Society for Quality Orange Empire Section 0701

Presentation

1. Some statistics and problems in U.S. Healthcare2. Healthcare as a System, and Systems Thinking3. Lean is a Critical Element of Healthcare4. LMU-KP Partnership5. Lean improvements in KP Medical labs 6. Summary

• $8,508 per capita (UK: $3,406)

• Millions still without medical insurance

• Medicines unaffordable to a hundred million people

• Over 30% of U.S. adults skip a recommended test or treatment because of cost

• U.S. ranked #70 in wellness (mostly due to obesity)

• U.S. ranked last among 11 countries in preventable deaths

The Present Imperfect State

Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu 7

Many reasons for high cost and poor outcomes…

• Historically wrong financial incentives (pay per service)• Lack of universal care, highly fragmented system• Employer-based system• Weak systemic push-back on costs• Crazy reimbursement/insurance system

2. Healthcare as a System and Systems Thinking

SuperSyste

m 1

SuperSystem

3

SuperSystem

2

SuperSystem

4

Complex System 1

Complex System 2

U.S. Healthcare = Dynamic Hyper System

Help from Systems

Engineering

Healthcare Stakeholders• Patients (300,000,000+ in U.S.)• Medical professionals• Medical facilities, hospitals,

clinics, labs• Medical Equipment• Pharmaceuticals• Researchers and academia• Insurances• Employers• Federal & State Governments • Military and Veterans

Administration• Fire Departments and

Ambulances• and more

Powerful Solution

Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

6

Powerful Studies Using Huge Databases of Patients’ Records

© 2014 Gary Robert Smith, Understanding Disease Through Systems Thinking, INCOSE IS 2014.

Number of potential medical records: • Kaiser Permanente: 10,000,000• U.S. 300,000,000• World 7,000,000,000

Huge data „mining” now permits powerful studies of simultaneous effects of numerous factors and complex interations. We are no longer constrained to simplistic clinical studies that filter out confounding and interaction effects. This yields rich medical knowledge and potent treatments.

Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

7

3. Lean is a Critical Element of Healthcare

Lean does not tell MDs how to treat patients – it frees the

MDs to do it more and better

Desired Characteristics of Healthcare

• Affordable & Accessible• Safe • Effective• Patient centered• Timely• Efficient• Inclusive of Latest Science• Well integrated

Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu 6

Streamlining operations and removing waste using LeanAdded Value from Systems Engineering in Healthcare

Lean does not tell MDs how to treat patients – it frees the

MDs to do it more and better

Lean Principles

Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

10

Ohno’s Eight Types of Waste

Type of waste Brief Description Hospitals examples Defects Time spent doing something

incorrectly, inspecting for errors, or fixing errors

Surgical case cart missing an item; wrong medicine or wrong dose administrated to patient

Overproduction Doing more than what is needed by the customer or doing it sooner than needed

Doing unnecessary diagnostic procedures

Transportation Unnecessary movement of the “product” (patients, specimens, materials) in a system

Poor layout, such as the lab being located a long distance from ED

Waiting Waiting for the next event to occur or the next work activity

Employees waiting because workloads are not level; patients waiting for an appointment

Marc Graban, "Lean Hospitals, Improving Quality, Patient Safety, and Employee Engagement”, Second edition, (CRC Press, 2012) 11

Ohno’s Eight Types of Waste

Inventory Excess inventory cost through financial costs, storage and movement costs, spoilage, wastage

Expired supplies that must be disposed of, such as out-of-date medications

Motion Unnecessary movement by employees in the system

Lab employees walking miles per day due to poor layout

Over processing

Doing work that is not valued by the customer or caused by definitions of quality that are not aligned with patients needs

Time/date stamps put onto forms, but the data are never used

Human potential

Waste and loss due to not engaging employees, listening to their ideas, or supporting their careers

Employees get burned out and quit giving suggestions for improvement

Marc Graban, "Lean Hospitals, Improving Quality, Patient Safety, and Employee Engagement”, Second edition, (CRC Press, 2012) 12

Waiting (one of the eight wastes of lean healthcare) has a huge impact on patient Outcomes and Costs

Faster treatment means quicker, more complete recovery.

John Toussaint, MD and Roger A. Gerard, PhD with Emily Adam, “On the Mend, Revolutionizing Healthcare to Save Lives and Transform the Industry”.

13

Example: Lean improved STEMI Value Stream by 80%(Heart attack caused by a prolonged period of blocked

blood supply)

John Toussaint, MD and Roger A. Gerard, PhD with Emily Adam, “On the Mend, Revolutionizing Healthcare to Save Lives and Transform the Industry”14

Visit Clinic

Phone call

Phone call

LEGEND

2.1

4.4

Discha

rge

Discha

rge

3.1

14.0

1.6

2.2

9.7

19.1

20.7

31.2

Phone call

- No shows – 2%

- On-time starts – 37%

- Document delays – 12%

Reception

Obtain Demographics

“mini-reg” & Send packet Reception

Call patient to schedule

- Volumes by service – 13.0%

- Lead-time by service - varies

Reception

Input Med HistoryHot

Jefferson Healthcare Clinic – Future State Focus (2008)OVERALL CLINIC DATA

- Cost per visit - $125.39

- Avg. Pts per hour - 1.83

- Available hours per day – 67

PATIENT

Reception

Check-in patient for

visitRN

Room & perform

vitals, etc.

- On-time starts – 37%

- Time by diagnosis – Chart D

- Volume by hour – Chart E

- Schedule on 1st call – 0% - # of Pts on panel - 5998

- Days out for first 3rd visit 2.00

- Days out by provider- see chart C

2.3

4.8 walk or return

Walk tohospital

Hospital Registration

Register for Ancillary Services

- Referral volume – 14.5 %

MD, PA

See patient

HOSPTIALAncillary Services

PATIENT DATA

- Volumes - 131 visit/day

- Market share - Hospital 46.7%

- Cancel by reason - see chart A

- Payor mix – commercial 38%

- Satisfaction – overall 74.4

- Volume by Diagnosis – See chart BWait for ex prov

to return info

Wait for pt to

return packet

Reception

Receive call & Send

registration packet

Reception

RequestMed

History records

Reception

Receive Med History

& Call to Schedule Reception

InputMed History

Document delays – 2%- Schedule on 1st call – 0% - # of Pts on panel – 5997

- Days out for first 3rd visit – 3.75

- Days out by provider - See C

EXTERNALPROVIDERS

Disc

harg

e

Reception

Pre-reg, Schedule, & Send packet

Reception

Input Med History

following Check-in

- Document delays – 30%- Schedule on 1st call – 100%

- # of Pts on panel 5886

- Days out for new visit - 15.01

- Days out by provider – See Chart C

Days out for first 3rd visit – 1.16

= JMPG Scheduling

= OPC Scheduling

= PTFP Scheduling

= Clinic flow (all sites)

= Hospital Services

= Patient

Reg PktV1

Reg PktV2

Reg PktV2

Enterprise

Enterprise

Enterprise

Enterprise

Enterprise

ROSV1

ROSV1

ROSV2

MedHistory

Enterprise EMRInterfaceMedlist

EMR Orders

Scripts

Educ.

Routing Slips

EXTERNALPHARMACIES

Referral Coordinator

Check-outpatient

MediTechInterface

Scripts

EMR Referrals

Radfilm

MediTechEMR

EMR

EMR

Salmon reminder (PTFP)

= Patient on schedule

- Blocked Hours – 67/day

- Contact Hours 59/day

- Utilization 88%

C/T

L/T

Develop standard scheduling template

by 4-1-08

Develop clinic service

standards by 12-31-07

Develop standard registration packet

by 12-31-07

Develop pre-order & future lab

capabilities in EMR by 7-1-08

Develop standards for scheduling &

reception by 4-7-08

Develop process for capturing Hx

pre-visit by 7-1-08

Implement daily huddle by 11-1-08

Develop standard room

by 4-1-08

Develop post-visit standard work by (TBD)

Align to care teams in pods

by (TBD)

Standardize visit documentation

by (TBD)

Hire/train MA resources

Improve staff satisfaction

by (TBD)

Improve Pt satisfaction

by (TBD)

Establish Pt focus group

by 4-1-08

Address safety measures &

gaps by 10-31-08

Eliminate need to re-register in

hospital

Source: Jefferson Healthcare, Port Townsend, WA

EdNET 2012

Example of Lean VSM – Jefferson Healthcare Clinic (2008)

15

Less than 20% Value AddedSource: University of Iowa Hospitals and Clinics

Write O

rders

Clerk w

rites req

Req Tubed

Assescioned

Print Labels

Sorting

Checking

Travel

Checks B

ook

To R

oom

Get S

upplies

Wait

Check ID

Sam

ples

Label

To B

asket

Runners

Test

Post

Read

Wait

Treat

5 20 10 5 5 5 5 10 5 5 5 10 5 5 5 10 10 10 15 5 20 5 180

Example: 80% or more of the time spent in a healthcare processes is waste

EdNET 2012

A real medical example - a test-and-treat cycleMost of the patient time is spent waiting, moving, etc.

16

Example: Lean Optimization of Outpatient Visits(Removed wasted time, gave more time to MDs and Nurses)

Source: Jefferson HealthcareEdNET 201217

Example: 6S - A simple “Lean tool”

• Sort• Safe• Straighten• Scrub• Standardize• Sustain

Before

After

Source: University of Michigan Health System, Ann Arbor, MI

EdNET 201118

Example: 6S in Clinic Rooms

Source: Jefferson HealthcareEdNET 201219

Example: Study of Bottlenecks

GP Referral AppointmentMade

OutpatientVisit

Add toWaiting ListSurgeryFollow-up

Discharge

100/day 100/day 50/day

150/day15/day60/day

140/dayBottleneck!

EdNET 2012 20

So, Lean has a big role in Healthcare

• Lean is very different from traditional “COST CUTTING” approaches

• Lean hospitals do not…

– improve quality by asking people to be more careful

– improve productivity by asking people to run around faster

• Lean removes waste, to give more time and resources to MDs, patients, nurses

4. LMU-Kaiser Permanente Partnership in Lean

Healthcare

LMU-KP Partnership in Lean Healthcare

• Initiated by LMU in 2012 as a partnership of the best…– Selected KP because of top national rankings – LMU is a national leader in Lean

• Created an advanced 3-course graduate Certificate in Lean Healthcare

• First focus on streamlining huge medical labs– 10 KP students in 1st cohort, all managers of KP labs– Remarkable results, high praise from students and KP managers– Second student cohort finishing soon

• LMU expanding to other medical facilities in SC• More partnership projects planned with KP in Healthcare Systems

Thinking, Big Data

Graduate Certificate in Healthcare

Courses1. Lean Healthcare (teach Lean basics in healthcare context), based

on MIT EdNet work)

2. Project (learn by doing). 10 students, all lab managers streamline their labs with intensive on-site mentoring by Bo Oppenheim ($15 million saved, throughput time saved 30% -70%, higher quality of tests, numerous wastes eliminated…High praise from KP top management

3. Advanced Lean Management of Healthcare, (learn by teaching) Students develop Lean Enablers, (i.e., best practices inspired by Lean) for managing their and other medical labs. LMU has significant experience in development of Lean Enablers for SE and Program Management.

5. Six Examples of Lean Improvements

in KP Medical Labs Credits: • Onie Bueno, Manager, Bacteriology Lab• Leland Chan, Specimen Processing Department (SPD)• LaRonda S. Frazier, MS, Director of Microbiology Lab• Jocelyn Javier, Glenda Lumampao, Carlo Punu, Medical Centers• Mike M. Moradian, PhD, Director of Genetics Lab• Chiemi Tabata and Vincent Dizon, Managers, Automated Chemistry Lab• Michael Tiffert, Section Manager Cytogenetics and FISH Lab

Most Samples (blood, urine, biopsy…) tested in regional lab in Sherman Oaks

5

2802

9970

1972

101

1292

7103

3453

2157

923

2443

3806

441 3710 0

786220

484 430

2096

3999

2107

0

5:00PM

6:00PM

7:00PM

8:00PM

9:00PM

10:00PM

11:00PM

12:00AM

1:00AM

2:00AM

3:00AM

4:00AM

5:00AM

6:00AM

7:00AM

8:00AM

9:00AM

10:00AM

11:00AM

12:00PM

1:00PM

2:00PM

3:00PM

4:00PM

24 HOUR SPECIMEN ARRIVAL PROFILE (12/09/13 TO 12/10/13)

27

Specimen Processing Department (SPD)

LabotixAutomation

SPD DistributionTable

Couriers fromMedical Centers/ MOBs

SpecimenProcessingDepartment

(SPD)

AutomatedChemistry/

Endocrinology

Special Chemistry Immunology

Cytology8-12 hrs

Virology4-48 hrs

Blood Donor12 hrs

FrozenSpecimens

8-16 hrs

Outside Lab8-24 hrs

Genetics 4-8 hrs

Allergy Lab8-16 hrs

Bacteriology10 mins-4 hrs

B&T Lab4-8 hrs

Manual Processing

Automated Processing

IFOBT1-3 days

28

Manual Sorting in SPD

29

Sorted Samples from Evening Delivery

30

Lean Improvements in SPD

• Eliminate errors• Reduce batching and inventory• More JIT processing• Streamline operations• Eliminate waiting

31

Medical Center

Specimens

Couriers

MOBSpecimens

Specimen Processing Department

(SPD)

STATTest?

Yes

No

Yellow Bag

STAT Alert?

Yes

No

Specimen received, processed & logged

in for Testing Department

Manually locate or Labotix Rejection

Manually deliver specimens to

Testing Department

2-4 Hours

Routine Test?Yes

No

Labotix Automation

Labotix throughput is 1,500 specimens/

hour

Manual Process

Manual ProcessAutomated Process

ImmunologyAnalyzer

Automated Chemistry/

EndocrinologyAnalyzer

Special ChemistryAnalyzer60

minsManual Process

BactiTest?

Histology Test?

Cytology Test?

Genetics Test?

B&T/Allergy Lab

Test?

No Yes

All BacteriologySamples

Deliver to BacteriologyAutomation

No

No

No

Yes

Regional Couriers delivers directly to Histology Dept. Specimens

do not stop at SPD.

SPD Lab Staff receives Non-Gyn specimens and sends to

Cytology. SPD Lab Staff sends PAP specimens to Cytology

SPD sorts, place onTransfer Lists

SPD Lab Staff sends Outer Tub to

Genetics Lab via Regional Courier

Yes

Yes

SPD sorts, place onTransfer Lists

SPD Lab Staff sends Outer Tub to B&T or Allergy Lab via

Regional Courier

Archiver

Lean Improvements in SPD

Current Process

Non-value added

Required / Non-value added

Value added

Legend

32

Lean Improvements in SPD

SPD Before and After

Operational Impacts Current State Future State

Throughput (# specimens) 2800 4,000

Quality Medium-High High

Frustration to Staff High Low-Medium

Frustration to MD, Members/Customer High Low-Medium

.

33

34© LMU SELP 695, Dr. Oppenheim

Pos

t-A

naly

tica

l

Analyze results on instrument

software

Analyze results on instrument

softwareExport raw data to an excel file

Export raw data to an excel file

Copy paste Ct values to excel

sheets and graphs to a word

document

Copy paste Ct values to excel

sheets and graphs to a word

document

Prepare a WSD and WSL

NotePad file

Prepare a WSD and WSL

NotePad fileFormat

correct?Format

correct?

Transfer data to the excel with

raw data

Transfer data to the excel with

raw data

Use macro to format and then transfer WSD & WL reports into excel

Use macro to format and then transfer WSD & WL reports into excel

Manually enter RNA information

in the excel sheet

Manually enter RNA information

in the excel sheet

Prepare patient last run history list and confirm the history by checking LMS

Prepare patient last run history list and confirm the history by checking LMS

Enter prior history for

patients with changing result

trends

Enter prior history for

patients with changing result

trends

Enter the results into word

template one by one

Enter the results into word

template one by one

No

Yes

Copy and paste the results to

LMS report and verify correct

entry

Copy and paste the results to

LMS report and verify correct

entry

Print out the LMS report and check

for errors

Print out the LMS report and check

for errors

Prepare and print out the repeat list for sample removal from

LMS

Prepare and print out the repeat list for sample removal from

LMS

Copy request form for repeat sample for next

batch and complete the

report

Copy request form for repeat sample for next

batch and complete the

report

Second licensed Molecular tech

check the prepared report

Second licensed Molecular tech

check the prepared report

Report correct?Report

correct?

Manger/Director review

Manger/Director review

Correct report Correct report

No

Yes

Send to sign out by MD

Send to sign out by MD

Report correct?Report

correct?Release reportRelease reportYes

No

Stamp and sign the printouts And the document

Stamp and sign the printouts And the document

Wait Rework

Muri

Wait Rework

Muri

Wait Rework

Muri

Wait Rework

Muri

Wait Rework

MuriWait

Rework Muri

Wait Rework

Muri

Wait Rework

Muri

Wait Rework

Muri

Print out WSD to highlight the

repeats

Print out WSD to highlight the

repeats

5 min/batch30 min/batch90 min/batch

5 min/batch 30 min/batch60 min/batch

30 min/batch60 min/batch90 min/batch

10 min/batch30 min/batch

10 min/batch

5 min/batch

30 min/batch

30 min/batch

90 min/batch

10 min/batch- 50% incorrect

10 min/batch10% of reports

10 min/batch 90 min/batch30 min/batch

15 min wait

30 min wait

720 min wait

60 min wait

60 min wait

120 min wait

10 min wait

720 min wait

Lean Improvements in Genetics Lab

Current SMFuture SM (W/O

GLIS)Future SM (With

GLIS)Ideal SM

Touch time 1.7 hours/sample1.55 hours/sample

(8.8%)1.1 hour/sample

(35%)30 min/sample

Cost (approximate) 100% 94.3% 65.4% 43%

Quality Mod Mod High High

Frustration of lab staff High High Low Low

Frustration of MD & patient

High High Mod Low

35© LMU SELP 695, Dr. Oppenheim

Lean Improvements in Genetics Lab

Lean Improvements in Genetics FISH Lab

36

Current State MapFuture State Map

without Genetics LISFuture State Map with

Genetics LISIdeal State Map

Throughput time 10 days 5 days 3 days 1 day

Quality Moderate Moderate High High

Frustration of lab staff High Moderate Low Low

Frustration of MD & patient

High Moderate Low Low

Lean Improvements in Genetics FISH Lab

37

Lean Improvements in Automated Chemistry Lab

SELP 695 - Capstone Project 2014 39

Lean Improvements in Automated Chemistry lab

SELP 695 - Capstone Project 2014 40

• Stagger the work on the instruments: Perform maintenance, reagent replenishment, calibration and quality control one analyzer at a time Enables continuous testing Maximizes throughput

• SPD to loads samples directly onto instrument racks (HbA1c, MAU), eliminating manual sample transfers between multiple rack types.

• Hourly sample delivery from SPD.• Auto-release the majority of results based upon rule-based algorithms.• Eliminate wasteful Hemastix testing (study justified during LEAN

observations)• Improve throughput• Provide training and tools to employees to ensure correct sample

collection

Lean Improvements in Automated Chemistry lab

SELP 695 - Capstone Project 2014 41

Lean Improvements in Automated Chemistry

Current State Ideal State Future State

Throughput Time (Olympus) 733.5 minutes 36 minutes 140.5 minutes

Cost Savings Baseline $1,570,976.50 $994,876.50

Quality Mod High High

Frustration of Lab Staff HIGH Low Moderate

Frustration of MD Mod Low Mod

Frustration of Patient High Low Mod

Lean Improvements in Microbiology Lab

Excessive batching and storage

42

SELP 695 - Capstone Project 2014 43

• Deliver trays of instrument-ready racks directly to each instrument area and eliminate the cabinet storage

• Improve lab layout • Expand hours• Use smaller batch sizes• Enable testing and result verification for up to 2,000

specimens verses 500 specimens on the day of testing.

Lean Improvements in Microbiology Lab

SELP 695 - Capstone Project 2014 44

Future

Testing is performed on all

instruments

Instrument-ready trays of specimens are delivered on carts

directly to the instrument sites

in Virology

START

END

Three CLSs are assigned, to prepare the three TIGRIS instruments

for testing.

Specimen racks are continuously loaded onto the instruments

Results for all 2,000 CT/GC specimens loaded

are verified before the end

of the day

Each of the three CLSs loads the first specimen

racks onto the instrument immediately

on completion of the daily PM.

The three stages of the post-analytical specimen discard,

rack bleaching/rinsing/ drying, and loading onto trays for

return to the SPD are located in close proximity, saving

processing time and steps

Specimen racks are removed from

instrument and placed back on carts

WASTEIDENTIFIED

6.5 hours

Testing of samples performed

Specimen Processing delivers Instrument-

ready trays of specimens to Virology at 5 a.m. and 10 a.m.

START

END

10 minutes

Specimen Processing places Itrays of specimens

in cabinet

90 minutes

CLSs loads specimen racks onto instrument (7:00 a.m. through 3:30

p.m.)

Results for 500 of the 2,000 CT/GC specimens loaded are verified before the end

of the day

Results for the remaining 1,500 CT/GC specimens are verified the following

day, Monday-Friday

Waste Identified

10 minutes

CLS moves trays of specimens to carts

and rolls to instrument

10 minutes

Specimen racks are removed from the

instrument and placed back on carts

90 minutes

CLS prepares instruments for

testing

Specimens are pulled for repeat testing as

needed

Cart of racks is rolled to discard area and

specimens are discarded

Specimen racks are washed, dried, and transported back to

testing area

WASTE

WASTE IDENTIFIED

Lean Improvements in Microbiology Lab

Current

Lean Improvements in Microbiology Lab

45

SELP 695 - Capstone Project 2014 46

Current State Future State

Throughput Time (Virology) 57 hours 13.5 hours(76%)

Test Quality Optimal Optimal

Patient Complaints ↑ ↓

Provider Complaints ↑ ↓

Employee Morale ↓ ↑

Lean Improvements in Microbiology Lab

Lean Improvements in Sample Collection in Medical Centers

© LMU SELP 201447

CSM FSM ISM

Throughput Time 696 minutes 350 minutes 90 minutes

Cost Savings Annually (approximate)

$ 0 $ 37,950/year (Rejection rate lowered by 10%)

$39,750/year(Rejection rate lowered 50%)

Errors on Specimen Processing

High Medium- High Low

Frustration of Lab Staff High Medium- High Low

Frustration of MDs & Patients

High High Low

Lean Improvements in Sample Collection in Medical Centers

48

6. Summary

Summary• US Healthcare has great elements: R&D, equipment, facilities,

medical schools, dedicated professionals• Yet, ranks last in healthcare delivery international rankings

• And the costs are huge and unsustainable • In order to improve it, Healthcare must be seen as a highly

complex System, and we need to use Systems Thinking• Lean must be a critical part of Healthcare Systems

• Hard evidence presented that Lean is highly effective in reducing waste and costs, and improving quality and throughput.

• LMU-KP Partnership demonstrated significant benefits

Lean does not tell MD and other medical professionals how to treat patients – it frees them to

do it more and better