Lean in Healthcare
Lean Thinking, or Lean for short, originated in Toyota factories in the 1960s, was “transplanted” to the U.S. in 1992 with the publication of Lean Thinking: Banish Waste and Create Wealth in Your Corporation , and evolved globally to practically all work domains: healthcare, engineering and systems engineering, science, administration, supply chain, government, banking, aviation, and many others . Lean has proven itself as the most effective methodology for improving operations identifying and eliminating waste from work processes [1-5].
Since 2003, Lean has established itself in healthcare operations. Entire medical organizations (e.g., Theda Care, WI; Jefferson Healthcare, WA; Virginia Mason, WA; Geisinger Health (now called ProvenCare), PA; St. Elizabeth, Tilburg, The Netherlands, and numerous others [3, 4]) have been transformed with Lean. These sources contain rich data on specific improvements. Most leading healthcare institutions now have Lean centers of excellence or use Lean consultants, including Kaiser Permanente, Mayo Clinic, UCLA, Veterans Administration, and others. Lean has proven itself in reducing turnaround time of clinical tests, the time spent by patients in emergency departments, operating suites, pharmacies and clinics. Lean improvements in healthcare on the order of 30-50% are routine because traditional healthcare operations are burdened with this much waste, which remains “unseen” by the employees unless they are trained in Lean. Lean is now an established paradigm for improving healthcare delivery operations: increasing quality of healthcare, delivering care faster, shortening patient time in the system, increasing the time of medical professionals with the patient, reducing bureaucracy, increasing capacity of operations, and reducing healthcare costs and frustrations [3, 4].
Lean does not mean that people have to work faster or "attach roller blades to move around faster". In Lean systems employees work at their regular ergonomic and intellectual speeds. The time savings come from finding and eliminating idle states (e.g., waiting in numerous queues in the emergency departments), reduction of mistakes and rework, elimination of non-value adding tasks, and more streamlined movements of patients, staff, equipment, and supplies. And, most emphatically, Lean does not mean “mean layoffs”. Quite the opposite is true: Lean improves human relations at work and changes the culture from the traditional "blaming and shaming" to teamwork and cooperation focused on the good of the patient [3 (in particular see the endorsements from eight medical professionals on pages ii and iii), 4].
With the endorsement of book  in the Wiley Series in Systems Engineering and Management the International Council on Systems Engineering (INCOSE) has effectively adopted Lean as one of its essential competencies. This book was followed with a major joint Project Management Institute (PMI)-INCOSE-MIT publication of  integrating Lean with Systems Engineering and Program Management. Indeed, when applied with Systems Engineering and Systems Thinking, Lean becomes a powerful weapon in bending the healthcare cost curve and improving the quality of care.
Three concepts are critical to the understanding of Lean: value, waste, and the process of creating value without waste, which has been captured into the so-called Six Lean Principles, as follows.
- Value: M. Porter  suggested that patients value three levels of care: (1) survival and the degree of recovery; (2) the time required to get back to normal activities, and (3) the sustainability (individual and social cost) of treatments.
- Waste: Table 1 lists the eight categories of waste used in healthcare [3, 4].
|Waste Type||Healthcare Examples|
|1. Waiting||Patients wait in numerous queues in clinics, test facilities, ERs, pharmacies, and for insurance approvals; MDs wait for next activity to occur (e.g. test results, information, approvals.)|
|2. Over-processing||Performing work that is not valued or needed, e.g. MDs and RNs spending time on computer filling out bureaucratic forms that nobody will review.|
|3. Over-production||Performing more work than needed for value. Transport of a patient in a wheelchair performed by expensive medical professionals because of the lack of transporters.|
|4. Inventory||Excess inventory costs. Expired supplies that must be thrown away.|
|5. Transportation of Patients||Transportation of patients over long distances to test offices in hospitals. Poor layout of hospitals, EDs, or test facilities.|
|6. Motion of Staff||Staff walking over long distances to fetch supplies, and between patients and central hospital stations.|
|7. Defects||Treatment of hospital infections. Failed and repeated tests, repeated paperwork. Surgical cart missing an item. Wrong medicine.|
|8. Waste of Human Potential||Burnout of medical staff. Frustrated employees quit making suggestions for improvements.|
Table 2 lists the six Lean Principles [3[ and provides healthcare examples. 
|1. Value||Specify value from the perspective of the customer: the patient.|
|2. Value Stream||Identify all the value-added steps across the entire process, crossing all departmental boundaries, linking the steps into a seamless process, and eliminating all steps that do not create value.|
|3. Flow||Keep the processes flowing smoothly through all the steps, eliminating all causes of delay, such as batches of patients or items, and quality problems.|
|4. Pull||Avoid pushing work onto the next step or department; let work and supplied be pulled, as needed, when needed.|
|5. Perfection||Pursue perfection through continuous improvement, Kaizen events, implement best work standards, checklists, training, and promote improvement teams and employee suggestions.|
|6. Respect People||Create work environment based on synergy of cooperation, teamwork, great communication and coordination. Institute leadership. Abandon the culture of blaming and shaming.|
Lean Practices 
Lean healthcare strongly promotes engaging and leading employees. Lean places a big value on continuous education and training of employees at all levels. Lean management promotes standardization of best practices (“the best known way of doing it”, but not necessarily “identical”), checklists, redundancies, patient safety and privacy rules, and patient data security and cybersecurity. Lean advocates visual management, with electronic or “black” boards updated in real time and displaying all information important for the local employees to manage their operation efficiently. Patient safety is still a significant problem in the U.S., in 1999 causing almost 100,000 deaths (Institute of Medicine, 1999) and medical errors occur in one of three admissions. Instead of “blaming and shaming” Lean promotes error and harm prevention and deep root-cause analysis, implementing processes and tools that make it impossible to create an error.
Systems Thinking and Lean
Healthcare is the most complex socio-technological system in our society, consuming nearly 20% of the U.S. GDP. Healthcare should be safe, effective and evidence based , as well as affordable and accessible, efficient, patient centered, timely, well integrated, and inclusive of latest science . Healthcare has many stakeholders: the patients, medical professionals, medical facilities, hospitals, clinics, labs, medical equipment makers and users, pharmaceuticals, healthcare researchers and academia, insurances, employers, federal & state governments and international disease prevention centers, military and veteran’s administration, fire departments and ambulances and others. The number of potential interactions (interfaces) in this hyper-system is extensive, and many interfaces are nonlinear, “wicked” (interacting with unpredictable humans), often creating unintended consequences and emergent behaviors. Because of these vast complexities, healthcare leaders (e.g. ) point out the need for intensive application of systems thinking and Lean when addressing these challenges. Attempting to solve the complex healthcare problems without systems thinking risks myopic and unsafe attempts which create more problems than they solve. Attempting to solve the challenges without Lean inevitably promotes excessive wastes, costs, and inefficiencies. Good healthcare needs both, Systems Thinking and Lean, to be applied simultaneously.
Lean and Agile in Six Healthcare Value Streams
The Healthcare Working Group of INCOSE identified six following value streams for HSE:
- Systems Engineering for medical devices
- Systems Engineering for healthcare informatics and medical records
- Healthcare delivery (operations)
- Biomedicine and big data analytics
- Pharmaceutical value streams
- Healthcare public policy
As described above, Lean is extraordinarily effective and well established in improving healthcare delivery operations (C). Agile is highly effective in (B) because this value stream works with software, the domain from which Agile originated. Since the stream (A) is the most similar to traditional systems engineering, Agile is expected to be effective therein, although Agile is not yet highly popular in healthcare outside of the software domain. Elements of Lean improvements which are localized and weakly convoluted (e.g., Kaizen events) have strong overlap with Agile/Scrum methodology .
MBSE and Lean
A highly powerful Model Based Systems Engineering (MBSE) is clearly the tool of choice for those applications where the benefit from multiple use of a standardized (reference) architecture and standard model compensates for the significant effort of creating such a model or architecture . In healthcare the value streams (A), (B), (E) and potentially F are the most conducive to the application of MBSE. Lean thinking is applicable to any healthcare operation without limitation. The Lean improvements always begin with the so-called Gemba waste walks, during which experts together with local process stakeholders walk along all the process steps, interviewing stakeholders and identifying and measuring the wastes wherever they occur. The rich menu of Lean thinking processes and tools is then applied to eliminate the wastes. Training and active participation of local stakeholders is always required.
Examples of Lean Improvements
- In Jefferson Healthcare, WA :
- In Acute Myocardial Infarction (a severe heart attack) time is critical as the greatest loss of heart muscle is in the first two hours. Recommended treatment is catheter insertion of balloon within 90 min of the contact with the patient (wherever the patient happens to be located). The Lean approach has reduced the treatment time from 165 min to 20-60 min at the patient site, vastly increasing patient survival rate.
- The five Jefferson Healthcare clinics increased the cumulative available clinic hours from 1400 to 5600 in two years of Lean improvements which were focused on reorganizing medical staff schedules and eliminating wasted times, with no staff additions. The available clinic hours directly translate into billable visits: 1175 additional patients have been seen in 2009 compared to 2008 across the five clinics.
- The Operating Room daily “on time start” of actual operations went from 14% to 96% using Lean tools for process planning and workplace organization.
- Harder to measure is the culture change, although the staff participation at Lean improvement events was at 50%.
- In Kaiser Permanente Southern California :
- In nine regional clinical laboratories Lean improvements cut the turnaround time for laboratory results by between 30 and 70%, with significant corresponding reductions of cost, rework, errors and work morale, and without hiring new staff or adding equipment.
- In two Emergency Departments (ED) the average patient length of stay was reduced by 40% by the elimination of various idle states. The ED capacity increased accordingly.
- The amount and cost of inventory of supplies on hand was reduced by nearly 30% by introducing the Just-in-Time tools of Lean.
- In Alegent Health, NE  the turnaround time for clinical laboratory results was reduced by 60% in 2004 without adding new staff or equipment; and by another 33% from 2008 to 2010.
- In Kingston General Hospital, Ontario  the instrument decontamination and sterilization cycle time was reduced by 54% while improving productivity by 16%.
- In Allegheny Hospital, PA the central-line associated bloodstream infections were reduced by 76%, reducing patient death from such infections by 95% and saving $1 million.
- In UPMC St. Margaret Hospital, PA  the readmission rates for chronic obstructive pulmonary disease (COPD) patients were reduced by 48%.
- In ThedaCare, WI  the waiting time for orthopedic surgery was reduced from 14 weeks to 31 hours (from first call to surgery); improved inpatient satisfaction scores of “very satisfied” rose from 68% to 90%.
- In Avera McKennan, SD  the patient length of stay was reduced by 29%, and $1.25 million in new ED construction was avoided.
- In Denver Health, CO  the bottom-line Lean benefit was increased by $54 million through cost reduction and revenue growth, and layoffs were avoided.
- In Seattle Children’s Hospital, WA $180 million in capital spending was avoided through Lean improvements.
These examples demonstrate that Lean is successful in cost and throughput time reductions, and improvements in quality and patient and staff satisfaction. The improvements of this level are possible, even routine – because the amount of initially-invisible waste in traditional healthcare organizations is so high. The broad range of operations described in the examples manifest that Lean is applicable across the board to healthcare operations, without limitations.
Education in Lean Healthcare
Increasingly, Lean Healthcare becomes an inherent part of Healthcare Systems Engineering (HSE) Master’s Programs, e.g.  which has been developed in collaboration with Kaiser Permanente. The program includes two courses in Lean, basic and advanced, focused on improving operations in clinics, hospitals, emergency departments, clinical laboratories, radiology testing, operating rooms, pharmacies, supply chain, and healthcare administration. After the basic courses in systems engineering, project management, and systems thinking, the students also take courses on healthcare system architecting, modeling and simulations; medical data mining and analytics; systems engineering for medical devices, healthcare enterprise informatics; and healthcare delivery systems. All these advanced courses contain elements of Lean thinking because all these subdomains risk being burdened with waste and poor quality if Lean is ignored. Simply put, Lean is not really an optional extra if you want to achieve efficiency and effectiveness.
1. J.P. Womack and D. T. Jones, Lean Thinking: Banish Waste and Create Wealth in Your Corporation, Free Press, 2003
2. B.W. Oppenheim, Lean for Systems Engineering with Lean Enablers for Systems Engineering, Wiley Series in Systems Engineering and Management, 2011
3. M. Graban, Lean Hospitals; Improving Quality, Patient Safety, and Employee Engagement, CRC Press, 2012
4. J. Toussaint and R. Gerard, On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry, Lean Enterprise Institute, Jun 6, 2010
5. J. Oehmen, The Guide to Lean Enablers for Managing Engineering Programs, PMI-INCOSE-LAI MIT, May 2012
6. M. Porter, What is Value in Healthcare?, New England Journal of Medicine, Dec. 8, 2010
8. M. Kanter, M.D., Regional Medical Director of Quality & Clinical Analysis, Southern California Permanente Medical Group, quoted in Strategic Partnership of Healthcare and Systems Engineering, INCOSE HWG presentation, 2015
9. E. Murman, MIT 2010 LAI Annual Conference, Boston MA.
10. D. Berwick, 2009 National Forum Keynote, http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/BerwickForumKeynote2009.htm (accessed July 4, 2011)
11. B.W. Oppenheim, Lean Healthcare, INCOSE Healthcare Working Group webinar, April 30, 2015. https://onedrive.live.com/redir?resid=147E5C4249DA0EFB%21142
12. Á. Medinilla, Agile Kaizen: Managing Continuous Improvement Far Beyond Retrospectives 2014th Edition, Springer, 2014
13. http://www.omgwiki.org/MBSE/doku.php (last accessed March 29, 2016)
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