One Doctor’s View on Lean


    Healthcare Efficiency: Lean and Mean

    Here is a short blog piece on the American Society for Quality website, written by a doctor. It's positive about lean, which makes me cringe at the ole' “Lean and Mean” title. I presume that people think it's cute rhyme and use it without thinking sometimes.

    He makes a point about changeover:

    We used to schedule all the left eye cataracts in the AM, right eyes in the PM to minimize time in moving the microscope. Same for knee arthroscopy.

    I've seen this too at a hospital — large batches in order to minimize the amount of Operation Room setup and changeover. It's classic non-lean sequencing: AAAAAABBBBBB (or LLLLLLRRRRRR). They assume the changeover time HAS to be long, it's not standardized or made efficient (by analyzing external vs internal setup). Using “SMED” principles, you could do the procedures in a “mixed model” sequence:


    But, I wonder what the value is medically to doing all of the changeovers? Part of the argument in manufacturing is inventory reduction, quality, and cycle time. But, in an OR setting, each patient is unique, they aren't going “into inventory” after their procedure. So I wonder what's wrong, really, with scheduling the procedures LLLLLLRRRRRR?

    Am I missing something? Or is there a risk that some hospitals are adoping a lean method without thinking about what waste is caused by LLLLLRRRRR? Do surgeons get sloppy if they're doing too many of the same side? Or is there actually a surgical quality advantage to doing the same thing many times in a row?

    What would you say?

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    Mark Graban
    Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


    1. Honestly, with the number of surgical mistakes that you hear about, I would feel better knowing that if I was to have surgery on my right eye, and they scheduled me for 9 AM, I had a “visual” indicator that they would be working on the wrong eye.

      I think too many times people focus on lean to get speed, where the principles taught by Dr. Deming, Taiichi Ohno and others were to focus on quality and prevention.

      And the interesting thing that happens when you focus on quality and prevention — speed naturally occurs because you have less re-work or mistakes happening.

    2. I agree: it seems like the best reason for doing left eyes in the AM and right eyes in teh PM is pokayoke. Maybe they are doing the right thing for the wrong reason. :-)

    3. When I had a cornea replacement a few years ago those doing the prep asked me again which eye was getting the work, marked the right side of my face with dye and put a big black x on my right hand. I guess that’s so Doctor would know which side to stamp out and replace.

    4. The value is in the setup reduction – which eliminates cost and frees up capacity. If, in fact, it takes an hour to move the machine from right to left, that is two hours of surgical capacity lost each day, and and two hours of cost to pay the person to move it.

      Going to LRLRLR is simply the forcing function to make them address the setup cost. Left alone, the long setup will remain intact and the waste will stay in place.

      Once the setup is reduced, the actual sequence should be driven by customer demand – not by complying to LRLRLR sequencing merely to conform with the theory of heijunka.

      A case can probably be made in medical situations that each setup creates a defect opportunity, and minimizing the frequency of setups reduces exposure to defect opportunities. That may well be the case, but it should not be used as a license to keep the waste of the long setup inact.

      In summary – reduce the setup time, then decide whether LLLLRRRR or LRLRLRLR makes the most sense based on quality considerations – not based on how best to amortize waste of setup costs.

    5. Your answer makes a lot of sense, Bill. Patient “demand” is a weird thing to figure out because patients don’t get to request their procedure time — they’re not given much choice other than “day” maybe. The scheduling department pretty much tells patients when, so the demand (who prefers morning, who prefers afternoon) is hidden or never exposed. Hard to say if true demand is LRLRLRL or LRRLLRRRL or LLLLRRRR. But, I agree you should have changeover time down (applying external setup and standardization) to have flexibility when you need it. Great point.

      It’s probably a good practice to standardize the changeover, from a quality standpoint. I agree with John that they are probably trying to minimize the opportunity for errors through changeover (someone forgets a setting, etc.). But, the answer isn’t to avoid changeovers — it’s to standardize through checklists and visual controls and I bet speed will come with the error proofing (less doublechecking and rework in the changeover process).

    6. I agree with Bill and Mark. Another reason would be to decrease patient Lead Time to have the procedure. If there is a rash of L that need to be completed but no R then patients needing the L procedure could wait days extra where they could have moved up in days and the Lead Time decreased, instead of waiting for R to fill the spots. Truer FIFO too.


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