Lean in Hospitals: Which Tool or Which Need?
As people first learn about Lean, they often ask questions like “what tools or methods should we use first?” These tools include things like 5S or varied forms of rapid improvement events. As I have heard Jim Womack say, tools are helpful, but not sufficient.
Taiichi Ohno, one of the fathers of the Toyota Production System wrote that we should “start from need.” Simple words, powerful message. What are a hospital's needs? What are the patients' needs? I think those are the right questions to ask…
One could argue nothing matters but the two pillars of the Toyota Production System, “just in time” and “quality at the source,” or jidoka. Quality and patient safety are the most important problems to work on in healthcare and these should have priority over small cost reduction exercises.
But, the pillar of “just in time” is what I'd like to talk about here. The idea of JIT in manufacturing was to provide the right part, in the right quantity, at the right time, to the right operation, customer, or process. JIT often gets confused with “low inventory,” especially in the WSJ. Actually, these two pillars are linked together, especially so in healthcare, as providing medications and materials (just in time) is a critical aspect of quality.
In the early 2000s, I learned from am experienced Japanese Lean sensei who said, “First, keep the line running…. second, low inventory.” This seemed shocking at first, as I thought the primary goal was low inventory, as did many others. But, low inventory as a primary goal often means low production (because inventory was TOO low). He taught me to keep the line running, while keeping inventory as low as possible to meet that goal (and the goal wasn't really 100% uptime, because that would require massive inventories, in most settings). We also don't keep the line running 100% of the time because the small downtimes are the way we drive improvement to prevent future downtimes.
What does JIT mean in healthcare? I can think of two examples – getting the right medication to the nurses and getting the right surgical instruments to the surgeons. We focus on meeting their needs, of course, because it benefits the patients. The first goal isn't keeping the inventory of medications or instruments as low as possible. First, provide patient care… then, keep inventory as low as possible while meeting that primary goal. But we need to be much closer to 100% availability with our medications and materials, because it could be literally life and death.
We know that nurses far too often don't have the medications they need for their patients. This often forces nurses into workaround mode – often violating formal procedures to get patients what they need. Surgical procedures are often delayed and/or staff members run and scramble to find instruments that were missing or they “flash sterilize” them or do other things that aren't optimal.
Why are we putting staff members in that position? Why are we putting patients in that position?
It's safe to assume the average Toyota assembly line worker never has to go running to look for parts. That's because Toyota factories (and other Lean factories) have support staff and systems that ensure parts are available. While there might be line stoppages or shortages of parts from suppliers in a factory, a good Lean factory generally does a better job of supporting the people who do the value adding work.
If you are working on relatively peripheral things like 5s-ing the pharmacy, but nurses and patients don't always have the medications they need, maybe it's time to step back and think about what problem you should be solving?