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Lean Hospitals, 3rd Edition

Book Description

Organizations around the world are using Lean to redesign care and improve processes in a way that achieves and sustains meaningful results for patients, staff, physicians, and health systems. Lean Hospitals, Third Edition explains how to use the Lean methodology and mindsets to improve safety, quality, access, and morale while reducing costs, increasing capacity, and strengthening the long-term bottom line.

This updated edition of a Shingo Research Award recipient begins with an overview of Lean methods. It explains how Lean practices can help reduce various frustrations for caregivers, prevent delays and harm for patients, and improve the long-term health of your organization.

The second edition of this book presented new material on identifying waste, A3 problem solving, engaging employees in continuous improvement, and strategy deployment. This third edition adds new sections on structured Lean problem solving methods (including Toyota Kata), Lean Design, and other topics. Additional examples, case studies, and explanations are also included throughout the book.

Mark Graban is also the co-author, with Joe Swartz, of the book Healthcare Kaizen: Engaging Frontline Staff in Sustainable Continuous Improvements, which is also a Shingo Research Award recipient. Mark and Joe also wrote The Executive’s Guide to Healthcare Kaizen.

Table of Contents

  1. Half Title
  2. Endorsements
  3. Title Page
  4. Copyright Page
  5. Contents
  6. Foreword
  7. Preface
  8. Author
  9. Chapter 1: The Need for Lean Hospitals
    1. Better Results with Lean
    2. Why Do Hospitals Need Lean?
    3. A Renewed Sense of Purpose
    4. Lean Methods Are Not New to Healthcare
    5. Toyota’s Role in Popularizing Lean
    6. Origins of the Term Lean
    7. Lean Is Proven to Work outside Automotive Factories
    8. Lean Is Helping Hospitals Improve
      1. Safety and Quality
      2. Waiting Times and Length of Stay
      3. Flow
      4. Satisfaction
      5. Financial
    9. Problems in Healthcare
      1. Price Pressures and Cost Challenges
      2. Employee Shortages
      3. Quality and Patient Safety
    10. Good Quality Costs Less
    11. Interconnected Benefits
    12. A Snapshot of Department Success: Laboratory, Children’s Health Dallas
    13. From Departmental to Hospital- and System-Wide Success
    14. Conclusion
    15. Lean Lessons
    16. Points for Group Discussion
    17. Notes
  10. Chapter 2: Overview of Lean for Hospitals and Health Systems
    1. What Is Lean?
    2. Ohno’s Definition of Lean
    3. Lean Thinking
    4. The Toyota Triangle: Tools, Culture, and Management System
      1. Human Development
      2. Philosophy
      3. Technical Tools
      4. Managerial Methods
    5. The “Toyota Way” Philosophy
      1. Continuous Improvement
      2. Respect for People
    6. Four Organizational Capabilities for Lean
      1. Capability 1: Work Is Designed as a Series of Ongoing Experiments That Immediately Reveal Problems
      2. Capability 2: Problems Are Addressed Immediately through Rapid Experimentation
      3. Capability 3: Solutions Are Disseminated Adaptively through Collaborative Experimentation
      4. Capability 4: People at All Levels of the Organization Are Taught to Become Experimentalists
    7. Lean and Other Methodologies
    8. What Lean Is Not
    9. Conclusion
    10. Lean Lessons
    11. Points for Group Discussion
    12. Notes
  11. Chapter 3: Value and Waste
    1. Waste: A Global Problem with Local Solutions
    2. Reducing Waste Is a Better Goal Than Reducing Cost
    3. What Is Waste?
    4. What Is Value? Start with the Customer
    5. How Do We Define Value in a Broad Sense?
    6. How Does Lean Define “Value?”
      1. Rule 1: The Customer Must Be Willing to Pay for the Activity
      2. Rule 2: The Activity Must Transform the Product or Service in Some Way
      3. Rule 3: The Activity Must Be Done Correctly the First Time
    7. Examples of Value-Added and Non-Value-Added Activities
    8. Learning to Identify and Describe Waste
      1. Waste of Defects
      2. Waste of Overproduction
        1. Reducing Unnecessary Care
      3. Waste of Transportation
      4. Waste of Waiting
        1. Patients and Products Waiting
        2. Employees Waiting
      5. Waste of Inventory
      6. Waste of Motion
        1. Waste of Nursing Motion
      7. Waste of Overprocessing
      8. Waste of Talent
    9. There’s Not Always an Easy Answer
    10. What Non-Value-Added Activities Are Required?
    11. Non-Value-Added, Pure Waste
    12. Conclusion
    13. Lean Lessons
    14. Points for Group Discussion
    15. Notes
  12. Chapter 4: Observing the Process and Value Streams
    1. Learning to See
    2. How Do We Find Waste? Go and See
    3. What Is a Value Stream?
    4. Value Stream Mapping
    5. Creating a Current-State Value Stream Map
    6. The Future-State Maps
    7. Breaking Down Silos and Reducing Suboptimization
    8. Observing the Process
    9. Activity of the Product
      1. Activity of the Product—Laboratory
      2. Activity of the Product—Patient
    10. Activity of the Employee
      1. Activity of the Employee—Nursing
      2. Activity of the Employee—Primary Care
      3. Activity of the Employee—Perioperative Services
    11. Conclusion
    12. Lean Lessons
    13. Points for Group Discussion
    14. Notes
  13. Chapter 5: Standardized Work as a Foundation of Lean
    1. Helpful Standardization: From 171 Forms to Just Six
    2. The Need for Standardized Work
    3. The Toyota House Metaphor
    4. Overview of the Lean Foundations
    5. Lean Foundations: Standardized Work
    6. Definition of Standardized Work
      1. Current
      2. Proper Outcome and the Highest Quality
      3. To Safely Complete
      4. One Best Way
      5. Fewest Possible Resources
    7. Standardized, Not Identical
    8. Written by Those Who Do the Work
    9. Considering How Long Tasks Take
    10. Staffing Based on Data
    11. Types of Standardized Work Documents
    12. Standardizing Daily Routines
    13. Defining Roles and Responsibilities
    14. Quick Changeover as Standardized Work
    15. Explaining Why through Standardized Work
    16. Standardized Work Documents and the Standardized Work System
    17. Measuring and Observing for Standardized Work Adherence
    18. “Resistance” to Standardized Work?
    19. Asking Why When Standardized Work Is Not Followed
    20. Standardized Work Can Apply to Physicians
    21. Lean and Checklists
    22. Standardized Work for Raising Concerns
    23. Standardized Work Can Apply to Leaders
    24. Training through Standardized Work
    25. Conclusion
    26. Lean Lessons
    27. Points for Group Discussion
    28. Notes
  14. Chapter 6: Lean Methods: Visual Management, 5S, and Kanban
    1. Lean Is More Than Tools, but Tools Can Help
    2. Reducing Waste through Visual Management
    3. Examples of Visual Management for Patient Flow
    4. Examples of Visual Management to Prevent Process Problems
    5. 5S: Sort, Store, Shine, Standardize, and Sustain
      1. First S: Sort
      2. Second S: Store
      3. Third S: Shine
      4. Fourth S: Standardize
        1. Standardize Things That Matter
        2. Standardizing Airway Carts
      5. Fifth S: Sustain
    6. Safety as a Sixth S?
      1. A 5S Case Study: Saving Time for Respiratory Therapists
    7. Kanban: A Lean Approach to Managing Materials
    8. Problems with Traditional Materials Systems
      1. Problems with Standing Orders
      2. Problems with Par Levels
      3. Problems with Electronic Inventory Cabinets
    9. Trade-Offs with Inventory
    10. Using Kanban to Replenish Supplies
      1. A Kanban Case Study
      2. Case Example: The Use of Lean Methods to Prevent Patient Harm
    11. Conclusion
    12. Lean Lessons
    13. Points for Group Discussion
    14. Notes
  15. Chapter 7: Proactive Root Cause Problem Solving
    1. The Tragic and Preventable Mary McClinton Story
    2. Improving Quality and Patient Safety
    3. Cultural Obstacles to Quality Improvement
    4. Why Do Errors Occur?
      1. Violations and Errors, Lapses, and Slips
      2. Just Culture
    5. Examples of Quality Improvement
    6. Finding Root Causes and Preventing Errors
    7. Workarounds and the Need for Fixing Root Causes
    8. Asking Why Instead of Who
    9. Start at the Gemba
    10. Find Root Causes Using Simple Methods
    11. A3 Problem Solving
      1. Example of the Five Whys: Hand Hygiene
      2. Example of the Five Whys: Lost Specimens
    12. Toyota’s Practical Problem Solving
      1. Clarifying the Problem
      2. Breaking Down the Problem
      3. Target Setting
      4. Problem Solving Is Iterative
      5. Countermeasures Help Verify or Disprove Root Causes
      6. Standardize Successful Improvements
    13. Be Proactive and Use Failure Modes and Effects Analysis
    14. Proactive Resolution of Near-Miss Problems
    15. The Heinrich Safety Pyramid
    16. Conclusion
    17. Lean Lessons
    18. Points for Group Discussion
    19. Notes
  16. Chapter 8: Preventing Errors and Harm
    1. A Serious Problem with Large, Unknowable Numbers
    2. Moving beyond Blaming Individuals
    3. The Darrie Eason Case
    4. Creating Quality at the Source through Error Proofing
    5. Being Careful Is Not Enough
    6. Why 100% Inspection Is Not 100% Effective
    7. Types of Error Proofing
      1. Make It Impossible to Create the Error
      2. Make It Harder to Create the Error
      3. Make It Obvious the Error Has Occurred
      4. Make the System Robust So It Tolerates the Error
    8. Error Proofing, Not Dummy Proofing
    9. Examples of Error Proofing in Hospitals
      1. Banned Abbreviations as Error Proofing
      2. Computer Systems as Error Proofing
      3. Case Example: Best Practices versus PDSA
      4. Preventing Surgery Errors through Error Proofing
    10. Stopping the Line (Andon)
    11. Error Proofing the Error Proofing
    12. Conclusion
    13. Lean Lessons
    14. Points for Group Discussion
    15. Notes
  17. Chapter 9: Improving Flow
    1. Lean Is Both Quality and Flow
    2. Waiting: A Worldwide Problem
    3. Targets without a Means for Improvement Might Lead to Improvement or Dysfunction
    4. Focusing on Flow
    5. Value Streams Should Flow Like a River
    6. Uneven Workloads as a Barrier to Flow
      1. Naturally Occurring Unevenness
      2. Mura Caused by Morning Rounds
      3. Level Loading Physician Charting
      4. Mura Caused by Suboptimizing Courier Routes
      5. Mura Created by Clinic Scheduling
      6. Mura in the Patient Discharge Process
    7. Addressing Mura by Matching Staffing to Workloads
    8. Improving Patient Flow
      1. Improving Patient Flow in the Emergency Department
      2. Reducing “Door-to-Balloon” Time
      3. Improving Patient Flow in Outpatient Cancer Treatment
    9. Improving Flow for Ancillary Support Departments
      1. Improving Flow in Clinical Laboratories
      2. Reducing Delays in Specimen Collection
      3. Reducing Delays in the Receiving Areas of the Lab
      4. Improving Flow Also Improves Quality and Teamwork
      5. Reducing Delays inside the Testing Areas of the Lab
      6. Improving Flow in Anatomic Pathology
      7. Improving Flow in Pharmacies
    10. Conclusion
    11. Lean Lessons
    12. Points for Group Discussion
    13. Notes
  18. Chapter 10: Lean Design
    1. Better, Faster, and Cheaper
    2. Understanding the Current State before Designing the Future
      1. Better Care at a Lower Cost through Better Design
      2. Designed to be Staff Centered and Patient Centered
      3. Designed for Uncertainty of Volumes or Workflows
      4. Designed Using Mockups and Iterations
    3. Lean Design at East Tennessee Children’s Hospital
    4. Integrated Lean Project Delivery at Akron Children’s Hospital
    5. Conclusion
    6. Lean Lessons
    7. Points for Group Discussion
    8. Notes
  19. Chapter 11: Engaging and Leading Employees
    1. Improving the Way We Manage
    2. What Is a Manager’s Role?
      1. Engaging Employees in Change
    3. Strategy Deployment
    4. Common Management Problems
    5. Lean as a Management System and Philosophy
    6. A Daily Lean Management System
      1. Process Audits or Rounding
        1. Standardized Audits of the Standardized Work
        2. A Hierarchy of Rounding
    7. Performance Measures
      1. Timely Measures Can Drive Timely Improvement
      2. A Balanced Scorecard Focuses on All Stakeholders
      3. Metrics Should Be Visible, Visual, and Statistically Meaningful
      4. Daily Stand-Up Team Meetings or Huddles
      5. Kaizen and Daily Continuous Improvement
        1. Toyota Kata
        2. The Problems with Suggestion Boxes
        3. The Role of Leaders in Kaizen
        4. Finding a Better Method for Managing Kaizen
        5. Visual Tracking of Kaizen Ideas
        6. Communicating Kaizen Improvements
    8. Conclusion
    9. Lean Lessons
    10. Points for Group Discussion
    11. Notes
  20. Chapter 12: Getting Started with Lean
    1. How Do We Start?
    2. The LEI Lean Transformation Model
    3. Where Do We Start?
      1. Starting in the Midst of a Crisis
      2. Assessing and Choosing Where to Start
    4. What Do We Call It?
    5. Getting Started with Kaizen
    6. Kaizen Events
      1. Pitfalls of Kaizen Events
    7. Lean Transformation Projects
    8. The Lean Project Team
    9. Executive Sponsorship and Leadership
    10. Starting from the Middle
    11. Establishing a Model Line and a Road Map
      1. A Model Cell for Kaizen
      2. Pros and Cons of a Road Map
    12. Dedicating People to Lean Beyond Projects
    13. The Lean Department
    14. The Importance of Change Management
    15. A Snapshot of Hospital Success: Avera McKennan Hospital & University Health Center
      1. Starting in the Lab
      2. Improving Inpatient and Emergency Flow and Care
      3. Lean Design for Long-Term Care
      4. Lean is a Turning Point for Home Medical Equipment
      5. Improving Clinic Scheduling and Appointment Availability
      6. Improving Inpatient Care and Implementing EHR and CPOE
      7. Lean Transformation Projects and Other Forms of Improvement
      8. Respect and a Leadership Commitment to Staff
      9. A Commitment to Lean Thinking, Better Management, and Continuous Improvement
    16. Conclusion
    17. Lean Lessons
    18. Points for Group Discussion
    19. Notes
  21. Chapter 13: A Vision for a Lean Hospital and Health System
    1. Introduction
    2. When Is a Health System Lean?
    3. What Would a Lean Health System Look Like?
    4. What Would a Patient Experience in a Lean Health System?
    5. What Would It Be Like to Work in a Lean Health System?
    6. How Would We Describe a Lean Health System?
      1. Strategy and Management System
      2. Patients
      3. Employees
      4. Waste and Kaizen
      5. Technology and Infrastructure
    7. In Conclusion
    8. Points for Group Discussion
    9. Notes
  22. Glossary
  23. Index