Lean production (Lean) is a type of quality improvement methodology which has been implemented in many industries. Its principles and practices also have been applied to health care organizations with success. This has been accomplished with refinement for the nuances of health care. Lean is a process management philosophy which has its roots in manufacturing and technology. It was developed as part of the Toyota Production System for the process assembly of automobiles (Toyota Motor Corporation, 2009). The Toyota System is comprehensive and spans a large number of methods and practices. It was initially influenced by the work of W. Edwards Deming and Henry Ford and was also inspired by innovation in the American grocery store industry of the 1950s (Keller, 2006). This is reflected in the Just-in-Time philosophy of productivity improvement, which emphasizes producing quality products efficiently through the complete elimination of waste, inconsistencies, and unreasonable requirements (Toyota Motor Corporation, 2009). Though the Lean methodology was initially developed as part of an overall system focusing on the production of automobiles, its principles also have been adapted for health care. As certain case studies indicate, Lean thinking and tools have been successfully applied to specific health care settings. The scope and value of Lean production within this field will be explored in this paper.Significance:ValueA significant component of Lean is the concept of value: the theoretical concept of value, the measurement of value, and the tangible processes behind delivering value. Lean is unique in that it accounts for the reduction of waste in order to achieve both real and potential value. Recovering this value can present itself in the form of saved costs or other tangibles. Lean thinking dictates that the expenditure of resources for any purpose other than delivering value to the customer is considered to be wasteful. The reduced expenditure of time, money, and resources is thought to bring additional bottom-line benefit to the customer. The customer-centric focus of Lean thinking is especially relevant to health care. Broader levels of patient/customer satisfaction are constantly being sought. This mode of thinking has been brought on by increased competition among organizations and the need to differentiate services. It is recognized that providing complete customer satisfaction can be vastly beneficial to health care organizations. Customer satisfaction can be an equally important measure of an organization’s performance as the delivery of quality health outcomes. This is a factor which is exemplified in Noriaki Kano’s model. Lean thinking dictates that processes and methods must be efficiently optimized with the needs of customers in mind in order for organizations to be fully effective.Problem Addressed: WasteLean focuses on the maximization of process velocity through the reduction of waste. It provides tools for analyzing process flow and delay times at each activity in a process. The focal point is the separation of “value-added” from “non-value-added” work. This is complemented by tools which aide in the identification and elimination of root causes of non-valued activities. The primary problem addressed by Lean is waste, which can affect value in a number of ways. It may result in lower quality products, higher costs, less favorable customer experiences, excessive time or effort expended to complete goals, or fewer resources available for innovation which could provide potential value at a future date. Waste can be found in people, processes, tangibles, and other areas. Eliminating waste through the lens of Lean production can help to achieve the goals of health care organizations. There are eight generally identifiable centers of waste: overproduction, waiting (time on hand), unnecessary transport or conveyance, over-processing or incorrect processing, excess inventory, unnecessary human movement, defects, and unused employee creativity (United States Army, 2009). There are variations on these categories of waste depending on the setting or industry. For the purpose of health care Caldwell (2005) slightly refines these measures into seven categories of waste. These consist of “in-quality/out-of-quality staffing or overcapacity, overcorrection, over processing, excess inventory, waiting, motion of patients or staff, and material and information movement (Caldwell, 2005, p. 46).” Regardless of the differences in terminologies used, there are common centers of waste in health care which can be targeted for elimination. These can be identified through Lean processes which focus on root cause analysis.Process: Root Cause AnalysisA crucial process in Lean is the identification of waste through root cause analysis. Root cause analysis in Lean involves a method called 5-Whys (Toyota Manufacturing Kentucky, 2003). This method rapidly identifies root causes and aides in determining the relationship between multiple root causes. It can be learned quickly and does not require statistical analysis. This method is especially effective for an implementation team in the initial stages of problem exploration. The application of this strategy involves asking a series of why-related questions to drill down into a problem area. Asking progressive questions about a perceived difficulty forces team members to think critically about the actual sources of waste and inefficiency. It is suggested that at least five questions (5-Whys) are posed to arrive at the root cause, though a root cause may be discovered in more or less inquires.The following is an example of a 5-Whys exercise used in a hypothetical hospital setting:(Q1) Why are patients being diverted to neighboring hospitals?(A1) Because wait times for our hospital are exceeding industry norms.(Q2) Why are our wait times exceeding industry norms?(A2) Because patient volume is exceeding capacity.(Q3) Why is patient volume exceeding capacity?(A3) Because not enough hospital beds are available.(Q4) Why are not enough hospital beds available?(A4) Because hospital patients are not being discharged efficiently.(Q5) Why are hospital patients not being discharged efficiently?(A5) Because ER staff is not following best practices for proper discharge.In this example, waste in the throughput process comes from incorrect processing. Once hospital management determines the root cause they can implement further training, ensure compliance with existing standards, or eliminate other barriers. In this case the hospital might consider implementing a training program to ensure that ER staff is following best practices for patient discharge. The hospital might also conduct additional 5-Whys analyses to uncover other problem areas. Once root causes of waste are uncovered, the elimination of waste or other related action plans can be executed.Sources of wasteSources of waste vary greatly by industry. The majority of waste encountered by health care organizations occurs in flow and throughput. As a result, Lean implementations in this field are primarily focused on the elimination of waste in staffing and staff/patient processes. Unlike manufacturing industries most health care organizations have very little inventory. Thus, some of the Lean concepts related to inventory control are less applicable to health care. Health care organizations typically spend a larger percentage of operating expenses on overhead and labor costs. This can account for 50 percent of the operating costs while inventory is in the range of 2 percent (Caldwell, 2005). Understanding waste in throughput entails a comprehension of the relationships between process variables and costs. Costs are not causes of waste but are indicators of interrelationships between processes. While the ultimate goal of most Lean implementations is to recover costs as tangible benefits, eliminating costs without fully understanding processes is problematic. Looking at the types of cost recovery is essential to determining an action plan.Solution: Cost RecoveryThe ultimate goal of most Lean implementations is to attain a tangible benefit, often in the form of a cost recovery. However, not all process improvement opportunities will result in immediate returns. The actual realization of a benefit depends on the nature of the improvement as well as the additional steps that management takes to achieve it. Caldwell (2005) cites three types of cost recovery through the elimination of waste: Type 1, Type 2, and Type 3. In a Type 1 situation the process throughput improvement will yield a direct cost recovery. For example, a process improvement that reduces length of patient stay would recover costs in the form of reduced resources expended. In a Type 2 situation, the process improvement saves time but does not result in cost recovery without additional hours worked per unit of service. A provider may spend less time per patient because of reduced length of stay but scheduling will need to be adjusted in order to capitalize on the benefit to workflow. Lastly, Type 3 yields savings in the form of immediate optimization of capacity. In this situation a process improvement in an emergency room, for example, may allow a provider to see more patients in the same staffed time without additional action taken by management. This is similar to a Type 2 recovery but with no changes to scheduling. This can occur if the provider is willing to see more patients per unit of time and sufficient patient volume exists to achieve capacity. Maximum velocity is achieved without additional action needed to be carried out by management. These examples show that throughput improvement may not achieve an immediate benefit without other factors. It also brings to light the fact that throughput improvement may yield different benefits such as recovered costs, time saved, or increased revenues. Regardless of the actual benefit achieved and the way that it is realized, the ultimate outcome must increase bottom-line value and satisfaction to customers in some way.Examples of Lean implementation in HealthcareThe study of actual Lean implementations in health care is essential to understanding their application. One example of a successful implementation is outlined by Fairbanks (2007) at a medical center in Vermont. This implementation dramatically improved overall throughput processes within the organization. An implementation team was assembled and delved into all steps of the processes they were analyzing in order to determine the sources of waste. They utilized various Lean steps and methodologies to conduct root-cause analyses and prioritize process improvements. The team measured time involved, identified activities, and made rapid improvements through the elimination of non value-added activities. A large part of their improvements involved the elimination of redundancy. The topic of redundancy shows the importance of analyzing all processes, even those which are perceived to contribute to customer value. Even though a particular function may provide value in an organization it is possible that a redundant function may exist which can be eliminated. In another case example Lean methodology was used to streamline the physical space and inventory areas of a Denver-area hospital (Gabow, Albert, Kaufman, Wilson, & Eisert, 2008). The implementation team utilized the 5-S approach to organize physical work spaces within the hospital. 5-S is a Lean improvement which incorporates visualization management to organize objects and supplies. The five Ss stand for sort, set in order, shine, standardize, and sustain. These steps involve tasks ranging from simple clean-up and organization to the implementation of detailed visual controls. In a 5-S environment there is “a place for everything and everything in its place, when you need it (Lean Innovations, 2003).” The Denver hospital used this approach in a series of projects focusing on individual offices, nursing stations, entire laboratories, and financial services departments. These spaces were reorganized to achieve optimal work flow and good space management. The successful outcomes included reclaimed physical work space, improved lab turnaround time, reduced time in locating equipment, and better processes which could improve patient care (Gabow et al, 2008). The 5-s method is an excellent first step in implementing Lean programs in a health care organization. Improvement of physical work space can positively affect mindset and mental perception of work. Another case example of a successful 5-S implementation involves a rural health clinic in Georgia. Lean techniques were used in this organization to resolve problems with bottlenecks, turnaround times, customer satisfaction, and overworked nurses (Cross, 2009). 5-S is one of many Lean tools which can provide immediate benefit.ConclusionLean is a multifaceted approach to quality improvement which has tangible benefits to health care organizations. There are aspects which focus on reducing non value-added work and waste to achieve value in various ways. Successfully implementing Lean in health care depends on the setting involved and the motivation of management and teams. Health care encompasses a wide range of organizations and each has unique characteristics which must be considered in light of Lean processes. Important considerations in implementing lean in any environment can be reduced to a few key points: Understanding the concept of value Understanding waste and its sources Learning how to determine and analyze root causes Prioritizing multiple root causes Devising methods to eliminate waste Determining ways to recover costs or achieve benefits Analyzing effectiveness and repeating steps if necessary In addition, it is important to note that eliminating waste through a Lean process may not immediately result in tangible benefit. Management must thoroughly analyze action plans and make adjustments based on actual outcomes. Additional steps may need to be taken following initial process improvements. This is especially relevant in health care where process throughput improvement and staffing are areas which are commonly targeted. These areas may involve more challenges when trying to extract benefit. Freeing time for providers cannot always be capitalized upon without other capacity and throughput improvements. Scheduling or work flow functions may need to be overhauled in order for providers to increase overall process velocity and maximize value per unit for time. It is also crucial to realize that humans are not machines. Theoretical methods of quality improvement in Lean may not always be feasible to achieve at maximum levels. The Lean methodology developed by Toyota is very cognizant of respect for people. It is reflective of a collective culture and a holistic concept rather than a series of parts or steps. This is a fact which cannot be overlooked by management and teams when planning an implementation. People perform processes with normal human variation and improvements must be sensitive, appropriate, and sustainable.

First, let’s get a little historical perspective on American health care. To do that, let’s turn to the American civil war era. In that war, dated tactics and the carnage inflicted by modern weapons of the era combined to cause terrible results. Most of the deaths on both sides of that war were not the result of actual combat but to what happened after a battlefield wound was inflicted. To begin with, evacuation of the wounded moved at a snail’s pace in most instances causing severe delays in treatment of the wounded. Secondly, most wounds were subjected to wound related surgeries and amputations and this often resulted in massive infection. So you might survive a battle wound only to die at the hands of medical care providers whose good intentioned interventions were often quite lethal. High death tolls can also be ascribed to everyday sicknesses and diseases in a time when no antibiotics existed. In total something like 600,000 deaths occurred from all causes, over 2% of the U.S. population at the time!Let’s skip to the first half of the 20th century for some additional perspective and to bring us up to more modern times. After the civil war there were steady improvements in American medicine in both the understanding and treatment of certain diseases, new surgical techniques and in physician education and training. But for the most part the best that doctors could offer their patients was a “wait and see” approach. Medicine could handle bone fractures and perform risky surgeries and the like (now increasingly practiced in sterile surgical environments) but medicines were not yet available to handle serious illnesses. The majority of deaths remained the result of untreatable conditions such as tuberculosis, pneumonia, scarlet fever and measles and/or related complications. Doctors were increasingly aware of heart and vascular conditions, and cancer but they had almost nothing with which to treat these conditions.This very basic understanding of American medical history helps us to understand that until quite recently (around the 1950′s) we had virtually no technologies with which to treat serious or even minor ailments. Nothing to treat you with means that visits to the doctor if at all were relegated to emergencies so in that scenario costs were obviously minuscule. A second factor that has become a key driver of today’s health care costs is that medical treatments that were provided were paid for out-of-pocket. There was no health insurance and certainly not health insurance paid by someone else like an employer. Costs were the responsibility of the individual and perhaps a few charities that among other things supported charity hospitals for the poor and destitute.What does health care insurance have to do with health care costs? Its impact on health care costs is enormous. When health insurance for individuals and families emerged as a means for corporations to escape wage freezes and to attract and retain employees after World War II, almost overnight there was a great pool of money available for health care. Money, as a result of the availability of billions of dollars from health insurance pools, encouraged an innovative America to increase medical research efforts. As more and more Americans became insured not only through private, employer sponsored health insurance but through increased government funding that created Medicare, Medicaid and expanded veteran health care benefits, finding a cure for almost anything has become very lucrative. This is also the primary reason for the vast array of treatments we have available today. I do not wish to convey that this is a bad thing. Think of the tens of millions of lives that have been saved, extended and made more productive as a result. But with a funding source grown to its current magnitude (hundreds of billions of dollars annually) upward pressure on health care costs are inevitable. Doctor’s offer and most of us demand and get access to the latest available health care technology, pharmaceuticals and surgical interventions. So there is more health care to spend our money on and until very recently most of us were insured and the costs were largely covered by a third-party (government, employers). This is the “perfect storm” for higher and higher health care costs and by and large, the storm is intensifying.At this point, let’s turn to a key question. Is the current trajectory of U.S. health care spending sustainable? Can America maintain its world competitiveness when 16%, heading for 20% of our gross national product is being spent on health care? What are the other industrialized countries spending on health care and is it even close to these numbers? Add politics and an election year and the whole issue gets badly muddled and misrepresented.I believe that we need a revolutionary change in the way we think about health care, its availability, its costs and who pays for it. And if you think I am about to say we should arbitrarily and drastically reduce spending on health care you would be wrong. Here it is fellow citizens – health care spending needs to be preserved and protected for those who need it. And to free up these dollars those of us who don’t need it or can delay it or avoid it need to act. First, we need to convince our politicians that this country needs sustained public education with regard to the value of preventive health strategies. This should be a top priority and it has worked to reduce the number of U.S. smokers for example. If prevention were to take hold, it is reasonable to assume that those needing health care for the myriad of life style engendered chronic diseases would decrease dramatically. Millions of Americans are experiencing these diseases far earlier than in decades past and much of this is due to poor life style choices. This change alone would free up plenty of money to handle the health care costs of those in dire need of treatment, whether due to an acute emergency or chronic condition.Let’s go deeper on the first issue. Most of us refuse do something about implementing basic wellness strategies into our daily lives. We don’t exercise but we offer a lot of excuses. We don’t eat right but we offer a lot of excuses. We smoke and/or drink alcohol to excess and we offer a lot of excuses as to why we can’t do anything about it. We don’t take advantage of preventive health check-ups that look at blood pressure, cholesterol readings and body weight but we offer a lot of excuses. In short we neglect these things and the result is that we succumb much earlier than necessary to chronic diseases like heart problems, diabetes and high blood pressure. We wind up accessing doctors for these and more routine matters because “health care is there” and somehow we think we have no responsibility for reducing our demand on it.It is difficult for us to listen to these truths but easy to blame the sick. Maybe they should take better care of themselves! Well, that might be true or maybe they have a genetic condition and they have become among the unfortunate through absolutely no fault of their own. But the point is that you and I can implement personalized preventive disease measures as a way of dramatically improving health care access for others while reducing its costs. It is far better to be productive by doing something we can control then shifting the blame.There are a huge number of free web sites available that can steer us to a more healthful life style. “Google” “preventive health care strategies”, look up your local hospital’s web site and you will find more than enough help to get you started. Let’s go America – we can do this!