From the Venetian Arsenal to
Henry Ford to Taiichi Ohno:
Putting a Global Perspective on
Healthcare Process Improvement
Keith A. Willoughby, Ph.D.
Hanlon Scholar in International Business
Edwards School of Business
One-slide bio
Born and raised in Canada
B.Comm. – University of Saskatchewan (U of S)
M.Sc. - UBC
Transportation analyst, BC Transit
Ph.D. - University of Calgary
Professor, U of S, 1997-1999
Professor, Bucknell University (Lewisburg, PA), 1999-2005
Senior Operations Research Specialist, Saskatchewan Health
Quality Council, 2005-2008
Professor, U of S, 2008-present
Purpose (long version)
Discuss the application of process improvement
methods and principles (known as “Lean”) to
investigate, analyze and improve health care
systems
Demonstrate the global nature of health care
process improvement
Purpose (medium version)
Lean methods are advantageous and
valuable
Hospital systems have boatloads of
inefficient processes
Can we connect the two?
Purpose (short version)
To make common sense common practice
Presentation overview
1. Historical background
2. Overview of Lean process improvement
3. Description of Lean tools
4. Case study
Words of warning
I am not a clinician… but I will be talking
about the delivery of health care
I am not an historian… but I will be
discussing global history
I am a “process engineer”
Is this “international” research?
Health care is
perhaps the most
international of all our
industries
Is this material relevant?
In various
circumstances and
situations, the
delivery of health care
affects each and
everyone of us
Some sobering statistics...
Total Canadian health care expenditure
per capita
4,500
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
0
Total Canadian health care expenditure
(% of GDP)
12.0
10.0
8.0
6.0
4.0
2.0
0.0
Total expenditure per capita (US$)
United States
Norway
Canada
Belgium
Austria
Germany
France
Sweden
United Kingdom
Finland
New Zealand
Korea
Czech Republic
Mexico
Turkey
0 1000 2000 3000 4000 5000 6000 7000 8000
How can we improve the situation?
Rewind to 2005…
Application of Lean principles
in health care
Two years later
2007: UK hosted the First Global Lean
Healthcare summit
What is “Lean”?
A set of quality improvement tools and
philosophy designed to eliminate the sources of
waste in a system
“The least wasteful way to provide better, safer
healthcare to patients – with no delays”
– Going Lean in the NHS (2007)
Why did they call it “Lean”?
Jim Womack (1990)
5-year, $5 million study of
global vehicle production
– International Motor Vehicle
Program
Co-authored “The Machine
That Changed the World”
with Dan Jones and Dan
Roos
18
Japan’s contribution
Taiichi Ohno (1912-1990)
1950’s: Toyota Production
System
– Continuous Flow Production
– Just-in-Time (JIT)
– Eliminate defects
– Top management commitment
– Employee participation
1969: Established the Operations
Management Consulting Group
– “Trainers” commissioned to
promote Lean thinking within
Toyota and the firms in its supplier
group
19
Earlier contributions
Henry Ford, 1920s
Continuous Flow Assembly
Reduce wasted time
– 1913-1914: doubled
production with no
increase in workforce
– 1920-1926: Cycle time
dropped from 21 days to
2 days
20
But this was all based upon…
The Venetian arsenal
Republic of Venice, early
16th century
Could produce nearly one
ship each day
– Standardized parts
– Production-line basis
The 8 sources of waste
Correction (defects) Waiting
Overproduction Inventory
Motion Overprocessing
Material movement Underutilized human talent
(transportation)
Correction or Defects
Overproduction
Motion
Waiting
Waiting
Ever feel like you’ve been waiting too long?
Excess inventory
Overprocessing
How do production methods apply
to Healthcare?
Healthcare has several “production” processes
Manufactured products and health care services involve the
concepts of quality, safety, customer satisfaction, staff
satisfaction and cost effectiveness
The completion of a product involves thousands of processes-
many of them very complex.
Many products, if they fail, can cause fatality
Two Lean tools
Poka-yokes
– Fail-safe measures
5S
– Order, organization, visual display
Vehicles
Gas cap tether does
not allow the motorist
to drive off without the
cap
Arrow to indicate
location of fuel tanks
(driver/ passenger
side)
– Great for rental
vehicles
Poka-yokes in London streets
Tourists used to
right-hand side
driving
Instructions are
printed right on the
asphalt
At the airport
If your bag fits
in the size-wise
unit it will fit in
the overhead
compartment
Here’s one from my old neck of the
woods!
Route 220 in
central
Pennsylvania
In theory… helps
motorists to drive
safely
Is it followed?
Sandwich trays
Preventing
customers from
discarding the
tray means
making the trash
can opening
smaller than the
tray
In the kitchen
This stove burner
turns off
automatically
when a pot or
pan is removed
Poka yokes in health care
Medical gas outlets
are designed so
that the proper
valves will only fit in
their corresponding
outlets.
The philosophy of 5S
“5S” stands for 5 Japanese words each
beginning with the letter “S”
English translation:
– Sort, Set, Shine, Standardize, Sustain
5S in practice
A system for making
the abnormal look
visually obvious
More 5S
Inventory organization
from a Saskatchewan
health care unit
Case study
Applying Lean methods and principles in
Emergency department patient flow
Background
Saskatoon Star-Phoenix (Jan. 12, 2002)
And some more
Saskatoon Star-Phoenix (April 17, 2003)
It’s a political issue
Regina Leader-Post
(June 10, 2004)
Data collection
City Royal St. Pasqua General
Hospital University Paul’s
Total 217 536 324 324 327
patients
observed
A walk through the Emergency
Department…
Triage Initial
+ + ED Occupancy time
time Wait
time
What did the data tell us?
400
350
300
Time (minutes)
250
200 ED occupancy time
Initial wait time
150
Triage time
100
50
0
H
al
PH
a
H
U
qu
er
C
R
S
S
en
as
G
P
Improvement efforts
Selected physician reassessment wait
times at Saskatoon’s Royal University
Hospital (RUH)
Saskatoon improvement project
Collaborated with RUH Quality
Improvement (QI) teams
Used Model for Improvement and Plan-
Do-Study-Act (PDSA) cycles
PDSA cycles
Small tests of change, with multiple attempts of each idea
1. Create colour-code for responsible ED physician for each patient
2. Create visual cue on white board indicating patient is ready for
reassessment
3. Create “Think Reassessment” worksheets to help ED RNs know
the appropriate time to ask MD to reassess
– Development of standard processes
Physician Reassessment
Wait Times
100
80 Day 1 Day 2 Day 3
Time (minutes)
60
40
20
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Wait times 42 19 42 44 54 48 58 23 50 38 43 59 5 5 3 2 4 10 48 3 7 20 0 5 0 15 30 15 5 30
Median 43 43 43 43 43 43 43 43 43 43 43 43 43 43 43 43 43 43 43 43 43 43 43 43 43 43 43 43 43 43
Achieving process improvement
Much more difficult than the previous slide
makes it appear
Admittedly, we struggled to carry out 3
days of PDSA cycles
Tale from the front
Saskatoon teams
were repeatedly
pulled back from
QI duties due to
busy conditions
in the ED
Conclusions
Patients who visit EDs spend a significant amount of time waiting
(50% of visit)
For some high-level processes, wait times are substantially longer
than service times
Lengthy wait times:
– Bed ready, consultations, physician reassessment
QI teams can generate improvements with minimal materials cost
Impediments
Staff turnover
QI teams pulled back into regular care duties
Impediments
Data gathering takes time and costs
money
Every one in the care team needs to be
involved
Lessons learned: #1
All seem to acknowledge the value of
Lean tools
Lessons learned: #2
How do you create/facilitate a culture that
can accept/adopt/implement such
improvement methods?
Lessons learned: #3
Listen to the voice of the patient… but be
prepared to act on their voice!
Lessons learned: #4
The wording is important
Is “Lean” the best term?
UK has recently begun an initiative called
“Releasing Time to Care”
Lessons learned: #5
Top-down + Bottom-up = Success
One final word
“Improving the ED is like
trying to change your fan
belt with the engine
running”
Dr. Les Vertesi, Associate
Director of Health
Research (Fraser Health
Authority, British Columbia)
There are no quick fixes
Thank you for your time
Questions?