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Lean - a Care Plan Approach to Focusing on the Impact in Healthcare

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LEAN: A Care Plan Approach to Focusing on the Impact in Healthcare

Sheryl M. Gore

East Carolina University

22 April 2011


LEAN is making a global impact in healthcare today. Healthcare costs are on the rise, patient's injuries and even deaths occur due to preventable errors, and hospital employees, nurses, and physicians are exhausted and frustrated with current processes that are broken. To adapt to declining reimbursements, hospitals and healthcare organizations have focused on enhancing both operational and clinical improvements. LEAN Six Sigma methods use different but standard tools to solve problems, correct processes and reach desired improvements. It looks at the details of the process, utilizes the employees who do the work to fix the processes, and this approach occurs where the work is actually done. This paper will use Sister Callista Roy's Adaptation Model to conceptualize the LEAN processes. We will take a deep dive into defining the attributes, antecedents, and consequences of LEANs impact on healthcare. Ultimately we will summarize that the literature reviewed demonstrates the positive impact LEAN is having on cost-effectiveness, quality of care, and employee and patient satisfaction of using LEAN tools and methodologies. LEAN tools are guiding hospitals to improve their current processes and have a significant role in the future of healthcare.

Definition and Attributes of Lean Impact in Healthcare

Walker and Avant (2005, p. 41) identify attributes as clusters of behaviors that are frequently associated with the concept, which helps differentiate the concept from others similar or related to it. Before we discuss the attributes of LEAN we must first know what the definition of LEAN is. LEAN is a system or method that uses a toolset for continuous improvement, employee engagement, and an approach of solving or improving processes that are broken. LEAN focuses on identifying and removing waste. George Koenigsaecker views the waste as "not just a list but a starting point to change the way you view waste" (2009, p. 11).

8 WASTES in Healthcare

Defects Mistakes and errors

Overproduction Working ahead

Waiting Idle time for patient, employee, or process

Non-value added processing Effort which adds no value to a service

Transportation Patients, paperwork, or equipment

Inventory Excess supplies or equipment

Motion Unnecessary movement of people

Employees Underutilization of staff

Toyota's Taiichi Ohno was a primary creator of LEAN methods. He wrote, "All we are doing is looking at the timeline from the moment a customer gives us an order to the point when we

collect the cash. And we are reducing that timeline by removing the non-value-added wastes" (Graban, 2009, p.19). One way of looking at value-added versus non-value-added is by asking two questions: "If a customer saw me doing this step, would he or she be willing to pay for it?" and "If I did this step twice, would the customer pay me twice as much?" (Koenigsaecker, 2009, p. 11). Delivering value to the patient or customer is an attribute that hospitals must utilize. Value in LEAN thinking is defined as "the capability to deliver exactly the product or service a customer wants with minimal time between the moment the customer asks for the product or service and the actual delivery at an appropriate price" (Joosten, Bongers, Janssen, 2009, p. 342). If the patient or customer is waiting too long for results or to see the physician or has answered the same questions three times during the same visit, it is viewed as non-value-added. LEAN adopts the old saying of "work smarter not harder." Lastly, LEAN is defined as a problem identifying and problem solving system. This requires resolving the problem at the root cause level. According to Graban, to be most effective, the standard work forms should be written by the people who do the work because the employees know the work best and will be more accurate and effective in documentation (2009, p. 79). Employees who know the processes will make it easy to do things right and hard to do things wrong. Recognizing the value and skill of the employee is an attribute that is essential in the implementation of the LEAN process flow.

Antecedents of LEAN Impact in Healthcare

Walker and Avant define antecedents as "those events that must occur prior to the occurrence of the concept" (2005, p. 73). Antecedents of LEAN impact in healthcare include employee engagement/involvement, willingness to change and sustain change, and support from senior/upper level management.

Employee engagement and involvement are a critical antecedent in the transformation process. According to Jo Beale, who conducted research on employee's motivation to adopt LEAN behaviors, he found that the employee's motivation to adopt was directly linked to attitudes, perceptions of one's ability, and the perceived social pressures to adapt. Other distal antecedents were job satisfaction, organizational commitment and organizational level (2007, p. 21). LEAN processes involve changes from current processes to a new target state. If employees do not see the value of change or understand why the change is necessary, they are more likely to not engage in the process. "Through carefully designed communication and training programs, organizations should be able to manage to some extent, employee motivation for LEAN" (Beale, 2007, p.22).

A willingness to change and sustain the changes of the LEAN process is also a crucial antecedent. Once the employees are engaged and involved, the flow mapping process begins starting with the current state and progressing to the target state. True culture change happens when staff and management consistently experience and participate in a work environment where the goal is to problem solve. John Kenagy, MD (2009, p. 113) discusses the seven cultural barriers to sustainable improvement:

1. Workarounds: Eliminate workaround behaviors by solving "trivial problems."

2. Fear of Failure: Decrease



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