Applying Lean in an Academic
Medical Center
Lessons Learned
Eric Dickson MD
Professor of Emergency Medicine
University of Massachusetts Medical School
Sr Medical Director UMass Memorial Medical Group
1
International Comparison of Spending on Health, 1980–2007
Average spending on health
per capita ($US PPP*)
$8,000
$7,000
$6,000
United States
Netherlands
Germany
16
$7,290
OECD Mean**
10
$4,000
$2,000
14
16.0%
12
$5,000
$3,000
18
Total expenditures on health as
percent of GDP
$3,837
$3,588
8
6
4
$1,000
2
$0
0
80 82 84 86 88 90 92 94 96 98 00 02 04 06
19 19 19 19 19 19 19 19 19 19 20 20 20 20
10.4%
9.8%
United States
Germany
Netherlands
OECD Mean**
80 82 84 86 88 90 92 94 96 98 00 02 04 06
19 19 19 19 19 19 19 19 19 19 20 20 20 20
Courtesy of The Commonwealth Fund. Used with permission.
* PPP=Purchasing Power Parity. ** All 30 OECD countries except U.S.
Source: OECD Health Data 2009, Version 06/20/09.
2
LONG, HEALTHY & PRODUCTIVE LIVES
Mortality Amenable to Health Care
Mortality from causes considered amenable to health care is deaths before age 75
that are potentially preventable with timely and appropriate medical care
Deaths per 100,000 population*
International
variation, 1998
150
100
75
92
88 88 88
81 84
97 97 99
106 107 109 109
129 130 132
115 115
50
Fr
an
ce
Ja
pa
n
Sp
a
Sw in
ed
en
I
Au ta ly
st
ra
Ca l ia
na
N da
Ne or
th wa
y
er
la
nd
s
G
re
G ece
er
m
an
y
A
Ne
us
w
t
Ze ria
al
De an d
Un
n
ite m a
rk
d
St
at
es
Fi
nl
an
Un
ite Ire d
l
d
Ki and
ng
d
Po o m
rtu
ga
l
0
Courtesy of The Commonwealth Fund. Used with permission.
* Countries’ age-standardized death rates, ages 0–74; includes ischemic heart disease.
See Technical Appendix for list of conditions considered amenable to health care in the analysis.
Data: International estimates—World Health Organization, WHO mortality database (Nolte and McKee 2003);
State estimates—K. Hempstead, Rutgers University using Nolte and McKee methodology.
3
Mortality Amenable to Health Care
Deaths per 100,000 population*
1997/98
150
100
76
81
88
84
89
50
65
71
71
74
74
89
77
99
80
97
82
88
82
2002/03
109
97
84
84
106
90
130
116
115
93
96
134
128
115
113
101
103
103
104
110
Fr
an
ce
Ja
p
Au an
st
ra
lia
Sp
ai
n
Ita
Ca ly
na
d
No a
Ne
r
th way
er
la
nd
Sw s
ed
e
Gr n
ee
c
Au e
s
Ge tria
rm
an
y
F
Ne inl
an
w
Ze d
al
De and
Un
nm
ite
d
Ki ark
ng
do
m
Ire
la
Po nd
Un
r
ite tug
a
d
St l
at
es
0
Courtesy of The Commonwealth Fund. Used with permission.
* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.
Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health
Organization mortality files (Nolte and McKee 2008).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008.
4
Courtesy of The Commonwealth Fund. Used with permission.
S. C. Schoenbaum, C. Schoen, J. L. Nicholson, and J. C. Cantor, Mortality Anable to Health Care in the United States: The Roles of
Demographics and Health Systems Performance, Journal of Public Health Policy, published online Aug. 25, 2011.
5
THE
COMMONWEALTH
FUND
The US Healthcare System
What we pay for
What we get
Image; Flickr. thisisbossi. CC BY-NC-SA.
Image; Flickr. dave_7. CC BY.
6
Lesson 1
Focus on true North Metrics
7
TRUE NORTH METRICS
SAFETY/QUALITY
Preventable Mortality
Medication Errors
CUSTOMER
SATISFACTION
Access
Turnaround Time
Quality of Time
FINANCIAL
STEWARDSHIP
PEOPLE
OSHA Recordable Injuries
Operating Margin
HAT Scores
Employee Engagement Index
Productivity
Image by MIT OpenCourseWare. Based on Figure 13 from Toussaint, John and
Roger A. Gerard. On the Mend. Lean Enterprise Institute, 2010.
8
Slide Courtesy of John Toussaint
Access to Care
Patient Satisfaction
High Quality Care
High Quality Education
Clinical Innovation
Faculty and Staff
Satisfaction
Faculty
Productivity
9
Net Income
to Plan
Lesson 2
Find your Potato Head
TRAUMA CENTER
10
Lesson 3
Find some clear (safe) examples
of waste in your organization and
highlight them.
11
12
12
13
Lesson 4
Find some “bright spots” in your
organization and highlight them.
14
Lean Processes that Typically Exist
in Hospitals
•
•
•
•
•
•
Trauma Activations
Code STEMI
Code Stroke
Central Line Bundle
WHO Surgical Checklist
Integrated Care Pathways
15
Lesson 5
Reducing Waste Improves Staff
and Patient Satisfaction
16
Ethically
Obligated to
Eliminate
Maximize
Revenue
Producing
Non-value
Added
Value
Added
Necessary
Non-value
Added
Pure Waste
Eliminate
Minimize
17
Lesson 6
Create an experimental system.
18
Lesson 7
Go and see for yourself what the problem
is for problems can only be solved where
they exist.
Genchi Genbutsu
19
Lesson 8
Inflexibility is the greatest barrier to
successfully applying Lean in health care
and it is best overcome by Genchi
Genbutsu
20
Lesson 9
Standardization must occur before
you can have innovation and
improvement
21
“It is impossible to improve any process until it is
standardized. If the process is shifting from here
to there than any improvement will just be one
more variation that is occasionally used and
mostly ignored. One must standardize the
process before improvements can be made.”
Masaaki Imai
22
The first step in improving the treatment of any
disease is standardizing its care. If the treatment
of an acute or chronic condition within our system
is variable, any effort at improvement will just be
one more variation that is occasionally used and
mostly ignored. We must standardize our care
using evidence- or consensus-based pathways
before we can improve it using discovery and
innovation.
Based on work by Masaaki Imai in the book Kaizen
23
Lesson 10
Front line staff suggestions are
always better and more
acceptable that mangers solutions
24
QS x AS = likelihood of success
25
Why Lean?
Systems
Thinking
Theory of
Knowledge
Psychology
Understanding
Variation
Image by MIT OpenCourseWare.
26
Lesson 11
When working with physicians always
focus on using Lean to reduce
physician muda and increasing
physician productivity
27
Lean has improved physician
productivity by > 50%
WORK RVU PER CLINICAL HOUR
5.87
4.00
6.42
4.66
FY 05-06
YTD 08-09
FY 06-07
FY 07-08
28
MIT OpenCourseWare
http://ocw.mit.edu
16.660J / ESD.62J / 16.853 Introduction to Lean Six Sigma Methods
IAP 2012
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