Lean and Waste at Hospitals

Porter (2010, p. 2) states that “value should define the framework for performance in healthcare”. However, many hospitals struggle to both identify and measure the values of their patients along with value-adding activities. To cope with this, the organization can conduct VSM. VSM is a popular tool in Lean healthcare, and its focus is to eliminate all non-value-adding activities and waste from a given process (Daultani et al., 2015; Rother & Shook, 2003). VSM can reveal waste that originates from poor organization of the workplace and even the facility layout (Nicholas, 2012). Examples here might be nurses wasting their valuable patient-time looking for supplies or simply walking great distances between patients and the nursing station. The reason for these revelations is that VSM show both time and resources spent in each activity. Examples are: waiting between the steps, the size of the inventory, performance of cycle time per activity and also the change-over time between the various activities (Kovacevic, Jovicic, Djapan, &

Zivanovic-Macuzic, 2016). Consequently, VSM is used to get an understanding of the as-is situation before designing a future state for the flow of both materials and information that would bring service to a patient (Khorasani et al., 2017; Leite

& Vieira, 2015).

2.3.5 Lean and Waste at Hospitals

Hospitals have tried to reduce costs for a long time, but costs keep rising (Kaplan

& Porter, 2011; Porter & Kramer, 2019). The Lean concept brings hospitals to focus more on reducing waste than cutting costs (Graban, 2011). Reducing waste can often provide more value to the patients through providing improved service and quality, with less effort and costs. The presence of waste is not an indication of employees not working hard, rather waste causes employees to work too hard combating the issues that interrupt the value-adding activities. Waste is often driven by the (lack of proper) design and the system itself (Graban, 2011). Ohno (1988) proposed that there are in particular seven types of waste and his list of waste has later been customized to a hospital setting (Graban, 2011; Khorasani et al., 2017; Nicholas, 2012; Noori, 2015a; Platchek & Kim, 2012), displayed in the table below:

Waste category

Brief description Example(s) from a hospital setting

Overproduction Producing greater, faster or sooner than required

Requesting unnecessary test, e.g. MRI

Waiting Patients and information idle time

Waiting for a page to be returned, diagnosis process, exam delay, discharge patients delay, the length of stay, patient waiting for doctor

Transportation Unnecessary movement of the product in the system (patient, specimens, materials)

Poor layout, excess travel distance e.g. lab located far away from the department

Overprocessing Doing work that is not valued by the patient

Lack of basic equipment in each room, nurse walking to several rooms searching for supplies e.g. manual blood pressure cuff Inventory Excess inventory cost through

financial costs, storage and ideas for improvement but not given the opportunity to act on those unreliable treatment and constant interruptions (Hallam & Contreras, 2018). Dart (2011) pointed at the importance of waste reduction as patients are infuriated by waste because it forces them to endure boring, tedious and bureaucratic processes that do not add value to their health problem.

Non-value-adding activities are typically viewed as “a part of the way we work around here”. Thus, understanding waste is critical for improvement because it adds costs but not value (Simon & Canacari, 2012). Further, building awareness regarding which activities that actually are waste can be motivating. The employees often struggle with these activities daily, but rarely have the ability to change them. The motivation can be further increased when it is emphasized that

Additionally, it is more cost-effective and sustainable to reduce waste and redesign workflows, than to work more and harder (Graban, 2011). Thus, instead of increasing employee count to overcome an overworked hospital, reduction in waste is the more favorable solution. Bicheno and Holweg (2009) emphasize in their book that everyone in an organization, from the chairman to the cleaners should wear the “muda spectacles” at all times in order to improve efficiency.

In terms of our research question, motion and inventory appear to be the two waste categories that could have most impact to an efficient material flow and product availability. Thus, these two types are elaborated. Not all inventory is inherently wasteful, but excessive inventory is waste (Graban, 2011).

Overstocking lead to hospital cash being tied up in the inventory, and possibly expiration of supplies and medication. Despite that too much inventory waste space and cash, stockouts can result in harm to patients (Grunden & Hagood, 2012). Further, inventory shortages may lead to additional wasted motion and costs as employees might have to place expensive orders to vendors or take unplanned trips to stockrooms (possibly located far away from the patient room).

The balance is delicate, but improved inventory management can help reduce this waste. One important factor to include in inventory management is the suppliers’

lead time, as this often is a root cause of holding inventory (Wild, 2018). Under the Lean philosophy, keeping the right supplies and inventory available will facilitate delivery of quality patient care, while reducing hospital costs and waste (Torabi, Pour, & Shamsi, 2018). Kanban is a tool which aims to control material flow in a SC, and is frequently used under Lean, (Ohno, 1988; Torabi et al., 2018).

The Kanban method allows the organization to quantify an optimal reorder point for suppliers (Graban, 2011). It entails that when a stockroom is low on a specific item, a signal is sent by e.g. an empty bin or a message sent by a barcode scanner (Torabi et al., 2018; Trent, 2008). The method can be used to pull materials from a central internal warehouse to POU location (Graban, 2011). Graban (2011) further states that Kanban minimizes stockouts along with preventing an accumulation of excess inventory. This is supported in a study by Aguilar-Escobar et al. (2015) who found that changing to a Kanban system contributed to reduced time spent by nurses on logistics activities. In addition, the results of the study conducted by Khorasani et al. (2017) demonstrated that waste in a

healthcare SC can be reduced from 17% to 5% by utilizing the EOQ model together with a Kanban system. EOQ is an inventory-oriented model used to calculate optimal order quantity at minimum costs where ordering costs and holding costs are central (Chopra & Meindl, 2016). Although the effect of improving the quantity of orders was more significant than using Kanban, the improvement achieved through the latter was meaningful. Therefore, Khorasani et al. (2017) suggest that investing in Kanban in HSCs can yield significant improvements in waste, and ultimately reduction in costs.

A workday at a hospital ward is full of interruptions, wasted motions, and workarounds (Graban, 2011). The waste of motion refers to the movements required by employees to get their work done. The most obvious wasted motion in a hospital setting is unnecessary walking. A study conducted in the US, covering 36 hospitals, found that the nurses spent under 20% of their time at work on patient care, and that average walking distances per dayshift was 3 miles (Hendrich, Chow, Skierczynski, & Lu, 2008). More recent studies found that the major driver of nurses wasting time on other activities than direct patient care was looking for and restocking supplies (Jackson Healthcare, 2013; Nabelsi &

Gagnon, 2017; Simon & Canacari, 2012). Toussaint and Berry (2013) refers to a study where one of the findings show that nurses were spending 38 minutes per shift on average looking for needed equipment. Relieving nurses from this non-patient care related activity, searching for supplies, will free up more time for the employees to conduct value-adding activities, particularly more and better patient care (Volland et al., 2017).

Hospital employees often think their job is their ability to deal with problems, for instance when supplies are missing, hospital staff will run to find them. Further, if the workspace is poorly designed, the distances to get supplies can be quite far.

According to Nabelsi and Gagnon (2017) this issue is more present at the larger hospitals, were nurses report that they have to look for medical supplies outside their ward, often across several floors and often without success. However, these extra efforts put in by the nurses will not prevent the same situation from re-occurring. Yet, improving the workflows, in particular the layout of the departments and the organization of supplies and equipment, can reduce these walking distances (Graban, 2011; Hicks et al., 2015). Consequently, when the

waste, instead of just asking for more resources and people (Graban, 2011).

Investigating improvements that may be achieved through a good facility design should be a priority.

5S standardization is a tool that can be applied in the work of organizing supplies to reduce waste of inventory and motion. 5S involves sort, set in order, shine, standardize and sustain (Cohen, 2018; Graban, 2011; Nicholas, 2012). Leite and Vieira (2015) emphasize that especially in the service sector with frequent movement of people and materials, 5S can help ensure process stability. Torabi et al. (2018) claim that as time is an increasingly sensitive factor, the necessity of performing 5S increases. By 5S, preferably combined with VSM, supplies can be sorted by need and accessibility (Nicholas, 2012). High volume-items are located close at hand while low-volume items are less accessible and zero-volume items are removed. When the stockrooms additionally are set in order and shined this can results in large benefits. Nicholas (2012) claims that the time spent looking for supplies can be reduced by 50-80%, which frees up more bedside time with the patient. Further, Torabi et al. (2018) found that an organized stockroom with closets and labeled equipment located correctly reduces mistakes associated with not finding the appropriate equipment at the required time.