Case Study: Lean Management

According to the U.S. Department of Health and Human Services, national health expenditures in 2006 were $2.1 trillion, or more than 16 percent of the Gross Domestic Product. This healthcare crisis has put pressure on medical organizations to improve patient care and cost efficiency, a challenge that might seem as likely as raising both ends of a seesaw.

ThedaCare, a community health system located in Appleton, in northeastern Wisconsin, has met that challenge and showed that improving patient outcomes and reducing costs not only can be done, but can complement each other.

Comprised of four hospitals and nearly 5,300 employees, ThedaCare is the third largest healthcare employer in Wisconsin. Its recent purchase of the CyberKnife® system for its radiation oncology department was the initial spark igniting a wave of transformation across the health system.

Sunnyvale, Calif.-based Accuray Inc.’s CyberKnife allows radiology oncologists to treat tumors, anywhere in the body, noninvasively with sub-millimeter accuracy – a valuable addition to any radiation oncology department.

Kim Barnas, vice president of the radiation oncology department, wanted to ensure she capitalized on her investment by maximizing the number of patients who could be treated and efficiently maximizing her staff’s time.

“We began this journey five years ago when our CEO recognized that the value proposition in healthcare is improving quality while reducing cost,” says Barnas. “Quality improvement used to be thought of as expensive, but what we were finding was that by improving quality, we were actually reducing costs.”

ThedaCare then teamed up with Simpler Healthcare (www.simplerhealthcare.com), a global consulting firm with offices in Ottumwa, Iowa, to coach hospital staff on the application of lean management skills in order to relieve overburdened employees, improve patient care, and save money on the bottom line.

Implementation of the lean management program has allowed ThedaCare to identify waste and inefficiencies throughout their organization, eliminate them, save money, use their staff’s time effectively and efficiently, and improve patient care. 

“The cost-benefit is secondary to the improved quality and the improved patient experience. It comes with it, but you shouldn’t go into it with the intention of reducing cost; you should go into it with the intention of improving processes and improving quality,” Barnas says.

ThedaCare’s radiology department has increased gross revenue by 20 percent over 2007 alone and decreased patient waiting time from first consult to first treatment from a baseline of 23 days to 8 days – wasted time that was a primary target of the lean management strategy. These are just two of many gains that emerged from the lean strategy.

Specifics of Lean Management

“Lean management is an approach that enables the true performance potential of a business or process to be realized. In practice, lean management achieves this through the applications of various tools that help employees see and eliminate waste. The principles originated from Toyota,” says Michael Chamberlain, senior vice president and general manager of Simpler HealthcareSM, Simpler North America.

Simpler Healthcare developed a powerful and systematic approach, called the Simpler Business System®, that helps healthcare organizations achieve strategic advantage through improvement across the enterprise. The Simpler Business System methodology is a derivative of the Toyota production system and has been used in multiple industries, including healthcare.

According to Chamberlain, eight common forms of waste exist in healthcare, just as they exist in every other industry. “While each of the wastes is very common, unused human potential seems to be the one that organizations can most easily relate,” says Chamberlain.

Furthermore, Chamberlain says, “If we define the customer to be the patient, and we define value as how we treat patients, then having physicians and clinicians do anything but that, does not fully utilize their talents.”

The eight common forms of waste that Chamberlain is referring to are:

Implementation of Lean Management

The No. 1 waste that ThedaCare’s radiation oncology department identified was patient waiting time. The process from referral to treatment often took several days. “Every day that they lose time before treatment, we consider that wasted time,” says Barnas.

Editha Krueger, MD, a radiology oncologist at ThedaCare, stresses how critical time is for their patients. “For our cancer patients, time is of the essence. We need to begin treatment fast, not only for cancers that are rapidly growing,” she says.

“But also, psychologically, there is definitely a need for patients to start their treatments quickly so that they feel that at least things are being handled in a timely manner.” Any time a physician or a nurse is not with the patient is not considered value-added time, so ThedaCare and Simpler Healthcare evaluated the process to identify areas they could improve and cut waste.

There are four fundamental steps of the implementation process, which, Barnas explains, begins with a value stream. ThedaCare is on the third round of a value stream. A department’s value stream is a mapping of all processes provided in a service line.

ThedaCare’s radiation oncology department chose to improve the process between when a patient has their first consultation and the start of cancer treatment. According to Barnas, the value stream should include all staff, from all disciplines, that participate in the management of patients with cancer.

It should also include several cancer patients, as they are a critical part of the team. Although patients may not understand the process, they can point out what they thought went well, and what they thought didn’t go well – where the value is, and where it’s not.

“The first time we went through [the value stream] was an incredibly eye-opening experience, because nobody wants to believe that their work isn’t value-added,” says Barnas.

“When patients point out aspects of the process they care and don’t care about, you realize that there is a significant amount of waste. Eighty percent of your process is considered not value-added, and that was hard for the staff to hear.”

Barnas explains that they set forth three metrics: a business, quality, and employee metric. Once the value stream is established, the second step is to develop an action plan from that value stream that will help improve the established metrics.

 “You get a team together, you spend a few hours writing the work, and you start piloting it,” says Barnas. “The third step is to just do it. You experiment, you play with it, and you pull the team back together and rework the process before you fully implement it.”

Once a stable process is developed, the fourth step is daily continuous improvement. Staff members should evaluate processes on a day-to-day basis, noticing the sometimes small aspects that can be corrected. The goal is to continue to do this year after year.

Small Adjustments Make a Big Difference

According to Krueger and Barnas, changes to streamline the patient management process are not always obvious. Often, small things add up to significant increases in value-added time.

“One of the simple tools that [the lean system] uses is someone walking around with a measuring tool to see how far you walk from one place to the next to see if the distance can be reduced,” says Krueger. “It’s easy to be a cynic to such a small improvement, but you have to get over that initial reaction, because in the end, you can’t argue with data.”

Krueger’s schedule, for example, also had to change, and she admits there is nothing harder than changing a physician’s schedule. “But it’s really helped me be more efficient and get my work done in a timely fashion,” Krueger adds.

Instead of having Krueger determine and delineate tumor volumes at the end of the day after doing clinic work, time was blocked out early in the day. Making that small adjustment enabled dosimetrists to complete their work during that same day, instead of waiting until the following day.

“That was waste that is now eliminated after a scheduling event,” says Krueger. “I’m getting my work done in a fashion that’s fast for who is doing the work afterward – the hand-off goes a lot smoother.” Rapid improvement of events around pieces of the process also eliminated waste in waiting time.

The radiation oncology department was able to eliminate several wasted days in a patient’s referral to treatment process.

“We brought the whole team together (e.g., physicist, the nurses, the dosimetrist, the stimulator therapist, and the physicians), and we now block our schedules in ways so that, when that patient comes in for a consult, we know what their potential diagnosis is going to be, and we plan for them to go through the simulation and any MR images they might possibly need the same day,” says Barnas.

“And before they leave, the physician looks at those images to make sure that they are accurate and that we’ve got the right views,” Barnas continues. “So when they leave that day, we’ve got all the information we need to make a plan. We condensed the process from one week to one day.”

The goal for the quality metric was to increase flow time from referral to treatment by 37 percent, and it is currently reduced by 50 percent from last year, moving from a baseline of 23 days to eight days from first consult to first treatment.

Results Speak Louder Than Words

According to Krueger, physicians tend to be “naysayers” when it comes to critiquing their work performance. “We’re used to being the quarterback, if you want to use an analogy, and running the whole the game,” Krueger says. “It really requires you to stand back and really look at what we do, critique it, and see where there is waste.”

One of the biggest challenges for physicians is accepting change. It’s impossible to argue with numbers reflecting the improvements in a process that eliminates the waste, betters patient care, and financially benefits the organization.

“One of the things that we haven’t done very well in hospitals before is to speak to our physician partners with data,” says Barnas. “Physicians respond well when you can show them the data rather than my administrative gut intuition.”

A tracking center in the hallway and regular discussions demonstrating improvement on a week-to-week, month-to-month, basis – real data, not anecdotes – speaks louder than words and should spur more staff to actively participate. Employee measure is how many people are using the lean tools to solve problems.

Last year, 14 percent of the radiation oncology team was using the tools, and this year 87 percent are using the lean tools to solve problems daily.

“ThedaCare is an excellent example of how hospitals can see a powerful transformation if they teach their staff to see and eliminate waste in everything they do. Most organizations think reducing costs means reducing patient care,” says Chamberlain.

“ThedaCare’s experience proves this is not the case,” says Chamberlain. “In today’s tough economic climate, this is more important than ever, not just for healthcare organizations, but also for the patients and communities they serve.”

Because ThedaCare streamlined its process, it was able to maximize the number of patients who could be treated, as well as free up and redeploy staff to work with patients who were being treated with the CyberKnife, a $3-million investment that is now more lucrative and can improve overall patient treatment.

“It’s hard to be inspired after many years of medicine. But when you see real changes happening in a system that affects your patients in a very positive way, it increases job satisfaction,” says Krueger.

— Janine Anthes is a New Jersey-based freelance writer. Direct all questions and comments to editorial@rt-image.com.