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An integrated model of LEAN production concepts, practices, and climate as a tool for improving efficiency and effectiveness in hospitals and R&D units

Final Report Summary - LEAN (An integrated model of LEAN production concepts, practices, and climate as a tool for improving efficiency and effectiveness in hospitals and R&D units)

Project Summary
In order to survive, organizations need to keep high efficiency and effectiveness by targeting the right quantity, at the right quality, at the right time, and in the right place. Lean production seeks to identify and eliminate wasted time, effort, and resources, leaving only streamlined processes that add value at every step. For example, by reducing protective buffer inventories, and improving the organizations’ capacity to ameliorate the potential damaging effects of variability in supply, processing time, or demand. Lean production has been implemented in many industries and has been proved highly successful in improving organizational processes, efficiency, and effectiveness (Shah, & Ward, 2007). Recently, Lean has been implemented in two unique contexts; hospitals and Research and Developments departments. Both contexts are characterized by the need to balance on the one side innovation and creativity, while on the other side, the need to standardize processes to keep high efficiency and effectiveness.
Hospitals have started to implement Lean practices in order to improve their efficiency and quality of care. However, there are mixed results regarding their success to improve processes and in some cases, there are even reports of negative effects such as higher costs and more treatment errors (Katz-Navon, Naveh, & Stern, 2007). In the context of research and development (R&D) departments, there is a reluctance from implementation of Lean practices that standardize and minimize variation because of the need to innovate and be creative.

Our team aimed to develop a better understanding of Lean implementation in hospitals and R&D units, and specifically, identify conditions that explain why and how Lean would have a positive effect on hospital and R&D units’ efficiency, quality, and potential for innovation. Improving efficiency and quality in the Lean way have the potential to save healthcare and R&D costs.

The research team included four groups with different expertise; Operations Management (The Technion and MIT groups), Error Management (The Leuphana University group), and Organizational Behaviour (The IDC group). The team exchanged senior researchers and Ph.d students and transferred knowledge among the four research centres. We collected data on quality evaluation frameworks in the health systems and R&D units in Israel and USA to assess (i) the common assessment criteria, (ii) specific criteria and models we wished to sustain in our evaluation framework, (iii) success factors and documented outcomes (e.g. auto-assessment by physicians and R&D engineers, success and failure cases). Specifically, methods were assessed based on their ability to lead to decisions balancing cost-efficiency, patient satisfaction, quality of care, and innovation. As a result, we created a unique and innovative data set that characterised the current state-of-the-art of Lean models employed. Based on that we analysed the efficiency of the Lean models and methods and defined the specific objectives for the following development stages, in terms of Lean, health, and R&D indicators, measurements and evaluation criteria.

Specifically, in the hospital context we explored the example of chest pain and emergency departments (ED). Emergency departments provide an excellent context for both theory building and empirical testing of Lean since both Lean and EDs emphasize the continuous flow of processes. Thus, concentrating on EDs is a natural focus for Lean research. Five million people with chest pain are examined in American emergency departments every year. The percentage of incorrectly discharged chest pain patient from EDs is estimated to be between 3.5% and 6%, and even 11% in some medical centres. On the other hand, the problem of unnecessary hospital admissions is also an issue of economic concern. Thus, chest pain is a worrying source of potential grave medical errors as well as high costs. Heart disease is the leading cause of mortality in western countries, with more than 710,000 people dying annually from the disease in the USA alone. One symptom of heart disease, specifically the onset of a myocardial infarction, is chest pain. Generally, when people feel chest pain, fearing a ‘heart attack’ they tend to go directly to a hospital emergency department. Physicians are also likely to be extra careful in their evaluation of the patient who comes to the ED complaining of chest pains. However, chest pain is not necessarily an indicator of heart disease and could be a consequence of other causes. As part of the Lean approach, we studied the issue with a holistic approach and thus explored the patient flows from the ED also to the internal and cardiology departments.

The ED implemented a new Lean intervention that was based on two basic Lean practises adopted to the hospital context: Standardization of processes based on clinical guidelines and cell approach. The physicians in the ED received a new check list which specified the medical tests they should perform on patients who arrived to the ED with complains on chest pain and specific guidelines for hospitalization or discharge based on the tests results. In addition, a “cell” was organized within the ED that included all that is required for diagnosis, e.g. a cardiologist.

Result of the intervention demonstrated that standardization of processes only in the ED “pushed” the problem to other hospital departments. I.e. indeed, less patients were discharged and thus readmissions within a week to the ED with the same symptoms decreased. However, bed occupancy in the internal department increased, and readmissions within a week to the ED with the same symptoms increased. These results demonstrated the need to take an integrated approach that includes a change in processes of all wards involved in the treatment of chest pain. The implementation of the integrative “cell” resulted in a significant decrease of patients readmissions within a week to the ED with the same symptoms. However, overall hospital costs significantly increased.

Comparing to R&D units of high tech organizations we found high tensions between initiatives to implement Lean practises and innovation, i.e. perceptions that standardization and quality assurance activities are at odds with development of state of the art innovative product characteristics.

The implementation of Lean practices and climate as a tool for improving efficiency and effectiveness in hospitals and R&D units is complicated. Thus, there is a need to design a strategy for ‘best practice’ implementation of Lean into a specific context. Based on our results, we developed and suggest a model (see Figure) that includes relevant criteria and variables in different organisational levels and we point to the interface between them. The proposed model aims at maximizing the value of the performance measures while satisfying the relevant constraints. The huge number of decision variables and the large scale of the problem is handled by decomposing the entire problems into sub-problems.

Our results demonstrated that while sustaining some of the efficient methods used today across Europe and USA, we suggest to develop innovative solutions for the analysis of complex implementation in the health care and R&D systems that can later be integrated into one standard tool. This standard tool will contribute to the deployment of performance measurement that will better enable monitoring and improvement initiatives. In addition, Lean may enable hospitals to effectively, efficiently, and reliably change value, however ‘value’ should be defined holistically by policy makers: is it dollar value to the hospital or to the nation health system? Is it now or in the long run? Lean that was originally designed to effectively and efficiently manage manufacturing lines may be effective in hospitals if the health care system as a whole is considered instead of local profit centres.