Lean thinking in healthcare

Dean Westcott examines the ways health systems worldwide are improving productivity and efficiency

Principally, populations are ageing at a faster rate, with significant implications in terms of the age/cost curve, increasing public expectations in terms of quality and types of healthcare available, and the advancements in the fields of medical technology and pharmaceuticals. So what is the answer given that the level of resources available to be spent on health is finite regardless of whether a system is state-funded, insurance-based or a hybrid?

The obvious answer is to improve productivity and efficiency, and healthcare systems around the world are adopting different strategies to achieve this. However, one particular approach currently being championed in the UK's NHS and the Singaporean health system, among others, uses thinking and practices developed by the car producer, Toyota, since the 1940s.

The 'lean' or Toyota production system concept is essentially a strategic approach and a series of tools that seek to improve systems flows by removing unnecessary steps and waste, thereby improving efficiency, increasing reliability and reducing costs.

Lean means 'using less to do more' by 'determining the value of any given process by distinguishing value added steps from non-value added, and eliminating waste so that ultimately every step adds value to the process' (1).

The concept has been adopted across a range of sectors and organisations, including Tesco, the Royal Air Force and the Royal Navy, and proponents argue that the technique is equally relevant and applicable to healthcare organisations.

The potential in the healthcare sector to improve efficiency, quality and patients' safety by employing lean techniques is enormous. Processes such as ordering tests, managing medical records and patients' appointments systems could all benefit from improving systems flows. The focus needs to be on reducing variation and waste in all of these processes by reviewing and questioning the way things are done.

There are five key principles of the lean concept and, in a health context, these could be defined and applied as follows (see box).

So how are the principles and techniques being used in practice? The National Healthcare Group (NHG) in Singapore is one of two clusters responsible for the provision of healthcare to the population as a whole through a range of general and specialty hospitals and primary care facilities. It aims to improve health and reduce illness through patient-centred healthcare, which is based on continuous improvement through both medical and process breakthroughs. Through the application of lean principles, the group has achieved a number of successes in changing processes which have improved overall efficiency, while at the same time improving the patient's experience. Two examples of NHG's drive to improve process flows are as follows.

Computerised clinical order entry system (CCOE)

Historically doctors were required to complete hardcopy prescription forms to order diagnostic investigations and medications. The principal drawbacks of this manual system were that prescriptions were often illegible, which sometimes meant that patients would be sent for, and pay for, the same test twice due to misplaced and lost paper laboratory results. In some cases due to illegibility problems there were prescribing errors, and not surprisingly there were frequent unnecessary delays for patients. A thorough examination of the process has led to the introduction of an online system across both secondary and primary care facilities. The system incorporates an 'e-prescribing' module which has significantly improved patients' safety through automated checks for drug allergies and drug-to-drug interactions for certain medical conditions, with clear benefits for organisational risk. The overall benefits of the system for the organisation have been significant, particularly in terms of productivity, given that access to results and orders is now instantaneous, which in turn has had a positive impact on staff frustration. From a patient perspective not only has safety been improved due to reduced prescribing errors, but the experience is improved through a much more seamless system with faster turnaround times.

Laboratory automation system

A total streamlining and automation of laboratory cycles using lean principles has delivered significant efficiencies, with doctors now able to access results electronically in real-time and turnaround times for laboratory results, reduced from up to three hours to between 30 minutes and one hour. The calculated benefits of re-engineering these processes are increased staff productivity of 46% over three years, with estimated cost savings of S$10m over seven years. In terms of the patient's experience, doctors are now able to arrive at diagnosis earlier and provide much more timely interventions and treatments. There are also benefits in terms of staff safety, as sample transfers are now entirely automated, reducing risks of potential bio-hazard exposure.

It is estimated that, in a typical NHS setting, clinical processes represent 80% of costs and, with significant variations across a range of performance indicators, the application of process improvement techniques such as lean has a significant potential to reduce costs and improve the patient's experience. The application of lean thinking can also dispel the traditional myth that reducing costs while at the same time improving quality is mutually exclusive. There are many examples of where the reorganisation of processes has reduced variations in clinical outcomes and reduced waste, improving the quality of care delivered and reducing costs.

The affordability of a comprehensive healthcare system continues to present a challenge across the globe. A recent survey by PwC across 27 countries predicted that healthcare spending could triple by 2020 unless there are changes. Fundamental to this will be constraining costs, while improving quality and controlling the ever-growing demand for healthcare.

References
(1) Miller. Going Lean in Healthcare, IHI Innovation Series white paper, 2005.
(2) Institute for Innovation and Improvement. Going Lean in the NHS. 2007.

Dean Westcott is finance director and deputy CEO of West Essex Primary Care Trust, and an ACCA Council member.