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LEAN HOSPITAL APPROACH IN HEALTH CARE

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INTERNATIONAL JOURNAL
OF CURRENT RESEARCH
International Journal of Current Research
Vol. 9, Issue, 01, pp.45032-45037, January, 2017

ISSN: 0975-833X
REVIEW ARTICLE
LEAN H OSPITAL APPROACH IN HEALTH CARE

*Haluk ŞENGÜN
Bahçeşehir University, Faculty of Health Sciences, Department of Health Manageement, İstanbul, Turkey

ARTICLE INFO ABSTRACT

Article History: The co st of health care has been rising rapidly in our country and in the world and it takes more from
th
Received 17 October, 2016 the budget. Costs, malpractices, wasted time, and general bureaaucratic inefficiencies has bought a
Received in revised form 14th need for the new approches. Lean management is the elimination of any activity that does not add
November, 2016 Accepted 27th value to an organization's end product, and using what is referrred to as a "just-in-time" inventory
December, 2016 Published online strategy, which aims to reduce inventory and associated carryin g costs. Technology can reduce the
31st January, 2017 manual labor involved in many processes that take place within a hospital and improve overall
efficiency. Lean organizations differ from traditional organizations in putting the power of improving
Key words: an organization into the hands of the employees that directly interact with the end product, rather than
Lean Hospital, management. The largest difference between traditionally managed organizations and lean
Lean Management, organizations is their focus on systemic improvement. Lean organizations focus on identifying the
Lean Thinking, root ca uses of all problems and adjusting processes to stop the saame problems from occurring in the
Health Care Services, future. The purpose of this study is to present lean hospital management system to the health sector in
Hospital. Turkeyy, which can benefit us in all means, can be used. In this way, lean system can support health
care workers and doctors, making sure that they can give their full attention to the situation in their
hands. This system will reduce risks, costs, and waste while empoowering and making it easier for the
hospit als to improve in the long run.
Copyright©2017, Haluk ŞENGÜN. This is an open ac cess article distributed under the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.

Citation: Haluk ŞENGÜN. 2017. “Lean hospital approach in health care”, International Journal of Current Research, 9, (01), 45032-45037.

Flow means a product or servicce which fulfills the

INTRODUCTION expectations of many of the activities that create value for
customers and is arranged in a process. Tension means
Lean thinking is, to dismiss any excessive m ovement and idea withdrawing from the production value of the resoource to be
that has no contribution to value stream. According to lean consumed by the customer. Excellence can be defined as the
these are considered to be and they must be eliminated. Lean constant efforts wasted to perform production process in the
thinking focuses on the production approach and is directly best way (Aktaş and Kargin, 2011). In the light of this
based on the actual activity whilst being oriented towards informations lean implies to eliminating non-contrubutive
highlighting the necessity of value-added activities: therefore, energies, the production factors that is used, providing
lean thinking, products and means, leading to the elimination advanced technology equipments and the skilled lab or,
of waste and non-value added processes for customers. In other performing the task in once and best, preventing the errors as
words, labor, materials, equipment, time and means to create much as possible and managing all of the in accordance
high value-added processes (Womack and Jones, 2003). In this (Türkan, 2010). Lean consists of a bunch of norms and
way, by removing all unnecessary burdens on businesses methods that the companies to be competitive in feature. Lean
expenses in order to foster the process of si mplification. Thus, thinking, is applicable for any case in the presence of tim e,
the production process progesses faster, moree efficiently and money and supply. The main interests of lean are product
in a less costly manner (Graban, 2011). The un derlying management. Product development, supply chain management
principles of lean thinking are: value, value stream , flow, pull and after-sales service (Warnecke and Huser, 1995). It is
and perfection. Value, stands for producing g oods or services claimed that a lean activity is for the usages of resources build
which customer pays a fixed price to fulfill his needs. Value the process and capacity (Aronsson et al., 2011).
stream implies the contributive or execessive energies to
produce that good or service. The History of Lean Management

The definition of lean manage ment as a historical

*Corresponding author: Haluk ŞENGÜN,
development is also important.
Bahçeşehir University, Faculty of Health Sciences, Department of
Health Management, İstanbul, Turkey.
45033 Haluk ŞENGÜN et al. Lean hospital approach in health care

Henry Ford, in 1927 with the revolutionary Ford Production the physical layout, establishing of the treatment process
System (FPS Ford Production System) announced the basic checklist and applying integrated decision support software
principles underlying it. Toyota's founders have worked on (Graban, 2007).
FPS and further developed and defined the principles and tools
for the Toyota Production System (TPS-Toyota Production It is intended to ensure continuous improvements in the
System). Full-time (JIT) method were the key point of the treatment process in Lean hospitals, to eliminate delays in
Toyota production system. The main purpose was to reduce the patient care, to destroy waste and foreground respect for the
costs of TPS. Quantity control and quality assurance are individual. Lean thinking is the starting point of "value" which
required to provide it. Thus only the necessary products, the is a created concept. Time spent with the patient's physician
required amount of time and the production is addressed. Due when viewed in terms of health services, patient analysis
to the oil crisis of 1973, a sudden increase in interest in processing, imaging processing, services such as surgery and
production and management application with new Japanese-hit care services are covered under the value (Aksoylu, 2014). The
North America and there have been many studies on this principals of lean managment can be itemize such: end-user
subject (Weinger, Matthew, Jason, Nelda, 2003). must name value as a service, value flow steps for each service
must be determined, non-contrubutive steps must be eliminated
To define the production system used by Toyota in 1988, in advance, the service must be delivered to customer regularly
"lean" is the word used. Lean system describing the details of contrubutive steps must be augmented, this process must be
the book "Machine that Changed the World" was published in pursued and repeated until value stream reaches to the peak
1990. This book introduced lean manufacturing, and the (McConnell et al., 2006).
underlying components of Toyota’s production system. There
are many articles and books on lean thinking and lean systems Hospitals and processes are full of waste and inefficiency.
from the time (Shah and Ward, 2007). Toyota has completed Lean as applied to the hospital has the objective of providing
the evolution of production and management systems six zeros: zero stock, zero defects, zero contradiction, zero wait
developed over many years. In today's health care budget time, zero dead-time and zero bureaucracy (Womack, James,
excess healthcare costs, errors endangering patient safety, time Daniel, 2007). Lean techniques also allow us to improve
wasted and patients and health workers from hospitals and service delivery by understanding and examining the details of
bureaucratic inefficiency have led to the search for a new how the provision of safe health services. Effective and high
management style. First, lean management has become the quality services to support our application process are required.
indispensable standard for US hospitals, and later spread Lean offers the best way to do it (Graban, 2007). Most authors
rapidly around the world. In all business processes with the in the health sector assume a natural balance between cost and
principles developed by the Toyata hospital studies showed a quality, and a higher quality in new Technologies. It is true
significant improvement. Patients reduced costs, increased that treatments or drugs are some of the more costly methods
employee satisfaction and patient care services improved. The for promoting the healing quality. However, the hospitals, the
implementation of a lean thinking approach to this hospital led quality of health service delivery methods and processes that
to the term "Lean Hospitals" being used (Womack, James, can improve the way have many opportunities for reducing
Daniel, Jones, Daniel, 2000). costs while increasing quality. All hospitals in the United
States, by preventing mistakes may be able to make cost
Lean Management Approach in Health Care savings, and, it has been revealed, increase quality to a large
extent. For example, the drug which may prevent adverse
Healthcare professionals eliminated waste maximizing value effects resulting from errors in hospitals is estimated to cost $
owned Lean hospitals, as well as other organizations, to 2 billion a year. Lean thinking is seen as a means of quality
determine the desired values of users, eliminating steps improvement and cost reduction. This philosohy yield more
without added value and they have to move them all to the end effective results comparing to the methods based on slightly
of the beginning of doing value stream according to the needs focusing on cost. Lean, is rather a quality initiative relating to
of the patients (Graban, 2011). Lean implementation of the cost reduction initiatives. As a result, quailty is improved and
health institutions has created a positive impact in both costs are reduced (Bodek, Norman, Kaikaku, 2004).
administrative and clinical processes which has been
demonstrated in many studies. As well as to patients in the care Lean thinking requires sustainable quality and process
process, and health workers in giving treatment, the operation improvement. Looking at how we do our business, lean
process can also be applied in areas such as imaging services management considers ways to improve the way work is
(Graban, 2007). According to the stockpiling function of the performed. Lean prefers to solve problems permanently instead
instruments and equipment used in the treatment process, the of strolling around them. Lean management avdocates on the
creation of the checklist after each process and ensuring patient one hand improving patient safety and preventing delays while
safety will minimize the possibility of error on the part of the employee satisfaction, and on the other quality and cost-
medical staff. Ensuring product availability and minimizing effective methods of healing. Lean management of hospitals
storage space, it is possible to improve patient care areas and creates higher growth while creating revenue
(Ducharme and Lucansky, 2002). There are many positive opportunities, and also helps in terms of saving money.
effects of lean methods on these organizations. Therefore, Ultimately lean methods can benefit everyone associated with
collecting data relating to both medical and non medical the hospital. Understanding the Lean principle is only a
processes, mapping and analyzing them are suggested to all starting point. The real challenge is to apply these principles
health institutions and organizations operating in the health and strategies. Lean leads support for transforming the way
sector. Thus, they will be able to design their processes hospital services are presented. Everyone also has to be ready
effectively and efficiently with activities such the use of an to adapt to this great transformation and lean thinking in the
effective inventory management method, designing material hospital should be taken responsibility for in this process
flow processes by eliminating waste, making improvements in (Galsworth, 2005).
 45034 International Journal of Current Research, Vol. 9, Issue, 01, pp.45032-45037, January, 2017

Positive reasons for adopting lean management of the business purposes. Increasing customer satisfaction, reducing cycle time
are listed below (Maskell et al., 2011): and reducing error levels are the focus of 6 sigma. For the
management of risks that may occur with the correct data
 By providing better information in order to take simple analysis is a proven methodology that manages administrative
decisions, an increase in revenue and profitability will and statistical tools. It moves with the philosophy of error-free
 occur accordingly. processes as a result of drastic improvements. Structural and
 Procedures and systems that lead to wasted time and systematic change to achieve excellence in all areas is
 cost is reduced. implemented. Error Types and Risk Analysis: These are
 Descriptions of the potential financial benefits of Lean processes aimed at preventing errors before they occur and
thinking focus on development initiatives and strategies perfect quality. It is an approach that aims to identify problems
required to achieve these benefits. before they occur and to determine the elimination, and one of
 Knowledge of Lean Thinking is taken into account and is the most important techniques to prevent malpractice in health
able to motivate improvement in the long term by services (Graban, 2007). Value Stream Mapping: This
provides the ability to process a fresh look. To understand the
 providing the statistics presented in this line of thinking.
 It is to keep ahead of customers' values. functioning of the present process, to see how resources are
being wasted, to understand the root causes of waste and visual
These activities add value to activities and can be expressed in techniques used to plan for simple applications. Earnings are
value-added activities. These activities must be followed; in calculated to provide a roadmap for achievement. This road
order to be distinguished from each other there are some map is an important tool to perform simple applications in a
special rules. The rules should be adhered to as specified by short time.
the value-added activities. Performed activities can be stated as
follows. Lean Philosophy refers to the corporate culture A3 Thinking: Actually A3 "is just a paper size" (11X13). A3
(Pedersen, Philip and Douglas, 2005). Value and the Seven processes large or small, all the plans or reports are shown on a
Waste: There are seven basic types of waste According to Lean page in a visual representation everybody can understand
approach: "More Production Waste Inventory Waste, Standby which tell a story visually and clearly. The A3 process in the
Waste, Transport Waste, Motion Waste, Process Waste and PDCA (Plan, Do, Check, Measure) takes place in the process.
Faulty Production waste." Too many medical tests also create It makes it possible to take decisions based on facts. Pulling
an overproduction of waste too, mia had passed drug in
pharmacies and material inventory waste in the long patient System: If you have only what you need, the services being
queues to wait waste, missing drugs and materials handling offered voluntarily to make it are never spent on unnecessary
waste in the medical device incorrect positioning of the energy.
moving waste-conceived and unnecessary treatment to process
waste, improper treatment are examples of faulty production Ando: This is a system that is used as a warning tool. Sound or
waste. light stimulus is used for notifying. Problems that occur in the
main objective of this system service are quickly revealed, and
Lean Methodology it continues without loss over the service.

Lean methods started in the factory, but also proved successful Kanban: Kanban again is a Japanese term and means card or
in many service sectors, including the health sector. The idea sign. The main purpose of Kanbans is to show which work has
of lean philosophy for creating greater impact, argues that you to be done at what time to ensure optimal flow. Due to their
should start with smaller steps. Lean continuous quality physical presence these signs are somewhat self-evident or self
improvement in hospitals provide cost reductions (Graban, explanatory and belong to the pull concept
2011). Lean management is used in many problem solving
techniques and methods. They include the following Muda: This is the process of eliminating non-value adding
prerequisites: 5S, Lean Philosophy, Values And The Seven supply. For example, it can do the work of five or six people.
Waste, 6 Sigma, Failure Mode and Risk Analysis, Value Muri: Employees are allowed to work more than willingly
Stream Mapping, A3 Thinking, Pull System, Andon, Kanban, excessive load. For example, it is like a person can do the work
Muda, Muri, Mura, Kaizen, Genba, Poka-Yoke. 5S: This was of four to five people.
first introduced in Japan and is arrangement in the workplace.
The layout is simple and effective, a method used to ensure Mura: Causing the operator to hold or to rush in a
cleanliness and discipline. Land is visual basic. It is an continuously variable operation is caused by the improper
organization consisting of 5 stages. Each of the 5 represents operation of the production plan. That consists of a mixture of
the first letter of the Japanese words. These; "Seiri" (Sweep, Muria Muda.
sorting), "Seiton" (Sort, Edit), "Seiso" (Delete, Clear),
"Seiketsu" (standardization) and "Shitsuke" (Resume, Kaizen: Kaizen describes the Japanese philosophy of
Discipline). Waste removal of the "5S" method is very useful. continuous improvement. With Kaizen, all functions of a
Drug cabinets, anesthesia in sterile and non-sterile cabinets, business are analysed and all participants involved in the
code blue car and bedside units can be organized in this way. business process are focused
This ensures a more orderly and clean environment. Storage
areas are destroyed, carrying waste is reduced, problems and Genba: Risk factors for the business areas is analyzed
hazards can be seen early and thus increase productivity consideration. All the facts of the organization is seen in this
(McConnell et al., 2006). 6 Sigma: A measurement scale that walk.
allows the comparison of facilities and the measuring of the
adequacy of services and processes. Define, measure, analyze, Poka-Yoke: This means error prevention. A lean production
is a management strategy that pursues development and control methods to prevent the errors made during the service. It aims
45035 Haluk ŞENGÜN et al. Lean hospital approach in health care

to prevent human errors before they occur rather than fix or These rules are in line with the hospital, the value of adding
uncover them. The adoption of the Lean manufacturing value to the activities carried out in the stream, and it is
approach in the hospital should be considered, and should then possible to specify the value-added activities (Graban, 2011). It
be carried out according to these principles is shown in Table 1 is a medical laboratory technicians working in service of any
(Şengözer, 2011). According to Graban (2011), lean hospitals patient's test results of the sample activities that add value to
and patients reduce errors occurring in transactions, and interpret the value stream processes. This, as well as medical
reduction in the waiting time to a minimum is an approach that technicians to repair the damaged tool in laboratory. Values to
allows them to improve the quality of care provided to the same amount can be given as an example of the process
patients. Value is the total of the activities carried out for the flow-added activities. Hospital clinical laboratory service
diagnosis and treatment of any disorder occurring in a patient processes located in the patient sample are identified as
(Osmanbeyoğlu, 2013). These activities add value to activities products that add value to activities samples.
and value added activities are divided into two categories.
Table 1. The Lean Manufacturing Principles

Principle What lean hospitals need to do

Value The value should be determined in terms of the end user i.e. the patient
Value Stream All value-added services beyond the borders of the steps in the hospital identified that value streams,
creating value in non-flow steps should be removed.
Continuous Flow Eliminating collective work and the reasons for the delay as quality problems arise in the hospital, the
process should flow smoothly.
Pull Work to be done should not be pushed to the next process or service, it should be allowed to withdraw
when the job should and facilities.
Excellence Continuous improvement should be achieved by ensuring excellence in the hospital.

Table 2. The types of waste as seen in hospitals

Waste Type Brief Description Examples Hospital

Errors Doing something wrong, correct the error or errors by Surgical supplies car is missing a substance;
checking the time spent Giving patients the wrong drug or the wrong
dose
Necessity more production Because customer needs to do more or has less time than Apply unnecessary diagnostic procedures
thought
The catheter laboratory as a bad layout is very
Unnecessary Material Movement The product of the system (patients, samples, materials) far from the emergency services
unnecessary movements
Waiting staff are required to be equal to the
Wait The realization or the next business activities for the next workload; Patients waiting for appointments
event
wait
Unnecessary drugs, expired supplies need to be
Financial costs, storage and moving costs, because of destroyed
Excess Inventory corruption and clear excess inventory costs
Unnecessary Human Movement Laboratory workers walking for miles each day
Unnecessary movement of employees in the system due to bad layouts
Customers that do not value or do not meet the definition of When overcome Form / date stamp; but history
Too many Operations quality jobs that lead to patient needs will never be used
Human Potential Not including employees, listen to the ideas arising from or They give employees offers and suggestions
supporting the career.. and development

Table 3. Findings of three separate research groups about the benefits of the implementation of lean management in the health sector

inpatient and outpatient satisfaction has increased

increased motivation of staff
Papadopoulos UK NHS NHS Hospital Pathology Unit Costs are reduced
It helps to speed clinical decision
Patient care is more effective and efficient
Waiting times are reduced
Rexhepi and Shrestha Kosovo University Clinic It decreases stress in employees
Center in the Department of Rheumatology Patient safety is increased
Organizations have higher revenues
There is no unnecessary movement within the hospital
Folinas and Faruna Abuja and Nigeria in the Federal Capital Waiting times are reduced
Territory's three major hospitals in Patient safety is increased
Costs are reduced
Excellence in service flow process can occur with the elimination of waste

These activities have some specific rules that must be followed The example of the value-added activities, with transport as
in order to be distinguished from each other: part of a collective work of the samples taken from the patient,
is waiting (Şengözer, 2011). The other concept of waste
  Patients do not want to pay for an activity. identified as belonging to a lean approach by Graben
 Activities of the product or service in a way conversion. (2009/2011), is hospital patients and is defined as the act or
 The activity needs to be done right the first time. having made the effort to provide any value (Sengözer, 2011).
45036 International Journal of Current Research, Vol. 9, Issue, 01, pp.45032-45037, January, 2017

According to another definition, hospitals, businesses, and more and more important. In addition to the main goal of cost
patient care in the case of work done on the problems and reduction, telemedicine further enables hospitals to cope with
obstacles that may be the continuation of the difficulties of international competition and to fulfil current demands of EU
these problems can be defined as waste. The waste types that standards and regulations within the European Single Market.
occur in hospitals are shown in table 2 (Osmanbeyoğlu, 2013).
Table 2 also revealed the types of waste as seen in hospitals: Patient-Oriented Management
more production, inventory, shipping, motion, waiting, errors,
unnecessary processing, are expressed in human potential. Patient-oriented management is another priority of lean
Thanks to the prevention of waste from hospitals and management in hospitals. It helps hospitals to concentrate on
remarkable achievements in lean process improvement, and the their core competencies and to avoid ineffective and inefficient
lean thinking movement in health, "Lean Healthcare" has activities. Above all, patient satisfaction and loyalty are
entered into a global movement. First, the US hospital important for the continuity and profitability of a hospital. To
practices spread rapidly. A number of problems have been increase this satisfaction and loyalty level, hospitals must stand
fundamentally solved with lean management practices. Today, out from its competitors by differentiation. This calls for a
many examples of the positive impact on lean hospitals all comprehensive analysis of the company’s resources and
over the world are available. Some striking examples of the capabilities as well as for the understanding of patient
results of lean methods are as follows: demands. As a result, strategic alliances gain interest because it
turned out that strategic alliances are one possibility for
Espirito Santo Hospital in studies of the lean management hospitals to cope with harsh market conditions. Thus, hospitals
approach has been applied to the material procurement can expand their service portfolio without additional financial
process. At the time of supply, as a result of studies using costs; they can concentrate simultaneously on their core
process flow diagrams of the process a reduction in stock competencies and follow trends by streamlining their activities
levels was observed (Bendito, Martins, 2012). "Seattle according to patient demands; they can increase their
Children's Hospital," the surgical clinic: Due to the mapping profitability and efficiency without personnel cutbacks.
process, comprehensive data collection and analysis, Moreover, any business cooperation should also be supported
elimination of patient value added process elements, by professional marketing. In times of increasing competition
immediate implementation of the modified process and and changing patient self conception, hospitals cannot afford to
reduced process steps due to the re-evaluation process, neglect marketing activities that help to stick in to customers’
valuable time for patients has increased; patients have been minds (Graban, 2011).
treated with a reliable method for flow and provision of health
care to those patients and more time was able to be spent on One of the most important aspects in hospitals is the successful
them. management of patients. This is true just because of one simple
reason: without patients there is no need for hospitals. The
Avera McKennan Hospital: The histology laboratory,
patient satisfaction, strategic alliances in the healthcare
pharmacy, emergency room, surgical services, maintenance environment and hospital marketing are of main focus since all
and cleaning, medical surgical nursing, engaged in lean these aspects are considered value-adding steps that help to
projects in many fields such as clinical activities. For example, increase service quality and to streamline processes in
a project to improve patient discharge processes from leaving hospitals. Patient satisfaction and loyalty have a considerable
the patient's room, shortened the delay between the preparation impact on bed occupancy rates which are actually the basis for
of the next patient's room. Thus, increased room use. The a hospital’s profitability. Consequently, it is this aspect of
length of the patient’s stay decreased by 29% which prevented profitability which forces hospitals to increasingly direct their
the new emergency services building spending 1.25 million attention to patient satisfaction and loyalty.
dollars.
Alegent Health (Nebraska): In staffing or the addition of new Findings of three separate research groups about the benefits of
tools, the time taken for clinical laboratory results were the implementation of lean management in the health sector
reduced by 60%. Kingston Hospital (Ontario): The instrument are shown in Table 3.
sterilization cycle time was shortened by more than 70%.
Obion Health (Obion): Operating income 808.000 dollars plus Conclusion
per year (Graban, 2011). Lean is an improvement strategy that
concentrates on waste-free production and process Leaders who have successfully exploited lean thinking in many
optimisation. For lean leaders, it is indispensable to identify, hospitals, knows that this is not an academic practice.
analyse and categorise existing types of waste to successfully However, simple methods are a useful approach that allow us
elaborate a strategy for breaking the cycle of waste. Hospitals to improve the hospitals' current management style. The health
are complex business environments with a multitude of services relate to human life; any problems occurring in the
wasteful situations that require distinctive solution approaches. process can lead to irreversible consequences. Adding value to
Kanban, Kaizen, 5S principle and Value Stream Mapping are processes and increase efficiency by eliminating waste is
adequate tools that help to identify and eliminate waste and possible with simple applications and "security", "cost-
non-value adding activities. However, certain problems may effectiveness", "quality", "activity", "profitability",
remain unresolved or difficult when systems and structures are "innovation" and "work-life quality" in the health institutions
too complex to be streamlined with lean principles only. This as well as important changes on key concepts for each business
is the moment, when Lean Sigma comes into play because can be created.
with Six Sigma the lean methodology is supported by error
proofing and future avoidance thereof. Since the healthcare Summing up, it can be stated that key factors for successful
environment is a fast moving business field, state-of-the art implementation of lean management in hospitals are
technology such as telemedicine and e-health are becoming concentration on process optimisation, knowledge about main
45037 Haluk ŞENGÜN et al. Lean hospital approach in health care

lean principles and intelligent application of its general tools. Graban, M. 2011. Allocating İnternal Audit Costs İn A Lean
For Lean to tap its full potential, the human aspect must be Environment. Pınar Şengözer (Çev). İstanbul, Optimist
considered likewise. Thus, a patient oriented management as Yayınları.
well as engaging and leading employees will lead to success of Lindenau-Stockfisch, V. 2011. Lean Management in Hospitals,
lean management in the healthcare environment (Verena, Principles and Key Factors for Successful Implementation
2011). Maskell, B., Baggaley, B. and Grasso, L. 2011. Practical Lean
Accounting: A Proven System for Measuring the Lean
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