142 ◾ Karl Kraebber
Waste Description Examples in Health Care
Process Remedies at Virginia Mason
Medical Center
Waste of
overproduction
Producing what is unnecessary, when it is
unnecessary, and in an unnecessary amount
Fragmented, parallel care: separate resident,
attending, social services, pharmacy, and care
management rounding cycles; making
photocopies of a form that is never used;
providing copies of reports to people who
have not asked for them and will not actually
read them; processing piles of documents
that then sit at the next work station; cc’s on
e-mails
Multidisciplinary bedside rounds, with
contemporaneous documentation and order
entry by portable wireless computer; primary
care physician ow stations incorporate
many lean principles
Waste of time on hand
(waiting)
Waiting for materials, operations,
conveyance, inspection; idle time attendant
to monitoring and operation procedures,
rather than just-in-time supply or pull
production
Patients waiting to see their physician; oce
sta batching test results for patients; waiting
on the phone to schedule appointments;
early-morning admits for surgeries that won’t
be performed until later in the day; waiting
for support services such as internal
transport; waiting for oce equipment
(computer, photocopier, etc.) to be repaired
before being able to do work; waiting for a
meeting that is starting late
Patients are advised at point of care when
tests will be available, and test results are
reported as they become available;
emergency department physicians enter
orders in the electronic medical record
within 15 minutes of patient arrival
Waste in transportation Conveying, transferring, picking up/setting
down, piling up, and otherwise moving
unnecessary items; problems concerning
conveyance distances, conveyance ow, and
conveyance utilization rate
Moving individual les from one location to
another; moving supplies into and out of a
storage area; moving equipment for surgeries
in/out of operating and procedure rooms;
patients receiving chemoradiation treatment
traveling 1220 horizontal feet and 25 vertical
oors per episode
Travel for chemoradiation reduced 55%, to
544 feet and 12 oors, by providing injections
and dressing changes in radiation oncology
department; instead of patients or supplies
traveling to and from isolated process
villages, the input proceeds through the
operations in single-piece-ow in 1 short
space
Figure 17.2 Waste in healthcare. Continued
Lean in Healthcare ◾ 143
Waste Description Examples in Health Care
Process Remedies at Virginia Mason
Medical Center
Waste of processing Unnecessary processes and operations
traditionally accepted as necessary
Hard copies of memos already sent by e-mail
or posted on intranet; redundant capture of
information at admission; multiple recording
and logging of data; writing by hand, when
direct input to a word processor could
eliminate this step; producing paper hard
copy when a computer le is sucient;
patients waiting for preapproval of urgent
treatments
Hyperbaric oxygen indications negotiated
with payers who have agreed to waive
preapproval; redesign of chamber to allow
emergency cases without canceling
scheduled patients; eliminate medication lists
on electronic medical records progress notes
Waste of stock on hand
(inventory)
Inventory waste is when anything—materials,
parts, assembly part—is retained for any
length of time, including not only warehouse
stock but also items in the factory that are
retained at or between processes
Oce supplies in hallways; expensive clinical
supplies and implants that can be ordered on
a just-in-time basis; charge slips piled up to
be dictated; unnecessary instruments in
operating room kits
Surgeons now accept only those instruments
that are frequently used, or 25 instruments,
in the operating room kit
Waste of movement Movement that is unnecessary, that does not
add value, or that is too slow or too fast
Physicians and nurses leaving patient rooms
for common supplies or information
Common supplies are stocked in hospital,
operating, and outpatient rooms, with
visually controlled restocking system;
computer access in outpatient examination
rooms and wireless portable computers for
inpatient rooms
Waste of making
defective products
Waste related to costs for inspection of
defects in materials and processes, customer
complaints, and repairs; passing defects
down to a coworker or patient, rather than
the defect producer “feeling the pinch”
Iatrogenic illness; xing errors made in
documents; misling documents; dealing
with complaints about service; mistakes
caused by incorrect information or
miscommunication; handwritten orders;
sending out bills with an incorrect address
Ventilator-acquired pneumonia bundles
decreased annual incidence from 40 to 5
cases; patient safety alerts; computerized
clinician order entry
Source: Adapted from T. Ohno, Toyota Production System: Beyond Large-Scale Production (New York: Productivity Press Inc., 1995).
Figure 17.2 (Continued ) Waste in healthcare.
144 ◾ Karl Kraebber
e rst step in any Lean transformation (and project) is to understand the current state by
conducting in-depth process or value stream mapping and assessing the current process for waste.
e clear identication of waste in the current state is vitally important to challenging them in the
future state. A redesigned future state follows with clearly dened opportunities for improvement
that sets the stage for action plan development, waste elimination, iterative improvement, and
sustained benets. Waste elimination becomes much easier when problems are clearly identied
using a team-based approach within the context of the entire system rather than the narrow scope
of an individual or isolated department.
Waste Elimination
Lean arms healthcare clinicians and professionals with tools that assist in the elimination of waste,
improvement of quality, decreasing of production time, and cost reduction. Waste elimination
can be accomplished by using a number of Lean tools; however, it is important to remember that
waste elimination in isolation just leads to more waste. Cherry picking Lean tools to solve indi-
vidual problems does not promote systematic and sustainable improvement. e Lean “toolbox”
includes the following: quick-and-easy Kaizen, cellular design, single piece ow, quick change-
overs, standard work, error-proong (“stop the line” or no defects passed downstream), 5S work-
place organization, kanban/pull inventory systems, visual management and status boards, jidoka
(autonomation), and total production maintenance (TPM). Two of the most fundamental tools
for waste elimination in healthcare are 5S and Kanban to promote a visual work place.
Visual Workplace: 5S, Workplace Organization, Kanban
“A place for everything and everything in its place,” is the mantra for 5S in Lean. 5S is a work-
place organization tool used to eliminate waste and improve ow. 5S stands for sort, set in order,
shine, standardize, and sustain. 5S is often performed as an initial part of a Lean transformation,
whereby processes become more visible and identied waste is eliminated. Benets of 5S in health-
care are: eliminates the need for searching, reduces probability of error, increases quality, improves
productivity, expedites response time, improves sta morale, and enhances the professional image
of an area. 5S drives a cleaner work environment and establishes a standardized organization of the
workplace. 5S is a Lean tool that can set the stage for subsequent process improvements that have
been identied during a VSM event and documented on an action plan.
1. Sort: What Do We Have and What Do We Really Need?
Sort involves the identication of what is required for work (necessary) and what can be removed
from the workplace (unnecessary). Necessary items are then subdivided by how frequently the
item is used (required for set in order). Unnecessary items are either discarded or red-tagged (see
Figure17.3). Red-tagged items are sequestered on a cart or in a designated area for review by col-
leagues from all shifts prior to nal disposition. e red tag documents the item description, sug-
gested disposition, date tagged, disposition date, and includes the name of the tagger. Figure17.4
shows examples of overstocked and unnecessary items being sorted out of birth center patient
rooms and clean utility storage closets at St. John’s Hospital in Springeld, Illinois.
Lean in Healthcare ◾ 145
Red Tag: is item identied for
disposal or permanent relocation.
Item description
Suggested
disposition
Today’s date
Planned date to
disposition
Concerns?
Contact
Figure 17.3 Red tag.
Figure 17.4 St. John’s Hospital Birth Center patient room and clean utility storage sort.
Continued
146 ◾ Karl Kraebber
Figure 17.4 (Continued ) St. John’s Hospital Birth Center patient room and clean utility storage
sort. Continued
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