Lean Six Sigma for Healthcare

Lean Six Sigma for Healthcare

How Do We See Poor Processes?

Defects (Errors): Checking to assure physicians have responded to the latest diagnostic information, assuring physicians have written discharge orders, inspecting insurance claims. Over 50% of medication errors occur at the “interfaces of care” – 7 Error Types 

Over Production/Capacity: Doing unnecessary diagnostic procedures or having more staff than demand requires.  Probably the most common form of waste.

Transportation: Movement of materials (linen, food, etc) and information (case notes, X Rays, etc)

Waiting: Healthcare is the only place that has a name for this type of waste “ Waiting Room” or “Holding Areas”

Inventory: Often can be discovered when caregivers tell you the secret hiding place for linen, wheelchairs, etc. The necessity for these supplemental inventory locations results because demand and resources are out of balance. Expired supplies that must be disposed of (OOD medication)

Motion: Every time a patient is moved or lab staff walking around. An ideal is a patient to be taken to their room and all registration, intake, diagnostic tests, and therapeutic interventions to occur in this room. This would be best for quality and cost. The issue is equipment for different care settings.

(Over)Processing (Redundancy): Whenever a process is redundant such as a patient restating their personal details more than once during a visit



Put Another Way in Hospital Departments

 Departement  Role  VA  NVA
 Operating Room  Surgeon  Operating on Patient  Waiting for a delayed procedure or performing   unnecessary steps
 Pharmacy  Technician  Creating an Intravenous   Formula  Reprocessing medications that were returned   from patient units
 Inpatient Unit  Nurse  Administering medications to   patient  Copying information from one computer system   to another
 Radiology  Technician  Performing MRI procedure  Performing a medically unnecessary scan
 Laboratory  Technologist  Interpreting a test result  Fixing a broken instrument


Value Add (VA) vs. Non-Value Add (NVA)


 Departement Role  VA  NVA
 Emergency  Department  Patient  Being evaluated or treated  Waiting to be seen
 Clinical  Laboratory  Patient Specimen  Being centrifuged or tested  Waiting to be moved as a batch
 Pharmacy  Prescription  Medication being formulated or prepared  Being inspected multiple times
 Perioperative Services (time before, during, after)  Sterilized Instruments  The time when instruments are being sterilized  Instruments being sterilized repeatedly without ever being used from a standard kit
 Nutrition Services  Patient Food Tray  The time when food is being cooked or tray is being assembled  Being reworked because the tray was prepared incorrectly



Do We really need Lean?

Let's look at an example of a patient journey for outpatient surgery (A patient who is admitted to a hospital or clinic for treatment that does not require an overnight stay)




Do We really need Lean?

A nurse walked 1825 feet in 50 minutes, a pace of more than 4 miles per day (A Chemotherapy Unit).

32% of the nurse's time was spent walking.

30% of the time was spent on Value Add activities which were loosely defined as any time with direct patient contact.

Ideally, as patients arrive they are located close together but this is not always practical so they get whatever chair is available and any nurse who happens to be available.

Other issues include frequently attended Tube Station, Non-Standardised Medication Carts, and inconveniently located storage/supplies.









Do We really need Lean?

A perioperative services department, technicians, and nurses build case carts that are later rolled into the operating room for surgery.

In two observed cases, a technician and nurse walked more than 1000 feet to build each of their carts.

In two carts, 44% of the technicians and 36% of the burses time was walking.











Traditional Processes


Lots of Stuff in Process = Long Cycle Times



Cycle Time = WIP / Exit Rate


Throughput Time  = WIP/Exit Rate = 5 people/1 person /minute

 Throughput Time = 5 minutes

 Throughput Time = WIP/Exit Rate = 13 people/1 person /minute

 Throughput Time = 5 minutes








Suppliers Inputs Process Outputs Customers
  • Physicians and nurses
  • Patients
  • Lab technicians
  • Insurance Company
  • Pharmacist
  • Supplier of Chemicals and other suppliers
  • Renal dialysis Guideline
  • Dialysis Machines
  • Water supply
  • Chemicals
  • Supplies and Chemicals
  1. Patient Registration
  2. Patient Examination, Weight, BP and Temperature
  3. Dialysis Process
  4. Patient follow up during dialysis
  5. Separation of Patient from the dialysis machine
  • Successful dialysis
  • Short waiting time
  • Good clinical and functional outcome
  • Health Education
  • Referred Patients
  • Daily reports
  • Statistics
  • Patients
  • Physicians and Nurses
  • Insurance Company
  • Referring Hospitals
  • Administration
  • Laboratory
  • Pharmacy




Example of a Process Activity Charts

Process Activity Chart                                                                              Page: 1 of 1

Process:                 X-ray                                                                           Date: 5/1/07

Developed by:       Boulder Community Hospital 

For each activity, fill in the required information. Also, connect the symbols to show the flow through the process.

The value code indicates whether the activity adds value (V), does not add value (N), or controls)

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