Friday, April 3, 2009

Going Lean

In November, the California Health Care Safety Net Institute (SNI)launched its Lean Core Measures Improvement Initiative. Funded by the California HealthCare Foundation, the program will introduce and spread the use of Lean as a management strategy to streamline processes and create a more patient-focused environment that supports timely delivery of treatment and other healthcare services with optimum quality at the least cost. CCRMC, along with three other public hospital systems was awarded a grant to bring 'Lean' thinking to our system.

We have learned from other public systems such as Denver Health and New York City Health and Hospitals that Lean Management can yield tremendous results in a public system.

What's happening here at CCRMC?

As part of our award Mike Rona and Patti Crome from Rona Consulting provided a three-day Lean Intensive for some members of our leadership team. You may have seen some of the teams out in the medical center and clinics participating in an exercise called a waste walk.

This was an eye opening experience for those of us who went. We went out to the clinics and hospital in search of waste. We wrote down our examples on sticky notes and placed them on a wheel based on what type of waste they were. At times it was almost laughable, until we began to see the waste literally falling off our waste wheel. Some of us did what is called a spaghetti diagram. We followed the path of workers to see where they go to get their work done. The movement was phenomenal to watch. In summary, although it was a fun and very easy exercise, it was also quite sobering.

What is Lean?
Lean manufacturing or lean production, which is often known simply as "Lean", is a production practice that considers the expenditure of resources for any goal other than the creation of value for the end customer to be wasteful, and thus a target for elimination. Working from the perspective of the customer who consumes a product or service, "value" is defined as any action or process that a customer would be willing to pay for. Value is defined by the external customer and in our case it's always the patient. Basically, lean is centered on creating more value with less work. Lean manufacturing is a generic process management philosophy derived mostly from the Toyota Production System (TPS). It focuses on reduction of the original Toyota seven wastes in order to improve overall customer value.

Lean manufacturing is a variation on the theme of efficiency based on optimizing flow; increasing efficiency, decreasing waste, and using empirical methods to decide what matters, rather than uncritically accepting pre-existing ideas.

Why Lean and why now?

"The future is already here…it’s just not evenly distributed yet." *

For many of us it is difficult to hear our system described as "financially unsustainable," but that is how our system was described at last weeks board meeting. This shouldn't surprise any of us. As a government owned and operated system, we are in fact a reflection of the US Health Care system. I understand many would argue that industry is a better description than system. However you prefer to describe it, we do offer a glimpse of what the nation faces.

Currently health care makes up about 17% of the GDP and is climbing at a steady and very unsustainable rate.In America, we hear daily debates about bailouts, stimulus packages and health reform. Although the solutions are still in the development phase it is clear we must change course nationally and it is just as clear we must do the same here at the local level. Lean Management offers a systematic way of improving efficiency while improving not compromising quality.

What's Next?
Mike Rona and Patti Crome are on their way back to CCRMC. On April 20th we will work with teams of key stakeholders and perform an exercise called value stream mapping. This mapping will examine steps in our processes and weight them in value from a patients perspective. We will then follow this up with a series of rapid improvement events or kaizen events (also known as kaizen blitz). I know this seems like a foreign language, but that's because it is!

It feels like so much to learn, but we will learn together. We will take one step at a time. If we fall down seven times, we will get up eight. Please ask questions and keep an eye out for updates. Anyone from the Operations Team can answer your questions so please don't hesitate to ask.

More very soon...


  1. Hello Anna,

    With great excitement, I read your April 3 entry in your safetynethospital blog about plans to implement Lean Management within our health system. I was very impressed by all I learned at the IHI conference in Vancouver but feel mostly powerless, as an individual provider, to implement new strategies. It is great to see that those honored within our system with this authority are pursuing ambitious goals.

    If there are ways that I can be of assistance in either my work at Pittsburg Health Center or the newborn nursery, please tell me.

    Good luck!

    Tai Roe

  2. Tai,
    I do understand feeling powerless as an individual. I once shared those feelings. However, I have seen transformation in systems from all over the world. I learned from the experience of these great systems and through study of the work of great leaders in improvement such as Deming and S. Toyoda, K. Toyoda, Ohno, Juran, Donabedian, Shewhart, Berwick, and Nolan (I'll stop but there are many more!), that change begins with one person.

    Without your excitement and the excitement and willingness of others in our system to engage in relentless reflection and continuous improvement, we as a system will not be able to change. The power lies within each one of us. The final slide of our three days said two words "CHANGE ME"
    Transformation always begins with the individual. I'm so pleased you’re excited and looking to contribute.

    We've been looking for you!

  3. The goals of your organization appear to be well suited to a lean transformation. And lower waste is certainly the most visible outcome of lean. Still, I hope that you’ve been cautioned that directly targeting this outcome without first understanding the organization’s dynamic conditions--those uncertain demands and shifting needs that often drives these wastes to accumulate in the first place--can affect what your efforts are able to achieve.

    This dynamic focus, which has been demonstrated by some of the world’s most successful firms, seems particularly important for dealing with the types of challenges faced by healthcare.

  4. Dear Mr. Ruffa,

    Your comments are greatly appreciated. I agree that the shifting demands and the root cause of those are critical for us to understand. It will be a great challenge.

    We have been told how important it is to avoid oversimplifying the journey of a Lean transformation and that although many organizations employ Lean techniques, far less experience total transformation.

    I do believe that we (the system) create not all, but a significant amount of the variation in demand, and that our fully integrated health system is well positioned to significantly level or smooth our flow using Lean principles.

    I would like to learn more. I have read your book "Going Lean" and am waiting the arrival of "Breaking the Cost Barrier". Can you direct me to any other resources?

  5. I'm glad my comments were helpful. In response to your question, I just wrote an article to help explain the importance of applying a "lean dynamics" methodology to challenging circumstances (like those seen in healthcare)--how this produces stronger, much more sustainable results that lead to greater innovation.

    The article titled, "Going Lean as a Solution to Navigating Uncertainty and Crisis", and you can link to it through my book's website at

    Also, more is on the way--including training and other publications. If anyone has specific questions, they can reach me through the same website.