Leveraging Lean in Ancillary Hospital Services: Creating a Cost Effective, Standardized, High Quality, Patient-Focused Operation, 1st Edition (Paperback) book cover

Leveraging Lean in Ancillary Hospital Services

Creating a Cost Effective, Standardized, High Quality, Patient-Focused Operation, 1st Edition

By Charles Protzman, Joyce Kerpchar, George Mayzell

Productivity Press

354 pages | 106 B/W Illus.

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This book is part of a series of titles that are a spin-off of the Shingo Prize-winning book Leveraging Lean in Healthcare: Transforming Your Enterprise into a High Quality Patient Care Delivery System. Each book in the series focuses on a specific aspect of healthcare that has demonstrated significant process and quality improvements after a Lean implementation.

There are many departments within a hospital that support the primary function of caregiving and each can benefit from implementing Lean methodologies. Leveraging Lean in Ancillary Hospital Services: Creating a Cost Effective, Standardized, High Quality, Patient-Focused Operation provides a functional understanding of Lean processes and quality improvement techniques in nutritional services, inpatient floors, pharmacy, and radiology.

This book is ideal for healthcare executives, leaders, process improvement team members, and inquisitive frontline workers who want to implement and leverage Lean. Supplying detailed descriptions of Lean tools and methodologies, it identifies powerful Lean solutions specific to the needs of ancillary hospital services.

The first section provides an overview of Lean concepts, tools, methodologies, and applications. The second section focuses on the application of Lean in the ancillary hospital services environment. Presenting numerous examples, stories, case studies, and lessons learned, it examines the normal operation of each area in radiology, pharmacy, and nutritional services and highlights the areas where typical problems occur.

The case studies walk readers through various Lean initiatives and demonstrate how Lean tools and concepts have been used to achieve lasting improvements to processes and quality of care. It also introduces actionable blueprints that readers can duplicate or modify for use in their own institutions.

Illustrating leadership’s role in achieving departmental goals, this book will provide you with a well-rounded understanding of how Lean can be applied to achieve significant improvements throughout the entire continuum of care.

Table of Contents

Introduction to Lean

The Need for Change

National and Global Competition

Challenges for the Healthcare Worker

Lean and Layoffs

Traditional Healthcare Model

Introduction – So What is Lean?

Lean and Hospitals

What Results can you Expect?

The CEO and Lean

Typical Lean Metrics and Outcomes

Potential Lean Returns by Department

Typical Results/Return on Investments (ROI) and Implementing Lean

Lean and Systems Thinking

Boiled Frog Syndrome

Systems Thinking Principles

Viewing the Hospital with Systems Thinking

What is a Lean Business Delivery System?

Lean Business Delivery System Vision

Understanding the Value of the Lean Business Delivery System

Just In Time: The First Pillar of the Toyota Production System Model

An Example of One of the Rocks—Short-Staffed

Jidoka—The Second Pillar of the Toyota Production System

Jidoka Means: Never Pass on a Bad Part or Patient

Applying Jidoka to Healthcare

The Top of the Toyota House—Respect for Humanity

Lean is a Journey

Batching vs. Lean Thinking and Flow

Batching vs. Lean Thinking and Flow

Batching vs. Flow in a Healthcare Environment

Bathing Examples

Process Definition

Batching Systems

Why People Love to Batch?

One-Piece/Patient Flow

One-Piece Flow Example

Group Technology

Productivity - Definition

Batching The Domino Effect

Peak Demand

Examples of Batching in Healthcare

Chart Preparation

Application of One-Piece Flow to Healthcare

Flow—One-Piece Flow or Small Lot

Lean and Change Management

Implementing Lean is about Balance

Lean Culture Change


Change Equation

C ∙ Compelling Need to Change

Why Change?

V ∙ Vision

N ∙ Next Steps

Change and What’s In It For Me

Lean and Change Management

Lean and Organizational Change - "Right Seat on the Right Bus"

Resistance to Change

Changes… Highs and Lows

Rule of Unintended Consequences and Bumps in the Road

Change is a Funny Thing

We are all Interconnected but not Typically Measured that Way

Horse Analogy

Comparison to Where We are Today

Employee Suggestion Systems

Barriers to Change

Most Loved Words

Does Your Organization have Sacred Cows?

Leadership and Organizational Changes

Communication, Change and Lean


Lean Foundation

Lean Foundation Baseline in the Basics Model

Think—See—Act Lean

System Lean Implementation Approach Utilizing the Basics Model

A Customer Service Story

Baseline Metrics

Data, Revenue, and Hospitals

The Impact of Data on Lean – Process Focused Metrics

Customer Satisfaction

Voice of the Customer Surveys

The VIP Visit

Easy to Do Business With

Centralized = Batching

What Does All This Have to Do with Hospitals?

Customer Value-Added Proposition

Customer Quality Index

Baseline the Process

Value Stream Map (VSM) the Process

Value Stream Discussion

Value Stream Mapping and Healthcare

Value Streams Objectives

Traditional Hospital Systems - SILOS

Lean Goals

Parts of a Value Stream Map

Value Stream Map Icons

Value Stream Map Definitions

Day 1

Day 2

Day 3

Day 4

Day 5

Current State Value Stream Mapping

Ideal State

Future State Value Stream Mapping

Value Stream Map Project Lists, Prioritization Matrix, and Tracking

Value Stream Layout Maps (sometimes referred to as Skitumi maps)

Baselining the Process—Data Collection and Analysis—Current State

Takt Time/Production Smoothing

Available Time

Customer Demand

Peak Demand

Cycle Time

Cycle Time and Takt Time—What’s The Difference?

Designing Cycle Time to Takt Time

Length of Stay (LOS)

Length of Stay (LOS)

Length of Stay is Directly Correlated to Inventory

Length of Stay—A Key Metric

Reducing Length of Stay

Number of Staff Required

Total Labor Time


Weighted Average

Financial Metrics

Measuring Inventory and Cash Flow

Work in Process Inventory

Sales of Reimbursement per Employee

Contribution Margin

Cost Per Case

Data and What People Think

Sustainability and Accountability

Process Owners Do Not Always have the Skill Sets Necessary to Manage in a Lean Environment


Basic Lean Concepts and Tools – Assessment and Analyze

Levels of Waste

Low-Hanging Fruit

Five S Wastes

The Seven (Eight) Wastes

How do you Find Waste?

30-30-30 Exercise




Visual Controls


Cost of Waste

Baseline Entitlement Benchmark

Five Why’s


Another Tool to Get Rid of Waste: The Five W’s and Two H’s

Root Cause Analysis—A3 Strategy

Fishbones and Lean

Problem-Solving Model

Problem Statements

Lean Tools - Analyze/Assessment

BASICS—Assess the Process

Step One: Understand and Assess the Overall Process


Non-Value-Added Activities/Work

Non-Value-Added but Necessary Work

Unnecessary Work

Idle Time

Warranted IDLE Time Exceptions

The Patient Physical Examination

Step 1: Process Flow Analysis (PFA)—Following the Product/Patient

Mapping the Process—Identifying Process Boxes

Product Process Flow Analysis Tool

The Four Components Of PFA - Tips Analysis

Basic Lean Tools Understanding Types of Storage

Raw Material Storage

Work in Process Storage

Finished Goods Storage

Further Delineating Storage—Types of Work in Process

Lot Delay

Potential Lean Solution Example #1

Potential Lean Solution Example #2

Between Process Delay

Within Process Delay

Why Break Down Types of Storage?

Total Throughput Time

Product Process Flow Worksheet

Product Flow Point-to-Point Diagrams

How to Do a Point-to-Point Diagram

Network of Process vs. Operations Defined

Group Technology Matrix—Stratification Analysis

Example: Group Technology Applied to a Surgical Services Unit

Step II: Assess the Process—Operator Analysis or Full Work Analysis

Why Make the Operator’s (Staff Person’s) Job Easier?

Total Labor Time

Workload Balancing

How To Balance The Work

Separate Worker from Machine

Machine Time vs. Labor Time

Diagrams: Spaghetti Diagramming—Operator Walk Patterns

How to Do a Spaghetti Diagram

Network of Process vs. Operations Defined

Motion Study—Just When You Thought You Were "There"

Time is a Shadow of Motion

100% Efficiency with Humans

Operator Resistance

Step III: Assess the Process—Changeover Analysis

Internal Vs External Time

Four Parts of a Setup/Changeover Process

Healthcare Setup Translation

Why Reduce Setups? Benefits of Smed/SMER (Single Minute Exchange of Rooms)


Putting It All Together

Understanding Demand and Resource Needs

Appropriate Resourcing Can Drive Metrics

True Bottlenecks


How to Construct a Cross-Training Matrix

Heijunka—Sequencing Activities, Load Balancing

Standard Work


Job Breakdown/Work Flow Analysis

Developing Standard Work

Standard Work Form

Work Standards

Eventually Standard Work Can Lead to Semi- or Complete Automation

Leader Standard Work

Capacity Analysis—Part Production Capacity Sheet

Layout Design

Master Layouts

Creativity Before Capital

Lean Layout Design—Configurations—Determining the New Flow for the Area

The "U-Shaped" Layout

Straight Line Layouts

Parallel Layouts

Other Layout Considerations

Guidelines to Layout Re-design—Non-Negotiable

How Do We Know When the Layout is Right?

Work Station Design

Stand Up vs. Sit Down Stations with Chart Flow

Work Station Design Summary

Master Layouts and Lean Design

Lean and Architects

Do We Really Need to Add More Rooms or Space?

Layouts Drive Waste in the Form of Increased Labor Costs—Consider Adjacencies

Some Practical Examples of Lean Designs

Nursing Floors

Other Design Considerations

Lean and Regulatory Environment

Rate Companies on the Ability to Sustain Continuous Improvement Plan for Every Part—Amount of Supplies/Inventory Needed



What Parts Do We Kanban?

Constant Time or Constant Quantity

Implementing Lean in a Healthcare Environment

How to Implement Lean Methodology

The Lean System Implementation—Are You Ready for It?

What Type of Commitment is Required?

What is Kaikaku?


Importance of Lean Pilots

Keep the Ownership with the Line Organization

Lean Implementation Objections and Retail Sales Techniques

Objections are Good!

Types of Closing Questions

General Overarching Lean Implementation Tips

Team Charters

Guidelines for the Supervisor

Train the Staff in the New Process

Types of Training

Overview Training

On the Job Lean Training

Executive Training

The Lean Implementation Model

General Discussion of the Four Methods

Kaizen (Method 3) vs. the Traditional Point Kaizen (Method 2) Event Approach


Point Kaizen Events

Potential Pitfalls of the Traditional Point Kaizen Approach

Disadvantages of Point Kaizen Events Used for First Time Implementation

Advantages/Results of Kaizen Events

Visual Management System Components

Five S

Visual Displays

Visual Controls


Visual Management System

Lean Goal is Zero Defects—Difference Between an Error and a Defect

Poka Yoke

Types of Control and Warning Devices

Examples of Cause and Effect

Total Productivity Maintenance

Total Productivity Maintenance Goals

Overall Equipment Effectiveness

New Maintenance Paradigm

Lean and Maintenance in Hospitals

Construction Challenges

Hospital and IT Systems

BASICS—Checking the New Process

BASICS—Sustaining the Process

Sustaining Tools

Sustain Plans/Control Plans

Leader Standard Work

Visual Management



Staff Involvement

You Get What You Expect; You Deserve What You Tolerate

Additional Sustaining Tools

Repeat the Cycle!

Lean Practitioners.

Lean Hospital Implementation (System Kaizen and Point Kaizen) Lessons Learned

Create the Leadership Road Map

Make Sure Your Organization is Ready

Create a Lean Steering Committee—But Make It the Senior Leadership Team

Lean Consultants Should Report to the CEO

Create a Lean Organizational Infrastructure

Communication Plan

Training Plan

Leadership Cannot Stay in Their Ivory Tower

Leadership Must Lead and Drive Lean Changes, Not Just Support Them

Leaders Must Participate in Lean. You Cannot "Get It" in a Two hour or Four Hour PowerPoint Pitch

Don’t Let Lean Turn into Finance-Driven FTE Witch Hunts

Work to Establish the Lean Culture, Not Just the Tools

Insist On Updating Standard Work

Do Not Reward Work Arounds

Don’t Encourage the Victim Syndrome

Physician Resistance to Lean

Get Everyone Involved in the Analysis Phase

Give Lean System Implementation Time to Work Before Trying to Change the Underpinnings

Dedicate Resources Up Front

Include a Strategy for Accountability and Sustaining as Part of the Continuous Improvement Road Map

Listen to Your Lean Consultants/Experts

Adopt and Integrate Standard Work and Create a Suggestion and Reward Systems

Don’t Leave Managers in Place Who Aren’t Going to Get It

Don’t Lay People Off After Lean Implementation

Don’t Shortcut the Tools

Encourage Lean Architectural Designs

Include a "Go Forward" Person on the Team

Train, Train, Train

Create an Escalation Process

Identify the Process Owner and the Team Leader Up Front

Change Reward System

It’s Just a Bump in the Road

Multiple Site Rollout Strategies

Site/Area Selection

Trying to Implement Several Projects at Once without Sufficient Resources

Executives and Lean


Been There, Done That

More than just a Competitive Advantage

Board of Directors Training

Differences Between Lean and Six Sigma

Define Reality for the Lean Initiative

Resources and Accountability

Lean Should Be Where the Action Is

Removing Barriers

Measurements to Drive Outcomes

Who is to Blame?

You are What You Measure

Control or Sustain Process

Lean and Audits


Human Error Factor

Fair and Just Culture

Communication, Communication, and more Communication

Gemba – Where the Truth Can Be Found

What Questions Should You Ask When Doing a Gemba Walk?


Paying for Suggestions

Physician Engagement

The Cog in the Chain of Command

Value Stream Managers in the Lean Organization

Role of the External Consultant


Punch List of Considerations/Ideas for the Executive Leader

Roles and Responsibilities of Managers and Supervisors

Setting the Stage: Role of Managers and Supervisors

Do You Really Want to Know What I See? Do You Really Want to Know

What I Think

Key Responsibilities and Tools for Managers and Supervisors


Identify and Provide Resources

Time Management and the "Fires"

Standard Work and Healthcare

Following Standard Work Does Not Mean We Stop Thinking


Problems with Behaviors

Understanding Employee Satisfaction

Management and Supervisor Performance


The Journey of a Lean Sensei with a Star Wars Analogy

On-Line Lean Training

What It Means to Have a Lean Culture

Organizational Dissemination of Lean

Understanding what a Lean Culture Looks Like—"the People Piece"

Importance of the 50% People Piece

People vs. Task—We Need a Balance


Organizational Value Systems

Pearls of Advice

Managing Resistance to a Lean Culture Change

Lean Culture Assessment

Assessment Issues and Discussion

Motivation and Continuous Improvement

High-Level Steps to Implementing a Lean Culture

Step 1: Utilize Skip Levels to See What Your Employees are Thinking

Step 2: Education and Training

Step 3: Create a Pull for Lean

Step 4: Create a Lean Implementation Plan

Step 5: Create a Lean Steering Committee

Step 6: Baseline Metrics

Step 7: Implement a Pilot—Utilize the BASICS Model

Step 8: Gemba Walks

Step 9: Sustain—Hoshin and Suggestion System

Step 10: Continuous Improvement

Barriers to Continuous Improvement

Effort to Overcome Each Barrier Types

Work to Sustain and Improve with Lean

How Do You Get the CEO on Board?

Story…Lean in County Government

Committing the Right Resources to Sustain

Human Resources and Lean

Sustaining the Continuous Improvement Culture

Leveraging Lean in the Support Services

Leveraging Lean in the Pharmacy

Traditional Flow Hospital Pharmacy

Who Is to Blame When There Are Problems?

Steps We Follow and Tools We Use with Lean

What We Normally Find

Problem with Dispensing Robots (not to be Confused with Transport Robots)

First Level

Typical Results

Proposed Pharmacy Layout

Lean Recommendation

Second Level

Lean Results: Pharmacy

Leveraging Lean in Radiology

Traditional Flow

Story Charlie Protzman’s Personal Journal

Health Insurance Portability and Accountability Act and Lean

What We Find in Radiology

Tools We Use

Value Stream Map—Outpatients, Inpatients, Emergency Department Patients to X-Ray

Process Flow Analysis

Operator Work Flow Analysis

Standard Work

Turnaround Times and Calculations

Creating the Benefit—Increasing Capacity

How Do We Improve Turnaround Time?

How Do We Calculate Staffing for Radiology?

Other Considerations


Five S

Benefits of Applying Lean

Lean Results: Radiology

Leveraging Lean in Nutritional Services

Traditional Tray Line Assembly

Problems with Traditional Tray Lines

Batching Salads and Sandwiches—Cold Production Example


Steps to Improve the Process

Work Cells vs. Tray Line

Benefits of the New Lean System

Batch vs. Make to Order

Hot Food, Cold Preparation

Lean Solution

Dish Rooms

Lean Lessons Learned from a Nutritional Services Director



Change Management

Employee Relations


Computer Skills


Lean Team Location

Facilities and Engineering


Recognition and Incentives

Expansion Pains: "We Don’t Have Enough Space!"

Food Service Design

Food Service Leader’s Role in Lean

Learning through Lean

Cold Production for a Retherm System

Change Management - "The People Piece"


Appendix: Glossary


About the Originator

Subject Categories

BISAC Subject Codes/Headings:
BUSINESS & ECONOMICS / Industries / Service Industries
MEDICAL / Administration