1st Edition

Process Redesign for Health Care Using Lean Thinking A Guide for Improving Patient Flow and the Quality and Safety of Care

By David I. Ben-Tovim Copyright 2017
    222 Pages 35 B/W Illustrations
    by Productivity Press

    222 Pages 35 B/W Illustrations
    by Productivity Press

    222 Pages 35 B/W Illustrations
    by Productivity Press

    Process Redesign for Health Care Using Lean Thinking is a response to a simple, but hard to answer, question and is the result of the experiences of a working doctor who was also the chief safety and quality officer of an Australian teaching hospital. At this hospital, he observed that the Emergency Department was staff by talented, well-trained, and respected doctors and nurses. The facilities were modern, and the work load unexceptional, but the department was close to melt down. Bad things were happening to patients, everyone was blaming each other, lots of things had been tried but nothing was getting better and no one could explain why. The problem was not a lack of technical knowledge or expertise, the problem was that no one stood back and said, "what’s the best way to move 200 or 300 patients a day through the complicated and varying, sequence of steps needed to sort out the many different problems that bring patients to our department?"

    These challenges are faced by hospitals and health services all over the world. There are difficulties with patient flow, congestion, queues, inefficient utilization of resources, problems engaging clinical staff in improvement programs, adverse incidents, and budget constraints.

    Lean thinking and value stream analysis gives hospitals and health services struggling with these issues the insights they need to help themselves. This book provides a method that systematically turns those insights into working programs of service and system redesign.

    The book is divided into two sections. The first section gives the background to the approach, and systematically works through the Process Redesign methodology, step-by-step. The second section is a series of case studies that show the methodology in action, what worked and what didn’t work. The goal of any process redesign is simple: the right care, for the right person, at the right time, in the right place, and right the first time. This book helps the people who work in hospitals and health services realize these goals by working together.

    Part 1: Process Redesign – the complete method

    Chapter 1: Introduction: An accidental redesigner

    •  Why redesign?
    •  Learning about Lean
    •  A decade later

    Chapter 2: Craft, Flow, Mass

    •  British manufacturing: the extension of the craft work system
    •  The American method of production
    •  Moving to mass

    Chapter 3: Taiichi Ohno and the Birth of Lean

    •  Toyota and Taiichi Ohno
    •  Waste and flow
    •  Push and pull
    •  Workers as problem solvers: the challenge for managers

    Chapter 4: The Principles of Lean Thinking

    •  The process viewpoint: the golden thread of Lean
    •  The Lean principles
    •  Principle 1: specify value from the standpoint of the end-customer
    •  Principle 2: identify the value stream for each product family
    •  Principle 3: eliminate waste and make the product flow
    •  Principle 4: so that the customer can pull
    •  Principle 5: as you manage towards perfection

    Chapter 5: Healthcare is not manufacturing

    •  The Lean principles are very important – but
    •  Placing an order: customers and raw materials
    •  Redesign double vision
    •  Complicated: or complex and adaptive?

    Chapter 6: Knowledge work

    •  Knowledge work
    •  Knowledge workers own their knowledge capital
    •  Design
    •  Or Redesign

    Chapter 7: Redesigning care: authorization, permission, teams and governance

    •  Authorization and permission
    •  The redesign team
    •  Governance
    •  The workgroup and the improvement event

    Chapter 8: The virtuous circle of Process Redesign and the A3

    Chapter 9: Identifying the problem

    •  Primary purpose, problems and concerns
    •  Problem statements
    •  What kind of problem, and where to start?

    Chapter 10: Defining the scope

    •  The benefits of starting with scope
    •  Scope and scoping: an evolving task

    Chapter 11: Diagnosis (1) Mapping – the Big Picture

    •  The process of Big Picture Mapping: a social intervention
    •  Setting up and undertaking a Big Picture Mapping

    Chapter 12: Diagnosis (2) Direct observation

    •  External or internal redesign capacity?
    •  The structure of the learning to see phase
    •  Tracking patients or tracking specific process steps
    •  Analysis

    Chapter 13: The real problem (1): Identifying the real problem

    •  Root cause analysis, the five whys and effect-and-cause analysis

    Chapter 14: The real problem (2): Measurement

    •  Measurement for redesign-types of measurement
    •  The basic triad of analysis design
    •  Measurement focus: releasing time or improving outcomes (or both)
    •  Measuring processes or outcomes

    Chapter 15: Goals, the scientific method and the future state

    •  Experiments and the Plan-Do-Study-Act cycle
    •  Goals

    Chapter 16: Value stream, batching and flow improvement

    •  Making the process viable
    •  Splitting into value streams
    •  Flow
    •  Takt time
    •  Batching
    •  Improving flow: eliminate, combine, reduce, simplify

    Chapter 17: Targeted interventions – 5s, visual management and visual systems

    •  5s
    •  Visual management
    •  The ideal visual management system

    Chapter 18: Queues, prioritizing, capacity and demand

    •  Acknowledging Erlang – the Calling population
    •  Queue discipline – First in, first out
    •  Queue discipline: planned work, short term queue, shortest service time
    •  Capacity lost, demand moves forward
    •  Queues and priorities
    •  Analysis of capacity and demand
    •  Exponential growth in queue length
    •  Impossible jobs

    Chapter 19: Embedding and sustaining

    •  Measure, monitor, evaluate
    •  A formal decision to adopt the new way
    •  The front-line manager
    •  A culture of continuous improvement

    Part 2: Case Studies

    Chapter 20: Case Study 1: Redesigning Emergency Department flows

    •  The problem
    •  Scoping
    •  Diagnosis
    •  The real problem
    •  Intervention
    •  ED works
    •  Evaluation
    •  Embedding and sustaining

    Chapter 21: Case Study 2: The Care-After-Hours Program

    •  The problem
    •  Authorization and permission
    •  Scoping
    •  Diagnosis
    •  Four major-work streams
    •  The real problem
    •  Intervention
    •  The Electronic Medical Task Board
    •  Evaluation
    •  Embedding and sustaining
    •  Continuity of information

    Chapter 22: Case Study 3: Visual Management

    •  The Patient Journey Boards
    •  Scoping
    •  Diagnosis-tracking
    •  The real problem
    •  Intervention
    •  Evaluation
    •  Discharge traffic lights and blue dots

    Chapter 23: Case Study 4: Redesigning podiatry care

    •  The problem
    •  Diagnosis
    •  The real problem
    •  Interventions
    •  Evaluations

    Chapter 24: Conclusion – Redesigning Process Redesign


    Dr. David Ben-Tovim is a psychiatrist and Clinical Epidemiologist by background. He trained in medicine and psychiatry in London, at the Middlesex and St Georges University Hospital, and later in Clinical Epidemiology at the Institute of Psychiatry, also in London. He worked for three years in Botswana before migrating to South Australia where he has lived and worked in 1984. In 1998, whilst continuing part-time practice as a psychiatrist, he became the Director of the Clinical Epidemiology Unit at the Flinders Medical Centre, and in 2000, became Director of Clinical Governance. He initiated the Redesigning Care program at Flinders in 2004, and continued as the Director of the Redesigning Care and Clinical Epidemiology Units until 2014.Whilst Director of the Redesigning Care Unit, Dr. Ben-Tovim became involved in teaching, training, and the development of programs of flow improvement, and process redesign, in all the Australian states and territories, in New Zealand, Singapore, the Middle East (including Dubai, Oman and Saudi Arabia) and South Africa, as well as various parts of Europe and occasionally, the U.S.A.

    He is the chairman and co-founder of the Australasian Lean Healthcare Network . Since 2005 the Network has put on annual Redesigning Care Summits in conjunction with Lean Enterprise Australia. The Summits draw participation from across the region.

    Dr. Ben-Tovim has a PhD as well as medical qualifications. He has been an active clinical researcher throughout his career. He is currently Professor, Clinical Epidemiology and Process Redesign, Flinders University Centre for Epidemiology and Biostatistics and the Department of Primary Care. Currently, he concentrates on training and research in Redesign and Process Improvement, and on measurement and evaluation of indicators of healthcare safety and quality.

    Dr. Ben-Tovim has published on a range of topics in the peer reviewed literature, including a series of frequently quoted articles on Lean Thinking and Redesign in Healthcare. He has also co-authored a textbook of psychiatry for developing countries, and a book about his work in Botswana, published by Tavistock /Routledge.

    "I loved David’s book. He speaks with a distinct personal voice that combines deep personal experience and a framework that places that experience in a universal healthcare context. There is nothing else like it."

    John Shook, Chairman, Lean Enterprise Institute Inc, Cambridge MA