I want to tell you some ways to eliminate waste at your medical site. Am I talking about physical waste, like soiled bandages or used needles? No, I mean any action that results in a poor or unintended outcome. I mean taking too long to accomplish some outcome, like taking too long to get an operating room ready for the next surgery. The National Institute of Health in “Crossing the Quality Chasm” stated that any waiting time for a patient is a waste. A patient waiting past the time of his/her scheduled appointment is an example. A patient having to wait too long to be admitted to a hospital after being seen in the emergency room is an example of poor processes—a waste. A patient who develops an infection after being treated or going through surgery is a good example of waste from unintended outcomes. These are just a few examples. I am sure that you are aware of many more.



Japanese manufacturers are leaders in eliminating waste. One trick they use is to send a new employee to the manufacturing floor and have him/her watch someone performing a task; the new employee is told to watch until he/she sees a better way to do the job. These manufacturers know that the time spent doing this will save more time and money in due time. Hospitals and healthcare sites are not manufacturing plants, though. Yet many of the same principals can be applied. The effort will more than pay for itself. In fact, savings of 3 to 100 times the investment is not unusual. The movement going on in the healthcare field adapted from the Japanese manufacturers is commonly called “lean healthcare.” Perhaps you have heard of some of the terms associated with it, like Kaisen events or poka-yoke. You don't have to be a master of these tools and terms to make good use of them, though. Many are just applying logic with common sense.

The tools are best applied in efficient working teams or groups where some problems with processes or outcomes are already agreed upon. If the working group is larger than 3 or 4 people I suggest that one tool you use are string and 3 by 5 cards. You are going to use these to map out a process from beginning to end and see if the group can find waste and suggest ways to eliminate it. Use the cards to describe what physically happens during a process and use the string to connect the activities that flow from one to another. For example, you might want to track a patient in a doctor's office coming in for a physical. The first card would represent the patient's encounter with the first staff person who records the patient's presence. From there, strings would indicate communicating with other pertinent personnel of the patient's presence and the ensuing events as well a string and card that would indicate the patient waiting in the waiting room. In all of these mappings you should be thinking of what you would like to use as variables to measure. You certainly should be measuring time by all involved parties. You might also want to count the number of successes/failures in communications. Many unintended consequences occur at transition points and handoff points due to poor communication. You might count if a supply was missing and someone had to scurry to find another one. You will want to later find the mean and standard deviations of these measures. The goal is achieve a target mean with as small as possible standard deviation. For example, you should have 0 as a target for the number of times a supply was missing.

After reaching a mapping that all agree represents as best as possible the present flow of events, the group should brain storm ways to improve the flow. The goal is to find a significantly better path. If a consensus is reached, fine; implement it. If not, then perhaps you will want to try the various ways and then decide which is best, based upon agreed upon measures of outcomes.

Once an optimized process is developed by the staff, you should write it down. Make it a standard operating procedure and try to have all involved parties adopt it. You might want to allow a little bit of wiggle room for individual differences in performing a task; the goal of a common target with small standard deviation should the goal of all, though.

Another tool to use is open communication. Too often a staff person or nurse will see some event unfolding that will lead to poor outcomes. If the work environment is not conducive to positive communication—communication which does not result in negative outcomes for the reporting individual—mistakes and waste will always occur that could easily have been prevented. To reach a high level of positive communication, the leaders at a site must work long and patiently to build trust. It is not easy to do, but the payoffs are tremendous. Everyone wins!

Most healthcare leaders think of quality improvement as applying to activities that directly involve the patient. However, the best healthcare providers use these tools and others to evaluate all the processes at a healthcare site. The admissions and billings departments are ripe targets, for instance. The result will be happier, more motivated employees who are working more efficiently. In fact, sites which were experiencing a shortage of staff often finding themselves well staffed because of quality improvement processes. I do suggest that you promise all employees involved in these processes that you guarantee there will be no layoffs. Doing so will produce better outcomes.

If you want more examples of system wide applications of quality improvement in healthcare facilities, I suggest that you go to the Baldrige Award site on the internet and read the success stories of winners. Their results will amaze you, I promise.

I hope that you seriously consider adopting these tools and research other methods. Many are described at various healthcare sites. Two of my favorites are Institute for Healthcare Improvement and the American Academy of Family Physicians.