LEAN HEALTHCARE IMPLEMENTATION: EXPERIENCES AND LESSONS LEARNED FROM BRAZILIAN HOSPITALS

RÉGIS, TATYANA KARLA OLIVEIRA; GOHR, CLÁUDIA FABIANA; SANTOS, LUCIANO COSTA

doi:10.1590/S0034-759020180104

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ARTICLES • Rev. adm. empres. 58 (1) • Jan-Feb 2018 • https://doi.org/10.1590/S0034-759020180104 copy

LEAN HEALTHCARE IMPLEMENTATION: EXPERIENCES AND LESSONS LEARNED FROM BRAZILIAN HOSPITALS

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

This study aimed to analyze the process of implementing lean healthcare in three Brazilian hospitals that have played a pioneering role in the implementation of this system. We adopted the case study approach and collected data through interviews, document analysis, and observation. The results showed that the processes of implementation of lean healthcare in the hospitals shared many similarities in terms of the flow of patients, materials, or information. Finally, it was possible to obtain some guidelines for the application of lean principles and techniques in order to facilitate the implementation of lean healthcare in hospital operations.

KEYWORDS
Lean production; lean healthcare; service operations; healthcare operations; case studies

Categories	Implementation process	Authors
History and trajectory of implementation	- Motivational factors - Implementation structure	Bertani (2012)Bertani, T. M. (2012). Lean healthcare: Recomendações para implantações dos conceitos de produção enxuta em ambientes hospitalares (Dissertação de mestrado). Recuperado de http://www.teses.usp.br/teses/disponiveis/18/18156/tde-29102012-235205/es.php http://www.teses.usp.br/teses/disponivei... ; Carter et al. (2012)Carter, P. M., Desmond, J. S., Akanbobnaab, C., Oteng, R. A., Rominski, S. D., Barsan, W. G., & Cunningham, R. M. (2012). Optimizing clinical operations as part of a global emergency medicine initiative in Kumasi, Ghana: Application of lean manufacturing principals to low-resource health systems. Academic Emergency Medicine, 19(3), 338-347. doi:10.1111/j.1553-2712.2012.01311.x https://doi.org/10.1111/j.1553-2712.2012... . Radnor et al. (2012)Radnor, Z. J., Holweg, M., & Waring, J. (2012). Lean in healthcare: The unfilled promise? Social Science & Medicine, 74(3), 364-371. doi:10.1016/j.socscimed.2011.02.011 https://doi.org/10.1016/j.socscimed.2011... ; Burgess and Radnor (2013)Burgess, N., & Radnor, Z. (2013). Evaluating lean in healthcare. International Journal of Health Care, 26(3), 220-235. doi:10.1108/09526861311311418 https://doi.org/10.1108/0952686131131141... .
Implementation of lean techniques	- Process waste - Hospital processes versus lean techniques - Results achieved - Difficulties	Jimmerson (2010)Jimmerson, C. (2010). Value stream mapping for healthcare made easy. New York, USA: Editora Productivity Press.; Graban (2013)Graban, M. (2013). Hospitais lean: Melhorando a qualidade, a segurança dos pacientes e o envolvimento dos funcionários. Porto Alegre, RS: Editora Bookman.; Ben-Tovim et al. (2008)Ben-Tovim, D. I., Bassham, J. E., Bennett, D. M., Dougherty, M. L., Martin, M. A., Neill, S. J., ... & Szwarcbord, M. G. (2008). Redesigning care at the Flinders Medical Centre: Clinical process redesign using "lean thinking". Medical Journal of Australia, 188(6), 27-31.; Teichgräber and Bucourt (2012)Teichgräber, U. K., & Bucourt, M. (2012). Applying value stream mapping techniques to eliminate non-value-added waste for the procurement of endovascular stents. European Journal of Radiology, 81(1), 47-52. doi:10.1016/j.ejrad.2010.12.045 https://doi.org/10.1016/j.ejrad.2010.12.... ; Laganga (2011)LaGanga, L. R. (2011). Lean service operations: Reflections and new directions for capacity expansion in outpatient clinics. Journal of Operations Management, 29(5), 422-433. doi:10.1016/j.jom.2010.12.005 https://doi.org/10.1016/j.jom.2010.12.00... ; Sullivan et al. (2014)Sullivan, P., Soefje, S., Reinhart, D., McGeary, C., & Cabie, E. D. (2014). Using lean methodology to improve productivity in a hospital oncology pharmacy. American Journal of Health-System Pharmacy, 71(17), 1491-1498. doi:10.2146/ajhp130436 https://doi.org/10.2146/ajhp130436... .
Development of improvement culture	- Human resources training - Commitment to human resources	Bertani (2012)Bertani, T. M. (2012). Lean healthcare: Recomendações para implantações dos conceitos de produção enxuta em ambientes hospitalares (Dissertação de mestrado). Recuperado de http://www.teses.usp.br/teses/disponiveis/18/18156/tde-29102012-235205/es.php http://www.teses.usp.br/teses/disponivei... ; Papadopoulos et al. (2011)Papadopoulos, T., Radnor, Z., & Merali, Y. (2011). The role of actor associations in understanding the implementation of lean thinking in healthcare. International Journal of Operations & Production Management, 31(2), 167-191. doi:10.1108/01443571111104755 https://doi.org/10.1108/0144357111110475... .

Information	Cases
Information	A	B	C
Type	Medium-sized philanthropic	Large-sized private (private services or agreements)	Private
Founding year	1920	1945	1995
Employees	600	1650	150
Services	Oncology (cancer treatment: surgeries, chemotherapy, radiotherapy, and tests) by the Unified Health System (Sistema Único de Saúde - SUS)	Foco em cardiologia, neurologia, Focused on cardiology, neurology, oncology, emergencies, trauma/orthopedics, and kidney, pancreas and liver transplants; performs transplants and tests by the SUS.Teaching and research institute	Specialized in cancer diagnosis and treatmentResponsible for the oncology service of a state hospital (Hospital C1)
Characteristics	Two buildings: outpatient (capacity for 210 appointments per day) and hospital (76 beds and 4 surgical rooms)	30 mil m² area, 258 operational beds, 68 ICU beds, capacity for 1,000 surgeries/month, 1,160 admissions/month and 6,050 emergency attendances/month	No information
Beginning of LP	2011	2013	2008

Case	Interviewees	Collection tools	Duration of the interview
A	Quality coordinator	Semi-structured interviews, document analysis, and unsystematic observations	1h30 and 1h
A	Radiotherapy coordinator		1h05
B	Quality coordinator		2h30 and 30min
C	Quality manager	Non-structured interviews, unsystematic observations	1h05

Process	Techniques	Results
Chemotherapy	VSM, kaizen, 5S, workload leveling, standardization, team work and multifunctional workers, visual control, and zero defect quality control.	Increase of 23% in the capacity of chemotherapy application.Decrease of patient waiting time for chemotherapy infusion to 1 h.Decrease in the time of seat loading of 40 min.
Triage	VSM, kaizen, workload leveling and standardization.	^* * Processes with results that were not described.
Authorization of High Complexity Procedures (Autorização de Procedimentos de Alta Complexidade [APAC])	VSM, kaizen, standardization.	Decrease of 74%, or up to 28 days, in patient lead time.
Reception	VSM, kaizen, 5S, standardization, and zero defect quality control.	^* * Processes with results that were not described.
Patient record control		^* * Processes with results that were not described.
Laboratories		Decrease of 90% in test deadline.
Pharmacy	5S, standardization, and zero defect quality control.	Increased productivity in drug handling.
Radiotherapy	VSM, kaizen, standardization, visual management, 5S, SMED, zero defect quality control.	Decreased waiting time from 50 min to 20 min.Creation of a reception.

Processes	Techniques	Results
Surgery scheduling	VSM, kaizen, 5S, standardization, workload leveling, takt time synchronization, zero defect quality control, and cellular layout.	Decreased waiting time, decrease of 28% in the number of cancelled surgeries.
Patient reception	VSM, kaizen, 5S, standardization, takt time synchronization, visual control, and zero defect quality control.	Decreased waiting time.
Bed management	VSM, kaizen, 5S, standardization, workload leveling, takt time synchronization, zero defect quality control, and visual control.	Decreased bed turnaround time from 5 h 30 to 2 h 30, growth of 300% in the number of opened vacancies and decrease of 56% in the time of bed cleaning.
Patient admission in the admissions unit	VSM, kaizen, 5S, standardization, takt time synchronization, visual control, and zero defect quality control.	Decreased times.
Release process		^* * Processes with results that were not detailed in the field research.
Surgical center: sterilization central, post-anesthesia recovery	VSM, kaizen, 5S, standardization, takt time synchronization, zero defect quality control, autonomation, SMED, total productive maintenance, visual control, cellular layout.	Lean room project (through a pilot, decrease in turnaround time from 100 min to 16 min), elimination of pharmacy rework.
Patient transportation	VSM, kaizen, 5S, standardization, takt time synchronization, total productive maintenance, zero defect quality control.	^* * Processes with results that were not detailed in the field research.
Information flow	VSM, kaizen, 5S, standardization, takt time synchronization, visual control, zero defect quality control.	^* * Processes with results that were not detailed in the field research.
Supplies	VSM, kaizen, 5S, cellular layout, standardization, takt time synchronization, zero defect quality control, visual control, kanban.	Decrease of 3% in inventory, deactivation of the pharmacy that supplied ICUs, and creation of a new ICU with 10 beds.Deactivation of four satellite pharmacies and use of bedside carts.
OPSM flow	VSM, kaizen, 5S, standardization, takt time synchronization, visual control, and zero defect quality control.	^* * Processes with results that were not detailed in the field research.
Invoice central	Group technology and cellular layout.	^* * Processes with results that were not detailed in the field research.
Billing	Group technology and cellular layout.	^* * Processes with results that were not detailed in the field research.

Process	Techniques	Results
Reception	VSM, kaizen, visual control, 5S, standardization, zero defect quality control, team work, and multifunctional workers.	Decrease of 30% in waste.
Invoice central	VSM, kaizen, visual control, 5S, standardization, zero defect quality control.	Decrease of 90% in waste.
Supplies	VSM, kaizen, visual control, 5S, standardization, zero defect quality control.	Decrease of 70% in inventory.
Billing	VSM, kaizen, visual control, 5S, standardization, zero defect quality control, team work, and multifunctional workers.	Billing in real time.
Outpatient	VSM, kaizen, visual control, 5S, standardization, and zero defect quality control.	Increase of 170% in appointment capacity.
Pharmacy		^* * Processes which results were not described.
Laboratories
Emergencies
Chemotherapy
Radiotherapy	VSM, kaizen, visual control, 5S, standardization, zero defect quality control, and SMED.	Decreased waiting time for radiotherapy from 2 h 30 to 1 h Increased efficiency of radiotherapy machines from 44% to 70%.
Maintenance	Visual control, 5S, standardization, and zero defect quality control.	^* * Processes which results were not described.
Laundry	5S.	^* * Processes which results were not described.

Process	Hospital	Techniques applied	Number of techniques
Chemotherapy	A	VSM, kaizen, 5S, workload leveling, standardization, team work and multifunctional workers, visual control, and zero defect quality control.	8
Chemotherapy	C	VSM, kaizen, visual control, 5S, standardization, and zero defect quality control.	6
Radiotherapy	A	VSM, kaizen, standardization, visual control, 5S, zero defect quality control.	6
Radiotherapy	C		6
Laboratories	A	VSM, kaizen, 5S, standardization, and zero defect quality control.	5
Laboratories	C	VSM, kaizen, visual control, 5S, standardization, zero defect quality control.	6
Pharmacy	A	5S, standardization, and zero defect quality control.	3
	B	VSM, kaizen, 5S, cellular layout, standardization, takt time synchronization, zero defect quality control, visual control, kanban.	9
	C	VSM, kaizen, visual control, 5S, standardization, and zero defect quality control.	6
Reception	A	VSM, kaizen, 5S, standardization, and zero defect quality control.	5
	B	VSM, kaizen, 5S, standardization, takt time synchronization, visual control, and zero defect quality control.	7
	C	VSM, kaizen, visual control, 5S, standardization, zero defect quality control, team work, and multifunctional workers.	7
Invoice central	B	Group technology and cellular layout.	1
Invoice central	C	VSM, kaizen, visual control, 5S, standardization, zero defect quality control.	6
Billing	B	Group technology and cellular layout.	1
Billing	C	VSM, kaizen, visual control, 5S, standardization, zero defect quality control, team work, and multifunctional workers.	7

Fundação Getulio Vargas, Escola de Administração de Empresas de S.Paulo Av 9 de Julho, 2029, 01313-902 S. Paulo - SP Brasil, Tel.: (55 11) 3799-7999, Fax: (55 11) 3799-7871 - São Paulo - SP - Brazil
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