This much is obvious: People are not cars. And yet, the same "lean thinking" techniques that fueled Toyota's global success in quality and market share are having a dramatic impact on the delivery of health care, and helping the University of Michigan to map a future of medicine that relies on new efficiencies and smart innovations to improve patient care and lower health care costs.

Lean efforts—which reassess work to maximize value and learning while minimizing waste—have been under way at U-M for several years. Recent initiatives cut door-to-balloon times for heart attack patients, reduce the lengths of stay for critical care patients on ventilators, and improve access for new patients to the Urology Clinic.

Lean, Mean Operating Scene

One significant project illustrates the impact of looking at medicine through lean-colored lenses. For a year-and-a-half, Department of Otolaryngology Chair Carol Bradford, MD '86, turned her operating room into a laboratory—the first anywhere to apply the lean model to head and neck surgery. Not only were she and her colleagues able to identify about 75 hours of wasted time per year within her weekly block of two operating days, they showed that focusing on efficiency and profitability does not have to come at the expense of staff morale, surgical resident education, or patient care.

If the approach were extended to all 35 adult operating rooms over a five-day work week, it could add as many as 6,500 additional hours of OR capacity each year and potentially millions in new revenue, according to the team's study, which was published in the June issue of the Journal of the American College of Surgeons. "Most of the changes we made were actually pretty simple—like doing certain tasks simultaneously rather than in series," says Bradford. "But simple things can pay big dividends."

"Efficiency is without question part of health care reform ... simple things can pay big dividends."—Dr. Bradford

The findings come at a time when hospital budgets have been strained by financial downturn, high rates of uninsurance and underinsurance, and potential impacts from changes to federal health care laws. "Efficiency is, without question, part of health care reform," Bradford says.

Adding Value

The 1990 bestseller The Machine That Changed the World describes the difference between mass production and lean production as a "difference in goals." Mass production settles for being cost effective and "good enough," while lean producers "set their sights explicitly on perfection" and continual improvement. At its core, lean thinking is about ensuring that each step of a particular process adds value for the customer. In Bradford's case that covers all aspects of an operation, from the induction of anesthesia to application of surgical dressing.

"Doctors and nurses already do this process in their clinical practice every day," explains U-M's lean guru John E. "Jack" Billi, M.D., professor of internal medicine. "The only difference here is the patient is the Health System."

Billi heads the Michigan Quality System (MQS), the unit implementing lean across UMHS. MQS efforts are coordinated by an operations team and supported by seven full-time lean coaches and more than 20 additional part-time coaches embedded across various departments.

Besides valuing the insights of front-line workers over top-down directives, leaders of lean-thinking organizations also spend time in the trenches observing the real capabilities and difficulties within an organization. Above all, lean principles are stubbornly practical, says Michael W. Mulholland, M.D., Ph.D., the Frederick A. Coller Distinguished Professor of Surgery and chair of the Department of Surgery.

Lean principles are stubbornly practical; almost too simple, too common-sense.

"At first the idea that one would go and look at a problem, talk to workers about it, write down problems, dissect them to their root causes, and then address them one by one almost seemed too simple, too common sense," he says.

But Mulholland's initial skepticism of the lean approach was eclipsed after witnessing the success of projects like Bradford's, which was a finalist for the 2011 National Lean Best Practice Award presented by the Institute of Industrial Engineers. Competitors included innovators at IBM, Xerox, and Vought Aircraft Industries.

"Every discrete improvement is cumulative," Mulholland says.

Building Mutual Trust

The analysis in Bradford's OR, spearheaded by the study's first author, Ryan M. Collar, M.D., and lean trainer Mary Duck, began by mapping the actions and responsibilities for each of seven roles—from surgical faculty to scrub nurses, from anesthesiologists to OR technicians—for every stage of an operation.

"By doing the timelines and working out who is doing what, when and why, we could actually see as a group where the issues really were," says David Healy, M.D., assistant professor of anesthesiology and director of head and neck anesthesia. The exercise helped each role to better understand their colleagues' unique responsibilities and challenges, he notes. "It gives you renewed respect for the people you work with."

"Every discrete improvement is cumulative."—
Dr. Mulholland

Adds Bradford: "Creating a team of people who trust each other and who can ask questions and work together as a team is probably the most important take-away from this process."

The study measured staff morale, feelings of support, and thoughts about problem-solving before and after the lean implementation. Progress was made in every category, with the composite score rising from 2.93 to 3.61—an improvement of more than 20 percent. The research also surveyed surgical residents and found the increased emphasis on efficiency did not have a detrimental effect on their education.

Right System, Right Culture

Although he wasn't a doctor, what naturalist John Muir said of the entire universe is equally true of health care systems: When you try to pick out anything by itself, you find it's hitched to everything else.

Thus, creating 6,500 hours of new operating room capacity would require having enough inpatient beds for all those new patients. As problems are addressed, bottlenecks tend to shift downstream. "U-M has been so successful that we don't have enough beds and operating rooms to easily accommodate all the patients who want to come here," Mulholland says. "So the top-priority projects within the surgical value stream deal with capacity, which can be improved by more efficient and coordinated use of our physical assets."

U-M received coaching on its first few lean initiatives from General Motors Corp., which itself had come to realize the value of lean principles, but coaching alone will never get the system where it needs to go, says Billi.

"Like every health system in the country, we have challenges. We need to be honest about them and try to understand their causes—and then help the front-line workers find and fix the root cause of the most important problems because they know the work the best."

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Since 2009, more than 200 "everyday lean" ideas have been implemented. Something as simple as adding drawer dividers and reorganizing a single supply cart can save a nurse an estimated hour per day.

That said, the lean approach doesn't attempt to tackle the existing organizational culture head-on, according to Billi. "Within lean thinking, the concept of culture is really important. But culture is a result of the right processes. If you want a culture that empowers workers to solve problems, you don't get a culture transplant—the right system will build the right culture.

"Toyota's leaders have said they combined average workers with brilliant processes to produce superb work," Billi says. "We have brilliant people at the U-M. Imagine what we can do when we make our processes equally brilliant."

What do you think about U-M's effort to bring lean principles into health care delivery?

This story appeared in the Summer 2012 issue of Medicine at Michigan.