Literature week 6 HSOM
Young et al. (2004) Using industrial processes to improve patient care.
Education and debate.
Three established industrial approaches (which might help improve health care):
- Lean thinking: started with Toyota, seeks to provide what the customer wants,
quickly, efficiently, and with little waste. In health care, this lies in
minimizing/eliminating delay, repeated encounters, errors and inappropriate
procedures. It’s hard to say that patients are customers, and health outcomes and
satisfaction defines value. The process is also not clearly defined in hc. This way of
thinking reduces staff, because the products can be produced with less people. A
lean environment will thus have sufficient capacity to handle variations without
introducing queues. But, high utilization of a service might not outweigh the costs of
moving people from unit to unit, waiting times etc. High efficiency is therefore only
part of the story, need to also take the waste into account. Also, if an expensive
piece of equipment supports more effective and efficient pathways, its costs might
be justified even if utilization is low.
o Challenge 1: The different types of records held by each sector make it
difficult to piece whole trajectories together for a complete data overview on
patient flows.
o Challenge 2: delivering care under a truly lean model. It is not clear how
certain things would be made more lean, like eliminating waiting
time/queues completely. For this, interactive/gaming approach scenario
simulation could be useful.
- Theory of constraints: a chain is only as strong as its weakest link. This methodology
targets bottlenecks or constraints. The location of bottlenecks in healthcare is not
obvious, and a rigorous analysis should take place. Access to primary care might be a
bottleneck. However, there will always be a bottleneck, it is about where one wants
it. Another perspective says that anything that increases throughput at the
bottleneck adds value to the system so long as it is safe. This theory would lower an
occupancy to match the bottleneck’s (e.g. OR) throughput, even if a proportion of
the resources (staff costs, heating, lighting etc) seem to be wasted as a
1
, consequence. The focus of this theory really is on relieving bottlenecks rather than
agonizing over wasteful idle resources.
- Six sigma: Motorola made this universal system to assess quality, produce
quantifiable results, and establish quality goals. Six sigma usually defined as 3.4
defects per million. It needs good data, clearly defined critical outcomes and
agreement on what a defect is. In hc it must also include the clinicians’ and other
stakeholders’ perspectives and clarify who the customer is. Key issue: not the
number of errors, but having a systematic process to identify the sources of error
and drive them out.
- Common features of these three approaches: each emphasizes the concept of
production as a complex interaction of activities. It also recognizes that for
production to be efficient and effective, it’s necessary to coordinate and balance
activities, identify weak links/bottlenecks, and take appropriate action. All
approaches require strong leadership, problem solving and participation of all in all
parts of the system. Gradual improvement, with all stakeholders included (even
patients).
2
Young et al. (2004) Using industrial processes to improve patient care.
Education and debate.
Three established industrial approaches (which might help improve health care):
- Lean thinking: started with Toyota, seeks to provide what the customer wants,
quickly, efficiently, and with little waste. In health care, this lies in
minimizing/eliminating delay, repeated encounters, errors and inappropriate
procedures. It’s hard to say that patients are customers, and health outcomes and
satisfaction defines value. The process is also not clearly defined in hc. This way of
thinking reduces staff, because the products can be produced with less people. A
lean environment will thus have sufficient capacity to handle variations without
introducing queues. But, high utilization of a service might not outweigh the costs of
moving people from unit to unit, waiting times etc. High efficiency is therefore only
part of the story, need to also take the waste into account. Also, if an expensive
piece of equipment supports more effective and efficient pathways, its costs might
be justified even if utilization is low.
o Challenge 1: The different types of records held by each sector make it
difficult to piece whole trajectories together for a complete data overview on
patient flows.
o Challenge 2: delivering care under a truly lean model. It is not clear how
certain things would be made more lean, like eliminating waiting
time/queues completely. For this, interactive/gaming approach scenario
simulation could be useful.
- Theory of constraints: a chain is only as strong as its weakest link. This methodology
targets bottlenecks or constraints. The location of bottlenecks in healthcare is not
obvious, and a rigorous analysis should take place. Access to primary care might be a
bottleneck. However, there will always be a bottleneck, it is about where one wants
it. Another perspective says that anything that increases throughput at the
bottleneck adds value to the system so long as it is safe. This theory would lower an
occupancy to match the bottleneck’s (e.g. OR) throughput, even if a proportion of
the resources (staff costs, heating, lighting etc) seem to be wasted as a
1
, consequence. The focus of this theory really is on relieving bottlenecks rather than
agonizing over wasteful idle resources.
- Six sigma: Motorola made this universal system to assess quality, produce
quantifiable results, and establish quality goals. Six sigma usually defined as 3.4
defects per million. It needs good data, clearly defined critical outcomes and
agreement on what a defect is. In hc it must also include the clinicians’ and other
stakeholders’ perspectives and clarify who the customer is. Key issue: not the
number of errors, but having a systematic process to identify the sources of error
and drive them out.
- Common features of these three approaches: each emphasizes the concept of
production as a complex interaction of activities. It also recognizes that for
production to be efficient and effective, it’s necessary to coordinate and balance
activities, identify weak links/bottlenecks, and take appropriate action. All
approaches require strong leadership, problem solving and participation of all in all
parts of the system. Gradual improvement, with all stakeholders included (even
patients).
2
