Role of Information Technology in Promoting Lean Thinking/Practices in a Hospital: How it Helps Streamlining Processes

Lean Thinking and Healthcare

Lean thinking has evolved from well-known business management disciplines such as the Toyota Production System (TPS), Just-in-Time (JIT) and Kaizen. The core principles of lean are fundamentally the same as these other disciplines, but lean thinking has developed this theory into a generic concept that can be more readily applied in a diverse range of industries using a more people focused approach. Lean thinking is more than an initiative; it is an all-encompassing business ethic that every function throughout the company supply chain must be committed to if the company is to achieve an integrated approach to improving our products, processes, people and plant capability.

Lean thinking is based on creating value driven activity by defining the value stream of a product from the customers' perspective. The value stream is the entire collection of activities and information flows that are essential for producing and delivering a product or service. Waste is the opposite of value. It is everything we do that does not add value to the product and it is not just materials or components we discard, it includes unnecessary moving or handling of materials, reworking the product to remove defects, using inadequate processes that cannot produce a product of the desired quality, etc. Taiichi Ohno, the founder of TPS and JIT, summarized this into seven key areas of waste.

These wastes must be challenged to find ways to reduce their impact or eliminate them from the process so that only essential operations are performed that will add value to the product or service being delivered.

Although lean thinking is based on creating value and value driven activity within business processes, it is not efficiency obsessed. Taiichi Ohno once said that the real objective of the Toyota Production System was to "create thinking people" and he considered it to be a waste on the company's part to undervalue the creative brainpower and potential of their employees. 'Untapped human potential'

is now often classified as an eighth type of waste. BM relies on everyone to develop, implement and sustain practical solutions to eliminate wasteful or potentially risky operations and this requires a culture of trust, support and mutual respect within the business. This culture is being developed via a program called 'lean culture' and also through the issue of 'behavioral safety standards'.

The Evolution of Information Technology, the Internet and the Practice of Medicine in Hospitals

Perhaps the field of medical ethics has grown so dramatically in response to the explosive growth of information technology and lean practices. It truly may have been simpler to do the right thing when there weren't that many things that could be done. The basic Hippocratic ethical dictum is to "first, do no harm."

Before the advent of sophisticated and invasive new procedures, that dictum was easier to follow. Physicians couldn't do much, so they couldn't do much wrong. Just as electricity slowly and then dramatically changed the ways in which Americans worked, lived, and played in the last century, so the Internet will change American lives in deeply significant ways in the new century. We are at a watershed moment in the definition of lean practices. Much of what physicians do is being redefined. Consider what they do today, for example. They listen to patients and their families. They observe and examine patients. They identify problems, stratify those problems, and order tests to attempt to further clarify the problems. This leads to a differential or probable diagnosis, which in turn leads to a diagnosis.

The diagnosis was the principal goal in the early 1950s. Today the diagnosis itself probably is not important. It is the problem that's important.

Even more important is doing something about the problem. Patients are not concerned about diagnoses. They are concerned about symptoms. Having clarified the problem by coming to a diagnosis, the physician institutes interventions of various kinds. The physician monitors the course of the patient's recovery and then may institute preventive measures to prevent a recurrence or the development of other diseases in the future. The thread holding all of this together is information. A majority of the dollars spent in medicine and health care in developed countries today is expended on gaining information, including tests.

When we think of dollars spent, we think of drugs, surgery, radiation, physical therapy, and bricks and mortar in hospitals and clinics, but these expenses are relatively small in comparison to what physicians and patients spend most of their time doing seeking...

The quest is for information, and physicians pursue it by observing, gathering bits and pieces of data, assimilating and interpreting them, and then dispensing their conclusions; telling the patient what is wrong and what to do about it. During the course of treatment further information is elicited. The physician encourages feedback from the patient on how the treatment is progressing and thereby monitors the course of therapy through information exchange.
In fact, the entire process is almost nothing but information. Lab tests may be ordered, but only for information. If they are not needed, they are not ordered. It is all information. Do this. Don't do that. Take this drug. Stop taking that one. That is what the practice of medicine is all about today.

The question has been raised as to how much of this might be done over the Internet to facilitate lean processing and thus eventual streamlining of everyday chores. Remarkable amounts of information can flow back and forth over the Internet. Hand-delivered notes can be replaced. So can letters, brochures, certificates, and even printed lab results. Test orders can be placed and results can be handled expeditiously over the Internet. The only information-gathering action that cannot be done, it seems, is the drawing of specimens, but after the test is ordered, the patient can stop by a designated facility to give a specimen. If pharmaceutical agents are required, they can be ordered over the Internet, and the pharmacist can make them available or deliver them to the patient. Verbal communications can become electronic, eliminating the factor of distance and reducing the factor of time. Copies can be provided immediately. The new digital X-ray technology attached to a medical record offers protection against loss or misplacement.

Typically, about 10% of film X-rays at hospitals are misfiled, and an additional 2 to 3% are lost.

The Internet is perfectly designed to straighten out all of these information snafus. One question that remains unanswered is whether medicine should be practiced over the Internet between patients and physicians who do not have an existing therapeutic relationship. The group felt that some things could be handled over the Internet in the absence of an existing relationship, but that many other things probably could not. This is an area that requires further research. The question has to be studied and subjected to risk-benefit ratio analysis for different circumstances and different diseases. At the moment there is little or no information in the published literature on which diseases could be so handled, but this is a case in which ethics could follow science. Once we know what can be done safely and effectively solely on the Internet, an ethic for that practice will become clear.

Information Technology and Lean Practices

In an orderly world, the lean practices, before-and-after relationship between information technology in hospitals would always be tidy and traceable. A happy sequential example is found in the case of the clinical condition called congestive heart failure; the host of technologic tools that today's clinicians can trot out to deal with this common problem can be traced back to a succession of discoveries in the medical sciences: anatomy like Vesalius in the 16th century recognized that the human body contains arteries, veins and a heart, physiology.

Harvey, a century later, deduced the continuous pump-pipe system of the blood's circulation, pathologic physiology. Starling more recently hypothesized that, with too much pressure in the system, the heart would fail in its pumping function, and biochemistry: the discovery, by several researchers, that excess salt can be a factor in overloading the circulation.

The world of medicine is not always so orderly. Not infrequently, the hare of technology is found to outstrip the tortoise of science. Over and over again, technology has had a way of showing up first -- whether by chance or through careful observation -- and only later has the underlying science been untangled.

In the heart circulation scenario, for instance, Withering in the 18th century happened to notice, well before the scientific basis of heart failure was clarified, that foxglove (digitalis) was useful in clearing dropsy fluid accumulation in the tissues.

Serendipity was also at work when a young doctor named Auenbrugger remembered that his vintner father had thumped at kegs of wine to locate the line between air and fluid produced by the fermentation process, and applied the same finger-tapping technique (percussion) to human lungs. Similarly, before sound waves were understood, Laennec devised a tube for listening to heart and lungs, inventing what would later become the familiar auscultatory stethoscope.…