Role of Information Technology in Promoting Lean

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 and using information. 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. Part of his motive, historians claim, was to spare gentle ladies the embarrassment of having a male ear in direct contact with their unclothed chests. Leeuwenhoek, in the infancy of optical science, put two lenses together to create a rudimentary microscope; he was amazed by the "little animalcules" he could see in a drop of water, not dreaming that out of his observations would come the science of microbiology and the technology of antibiotic use.

And long before the microscope revealed the malaria parasite, some perspicacious Peruvian took note of the fact that the bark of the cinchona tree contained something, later called quinine, that was a specific therapy for certain tropical fevers.

Intensive Care and Academic Subspecialization

Academics built perinatal centers that combined neonatal and obstetric intensive care units. As in neonatal intensive care, obstetric intensive care functionally divided labor and placed subspecialists at the top of the hierarchy. Specialists and subspecialists recognized that assigning tasks to trainees and nurses enhanced their own productivity.

Teamwork often meant substituting nurses for physicians in routine care, but it did not necessarily mean nursing authority to match the enhanced responsibilities. Nursing organizations, including the one set up by the American College of Obstetricians and Gynecologists, officially concurred with the college's pronouncement that the specialist was the team manager. The obstetrician was the "chief executive officer," whose role included setting standards, monitoring task distribution, and supervising all team members.

Nurses were to take care of the patient, plot the progress of labor on a graph, and perform procedures under protocol or direct orders.

It did not take long for community hospitals to build competitive high intensity obstetric units of their own. After the number of trained subspecialty fellows increased to fill the faculty slots in academic centers, perinatologists; like their neonatal colleagues; moved to establish intensive care units in community hospitals. By 1984, 576 high-risk centers responded to and were listed in the National Perinatal Information Center's Perinatal Center Directory.

Although nearly 40% of the country's births that year occurred in the named centers alone, they aspired to a still higher share of the birth market. Using brand-name marketing tactics, perinatal leaders placed articles describing their high-tech capabilities and their "miracle babies" in popular books, magazines, and newspapers.

One book specifically advised its pregnant middle-class readers (high- and low-risk) to choose perinatologists practicing at the high-tech hospitals named in the Directory.

Electronic Fetal Monitoring

Being the structural foundation for obstetric intensive care, electronic fetal monitoring was the initial crucial technology for the subspecialty of maternal-fetal medicine. Richard Paul, Edward Hon and Edward Quilligan initiated electronic fetal monitoring in the 1960s and 1970s as they migrated from Yale to the UCLA.

Hon developed the technology and started Corometrics Medical Systems to manufacture it commercially; he also performed the company's research and development studies, ran its marketing classes, and supported its equipment in court.

Feminist scholar Judith Kunisch suspected that in excess of 50% of Corometrics stock was in possession of the same men who slogged to endorse the product as an industry standard of obstetrical healthcare. Kunisch also connected EFM to remedial patriarchy.

Relaying a different tale, nursing researcher Margarete Sandelowski wrote that in practice, nurses conquered EFM use. For the reason that they cared for women throughout the long hours of labor, obstetric nurses turned out to be the experts in EFM use, according to Sandelowski, and corporations such as Corometrics promoted the technology to them. 83 subsequent to targeting nurses in academic centers originally, Corometrics dominated the EFM market as every birth in the country. Corometrics with other EFM manufacturers frequently packaged extra technologies such as intrauterine pressure measurement into their equipment, thus making their older equipment out of date.

present-day Ob / Gyn, a journal with a penchant for advertising and promoting information technology, kept the profession updated of each feature. The innovative features not only shaped a constant market for latest machines, they in addition stretched interventional intensity as nurses implemented all the built-in technologies to the patients. Obstetricians respected EFM for the scientific decorum it brought to their area of expertise, but its growth was not determined or even warranted by scientific evidence of effectiveness.

Supporters had shown EFM technology to function in terms of gauging fetal heart rate patterns, but they had not made it known to work with regards to improving birth outcomes. Research obstetrician Arnold Haverkamp relayed to a U.S. Senate group that the March of Dimes and the National Institutes of Health had each objected to his initial grant offers to evaluate electronic fetal monitoring on the basis that the technology was already recognized as necessary and useful.

While mechanistic and patriarchal paradigms were indeed prevalent, EFM's continued use was based on more than birth paradigms or dogma. Operating intensive labor units equipped with monitoring devices in itself reinforced mechanistic and pathologic paradigms of birth. Advising his colleagues to embrace an "intensive care orientation,"