From Cars to Coding: Lean’s Impact on Healthcare Business
Rethink leaner quality improvement strategies by integrating car manufacturing concepts.
Over the past 15 years, quality improvement strategies originating in manufacturing have been increasingly adapted and adopted into healthcare settings. As in manufacturing, the demand for quality has driven the healthcare industry to focus on eliminating waste in the system and maximizing value to its customers.
The Toyota Production System, also known as Lean, was developed by Japanese industrial engineers Taiichi Ohno and Eiji Toyoda to identify the principles that increase efficiency, quality, and speed while decreasing costs. The resulting principles may be applied to any industry that is burdened with waste and chooses to focus on continuous improvement as a way to increase value for its customers. Mandatory reporting of quality data to the public, along with reimbursement constraints, show a need to integrate these concepts into healthcare settings and practices.
How Does Lean Work?
Lean is a cultural transformation requiring buy-in and engagement from all individuals in an organization, from front-line staff to top leaders. The first step begins by initiating the transition to an environment that focuses on continuous daily improvement.
Lean’s intent is to increase value by removing waste, so it’s important to understand the definition of waste. W. Edwards Deming, engineer and conceptual founder of total quality management principles, defined waste as anything that does not add value to a process. There are eight specific types of waste:
- Non-use of talent
- Excess processing
Knowing what constitutes waste (down time), enables you to recognize it in current processes of your business. Think of a river with large rocks scattered throughout, with the rocks being waste. When the rocks are removed, the river flows more efficiently and smoothly.
Begin by creating a map of current processes, in which each individual process is dissected step by step. Ultimately, this detailed observation allows you to see current inefficiencies and identify opportunities for improvement, known as “Kaizen” by Lean practitioners.
The next step is to create a “future state process” map. The future state map allows you to see how the processes flow after the removal of waste. It should be designed with customers at the forefront and processes primarily value-added, based on customers’ perspective.
The final step is to implement the improvement strategies necessary to achieve the desired future state of the process or system. Measure each improvement opportunity to determine if the predicted impact is achieved. Re-evaluation and modification of the strategy may occur at this time. When the strategy is in place and supports the goal of implementation, standardize the processes to become part of a sustainment model.
Lean in Action
Although quality improvements sought by Lean processes must occur system-wide, it can begin in one area or one department.
For example, when examining the business revenue cycle for a large healthcare organization, you can recognize quickly a multi-faceted system that is complicated, often inefficient, and heavily burdened by waste. This model demonstrates how processes are segmented by multiple departments, without a detailed understanding of who does what, what happens where, and how processes affect one another. To gain clarity of the billing and coding processes for the organization, a panel of experts from each area of the revenue cycle built a detailed value-stream map of the current processes in the revenue cycle. The simple act of having a group of professionals representing each piece of the process is paramount for showing the team the existing waste in their current state.
The mapping incorporated clinical documentation, billing, and coding, which highlighted two major opportunities for improvement:
- The importance of quality documentation from clinical providers is key to preventing billing and coding errors that can happen downstream. Although the electronic health record has opened the door for growth in clinical documentation, it has not eradicated the over-processing that accompanies the remaining manual documentation processes. Eliminating paper documentation processes, particularly physician billing forms, allows providers to focus on electronic documentation quality and transitions all billing and coding functions away from clinicians to Certified Professional Coders (CPCs®), who are trained to capture this data. For physicians to be knowledgeable and understanding of coding regulations, as well as to select procedural codes, is considered non-use of talent (one of the eight forms of waste). Removing this waste allows for same-day coding and impacts the revenue cycle positively with fewer bill hold days.
- Redundancy in coding processes may create variation in how documentation is interpreted, pointing to the need for a single-path coding model. When many individuals access, read, and code the same medical record, it’s over-processing. The single-path coding model offers a streamlined, waste-free process where coding and charge capture may be assigned by one coder for both the facility and professional billing departments. It maximizes revenue potential and reduces the possibility for reimbursement denials.
Drive It Home
Strive to reach a culture where front-line staff — rather than managers — drive continuous improvement. Encourage teammates to look for problems and suggest opportunities for improvement. Make those problems visible to all team members with daily updates on how they are being improved. Conduct daily or weekly experiments to trial new ideas for improvement. Measure the outcomes of your experiment and, if successful, make them a part of your daily process.
Vickers, S. M. (2014). “Lean and learn: Applying the principles of Lean in the ED,” Nursing, pages 18-20.
Best, M., & Neuhauser, D. (2005). “W Edwards Deming: Father of quality management,
patient and composer,” Quality & Safety in Healthcare, pages 14, 310-312:
Kevin Hindsman, MSN, RN, Lean Practitioner, has been involved in some facet of the healthcare industry for over 15 years. He has worked as a registered nurse in emergency departments and now serves in the role of Lean Practitioner, focusing on continuous improvement for a large healthcare system.