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Lean manufacturing or lean production is a practice that considers the expenditure of resources for any goal, other than the creation of value for the end customer, to be wasteful and thus a target for elimination.

you need to look at how in fact you can build that hospital in a way that will provide for the most efficient staff processes

lean construction is an adaption of lean manufacturing principles and practices to the design and construction process

As part of this new approach, Dyble said the ministry of health is also moving forward on a different way of managing capital projects. According to Dyble, capital boards have been created to provide an overarching look at the capital program for big projects with a cost of more than $50 million. They look at how much is being spent on rehabilitation and projects, to make sure the best possible capital projects are provided in the future. The project board is made up of senior members from Ministry of Health Services, the health authority, Partnerships BC and the Ministry of Transportation and Infrastructure.

Under the project, four wards with 18 beds each were opened to quickly accept the general internal medicine patients from emergency. Instead of waiting one full day in emergency, patients now wait an average of 5.1 hours before being transferred to the new units

Once there, the medical professionals come to them

has reduced the average length of stay in hospital by about five days, from 10 for these specific patients.

look at a product or service from a customer's perspective and identify waste, or aspects a customer wouldn't pay for by choice

"The old way of cost-cutting was absolutely wrong-headed," he said. "I realized for the first time why we were so mistaken in the '80s and '90s when we were cutting budgets and ending up with poor service at the end of the day."

high-level executives will run their proposed priorities before teams of lower-level managers and front-line workers, then consider their feedback before proceeding

Phase 2 will take several years and involves building up local expertise and getting more than 43,000 workers in the province's health regions, the Saskatchewan Cancer Agency, the Health Quality Council and the Health Ministry thinking like a synchronized lean machine: Identify waste, test a possible fix, evaluate the outcome and repeat.

one contract for about six months of lean leadership to do the first phase of planning - hoshin kanri - and a longer-term contract to help roll out the lean system

the first contract was awarded in October to American consultants John Black and Associates, and SAHO plans to award the second longer-term contract in January

how much taxpayers are spending on these senseis is not being made public

The most important aspect, Broten said, is that the perspectives and knowledge of front-line workers carry weight in any changes.

The Children's Hospital of Saskatchewan is the first capital project in the province where the lean approach is influencing design.

Medical buildings often have standard benchmarks — basing the number of examination rooms, for example, on the expected volume of patients. Ms. Brandenberg and her team instead used C.P.I. to map out common paths that patients, staff members, supplies and information would flow through. They worked in an empty office building, using cardboard mock-ups of surgical sites, recovery rooms, anesthesia areas and waiting rooms. Fifty staff members then play-acted various scenarios to test the design’s effectiveness. The final design reduces walking distances and waiting times for patients by grouping related facilities together and creating rooms that can be used for more than one purpose. The hospital was able to shave 30,000 square feet and $20 million off of the new building

Last year, amid rising health care expenses nationally, C.P.I. helped cut Seattle Children’s costs per patient by 3.7 percent, for a total savings of $23 million, Mr. Hagan says. And as patient demand has grown in the last six years, he estimates that the hospital avoided spending $180 million on capital projects by using its facilities more efficiently. It served 38,000 patients last year, up from 27,000 in 2004, without expansion or adding beds.

checklists, standardization and nonstop brainstorming with front-line staff

The program, called “continuous performance improvement,” or C.P.I., examines every aspect of patients’ stays at the hospital

The system is just one example of how Seattle Children’s Hospital says it has improved patient care, and its bottom line, by using practices made famous by Toyota and others. The main goals of the approach, known as kaizen, are to reduce waste and to increase value for customers through continuous small improvements.

Similar methods are now in place at other hospitals and health systems, including Beth Israel Deaconess Medical Center in Boston, Park Nicollet Health Services in Minneapolis and Virginia Mason Medical Center, also in Seattle.

All medical centers, especially larger ones, would have significant return on investment by using operations management techniques like C.P.I., says Eugene Litvak, president and chief executive of the Institute for Healthcare Optimization and an adjunct professor of operations management at the Harvard School of Public Health.

“The health care industry could be on the verge of an efficiency revolution, because it is currently so far behind in applying operations management methodologies,” says Professor Litvak.

TO be sure, not everyone believes that factory-floor methods belong in a hospital ward. Nellie Munn, a registered nurse at the Minneapolis campus of Children’s Hospitals and Clinics of Minnesota, thinks that many of the changes instituted by her hospital are inappropriate. She says that in an effort to reduce waste, consultants observed her and her colleagues and tried to determine the amount of time each of their tasks should take. But procedure times can’t always be standardized, she says. For example, some children need to be calmed before IV’s are inserted into their arms, or parents may need more information. “The essence of nursing,” she says, “is much more than a sum of the parts you can observe and write down on a wall full of sticky notes.”

one-day strike by the Minnesota Nurses Association against six local health care corporations, including her employer, partly in protest of lower staffing levels her union thinks have resulted from hospitals’ “lean” methods

the Lean Enterprise Institute

George Labovitz, a management professor at Boston University, says there are limits to performance-improvement methods in hospitals. “Human health is much more variable and complex than making a car,” he said, “so even if you do everything ‘right,’ you can still have a bad outcome.”

Joan Wellman & Associates, a process improvement consulting firm in Seattle

examine the “flow” of medicines, patients and information in the same way that plant managers study the flow of parts through a factory

In a typical workshop at Seattle Children’s, a group of doctors, nurses, administrators and representatives of patients’ families set aside a 40-hour week to work through C.P.I. methods. They plot each “event” a patient might encounter — like filling out forms, interacting with certain staff members, having to walk various distances or having to wait for assistance — and brainstorm about how each could be improved, or even eliminated.

it never ends

Standardization is also a C.P.I. cornerstone. Last year, 10 surgeons at Seattle Children’s performed appendectomies, and each doctor wanted the instrument cart set up differently. The surgeons and other medical staff members used C.P.I. to come up with a cart they all could use, reducing instrument preparation errors as well as inventory costs.