INTRODUCTION

It is not unusual for several weeks to pass before a patient with a serious wound receives the proper care for that wound.  Every wound care specialist has experienced the following: a patient with ulcer goes to the emergency department (ED), the ED clinician applies a dressing and refers to a minor injury clinic. Minor injury clinic refers to the primary care physician (PCP), the PCP requires a visit for a look and see. PCP sends a request for authorization/ referral to see a wound care specialist, and finally, after care is approved, the wound care clinic calls the patient to schedule an appointment 3 weeks out. The entire process can take 5-6 weeks. 

It is not hard to imagine how much better the outcome for that patient would be if they received the proper care within days, or even hours, instead of weeks. The approach that many leading organizations use to reduce the amount of time that these processes take is known as lean:

• Lean is a management philosophy developed at Toyota that has been successfully implemented in just about every type of business.[1] The core tenant of lean is that any process can be broken into steps that either add value or create waste. Value is from the perspective of the customer, or in our case, the patient.[2][3]

In the example above, the only steps that add value are those that cause the wound to heal. The ED clinician and the PCP may have applied a temporary solution on the problem, but the healing really began when a qualified wound specialist treated the patient.

LEAN FRAMEWORK FOR PROBLEM SOLVING

Lean solutions involve breaking the current process down into sequential steps, keeping parts that bring value to the patient and eliminating waste. The team then envisions and implements the desired state for the care delivery system. The process analysis is always performed from the customers’ view-point. In healthcare organizations, customers are patients. Thus, patients’ values need to be identified and processes need to be analyzed with these values in mind.

Value Stream Mapping

Lean practitioners use an approach called value stream mapping (VSM) to break a process into value adding and non-value adding (waste) steps.[4]  A very high level VSM of the example described in the Introduction above would reveal that the vast majority of time is wasted time – and time is tissue (Tab 1).

Table 1. Mapping the waste using a value stream map

In the above example the total waste in the system can be determined like this:

• Total wound healing time: 48 days (total time from initial visit to healed wound)
• Wound specialist healing time: 21 days (wound healing time if seen by specialist)
• Waste in the system: 27 days (delays in seeing wound specialist)

Possible solutions to the delay in treatment problem

The improvement opportunity in our example is to eliminate as much of the time between the arrival of the patient into our system and the delivery of appropriate wound care.  Here are some possible interventions to test in redesigning the system of wound care:

• Video conference between the ED and wound care specialist on the same day (create “reserved” same day appointments based on data)
• Use the Prep& Dress tool (wound care specialist teaches/walks the ED provider through the tool
• Define roles and responsibilities between the ED clinician and wound care specialist
• If patient presents to the PCP first (no ED visit), design system that allows PCP to video conference with wound care specialist on the same day
• Use the Prep& Dress tool (wound care specialist teaches/walks the PCP provider through the tool to ensure patient receives the correct wound management

Lean management promotes clinician participation in process improvement by putting together a multidisciplinary team (e.g. ED, PCP and wound specialist) to redesign flow.  This redesign promotes better access to care as timing is critical to wound healing.

LEAN PRINCIPLES

W. Edwards Deming, the father of "Total Quality Management", famously said: “Every system is perfectly designed to get the results it gets".  Lean focuses on improving the system.  Value stream mapping is the primary tool for analyzing the system and identifying improvement opportunities.[4] There are many other lean tools that are used to fine-tune systems like workplace organization, visual aids, standard operating procedures, inventory management, and clearly defined roles and responsibilities.[2] Lean practitioners rely heavily on the people who perform the work to find ways to improve their own jobs.  They also bring together people from the entire value stream so that they understand how their jobs affect other parts of the process – up and down the line.

For healthcare professionals interested in learning more about lean, there are several “how to” materials available (e.g., The Lean Enterprise Institute). Some organizations have been successful using employees to learn lean, and implement it in-house.  The more common approach is to bring in a sensei, or “teacher” in Japanese.  The sensei will quickly recognize the “low hanging fruit” and train employees in lean techniques through implementation of actual improvement events within the facility.