Bringing lean to Chinese hospitals
FEATURE – Lean healthcare is new to China. The authors share some examples of improvements projects taking place in Chinese hospitals, which they hope will inspire more organizations to take lean on.
Words: William Luo and Dr. Marcus Chao, Lean Enterprise China
With the rapid development of the society and economy, more and more Chinese people are paying attention to personal and family health. The demand for healthcare service from hospitals and community clinics has increased exponentially, and with it the number of regulations introduced by the central and local governments.
In the face of increased demand and complexity, Chinese organizations now have an opportunity to embrace lean healthcare principles in order to fulfill the requirements for better care by shortening delivery times and eliminating process wastes. Lean is still new to the Chinese healthcare sector and we hope that the lessons included in this article – which result from Lean Enterprise China’s experience coaching 12 hospitals in southern China (providing care to some 27 million people annually) and training over 900 people – will be useful for other healthcare organizations in the country.
Our purpose at Lean Enterprise China is to improve the quality of healthcare in China, the working lives of hospital employees and the overall performance of hospitals. We do so with the Lean Healthcare Greenbelt Program, an approach that combines coaching and training and that includes: 40 hours of lean healthcare classes and gemba activities to introduce lean healthcare concept and methodologies; online learning to strengthen the trainee’s understanding; the completion of an improvement project (of 12 weeks on average) to connect theory to the daily work; the presentation of an A3 to report the lessons learned during the project; and an evaluation of the A3 and project by LEC.
The main goal of the program is to develop problem-solving capabilities and we are very grateful for the engagement we have witnessed from many of the hospitals’ top management teams. We have held over 30 Greenbelt Programs at different hospitals, mostly in GuangDong province, with about 30 students in each class. We are confident that the over 900 lean seeds we have planted will continue to grow.
In this article, we would like to share some of the best projects we have seen to date.
Case 1: Optimizing “D2B” process to save lives of heart vessel blockage patients.
Guangdong Provincial Chinese Medicine Hospital made an effort to improve its door-to-baloon (D2B) process in the Emergency Room so that patients with sudden blockage of an artery – acute coronary syndrome – can be treated in the shortest possible time. This means reducing the time between the admission and the insertion of the baloon in the patient’s blocked coronary artery – D2B. (The international D2B standard is 90 minutes, to provide patients with coronary artery blockage with the best chances to recover.)
Dr. Guo, the Head of Cardiac Surgery, led a team of doctors, nurses, and administrative staff through the redesign of the entire process, from ambulance to ER. By applying value stream mapping, the team was able to identify bottlenecks and make numerous changes to the procedures so that the D2B time could be shortened. The graph below shows that, before the process redesign, the D2B 90-minute target was achieved 39% of the time, whereas in 2019, after several rounds of kaizen, the figure went up to 96%. The team’s ability to sustain this newly created benchmark meant that hundreds of patient lives were saved and that the social burden of caring for long-term cardiac patients was greatly diminished.
Case 2: Optimizing the OBGY process to improve patient safety and satisfaction
Dr. Hao, the Head of Outpatient Registration Department at the ShenZhen Bao An Chinese Medical Hospital, kickstarted this project in 2018. She personally followed a pregnant woman through a regular prenatal check-up as she went from the registration desk to the cashier office for payment, then on to the lab tor testing, to the doctor’s visitation room for the check-up, and finally to the pharmacy to pick up medication. It took the patient about 3.5 hours, during which she had to walk up and down the stairs several times, to complete the process.
A mother herself, Dr. Hao took it upon herself to improve the pregnancy check-up process. She led a cross-functional team to draw spaghetti diagrams and a VSM to identify barriers and to rearrange and consolidate as many operations as possible onto one floor, so that patients wouldn’t have to walk up and down the stairs. The improvement plan won the approval of the hospital management team and team managed to bring together on the first floor all the steps in the pregnancy check-up process and organize them in a flow. As a result, the average time for a pregnancy check-up dropped from 210 to 55 minutes and the patient satisfaction score went up from 78% to 94%.
The average prenatal check-up time (min)
Pregnancy patient satisfaction survey
Case 3: Reducing patient discharge time to increase hospital bed turnover rate
Mrs. Tan, Nursing Department Head at ShenZhen Hospital of Southern Medical University, initiated a project to improve patient discharge procedure in 2019. Discharge time is a problem in hospitals around the world, which directly impacts patient satisfaction, hospital bed turnover rate, and hospital financial performance.
A kaizen team was formed and applied VSM to find barriers and their potential causes. The analysis of the gap between current state and future state led the team to compile a list of improvement actions they could take. After the obstacles were removed, the average patient discharge time was reduced from 248 minutes to 117 minutes, and hospital bed availability before noon increased from 40% to 86%. This improvement project led to a large increase in hospital revenue as well as patient satisfaction.
The average patient release process time in minutes
Case 4: Increasing operation efficiency to improve customer satisfaction
The Eighth People’s Dong Guan Hospital faced a challenge common to many hospitals in China: not meeting patients’ expectations and recording low satisfaction scores. This problem was associated with a large increase in demand for healthcare, high levels of staff overtime, and falling behind on medical research projects.
The hospital decided to engage a selected group of professionals from key departments in a number of Lean Healthcare Greenbelt projects in 2019 to develop individual as well as organizational capabilities. The Orthopedics Divisional Hospital initiated five projects, including: in-patient check-in process; reducing usage of antibiotics in preventive category I operations; improving first operation on-time start rate; shortening operating room turnover time; and reducing waiting time for post-surgery checks. These inter-connected projects enabled the Divisional Hospital to increase the number of operations from 960 in Q1 of 2019 to 1,132 in Q3, a 20% improvement. At the same time, customer satisfaction increased from 65.5% to 96% and healthcare professional satisfaction improved from 50% to 95%.
The number of operations
Case 5: Reducing the usage of antibiotics (DDD) to ensure patient safety
Antibiotics are some of the mostly commonly used drugs. However, excessive use or excessive dosage of antibiotics can cause harm to patients and increase antibiotic resistance in bacteria. ZhongShan GuangJi hospital started an improvement project in 2020 to better manage the use of antibiotics. Data showed that the Surgical Department’s DDD (defined daily dose) had a value of 102 (a 10-month average) where the hospital’s target was 60. The team applied the 5 Whys analysis to dig out root causes and developed an action plan to address several issues. As a consequence, they installed mew guidelines on the physicians’ software to update and prepare electronic health record, to ensure they prescribe the correct medication. They also set up a closed loop check between nurses and pharmacists to ensure each antibiotics prescription was indeed necessary. After three months, the Department was able to bring its DDD value down to 55.
The DDD at the 2nd Surgical Department
The reason behind the success and the popularity of the program is that healthcare professionals have realized that lean thinking and practices actually make their work easier. Despite the great results achieved by the project teams (in 2020, LEC coached 139 healthcare kaizen projects), which we salute, we recognized that we needed to develop a more systematic way to transform a hospital department, one that ensures that a lean culture can be sustained even in the face of policy shifts and leadership changes.
In light of this, we launched a second program aimed at clinical department, which we are running in three community clinics and nine clinical departments at different hospitals. The departmental approach combines hoshin kanri, daily management system, and A3 problem solving to foster the development of a continuous improvement culture. We hope to introduce a hospital-wide program soon. We look forward to the lessons we will learn along the way.
We appreciate the support from our mentor Dr. Jack Billi from the University of Michigan Healthcare Systems. His guidance and willingness to share are greatly valued by the LEC Lean Healthcare team.