Marian Benjamin

Budget cuts, staff reductions, HITECH Act requirements, health care reform. What’s a respiratory care department to do to survive? How about thinking lean? Lean management principles have been used in manufacturing companies for decades—notably the Toyota Production System1—but health care? Patients aren’t cars! Yes, writes Robert James Campbell, EdD, CPEHR, in an article in the Journal of AHIMA.2 Lean thinking is the efficient use of staff, resources, and technology to provide the highest level of service possible to the customer, and is as important in health care as in manufacturing. So, how does one go about applying lean thinking principles?

The Basics2

  • Value. Each step in a process must produce value for the patient, physician, or administrator or it is eliminated
  • The value stream. The steps required to complete a process or service. Examining each step helps to identify waste.
  • Flow. Eliminate batching or queuing, which occurs throughout health care: A patient makes an appointment with his physician, waits for an appointment, waits in the provider’s office, waits to see a specialist, waits for laboratory tests, waits to begin a prescribed medication. Batches and queues are also evident in reimbursement, coding, and chart review. Even electronic health records, Campbell says, rely on some form of batching and queuing.
  • Pull. Performing work as it is requested. This is the opposite of push technology, which can lead to steps in service being performed out of order if a next step is not ready. For example, a baby is transferred from surgery to the NICU, and the vent and respiratory therapist are not there. Pull ensures that the vent and RT are ready and waiting.
  • Perfection. No matter how many times a process is improved, there’s always room for more—continuous improvement through incremental change based on outcomes.

Waste Not

Any department can improve service by reducing or eliminating waste, which in health care can mean multiple patient forms that ask the same questions, and incompatibility of systems that are unable to share data, possibly resulting in medical errors and a waste of staff resources.

Process waste includes rework, workarounds, approvals, and waiting; but according to Campbell, defects—when a process or service does not serve the purpose for which it was created—account for most process waste. “With as many as 98,000 deaths due to medical errors,” he writes, “process waste is a serious problem.”

Physical environment waste includes unclear roles, responsibilities, authority, and accountability, and lack of training. The most common physical environmental waste is safety: clinicians not washing their hands and improper sterilization techniques that can lead to hospital-acquired infections and long-term illness and death.

Health care reform is fast upon us, and all of you are being tasked with improving outcomes in an economically straitened environment. Lean principles hold the promise of reducing or eliminating wasted time, money, and energy in health care. They can help your departments to be efficient and effective and responsive to your “customers”—the patients with whose care you are entrusted.

Marian Benjamin
[email protected]


  1. Institute for Healthcare Improvement. Innovation Series: Going Lean in Health Care. Available at: Accessed June 5, 2009.
  2. Campbell RJ. Thinking lean in healthcare. J AHIMA. 2009;80:40-3..