Where is the waste in healthcare?

The essence of lean thinking is the continuous elimination of unnecessary activities, the wastes that permeate virtually all types of processes: care, support and administrative. If we are able to eliminate unnecessary effort, there will be more time and resources available for the things that really matter. Eliminating waste means being able to stop doing what is irrelevant, freeing up capacity to improve what really counts: patient safety and quality of care.

The first challenge is to see. Everything that does not create value for the customer is waste. With this simple definition, we can draw a reasonably clear dividing line to distinguish the steps that create value from those that do not. In this way, we can begin to exercise our perceptions and seek alternatives for the real problems that are leading to waste.

Customers, according to this definition, can be “external” (e.g., patients under treatment, family members waiting) or “internal” (e.g., physicians, nurses, managers). To illustrate: a surgeon is an internal customer of a series of processes managed by the hospital in whose operating room the procedure is being performed. The patient, in turn, is the external customer, not only of the hospital, but of the physician, the health insurer, the nursing team, etc. To illustrate how we spend considerable time in our workdays on activities that only add time and cost, here are some examples of very common wastes in hospitals, clinics and laboratories. The classification used below, by “types” of waste, was adapted from the one originally proposed by Taiichi Ohno, one of those responsible for consolidating the Toyota System, the basis of lean thinking.

Following this logic, waste could be categorized into 7 basic types: rework, waiting, motion, transportation, inventory, overprocessing and disconnection. To this list, an eighth waste can be added, one that increasingly deserves our attention: the waste of human knowledge/talent. Let us see how each of these types of waste shows up in healthcare:

1 ) Rework: the need to redo something as a result of an error or defect in the process. If the patient is involved, this dimension relates to their safety and, unfortunately, rework is not always possible. Errors can cost lives or leave deep sequelae. But rework also permeates administrative and support processes. Incorrect or incomplete information is common, making authorizations and account closings, for example, much slower processes than they should be.

2 ) Waiting: people waiting. For test results, for an appointment, for a bed, for the release of documents, for the bill to be closed, for the insurer’s authorization, for the physician, for the scissors, for the system, for cleaning. It may be the most explicit type of waste, since it easily bothers us. Internal and external customers are subject to frequent waiting in most of the processes they interact with.

3 ) Motion: people moving unnecessarily. Some frequent examples: fetching material that was missing, taking back leftover material, carrying equipment between rooms, looking for documents, looking for test results, looking for people, returning material to the stockroom, moving between wings and buildings.

4 ) Inventory: materials, medicines and information that do not flow, sitting “idle” in the middle of the process, unnecessarily. Inventory costs money, so having too much of it can be too expensive, with the risk of losing it due to expiration dates. On the other hand, a lack of certain products can lead to critical interruptions in treatment or generate additional costs due to emergency substitutions. Within large hospitals, there are also problems arising from internal logistics, which creates redundancies and noise between central and satellite pharmacies.

5 ) Transportation: unnecessary movement of materials and information. All energy spent on transportation beyond what is strictly necessary can be considered waste. Examples: rushing medicines, test results and equipment back and forth due to superficial planning, transferring information between databases and systems, generating long processing times, etc.

6 ) Overprocessing: steps that are redundant or simply unnecessary from the customer’s/patient’s point of view. People answering the same questions two or three times, test names being copied by hand onto two or three different documents, superfluous forms and procedures, patients undergoing unnecessary procedures, bureaucratic steps and information systems that are not very user-friendly.

7) Disconnection: occurs due to poor communication, which causes unwanted interruptions in processes. Some typical examples: excess/shortage of beds, shortage/surplus of medicines, inadequate treatments, overcrowded recovery rooms, delayed and cancelled surgeries, idleness coexisting with overtime, etc. Poorly connected steps generally cause systemic impacts, with repercussions on adjacent functional areas/teams.

8 ) Talent: means wasting human creative potential and the ways in which people express the knowledge and skills they have acquired. Some examples of attitudes that feed the waste of talent: not listening to the people involved in the work about their perceptions, not involving them in identifying and solving the problems they deal with every day, limiting access to management information, among others.

Seeing waste is always the first step, but we should not stop there. We must recognize that waste is a symptom of the real problems, whose causes need to be properly identified and addressed. It is necessary to deeply understand what lies behind the visible waste and what implications must be considered to eliminate it, attacking its origin. In other words: we need to find the root causes of waste in order to define effective countermeasures that prevent its recurrence. If we do not eliminate the cause, the effect will not stop.

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