All posts by juamarto

Lean in Healthcare (II)

In my previous post I mentioned the differences between the application of Lean in manufacturing and healthcare. However, which are the similarities? Moreover and perhaps more importantly: how to succeed implementing lean in healthcare?

First, it is very important to achieve the management commitment, and we should start making them understand Lean in order to get their support because a manager’s most important task is to create an environment where interaction between team members leads to a high level of performance. In addition, it is important taking into consideration that lean is a learning method more than anything else, and learning cannot occur if basic stability has not been achieved.

Second, the tools used for eliminating waste are similar in every type of organization, including healthcare. For instance, tools such “5 Whys” (used to discover the root cause of the problems), “5S” (used to create order and cleanliness, and to ensure that are maintenance day to day), “Kanban” (used to avoid the run out of supplies and to ensure that the oldest items are used first, eliminating waste due to expiration), “visual controls” (used to create a workplace where everything needed is displayed and immediately available) and “standardization” (used to identify and eliminate waste on processes, making the changes standard) can help any organization to implement Lean transformation. Furthermore, there are other tools like “Value Stream Map” (used to distinguish value-adding versus non-value-adding steps) that can be easily adapted to both health care operations and manufacturing processes.

In order to succeed with Lean in the healthcare environment is important that people involved understand what Lean means first. The Key concept is value, which is defined as the capability to deliver exactly the product or service a customer wants with the minimal time. For that reason, people involvement and support for front-line staff to make improvements is very important. Some employees tend to resist imposed change, but most employees will be ready to make changes that will improve their own work and efficiency.

Having achieved people involvement, the first step of the process is direct observation to understand what is going on the clinical area, to see how patients flow through the system and what obstacles and barriers are. Doing that we will understand what is truly valuable to patients, as well as establish whether or not what we are delivering is valuable.

Keeping this in mind, a good way to start implementing Lean tools is using a Value Stream Map. VSMs are easily adapted to most healthcare operations and are designed to distinguish value-adding versus non-value adding steps. In healthcare, a value-adding step would be a nurse’s interview to obtain important information from the patient, whereas a non-value adding step would be a patient waiting for doctor to arrive at the examination room. Once discovered the wastes is time to eliminate them and improve the processes. As we said before, Lean proposes several tools for eliminating waste. However, it is very important to underline that continuous improvement is needed in Lean and continued adoption and application of the tools will lead Lean becoming a standard way of solving problems.

VSM - Odense Hospital

Source: Linköping University. Department of management & engineering

Implementing all explained above, we will reach the 5 Lean principles in healthcare which are the following: specify value from the standpoint of the patient, identify the value stream to diagnose and treat the patient, enable patient to flow smoothly through every step, match capacity with demand and manage towards perfection

Implementing lean is a difficult task. Perseverance, high quality leadership, patience and dedicated professionals are needed. Scepticism and resistance will be high and success not guaranteed. However, Lean can really work in a healthcare environment and its application can improve quality, productivity and team working environment.


Ballé, M. and Regnier, A. (2007), “Lean as a learning system in a hospital ward”, Leadership in Health Services, Vol. 20 No. 1, pp. 33-41.

Fillingham, D. (2007), “Can lean save lives?” Leadership in Health Services, Vol. 20 No. 4, pp. 231-241.

Jimmerson, C., Weber, D., and Sobek, D. (2005), “Reducing waste and errors: Piloting Lean Principles at IHC”, Journal on Quality and Safety, Vol. 31 No. 5, pp. 249-257.

Joosten, T., Bongers, I., and Janssen, R. (2009), “Application of lean thinking to health care: issues and observations”, International Journal for Quality in Health Care, Vol. 21 No. 5, pp. 341-347.

Poksinska, B. (2012). Lean Healthcare, Lecture slides . Linköping University

Zidel, T. G. (2006), “A Lean Toolbox: Using Lean Principles and Techniques in Healthcare”, Journal for Healthcare Quality Web Exclusive, Vol. 28 No. 1, pp. 1-7.

Lean in Healthcare (I)

Implement Lean in a healthcare environment is a difficult task. Its application often leads to resistance and the common arguments are (among others) that a manufacturing approach cannot work in a hospital setting, that the personnel are too busy to implement lean, or that business approaches neglect the sociotechnical aspects of health care. Many people are reluctant to view the work they have been performing for many years as wasteful and according to that, they become defensive and resist any effort to change the situation.

However, several experiences have demonstrated that techniques developed in manufacturing really work in hospitals and the potential gains of Lean application are enormous. Bolton Hospitals NHS is one of these experiences: before Lean implementation the hospital had a financial deficit and significant problems with long waits for diagnostics and treatments, after three years of Lean application, the financial balance was restored and the waiting times reduced.

lean in healthcare


Lean can improve safety, improve staff morale and reduce costs, but some differences between the application of Lean in manufacturing and healthcare have to be taken into consideration. First of all, healthcare professionals deal with a group of customers who are often weak, vulnerable and frightened and in addition, the degree of organizational complexity is high and many procedures have a significant level of risk. Due to that, the outcomes of mistakes (drug errors, infections or misdiagnoses, among others) are often more critical than in manufacturing companies. Moreover, the patients consider as truly valuable aspects such as pain relief, wish for information, cleanliness or hygiene which are completely different of the value consideration in manufacturing.

Second, the balance between achieving high quality and remaining financially viable is becoming a major issue for hospitals today. If hospitals were like most companies, they could compensate the rising costs increasing the selling price; nonetheless hospitals are not like most companies. According to that, the goal is to understand that good quality can cost less not more. In addition, setting delivering benefit in a healthcare environment is one of the most difficult tasks and it is important to define whether it is reduction of mortality, improvements in productivity or patient satisfaction increase. In health care, different actors have different views of value and for instance, the doctor’s clinical value oftentimes differs of the manager’s operational value.

Finally, how processes should ideally work is often described in manufacturing companies, but it is rarely described in health care operations. This creates inconsistency in care, unpredictable delivery systems, and constant caregiver interruptions which in turn create inefficiencies, higher operating costs, errors increasing and worker frustration. In addition, different hospitals units may require different approaches to implementation. Whereas laboratory, pharmacy and information staff are normally process-focused; nursing units and senior leaders experiment greater difficulty in that aspect.

Having examined the differences, in my next post I will consider the similitudes between the application of Lean in manufacturing and healthcare.


Fillingham, D. (2007), “Can lean save lives?” Leadership in Health Services, Vol. 20 No. 4, pp. 231-241.

Jimmerson, C., Weber, D., and Sobek, D. (2005), “Reducing waste and errors: Piloting Lean Principles at IHC”, Journal on Quality and Safety, Vol. 31 No. 5, pp. 249-257.

Joosten, T., Bongers, I., and Janssen, R. (2009), “Application of lean thinking to health care: issues and observations”, International Journal for Quality in Health Care, Vol. 21 No. 5, pp. 341-347.

Zidel, T. G. (2006), “A Lean Toolbox: Using Lean Principles and Techniques in Healthcare”, Journal for Healthcare Quality Web Exclusive, Vol. 28 No. 1, pp. 1-7.

Ships that carry ships

“Extreme engineering” is a documentary television series that explain futuristic and ongoing engineering projects. One of the best chapters shows how to solve the problem of transporting mega-structures to different locations. Do you need to carry a giant ship, or maybe 22 of them? The solution of your problems is The Blue Marlin ship.

The Blue Marlin does not lose its time carrying containers, oil or fishes. Instead, it can carry other ships, nuclear-powered submarines or oil rigs. This amazing vessel, commonly known as “flo/flo” (float on – float off), is a semi-submerging ship capable of carrying other ships out of the water. One part of the ship can disappear up to 13 meters below the water’s surface. For doing that, its ballast tanks are filled with water. Then, when the cargo is into position, the tanks are pumped out until the deck is in contact with the load.


The blue Marin is property of Dockwise, a Dutch shipping company and has been used for different purposes. As a matter of fact, it was sent for transporting the damaged USS Cole from Yemen to United States. Its biggest cargo was a BP oil rig (60,000 metric tons), which was carried from Korea to the Gulf of Mexico.

The Blue Marin is 217 meters long and it is powered by a 17,000 horsepower diesel engine. However, it seems small in comparison to a new one that was built in 2012 by the same company; the Vanguard. While the Blue Marin can carry 76,000 metric tons structures, this new ship (275 meters long) is able to transport up to 110,000 metric tons. In addition, The Vanguard includes movable casings, which facilitates adapting the vessel to different loads.


The following video shows how the Vanguard works:



Maybe it sounds a little bit nerdy, but I do like Carrefour because there I can spend my time discovering new products, new packaging, as well as comparing different brands. Moreover, these reasons also move me away from Mercadona (even knowing that could be cheaper), because I got bored and forced to buy always the same awful soviet-looking Hacendado products.

Nowadays, I have found another reason to remain in my decision: the single queue. I consider that queuing is one of the biggest wastes of time, and I have thought many times about how to create a queue system for fast people; people who only want to pick up their products and pay without discussing the prices, socializing with the cashier or searching for the perfect shopping bag layout before leaving the supermarket.

In the multiple queue system I am the typical customer who spends his time in thinking about whether I choose wisely or not, and wondering why the fortune has given an advantage to a customer who has arrived later. For that reason, I always try to take an advantage moving from queue to queue, which in most of the times means more waste of time, as clearly shows the following video:

In my opinion, the single queue seems to be long but gives its user the feeling of constant progress, as well as guarantying that any difficult customer will not stop the others. Also, it is fair for everybody: all customers and all cashiers will wait and work the same time respectively. On the other hand, I cannot avoid the pleasure of hearing everybody complaining about the length of the single queue, knowing that they are wrong.

The Dark Side of Logistics

Last weekend I watched “Darwin’s Nightmare”, a documentary that shows the devastating effects of the globalization on the inhabitants of Mwanza, a Tanzanian fishing village of Lake Victoria.

darwin's nightmare

The entire documentary is connected to the Nile perch, an alien fish species that was introduced during the sixties into Lake Victoria, and since then they have devoured every other kind of fish in the lake, also destroying the local ecosystem. A local fish industry (financed by the European Union and the World Bank) has been created to clean and strip the fish flesh, which is finally exported to wealthy countries. Around this industry, all the inhabitants of a country desolated by famine, endless wars, and AIDS, try to survive either offering their services as fishermen or factory workers, or either collecting and eating the factory food scraps (since they cannot afford fish prices). There are also prostitutes who keep company with the planes pilots and farmers who handle the rotting carcasses.

Paradoxically, the logistic system is working very well. The cargo planes are carrying to wealthy countries tons of processed fish, but it seems that these planes are not coming empty to Africa. The author tries to find out what the planes are bringing to Africa, and it appears that most of the times they bring weapons that fuel the continent’s wars.

To sum up, the documentary shows how the logistic system guarantees an effective forward and reverse flow of goods, in order to make the transport system profitable. In addition, the logistic system is supporting the development of many industries, although, in this case, the wealthy countries are taking all the benefits at African’s countries expense.

More information:

Information Flow

I would like to talk about how I deal with logistics in my daily work, focusing on the importance of information flow. I work as a production manager in a local furniture factory. The company focuses its efforts in creating exclusive and personalized products for the senior executive segment, being big meeting tables the most representative product.


In order to compete in the market, the company tries to deliver high quality customized products within a short delivery time (usually 35-50 days). All the meeting tables are designed specifically to meet each client needs (regarding sizes, materials, electronic devices); therefore most of the time gathering materials in advance is unnecessary.

I am aware of the short delivery time for such special products; consequently boosting the information flow is very important. The process normally works as follows:

The sales department receives the purchase order, and they are in charge of introducing it on the production program.  Sometimes the specifications and definition of the product are not complete. In those cases, I ask the sales department to talk to the client, but as we sell products to many countries, we do not immediately receive the answer.

Once the product is well-defined, it is time to speak with the technical department. They have to identify all the raw materials, make the CAD/CAM drawings, and define the products that we will order to the external suppliers. The purchase department is in charge of gathering what is needed. As we do not buy big batches of anything, it is important to have good relations (kind of friendship) with all of the suppliers, in order to reduce the delivery time.

Now, we are able to start the production phase. Do you remember those 50 days? We do not have them anymore. Some of the materials are delivered in the factory, but we also have to pick up some of them with our means. Metallic raw materials are delivered within 2 days, but wooden raw ones take around 10 days. Leather and electronic devices are delivered normally in 20 days. It is important to know exactly when all of them are coming.

There are five different areas in the factory (metalwork, woodwork, upholstery, assembly and packaging) and all of them have to know exactly what to do. The process starts manufacturing the wooden and metallic parts of the table. When they are finished, some of them are sent to an external supplier (finishing process / 6-8 days), and others are moved to the upholstery process. Once everything is finished, we assembly the table, check the quality, disassembly it and pack everything for delivering. Most of the times we also manufacture big wooden boxes to put the packaged parts inside and avoid problems during transportation.

To sum up, I consider that Information flow is very important among all the processes, in order to avoid time wastes, as well as to involve everybody in the delivery time. On the other hand, all suggestions about how to improve the process will be really welcome.