About this series

This series of tutorial articles is a joint project of the Association for the Healthcare Environment and Health Facilities Management.

Lean principles have a long history in manufacturing. Inspired by the famously efficient Toyota Production System, over time Lean has been successfully applied in other settings, including health care systems and even environmental services (ES) departments within health care facilities.

The goal of Lean not only is to identify opportunities to eliminate waste, but also to sustain them through the Lean process. The end result is a cycle of continuous improvement that puts your team closer to superior work practices.

Once put into play, Lean processes should become second nature, so improving quality, efficiency and problem solving is sustainable and ongoing.

Principles and processes

To implement Lean in a health care setting, ES professionals should be involved in the Lean journey from the very beginning. It needs to be an organizationwide effort, which means all departments must have access to valuable tools and resources as they make the transition. This includes training services and programs from within or outside the health care organization.

Lean training and practices can be implemented in as little as a year. The benefits quickly follow, coming in the form of patient satisfaction, increased quality outcomes, more efficient time use and better financial stewardship. While Lean is most effective when the entire organization is committed to the process, the tools and principles can be specifically applied to ES. To understand how to do this, ES professionals have to understand the core principles, tools and purpose of Lean.

Lean helps to identify and remove waste, which can be unneeded products, activities and time-consumption. Not only is waste a deterrent to productivity in itself, but it also can serve as a barrier between workers and the tools they really need. To address this, professionals look to a central Lean model known as "A3." It is named for a European paper size that is roughly equivalent to 11-inch by 17-inch tabloid-sized paper and used for the report.

Key steps in the model include identifying the issue, obtaining the background, understanding the current state, asking why, creating counter measures, confirming if results are as intended and making any needed alterations.

Lean thinking can be used often in ES work. One particular example is the process a team can use to access, stock and maintain supply closets, which is clearly an opportunity to eliminate waste. To enact Lean thinking in this particular instance, an ES department can employ a Lean method called "5S." This includes the following elements:

Sort. Get rid of unneeded items.

Set and straighten. Organize and label the location for items that are needed in the area.

Shine. Keep the area and equipment neat and clean.

Standardize. Develop cleaning methods and cleanliness standards to maintain the first three S's.

Sustain. Make the first 4 S's a habit and part of the culture.

By removing unneeded or rarely used items and reorganizing the supplies that are truly needed, ES professionals are able to access tools for work quickly and easily. When one considers how often ES personnel use these closets and supply areas, it's easy to see how a few wasted minutes searching to reach necessary items can quickly add up to many hours of wasted time and resources.

Using the tools

While learning about Lean processes and tools initially may feel overwhelming to ES professionals, they begin to make sense and become ingrained in thoughts and work processes once in practice. That isn't to say Lean doesn't require conscious effort after implementation. For instance, no matter how long a closet has been clean and organized, it still requires regular tidying and an agreement by all who access the closet to maintain its organization.

ES departments can use a number of Lean practices and tools in their daily work, whether it's addressing a problem, carrying out a plan or reviewing the effectiveness of efforts. Some of these practices and tools include:

Time studies. By conducting time studies, ES professionals can measure and establish the baseline amount of time needed per room cleaning, as well as time needed for fixed work that needs to be accomplished regardless of patient volumes. In turn, this helps ES professionals with appropriate staffing and scheduling while they remain accountable in the use of their time.

5S audits. To ensure that ES professionals sustain these standards, they should perform regular audits and hold each other accountable for results. For the Lean process to work, every employee must be committed to it.

Scripting. When carrying out their duties, ES staff should use scripted patient engagement. While this sounds regimented, the reality is that it frees staff to confidently engage patients with consistent hospitality in an informative and satisfying manner, which, in turn, enhances patient satisfaction as it relates to the ES staff.

Gemba. The Japanese translation of Gemba is "the real place." In the case of Lean, Gemba is the place the work is being done. For ES, it may be a supply closet, a patient room or hallway. In Lean leadership, meetings take place at the Gemba where the issues can be resolved.

These are just some of the tools that can be used in Lean. It may seem like a lot to process, but once these tools are put into play, their effectiveness and logic makes them increasingly easy to reference and employ.

Monitoring and accountability

A key aspect of Lean is continuous improvement. There is no mastery of Lean that triggers some sort of stopping point. This is crucial for a number of reasons, particularly in health care. First, it's easy to regress into old habits with one "off" week, just as it's easy for a chain to break because of one weak link. Additionally, health care and ES within the hospital setting are both constantly evolving, demands are changing and new faces are joining the team. Therefore, processes need to evolve, too.

To ensure that ES professionals are making improvements, they must search for ways to measure the results of changes. Instead of focusing on the outcome and stopping there, they examine the process that brought them to that outcome. Some measurement tools include:

5S and quality room audits. In addition to auditing supply areas and closets, ES professionals also should audit patient rooms regularly to ensure that they are adhering to standards while meeting established cleaning time goals.

Patient satisfaction scores. Press Ganey Associates Inc., South Bend, Ind., often is used for patient satisfaction survey systems, but ES-specific questions can be worked into any survey system. This also helps to gauge if ES professionals are engaging patients properly and politely and indicates whether scripting changes are needed.

Team huddles. Three times each week, quick huddles can be used to address any issues as a group, which helps to ensure that each team member is aware of new problems or changes. It also gives them a chance to offer input.

Team meetings. Monthly team meetings are valuable. Here, ES professionals can discuss departmental and organizational business in a thorough and planned format.

Future opportunities

Introducing and sustaining Lean practices isn't without its challenges. ES departments often will have to address and overcome such challenges as:

Securing education, training and buy-in. It is important that organizational and departmental leadership are committed strongly to Lean and, in turn, they encourage team commitment.

Sustaining Lean practices. There is a reason sustaining is a part of the 5S model. While anyone can make a positive change, the real challenge is maintaining the effort over time, so monitoring, evaluations and accountability must be part of the process rather than an optional afterthought.

Communicating clearly and consistently. This helps to ensure all team members are on board and engaged on a regular basis. A failure of communication can create a culture that isn't conducive to Lean in attitude or awareness. That is why team huddles and meetings should be proactive and routinely scheduled.

While an ES department already may have integrated Lean in many areas, other opportunities always can be identified. Examples of these include:

  • Standardizing ES carts;
  • Downsizing supply areas for future demands;
  • Standardizing supplies for each closet and identifying on-demand needs versus overstock;
  • Bringing storage of privacy curtains closer to their point of use.

These examples help to demonstrate the versatility and range of Lean applications. When it comes to Lean, no problem or process is too big or too small. Simply shaving a few wasted dollars or seconds off a practice can make a significant impact on quality and efficiency over the course of a year.

More opportunities

Of course, no matter how effectively Lean processes are implemented and sustained, there are always more opportunities for improvement. Where ES professionals once saw problems, they will instead begin seeing opportunities to learn and grow.

Lea Beach, CHESP, is executive director of environmental services at Ireland Army Community Hospital in Fort Knox, Ky. She can be reached at leabeach65@gmail.com.

Sidebar - Resources on the Web

There are many Lean resources on the Web. The following were used by the author in the preparation of this article:

• Healthcare Performance Partners — this private firm's process combines Lean, Six Sigma and effective methods for managing change to help generate significant sustainable improvements in patient safety and quality outcomes in health care: www.hpp.bz.

• Lean Enterprise Institute — this nonprofit group's website includes a number of books, tools and educational opportunities, including John Shook's book on Managing to Learn — Using the A3 management process to solve problems, gain agreement, mentor, and lead: www.lean.org.