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Education and debate

Using industrial processes to improve patient care
Terry Young, Sally Brailsford, Con Connell, Ruth Davies, Paul Harper, Jonathan H Klein Might industrial processes improve quality, reduce waiting times, and enhance the working environment?

Department of Information Systems and Computing, Brunel University, Uxbridge, Middlesex UB8 3PH Terry Young professor School ofManagement, University of Southampton, Southampton SO17 1BJ Sally Brailsford senior lecturer Con Connell senior lecturer Jonathan H Klein senior lecturer Warwick Business School, University of Warwick, Coventry CV4 7AL Ruth Davies professor School of Mathematics, University of Southampton Paul Harper lecturer Correspondence to: T P Young terry.young@ brunel.ac.uk
BMJ 2004;328:162–4

Radicalthinking about the design of industrial processes over the last century has greatly improved the quality and efficiency of manufacturing and services. Similar methods to deliver higher quality health care at lower cost would be extremely valuable. In health care, however, we must also consider how patients feel about the processes and the extent to which they are able to exercise meaningful, informedchoice. Although the potential of using industrial methods in health care has been discussed,1 2 their value is hotly debated. Some doubt that there is a valid analogue between industry and health care, while others see it as an excuse to force an overworked community to work even harder.3 4 We describe three established industrial approaches—lean thinking,5 6 theory of constraints,7 and sixsigma,8 9—and explore how the concepts underlying each might relate to health care.

Box 1: Five key concepts for lean thinking5 6
Value—Products should be designed for and with customers, should suit the purpose, and be set at the right price Value stream—Each step in production must produce “value” for the customer, eliminating all sources of waste. The concept of waste is far reaching and mayinclude waiting, travel, mistakes, or inappropriate processing Flow—The system must flow efficiently, ideally without intermediate storage. Among other things, flow depends on materials being delivered, as and when they are needed, to the quality required Pull—The process must be flexible and be geared to individual demands—producing what customers need when they need it Perfection—The aim isperfection. Lean thinking creates an environment of constant review, emphasising suggestions from the “floor” and learning from previous mistakes

Lean health care
Lean thinking started with Toyota in the 1950s and was developed by Womack and Jones.6 It seeks to provide what the customer wants, quickly, efficiently, and with little waste (box 1). An obvious application to health care lies in minimisingor eliminating (within a framework of clinical excellence) delay, repeated encounters, errors, and inappropriate procedures. Some conceptual issues that arise in relating lean thinking to health care include the extent to which patients, service providers, or even taxpayers equate to customers in the commercial setting and the way in which health outcomes, patient satisfaction, or even cost canbe legitimately used to define value. Furthermore, although the routes followed by items in a manufacturing process are clearly defined, those followed by individual patients depend on clinical judgments at various stages, which may complicate a rigorous analysis.

The NHS could learn from methods to improve industrial processes

Although lean thinking in industry often results in staffreductions, it first creates extra capacity by identifying and eliminating wasted resource. Indeed, one of the key problems Womack and Jones6 discuss is how to maintain the morale of a workforce that has just been reduced because the product can be made with fewer people. A lean environment will thus have sufficient capacity to handle variations without introducing queues. Maternity care, notable for...