FEATURE – In this article, we hear about how the lean successes of one hospital inspired an entire healthcare authority to introduce changes to their processes.

Words: Instituto de Oncologia do Vale and the logistics team of the São José dos Campos Healthcare Authority

If you are looking for an example of successful lean cross-pollination – the process by which improvement efforts in one place inspire lean efforts in another – look no further than the city of São José dos Campos, near São Paulo.

Home to Instituto de Oncologia do Vale (the cancer treatment center I run that has come to be recognized as an advanced example of lean transformation), in recent years São José dos Campos has seen several organizations across its healthcare system initiate lean experiments. What inspired these initiatives was the pioneering work of IOV.

One of the first organizations that saw how successful lean was at IOV and decided to give it a try was the Hospital Municipal José de Carvalho Florence. Over the years, this organization was able to achieve impressive results, including reducing the length of stay by four days, reducing mortality by 4.5%, and increasing capacity and creating a new maternity ward. In 2019 alone, their lean work to improve the way they dealt with sepsis allowed them to save 180 lives! All of this didn’t go unnoticed: the improvements caught the attention of the City Healthcare Authority, which asked to visit the hospital (as well as IOV) to see how they were managing their logistics.

The City Healthcare Authority provides and manages infrastructure, personnel and supplies (all kinds of drugs and materials) for the city’s 46 primary care units. Before lean was implemented, the process was chaotic. Deliveries to each primary care unit were made once a month, in large batches.

A value stream mapping exercise highlighted the shortcomings of this system based on batching and revealed how long it took on average to supply a primary care unit in São José dos Campos: it took 240 minutes. There were bottlenecks and delays through the process.

With little space to shelve this material, most units found themselves with entire rooms filled with boxes. This meant there was often little to no visibility over what medications were available and in what quantity. As a result, it was “easier” to just reorder a certain drug as an emergency delivery (that would sometimes take less than 24 hours). There was no control over the inventory. For the Healthcare Authority, this meant that emergency deliveries had to be arranged once or twice a week for each primary care unit.

Having to provide supplies to primary care units in large batches also meant the Healthcare Authority had to carry vast amounts of inventory in their central warehouse, in the region of 500,000 units per month.

Inspired by the lean work they had seen in other healthcare organizations in the city, the Healthcare Authority changed the supply system, moving to weekly deliveries of small batches to each primary care unit and trying to limit the number of emergency supplies.

With smaller, more frequent deliveries, both the central warehouse and the units noticed several immediate benefits.

First of all, they were all able to save up space. The central warehouse now carries 175,000 items per month, down from half a million, while most units were able to free up an entire room and place items on the shelves as soon as they are delivered. This made picking easier for the central warehouse staff and brought visibility of the inventory at the units. As a result, the number of requested emergency deliveries dropped.

In this context, the introduction of a Kanban system was critical: each item now has a Kanban card attached to it, informing replenishment efforts. A green card means the item is available; a yellow card means an item need replenishment, but that it can wait until next scheduled delivery; a red card means the item is out of stock and needs immediate replenishing. Of course, with weekly deliveries, no care unit is now left waiting for a drug or other item for more than a day or two, even when they run out. In the event of an emergency delivery becoming necessary, a Milk Run-like system ensures the item can “tag along” on one of the delivery vehicles, based on the route they follow and the destination unit.

By redesigning the flow and changing their way of organizing stock and delivering it, the Healthcare Authority was able to reduce the supply time per unit [set up time] to 168 minutes on average (down from ~240 minutes). This represents a 30% gain per unit, which, multiplied by 46, equals 55 hours saved per month.

They also cut their overall logistics costs by 89.6%: in 2019, they spent R$ 5.4 million, while today they spend R$ 570,000. These were transportation costs: prior to lean being introduced, a contractor was used to fulfil the countless emergency deliveries the Authority received, per delivery. Today, they use predefined daily routes (having cancelled most of the contract with the delivery company) to complete weekly deliveries and fulfil the occasional emergency orders. By eliminating the non-scheduled emergency deliveries and redesigning the flow, the amount of work decreased; the nature of the work changed, too: it is no longer firefighting, but predictable, scheduled work.

BLOOD SAMPLING, IMPROVED

Another interesting logistics project the Healthcare Authority completed focused on blood sampling. The Authority has a central lab that analyzes blood samples for all 46 primary care units in the city. Before lean was introduced, there was a massive bottleneck that caused very long waits for sample extraction (which in turn directly impacted the follow-up visit with the physician and any subsequent course of action). For urgent blood test, it took 7 days to get results back. For routine bloodwork, up to four months.

Once the blood sample reaches a lab, it is tested within two or three hours. It’s machine work, after all. So, the problem is how long it takes the sample to get to the lab. Previously there was no flow. With a cumbersome, bureaucratic process that had several duplicate steps, it was hard to imagine things might improve. The units routinely used less capacity than they had available. They often had to reschedule patients (whenever they showed up unprepared, either because they hadn’t faster as instructed or hadn’t brought a urine/feces sample). Additionally, the system didn’t automatically remove from the schedule patients who – for whatever reason – brought their appointment forward.

Proposed countermeasures included eliminating the physical diary, having the physicians themselves schedule the sampling when they request it, increasing the number of appointments according with the actual capacity. The Authority sent out directives to all primary care units in the city, instructing them to optimize the use of materials, reduce the number of steps in the sampling process and simplify it, and asking doctors to print out the instructions for the patient together with the prescription.

The new sampling process and redesigned flow helped primary care units across the city to save one hour in the blood collection process (it was around 90 minutes before, and it’s not between 30 and 45 minutes), which in turn allowed the central lab to process 80 samples per day – up from 45. In other words, they doubled capacity. Today, patients receive blood test results within 24 hours, both for urgent and routine tests.

This story is testament to lean’s ability to inspire improvement and spread like wildfire. All it needs is fertile ground!