Running on all Cylinders

Radiologists enhance efficiency using a method originally designed for the automobile industry.running on all cylinders

The common perception of Japanese efficiency has its roots in many facets of the nation’s past. One of these aspects is its history of whaling. Since Japan’s mountainous topography made it hard for inhabitants to cultivate livestock, around 12,000 B.C. they turned to whales for sustenance.

Although the modern practice of whaling has drawn ire due to the brutality of poachers worldwide, in ancient times, the Japanese held the animal in such esteem that it became tradition to show respect by using every part of it to produce meat, clothing, and fuel.

Over the millennia, this custom of leaving nothing to waste made its way into Japanese auto manufacturing. The first proponents of cutting inefficiencies in this process were the heads of the Toyota Corporation in the 1930s. These leaders sought to improve upon the revolutionary yet rigid production methods pioneered by Henry Ford by adding value to their product and eliminating inefficiencies.1

The Lean Approach

Dubbed “lean production” in the 1980s, Toyota’s approach to work “demands a commitment to a set of principles that allow people and organizations to become and remain efficient.”2 The business strategy has only recently been applied to medicine, with great success in many cases. The net effect of integrating the strategy into the field of radiology is to provide customers — both referring physicians and patients — with a higher level of value through continuous improvement.

Waste can take many forms, a few of which include using out-of-date protocols, requiring patients to wait due to inefficient scheduling, underutilizing equipment, and storing more supplies in inventory than is necessary.3 The practice of radiology is a very complex process, notes Lucy W. Glenn, MD, chief of the department of radiology at the Virginia Mason Medical Center in Seattle, which makes it a good fit for the lean process. “Any time you’re dealing with a complex process, you need a tool to simplify operations and look at them in a standardized fashion,” she says.

Virginia Mason was among the first health systems in the U.S. to implement lean, a transition that began with a simple conversation on a plane flight. “A member of our executive team happened to be sitting on an airplane next to a lean consultant,” says Glenn. “Lean hadn’t been attempted in health care, but the consultant explained to him how the approach could apply to medicine. By the end of the flight the Virginia Mason representative agreed with him.” And the rest is history.

In 2002, the hospital’s executive team, along with chairs from each department, traveled to Japan to learn more about the process at its source. After spending a few weeks observing how lean worked within companies as diverse as Toyota and Hitachi, the leaders came back and instituted lean training workshops for the health system’s vice presidents and administrative directors. Once top level staff became lean certified, others, including staff in the radiology department, were taught the same principles.

How It Works

Although lean is not a one-size-fits-all system, its principles can be customized to fit almost any radiology practice or department. Some of these aspects include the following:

Involve all staff members in identifying inefficiencies. The first order of business when implementing lean is to involve all staff members in identifying sources of waste. This principle has two benefits. First, frontline staff members, such as techs, may know of wasteful practices of which radiologists may be unaware. In addition, if staff members are brought in to help point out problem areas, they become more invested in the process and, by and large, are more likely to take ownership of maintaining an efficient workflow. “If a manager came up with a whole new way of doing something and imposed it on the staff, it would flop because he or she didn’t involve them in mapping out the change,” says Glenn. “You have to lay the groundwork.”

Standardize the workflow. In a complex ecosystem of scheduling, testing, and reporting imaging study results, minimizing variations wherever possible can save time and money, enhancing value to both patients and referring clinicians. Samir B. Patel, MD, a diagnostic radiologist at Radiology, Inc. in Elkhart, Ind., explains how, after earning a lean black belt certification in health care, he was able to save the hospital money by simplifying its intravenous contrast inventory. “For CT examinations requiring intravenous contrast, three types of contrast were available to choose from,” he says. “There was no standardization for when to choose which contrast type. After reviewing the literature, and referencing ACR Appropriateness Criteria® and the Manual on Contrast Media, the radiology department streamlined to only one type of contrast, saving the hospital hundreds of thousands of dollars with no adverse patient outcomes.”

Go to the gemba. The “gemba” is a Japanese term meaning “the place where the real work is done.” Given the successive cuts in radiologists’ Medicare reimbursements over the past few years, it is no wonder that many prefer to remain in the reading room, churning through more and more studies to maintain reimbursement levels. The lean process, however, requires that physician leaders step out from behind their PACS and walk the floor of their practice or department. This exercise allows staff members and physician leaders to interact in important ways. “We participate in gemba walks, where we actually go to the different areas on a routine basis,” says Jonathan B. Kruskal, MD, ChB, PhD, professor of radiology at Harvard Medical School and chair of the department of radiology at Beth Israel Deaconess Medical Center. “We are able to engage staff to seek feedback about opportunities for improvement.”

Despite the fact that these are time-tested methods of enhancing value to patients and referring clinicians, it may take some time to obtain staff buy-in. “We have found that the administrative and technical staff have been far easier to train and become more involved in the processes than the physician staff,” admits Kruskal. “By the very nature of technical work, the different modalities are ideally suited to the lean approach. Physicians have always focused more on their diagnostic and procedural work and we have had to work especially hard to get the physicians engaged.” Glenn agrees that implementing such thorough change in an organization will produce pushback from employees. “We had pushback from all levels in the beginning,” states Glenn. One of the top complaints from staff, she says, was that patients are not the same as cars, and that such a system cannot work in an environment where every patient is different. However, Glenn adds, this is an erroneous impression because most of the standardization is built around the process and not the treatment. She advises that it will take about five years to get everyone on board.

Tools of the Trade

The quality control tools now associated with lean were derived from research conducted three decades ago by the Union of Japanese Scientists and Engineers.2 These instruments, which are used to remediate inefficiencies, include flow charts, value-stream mapping, annual operating plans, and management dashboards. If used effectively, they can help increase staff productivity and create a less cumbersome process for patients and referring clinicians alike.

Kruskal notes that his department utilizes several of the standard lean tools to maintain efficiency at all times, including a variety of “countermeasures.” Countermeasures are “steps that are introduced to improve performance in a particular process.”2 Kruskal says, “These countermeasures typically would involve standardized work processes, such as mistake-proofing by using, for example, checklists and visual systems like posters and sign boards.”

But while using these tools may help keep everyone on the same page, they aren’t mandatory in order to accomplish enduring improvements. Patel says that when he decided to make it a point to begin identifying inefficiencies, he didn’t deploy a whole range of tools. “I didn’t do any surveys,” asserts Patel. “I just went around and talked to the ER physicians and asked them what gave them angst. I collected that information and then went back to them later and said, ‘This is where I think we have some defects, and here’s what I’m proposing we do about it.’ In essence, I got out of the reading room and started asking questions. It doesn’t have to be a sophisticated process.”

The lean approach is a way for radiologists to increase their value without investing a great deal of capital. By breaking down silos and opening the flow of communication — and by asking staff members to be more aware of their environment — radiology practices and departments can operate at full capacity. In fully embracing the team-based approach to management that lean requires, radiologists will make true the ancient Japanese proverb: “A single arrow is easily broken, but not ten in a bundle.”

By Chris Hobson

1. Lean Enterprise Institute. “A Brief History of Lean.” Accessed May 7, 2014.
2. Kruskal JB, Reedy A, Pascal L, Rosen MP, Boiselle PM. “Quality Initiatives: Lean Approach to Improving Performance and Efficiency in a Radiology Department.” RadioGraphics. Accessed May 7, 2014.
3. TriMed staff. “RSNA: Is Radiology Ready for Lean?” HealthImaging. Accessed May 7, 2014.

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