Lean Transformation for Radiology: Should Imaging Go Lean?

If you’ve ever changed a routine at home, like hanging your keys on a hook by the door instead of dropping them in random places, then you’ve engaged in lean transformation. Changing your routine to save time and energy and get better results is exactly what lean transformation does in the work place.

Think of it as continuous improvement.

Lean isn’t a new concept, but it’s gaining steam in the healthcare and imaging world. You know lean from its start with Toyota around the 1970s. Though they didn’t use the term lean then, the Japanese manufacturer started delivering cars that were cheaper and higher quality than its American counterparts. U.S. industry started adopting the system, traveling to Japan for training. A few large hospital systems followed suit decades later, including Denver Health System, Thedacare in Wisconsin and Seattle’s Virginia Mason Hospital and Medical Center, saving significant amounts of money, lowering the cost of care and increasing patient satisfaction and quality.

Radiology is a good fit for the lean tools and approach, said Jonathan B. Kruskal, MD, PhD, radiology professor at Harvard Medical School and chair of the radiology department at Beth Israel Deaconess Medical Center, given imaging’s many different complex processes. “If one simply looks at those many things that cause frustration on a daily basis, from trying to improve access to studies, trying to improve turnaround, getting reports out sooner, communicating findings, ensuring that equipment is all functioning efficiently, all of these can be monitored, managed, and improved using the lean approach,” he said.

While many of these concepts have been used in industry for years, radiologists, are only now realizing how to benefit from the expertise, he said.

Another advantage to using lean principles is standardizing approaches to care. “When it comes to physicians’ work, 80 percent is routine. They can do it almost without thinking,” said Andrew Gomes, MD, chief executive officer at the lean consulting firm Casper Radiology.

He said that like in other industries, this segment of routine healthcare should adopt an assembly line approach. “That is what will make prices affordable and quality high and consistent.” For the other 20 percent of cases, “you need to stop and pause, and move it out of the assembly line and treat with more care,” Gomes said.

The lean process

Lean is simple, but it’s not easy, said Gomes. The process involves identifying inefficient routines. It’s about creating a better workflow and getting groups to work together - what lean followers call “breaking down the silos” of different departments.

By joining forces and walking through a process involving two departments, each group may see the challenges facing the other, allowing them to create a better system, not blaming individuals. “People that understand lean understand that the vast majority of problems are system generated, not from people screwing up,” said Mark Welch, a lean consultant at Red Rock Health Ventures in Iowa.

If you read about or hear someone talk about lean, you might think it sounds like jargon mixed with Japanese words (e.g. muda, mura, gemba, kaizen and hoshin). The tools include flowcharts, mapping and matrices, which help demonstrate the identified problems, and they’re being reworked. The end result should be a better work flow, saved time and money, and a more enjoyable experience for staff and customers. For radiology, those customers are patients and referring physicians.

Doctors have complained to Welch that the lean process is cookbook medicine, something he adamantly denies. “We follow the basic process of plan, do, study, adjust,” he said. “It’s the scientific method applied to our work.”

To identify waste, the lean term for inefficiencies, the lean consultant and participating staff walk the flow of the process they’re focusing on, asking questions and taking notes. The staff identifies stumbling blocks to sees where the hitches are, enabling them to come up with an informed solution. “You don’t have to buy fancy software or equipment” to make lean work, said Gomes. Lean enables staff to work smarter, not harder.

By increasing productivity, the staff can take on additional volume. Obviously that’s good for the hospital, with more patients and extra revenue, some of which can be shared with front line staff. Plus the workplace is more pleasant since there are fewer frustrations from inefficient processes.

Who needs it?

While any facility can gain from using lean techniques, some experts feel that the hospitals and executives most enthusiastic about using them are those pushed to the financial breaking point. Lean is a big change, and those who are in a better place financially may not be willing to take the risk.

However not everyone feels that facilities implementing lean principles are desperate. With a shift from volume to value-based care in healthcare reform, radiologists need to understand that value isn’t just a word, but it’s satisfying customers, increasing safety and efficiency, said Kruskal.

Facilities can either use a top-down approach involving the entire hospital, or a more grass roots one, one department at a time. The entire facility approach used by ThedaCare, Denver Health System and Virginia Mason Hospital and Medical Center achieved excellent results, but they did take many years, said Gomes, and all were led by pioneering physician CEOs. They require a high upfront investment in time and resources, but those pay off in the long run, he added.

Those who don’t have that kind of time or backing might consider the bottom up approach, which Gomes said is still effective, and more palatable to institutions. You won’t save hundreds of millions of dollars this way, but you can generate significant savings and increased productivity.

Getting radiologists on board

Projects like these require cultural change, and staff members have to accept it and be willing to participate, or it will fail. “You’ll oftentimes get resistance from some individuals,” Gomes said. “Old habits are often tough to change.”

At Sutter Gould Medical Foundation in California’s Central Valley, radiologists responded best when they could see a direct relationship between the process and their work. Prior to that, “anything that pulls a radiologist away from the work list, they view as a waste,” said Roberta Edge, director of imaging services. They’re starting their third year of the lean process for imaging, and radiologists are finally beginning to see how the tools are working, and they’re able to read more studies. Now they’re taking an interest in lean.

If radiologists are working in several hospitals and only one is implementing lean, it can be even more difficult to bring them on board, said Dean Bliss, Gemba coach at Simpler Consulting in Iowa. “Sometimes they’ll play the hospitals off each other,” he said. “You’re messing with their world.”

To get buy-in from radiologists, the physicians need to understand why transformation is needed, and how patients, work flow and the work environment will benefit, said Kruskal. “We find that it is important to establish a sense of urgency,” so the radiologists want to participate. Recruit a team of “change champions,” who will go through formal lean training, as well as a vision group to communicate where the process is heading.

Radiologists might be fearful that the changes will lead to job loss. This isn’t a concern for all lean projects. But for some it is, said Gomes. “If truly committed to lean, healthcare leaders must be willing to make the tough choices, and that may include parting ways with resisters,” he said, adding that those who don’t adapt to change may not be a good fit for the organization.

“Physicians tend to be a very change-averse group. They’re used to doing things the way they’ve always done them, and they don’t like the boat being rocked,” Gomes said. “Sometimes, even if a CEO or VP of operations tells them that lean works and tries to educate them about it, many will pull ‘the doctor card’ and resist. Unfortunately, this often ends any meaningful conversation or dialogue, and progress is halted.” Radiology groups may be resistant to a hospital lean process because the financial incentives aren’t aligned with the lean principles.

“Physician salaries and group subsidies are often allocated in accordance with the perception of them working extremely hard and being overwhelmed,” Gomes said. “If lean fixes that, they feel they will lose a major negotiating chip. Plus, if lean is successful in increasing productivity, it’s possible that not all physicians will be needed. What doctor wants half his buddies laid off?”

Making lean successful

Facilities with successful lean experiences share traits. The top administration and department need to be totally committed, with hands-on involvement. Radiologists also have to be on board for it to work. “The most important thing we have learned is how much the staff and radiologists have to buy into the process to be successful,” said Edge.

Given the impact of change on individuals, teams and organizations, frequent – even daily – communication about the changes and urgency is critical, said Deborah McAllister, lean coach at Sutter Gould Medical Foundation. Once changes are made, showing staff members how they’ll benefit from the new process is key to sustaining the change, said Edge.

Lean works when those involved walk around the department tracing the system flow they’re focused on. The committee members and consultant will ask questions, finding out the various steps in the process, noting which parts frustrate the people involved. A lean consultant may guide the process, but shouldn’t be handing down answers. Those come from the staff members.

The process takes time. At Beth Israel Deaconess Medical Center, the lean transformation included formal training for physician and modality leaders, then training section chiefs. Residents get lean training as part of their quality improvement curriculum. “The biggest challenges we faced were faculty completing the course and not seeing the immediate benefits for the imaging environment. It took several months before faculty could start to apply the tools effectively, at which point they were able to share their experiences and disseminate this across the department,” said Kruskal.

Since lean encourages teamwork, the process improved morale, said Kruksal. “We have many more members of our department participating in these efforts who previously might not have had a voice at the table.” The hospital staff learned to engage and respect other staff members, and picked up simple tools helpful in any performance improvement project. Walking the floor to find inefficiencies relating to a process used to cause staff members anxiety, because they were concerned why it was being done. “We learned that visiting the workplace is actually an educational opportunity to help teach those in the workplace rather than simply trying to collect data and analyze this after the event,” he said.

Lean success stories

The opportunities for lean to improve the radiology workplace are endless. Radiology inefficiencies might include time transporting equipment or patients, wait time, scanning inefficiency, excess image acquisition, excess radiation dose, inventories of radioactive isotopes that expire and fumbled processing of images. 

One lean success at Gould was moving the nursing work out of the CT suite, saving five minutes of cycle time per scan. They now schedule 40 scans in the same time they previously slotted 25. They reduced their cost per MRI, CT and ultrasound by an average of 40 percent, plus are making patient-focused decisions based on data. They’re working better as a team and less as a silo, said Edge.

The human aspect can’t be dismissed. “We are learning we are a part of the entire patient experience, not the center of it,” Edge said. “Access is better and I have had more patients take the time to call and tell me how much they appreciate the caring of the staff in the last year, than I have in the last 10.”

As for radiologist wins, Bliss said one client hospital created a dashboard which helped the radiologists understand and plan out their workload. Previously the cases were piled in an inbox and they had no clue how many reads were outstanding.

A significant change made at some of Gomes’ hospital clients is converting from a traditional group model to an employed physician model in radiology. In many traditional group models, “the incentives are often mal-aligned,” he said. Many groups receive a hospital subsidy to operate, which may be unnecessary if physicians improve their productivity, completing more work in less time. By paying radiologists a salary, and incentivizing them to work smarter, not harder, the hospital can employ fewer radiologists, but pay them more.

Obviously, not all physicians would embrace this model. It may be resisted by independent groups. It may cost them in subsidies, or they may realize that some of them will get laid off.

Changing to an employed radiology model without instituting lean changes could backfire, making problems worse. The incentives must be aligned for radiologists to do quality work in a productive way.

Lean transformation is not easy, and those who have been through it liken it to entering a dark tunnel before emerging into the light. But the rewards are available. As Edge said, “It is well worth what is a very painful process at first.”