caSe StuDy Saint Bridget’s hospital11
When Denize ahlgren arrived at st Bridget’s, one of the
main hospitals in the Götenborg area, she knew that it had
gained a reputation for fresh thinking on how healthcare
could be organized to give superior levels of public care at
lower cost to the taxpayer. in fact, that was one of the rea-
sons she had taken the job of its Chief of administration
(Coa). in particular Denize had been reading about st
Bridget’s ‘Quality Care’ (QC) initiative. ‘Yes, QC is obviously
important’, explained Dr pär solberg who, in addition to
his clinical duties, also headed the QC initiative, ‘but don’t
think that it is only about “quality”. We don’t just throw
money at improving the quality of care; we also want to
improve efficiency. Any money saved by improving effi-
ciency can then be invested in improving clinical outcomes.’
‘it all started with quality’
although run by a private company, st Bridget’s is little
different from any other swedish hospital. to its patients,
treatment is free, after a minimal charge that is universal in
sweden. st Bridget’s gets virtually all its revenue from the
government. However, in terms of how it organizes itself,
it is at the forefront of implementing ideas that are more
common in private business. ‘It all started with our efforts
a few years ago to be systematic in how we measured qual-
ity’, said pär solberg. ‘We felt that quality must be reported
on a systematic and logical basis if it is going to be mean-
ingful. It should also be multi-faceted, and not just focus on
one aspect of quality. We measure three aspects, “reported
patient experience” (RPE), what the patient thinks about the
total experience of receiving treatment, “reported patient
outcome” (RPO), how the patient views the effectiveness
of the treatment received, and most importantly “reported
clinical outcome” (RCO), how the clinicians view the effec-
tiveness of the treatment. Of course these three measures are
interconnected. So, RPO eventually depends on the medi-
cal outcome (RCO) and how much discomfort and pain the
treatment triggers. But it is also influenced by the patient’s
experience (RPE), for example how well we keep the patient
informed, how empathetic our staff are, and so on.’
‘Measuring quality led naturally
to continuous improvement’
the hospital’s quality measurement processes soon devel-
oped into a broader approach to improvement in general.
in particular the idea of continuous improvement began to
be discussed. ‘Measuring quality led naturally to continuous
improvement’, explained pär solberg. ‘Once we had measur-
able indicators of quality, we could establish targets, and most
importantly we could start to think about what was prevent-
ing us improving quality. This, in turn, led to an understanding
source: Getty images: Caiaimage / robert Daly
of all the processes that affected quality indicators. It was a
shift to seeing the hospital as a whole set of processes that
governed a set of flows – flows of patients through their treat-
ment stages, flows of clinical staff, flows of information, flows
of pharmaceuticals, flows of equipment, and so on. It was a
revolution in our thinking. We started examining these flows
and looking at how they impacted on our performance and
how we could improve the working methods that we consid-
ered significant for the quality indicators that we wanted to
influence. That was when we discovered the concept of “lean”.’
‘continuous improvement introduced us to lean’
it was at an ‘improving european Healthcare’ conference
that was attended by pär and another colleague that first
introduced st Bridget’s to the idea of ‘lean’. ‘We were talk-
ing to some representatives from the UK’s National Health
Service Institute, who had been involved in introducing lean
principles in UK hospitals. They explained that lean was an
improvement approach that improved flow and eliminated
waste that had been used successfully in some hospitals to
build on continuous improvement. Lean, they said, as devel-
oped by Toyota was about getting the right things to the right
place, at the right time, in the right quantities, while minimis-
ing waste and being flexible and open to change. It sounded
worth following up. However, they admitted that not every
attempt to introduce lean principles had met with success.’
‘it can easily all get political’
intrigued by the conversation, pär contacted one of the
hospitals in the UK that had been mentioned, and talked
to Marie Watson, who had been the ‘Head of Lean’ and
had initiated several lean projects. she said that one of
the problems she had faced was her chief executive’s
insistence on bringing in several firms of consultants to
chapter 15 Lean operations 525
implement lean ideas. To make matters more confusing,
when a new chief executive was appointed, he brought
in his own preferred consultants in addition to those
already operating in the hospital. Marie had not been
happy with the change. ‘Before the change of executives
we had a very clear way of how we were going to move
forward and spread lean throughout the organisation,
then we became far less clear. The emphasis shifted to get
some quick results. But that wasn’t why we were set up.
Originally it was about having a positive impact, getting
people involved in lean, engaging and empowering them
towards continuous improvement, there were things that
were measurable but then it changed to “show us some
quick results”. People were forgetting the cultural side of
it. Also it can easily all get “political”. The different consul-
tancy teams and the internal lean initiatives all had their
own territories. For example, we [Marie’s internal team]
were about to start a study of A&E activities, when they
were told to keep away from A&E so as not to “step on the
toes” of the firm of consultants working there.’
‘We’re not making cars, people are different’
Pär was determined not to make the same mistakes
that Marie’s hospital had, and consulted widely before
attempting any lean improvements with his colleagues.
Some were sceptical: ‘we’re not making cars, people are dif-
ferent and the processes that we put people through repeat-
edly are more complicated than the processes that you go
through to make a car’. Also, some senior staff were dubi-
ous about changes that they perceived to threaten their
professional status. Instead of doctors and nurses main-
taining separate and defined roles that focused solely on
their field of medical expertise, they were encouraged
to work (and sit) together in teams. The teams were also
made responsible for suggesting process improvements.
But most could be converted. One senior clinician, at first,
claimed that ‘this is all a load of rubbish. There’s no point
in mapping this process, we all know what happens: the
patient goes from there to there and this is the solution and
that’s what we need to do.’ Yet only a few days later he
was saying ‘I never realized this is what really happens, that
won’t work now will it, actually this has been great because
I never understood, I only saw my bit of it, now I understand
all of the process’.
‘It works, it makes things better for the patients’
Over time, most (although not quite all) scepticism was
overcome, mainly because, in the words of one doctor, ‘It
works, it makes things better for the patients.’ As more parts
of the hospital became convinced of the effectiveness of
the lean approach, the improvements to patient flow and
quality started to accumulate. Some of the first improve-
ments were relatively simple, such as a change of signage
(to stop patients getting lost). Another simply involved a
roll of yellow tape. Rather than staff wasting precious time
looking for equipment such as defibrillators, the yellow
526  Part THREE  DELIVER
tape was used to mark a spot on the floor where the
machines were always kept. Another involved using mag-
netic dots on a progress chart to follow each patient’s pro-
gress and indicate which beds were free. Some were even
simpler, for example discharging patients throughout the
day rather than all at the same time, so that they can eas-
ily find a taxi. Other improvements involved more anal-
ysis, such as reducing the levels of stock being held (for
example, 25,000 pairs of surgical gloves from 500 different
suppliers). Some involved a complete change in assump-
tions, such as the effectiveness of the medical records
department. ‘It was amazing. We just exploded the myth
that when you didn’t get case notes in a clinical area it was
medical records’ fault. But it never was. Medics had notes in
their cars, they had them at home, we had a thousand notes
in the secretaries’ offices, there were notes in wards, drawers
and cupboards, they were all over the place. And we won-
dered why we couldn’t get case notes! Two people walked
7 miles a day to go and find case notes!’ (Pär Solberg)
‘We need to go to the next level’
Denize Ahlgren was understandably impressed by the
improvements that Pär had outlined to her; however, Pär
was surprisingly downbeat about the future. ‘OK, I admit
that we have had some impressive gains from continuous
improvement and latterly from the adoption of lean princi-
ples. I am especially impressed with Toyota’s concept of the
seven types of waste [see details in this chapter]. It is both
a conceptually powerful and a very practical idea for iden-
tifying where we could improve. Also the staff like it. But
it’s all getting like a box-ticking exercise. Looking for waste
is not exactly an exciting or radical idea. The more that I
study how lean got going in Toyota and other manufactur-
ing plants, the more I see that we haven’t really embraced
the whole philosophy. Yet, at the same time, I’m not totally
convinced that we can. Perhaps some of the doubters were
right, a hospital isn’t a car plant, and we can apply only
some lean ideas.’
Ironically, as Pär was having doubts, some of his col-
leagues were straining to do more. One clinician in par-
ticular, Fredrik Olsen, Chief Physician at St Bridget’s Lower
Back Pain Clinic, thought that his clinic could benefit from a
more radical approach. ‘We need to go to the next level. The
whole of Toyota’s philosophy is concerned with smooth syn-
chronous flow, yet we haven’t fully got our heads round that
here. I know that we are reluctant to talk about “inventories”
of patients, but that is exactly what waiting rooms are. They
are “stocks” of people, and we use them in exactly the same
way as pre-lean manufacturers did – to buffer against short-
term mismatches between supply and demand. What we
should be doing is tackling the root causes of the mismatch.
Waiting rooms are stopping us from moving towards smooth,
value-added, flow for our patients.’
Fredrik went on to make what Denize thought was an
interesting, but radical, proposal. He proposed scrapping
the current waiting room for the Lower Back Pain Clinic
and replacing it with two extra consulting rooms to add
to the two existing consulting rooms. patients would be
given appointments for specific times rather than being
asked to arrive ‘on the hour’ (effectively in batches) as
at present. a nurse would take the patients’ details and
perform some preliminary tests, after which they would
call in the specialist physician. staffing levels during
clinic times would be controlled by nurses who would
also monitor patients’ arrival, direct them to consulting
rooms and arrange any follow-up appointments (for Mri
scans, for example).
Denize was not sure about Fredrik’s proposal. ‘It seems
as though it might be a step too far. Patients expect to wait
until a doctor can see them, so I’m not sure what benefits
would result from the proposal. And what is the point of
equipping two new consulting rooms if they are not going
to be fully utilised?’
QueStionS
1 What benefits did St Bridget’s get from adopting first a
continuous improvement, then a lean, approach?
2 Do you think that pär Solberg is right in thinking that
there is a limit to how far a hospital can go in adopting
lean ideas?
3 on the St Bridget’s website there are several references
to its ‘Quality care’ programme, but none to its lean
initiatives, even though lean is regarded as important
by most clinicians and administrators in the hospital.
Why do you think this might be?
4 Denize cannot see the benefits of Fredrik’s proposal.
What do you think they might be?
5 are any benefits of scrapping the waiting room in
the clinic worth the under-utilization of the four
consulting rooms that Fredrik envisages?

proBLeMS anD appLicationS

1 think about the last time that you travelled by air. analyse the journey in terms of value-added
time (actually going somewhere) and non-value-added time (the time spent queuing etc.)
from the time you left home to the exact time you arrived at your ultimate destination.
Calculate the value-added time for the journey.

2 a simple process has four stages: a, B, C and D. the average amount of work needed
to process items passing through these stages is as follows: stage a = 68 minutes, stage
B = 55 minutes, stage C = 72 minutes and stage D = 60 minutes. a spot check on the work-
in-progress between each stage reveals the following: between stages a and B there are
82 items, between stages B and C there are 190 items, and between stages C and D there
are 89 items.
(a) Using Little’s law (see Chapter 6), calculate the throughput time of the process.
(b) What is the throughput efficiency of the process?

3 in the problem above, the operations manager in charge of the process reallocates the work
at each stage to improve the ‘balance’ of the process. now each stage has an average of
64 minutes of work. also, the work-in-progress in front of stages B, C and D is 75, 80 and
82 units respectively. How has this changed the throughput efficiency of the process?

4 a production process is required to produce 1,400 of product X, 840 of product Y and 420 of
product Z in a four-week period. if the process works seven hours per day and five days per
week, devise a mixed model schedule in terms of the number of each product required to be
produced every hour that would satisfy demand.

5 revisit the ‘operations in practice’ case in the chapter (and any other source of information
about the toyota production system) and (a) list all the different techniques and practices
which toyota adopts, and (b) state how the operations objectives (quality, speed, dependabil-
ity, flexibility, cost) are influenced by the practices which toyota adopts.

chapter 15 Lean operations 527