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Lean Tools for Healthcare Series
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PUBLISHED
5S for Healthcare
Standard Work for Lean Healthcare
Kaizen Workshops for Lean Healthcare
Mapping Clinical Value Streams
Mistake Proofing for Lean Healthcare
FORTHCOMING
Just-in-Time for Healthcare
Continuous Flow for Healthcare
Quick Setup for Healthcare
Kanban for Healthcare
Just-in-Time
for Healthcare
Rona Consulting Group & Productivity Press
Thomas L. Jackson, Editor
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Title: Just-in-time for healthcare / Thomas L. Jackson.
Other titles: Lean tools for healthcare series.
Description: Boca Raton : Taylor & Francis, 2017. | Series: Lean tools for
healthcare series
Identifiers: LCCN 2016038558 | ISBN 9781439837450 (pbk. : alk. paper) |
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Contents
Preface..........................................................................................................ix
Acknowledgments........................................................................................ xi
1 Getting Started....................................................................................... 1
1.1 Purpose of This Book.........................................................................1
1.2 What This Book Is Based On.............................................................1
1.3 Two Ways to Use This Book..............................................................2
1.4 How to Get the Most Out of Your Reading.......................................2
1.4.1 Become Familiar with This Book as a Whole.......................2
1.4.2 Become Familiar with Each Chapter......................................3
1.4.3 Use a Reading Strategy...........................................................3
1.4.4 Use the Margin Assists............................................................4
1.5 Overview of the Contents...................................................................5
1.5.1 Chapter 1: Getting Started......................................................5
1.5.2 Chapter 2: The Production Processes and Operations
of Healthcare...........................................................................5
1.5.3 Chapter 3: An Introduction to Just-in-Time............................5
1.5.4 Chapter 4: Creating Islands of Flow.......................................5
1.5.5 Chapter 5: Using Pull to Connect Islands of Flow................6
1.5.6 Chapter 6: Support Techniques for Just-in-Time....................6
1.5.7 Chapter 7: Reflections and Conclusions.................................6
2 The Production Processes and Operations of Healthcare.................... 7
2.1 The Industrial Origins of Lean Healthcare.........................................7
2.1.1 How Much Waste Is There in Healthcare?.............................9
2.1.2 Waiting Is Waste...................................................................10
2.1.3 Defects Are Waste.................................................................11
2.2 Production, Process, and Operation.................................................11
2.3 Improving Processes, as well as Operations....................................14
v
Contents
Summary....................................................................................................14
Reflections.................................................................................................. 15
3 An Introduction to Just-in-Time.......................................................... 17
3.1 What Is Just-in-Time?.........................................................................17
3.1.1 Why JIT Is Important............................................................18
3.1.2 The Benefits of JIT for Organizations..................................18
3.1.3 The Benefits of JIT for You..................................................19
3.2 Phases of Implementing JIT..............................................................20
3.2.1 Value......................................................................................20
3.2.2 Map........................................................................................22
3.2.3 Flow.......................................................................................22
3.2.4 Pull........................................................................................24
3.2.5 Perfect....................................................................................24
Summary....................................................................................................25
Reflections..................................................................................................27
4 Creating Islands of Flow...................................................................... 29
4.1 Introduction.......................................................................................29
4.2 Standard Work...................................................................................29
4.2.1 Standard Task........................................................................31
4.2.2 Standard Work Sequence......................................................31
4.2.3 Standard Cycle Time.............................................................31
4.2.4 Standard Patients in Process.................................................32
4.2.5 Standard Documentation......................................................33
4.2.6 The Foundation for Continuous Improvement....................37
4.3 Benefits of a Process Flow Layout....................................................39
4.3.1 U-Shaped Cells......................................................................42
4.3.2 Team-Based Operations.......................................................43
4.3.3 Stopping to Fix Defects........................................................46
4.3.4 Improved Handoffs...............................................................48
Summary....................................................................................................48
Reflections..................................................................................................50
5 Using Pull to Connect Islands of Flow................................................ 51
5.1 Introduction.......................................................................................51
5.2 Kanban and Pull Systems.................................................................51
vi
Contents
5.3 Benefits of a Pull System..................................................................54
5.4 Types of Kanban in a Pull System....................................................54
5.4.1 Production Kanban...............................................................55
5.4.2 Rooming or Restock Kanban................................................56
5.4.3 Move or Supplier Kanban.....................................................57
5.4.4 Exception Kanban.................................................................58
5.5 Basic Rules of Kanban......................................................................58
5.6 Buffers and Supermarkets.................................................................58
5.6.1 FIFO Lanes............................................................................59
5.6.2 Buffers...................................................................................59
5.7 Flow Management.............................................................................62
5.8 Improve the Process First..................................................................64
Summary....................................................................................................64
Reflections..................................................................................................66
6 Support Techniques for Just-in-Time................................................... 67
6.1 Introduction....................................................................................... 67
6.2 The 5S System for Workplace Organization and Standardization.... 67
6.3 Visual Management Techniques.......................................................69
6.4 Mistake Proofing................................................................................72
6.4.1 Mistake-Proofing Checklists.................................................73
6.4.2 Zero Defects through Zero Quality Control........................73
6.5 Quick Setup Methods........................................................................75
6.5.1 Stage 1: Observe the Setup Process to Determine What
Is Internal and What Is External to Setup...........................76
6.5.2 Stage 2: Separate Internal Setup from External Setup........76
6.5.3 Stage 3: Convert Internal Setup to External Setup..............77
6.5.4 Stage 4: Streamline All Aspects of Setup.............................77
6.6 New Measures of Healthcare Target Excellence..............................78
6.7 Lean Management.............................................................................80
6.7.1 Standard Work......................................................................81
6.7.2 Autonomation........................................................................82
6.7.3 JIT or Flow Production.........................................................82
6.7.4 PDCA.....................................................................................83
6.7.5 Socratic Method....................................................................83
Summary....................................................................................................84
Reflections..................................................................................................85
vii
Contents
7 Reflections and Conclusions................................................................ 87
7.1 Reflecting on What You’ve Learned.................................................87
7.2 Opportunities for Further Learning..................................................88
7.3 Conclusions........................................................................................88
Appendix..................................................................................................... 89
Index........................................................................................................... 93
viii
Preface
Just-in-time is an approach that can dramatically boost your healthcare orga-
nization’s capability to eliminate waste from processes, serve patients more
effectively, improve access, and reduce costs. Just-in-time means producing
the quality services patients require—when they need them, where they need
them, and in just the amount they need. It is a core element of any Lean pro-
duction system, and in fact has come to be used as another word for Lean.
The change from traditional ways of producing and managing healthcare
services to a just-in-time approach requires a new understanding about what
adds value for the patient or customer, and what does not. This book is
intended to share powerful knowledge that will help you participate effec-
tively in the change to just-in-time.
As you read this book, you will realize that just-in-time is not really one
approach, but rather a set of integrated approaches that supports a different
way of operating. Just-in-Time for Healthcare provides an overview of waste
and improvement in the operations and processes of healthcare (Chapter 2).
It then introduces the main concepts of just-in-time, why it is so important for
healthcare, and how it is implemented.
Next, the book addresses the concept of flow (the elimination of waits
and delays from processes)—from the critical foundation of standard work,
to process layouts that facilitate flow, to the importance of mistake proofing.
You will then learn how individual areas, or islands, of flow are connected
using the concept of pull. Kanban (signaling) methods are introduced, as well
as the concept of leveling (the scheduling of service production to smoothen
day-to-day variation and balance capacity with demand). The role of the flow
manager is also introduced.
The book also briefly covers some of the support techniques that make just-
in-time possible, including the 5S system for workplace organization, visual
management techniques, mistake proofing, quick setup, new performance
measures, and the five principles of Lean management.
ix
Preface
It is important to remember that this material is a general orientation to a
complex topic. The implementation and mastery of the comprehensive just-in-
time approach requires a deeper understanding of Lean production in health-
care, best obtained through experiential learning and application with the
help of a sensei—someone who has gone and done before you. Some further
resources for learning are also listed in the Appendix.
One of the most effective ways to use this book is to read and discuss it
with others in group learning sessions. We have planned the book so that it is
easy to use in this way, with chunks of information that can be covered in a
series of short sessions. Each chapter includes reflection questions to stimulate
group discussion.
The just-in-time approach is universal. Today, the basic principles of just-
in-time have been used to eliminate waste in all types of industries, and they
are being put to work in healthcare organizations all over the world. We hope
this book will show you how just-in-time can make your workplace better and
safer for both patients and staff.
x
Acknowledgments
The development of Just-in-Time for Healthcare has been a team effort. In
particular, I would like to acknowledge the Rona Consulting Group consul-
tants who have contributed to our facilitation and coaching of just-in-time (JIT)
implementation in our clients’ organizations. Special thanks to Dr. James H.
Hanson, who enriched the book with his insights. Thanks also to the team
at Productivity Press and CRC Press, especially to Kristine Mednansky, senior
editor.
I also acknowledge the many talented people of the Productivity Press
Development Team who created the original book, Just-in-Time for Operators
(1998), upon which much of this book is based. Cartoon illustrations in Figures
4.5 and 5.1 were created by Hannah Bonner.
Finally, we acknowledge the good work of the many doctors, nurses,
technicians, administrators, and executives who are now in the process of
implementing the JIT system in their own organizations. We are very pleased
to bring you this addition to our Lean Tools for Healthcare Series and wish
you continued and increasing success on your Lean journey.
xi
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Chapter 1
Getting Started
1.1 PURPOSE OF THIS BOOK
Just-in-Time for Healthcare was written to give you the
information you need to participate in implementing this
important Lean healthcare approach in your workplace.
You are a valued member of your healthcare organization’s
transformation team; your knowledge, support, and par
ticipation are necessary to the success of any major improve
ment effort in your organization.
You may be reading this book because your team
leader or manager asked you to do so. Or you may be
reading it because you think it will provide information
that will help you in your work. By the time you finish
Chapter 1, you will have a better idea of how the infor
mation in this book can help you and your healthcare
organization eliminate waste and serve your patients
more effectively.
1.2 WHAT THIS BOOK IS BASED ON
BACKGROUND
This book is about the just-in-time (JIT) system that is
INFO fundamental to providing Lean healthcare services and
eliminating waste from healthcare processes. In fact, JIT is
another way of saying Lean. The methods and goals dis
cussed in this book support the Lean healthcare system,
which is based on a production and management system
developed at Toyota Motor Company. Since 1979, Produc
tivity Press has published knowledge and information
about these approaches. Since 2007, Rona Consulting
Group has been applying the knowledge in healthcare.
Today, top organizations around the world are applying
1
CHAPTER 1
Lean healthcare principles to improve patient experience,
safety, quality, wait times, and affordability.
Just-in-Time for Healthcare draws on a wide variety of
resources (see the Appendix for further information). Its aim
is to present the main concepts and steps of JIT in a simple,
illustrated format that is easy to read and understand.
1.3 TWO WAYS TO USE THIS BOOK
There are at least two ways to use this book:
1. As reading material for a learning group or study
group process within your organization.
2. For learning on your own.
Your organization may decide to design its own learning
group process based on Just-in-Time for Healthcare. Or, you
may read this book for individual learning without formal
group discussion. Either way, you will learn valuable con
cepts and methods to apply in your daily work.
1.4 HOW TO GET THE MOST
OUT OF YOUR READING
1.4.1 Become Familiar with This Book as a Whole
There are a few steps you can follow to make it easier to
absorb the information in this book. Take as much time as
you need to become familiar with the material. First, get a
big-picture view of the book by doing the following:
1. Scan the Contents to see how Just-in-Time for
Healthcare is arranged.
2. Read the rest of this chapter for an overview of the
book’s contents.
3. Flip through the book to get a feel for its style, flow,
and design. Notice how the chapters are structured
and glance at the illustrations.
2
Getting Started
1.4.2 Become Familiar with Each Chapter
For each chapter in Just-in-Time for Healthcare, we suggest
you follow these steps to get the most from your reading:
1. Flip through the chapter, looking at the way it is pre
sented. Notice the bold headings and the key points
flagged in the margins.
2. Read the chapter; enhance your reading by doing the
following:
a. Use the margin assists to help you follow the flow
of information.
b. If the book is your own, use a highlighter to mark
key information and answers to your questions
about the material. If the book is not your own,
take notes on a separate piece of paper.
c. Answer the Take Five questions in the text. These
will help you absorb the information by reflecting
on how you might apply it to your own workplace.
3. Read the summary at the end of the chapter to rein
force what you have learned. If you do not remember
something in the summary, find that section in the
chapter and review it.
4. Finally, read the Reflections questions at the end of the
chapter. Think about these questions and write down
your answers.
1.4.3 Use a Reading Strategy
When reading a book, many people think they should start
with the first word and read straight through to the end. This
is not usually the best way to learn from a book. The method
described here is easier and more effective.
A reading strategy is based on two simple points about the
way people learn. The first point is this: It is difficult for your
brain to absorb new information if it does not have a struc-
ture in which to place it. As an analogy, imagine trying to
build a house without first putting up a framework.
3
CHAPTER 1
Like building a frame for a house, you can give your brain a
framework for the new information in the book by getting an
overview of the contents and then flipping through the material.
Within each chapter, you repeat this process on a smaller scale
by reading the key points and headings before reading the text.
The second point about learning is this: It is a lot easier to
learn if you take in the information one layer at a time instead
of trying to absorb it all at once. It is like finishing the walls
of a house: First, you lay down a coat of primer. When that is
dry, you apply a coat of paint and later a finish coat.
1.4.4 Use the Margin Assists
As you have noticed by now, this book uses small images
called margin assists to help you follow the information in
each chapter. There are seven types of margin assists:
BACKGROUND
INFO 1. Background Information: Sets the stage for what
comes next.
2. Definition: Defines important words.
3. Key Point: Highlights important ideas to remember.
4. Example: Helps you understand the key points.
5. New Tool: Helps you apply what you have learned.
6. How-To Steps: Gives you a set of directions for using
new tools.
7. Principle: Explains how things work in a variety of
situations.
4
Getting Started
1.5 OVERVIEW OF THE CONTENTS
1.5.1 Chapter 1: Getting Started
The chapter you are reading explains the purpose of Just-in-
Time for Healthcare and how it was written. It gives tips for
getting the most out of your reading and provides an over
view of each chapter.
1.5.2 Chapter 2: The Production Processes
and Operations of Healthcare
Chapter 2 describes the industrial origins of the Lean health
care methodology and discusses the concept of waste in
healthcare. It also defines the critical distinction between
healthcare processes and operations.
1.5.3 Chapter 3: An Introduction to Just-in-Time
Chapter 3 introduces and defines just-in-time. It explains why
it is important and the benefits of JIT for you and your orga
nization. Finally, it covers the five phases of changing to a JIT
system for producing healthcare services.
1.5.4 Chapter 4: Creating Islands of Flow
In Chapter 4, you will learn how flow is established in
discrete healthcare production units called cells. We create
flow when we eliminate waits and delays so that patients
move smoothly through a process that is perfectly syn
chronized with the actual demand for services. This chap
ter also covers the basic concepts of standard work—the
foundation for JIT.
5
CHAPTER 1
1.5.5 Chapter 5: Using Pull to Connect Islands of Flow
Chapter 5 explains how JIT teams and cells are connected
in a system called pull. Pull systems are defined and then
contrasted with the typical push production systems used in
healthcare. The chapter covers the basics of the kanban, or
signaling, systems that are used to transform the continuum
of care into a pull system. Finally, it explains how a flow
manager adjusts the schedule in real time to keep it in sync
with actual demand.
1.5.6 Chapter 6: Support Techniques for Just-in-Time
This chapter describes several important techniques that sup
port the smooth flow required for JIT in healthcare. These
include the 5S system for workplace organization and stan
dardization, visual management techniques, mistake proofing,
quick setup methods, and healthcare performance measures
that reinforce JIT. It also outlines the five key principles of
Lean healthcare management.
1.5.7 Chapter 7: Reflections and Conclusions
Chapter 7 presents brief reflections and conclusions for this
book. It also describes opportunities for additional learning
about JIT, which are further detailed in the Appendix.
6
Chapter 2
The Production
Processes
and Operations
of Healthcare
2.1 THE INDUSTRIAL ORIGINS
OF LEAN HEALTHCARE
Just-in-Time for Healthcare is a succinct overview of the
core methods of Lean healthcare that are explored in
more detail in other titles in the Lean Tools for Healthcare
Series. The purpose of the series is to introduce readers
to a set of methods that have been proven to dramati-
cally increase patient safety and reduce the cost of pro-
viding healthcare services. The term Lean is another way
to say just-in-time (JIT). It was coined to express the
notion that, like an athlete, an organization should be
without organizational fat or what Lean specialists refer
to as non-value-adding waste, where value refers to what
a patient would be willing to pay for. Figure 2.1 lists
seven distinct types of waste found in healthcare.
BACKGROUND
Lean or JIT tools and methods have important origins
INFO in the United States but were perfected principally within
the Toyota Motor Company between 1948 and 1963, and
have since been adopted by most sectors of the manufac
turing industry. The first major implementation in the
healthcare industry began in 2001, when the Virginia
Mason Medical Center in Seattle, Washington, engaged
consultants (most of whom had been production engi-
neers from Toyota and the Boeing Aircraft Company) to
teach them how to apply the Toyota Production System
7
CHAPTER 2
Seven wastes in healthcare operations and administration
Definitions Healthcare wastes Administrative wastes
1. Overproduction Performing services that patients Printing or processing reports,
Producing more, sooner, or don’t need or desire. Unnecessary emails, or other information
faster than is required by the backups between departments. products before they are needed.
next process. Multiple quality control checks. Overdissemination of reports.
2. Waiting Waiting for lab results. Waiting for Searching for information.
Time delays, process idle doctors. Waiting for nurses. Waiting for information system
time. Waiting for patients. Waiting for response. Waiting for approvals
decisions from hospital from superiors.
administrators. Idle people.
3. Transportation Excessive medical record Transferring data files between
Unnecessary handling or pickups and deliveries. Extra incompatible computer systems or
transportation; multiple hand-offs. Excess patient transfer/ software packages. Over-
handling. movement. dissemination of reports.
4. Overprocessing Asking the patient the same Re-entering data, extra copies;
Unnecessary processing, question 20 times. Multiple reformatting or excessive/custom
steps, or work elements/ signatures. Extra copies of same formatting. Unnecessary reviews.
procedures. form. Duplicate data input entries. CCs on emails.
5. Inventory Cabinets full of gloves. Piles of Decisions in process. Outdated,
Producing, holding or paper forms. Too many suture obsolete information in file
purchasing unnecessary materials. Too many prosthetic cabinets or stored in databases.
inventory. devices. Multiple storage sites.
6. Motion Long reaches/walk distances. Repetitive stress injuries
Excessive handling, Lifting more than 35 pounds. resulting from poor keyboard
unnecessary steps, Standing all day. Sitting all day. design. Excessive walking to and
nonergonomic motion. Not enough printers. Not enough from remote printers.
copiers.
7. Defects Adverse events. High infection Order-entry errors. Too many bill
Rework, correction of rates. Wrong meds. Wrong rejects. Design errors and
errors, quality problems, surgical site. Frequent rescheduling. engineering change orders. Invoice
equipment problems. Patient readmissions. errors. Info system downtime.
Figure 2.1 Seven wastes. (From J. Michael Rona and Associates,
LLC, doing business as Rona Consulting Group © 2008–2016. All
rights reserved. Reprinted with permission.)
to the production of healthcare services. A few years later,
another major implementation was launched by Park Nicollet
Health Services in Minneapolis, and a few other organiza-
tions, including Thedacare in Wisconsin. The success of these
implementations is well documented.*
* Black, John and David Miller. 2008. The Toyota Way to Healthcare Excellence:
Increase Efficiency and Improve Quality with Lean. Chicago: Health Administration
Press.
8
Production Processes of Healthcare
Naturally, readers coming to the subject of JIT for the first
time are often perplexed by the patently industrial point of
view taken by Lean healthcare specialists. How can healthcare
be treated as an industrial process? Isn’t medicine an art? Can
healthcare processes be standardized when all patients are
unique? In fact, medicine and healthcare practice are generally
becoming more scientific or evidence based, and the Centers
for Medicare & Medicaid Services and deeming authorities
such as the Joint Commission are quick to require adherence
to standardized, evidence-based practices. Moreover, industrial
engineering has long been applied to healthcare processes.
Some readers may recall actor Clifton Webb’s portrayal of
the time-and-motion consultant Frank Gilbreth in the movie,
Cheaper by the Dozen. The movie depicts Gilbreth’s ground-
breaking time and motion studies of surgery in hospital oper-
ating rooms. In many ways, the practice of Lean healthcare
continues in the tradition of Gilbreth’s time studies. The critical
difference is that the studies are not carried out by consultants;
the studies and improvement work are conducted by members
of the healthcare team (clinicians and support staff), frequently
with the voluntary participation of patients themselves.
2.1.1 How Much Waste Is There in Healthcare?
How much waste is there in healthcare today? In a recent
Journal of the American Medical Association ( JAMA) article,
it was reported that, in 2011, wasted expenditures on health-
care in the United States totaled between $558 billion and
$1,263 billion. The money was consumed by the following:
◾◾ Failures (defects) in care delivery
◾◾ Failures (defects) in care coordination
◾◾ Overtreatment
◾◾ Administrative complexity
◾◾ Pricing failures
◾◾ Fraud and abuse
Of the wastes cited in the JAMA article, all but pricing fail-
ures, fraud, and abuse can probably be explained in terms of
9
CHAPTER 2
the seven deadly wastes listed in Figure 2.1. Of these seven,
two wastes are the most obvious to the casual observer:
(1) waiting and (2) defects. In 2011, the low estimate—$558
billion—represented 17.5% of all spending on healthcare in
the United States. By 2020, this figure is expected to rise to
over 20%.*
2.1.2 Waiting Is Waste
Throughout healthcare, one can see patients waiting: waiting
to be seen by their clinicians, waiting for an appointment,
waiting to be admitted, waiting for a room, waiting to be
taken to the bathroom, waiting for lab results, or waiting to
be discharged. All of this waiting extends time in the clinic,
time in the lab, and lengths of stay in the hospital. The impli-
cations for patient satisfaction are obvious. It increases the
cost of healthcare and, in the case of long hospital stays,
increases the risk of deadly hospital-acquired infections. It
also reduces access to healthcare by other patients in the
population because valuable capacity is currently occupied.
Another type of waiting, almost invisible unless you know
how to look for it, is present in the form of interruptions.
Nurses, physicians, and their support staff are constantly
interrupted by pagers, text messages, emails, phone calls, call
lights, hospital codes, and questions from patients and fami-
lies and of course by waiting for patients, for other clinicians
and staff, for reports, for lab results, and so on. Although each
interruption may only require a few minutes or even seconds,
such interruptions take their toll.
The sum of all the time wasted on interruptions is a prob-
lem; extra time costs money. In manufacturing, where a similar
problem exists in the form of small but constant interruptions
in equipment performance, significant time and energy are
devoted to improving equipment to ensure smooth produc-
tion flow.
* Berwick, Donald M. and Andrew Hackbarth. 2012. Eliminating waste in U.S.
healthcare. JAMA, Vol. 307, No. 14, pp. 1513–1516, April 11.
10
Production Processes of Healthcare
In healthcare, there is even more at stake. Recent studies
in the field of interruption science show that, once distracted,
workers can take more than 20 minutes to get back into the
groove. While clinicians and staff members may pride them-
selves on their ability to multitask, the science shows that multi
tasking is an illusion. The human brain is simply not designed
to deal with constant changes in the context of decision mak-
ing. The implications for productivity in the healthcare industry
are staggering, not to mention the implications for clinical qual-
ity and patient safety. By eliminating interruptions (and other
wastes), JIT helps healthcare stay focused—on the patient.
2.1.3 Defects Are Waste
Defects—specifically, failures in care delivery and c oordination—
are an obvious form of waste. Defects compromise clini-
cal quality and put patient safety at risk. In healthcare, we
have known for over a decade that poor quality is epidemic.
Recent studies indicate that there are between 210,000 and
440,000 unnecessary deaths from avoidable medical errors
in U.S. hospitals. The number would rise to far more shock-
ing proportions if we included physical and mental harm
in the equation. While many of these defects are inadvertent,
the causes are deeply rooted in the culture of healthcare.
The New York Times has reported that only one out of seven
defects and accidents that harm Medicare patients is recog-
nized and reported. Clearly, this makes it difficult to analyze,
understand, and prevent defects in the future.*,†
2.2 PRODUCTION, PROCESS, AND OPERATION
Before studying the JIT system of Lean healthcare, you must
understand precisely how the notion of production applies
* Allen, Marshall. How many die from medical mistakes in U.S. hospitals.
ProPublica, Sep. 19. Available at http://www.propublica.org/article/how-many
-die-from-medical-mistakes-in-us-hospitals.
† Pear, Robert. 2012. Report finds most errors at hospitals go unreported. The
New York Times, January 6. Available at http://www.nytimes.com/2012/01/06
/health/study-of-medicare-patients-finds-most-hospital-errors-unreported.html.
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