Turn to lean thinking

by Norman Faull: Professor in Business Administration at the UCT Graduate School of Business. His expertise includes operations management, strategy and implementation.
The challenges facing South Africa’s public health sector are well documented. Last week alone there were new headlines of babies dying in a Pretoria clinic, and such events are not isolated.

Overworked staff and under resourced departments are often cited as contributing factors in the failure of the health sector, but recent evidence from the Lean Insitute Africa at the UCT Graduate School of Business shows that by changing the way people think about the problem and reorganising the way they do things – dramatic changes can be effected.

It’s a philosphy called lean thinking and it’s more commonly associated with the motor industry where Toyota made it famous in the 1980s and continues to prosper from it. However, the principles are gradually permeating other sectors and industries and the results are bearing fruit.

The premise of lean thinking is that through observing a situation, we come to understand what is value adding and what is not and why challenges or bottlenecks occur. From there, it is possible to identify simple steps that may lead to improvements, and to implement them.

In May 2010, the Lean Insitute Africa set out to test the efficacy of the lean approach in South Africa’s hospitals, using 18 hospitals in the most remote and needy areas as trial sites. The experiment saw a total of 336 hospital staffers from the hospitals participating in 18 one-week workshops, during which they were invited to ponder key considerations which, it was hoped, lead to a lean solutions. These considerations included identifying the major problems and their root causes, suggesting possible countermeasures, how to ensure buy-in from relevant stakeholders, developing an implementation programme and measuring the results of the countermeasures.

The results of the workshop were impressive: 65% of the participating hospitals reported improved practices which they can enhance further still, or at least sustain.

These success stories included a KwaZulu-Natal hospital which reduced the waiting time at the inhouse pharmacy from a frustrating three hours to an asonishing 15 minutes. A busy hospital located west of Pretoria experienced a similar triumph: here, the waiting period was just less than four hours, but now stands at less than an hour. This has also had implications for staff: in the past, each staff member was required to work two hours’ overtime in order to address the backlog. Now, overtime has become a thing of the past.

What’s most notable is that the hospitals did not secure additional resources to attain these results. Rather, they examined their existing infrastructure and resources, and reorganised them for greater efficiency. For example, in the case of the Pretoria hospital, the previous system relied on patients delivering their files to a clerk, who would transfer them to the pharmacy on an hourly basis in batches. The pharmacist would then fill the prescriptions, and place the medicines on a trolley. Once the trolley was full, patients were called by name to collect them. This unwieldy process received an overhaul, with patients delivering their files to the pharmacist themselves. The most popular medicines are placed upfront to ensure they are easily located, and two staff members man the dispensary. The staff member who used to receive and batch the files is now used as a queue monitor. This has had enormously positive implications for work flow, with batching – the enemy of efficiency – entirely eliminated.

Another example of a greatly improved facility can be found in a Limpopo-based hospital. The HIV out patients who rely on this hospital for ARV medication have become accustomed to waiting an average of eight hours for their check up and prescriptions, and this after travelling a day or more to reach the remote clinic. The reason for the wait is explained by a logistically complex system which involved the patients walking to several sites to collect their files, be examined by a doctor and then fetch their prescriptions from the pharmacy. Again, the solution was so simple as to appear obvious: the pharmacy was relocated close to the examination rooms, thus reducing walking time for patients. Added to this, the time allocated to administrative duties was increased, and the filing system was rearranged to improve flow.

A final example is to be found in the Free State, where the poor layout of equipment in an emergency room meant that nursing staff walked the equivalent of 520km each year in the average course of their duties. Not only could this time be put to better use; it also added unnecessarily to the stain upon the nurses. With some simple restructuring and rearranging of equipment, the hospital was able to reduce this time by half. More improvements were effected by removing the number of duplicate files for each patient (one patient had 16 files to their name), again clearing the way for greater efficiency.

Of course, not all the hospitals reported such progress: at 35% of the 18 workshop participant’s hospitals, the situation remains largely unchanged. Reasons for this are difficult to pinpoint. They could include resistance to change. People are almost always convinced that they are doing things the best possible way and it takes a good deal of courage to decide to do things differently. Frequently also hospital staff lack the appropriate support for staff: while doctors and nurses are, for the most part, hardworking and dedicated, management does not always display the same level of engagement.

Government has recognised that this is a problem; indeed, in the past, the minister has laid the blame for the poor performance of the healthcare sector on such factors as inadequate managerial skills, a failure to act on known deficiencies and poor accountability.

While these issues certainly play a role, it is clear that with the correct approach, lean thinking can play a major role in revolutionising service delivery. With this in mind, the Lean Institute is currently lobbying government to expand this pilot to hospitals throughout the country. If successful, the astonishing results recorded by the majority of participants in this study can be replicated elsewhere, with surprisingly little effort and extraordinary impact.

Useful resources:
University of Cape Town Graduate School of Business
UCT GSB is internationally renowned as one of a few business schools in Africa with the prestigious triple-crown accreditation with endorsements from EQUIS, AACSB and AMBA.
University of Cape Town Graduate School of Business, Executive Education
Executive Education at the UCT Graduate School of Business is dedicated to growing the leadership backbone in organisations and individuals and inspiring a new generation of leaders to engage with the challenges of the African continent in a hyper-connected and globalised world.
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