QUERI – Quality Enhancement Research Initiative

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Quality Improvement Methods

55. Waste Reduction

a. Definition: Waste (referred to as "Muda" in Japanese Lean terms) is work that is unnecessary or of no value from the patient's point of view. Eliminating waste is one of the primary objectives of the Lean method. In healthcare, waste includes over-ordering and unnecessary procedures as well as inefficient steps in clinical processes. The Lean literature identifies seven types of waste, which are:

1. Overproduction. Doing too much, such as more tests than are necessary or over-referral to specialists when they are not truly necessary.

2. Waiting. This is probably the most common complaint by patients. Waiting waste can include work waiting to get done, supplies waiting to get used or information needed but waiting for processing.

3. Unnecessary processing. For example; using overly complex equipment for a simple task, such as using an expensive tool when a simple low cost one is available.

4. Staff movement. Having staff walk more than the minimum necessary or equipment or materials moved further and more often than is necessary. Also, motion required for completing a task is something to be minimized or avoided.

5. Defects. Zero defects are the ideal. Errors, clearly, have no value. Setting up systems to prevent errors is far better than a system to catch errors, although both may be needed.

6. Transportation. Patient and material movement should be as near to zero as possible. The quality and effectiveness of patient care should avoid movement from one location to another. Movement of services to the patient is preferred over moving the patient but if the patient has to be moved, such as for radiology, the path should be short.

7. Inventory. Holding materials, even holding patients in anticipation of future steps, is to be avoided. Accumulation of inventory hides problems and holding inventory represents a cost.

Looking for waste is often challenging but by watching for these types of waste and being trained with examples of each type, observers are better at finding occasions and cases of waste.

b. Literature:

  • Berwick, Donald M., ; Andrew D. Hackbarth, Eliminating Waste in US Health Care, JAMA. 2012;307(14):1513-1516. doi:10.1001/jama.2012.362.
  • Womack, James P. and Daniel T. Jones Lean Thinking: Banish Waste and Create Wealth in Your Corporation, Productivity Press; 2nd edition (2003) Texts on the Lean method always include a discussion of waste.

c. Example: An egregious example of waste is orders for unnecessary tests such as CT scans for minor injuries, which is reported to have a high frequency of over-ordering. However, waste includes unnecessary walking by nurses due to a poor work layout, inventory of supplies more than is necessary to avoid being out of stock, and duplication of questions asked of patients.

d. Steps:

1) Train staff in identifying the various types of waste. By seeing examples of each type of waste, the observer is more likely to indentify waste in the workspace.

2) Observe actual processes in place (Gemba, see Section 18) and identify waste. It is helpful to categorize each waste occurrence as one of the seven types of waste so as to be sure the full extent if a problem is identified. Some of the tools discussed in this handbook are helpful in identifying waste such as a Spaghetti Diagram (see Section 46) to identify the waste of unnecessary movement.

3) Eliminate each waste found. This may require new procedures, instructions or changes to a workspace.

4) Combine activities to reduce waste.

5) Implement ongoing systems to prevent waste from reoccurring, such as with visual systems (see Section 54)