Right Sized Capacity in a Stockholm Hospital – Flow, Not Monuments

When I was in Sweden in late January, I had a chance to visit the Capio Saint Göran Hospital in Stockholm. I saw many amazing things, including Lean practices and culture. I haven't taken the time to write about this yet, but I'll start today with some thoughts on “rightsizing” of equipment and capacity.

My host for a good portion of the visit was Goran Ornung MD, PhD, the chief of the Emergency Department (and a regular reader of the Lean Blog!)

“Rightsizing” is a key Lean concept, especially in manufacturing. In the traditional manufacturing mindset, bigger is better — economies of scale rule. Bigger batches. Bigger machines. That's assumed to be most cost effective. But this often creates a “monument” machine – a large inflexible machine that hampers flow through the rest of the process. For example, a machining factory might have giant parts washer that everything goes through.

In a Lean factory, we would typically prefer one small parts washer for each line or cell. If we have five production lines, we'd want five smaller in-line parts washers. The cost of this capacity might be a little higher, but the overall effective and cost of the factory is lower.

Back to St. Goran… here is a picture of the front entrance, with the rest of the story below it.

Why the “Capio” name? From the hospital's website:

In one way Capio St. Göran differs completely from other hospitals in Sweden, since 1994 being the first and so far only privately owned emergency hospital in the country. Since the year 2000 we are part of Capio, one of Europe's leading health care companies.

The hospital was privatized as part of a Swedish government experiment. I'll blog more about this later, but the hospital's performance is dramatically better than before. I wonder if that's a one-off experiment or the start of the trend.

Dr. Ornung showed many areas, including the cardiology unit. This is where rightsizing comes into play. Hospitals often have the big batch mentality — that cost savings comes from economies of scale and that large centralized units are best. In manufacturing, large units of capacity were often called “monuments.”

Hospitals sometimes move to a large single centralized scheduling department, thinking that it must be more efficient or a single large registration desk. There might be some patient-centered benefits (a single point of contact or only one place to check in for the multiple departments you see in an outpatient visit), but the centralization might also hamper flow.

At St. Göran, the cardiology unit was sending patients to a centralized department for ultrasound testing and for stress testing. It was “a team-based decision” to put a small unit of capacity right in the cardiology space. They now, with Lean thinking, have their own ultrasound machine and a treadmill. They did this to avoid patient movement and delay.

But that's extra cost, you might say. In cases like this, you might just be re-distributing small pieces of capacity (treadmills) to decentralized locations. Or, even if you buy one more ultrasound machine, you have to look at total system cost. Are there fewer discharge delays because of the improved patient flow and faster test results? This is where Lean teaches you to look at the total system effectiveness, not just lowest unit cost for one part of the puzzle.

Based on that experience, the unit started to question the delays incurred in sending patients from cardiology to get pacemakers implanted in the operating rooms (a centralized department, as in every hospital). The centralized unit creates scheduling complexity – an increase in emergency patients or a delay in outpatient cases might hamper flow of patients from the cardiology unit.

So the team decided to build a dedicated and specialized small operating room in the cardiology unit. They now do pacemaker implantation right there — a shorter, more simplified patient flow. It's a rightsized resource, in terms of capacity and the size of the room (it's much smaller than a normal O.R., but big enough for that job). The pacemaker O.R. is “always ready” for the patients who need it. Again, this is a proper O.R. — no corner cutting here.

Dr. Ornung said they much preferred the Lean thinking over the old centralized approach, or what he described as “1950s and 60s mass production” approaches.

What do you think? Are there examples where your hospital is rightsizing equipment or capacity?

A few other examples I can think of, below. I can only think of a few examples, as hospitals still tend to favor large centralized resources.

• Each section of the lab has a small centrifuge instead of running everything through a single big-batch centrifuge
• Distributed medication cabinets in a unit instead of one large cabinet that becomes a bottleneck when every nurse wants to access it at the same time.

What else can you think of? What do you think of the St. Göran approach?

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