Japan gemba visit: Lean in hospitals

It has been surprising to me since moving to Japan six months ago to learn that very few hospitals and health systems are using Lean or the Toyota Production System principles in their operations. Japan is known for high quality clinical care, but from what I’ve heard these six months, there are many opportunities for improvement across the health delivery sector.

A few weeks ago, after my visit to the Toyota Kyushu plant, I had the opportunity to visit a Japanese hospital known for its application of Lean thinking and Total Quality Management. I was excited to see what they were doing, as it is rare to hear about Lean applied in healthcare in Japan.

Improvements through Lean and Kaizen

My host to this hospital has been the Director of the Kaizen Promotion Office (KPO) for the past two years. During her tenure, she has helped advance their application of Lean thinking in the hospital beyond its practice of TQM.

I appreciated the tour and seeing the great work my colleague is doing with their KPO and supporting kaizen and improvement the organization. They are leading the way for improvements in the Japanese health system.

While the application of lean hasn’t moved to a connected management system yet (such as through strategy deployment or linked checking), the KPO has created pockets of change that are laying the foundation for more improvements in years to come.

Hospital Overview

Aso Iizuka Hospital looks like any hospital you might picture – if you replaced the Japanese language signage, it could have been anywhere. There was a new wing, which felt very modern, connected to an older facility.

Outside the hospital on a rainy day.
Outside the hospital on the rainy day of my visit.

The hospital is one of the largest hospitals in the region, and is located in a semi-rural area in the southern part of Japan. It has roughly 1110 beds, with 36 departments, 275 physicians and 2300 employees.

Annually the hospital receives about 480,000 outpatients and 330,000 inpatients, and conducts about 5,400 surgeries.

Privately held – less common in Japan

Since my initial overview of the Japanese health system, I’ve learned that private organizations are not allowed to own or manage hospitals, except for those privately owned hospitals that were grandfathered in before the law regarding private ownership was put into place. Additionally, the law requires that the senior executive at a hospital be a physician.

About 30% of hospitals in Japan are privately held, with the remaining 70% managed by the government.

Improvement minded – Lean and TQM

The hospital I visited is well-known in Japan for the improvement work it has done for the past 25 years, primarily focused on Total Quality Management (TQM) Quality Circles. About 150 staff members in around 20 groups participate in TQM activities every year. In the past few years, it established the KPO to bring Lean thinking into its operations and hired my colleague to lead the team.

Relationship with global healthcare systems to learn

The patient care rooms and wards in the new building were modeled after the layout at Virginia Mason Medical Center.
The patient care rooms and wards in the new building were modeled after the layout at Virginia Mason Medical Center.

Aso Iizuka Hospital has a close relationship with Virginia Mason Medical Center in Seattle and conducts learning exchanges with Virginia Mason to learn about operations and improvement at both institutions. They host an annual process improvement summit that usually includes guest speakers from V.M.M.C.

In addition, they have relationships with several other hospitals and health systems in the U.S. and other countries to learn and improve their medial care.

Tour of the ORs

5S in the Operating Rooms

A recently reorganized supply room in the operating suites using 5S.
A recently reorganized supply room in the operating suites using 5S.

As part of my visit,I got sit in on a meeting (in Japanese – another opportunity to practice listening!) about follow-up from a 5S event related to their anesthesia supplies and operating rooms.

I learned during my tour that there are 17 operating rooms (including 3 for outpatient procedures), but there are only about 20-30 cases a day.

The KPO’s efforts with the anesthesia carts has resulted in decreased par level and amount of supplies needing to be stored, but other problems are now being made visible.

This hallway was once crowded with supplies.
This hallway was once crowded with supplies.

This is one of the powerful outcomes of applying Lean thinking and creating standard work – problems that were once visible now are surfaced, such as variation in ordering practices, duplication in supplies, and unclear restocking procedures.

This outcome is common and I’ve seen it in all organizations in which we’ve done Lean improvement work. The challenge is to not get discouraged! Kevin Meyer of Gemba Academy recently wrote a blog post that I enjoyed about this challenge that organizations face as they begin improvement activity.

Tour of patient care areas

In addition to seeing the 5S and improvement work that the KPO is actively working on in the ORs, I got to walk through several of the patient care areas.

Crowded waiting rooms

I don’t have any photos of the crowded waiting rooms as I wasn’t able to take pictures of patients, but I was astounded with the number of patients and family members waiting throughout the clinic areas.

I counted about 60 people waiting in the waiting room that covered the internal medicine and GI clinics! I was told that this is typical at Japanese hospitals and clinics – and that this hospital is considered one of the best.

Accessing the healthcare system in Japan

A clinic schedule on the wall in one of the waiting areas. This one shows doctors available morning and afternoon, but many clinics just showed doctors available in the morning.
A clinic schedule on the wall in one of the waiting areas. This one shows doctors available morning and afternoon, but many clinics just showed doctors available in the morning.

I learned something new about the Japanese system during this visit. In Japan, you don’t get an appointment for your first visit to a doctor. Instead, you go to the clinic (often located within the hospital) and show up with your issue, sort of like an urgent care.

Or if you have a referral by another physician and are able to get an appointment, you are given an appointment for a one hour block of time in which 20 other patients also have an appointment. I had heard of the “three minute appointment” but I hadn’t realized how this works in actuality.

Clinic schedules and workflow

Physicians at this hospital see about 30 patients a day, but this is primarily only in the morning. Since there are no hospitalists in the Japanese health system, physicians go out to the wards in the afternoon to check on their inpatients. Only one or two physicians stay in the clinic for the afternoon.

Clinic rooms and the waiting area - this photo does not capture the large number of people waiting to see the doctors.
Clinic rooms and the waiting area – this photo does not capture the large number of people waiting to see the doctors.

Also, physicians work in their own clinical rooms (occupying valuable clinical care real estate while they document or do other “office” work) and do all parts of the appointment themselves (from rooming the patient, taking vitals, etc).

In the picture to the left you can see these rooms – which serve essentially as the physician’s office and clinical area.

There are no medical assistants or nurses to help manage patient flow or assist with the appointment (though nurses help with doing injections and other aspects of clinical care) as we implemented at the Palo Alto Medical Foundation  and that are used by other U.S. outpatient practices.

Lots of waiting!

As a result of theses factors, patients end up waiting for a long time. A usual wait for an initial appointment could be 1-2 hours, and this is after already having to wait to register upon arrival. This was the burning platform for the improvement work that my colleague initiated when she joined the KPO.

Value stream kaizen improved patient wait time

My colleague shared that as a result of intensive value stream work over the past two years,they have seen a huge reduction in wait time in the General Medicine clinic. Over a series of four focused kaizen events, they were able to reduce patient wait time from 80 minutes to 30 minutes. They continue to work on improving the times further.

The proof-of-concept in General Medicine has created pull by some other clinical areas, and three departments this year have requested the help of the KPO – including requests by physicians.

Everyday Kaizen to bring improvement thinking to the frontline

Example of Everyday Kaizen (courtesy of the KPO)
Example of Everyday Kaizen (courtesy of the KPO)

In addition to supporting kaizen events, the KPO has established “Everyday Kaizen” as a method to spread PDCS thinking to the front line. Staff can fill out a small form following the steps of Plan Do Check Act.

Everyday Kaizen is similar to the kaizen approach that I’ve described used by some Japanese manufacturing organizations or by hospitals that I’ve worked with.

They had about 100 ideas submitted by staff in over 20 departments in the first three months of introducing Everyday Kaizen.

Japan’s healthcare opportunity

There is a huge opportunity in Japan to bring more Lean thinking and improvement into its hospitals and health systems. Given the number of companies in Japan who have been applying Lean thinking for decades, the Japanese health system may be served by going to some other industries in their backyards to learn about Lean management, or to establish learning relationships with hospitals in other countries (like this hospital does) to learn how they are applying Lean in a healthcare setting.

Mark Graban has made a similar observation in his visits to Japan that it is rare to see health systems applying Lean thinking.

This is further evidence to me that Lean and the Toyota Production System are not inherently easy concepts to apply for anyone – including the Japanese.

I am giving a talk about Lean and healthcare for aJapanese company that wants to learn more about how to manage hospital operations this week. I will be interested in getting their perspective about healthcare and Lean in Japan, and sharing my experiences in supporting improvements in U.S. and Australian healthcare systems.

What is your reaction?

Are you surprised that Lean/TPS is not used by healthcare organizations in Japan?

If you have lived in or visited Japan, what is your experience?

Please share your comments and experiences below.

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Katie Anderson
About Katie Anderson 122 Articles

Lean thinker and coach. Passionate about developing people. Healthcare change agent. Living in California again after 18 months in Tokyo. Writing about lean and leadership.

  • Charles Intrieri

    To me, after reading your interesting words, reflections and having visited Japan, as you know, Katie, is: “pockets of change that are laying the foundation for more improvements in years to come.” Total Lean cultural transformation takes time. Cultural change enables Lean implementation success. The people have to be empowered to improve processes and solve problems on the front line of the hospital.
    Some VSM is happening to improve waiting times which are very long with the system utilized today. I read between the lines and say to myself that a lot has to be done yet to be totally Lean and using TQM. Lean tools are not the answer. Cultural transformation is the answer. Perhaps other hospitals have not implemented Lean because of their current patient load, and lack of leadership conception of Lean?.

  • Charles – thanks for your comments. I think the challenge, from what I’ve been able to gather so far, is more of your latter suggestion about “lack of leadership conception of Lean”. My guess is that most hospital leaders don’t know that Lean concepts (beyond the tools) could be applied in healthcare or they think that they “are different” than a manufacturing environment.
    Similarly, this seems to to be a possible reason non-manufacturing areas of Toyota do not use as robust of an application of TPS. I have been told that “it’s for the production areas” (see my post: https://kbjanderson.com/toyota-kyushu-gemba-visit-part-3-if-you-always-ask-for-success-then-people-will-lie/). I will continue to seek out more explanation for this lack of Lean in healthcare and other industries in Japan while I’m here.

  • Carlos Frederico Pinto

    Hi Katie, great post, thanks for sharing! I’m sharing this too with some friends that asks me about lean in Japanese Hospitals. Most of them get surprised by this kind of info. Most believe that everything in Japan is Lean…

  • Charles Intrieri
  • Philip A Eccles

    Very interesting post, Katie! No, I have not visited Japan, although I am not surprised by the rarity of Lean in Healthcare settings based upon Japanese culture. American culture focuses more so on customer service and consumer demand, whereas Japanese culture is focused on submitting to rules and tradition. Lean, to be effective and sustained, requires buy-in from all parties. What is the voice of the customer saying about changing the clinics? Would the patients consider those changes to be scandalous, and perhaps cause them to seek healthcare in a different setting?

  • Dr. Joseph Ogundu

    Hello, Katie, Excellent job. I love what you are doing. My organization, Emerald Global Consulting Inc, is a lean and operations management consulting firm. We are deeply involved in working with organizations including hospitals to inculcate the concept of process excellence and total quality management through out the business enterprise. We adore what you are doing and if you need any support with your clients, please contact us and we will be ready to assist. Good luck in Japan.

    Dr. Joseph Ogundu, MBB
    Principal
    Email: mjogundu@emeraldglobalconsulting.com

  • Thanks for your comments and sharing the post, Carlos. Japan needs more physician leaders like you!

  • Thanks for the positive words about this post and the blog.

  • Philip – thanks for your comments and feedback. In my six months in Japan, I’ve learned that Lean/TPS is not inherently easy for Japanese, though I do think there are some cultural traits that also support aspects of Lean thinking. As I continue to learn about healthcare in Japan I’ll be interested in exploring the questions you pose. Japan has a strong culture of customer service as well – but only if it operates within the defined rules (as you mentioned).

  • Michael Bremer

    Good commentary Katie. My observation is that most businesses in Japan do not use lean or TQM methods to the extent practiced by the automotive manufacturers. So it is not surprising to learn that it is somewhat rare in healthcare. Doing these concepts in an elite way is a challenge in just about any culture. Enjoying your dialog.

    Next year we are going to be doing a two week vacation in Japan. Probably in the Fall. While my wife and sister-in-law (from France) will be doing touring, I’m hoping to visit a couple of factories. Please email me separately if you have any suggestions on whom I might approach to see a couple of outstanding companies. Thanks.
    best wishes,
    M

  • I’ve only been to Japan twice, but I’ve been blown away by their customer service. “The customer is god” seems to be the mindset. If you need something from a hotel front desk, they RUN to go get it. Stores, restaurants… all extremely service oriented.

    I don’t think it’s fair to generalize American companies as being extremely high in customer service orientation, either.

  • Philip A Eccles

    Mark, thank you for your comment. I wish I could have the opportunity to be immersed in that culture to observe it firsthand. I had not had the time, upon first reading, to click on the hyperlinks, so I am eager to read your perspective from your experiences.

    My comment was not intended as a declarative fact. In retrospect, I would prefer to think of Americans performing customer service as a result of consumer economic demands. It is an economic principle.

    Is not Japanese customer service based on an entirely different precept? It appears to be tied to cultural and social mores of honor/dishonor and respect/disrespect. Do I have a correct understanding based upon the experiences of yourself, and Katie?

  • Thanks for your comments Michael. What my six months in Japan has highlighted is that lean is not easy, no matter what country or industry you are in.

    I am surprised, however, that given the focus on lean in healthcare in the U.S. (such as the Healthcare Value Network organized by ThedaCare Center for Healthcare Value), Australia (via the Australasian Lean Heathcare Network) and other countries, that Japan is lagging far behind in bringing these principles to healthcare management. My colleague at the hospital I blogged about is trying to be a change agent more broadly in Japan.

    Let’s stay in touch as you are planning your trip about some possible gemba visits based on where you will be in Japan.

    -K

  • I’ve had the same experiences with Mark that the customer service in Japan is across-the-board amazing….except when you have a request that goes outside of one of the “rules” or predetermined scripts of what should happen.

    See one of my early blogs about my experience with our local gelato shop: https://kbjanderson.com/rules-are-not-made-to-be-broken/

    Tipping is not part of the culture, as providing high level of service and achieving the highest level of quality in your job is something that the Japanese people take pride in. To this degree, I believe it is likely tied to the mores of honor and respect.

    Basically, the service in Japan is amazing – as long as you don’t stray from the expected customer request. Don’t ask for no tomatoes on the sandwich if the menu says it comes with tomatoes!

    Japan = predictable in its consistency of high service, but no customization. U.S. = highly variable, with customization.

  • Philip A Eccles

    This has been a very interesting thread for me. It has caused me to ponder methods to accurately determine the voice of the customer in diversified populations.

    The bonds of social mores and traditions seem to slip away more rapidly as external influences replace the influences of a tightly-closed community. This phenomena is not relegated to specific cultures, but is observed throughout every culture. Determinism within the cultural group allows continued isolation in their social mores, whereas weak determinism to retain the traditional culture results in homogenization with other groups that have let their traditional values slip in influence on individuals. Please understand that this is my way of thinking through the process, and the variables. It always leads me to more questions!

    In changing the clinic operations, what group was considered to be the customer — the physicians, or the patients, or both? If the patient population voice was unaccounted for in the process improvement design, is it accounted for in the marketing plan for current patient retention, and future attraction?

    In a real sense, is that a concern in the application of Lean principles in a Lean healthcare organization?

  • The patient is the only real customer in the process of healthcare, in my opinion, just as the only real customer in a manufacturing organization is the end purchaser of the item (e.g. a car). Physicians and other providers are partners in the care delivery process. I am confident that my colleague at this hospital shares this perspective. Voice of the customer should be voice of the patient, although the voice of others involved in the process should also be heard and understood.

  • Ken Kikuchi

    Katie,
    Great article and perspective on the application of TPS outside of Toyota.

    As you travel in Japan, I thought you may have insight on how TPS and Lean thinking is prevalent in all aspects of the society and economy not because of Toyota but because the Japanese people have structured their austerity in their everyday interactions. Having traveled through Japan, the basic principles are not specific to healthcare, manufacturing, etc., but are found in their homes, in their transportation, and even in their retail stores (e.g. always having fresh sandwiches at the Circle K).

  • “Japan = predictable in its consistency of high service, but no customization. U.S. = highly variable, with customization.”

    That’s a really interesting observation… thanks for highlighting that

  • Ken – thanks for your comments. There are elements of Japanese culture that are supportive of Lean, as you shared, but there are some that seem to run counter to lean principles (such as the leader having all the answers, not wanting to to call out problems or issues for fear of causing disharmony, etc). I am intrigued by exploring these further over the next year that I”m living in Japan.

  • Zuhara Chavez

    Great post Katie !, it’s very interesting to me to read your experiences both in manufacturing and non manufacturing sector regarding Lean – TPS applications . I can’t say fortunately but have Great post Katie !, it’s very interesting to me to read your experiences both in manufacturing and non manufacturing sector regarding Lean – TPS applications . I can’t say fortunately but have had the opportunity to experience the healthcare service in Japan by myself last year (got a very bad cold a couple of months after my arrival in Japan) and other public services too like post office and I have found as you mention Japanese is not a synonymous of Lean there are many things that go against Lean but talking about the case of healthcare specifically when I had to visit the clinic that first time as patient , I was surprised because it was very good service in my opinion, the visit started with a friend helping me to in put some data in a machine (can’t a read kanji ) about general illness and insurance number then a nurse asked for my symptoms and she decided to send me to specialist, I had to wait probably like 3 hours (as I remember) to see the doctor, he did the examination and sent me to do blood testing (which I was able to do in the same building – no waiting) , then went back to see the doctor , right after I got results (no longer than an hour ) , had to do some more waiting to see the doctor again and finally he gave me the results and subscription for medicine which I was able to exchange in the pharmacy that was just crossing the street. The next surprising part for me was at the pharmacy , I got the exact quantity of pills the doctor had prescript not even an extra one. I wanted to see the way they separate , pack and storage the medicine and how they separate the individual patient doses per order but it was not visible , as is a FIFO service where each patient takes a turn – number , I imagine there must be a system behind, well my point is that there may be indeed improvements to make there, health care is not completely Lean but there are good initiatives, specialists in the same building , commuting distances reduced for patients (both blood testing center and pharmacy in the same place), my point of reference personal experience was Mexican healthcare both private and public. Here the waiting factor was worth for the quality I got and yes I lost all morning but that could take a couple of days in my country for a much higher price. If I analyze it from the lean practitioner view there are of course room for improvement as you mention . I would love to see if you could do something about the medicine supply system in Japan , that will be interesting to see, systems in place , perhaps there may be interesting systems in place, more Lean initiatives and good stories to learn from . I’m looking forward to read more about your discoveries . had the opportunity to experience the healthcare service in Japan by myself last year (got a very bad cold a couple of months after my arrival in Japan) and other public services too like post office and I have found as you mention Japanese is not a synonymous of Lean there are many things that go against Lean but talking about the case of healthcare specifically when I had to visit the clinic that first time as patient , I was surprised because it was very good service in my opinion, the visit started with a friend helping me to in put some data in a machine (can’t a read kanji ) about general illness and insurance number then a nurse asked for my symptoms and she decided to send me to specialist, I had to wait probably like 3 hours (as I remember) to see the doctor, he did the examination and sent me to do blood testing (which I was able to do in the same building – no waiting) , then went back to see the doctor , right after I got results (no longer than an hour ) , had to do some more waiting to see the doctor again and finally he gave me the results and subscription for medicine which I was able to exchange in the pharmacy that was just crossing the street. The next surprising part for me was at the pharmacy , I got the exact quantity of pills the doctor had prescript not even an extra one. I wanted to see the way they separate , pack and storage the medicine and how they separate the individual patient doses per order but it was not visible , as is a FIFO service where each patient takes a turn – number , I imagine there must be a system behind, well my point is that there may be indeed improvements to make there, health care is not completely Lean but there are good initiatives, specialists in the same building , commuting distances reduced for patients (both blood testing center and pharmacy in the same place), my point of reference personal experience was Mexican healthcare both private and public. Here the waiting factor was worth for the quality I got and yes I lost all morning but that could take a couple of days in my country for a much higher price. If I analyze it from the lean practitioner view there are of course room for improvement as you mention . I would love to see if you could do something about the medicine supply system in Japan , that will be interesting to see, systems in place , perhaps there may be interesting systems in place, more Lean initiatives and good stories to learn from . I’m looking forward to read more about your discoveries .

  • Zuhara – thank you for you comments and for sharing your personal experience with Japanese healthcare here. Just imagine if you could get the same quality without the waiting!

    I look forward to hearing more about what you are learning through your studies of TPS in Japan. Please continue to comment and share your own experiences and reflections on this blog.

  • Zuhara Chavez

    Exactly! .
    My pleasure Katie. Ill continue following your journey for sure. Thank you.

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