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Using Lean in Healthcare: Trends and Results

April 8, 2021  |   NewsWebinars

Our Guest Speaker, Roy Plaeger-Rockway, shares 30 years of experience spearheading innovations in government and health care. Roy has built a Kaizen Promotion Office and led for 7 years the Lean transformation for a $2 billion organization, and he has built the strategic planning and KPI management system for a $600M health care insurer. Over his career, he has engaged and trained 500 executives, senior managers, and teams to do lean problem solving. He has taught Lean methods to the US Center for Medicare and Medicaid (CMS), and is a past faculty with the Lean Enterprise Institute (LEI). Roy is the Co-Founder of Washington State's successful Centers for Occupational Health delivery system and has received the Washington State Governor's Distinguished Leader Award. He holds a MPA Health Policy University of Washington and has accomplished the Toyota Japan Study Mission Honsha.

In this webinar, Roy will discuss the following topics:

- Rapidly expanding size of US health care industry

- Performance challenges high costs, disjointed processes, medical errors

- Largest areas of health care costs

- Nature and scope of Lean improvements in health care and results

- Resources for additional knowledge


If interested in our past and future webinars, please subscribe to our YouTube channel. We also welcome you as a member of our LinkedIn Group where you will receive webinar updates and have a chance to network with hundreds of your peers: click here to join.


TRANSCRIPT

Disclaimer: This transcript was generated automatically by a software with 86% accuracy. Please forgive errors in the remaining 14%. Please listen to the video recording for exact accuracy. This automated transcript is provided "as-is".

All right, welcome, everyone. My name is Jabril Bensedrine, I am very pleased to host this webinar today on how to use Lean in health care and actually how Lean is used in health care, both trends and results. Our guest speaker today, Roy Plager dragway, but is an expert in the health care sector, Andon Lean. He comes with a background in public administration. Both University of Washington and Harvard University leadership program at the Kennedy School has worked on the state of Washington in a number of agencies in both managed care, occupational health. He'll tell us more about about his work because he's an award winning distinguished leader in the health care sector. Very pleased to have you with us. Thank you so much for sharing your experience. I'm going to say just a few words about our host, I guess. Partner sponsor Sesasystems Sesasystems is an expert in Lean equipment offering two thousand five hundred products to more than fourteen thousand companies worldwide, including many that you can see here. I'm sure and I know a lot of our audience members are part of some of these companies and across the spectrum in terms of equipment, both training games, Lean office, Lean workshop workstations, trolleys, Kanban systems, floor racks marketing floor marketing, safety signage, also digital solutions for people in management and visual management. This is this webinar is part of a series of webinars offered as part of the Sesasystems Lean Academy. Several hundred companies join our physical lab space where they can experience and experiment with different types of hardware, software. And the program that you've seen, this is the digital version of these programs. And we're very pleased to host Roy as a speaker today. So without further ado, I will let you take it from here, Roy, and let you share your screen.

Ok, so I'm assuming that my. Screen, let's see, I'm getting my screen up here. So you should have my screen at this point. Yes. OK, great. It's terrific to be here talking about Lean in health care. It's something I'm very passionate about and have been doing for probably the past 15 years. A lot of scientific work before that, improving health care delivery systems. But it is a area that we've had a lot of success in. And so I wanted to share some of what I've learned about it from my experience. So I'm not going to go over in a lot of detail. My background, basically, I've spent about 30 years spearheading innovations in government and health care. And one of the last really big innovations I did before I went into consulting was to build the Kaizen promotion office in a large state agency in Washington State. It was a two billion dollar agency. We led a seven year Lean transformation, working with alumni from Toyota to our senses, and we were able to engage and train five hundred executives and senior managers and a good portion of our twenty eight hundred employees to develop their Lean problem solving skills. And then after that, I went to work with the Lean Enterprise Institute and helped teach Lean methods to the US Center for Medicare and Medicaid. So that's that's my background. I have had the great honor of going to Japan to study at both Toyota and Nissan with the Hanschen organization, which is a Toyota alumni group, and got to see Toyota manufacturing up hand and as well as the Toyota Museum, which shows the evolution of the Toyota production system.

So what I want to cover today are these points. The health care system and the health care industry are expanding very rapidly and have been for decades. I want to give you some some specifics about that and then talk about performance challenges in the health care industry centering on high costs, disjointed, fragmented processes, medical errors which create problems of patient safety. And then I'm going to drill into what are the largest areas of health care costs so that you can get an idea of where where is most of the money being spent and where there are opportunities to use Lean to improve cost of quality. I'm going to talk about the nature and scope of Lean improvements in health care and the results that have been achieved, focusing on two leading organizations that started almost 20 years ago and were early adopters. And then I provided just some resources for additional knowledge. And we aren't going to have a question and answer session. But you can use my email, which I've included on this webinar, and feel free to connect and I'll try to answer any questions you have or refer you to someone who can. So I use the shark to get the point across of what the health care cost trend has been over the past fifty five years.

So we've got five decades now where we've gone from health care using up five percent of GDP in the US, all the way up to 18 percent. And it's got a very fast inflation rate compared to regular goods and services. So it moves and it grows at a rate that is higher than the rate of the consumer price index. And it's a problem for the country. It's a problem particularly for people with low income, and it's a problem for big employers who have to keep paying more and more of their overhead to support health benefit packages. So it's swallowing up our economy. And I want to show you how much. It has changed in terms of the size of the industry from nineteen sixty seven to two thousand and seventeen, so this is from Forbes, but it's become a huge economic center of economic sector over the last 50 years. It's moved from ninth largest economic sector in nineteen sixty seven to the third largest industry in twenty seventeen. So it's changed a lot. It's gotten bigger, it's gotten more complicated and it's gotten more expensive. So when you compare US expenses to other countries, what you see is that as a percent of GDP. We are consuming far more resources for health care than any other of the industrialized nations that we see here.

So France, Germany, Japan, Canada, United Kingdom, Italy, they are not using as much GDP. They're using between 11 percent and little more than eight percent of their GDP. We're all the way up at 18 percent. And this doesn't match the the previous slide. Exactly, because the data in this is a little earlier before we hit the 18 percent mark. But it's a big share of the economy using more and more resources. And that makes it a great place to actually try to do systematic improvement with Lean methods in order to improve quality and lower costs and improve patient satisfaction. So the highest expenditure areas in the US are hospital and professional services. So hospitals are by far the largest share of the health care dollar. So when you're working with your health plan in a health health insurer, whether you're an HMO or a health plan with a network. A about a big portion, a third of their their costs are going out to hospitals to pay for expensive services, and you can imagine you've probably had family members in hospitals and you know how intensive they are in terms of supplies and skilled care. Professional services includes your surgeons, your internists, your neurologist, your radiologists, physical therapists and all the people that create the team that helped you get well. So when you're looking at where can we focus our improvement efforts, hospitals and professional services are two areas that are really ripe for improvement.

And you'll see that that's an area that's begun to be addressed by leaders around the country, in the hospital industry to begin to implement Lean. So what are the problems? Well, there are very inefficient processes of health care. We've got a process with big delays, disjointed work, few standards and limited metrics, time to schedule a first time appointment with a physician. According to a recent study by Beckers Hospital Review, 15 to fifty two days to get a first time appointment with a physician. Because you're a new patient, wait time to see an orthopedic surgeon. Seven 19 days. Time to see a cardiologist. Twelve to forty five. And then if you're trying to get in to see a dermatologist, you can wait as many as seven to eight days. So big delays in the delivery process. So that gets that patient satisfaction with time to get care. Now I'm turning to patient safety and this is how safe are the processes that are in place in order to ensure there are no errors in the medical delivery of care. So according to this national study by the British Journal of Medicine, one in 20 patients experiences a medical error, or six percent. In the high risk areas are intensive care surgery and drug administration. So examples of where we have problems are in intensive care. It's a very complicated set of services that you're trying to deliver.

And it's easy to make mistakes with either drugs or the equipment that you're using in surgery. Often problems occur with wrong site surgery. So you're supposed to do a surgery on the left hand and you do it on the right. I personally have had a surgery where they didn't have the right equipment when I was under anesthesia and in the operating room. And in fact, the the surgery didn't come out exactly the way we wanted it to. So I I've lost some range of motion because of that. And they could have been more prepared and been more organized if they use a tool like this in order to make sure everything was in the operating suite. Drug Administration, big problems there because sometimes patients are given the wrong drugs when they're in the hospital. Sometimes they're given duplicate drugs. When they're only supposed to get one, they get two. And sometimes drugs get mixed up and they're given drugs that actually are harmful. So in some cases, if the wrong drug is administered, there are deaths from that. And a big hospital in Seattle had that problem and went to work on it with their Lean effort to eliminate years. So the big performance gaps in US health care are cost, timeliness and patient safety. So in terms of costs, talked about how much GDP we're using more than any other country in the industrialized world, timeliness patients often wait seven days to seventy eight days to be seen.

I know that in the area that we live in near Seattle, we sometimes have to wait up to four weeks just to get in to see some specialists, and that's not uncommon. And then quite a few patients who are looking for primary care doctors when they first move into the area have to wait quite a long time in terms of patient safety. As I mentioned, one in 20 patients experience a medical error. So. When you think about the amount of money that's going to hospitals and professional services, it seems like a very obvious place to use Lean. So the Clear Center, which is the Center for Lean Research and at the University of California at Berkeley, has done a great survey where they've surveyed forty five hundred hospitals in the state in the US and discovered what the extent of Lean adoption is in the hospital industry. So you'll see they surveyed forty five hundred. They got a twenty seven percent response rate, so they had one thousand two hundred twenty two hospitals responded. And of those sixty nine percent or forty seven said we're using lean Six Sigma or a robust process improvement method. And then twenty six percent said we're specifically using Lean. Twenty two percent said we're we're using a robust improvement and then 11 percent said we're using lean Six Sigma.

And then when asked what stage are you in terms of your adoption of Lean in the hospital, only 12 percent. We're at a stage where they had what you would call a mature implementation. So that would be having been working at it for probably five or six years. So when they drill down in the survey to get an idea of the approaches hospitals were using to do Lean, they found that thirty seven percent had some elements of Lean hospital life. So that would be kind of a mile wide and an inch deep. The next group was some elements in small numbers as a part of departments. So that wouldn't necessarily be a broad application, but it would be focused in some areas, probably where there were leaders who were really interested in simply. And then six percent, so that was forty one percent, some elements in a single department, six percent, and that's actually a good sign because that's a very weak imitation of Lean. So it's good to see that the hospitals are investing in Lean. But when asked do you have a comprehensive program of system wide, there was really very few, only 11 percent. So one in 10 have a hospital comprehensive system hospital wide. So that would be a mile wide and hopefully at least a half a mile deep. And then some had a comprehensive system in small numbers of departments. So are they going deep with Lean? But they just focused on specific departments and then comprehensive in a single department.

So this gives you an idea of the maturity curve for Lean adoption in at least 12 hundred hospitals around the US. It's a twenty eighteen study, so it's still very current. So in adopting Lean philosophy and practices, things that the two example hospitals and medical centers on getting used to illustrate Lean adoption. They follow these objectives and methods. So there is a leadership aspiration to have a culture of proactive scientific improvement. And sometimes that's because they've seen a manufacturer in their state get incredible results with adoption of Lean methods. So in Washington, Boeing had tremendous success with Lean and it caused a large health system to want to learn about it and then go to Japan, study and implement it in their system. So let's talk about them in a minute. Another principle is to create TrueNorth goals and metrics so that you're clear about what is it we're trying to achieve? Hospitals that I've worked with and and read about tend to really focus on patient safety and reducing medical errors. They also focus on access to care and then they focus on reducing the resource use so they keep their costs down. So these organizations focus on growing everyone's problem solving and Kaizen skills so that they are building a community of scientists who solve problems through a systematic, evidence based process instead of just using blanket solutions or just living with the approach that they've been using, which could be very inefficient and have a lot of errors.

So they study and improve their value streams to simplify the patient journey. They think scientifically and observe deeply at the gemba, and that's even the hospital administrators and the chief medical officers or at Dicamba working with teams to figure out how can we get our patient wait time down, how can we get our medical errors down? How can we improve being able to get people through our system in a much more organized fashion? So they practice iterative experimentalism propaganda using a scientific process with the use of PDK shift from top down leadership to team centered style. And this is something that both organizations are going to share with you really had to work on as they were learning to implement Lean and they discovered that they couldn't do it if it was a top down approach. So to early adopters in health care, which are just model organizations, which you can learn a tremendous amount from if you read about them, use their website to learn more about them, read articles on them, listen to podcasts. These are organizations that are models in the health care industry. So both organizations have roughly five thousand employees. They're big organizations. They started their Lean transfer transformation in the early 2000s. So they've been at it almost 20 years.

And one is Virginia Mason Medical Center in Seattle, Washington, and the other is theatric here in Appleton, Wisconsin. And they they handle a lot of northeastern Wisconsin. They have multiple hospitals and clinics throughout that area. Both leadership teams studied and applied the Toyota production system and didn't do Lean with less robust methods. They really made sure that they learned the actual Toyota system. Before they implemented it in their organizations, which is probably highly correlated with their success, so they're both now rated top hospitals in the US and the little curve that I shared here is just to show you that organizations started out with just some Horwitz early innovators and early adopters. And then over time, what happens is as they learn, more and more people get involved. And so more and more people are beginning to learn how to think like a scientist and do experiments rather than using blanket solutions to solve problems. So Virginia Mason, the CEO and leadership team, after talking to Boeing, went to Japan and studied on the factory floor making air conditioners and figured out what the system actually entailed. And they fell in love with it. And so they said before they came home, we need to do this in our organization. And so they worked with John Black and Associates who also had helped Boeing go Lean. And they were able to over, you know, within just a few years, spread Lean very rapidly in their organization and get some great results.

So this is these are results from Harvard Business Review study, Harvard case study that show some of the results they got in their first couple of years from two hundred and seventy five Lean initiatives that they launched. And you can see delivery times cut in half, error rates cut in half. And that is huge for patient safety. Employee walking distance might not seem like a really important metric, but it's a productivity metric. That means that if I'm not walking in hospital as a nurse or someone who's drawing blood or a physician, then I can see patients. So they've been able to dramatically improve productivity because they're not wasting time having people walking around their distance travel. You can see that materials travel has decreased significantly, supply inventory and then employee productivity is went up significantly. The other thing that happened was because they became such a safe hospital, their malpractice insurance continued to go down. So they spend much less on malpractice now than they did before they became a Lean organization. And it's because they actually have an Andon system for medical error, even spotting potential medical errors. So they're flagged. They're solved within 15 minutes, that they can't be solved in 15 minutes, then a higher level person is brought in. If that doesn't work, someone else won't be brought in to solve it.

But if it's not solved, at least temporarily, it ends up on the CEO's desk and possibly in the same day. So they've done a terrific job setting up a Andon system for their entire hospital. So this is one of the experienced experiments they did. It's about improving a lot of low back pain treatment. And what this shows is that if you look at the bottom right hand corner, total time to get treatment for low back pain at Virginia Mason before Lean was sixty six days and the cost was between twenty one and twenty two hundred dollars. So if you look at the patient flow here and you watch how the patients moving through the system there, they're here. And they might wait 10 to 30 days just to get in to see a visit which matches some of those statistics I showed you earlier earlier. So right there, you're spending half of this time of your sixty six days. Then they see a physician. And this is all done in silos and then they wait. So if they need to see if this is a primary care doctor and they need to see an orthopedic surgeon, they might wait another five to 10 days to see the surgeon. So they've seen a generalist. They wait again to see a specialist. And then the specialist may say, well, I need an MRI. So they wait another. One to six days here to get an MRI.

And then the results come back and the primary care doctor and the the orthopedic surgeon review it and then they get referred for physical therapy, which could take up to 20 days. So that gives you this long. Patient. Delivery time for the patient, not and not an easy thing, because they're coming back and forth, they're probably losing more so. What's wrong, you got a delayed recovery, long wait times, return visits, and it turns out when they looked at the process, most people didn't need to memorize. So what did they do using Lean and rapid improvement event with Kaizen and scientific problem solving? So after they tightly linked the steps, they made sure there were no delays and they figured out how to do the work with fewer resources. So now when the patient calls in, they get a same day appointment. When they come to see the doctor on that same day, the doctor. And the physical therapist or both in the room and they both evaluate the patient and then on that same day they actually start physical therapy. So what they've been able to do and they've cut out the MRI because only about 20 percent of patients need an MRI and they still refer for the MRI if needed. And they've reduced the patient time to 12 days from sixty six. So that's a huge decrease in time. And they cut the cost of half, largely because they've cut out of both specialists and MRI or an expensive, very expensive technology.

So now higher value care, patient centric, quick recovery, no fewer return visits and no unnecessary use of an MRI. So this is just a picture of what it used to be and the costly approach. And you can you can see that there is a lot of waste and delay in this whole process. So in the new process, it's very straightforward. You're starting treatment right here and here. You're not starting treatment till here. So same day in. To two types of providers seeing you and then you're right. Starting your physical therapy. So in terms of a patient recovery, when you have low back pain, you're functioning. If this is your functioning, you're functioning, goes down. You wanted to go back up and you can have it go back up. Pardon me. In the old way, it took sixty six days to get back to normal function in the new approach, it takes 12 days. So this is a huge improvement. It costs less and it's better for the patient. OK, so this is my drawing of Virginia Mason Hospital, and I'm not much of an artist, but I think I'll be able to get the point across. So another thing Virginia Mason did with their cancer care process was they had a very disjointed approach for cancer patients to come in and get treated and they would come in and they'd start in the parking lot and then they'd walk into the building.

They take an elevator, they go to a different part of the building and they might get some tests done. Then they'd have to go to another part of the building where they would get potentially some more tests or they'd see one type of specialist or a nurse. Then they take an elevator somewhere. Get out of one building and go to another building, go up in that building to get other parts of their treatment, and then they might spend a large amount of time, you know, at this point getting their infusions. Of their chemotherapy. So it was not a good process for patients, so they discovered when they were looking at this process by using blue yarn, exactly what the patient experience was. And what it shows is that the whole care process was designed around physicians and their silos rather than designed around the patient. So they spent several rapid improvement events using three key to redesign the process. So they ended up getting a large, quite large room. They decided to put all providers so to locate all providers in that large part of the building, and then they put patient rooms around the outside. So they had windows and then they had another area where they had windows. So you could look out on the bay and then they put the providers in the middle like a doughnut.

And so all the providers could talk to each other. They could work as a collaborative team. They weren't separated by buildings at care delivery silos. And the patient experience is just hugely better. The physicians and nurses like it better. The people doing pharmacy and lab like that, they're all connected and they can see more patients because they have a much more efficient process and they're not walking all over to deliver things back and forth between the different parts of the delivery team. So in terms of patient safety, something for Jameis Winston is to focus on doing improvement events for specific life threatening conditions. So this is these are results from sepsis. So they set a target to treat all of their hospital patients with sepsis signs. Within 60 minutes, they were able through rapid improvement and mapping their value stream and studying what they were doing. They were able to improve the flow and develop standard work, and they were able to get standard work used up from 40 percent to 70 four percent. And they reduce septic related mortality from twelve point five percent to eight point four percent. And that translated into fewer sepsis related deaths by four point five per hundred related discharge per year. So big improvement, lots of others that they've done that are like this, but they really drill down with their scientific methods and look at what how is this care really being delivered from a systems perspective? And then given what we've learned, how can we find countermeasures that will improve it? Theta Care is in Appleton, Wisconsin.

They began their Lean transformation in 2002. Their aim was to improve quality and lower costs. And they studied this with a snow blower company in Wisconsin. Lots of snow there. So they were using tips that Aaron's snow blower manufacturing. So the CEO, medical director of jobs, you saw who's the man on the left there, he said we need to go look at this. And so he brought his team, his leadership team over and they began learning Toyota production system and then they began applying. So they're now one of the top Lean health care systems in the country, a model like Virginia Madison. And they've become the lowest cost provider in Wisconsin. At the same time, they've improved patient quality and safety. And every year they make improvements in medical errors. So there were top ranked hospital in the U.S. The CEO and leaders started learning Lean from the snowblower manufacturer. They didn't go to Japan. So it probably wasn't as pretty amazing experience. But they also implemented five rapid improvement events in high stakes value streams where they really were having problems with either quality, safety or cost. They learn to include patients in at the front end of the improvement events.

So they knew what was wrong from the patient point of view with the process. And they would map it with patients in the room and they decided they were going to change their focus to what works for patients instead of what works for physicians. Big paradigm shift. They redesigned value streams to reduce medical errors, delays, costs with some great results, and shifted from top down leadership to his team center style. So they really changed the culture to one where people with higher educations and more status in society who tend to be who people look to for answers, they learn over time with some pain. That that would not be a good culture to combine with Lean, so they they went through the process of learning to be more humble and ask questions and not think that they had all the answers and let the team members come up with the answers so they didn't they never let up. They fully embraced Lean. They spread it to everyone. They did covert ways to make small improvements everywhere. Every day they applied on small scale. PDCA cycle was using a three thinking and eight step problem-solving learn to shift from specialty silos to integrated care created TrueNorth metrics and the visual management report so that the leaders in the organization were responsible in monthly report for how well they were doing that, reaching targets that they set up for the year or for the month.

So everything was visible. They track KPIs for financial stewardship. Quality and safety, patient satisfaction, timeliness of care and that people and that was measured by employee engagement. So an example of an improvement they did where they got great results was to apply Lean problem solving to improve chronic coronary artery bypass surgery. So these are complex surgeries. They happen more often than people would like, but when they happen, you have risks that you could die from it. So what they did was they looked at the process, improve standard work and physicians and surgeons adherence to standard work, as well as nurses in the operating room. And they decrease the mortality rate for that procedure from four percent a year to nearly zero. They reduced the length of stay from six point three to four point nine days and they lowered the cost by twenty two percent. So increase in quality, a shorter time in the hospital and lower cost. So those are huge improvements. They attack here in its first seven years, reduce waiting time and move to a same day appointment process, and they found that roughly 30 percent of people want same day and they're able to accommodate that 30 percent. They increase the volume of patients seen year over year because through their Lean efforts, they were reducing waste in their system and it was freeing up people and resources to be able to see more patients.

So the patient volume actually was increasing year after year. But their costs of care were increasing. So they weren't hiring more people to see more patients. They were actually seeing more patients with the same number of people. So it was a huge success. By pulling out all the waste in the system, they decreased resource use and became the lowest cost provider in the state. They reduced blood, draw errors from nine hundred forty one per million to one hundred per million. And if you have blood, draw errors that could lead to either sickness of the patient because of a mistake or you could actually harm the point, the patient to the point where they suffered death. So that's a huge improvement over time from a lot of little PDK cycles. They lowered the mortality rate for artery bypass and employee engagement increased from four and a half to five. They increased their operating margin, which is a huge deal for a big organization like that from two point five percent to six percent. So really good results from both Virginia Mason and Theta Killer in the application of a systematic approach, training people to use a systematic approach to studying how care is delivered. Learning about where the delays and the errors and the patient dissatisfaction is and then finding ways to do small experimental improvements to eliminate those problems and by having a community of scientists.

Trained and working together to really look deeply at their systems. And learn how to run experiments and make improvements and innovations, both organizations have become very solid financially. They're places people want to work because they have a lot of input into decision making. Most of them most people love having the ability to problem solve on their own or with a team and use a systematic method. And patients like going there because it's a better organized, more of an environment where care flows. There's not a lot of waiting and there are mistakes. So they've reduced the cost of care up to 50 percent. They've defragment an integrated care to improve patient flow and the patient experience improved service delivery times by up to 50 percent, increased employee engagement suggestions and innovation and productivity to the point where I know people in the Seattle area who say I want to work in Virginia Mason because I want to become extremely skilled and Lean. That's the kind of reputation they have and they're now a training institute that has an arm and an office in the United Kingdom where they're helping the National Health Service implement Lean in the British health system. They've shown that you can reduce errors by as much as 40 percent and create a culture of scientific problem solvers. So as I like to say, you have a scientist at every desk, a scientist at every desk. It's going to do much more for an organization than a person who is just following a bad process and not allowed to innovate and change.

So both of these organizations over the past 20 years have proven Lean is a great investment. So you can read about Virginiamycin in transforming health care. You can read about theta care and on the mend, you can read about early efforts at Virginia Mason and best practices. And then you can learn about some other hospitals that have used Lean in Lean hospitals, all highly recommended books. Or you can find podcasts that are by the same authors. And if you'd like to learn that way, I would recommend watching this five minute video. I gave you the link. It's on the Toyota website, but they have a pro bono group that helps small businesses and non-profits and organizations that stress, like if there's a hurricane, they come in and they help figure out. How can we get food faster to these people, how can we get health care faster to these people? So this is a great video of the they did at UCLA, a medical center where they had a bad process for treating people's eye problems. And they totally turned it around by bringing one of their Lean senses. And the effect on patients was fantastic. So it's just a great video. These are acknowledgments and sources. If you need a list of these, you can always e-mail me. And all of these people and organizations have done tremendous work in the Lean and Lean health care.

Thank you so much for this very informative and inspiring. I trying to share my screen here. There you go. And it's really like a serious situation that we're implementing Lean as a matter of life or death. And it's it's very inspiring for a lot of other sectors. Clearly, health care these days, for all the reasons you mentioned and the current circumstances also make it especially important to us to follow the example and the leadership of institutions like those you have presented. And there's some at the same time, the numbers you showed in the beginning really show also how much there is left to do. But there's some pioneering organizations that have shown the that it is possible the in both for their own, the patients and the the organization of the employees, financially speaking as well. And so I'm glad that we could have you with us today so you can get to contribute a little bit to spreading the word and hopefully getting even more people inspired. Andon. And I think it's definitely also inspirational for all the Lean and continuous improvement community and where you see the impact on society and on organizations that are important like these ones. So thank you so much for those interested. There are a number of resources. You mentioned a number of them, those who would like to receive the the presentation, I believe, accepted that we can Horwitz. Yes.

Yes, that's fine.

Right. So feel free to reach out. And we also have some resources related to to the same topics, more we become related to actually the physical aspect of implementing Lean, such as the Ergonomics Digital Solutions, trolleys that Kanban systems and also the training games, which can come in handy to get all the teams at all levels involved and familiar and enthusiastic about about things. So feel free to reach out just now. So thank you again. Right. Pleasure to have you. And look forward to continuing this, hopefully with another having you again soon.

Great. I appreciate being able to share a little bit about. Use of Lean in health care and how badly it's needed. I really appreciate getting to know you and we're working with you and I hope the the information is helpful to people that are in the health care industry. So thank you for the opportunity. Pleasure. Thank you.