Detecting errors, identifying causes, improving

processes – initial project serves as opportunity to

introduce Lean management at Berlin’s Charité Hospital

Founded in 1710 as a less than prestigious plague treatment institution outside

the gates of the city, 300 years later, , Berlin’s Charité has become Europe’s
largest university hospital. Its four locations represent cutting-edge medical
care with a worldwide reputation. Since 2009, the Charité has had even greater
trademark protection to prevent freeloaders from misusing its good name.
Last year, tremendous efforts resulted in a successful turnaround. Charité’s
management expects a balanced budget for the first time in 2011. But
conventional ways of saving money, such as in material procurement or task
loading, have been exhausted in many areas.

Key facts & figures on Charité –
Universitätsmedizin Berlin¹
• 4 locations (Benjamin Franklin
Campus, Berlin-Buch Campus,
Charité Campus Mitte, Virchow
Clinic Campus (CVK))
• 107 hospitals and institutes orga-
nized into 17 Charité Centers
• 14,500 employees (including
3,750 scientists and physicians,
250 university professors,
4,200 nurses and care assistants, and
746 administrative employees)
• EUR 1.1 billion in annual sales
• 3,200 inpatient beds
• 130,500 inpatient cases handled
each year
• 530,200 outpatient cases handled
each year
• EUR 203 million in state subsidies
• EUR 130 million in funds raised from
third parties
Precious efficiency potential can be
tapped through process management.
Anyone intending to increase the
efficiency and added value of processes
in a traditional institution like Charité
must be able to proove that this
approach can actually work. A pilot project
in the cardiac catheter laboratory of the
Cardiology Department at Charité
Campus Virchow Klinikum (CVK) has now
provided this evidence. The model project
was initiated jointly with Stryker Lean
Academy in the spring of 2010.
The project’s successes at a
glance:
Two days of ViMotion video analysis of
a typical 45-minute work process
• conveyed lean management skills to
participants
• enabled participants to analyze
processes
• generated enthusiasm and reinforced
team spirit
• revealed more than 30 improvements
in ergonomics and more than 50
ergonomic details that needed to be
improved in terms of occupational
safety
• revealed the potential to generate
additional revenue in the amount of
EUR 300,000 per year from just one
procedure
Not until the end of May 2010 did the
Berlin Senate decide to keep all three of
the Charité’s locations for inpatients.
Despite this favorable vote, it is too early
for staff at this venerable institution to
breathe a sigh of relief. Because of the
precarious budgetary situation, the city
can only provide just under 50 percent
of the funds needed for investment over
the next few years.
Potential for greater efficiency at
the interfaces with healthcare
So the strict savings program at the
Charité continues – even though the
annual deficit, despite additional costs
arising from collective bargaining
agreements and normal increases in
costs, such as for energy, have already
been cut back from EUR 56.6 million
(2008) to EUR 19.3 million (2009).
The ambitious target of presenting a
balanced budget for 2011 cannot easily
be reached using conventional business
methods for reducing expenditure. Any
leeway for negotiating price reductions
in procurement is dwindling. Further
cutbacks in personnel, especially in
the clinics, could have a negative effect
on the quality of care.
But there is still potential for healthcare
savings at the interfaces where health
care is provided, such as: when
admitting patients, transferring them
from one specialist department to
another, and moving them between

¹ Annual Report 2008

Authors

Dr. med. Wolfram von Pannwitz

Head of Corporate Development at Charité – Universitätsmedizin Berlin

“The success of our pilot project makes me hopeful that we can apply the ‘Lean Hospital’
philosophy to Charité’s other hospitals and specialized departments.”

wards, operating rooms, and other
specialized treatment rooms. Although
the clinics make successful use of
clinical treatment paths, these paths
mostly reflect the processes within the
respective specialized departments
and take too little account of the points
of contact with other departments.
Over the decades, processes at these
interfaces in particular have evolved and
multiplied, and are thus only efficient
to a limited extent.
Lean management focuses
primarily on customer benefits
The Charité worked on introducing tools
for more efficient process management,
particularly those with lean-management
features that became known in hospital
circles as the “Lean for Hospitals”
concept. Lean management is mainly
distinguished from other quality-
management approaches, such as the
industry-non-specific Six Sigma or the
hospital-specific KTQ (German acronym
for Cooperation for Transparency and
Quality) programs, by being primarily
oriented towards patients’ needs and its
implementation with and at the
employee base. The model gives
employees a lot of freedom in the way
they implement a project within the
strategic guidelines.
History and philosophy of lean management
Lean management refers to all of the principles and methods for an efficient
structuring of the value chain in corporate processes. From the middle of the 20th
century onward, the car manufacturer Toyota led the field in industrial production²;
the service industries followed in the nineties, and it was not until recently that
lean management also made its appearance in healthcare (“Lean für das
Krankenhaus/Gesundheitswesen” (Lean for Hospitals/Healthcare))³.
The core ideas of lean management are:
• Defining the value of a product or service from the customer’s perspective,
• Identifying the value chain and orienting business processes accordingly,
• Avoiding waste by concentrating on value-adding activities,
• Constantly improving quality,
• Continuous and smooth flow of all processes (the “flow principle”),
• Directing working procedures towards customers’ needs (the “pull principle”),
• Personal responsibility, empowerment and teamwork,
• Decentralized, customer-oriented structures,
• Open information and feedback processes.
Arguments in favor of “Lean for Hospitals” in hospitals and medical
healthcare centers:
• Treatment must be provided to patients directly and on a highly individualized basis.
• Medical treatment requires several – generally at least three – occupational groups
to be synchronized.
• Reducing variations in service improves its quality.
• Reducing waste (e.g. duplicate examinations, waiting times, unnecessary travel,
inefficient storage, etc.) streamlines processes.

² Jeffrey K. Liker: The Toyota Way. 14 management principles from the world’s greatest manufacturer. New York: McGraw Hill, 2004
³ Schön-Kliniken Deutschland; Virginia Mason Hospital, Seattle, Washington, USA
 Dr. med. Hank Schiffers
Director Lean Europe, Stryker Corp.
“This type of training enables people to streamline processes themselves. Lean Management projects
are the starting points from where lean management will grow throughout the whole company.”
In order to introduce the lean
management philosophy in the company
and after identifying the pilot project in
the cardiac catheter laboratory, the
Charité looked for a partner with proven
experience in the hospital field to
conduct an initial training session and
then provide support throughout the
project. Although many consulting
companies offer lean management
consulting, the Charité’s particular
requirements substantially reduced the
number of potential partners.
A taylor-made concept provided by
Stryker Lean Academy
Stryker does not base its pricing policy
on the individual price of the product but
rather on the total costs of acquisition,
usage, repair and maintenance (total
cost of ownership or TCO). Stryker Lean
Academy has also adopted this
approach; based on its expertise in the
hospital field and its tailor-made
concept, it was selected to conduct the
pilot project at the Charité. The project
was split into a two-day training seminar
and the defined task in the Cardiology
Department on the CVK campus,
including a (ViMotion) video analysis in
the cardiac catheter laboratory.
Key facts and figures of the
Charité’s cardiac catheter
laboratory on its CVK campus
• Three state-of-the-art X-ray systems
for diagnostics and treatment
• 2,500 patients annually
• More than 3,000 procedures
• Range of treatments: cardiovascular
diagnostics (left and right cardiac
catheter examinations), invasive
treatment of all types of cardiac
Twenty Charité employees took part in
the training seminar held in April 2010: in
addition to nursing and medical staff
from the cardiac catheter laboratory, it
was attended by representatives from
Corporate Development, IT and the
Works Council. The Stryker Lean
Academy coaches began by teaching
the basic principles of lean management
and how these can be applied in
healthcare: What are value-adding
activities in a hospital? How can waste
and bottlenecks in procedures be
identified and avoided through
improvements in process management?
Changing roles to get an unbiased
view of all processes
In order to make it possible for everyone,
including administrative employees, to
experience the processes of a cardiac
catheter laboratory, a 150-m² treatment
area was reenacted in which the seminar
participants simulated a complete
treatment procedure. A core element of
the simulation was the opportunity to
exchange roles among various jobs,
which enabled participants to gain a
new and unprejudiced view of the
working procedures in the cardiac
catheter laboratory. While other
management consultants rely too
much on abstract tasks in their Lean
Management role plays (“Let’s build a
lean car manufacturing facility in
Shanghai”), the Stryker Lean Academy’s
approach was based exclusively on
what happens in hospitals and their role
plays simulate actual on-site processes.
In the evaluation of the simulation that
was carried out concurrently,
participants, documented in detail which
procedures could be used in their
day-to-day work, which processes did
not run smoothly, and which activities
did not add value for the patient. The
core purpose of this evaluation was to
derive real suggestions from the
simulation to improve day-to-day work
in the cardiac catheter laboratory.
These were uncharted waters for most
participants as it was the first time for
many of them that representatives of
various professions sat at one table with
others from outside their respective
departments, to consider a problem
together and discuss possible solutions.
On a scale ranging from 1 (= excellent)
to 4 (= satisfactory), participants to the
 Univ.-Prof. Dr. med. Wilhelm Haverkamp
Director (interim) of the Charité Universitätsmedizin
Berlin Medical Hospital, Dept. of Cardiology

“Structured processes help us to provide our patients with the highest level
of medical care.”

training seminar seminar evaluated the
knowledge transfer with 1.1.
This success was also noticeable as the
project proceeded. Because participants
were now familiar with the specific
lean-management vocabulary and knew
which factors were relevant in the
concrete analysis of a process, this first
training session had the added benefit
of providing the basis for particularly
effective work in the second phase of
the project in May 2010. This is when
Stryker Lean Academy organized a
video-based analysis (ViMotion) of
various processes in the cardiac
catheter laboratory – such as preparing
patients or preparing for surgery.
Philosophy and training modules offered by Stryker Lean Academy
Founded by Dr. Hank Schiffers (MD and MBA) in 2006, Stryker Lean Academy
specializes in lean management solutions in healthcare. By April 2010, more than 300
people had participated in seminars and projects run by the academy.
The projects managed by Stryker Lean Academy/Lean Healthcare Services normally
comprise the following modules, the contents of which are adapted and combined
based on the needs of the partner clinic:
• Needs analysis involving all participants.
• Detailed video analysis of the processes (ViMotion) to identify superfluous
processes and activities that cause excessive strain to the musculoskeletal system.
ViMotion is video-based analysis software that breaks down footage of complex
procedures, e.g. in the operating room or cardiac catheter area, into their individual
steps, allowing for a structured evaluation. This evaluation is carried out jointly with
the employees from the partner clinic.
• 1 day: Lean Academy white belt (for employees from the strategic management
level who want to become more familiar with the lean-management philosophy).
• 2-3 days: Lean Academy yellow belt (for employees from occupational groups
relevant to the processes who learn the objectives and tools of lean management
by combining theoretical training and individual simulation).
• 5 days: Lean Academy green belt (for managers from the occupational groups
relevant to the processes who will continue implementing the Lean Management
approach within a company after the end of the project) plus three months of lean
coaching on-site (continuous project support means of regular follow-ups and audits).
• Individual assistance with projects/coaching.
• Strategy-oriented consulting.

References:
• Schön-Kliniken Germany. See: Tim Braun, „Haus-Berater“,
In: FTD/medbiz, 01.08.09.
• Jura Klinik Schesslitz, 2-year report on “Lean for Hospitals”
 Matthias Wiemann
Head Project Manager, project manager for improvements to
cardiac catheters at Charité’s CVK Cardiology Clinic
“When jointly analyzing the video footage, everyone saw something that could be improved.
The lean project has given us many valuable ideas.”
Data protection: all recording is
destroyed after the project ends
The use of video analysis was carefully
prepared. Participants agreed early on
to use a practical procedure that would
give no one cause for concern: all
footage would be irreversibly destroyed
following analysis so that it could not be
reviewed or fall into the wrong hands. In
addition, the records associated with the
individual video sequences did not
include the names of any of the
employees. All edited parts were made
anonymous in the presence of the
employees, so it will not be possible to
identify individuals later on.
As a result, the records provide detailed
information on weaknesses and
problems identified during the project,
but not the names of the employees
involved. This concept was approved by
the Charité’s Works Council and Data
Protection Officer, and assessed very
positively by all participants. The Works
Council immediately saw the potential in
the innovative tool for revealing
procedures that posed hazards to
people’s health and chose to support
the project.
Filming with a conventional video
camera was smoothly integrated into
the regular working procedures in the
cardiac catheter laboratory: an
employee from the Stryker Lean
Academy simply followed the various
employees and filmed everything they
did. This alone produced around 45
minutes of footage. This was followed
by intense dicussions to evaluate and
analyze the video sequences. Despite
the additional work created by the pilot
project, the employees involved were all
highly motivated.
Thomas Mewes
Deputy Head of Nursing
Care in the cardiac
catheter laboratory
“Once the video camera started, I
became more aware of what I was
doing. While I was being filmed, I was
already thinking about how we could
improve the process design.”
The Stryker Lean Academy is quite right
to attach great importance to on the
involvement of all employees working
on the processes under scrutiny:
unfiltered criticism from outsiders puts
most people on the defensive and rarely
leads to constructive solutions. On the
other hand, making sure everyone is
involved to jointly analyze the problems
creates trust and motivates people to
reflect critically and professionally on
what they do.
Anna Senz
Head of Nursing Care in
the cardiac catheter
laboratory
“The training made me aware that only
we, the employees, can recognize and
increase the efficiency of procedures
that we have established.
It was great to have management
entrust us with the task of finding
ways to improve processes. The video
analyses made various procedures
transparent and easy to follow for
all participants.”
ViMotion offered ideas for more
ergonomic and cost-effective
procedures
Accordingly, group participants
repeatedly analyzed the video
sequences and discussed their
observations, which were immediately
converted into concrete solution
proposals. In so doing, all employees –
including ward nurses, head physicians,
senior physicians, and the cardiac
catheter laboratory’s functional staff
– identified procedures and movements
that are very likely to cause physical
discomfort (e. g. back pain) – such as
bending down and turning
simultaneously under strain or lifting
heavy objects in the wrong way.
 Alexander Conz
Manager Lean Healthcare Solutions GSA, Stryker GmbH & Co. KG
“Direct technical communication with project participants is a decisive factor
contributing to the success of our projects.”
In view of the fact that back pain is the
number-one cause of staff absence in
hospitals, these observations produced
valuable ideas to improve working
procedures: 16 of these observations
related to improvements that could be
implemented quickly (“quick wins”),
some of which were even implemented
during the two days of ViMotion
analysis, while others were integrated
into the main Charité project. Some 30
observations related to opportunities for
improvement that should be possible to
implement in the short to medium term.
In addition while analyzing the video
sequences, employees discovered some
50 ergonomic details that need to be
addressed for occupational safety reasons
to reduce the physical strain on staff.
Gerhard-Peter Schulz
Project Manager for the
Charité’s Main Works
Council for the
“ProFu – Cardiac Catheter
Laboratories” project
“In my view, the project, which was
carried out in both the CVK and the
CCM cardiac catheter laboratories to
improve processes, revealed flaws in
task organization and thus shows ways
of improving them, reducing
unnecessary strain on workers,
promoting motivation and commitment,
and increasing patient satisfaction.”
A lot of time wasted on
unnecessary movement by
operations personnel
Apart from the occupational safety
aspects, the ViMotion analysis also
brought commercially inefficient working
procedures brought to light
commercially. For example, employees
recognized the need to improve the
organization of materials. The analyses
clearly showed how much time the
cardiac catheter staff spent spent
performing non-value added tasks, e. g.
when required items are stored in two
different places, so each item has to be
individually located and transported
although they are needed together as a
set. In the meantime, the employees in
the cardiac catheter laboratory have
worked out three separate concepts for
improving the organization of materials.
They are currently discussing and
testing them to see which of these three
proposals is best suited to keep all
materials ready at hand and to shorten
paths to the patient, without creating
cumbersome storage quantities.
Based on the ViMotion analysis, the
project managers from Stryker Lean
Academy analyzed the actual savings
potential that could be tapped by
preparing the cardiac catheter room as
well as the patients to implanting a
defibrillator (ICD). With regard to the
preparation of the catheter room
(a process that previously took
26.5 minutes), a conservative forecast
showed that 30% of the time required
could easily be saved through better
process management and organization
of materials. The time that could be
saved by preparing patients was about
20%. With 250 ICD implants every year,
this means that the simplest of measures
could free up 46 hours of cardiac
catheter time every year. This time would
then be available for more surgery.
Potential to raise revenue by more
than EUR 300,000 with just one
procedure
The cardiac catheter laboratory could
therefore carry out 16 additional ICD
implants every year in these 46 hours
(total time for the process = 2.75 hours)
and so generate more than EUR 300,000
of extra revenue. The investment
required to generate this extra revenue
is in the single-digit percentage range
and no additional work would be
required. As demand from patients for
ICD implants is very high at Charité, the
cardiac catheter laboratory could
increase the number of these operations
as well as reduce waiting times and
improve patient satisfaction – after all,
these are patients suffering from
life-threatening cardiac arrhythmia.
As the procedures for getting the cardiac
catheter room and the patient ready are
similar to all treatments provided in the
cardiac catheter laboratory, these
calculations can basically be applied to

all operations in the cardiac catheter
laboratory. Based on the saving potential
(expressed as a percentage) per
operation, the capacity freed up in the
cardiac catheter laboratory that
performs 3,000 procedures annually
would total 560 hours. In these 560
hours, the cardiac catheter laboratory
could carry out additional operations
generating an additional revenue of
more than EUR 2.5 million. This
projected additional revenue would also
require only relatively small investments
and no additional staff.
Stryker Lean Academy Coaches are
experts in different medical fields
These results speak for themselves
themselves. The basis of these results is
the concept behind the pilot project and
the criterion for its success, namely
empowering all participants to be more
aware of processes and to evaluate
them in accordance with lean
management principles. Another factor
contributing to success was the Stryker
Lean Academy team’s in-depth
understanding of the hospital sector and
the specialized medical background of
its consultants – certainly not a given in
the consulting field, particularly in the
healthcare sector .
The Charité’s management now wants
the initial project implemented in the
cardiac catheter laboratory of the CVK
Cardiology Department to be the
4 Wolfgang Hirn, Dietmar Student: “We have quality problems”. In Manager Magazin 7.2001
Charité Campus Virchow-Klinikum (CVK)
Augustenburger Platz 1
D- 13353 Berlin
Phone +49 30 450 - 50
www.charite.de
starting point for disseminating Lean
Management projects throughout the
whole organization. Because project
participants have learned how to deal
with Lean Management tools not all of
the future projects will require external
consulting. An ongoing dependence on
consultants also contradicts the Stryker
Lean Academy philosophy: Consultancy
is not about promoting an ever growing
need for more consultancy, but about
empowering hospital employees so they
themseves are able to make their
processes leaner, more efficient and
more patient-friendly.
www.charite.de
www.stryker.de
Authors
Dr. med. Wolfram von Pannwitz*
Dr. med. Hank Schiffers**
Prof. Dr. med. Wilhelm Haverkamp*
Matthias Wiemann*
Alexander Conz**
* Charité – Universitätsmedizin Berlin
** Stryker Lean Academy
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HCS-TLA-002
Artikel-Nr.: HCS-TLA-002
Stand: August 2010