PAUL NAGY, PhDQUALITY MATTERS

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Utilizing the 5S Methodology for RadiologyWorkstation Design: Applying Lean ProcessImprovement Methods

Paul Knechtges, MD, Courtney J. Bell, BA, Paul Nagy, PhD

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The Toyota Production System, alsoknown as Lean, is a quality improve-ment methodology developed byToyota over the past 50 years to trans-form the automotive manufacturingprocess. This methodology has beentailored with success to health care en-vironments [1]. Lean is a collection oftools coupled with an overall philoso-phy to deliver value by reducing wastethrough continuous improvement.Waste has a broad definition as any-thing that does not add value to a pro-cess [2].

Radiologists spend on average morethan 8 hours a day in front of comput-ers. Small inefficiencies, such as poorergonomics, software application lay-outs, or desktop clutter, can lead to sig-nificant time loss and even potentialinjury. In one study of 73 radiologistsin 2008, 58% reported repetitive stresssymptoms, and 38% had prior diagno-ses of repetitive stress syndrome [3].

Considering that diagnostic radi-ologists spend the majority of theirtime at their workstations, this is anarea where the principles of 5S can beeffectively used with only minimalinvestments of time and resources. Inpatient care, the value added of a di-agnostic radiologist is largely definedby rendering accurate, timely diagno-ses and reports. For radiologists,waste is any distraction that does notcontribute to patient care (eg, timespent acclimating to different, un-standardized workstations or search-ing for frequently used information).Working in a clean, organized, andpredictable environment can allowradiologists to spend more time withtheir eyes on the images and, ulti-

mately, adding value to patient care.

2013 American College of Radiology1-2182/13/$36.00 ● http://dx.doi.org/10.1016/j.jacr.2

APPLYING 5SMETHODOLOGY TOWORKSTATION DESIGNOriginally developed by Hiroyuki Hi-ranoinJapan, the5S’sarederivedfromthe words seiri, seiton, seiso, seiketsu, andhitsuke,whichroughlytranslateas sort-ng, straightening, sweeping, standard-zing, and sustaining (see Figure 1) [4-]. More recently, this systematicpplication of these principles hasielded significant results in the pathol-gy literature [5,6].

Although any one of these princi-les can be dismissed as commonense, it is important to rememberhat these principles also need to be

Fig 1. The 5S Japanese characters.Reproduced from Agency for Health-

care Research and Quality [5].

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pplied sequentially when designingr improving the work place. Hiranoas explicit that the removal of un-ecessary items had to be performedefore considering the layout andow of the workplace [4].

The 5 S’s of Optimizing anInefficient Work Desktop

Seri/Sorting. Inspect each itemon your workstation and considerthe last time it was used and forwhat purpose. Productivity can beenhanced with the correct worksta-tion size, height, and layout [7].Commonly used items should bearranged in a horizontal arc belowshoulder level (see Figure 2). Such alayout improves visual manage-ment (ie, the ability to quickly as-sess one’s workplace) [8]. The samegoes for the computer desktop.Create a folder on the desktop forinfrequently used icons. Howmany times do you need to scrollfrom one side of the screen to theother to perform common tasks?

Seiton/Straightening. It is impor-tant to maintain the same physicallayout from day to day at the sameworkstation. The principles of mo-tion economy can be specifically ap-plied to workstation design. Poorlydesigned workstations are a notori-ous source of waste [7]. In manypractices, there has been a strong fo-cus on computers and the electronicworkspace, to the detriment of thephysical workspace. Wasted motion,in particular, can be a significantsource of inefficiency.

Seiso/Sweeping. Keep the work-

space uncluttered and organized.

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634 Quality Matters

Eliminate all unnecessary, redun-dant papers and equipment. Noloose papers should be on the work-station. Any useful reference papersshould be laminated and put on theworkstation wall or, better yet, pro-vided as a reference web page on thecomputer itself.

Seiketsu/Standardizing. The work-stations in a department should beconsistent and standardized. Thereshould be a fixed place for all of theitems on a workstation. In the Leanlexicon, this is referred to as “shad-owing,” whereby the exact locationof equipment is highlighted by avisual cue [9]. Items are optimallypositioned less than 5 ft from theuser [10] and directly in front of theuser. Some authors recommendarranging items in a counterclock-wise manner depending on fre-quency of use, as this is more

Fig 2. An example workstationhorizontal arc: (A) desktop orgdictation headset, (C) PACS w(D) telephone. Note that this layoa paperless workflow, and onquently used information is ststandardized, frequently updatorganizer.

natural for right-handed individu-

pnagy2@jhmi.edu.

als [8]. Although these interven-tions may save only a small amountof time per study, the aggregate im-pact over thousands of studies con-stitutes a significant time savingsover the course of a year.

Shitsuke/Sustaining. It is impor-tant to maintain and review thestandards of the previous 4 S’s. The5S process is constant and ongoing,not something that is carried outonly before inspections.

Safety. A sixth S, safety, is oftenmentioned. Ergonomics are an im-portant consideration. Freeing thehands of as many tasks as possiblecan reduce wasted motion. For ex-ample, the use of headset dictationdevices and foot pedals can not onlyincrease productivity but also de-crease repetitive stress injuries.Similarly, height-adjustable work-stations can reduce fatigue and re-

out in aizer, (B)kstation,featuresery fre-

d in thedesktop

petitive stress injuries.

CONCLUSIONSIn addition to improving safety andproductivity,anappropriatelydesignedwork environment can improve mo-rale.Anorganizedenvironmentthatre-duces fatigue and interruptions canimprove job satisfaction. Improvedmorale can affect productivity beyondthe simple time savings associated withproper motion economy.

REFERENCES

1. Kenney C. Transforming health care: Vir-ginia Mason Medical Center’s pursuit of theperfect patient experience. Boca Raton,Florida: CRC Press; 2010.

2. Flug J, Nagy P. The Lean concept of waste inradiology. J Am Coll Radiol 2011;8:443-5.

3. Boiselle PM, Levine D, Horwich PJ, et al.Repetitive stress symptoms in radiology:prevalence and response to ergonomic inter-ventions. J Am Coll Radiol 2008;5:919-23.

4. 5S (methodology). Available at: http://en.wikipedia.org/wiki/5S_(methodology).Accessed April 2013.

5. Agency for Healthcare Research and Qual-ity. Mistake-proofing the design of healthcare processes. Available at: http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/mistakeproof/mistakefig1-7.html. AccessedApril 12, 2013.

6. Suneja A, Suneja C. Lean doctors: a boldand practical guide to using Lean principlesto transform healthcare systems, one doctorat a time. Milwaukee, Wisconsin: ASQQuality Press; 2010.

7. Weber A. Lean workstations: organized forproductivity. Assembly. February 6, 2005.Available at: http://www.assemblymag.com/articles/84001-lean-workstations-organized-for-productivity. Accessed May 22, 2013.

8. Joseph TP. Design of lean work cells: a Leanlab layout (part II). MLO Med Lab Obs2006;38:24, 26-8, 31-2.

9. Serrano L, Hegge P, Sato B, Richmond B,Stahnke L. Using Lean principles to improvequality, patient safety, and workflow in histologyand anatomic pathology. Adv Anat Pathol 2010;17:215-21.

10. Yerian LM, Seestadt JA, Gomez ER,Marchant KK. A collaborative approachto lean laboratory workstation design re-duces wasted technologist travel. Am J

Clin Pathol 2012;138:273-80.

Paul Knechtges, MD, and Courtney J. Bell, BA, are from the Medical College of Wisconsin, Milwaukee, Wisconsin. Paul Nagy,PhD, is from Johns Hopkins University, Baltimore, Maryland.Paul Nagy, PhD, Johns Hopkins University, Department of Radiology, 600 North Wolfe Street, Baltimore, MD 21287; e-mail:

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