Table 2.

Examples of waste and contributing factors with descriptive quotes

Types of Waste	Contributing Factors	Quotes
Time
Searching -for functional equipment -for covering physician -for materials	Separate cost centers/silos Staff inertia Lack of ownership Poor communication Poor inventory management Variation in resource needs False economies Poorly designed work space Lack of professionalism	“… if I can’t find a tongue blade in that room, and I have to come out, that’s inefficient. And, it would be so much more efficient, and less costly, for somebody who is ~ has a lower salary structure than the physician ~ to be able to go in, make sure all the rooms are stocked. So there's less of this Brownian movement trying to find supplies.”
		“ - the nurse on the phone… it’s the amount of time spent trying to find out who’s covering, who is actually assigned to the patient, that is a huge deal. “
		“But, again, it also signifies ~ so every time we have a discharge, we have to go search for that wheelchair.”
Waiting -for slow computers -for late starting meetings -for beds to be available -for response to pager	Poor system design Inconsideration Outdated technology Poor communication	“This is a picture of the Kronos box and my favorite thing of all time regarding waste is people lined up waiting to swipe the Kronos box because if they swipe it too soon they don’t get credit for the full day. So it’s silly.”
Transporting -scales from another floor -nurses retrieving wheel chairs for patients -nurses transporting patients	False economies Understaffing	“He’s waiting for the elevator. Waiting was my sense of the wasted resource going on there.”
		“We had a scale, it’s broken. It’s sent out to be fixed four months ago so we still haven’t gotten it back yet so we have to share with our sister floor… so it’s a big waste of time going back and forth to borrow it.”
Excess processing -unnecessary e-mails -duplicate documentation	Regulations/policies Poor administrative coordination Inconsistencies in patient care practices	“Okay, we do a lot of, I think, unnecessary running here in the ICU, meaning every day we go down to the mailroom to pick up our mail. Every day, we do blood runs… .so ~ there's people being pulled away from their [nursing] jobs to walk to the other end of the hospital, and that just seems crazy to me.”
		“Another one of my long-term interests is the volume of email. This morning, I received my ninth, ninth, full notice of tomorrow’s grand rounds and workshop. Nine. None of them came from my division; they all came in from the Department of Medicine. I think that’s crazy. So, I received so many notices of that grand rounds that it started to irritate me to the point where I don't want to go.”
Materials
Excess utilization -unnecessary testing/procedures -infection control regulations -wasted masks/gowns etc.	Defensive medicine Reimbursement system Patient/referring MD expectations Medical education Lack of knowledge Lack of feedback Medical uncertainty Physician inertia Regulations/Policies Need to use new technology	“But the thing with task you hit one, the biophysical, and it leads you to ten other things under that one and then you have to into each system to hit all the things and document and there’s duplication because then you have Braden scale and then you have a pain scale. And all this is in the biophysical but it’s duplicate.”
Inventory -too much medication in single use bottles -too much food at meetings	Avoidance of missing supplies/hoarding Poor planning Variation in resource needs	“.. .you know, the sad thing is if we didn’t waste all this money [on unnecessary tests], we wouldn’t be in the dilemma we were in, in terms of health care cost. And this is not just the United States, this is - I mean, it's a problem all over, although we’re probably worse.”
		“We had a British guy come to our place a few years ago and we talked a little bit about utilization of resources and he said, “Just amazing in the States. You take the youngest, most inexperienced doctors and let them order the most expensive things ad lib.” It’s true.”
Energy -failure to conserve -lights -computers -air conditioning -idling ambulances	Separate Cost Centers/Silos Conservation not a priority	“So, this is really on us; this has to do with procedures that we do that in our hearts we know don’t need to be done, that are referred by other cardiologists and they want their patients earned because they think they need to be earned. So, I mean, you know, if it’s totally egregious,”“
Talent -staff overqualified for tasks assigned -failure to recruit high quality staff -frustration with working -conditions	False economies Poor management Poor hiring practices	The first one here is a picture of two vials [10 and 30 cc with]… So, this is an instance of where we could use ~ several patients could receive drugs from, you know, one vial [but waste a lot have to use a new vial with each patient] We could have a solution maybe. A pharmacist draws up each 30cc into four or three lOcc, or six 5cc, or some combination thereof and we can use it, because we use standard amounts for most procedures”
		“What’s happened is, as a result of not having an identified space that we could all see as a place to go and sit, is … every single person has their own refrigerator, and their own microwave, and their own toaster oven.”
		“I can’t imagine these are efficient air conditioners in any way, shape or form, and they said there’s nothing they can do about them. This whole building has them. And they break all the time, but they said they have to fix them, because they can’t replace them.”
		“with the process [of hiring have a tendency to take for granted our residents and not treat them as a customer… we don’t actively recruit them like we should. They’re applying to other places. And they -- they see the differences. And they feel insignificant when [another employer] is trying to hire them.”