It is a scorned yet unavoidable feature of human enterprise, an impediment to productivity that quality-driven industries target scientifically and zealously for removal.  Muda: a Japanese term for waste.  Coined by revered quality improvement pioneer, the late Toyota production engineer, Taiichi Ohno, muda refers to any activity that adds cost but no value to a process.  It is uselessness.  Futility.  Or worse, in some translations:  “stupid-nothing.” 

In the health care arena, not a patient among us — or nurse, receptionist, surgeon, physical therapist, attendant or executive — is immune from muda.  It is so pervasive and deeply rooted in the machinery of care delivery that we expect it, become skilled at accommodating it, dutifully suffering the consequences.  Organizational scientists have defined five categories of muda, and there are plenty examples of each within the health care system:

• Delay: idle time spent waiting for something, such as utilization reviews, insurer payments, test results, patient bed assignments, OR prep, medical appointments.
• Re-work: performing the same task a second time, such as re-testing, re-scheduling, re-filing of lost claim forms, re-writing of patient demographic data, multiple bed moves.
• Overproduction: manufacturing of products or information that is not needed, such as precautionary “defensive” medical tests, surplus medications, excessive levels of paperwork.
• Movement: unnecessary transport of people, products or information, such as requiring patients to see a primary care provider before seeing a specialist who is clearly needed.
• Defects: design of goods that do not meet customer needs, such as medication errors, wrong side surgery, poor clinical outcomes.

Don Berwick, MD, MPP, IHI’s President and CEO, acknowledges that the scope of muda in our health care system is unknown.  His own theory is that 30-40 percent of the total “cost of production” — or half a trillion dollars — is waste: wasted supplies, wasted space, wasted time, wasted (never opened, never used) medical records, and so forth.  The problem is hidden, untracked and unexamined.  In part, Dr. Berwick says, this is because waste is a politically sensitive topic.  “The policy agenda,” he explains, “is not about finding resources within an institution; it’s about convincing insurers to pay us more; convincing Congress to increase Medicare funding, so there is very little self-interest at the organizational level for public disclosure or discussion about waste.”

Dr. Berwick believes this situation must change, that the search for waste is vital.  “We have to find an honest, accurate and aggressive strategy to find muda,” he says, “We have to be willing to look at ingrained habits, rules and beliefs about our systems and processes.”  And the assessment should focus on the front-line, Berwick says: “We need a culture in which staff know that they can report on the waste they see, call it by name, without breaking the rules.” 

The seriousness of the problem lies in the cost.  The consequences of muda go beyond daily frustrations of clinicians and patients; waste eats up vast amounts of resources, and squandered funds are a luxury our health care system cannot support. 

John Wennberg, MD, MPH, a Dartmouth Medical School expert in geographic variation in health care delivery, has uncovered substantial evidence of waste based on overuse — unwanted, unneeded health care.  In one analysis, for example, he found that, despite a lack of discernable improvements in health in the higher-spending locations, 70 percent of the children who grew in Stowe, Vermont, had tonsillectomies by age 15, but only 10 percent of the children from Waterbury did.  Similarly, some 50 percent of men in Portland, Maine, had prostate surgery by age 85, compared to about 10 percent of the men in Bangor.  And twice as many people had heart surgery in Des Moines, Iowa, as in Iowa City. 

In a 2002 study, Dr. Wennberg found that Medicare spending per recipient in Miami costs twice as much as in Minneapolis, with no corresponding improvements in life expectancy or outcomes. 

Such illogical, unsupportable excess of care in certain regions — unnecessary visits to specialists, tests, surgeries, hospitalizations — represent waste at far too high a cost to society.  It may be painful to examine these patterns, but it is essential.  As Dr. Berwick puts it, health care administrators and practitioners have to find a way to “put on muda glasses” as their counterparts do instinctively in automobile manufacturing or aerospace.  If we have the collective courage to address our rampant muda, we can begin to eliminate it, and move closer to the lean health care delivery system we would all be proud to represent.