Elements of Lean Surgery

In Bid for Better Care, Surgery With a Warranty – New York Times

This outstanding NY Times article isn’t about “Lean” per se (they don’t call it out by name), but you can definitely see elements of Lean Thinking abound. The article is about Geisinger Health System in Pennsylvania. The headline is about their push to offer a “warranty”on surgical work, where the hospital won’t charge you (or insurance) for follow up work after a procedure:

The group, Geisinger Health System, has overhauled its approach to surgery. And taking a cue from the makers of television sets, washing machines and consumer products, Geisinger essentially guarantees its workmanship, charging a flat fee that includes 90 days of follow-up treatment.

Even if a patient suffers complications or has to come back to the hospital, Geisinger promises not to send the insurer another bill.

This is an important experiment, because hospitals and physicians have traditionally been paid on a “piecework” basis — paid for the things they do as opposed to getting paid for the value or the outcomes that result. Dr. Atul Gawande points out, in his book Better: A Surgeon’s Notes on Performance, that this has been common medical payment practice going all the way back to Babylon and the 18th century B.C. The dysfunction here is that providers get paid for fixing their mistakes, in traditional (and current!) payment/insurance systems. They are not paid for “doing it right the first time,” which is a key Lean quality concept. Post continues after ad…


The article says:

Geisinger is trying to address what it views as a fundamental flaw in the typical medical reimbursement system.

Under the typical system, missing an antibiotic or giving poor instructions when a patient is released from the hospital results in a perverse reward: the chance to bill the patient again if more treatment is necessary. As a result, doctors and hospitals have little incentive to ensure they consistently provide the treatments that medical research has shown to produce the best results.

Nobody, myself included, is accusing doctors or hospitals of INTENTIONALLY padding their revenue by purposely letting mistakes happen. Let’s get real, that isn’t happening. Everyone is trying their hardest, let’s assume that as a given. The problem is that SYSTEM allows problems to happen (because we don’t have perfect processes or perfect error proofing). Remember the notion that a bad system will often defeat an excellent person (or people).

If hospitals and providers shared the cost burdens from “not doing it right the first time,” then they have more incentive to PREVENT errors through systemic means (not just telling everyone to be careful — that doesn’t work).

The system has been very successful in its first year of trials:

Since Geisinger began its experiment in February 2006, focusing on elective heart bypass surgery, it says patients have been less likely to return to intensive care, have spent fewer days in the hospital and are more likely to return directly to their own homes instead of a nursing home.

Geisinger presented the first-year results of its experimental program at a meeting last month of the American Surgical Association.

The Need for Standard Work:

One of the highlighted reasons for the variation in patient outcomes is the variation in the delivery of care. Here is where the article brings in manufacturing:

Around the world, other modern industries — whether car manufacturing or computer chip making — have long understood the importance of improving each piece of the production process to tamp down costs and improve overall quality.

This has long been considered true in the manufacturing world, as proven initially by Toyota, that improved quality and lower costs DO go together. It’s not a tradeoff where higher quality necessarily costs more. From a hospital standpoint, we’ll separate new technology from this discussion (which might be more expensive), but we’re focusing, instead, on processes — higher quality processes (with standardization and error proofing) should NOT cost more.

But hospitals have been slow to focus their attention on standardizing the way they deliver care, said Dr. Arnold Milstein, the medical director for the Pacific Business Group on Health, a California organization of large companies that provide medical benefits to their workers. Geisinger “is one of the few systems in the country that is just beginning to understand the lessons of global manufacturing,” Dr. Milstein said.

I’d correct Dr. Milstein and call this, instead, “lean manufacturing” instead of “global manufacturing,” since while is hardly practiced consistently throughout the world of manufacturing (although Lean IS a concept that works anywhere in the world).

In reassessing how they perform bypass surgery, Geisinger doctors identified 40 essential steps. Then they devised procedures to ensure the steps would always be followed, regardless of which surgeon or which one of its three hospitals was involved.

Here’s the key lesson — the standard wasn’t pushed on the doctors from the outside or from administration. The surgeons were asked to create their own best practices and standard work. That’s an important concept in ANY setting — the people doing the work need to be creating their own standard work if you want them to “buy in” to the concept.

How did they get the Docs on board?

For Geisinger, as with any hospital, the challenge is often in persuading the doctors to get on board. Before ProvenCare began, Geisinger’s seven cardiac surgeons each delivered the care they believed was best for patients. And that care varied.

“We realized there were seven ways to do something,” said Dr. Alfred S. Casale, the director of cardiothoracic surgery at Geisinger.

Seven different ways, but not necessarily seven equally good ways?

Reviewing the existing professional guidelines and medical literature, Geisinger’s cardiac surgeons came up with their list of 40 action items viewed as best practices — including giving a patient antibiotics within a specified time before surgery, and then giving beta blocker drugs afterward to reduce the chances of an irregular heartbeat.

The doctors nevertheless needed some persuading that ProvenCare would not be some form of inferior cookbook medicine, said Dr. Charles H. Benoit, a cardiac surgeon. “It’s not that we were a uniquely compliant group of personalities,” he said.

Here’s something about Standard Work that I’ve just begun to understand recently — Standard Work is a plan, not a script. Some improvisation (given a good valid reason) is OK. It’s not a script that can’t be deviated from no matter what. Now, if you’re deviating from the script ALL of the time, then you don’t really have a standard. But you have to leave some leeway for professionals to exercise their professional judgment:

Doctors can choose not to follow a particular measure, based on the needs of an individual patient. But they rarely do so. And they also know that any of the steps can be altered if new medical evidence emerges.

That’s Kaizen! The 40 steps of standard work are NOT carved in stone. An interesting challenge will be to see how the hospital and MD’s react when they have an update — are they able to create a NEW standard that is followed?

A key, final point, is that Geisinger is unique in that most of the MD’s are actually hospital employees, instead of being independent contractors:

Another Geisinger edge is that it directly employs the bulk of the doctors who practice at its hospitals. That is in contrast to most hospital systems, even the country’s biggest and best, where doctors typically act as independent contractors — making it harder for a hospital to coax them toward a uniform set of procedures, and often leaving it unclear who is responsible for follow-up care.

It would be harder for the hospital to offer this guarantee, and harder to try to enforce standard work, if everyone weren’t part of the same organization. It’s easier to have everyone’s objectives and incentives aligned where we’re all part of the same company.

For this reason, it might be difficult to adapt this model for other hospitals where the MD’s are NOT employees. Even so, this is a sign that Standard Work *can* work in medicine.


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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an eBook titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

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