Lean or ‘L.A.M.E.’ in a Hospital?

To build a better hospital, Virginia Mason takes lessons from Toyota plants

A number of you emailed me about the above article that was featured in the Seattle Post-Intelligencer about Virginia Mason Medical Center, a hospital that’s seen as one of the leaders in the Lean healthcare movement. If you read this article (via Rona Consulting), you can see the very positive improvements that have been made in terms of patient outcomes and quality of care (I’ll post more about that article in a future post.

The newspaper story is a fairly typical “Lean case study” article that you see in the news about the benefits from Lean methods.

“They began looking for a better way to improve quality, safety and patient satisfaction. After two years of searching, they discovered the Toyota Production system, also known as lean manufacturing. Developed in part by Japanese businessman Taiichi Ohno, the idea is to eliminate waste and defects in production. Virginia Mason has tailored the Japanese model to fit health care.”

That’s great, focusing on the benefits and the problems being solved. The point isn’t to “implement Lean” but rather to improve the system for patients, providers, and payers.

The article talks about the lean tools that Virginia Mason has used — identifying waste, kanban systems for replenishing supplies, standardized work, visual management, and a line stoppage system to immediately highlight and correct safety or quality problems.

But, again, beyond tools, it’s the benefits that matter:

Virginia Mason said overall benefits include an 85 percent reduction in how long patients wait to get lab results back, and lowering inventory costs by $1 million. They’ve redesigned facilities to make patient and staff work flow more productive. The hospital reduced overtime and temporary labor expenses by $500,000 in one year and increased productivity by 93 percent. While direct cost savings aren’t passed on to patients with the new system, less waiting, increased safety and more efficient care are.

That’s good stuff.

The real fireworks came, though, in the Comments Page for the article.

You always have to take anonymous internet comments with a grain of salt, but it’s interesting to see what comes up.

The first comment raises a good question:

I don’t see any of the regular hospital staff quoted in this article (RNs, CNAs, etc.). What do they think of these cost saving measures? Do they feel more productive? Do they feel like robots? What do the patients think?

It would be great to see quotes from staff and patients. If lean is being done properly, they will benefit from the improvements. If lean is done properly, the front line staff are being engaged in the improvements through their suggestions and ideas. I’ve heard a hospital employee say “I feel like a robot,” but that was BEFORE Lean. The employee (in a lab) was never asked by managers about improving the process. It was just “show up and do your job.” In Lean implementations (including those I’ve worked on), employees always comment about how they enjoy finally being involved in improvement and how they enjoy being listened to. So, I’d argue that lean should make people feel LESS like a “robot.”

Then, the comments start shifting into wild accusations and potential hyperbole.

Yeah….I left Virginia Mason because of this system. It has completely ruined morale among workers.

I tend to doubt complete blanket statements like this. There are always going to be some people who are upset with even the best lean implementations. Or, people could have legitimate complaints if lean efforts are approaching “L.A.M.E.” territory (“Lean As Misguidely Executed”).

The first complainer brings up a legitimate beef:

I was in the accounting office, but when they implemented this system I literally had a guy with a stopwatch standing over me for two days timing my every move, looking for ways I could accomplish more in less time. I can’t tell you how demeaning that felt.

That description could be more L.A.M.E. than lean. If an “expert” is standing over you and watching, without getting your input, partnership, and participation, that would certainly be very demeaning. That’s not how I would do time study or process observation like that. You have to involve people and you have to focus not just on “doing more” but also on quality and other factors — making sure you’re meeting customer needs, not just working quickly.

But, then the comment takes an uglier turn:

There’s also such a thing as being too lean. This system has actually caused problems at Virginia Mason, most notably the death of an elderly female patient because they had gone so lean that a certain chemical wasn’t properly labeled and she was injected with it.

I don’t doubt that a patient would be injected with the wrong medication or chemical – it’s a likely medical error that happens far too often. I’ve seen, in “pre-Lean” hospitals, unlabeled syringes and medications — circumstances that violate hospital policies and best practices. So, to blame “lean” for that error is hopefully misguided blame. I can’t think of a responsible lean project that would say “let’s save money by NOT labeling chemicals or meds.” That just wouldn’t happen, not in a truly Lean environment. For one, you wouldn’t cut corners like that. Secondly, there would be proper oversight and auditing of the “standardized work” that says everything must be labeled properly.

There are many more comments that I’d like to comment on… but let me address those in future posts.

What do you think is behind these comments? Real problems in how Lean is being down there or some sort of backlash driven by other factors?

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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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4 Comments on "Lean or ‘L.A.M.E.’ in a Hospital?"

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  1. Mark Graban says:

    One other thing I meant to say about stopwatching… most of the waste I’ve seen in hospital processes (care-giving or administrative) has more to do with:

    1) poor handoffs between roles or departments
    2) batching
    3) poor value stream design

    These are types of “gross waste” that don’t require stopwatches. At least early on, the use of a stopwatch to micromanage the specifics of “finding a faster way” to do something seems like overkill or it’s possibly misguided (looking at a specific tree, not the forest).

    Maybe VMMC is far enough along that they starting looking for waste at that level… I’m not there first hand, so I can only speculate.

    I’d just hate for other hospitals to think that’s a necessary starting point, hounding people with a stopwatch.

  2. Jason Yip says:

    Given the tone of the comments, it smells like the core problem is not engaging the people doing the work, even before looking at gross wastes and such.

  3. Mark Graban says:

    This was also covered on the “Pass the Buck” blog.

    LINK

    I agree with Brian’s comments. You can’t just write off people as “not buying into Lean.” It’s a leader’s job to sell Lean, sell the need for change, and to help alleviate anxiety that comes with change.

    That said, he’s right, some people are always going to be unhappy with changes.

  4. Anonymous says:

    Obviously the focus should be on managing the process not the person. Often for complex variable demand processes a stop-watch is a good proxy measurement tool to evaluate process compliance. If a process takes longer than expected then what went wrong?

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