"Loving Lean" is Way Better Than "Lean and Mean"

Health Care: Loving Lean -- Seattle Business Monthly

It's so nice to see a Lean overview article, yet alone Lean healthcare, that doesn't use the "Lean and Mean" cliche in the headline. This is a story from Seattle that discusses Virginia Mason and Seattle Children's and their Lean experience.

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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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Trying to Reduce Hospital Overprocessing

A Novel Plan Helps Hospital Wean Itself Off Pricey Tests - WSJ.com

Kevin, over at Evolving Excellence, raised a similar issue about misaligned incentives and misleading metrics in healthcare (thanks for the mention, Kevin).

This article, linked above, from the WSJ, focused on Seattle's Virginia Mason hospital, a hospital that has done a lot of lean work via their "Virginia Mason Production System." This was sent to me by a few observant blog readers, so sorry for the delay in getting to it on the blog.

One problem in healthcare is the "waste of overprocessing" -- via unnecessary or wasteful tests. This shows up as wasteful MRI's (high cost) or in the practice of drawing a "rainbow" of tubes for each patient showing up at the ER (drawing multiple tubes that have different colored caps indicating different types of testing.... long story, but it's often wasteful, as many of the tubes don't get used or the test results end up being irrelevant). But, the hospital gets paid for doing the work (rather than for the results), so the "waste" is often a matter of conscience.

As an example of the screwed up incentives in healthcare:

"...the hospital revamped how it treated some expensive ailments, cutting down high-tech tests and high-end specialists.

But a troublesome pattern emerged: The more cost-effective it became, the bigger financial hit the medical center took. "Everyone gained but Virginia Mason," says its chief of medicine, Robert Mecklenburg."

Virginia Mason reduced excessive testing, which meant they got paid less, even if the outcome for the patient was the same (and the payer/employer saved money).

With each MRI that Aetna and the employers avoided at around $850, Virginia Mason lost about $450 in profit. The payment system of government-sponsored Medicare, which private health plans also use as a template, tends to reward the big capital expenses of buying high-tech machines such as MRIs. The more the machines are used, the bigger profit margin they pack. Meanwhile, reimbursement fees for doctors' visits have stagnated.

"The payment system is so toxic," says Francois de Brantes, a former health-care program director at General Electric Co. "Unless you tackle it, any health-care reform doesn't have much chance." Mr. de Brantes coordinates a program funded by employers that pays doctors bonuses based on patients' outcomes.

Lots of interesting examples of systemic waste and misaligned incentives in the article... at least the WSJ gives them (and Toyota) credit for their lean improvements:

Virginia Mason routinely receives top marks for quality and patient safety in local and national report cards rating hospitals. The medical center has pursued efficiency by adopting some assembly-line methods of Toyota Motor Corp. and Hitachi Ltd., which hospital officials and doctors observed on a visit to Japan in 2002. For instance, Virginia Mason rerouted patient traffic in its cancer center, cutting the time patients had to wait for chemotherapy from four hours to 90 minutes.

At least Virginia Mason is being a leader and is trying to do the right thing. Rather than making excuses, they are trying to change the system for the better. Did you hear that, General Motors?

Lean Isn't Just About Cost -- Healthcare

Kaizen and Lean Manufacturing thoughts | Gemba Panta Rei

Thanks to the Gemba blog. The article he linked to talks about the need to cut costs in healthcare and mentions the Virginia Mason Hospital with its Virginia Mason Production System (as I wrote about this week).

Cost is just one metric. It gets a lot of focus because, well, that's how the business world, media, and society tend to look at things I guess. Lean healthcare is about 1) patients and 2) employees. For patients, safety, quality, time, and cost are important -- wait, that sounds just like the classic manufacturing SQDC metrics. Safety and quality go together - which is good for patients AND it decreases cost.

As long as "reducing cost" doesn't mean cutting heads, slashing budgets, or the other things that manufacturing companies typically do, it's OK to want cost reduction. You just don't focus on cost reduction. If you focus on safety, quality, time -- AND employee satisfaction, then cost drops.

Focusing on cost is putting the cart before the horse. This is true in manufacturing, healthcare, or any business.

Jon Miller wrote, on his blog, that the real goal of healthcare is prevention. That's a whole other level of complexity, sort of like Toyota's goal of a pollution free car (yes, that is a stated goal of theirs). In the short-term, build the "polluting" cars as efficiently as you can, while also focusing on research in the long-term. In the short-term, we need to use lean and TPS to fix the processes we currently have ("disease care"), while also looking for ways of reducing waste, such as through better preventive medicine.

Virginia Mason Production System

Oregon Health Forum - Events

Thanks to Andrea for this. Who is Virginia Mason and why does she have a production system? No, it's a hospital, one of the leaders in the lean healthcare world.

Here is a link to a presentation (pdf file)

"Seeking Perfection in Healthcare: Applying the Toyota Production System to Medicine"

by Sarah Patterson, Executive Vice President/Hospital Administrator, Virginia Mason Medical Center.

There are many great examples of how lean applies for patient safety and patient care, how it drives employee involvement, etc. Reducing the time between cancer diagnosis and the start of treatment is a powerful accomplishment. Great stuff, I'm glad they share this. It's an inspiration for all of us working in healthcare to spread lean.

Look on slide 26, showing the "after" view of 5S -- there is cart clearly out of place. I assume that's their point, to show how the visual controls make it obvious that there is a problem to be fixed.

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