The Need for Lean at BIDMC


I read Paul Levy's blog every chance I get. He is the CEO of Beth Israel Deaconess Medical Center in Boston. Although fellow blogger Kevin Meyer and I caused a bit of a kerfuffle with him, unfortunately, earlier this year (link here), I hope we have all moved beyond that. I respect his efforts to drive improvement at a hospital (with Lean and other methods) and I respect his openness with the public on quality data and his thoughts on Running a Hospital.

In two recent posts, he gives some great, very real insight into the types of problems that hospitals face today. This is my attempt to empathize, not criticize. These are all very widespread issues that most hospitals face (except for the skyrocketing Boston salaries, but that's a problem to some extent in smaller towns with competitive hospitals).

First is an outstanding post where he shared a letter he wrote to BIDMC employees. He started the letter (bold emphasis is mine):

What's the most important activity at our hospital? Providing patient-centered care?


But what do we spend most of our time doing? Patient care??

Wrong. It is fetching. As in spending time trying to find a piece of equipment, a certain paper form, or some other supply. Or it's re-doing work. As in writing the same piece of information in 3 different places.

Admit it. If you are a nurse on the floor or the OR or the PACU, a respiratory therapist in the ICU, a person cleaning surgical instruments in CPD, or a practice assistant in a clinic, think of how much time you spend fetching instead of actually taking care of a patient or doing the job you've been hired to do to support patient care – whether that's running lab tests, preparing food in our kitchen, or repairing a broken piece of equipment. How much of your day is spent in these ways versus face-to-face time with patients or in doing something tied directly to patient care and the support of that care? If you are a typical person here, it is way over 50% and more like 80%.

But I don't have to tell you that, do I?

Paul is pointing out what we would all recognize as “waste” in the Lean terminology. Employees are interrupted and distracted away from their true “value adding” work — caring for patients or supporting those who do directly care for them. The problems are by no means unique to BIDMC. Every hospital I've seen has these same problems, even if they are already working on Lean. The good news is that Lean methods help reduce exactly the waste that Paul describes, but you can't fix everything everywhere all at once. I hope they are making progress with their Lean efforts.

He continues to nail it right on the head:

Every day, thousands of you undertake “work-arounds” to solve the problems you face in delivering care. And you do solve those problems — by dint of personal commitment, hard work, and good will. As a result, our patients get extraordinary care.

But, because we all invent work-arounds, we often don't solve the underlying work process problems that pervade every aspect of what we do. And you go home feeling really tired and
wondering how you really spent your day.

Intermission for a shameless plug — these are exactly the concepts I'm writing about in my upcoming book on Lean Hospitals (not finished yet and not out until mid 2008).

Paul then starts writing about solutions… I wish he had mentioned Lean. I know nothing about the consulting approach he writes about, but an employee centered approach, making sure they feel pride in their work and appreciated sounds all right to me. But Lean will help too. I know I tend to be a bit of a one trick pony, but there's room for other complementary approaches.

So the hospital is full of waste and rework in their processes. Employees feel overworked and under appreciated. What does Paul describe in his next post? How they're hiring like crazy and how labor costs are skyrocketing.

In his theme of openness, Paul shares their staffing levels over the past few years:

Here is a summary of the average FTEs (full-time equivalents) on staff year by year.

FY2002 — 4,562
FY2003 — 4,694
FY2004 — 5,013
FY2005 — 5,353
FY2006 — 5,635
FY2007 — 5,792

For fiscal year 2008, we are budgeting another increase, this one in the range of 10%. Part of this is due to further expansion of staff — almost 450 new positions. Most of these are related to increased patient activity on our floors, clinics, and in the ORs. A significant number, too, are being added to enhance customer service and to meet safety and regulatory requirements.

Imagine the opportunity that comes from reducing waste with Lean. Some freed up time from existing employees would go toward more value adding time, so, for example, a Lean hospital might not change patient/staffing ratios. But patients and employees would be happier all around. It's hard to get your nurse to respond quickly when he or she is down the hall rummaging for supplies.

(On a somewhat parenthetical note, Lean factories do a much better job of using material handlers to keep assembly line workers productive and focused on value added work. Seems like this is a concept that hospitals would be anxious to adopt. I've seen basically that approach work very well in a hospital lab, eliminating the need for value adding Med Techs to walk and get their own supplies — that's material handling, not what they went to school for).

But, in other jobs, especially in support or ancillary areas, eliminating waste and Non Value Added time means that employees can do MORE value added work (more lab tests, more medications, more sterilized instruments). That's the kind of productivity improvement that helps you increase volume without increasing headcount.

I wonder what productivity increases the hospital is seeing through their existing Lean efforts? I wonder what industry wide productivity increases would do for the serious shortages of key technical staff, including nurses, medical technologists, and pharmacists?

Keep at it everyone. Good luck with your Lean efforts.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Thanks for the posting, Mark. There are many paths to improvement, and the first step is to recognize the problems. It appears to me that BIDMC has done just that, and I wish them much success in their efforts.

  2. It’s great to see a leader send such a personal letter to their people, and to take personal responsibility at the highest level.

    My only concern, if I were an employee reading this, would be something like “of course there’s tons of waste…so what are we going to do about it and how?”.

    They might glean something from the fact that a consultant has been hired, but I doubt most employees think that would help. More suits running around and all…

    My preferred angle is to cultivate a grass roots approach, with a clear message of the strongest support (time for team-based learn-by-doing, a reasonable budget, hands-on involvement, etc) from the top. A consultant providing advice as a teacher is fine. But the only way (IMHO) for a transformation like this to be successful is to have it driven by the people for the people. It needs to be the people’s transformation, not the consultant’s transformation.

    There are indications along these lines in the letter, but my advice would be to push the grass roots approach much harder, and treat the consultants as the experienced teachers (if they are…sometimes that’s not the case and the people end up training the consultant, which is waste from the patients perspective).

    I certainly wish them well, and commend them on being a leader in waste reduction in healthcare. Hopefully their model can be ported to other hospitals, and we can start widdling away on the national healthcare crisis.


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