Dr. Berwick and Lean in Business Week


Donald Berwick: Curing the Healthcare System – BusinessWeek

Good exposure for the applicability and use of Lean concepts in healthcare in BusinessWeek. Dr. Berwick is the head of the Institute for Healthcare Improvement (based in Cambridge, coincidentally, like the Lean Enterprise Institute – Dr. Berwick and Jim Womack are friends).

Dr. Berwick talks about studying Toyota and other areas outside of healthcare:

“Other industries had long ago started managing for continual improvement in products, services, cost structures,” says Dr. Berwick, who toured Bell Labs, NASA, and Toyota (TM) in the late '80s to see how those organizations approached quality control. “I soon realized that there was a need for this knowledge on a national level.”

The lack of “continual improvement” in healthcare leads, sadly, to infections, complications, and deaths for patients along with frustrated staff and medical providers. Lean is one avenue that many hospitals are using to help create a culture of continuous improvement. Ultimately, that culture is more important than whatever Lean tools you use.

Dr. Berwick uses an example of systemic waste across a hospital “value stream” of patients who are admitted via the emergency department:

Consider the problem of how to move patients through a hospital efficiently, from patient admission to the emergency room through surgery and recovery to discharge. ERs in the U.S. are typically operating beyond their capacity, and hospitals often respond by expanding the ER to accommodate more patients. But this worsens the problem by bringing more patients into the system (who will ultimately need more operating rooms or in-patient beds) and adds to hospital costs because more patients end up “parked” in expensive ER beds as they wait to be transferred.

Adding more ER beds does nothing to improve the flow of the value stream. Instead of improving a single department, you have to look across the entire process and Lean teaches us to do that.

To solve the problem, IHI studied how hotels manage patient flow and found that the answer lay in eliminating unnecessary fluctuations in demand. For instance, hospitals might not be able to control when patients show up, but they can identify and schedule patients to be discharged, just as hotels have a check-out time.

Leveling out the times when patients are discharged can have great benefits to patients and staff. Instead of trying to discharge everyone in a short afternoon window — something that creates a lump of work for support departments like housekeeping and patient transporters — spread the work out over the day. But this requires process and planning.

I think the hotel analogy is a poor one. Sure hotels have check-out times, but that's a “last” time. Hotel guests help level load the process because they CHOOSE when to leave. I'd assume, especially at business traveler hotels), people aren't being forced out at check-out time en massse. Hospital patients don't normally get to choose their discharge time.

Airports, though, are a better analogy. I've actually heard this analogy used in the IHI training, so I think it just didn't get communicated effectively to the BusinessWeek reporter. Airports have a fixed capacity in terms of runways and services. There are a certain number of takeoff and landing slots each hour that are allocated to airlines. Not every airline can have every plane depart at 5 PM. The workload is spread out for the benefit of all (except maybe for the inconvenience of those who cannot get a 5 PM flight — or have to overpay).

Thanks to these insights, published in IHI's 2003 report “Optimizing Flow,” Kaiser Permanente doctors now do rounds at 11:30 a.m. to identify patients who can go home the next day and start the discharge process. This helps the staff prioritize patient visits in the morning, and helps housekeeping know when a room will be ready to turn over.

That's a nice example of pro-active discharge planning and, again, sounds nothing like a hotel (except a hotel has a planned check-out date).

There's also a good example of error-proofing and visual management that impacts patient safety:

For instance, patients on a ventilator are susceptible to an often-deadly pneumonia. Every case adds an estimated $40,000 to the cost of a typical hospital stay. One of the four IHI-recommended approaches to preventing the infection is to ensure that a patient's head is elevated at least 30 degrees. To prevent the head from falling below that, IHI suggested drawing a line on the wall beneath which the bed shouldn't drop and instructing nurses, housekeepers, family members, and anyone else to alert the nurse if the line became visible. It's simple but effective, and it's the same story for the other 11 goals.

In addition to the article text, there's an online video, which you can see on the BusinessWeek site.

In the the video, Dr. Berwick talks, among other things, about the critical idea that quality AND cost can improve at the same time. Starting about 2 minutes in, he reemphasizes his point that up to 50% of our healthcare costs are driven by “waste” (in a classic Lean sense — activity that provides no value to patients). Reducing infections and reducing waiting times are examples of where quality and cost go hand in hand. He also emphasizes that nurses in med/surg units waste 60 to 70% of their time doing tasks that they shouldn't be doing.

I'd point out, also, that Lean is one method for actually meeting this goal, improving processes and the way work is done so that things are done right the first time. That leads to better quality and better cost. It's not a matter of just setting targets and collecting data — we have to improve the actual process with the people who do the work.

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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. Mark,
    Curious that you should choose airports as your example, considering how much trouble they have level loading in this way.
    The hub and spoke system, colossal example of batch-and-queue waste if there ever was one, means airlines are trying to bring in and ship out thousands of passengers and planes during a relatively short period. Think about every lay-over you’ve had that’s less than 90-minutes and greater than 45-minutes, no matter the origin and destination?
    Airports that are truly crowded, like Heathrow are experimenting with off-hour pricing to incentivize use of take-off and landing slots at non-peak times, but the airlines are fighting it since it doesn’t meet their existing business model.
    In my view, somebody could make a killing flying passengers direct and getting deals on non-peak runway slots.

  2. Great point, Andy. Airports aren’t nearly as level loaded as they COULD be, but they are waaaaay more level loaded than the typical hopsital’s discharge process!


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