More Online Criticism of Lean Healthcare
In the new story about CEO David Wessner's retirement, one of the listed accomplishments is their use of Lean methods:
Wessner, the first non-physician CEO at Park Nicollet, also brought Japanese-style lean manufacturing techniques to health care, adopting productivity principles later adopted by a number of other health care organizations. He declined to quantify how much the strategy saved Park Nicollet, saying only it has reaped more than what was invested into it. “It's not a short-term initiative,” he said.
It could be that the retirement is tied to recent financial difficulties and layoffs, events that led to some criticism of Lean (as discussed on my blog here).
As often happens with these stories, the newspaper's reader comments section brings out some vitriol from people who might be staff members (or just from the community).
The link to view all comments is here. Part of me hates to give these comments a wider audience, but I think we can try to respond constructively as a Lean community both here and maybe on the newspaper website.
One comment reads:
The idiots who run PN think treating sick people is like making cars – thus the kaizen system – total quality management for medicine – has been implemented. PN has spent millions – to no effect – on this huge boondoggle. Thus PN has implemented a “production” model on doctors, treating patients like cars on an assembly line. Note to PN management: Treating patients is almost NOTHING like making cars. Do cars live and breath, have thoughts and consciousness? No? Then why treat patients like cars? Because the process of medical care has been turned over to MBA morons who don't understand that everything is not a “business.”
You're right, working with patients *is* very different than building cars. I'm sure everyone at PN realizes that. You have to look at what Lean is — it's not a system for “building cars”, it's a management and quality improvement system.
So people might say they don't want to be like Toyota. What's wrong with:
- Investigating the root causes of problems (looking for systems and processes instead of blaming individuals) and preventing those problems from occurring again?
- Making the workplace run more smoothly by eliminating waste, improving processes, and
- changing the physical layout of the space?
- Making sure that quality is improved (improvements that always lead to productivity improvements as well)
- Listening to employees and staff and getting them involved in the improvement process (instead of being told to “check their brains at the door.”)
When you rant and rave and say “this isn't about building cars”, that misses the point. The four bullet points above can and DO apply to a factory or a hospital.
When Lean is done properly, the hospital employees should be DEMANDING more Lean instead of calling people idiots. So I wonder what the root cause of this person calling PN management “idiots” is? Lack of education about Lean? Are the managers not really living and practicing Lean as a daily mindset? Are the employees not being involved? Or it's probably a side effect of the layoffs and the anxiety created there?
Another interesting reader comment defends Lean but still points a finger of accusation against Park Nicollet:
Kaizen is not an improvement process with limited application to the automobile industry. Those who make such comments only demonstrate their lack of knowledge on the matter and thus demonstrate they are incompetent to comment. PNC is guilty of misguided application of Lean principals and kaizen techniques. My team successfully applies both in the construction industry daily. I watch PNC “fumble the ball” daily in the dysfunction generated in my spouse's workplace.
I have no first hand working experience with Park Nicollet — in what way are their Lean efforts misguided, I wonder? Is it the focus on “how many pencils we have at the nursing station” as the previous blog post highlighted? Are they running a lot of “kaizen events” without the proper follow up and proper focus on the management system? If so, that's a common dysfunction in the Lean world, the over-reliance on event-driven Lean.
Another reader comment further explained and defended Lean (highlighting is mine).
The Kaizen efforts do NOT treat patient's like cars. The make the work that staff does more efficient so that more time can be spent treating the patient. Without Kaizen at Park Nicollet, nurses would still be WASTING several minutes per hour walking back and forth to poorly placed printers, float receptionists would still be fumbling to find basic paperwork every time they sit down at a new desk, business office staff would be spending/wasting many valuable minutes an hour on hold with insurance companies. Everyone always thinks that because Kaizen was developed by a car company that it can't be applied across the board. MANY MANY MANY companies use it.
The point about printers being in the wrong location rings true because I see it everywhere. One reader asked why you need a million-dollar consultant to figure that out? The answer to that is very complex — why do people not see systemic waste (maybe someone suboptimized IS/IT costs by having fewer printers)? Or, if they see the waste, why are people powerless to make changes? Or why do they feel powerless? That's the important question, ultimately — why is there waste and why are things not fixed, not “why are the printers set up badly?”
While I cringe at reading criticism of Lean online, it doesn't do anything to shake my belief (a belief that comes from experience and evidence) in Lean working in healthcare. Does that mean “Lean” always succceeds? Well, no, because people and organizations are imperfect. Changing to a Lean culture is very difficult. I hope these are just bumps in the road for Park Nicollet, a starting point for a better Lean program in the future.
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I worked briefly with some PN folk during a facotry tour. One thing I noticed was no focus on Engagement/Morale metrics.
Maybe this is what is driving some of the employee negative criticism. Ohno always said we remove waste to make the worker's job easier/less frustrating. When you just forcus on optimization and not think of the people doing the work, Lean will backfire on your organization. I am not sure if this was always the case at PN. Maybe the lack of engagement/morale was an isolated incident. The message is still a powerful reminder.
Great point, Brian. Employee engagement and morale should be at the core of any lean effort.
When lean is "being done to us" people (doctors or any other role) will cringe and rebel. If they haven't been taught what Lean is and if they haven't been involved, there will be resistance.
I'm not saying this is what happened at PN, but it's a common failure mode with Lean — not engaging everyone enough.
Mark,one thing we have learned on our lean journey is it is important to figure out what's in it for me.In other words what is in it for the doctors and nurses to change.Change is hard for everyone and if change management isn't part of the prescription it is difficult to get people engaged.We actually found it took two or more lean events before we found statistically significant changes in morale.That's when we shifted gears and started to work more at the front line on continuous improvement and more at the leadership level in understanding and implementing lean leadership processes.
Sometimes organizations must slow down to speed up.We definitely got too far in front of the staff and doctors and needed to do a lot of rework.
Not sure if any of this impacted PN but we know lean works in health care because we now have many examples.
I've got two thoughts on this story.
First to echo Brian's comment, we really started getting traction when we stopped trying to improve or optimize targeted metrics and started making changes with Ohno's question in mind: "Why don't we make the work easier so our people dont have to sweat." The metrics all improved, and everyone was engaged. Pretty cool!
Second, whenever I hear a story like this I look at a quotation I have hanging on the wall that lists "Failure modes in lean deployments" taken from an interview I heard with Pascal Dennis. The failure modes are 1)Overload, 2)Tools approach, 3)Dysfunctional mental models ("thou shalt" vs. "what do you think?") 4)Not understanding deeply enough (the four rules and capabilities, per Steve Spear) and 5)The "been there, done that" mentality. Numbers 1,2,3, and 5 are the common mistakes, and number 4 leads to the lifetime of work and study that is learning to follow in the footsteps of Ohno, Shingo, et al.
Which of these is at work in Park Nicollet? I couldn't say from here, but my guess is more than one!
fascinating and heartening.
I have just started reading "lean blogs'and am very taken with Bob Emilianio's emphasis on Leadership and "Respect for People" These seem closely related to Dee Hock's insistence on the primacy of agreeing "Purpose and Principles". It looks as tho' the PN people had the tools but not the rest.
Second, every systems thinker in the US health-care field should read Atul Gawande's New Yorker piece "THE COST CONUNDRUM"and contribute to the many debates it has aroused. From what i've seen the emphasis is on cost control. and no-one seems to be coming from t on system-change perspective. As a Brazil-based Brit I'm too much of a foreigner to get the nuances.
Thanks for the comments. Andrew, you'll be happy (if you haven't already noticed) that the Ohno quote is one of the quotes that randomly appears in the top banner of my blog.
Lean DOES make people's work easier. For example, what nurse wants to spend time searching for missing medications or dragging heavy bags of soiled linens down the hall? In a Lean environment, neither of those waste activities would occur (we'd have a good standardized process for med delivery and storage and we'd probably have a tech or orderly doing the linen carrying).
Eliminating this waste frees up time for better patient care, which is why the nurses are there?
What's not to like?
Plenty, if Lean isn't done in a way that asks "what's in it for me?" for anyone, be it an MD (as John Toussaint rightly pointed out) or a nurse or a tech (or the person working in the cafeteria).
Eliminating waste benefits all. That's what makes Lean so powerful compared to other methodologies that aren't win/win/win like well implemented lean.
Thanks, Mark for not being afraid to take on issues like this. The criticism of lean is a shame… but it's nothing to run from because we know we have experience and philosophy to stand upon.
I have considerable direct knowledge of the Park-Nicollet situation and can tell you that lean is not the problem that is roiling the organization and which has led to Wessner's recent forced "retirement".
The organization was formed more than ten years ago between Methodist Hospital and Park-Nicollet Clinic (a large multi-specialty group practice).
Methodist first adopted Deming-style continuous improvement four years prior to this merger while the clinic focussed on top-down clinical improvement and never really understood "the organization as a system". This culture clash has continued to this very day and most of the problems in the organization stem from it.
The hospital's merger with the clinic has driven away all non-clinic affilated physicians and its former profitability has been drained by propping up the money-losing clinic operation and building "temples" to its cancer and cardiac specialists.
It is a sad situation that is bound to get worse as the organization continues to lose volume and market-share.
With Wessner's departure, Park Nicollet will once again return to a physician-driven model that is bound to fail as it has already time and again.
I have worked for Park Nicollet for 15 years. I thought "LEAN" would be great because I am all for organizing, saving time and saving money. When I was reading about LEAN processes I noticed a big thing was to listen to employees who are actually doing the job they are "improving". We, the employess (below management level), were told we would be included. That was not true in any way. We were told what to do and our ideas or concerns were not listened to. Most of us have a high level of education, long time experience in a job or just plain common sense and what Management fails to realize is that we do have brains and do not appreciate being treating us like children or just plain idiots. They never followed LEAN as it was meant to be. They took thier little management titles and had loads of fun destroying a well respected company that people like to work for into just a "job" that we can't wait for the day to end.
TO the blogger who said Park Nicollet is a drain on Methodist. Park Nicollet was a great place to work and when the Merge took place we saw our pride and "Joy" in working for Park Nicollet slide. Not to mention our benefits. Working for a company that at least pretends to care about the employees is much better than working for a Company that basically says if you don't like it leave. I have heard a manager say that to 3 employees who were just stating concerns on different issues at different times. 2 have found other jobs. The "top" is where the improvement needs to be done. There is not much left at the "bottom" so finding anywhere to change anything would be very hard. TO bad they can't outsource patient care jobs because if they could they would. I bet they are sorry slavery has also been outlawed. O.K. maybe I have gone a bit to far but my view is that management and its many worthless levels is what is destroying the industry. I am all for ditching Methodist which just brought Park Nicollet down.
I think it is better to listen respectfully and very attentively to angry complaints coming out of Lean implementations. Perhaps we can learn something that will help us to prevent similar sounds from following our departures from organizations where we implement Lean. And consider the culture of the organization that consulted to PN and VM.