Article about Lean in Canadian Cataract Surgery and More


    A clear vision for better health care – The Globe and Mail

    This is an article about Lean improvements in the British Columbia health system, where the physicians have been taught to:

    Identify and purge waste, and stop doing things that don't add value.

    Pretty basic formula, but powerful in application. It's great to see the clinicians so heavily involved.

    But I cringe at this somewhat stereotyped portrayal of the Lean coaches:

    Using management techniques pioneered by the Toyota Motor Company, “quality improvement” experts with stopwatches have teamed up with doctors and nurses to analyze every step in a patient's journey through the eye clinic at Royal Jubilee Hospital in Victoria.

    Ah, experts. Beware of experts. It's not the experts in Lean who are going to improve things. The “Lean Experts” can teach the methods to the process experts (the nurses and doctors) and they are the ones who implement sustainable change. I hate the stereotype of the stopwatch and clipboard-toting Industrial Engineer or Lean person… it's imposing and not necessarily friendly in appearance. It's probably more the attitude that counts than the tools being used by the person. And why did the reporter put “quality improvement” in quotes? Are they skeptical? To my dear reader, Kathleen, are those just an example of what you call “scare quotes?”

    The article highlights a great way of getting physicians on board — focusing on the patients, quality, and safety.

    Dr. Hamza Khan, who conducted Mrs. Taggart's surgery, didn't buy into the new “lean” methods, also called the Toyota Production System, just to help management control costs. He's embraced the new techniques because they lessen patient anxiety and reduce the risk of errors and infections.

    “Through this stream-lining process, we need to take more time to improve the safety for the patient. When you start with that, it's much easier to get front-line support.”

    Lower costs, better outcomes: What's not to like?

    Rather than leading with cost as a goal, which might bring resistance, leading with quality and safety is great because you can make improvements there and cost will follow.

    That's the goal our politicians are talking about: better quality AND lower cost. But Lean gives us a method, not just hope.

    I've quoted a bunch already, so please take a look at the article link up top. The article mentions improvements in:

    • Cataract surgery patient flow
    • Emergency Department flow
    • Improvements in the nurse's station design

    One other improvement I'll highlight is an example of eliminating the waste of “overprocessing” as we'd call it in the Lean approach. The hospital started using light sedation instead of general anesthesia. This wasn't just cost cutting, but a reaction to the discovery that the G.A. wasn't medically necessary. This is better for the patient AND it reduces cost. Perfect example of what sounds like a truly Lean improvement.

    As with many articles of this sort, the reader comments are always interesting and a mixed bag. The reflexive reaction amongst people to think that better efficiency = WORSE quality is the conventional wisdom and it's wrong with Lean.

    One commenter said:

    Dr Sutton tried this with his assembly line laser surgery. Many patients suffered as a result.

    My husband was one of his victims just prior in his cataract surgery practice. both eyes with continuous problems and even one lens put in crooked.

    Do some cuts in the fat cat bureaucrasy but stay our of the operating room and sanitation.

    That person obviously had a bad experience… but that shouldn't be used as an indictment against Lean in general.

    Glad to see the progress in Canada!

    p.s. You can also find a link to this article and others about healthcare at the LEI Knowledge Center.

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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. The goals of the Toyota Production System are "Highest Quality, Shortest Lead Time, Lowest Cost" — in that order.

      The rationale is that Built-In Quality enables Lead Time reduction, and this combination of Quality + Speed allows for the lowest cost.

      Also, the innovation of Jidoka predates JIT by more than 50 years, so the emphasis in Lean should always be on Quality First, and only then focus on Continuous Flow, Pull Systems, etc..

      Safety is a precondition for Quality. Quality is a precondition for efficiency (i.e., high productivity, lowest cost, etc.).


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