Noted patient safety expert Dr. Lucian Leape spoke out recently about medical school culture being a root cause of poor quality (see my blog post “Is Medical Education a Systemic Root Cause of Poor Quality?“).
Now, he's criticizing Lean in the publication “Modern Healthcare,” as part of this article “Leape sees potential for change.” (free registration required)
It's not the core of the article, but it has me wondering if he's criticizing generally accepted Lean principles or what I call “L.A.M.E.” — Lean As Misguidedly Executed. L.A.M.E. includes stuff that people call “lean” but isn't a good representation of true Lean mindsets and practices.
Dr. Leape seems to be in a pretty negative mood — although he thinks the patient safety battle can be won, he says healthcare still has a long way to go:
Despite some successes, “I think it's safe to say the patient-safety movement also has been a great failure,” Leape said. “No one to my knowledge has implemented all 34 protocols from the National Quality Forum. Why not? Why isn't that priority No. 1 for all hospitals in America?”
That's a great question — why isn't safety and quality a top priority? The latest American College of Healthcare Executive survey of CEOs found that the percentage who said quality and safety were a “top concern” FELL from 43% to 32%. Keep in mind they are allowed to give MORE than one answer. The survey results:
So protocols aren't being implemented. Lean thinkers would say you should use proven protocols and standardized practices that improve patient care. And CEOs don't list quality/safety as a top concern. Lean thinkers would absolutely say that quality and safety are top concerns. They should be, especially in healthcare.
If you're a hospital CEO and it's really not a top concern, wouldn't it be smart to at least just SAY it is? How hard is that? A friend commented recently that it shows how far off the CEO's radar quality and safety can be. I guess they didn't get the Dr. Deming lesson that quality starts at the top (and with the board).
Now to Dr. Leape's comment on Lean
All that was quoted in the Modern Healthcare piece was this:
…while hospital executives have dithered around with concepts like Lean process improvement, which have “industrialized” the system without regard to care.
“Healthcare has become a production system,” he said. “We think more about nursing ratios than we do about nursing. … I don't think most of us think this is progress.”
Without regard to care? Where is Dr. Leape seeing Lean in practice? Is he speaking from experience or just about what he's heard (or supposes about Lean)?
Lean is all about patient care. Look at the examples like ThedaCare – they've reduced mortality and improved patient outcomes while reducing cost. I've been involved in Lean efforts where the goals (and results) are all about improving patient care — better lab turnaround times or freeing up nurse time for patient care comes to mind (like the NHS “Releasing Time to Care” program works toward).
I guess Dr. Leape hasn't visited or talked with the leaders at St. Elisabeth Hospital in The Netherlands who describe their Lean effort's goals as providing “loving care.“
Terms like “industrializing” and “production system” are pretty empty — what exactly does he mean?
As for nursing ratios – Lean thinkers wouldn't blindly apply benchmarked nursing ratios. We'd look at the process and patient demand/volume and determine the staffing levels and processes that provide the best patient care. So I'm not sure what he's referring to, maybe he was misquoted.
How much “L.A.M.E.” is out there?
So with all of the great examples of Lean improving patient care and creating a better work environment in healthcare, what is Dr. Leape talking about? Has he seen “fake lean” or Lean done badly?
Has he visited hospitals where Lean “experts” follow staff around with stopwatches without engaging the staff in process and quality improvement? Has he seen places that think Lean is only about efficiency, ignoring quality? Has he seen “lean” leaders who blame and punish people who make mistakes? Has he been around a hospital that only does week-long kaizen events with strict cost saving targets that don't try to manage differently? All of those things would be considered “L.A.M.E.” – not real Lean that focuses on quality and the equally important pillars of continuous improvement and “respect for people.”
There are many out there who see something bad done in the name of Lean and they then make blanket statements about Lean always being bad. I hope Dr. Leape isn't one of them. I really wish I could sit down and talk to him about this. Maybe I'll pursue a podcast with him. I can even walk over to the Harvard Medical School to do it. I really do want to know more of his thoughts, more than a sound bite.
His National Patient Safety Foundation has given awards to Virginia Mason and their Lean efforts. He can't think it's all bad or that Lean is something to avoid. I hope it's just “L.A.M.E.” that Dr. Leape is against. If so, then we're on the same page. We're probably on the same page that executives are “dithering around” and not addressing core issues quickly enough.
Back to the question of “L.A.M.E.” – how much of that and “fake lean” do you think is out there? I'm always on the lookout for it, because stuff like that (Lean done badly or with the wrong mindset) gives Lean a bad name and makes it more difficult for those who are doing things right. I'm fearful of a backlash against Lean because of scattered L.A.M.E.-ness. Is L.A.M.E. becoming more widespread? I've heard some reports of it, but hoped it was isolated cases… what do you think?
John Toussaint is also going to blog about this soon on his ThedaCare Center for Healthcare Value blog, as I know he disagrees with Dr. Leapes assessment of Lean, from his own experience at ThedaCare.
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