These Primary Care Improvements Don’t Sound “Mean” to Me


Here's yet another article with the lazy “Lean and Mean” cliche' in the headline: “Make Your Physician Practice a Lean, Mean Healing Machine.” Real Lean isn't mean toward patients or staff or physicians. It's a shame the headline had to “go there” since it's a good read otherwise.

The article highlights their improvements in productivity and reduced patient waiting times through the use of Lean work analysis methods and value stream mapping. It also highlights how people left their titles at the door, figuring out their own process improvements.

The article states that, as readers of this blog know, an increasing number of healthcare providers are embracing Lean:

In the past few years, larger hospitals and health systems have bought into the process, and now a growing number of physician practices have embraced Lean, including Kalamazoo, MI-based Borgess Ambulatory Care (BAC).

“It is an intense effort, and it works,” says Ed Millermaier, MD, MBA, chief medical officer and COO at BAC. “Breaking down processes into individual steps is daunting work. We're learning that we need to focus on pieces of the process so we can measure improvement and track ourselves. This is a long-term process; there are no quick wins.”

That's dead on correct from Dr. Millermaier.

The University of Michigan Health System (a member of the Healthcare Value Leaders Network) and Blue Cross Blue Shield of Michigan provided help.

Again, from Dr. Millermaier:

“It is very difficult to truly embrace the principles of Lean without help. I don't think you need a major institution, but you may need some outside consultation or education assistance,” Millermaier says. “One could argue that, for the small physician practices, doing this on your own could be more challenging.”

You probably know my bias from my consulting experience, but outside help really helps. The Lean Enterprise Institute doesn't do consulting, but we're far from anti-consultant. For a small independent physician practice, you'd likely have to go the route of Sami Bahri, DDS, the “world's first lean dentist” — you likely won't be able to afford a consultant (or you'll choose not to), so you'll have to read books and experiment on your own… as Dr. Bahri did.

It's not impossible to go it alone. You could argue that Dr. Bahri has made more progress (and more sustainable progress) by going it alone, even if it took longer than if he had a consultant helping guide him. The risk with bad consultants is that they encourage copying others instead of learning from others and then figuring it out yourself.

What were their results?

At the end of the initial review, the wait time for pediatric well visits was reduced from 60 days to eight days, and mammography patients saw their wait times for follow-up testing after initial screening drop from 19 days to three days. The practices also created efficiencies in medical records filing, storage, and response time.

The article also details how U of M helps select primary care offices to receive free assistance — making sure there's deep organizational leadership support to make it happen and that there's somebody appointed to be trained as the internal Lean coach to keep the process going.

…BCBS Michigan has spent about $2 million funding physician Lean programs in the past two years.

It's great to see that level of partnership and cooperation across what we'd call the “extended value stream.”

The measures focus on productivity and access, but what about quality?

“We get improved quality of care for our members, reduced readmissions,” [Tom Leyden, manager of clinical program development at BCBS Michigan] says. “The better the physician organizations use their disease registries, the better care is delivered. Hopefully that results in less [emergency room] visits, in less patient stays, and things of that nature.”

BCBS isn't being charitable – this funding and cooperation leads to improvements for all: the primary care offices, the patients, the hospital, and the insurer. What's the least bit “mean” about that?? It would be great to see more of this across the country and beyond.

Dr. Millermaier also highlights the impact that those from outside of manufacturing can have in a medical setting:

“The principles of Lean can apply,” he says. “None of the Lean consultants had a healthcare background when they started with us. They brought to us a perspective around business operations that is challenging for us in medicine, particularly for physician leaders. It is not an area that we are strongly trained in.”

“Once you get past the notion of the widget manufacturers coming in to commoditize healthcare, it teaches us how to be more effective and efficient in what we are doing,” Millermaier adds. “And it aligns very much with the Institute for Healthcare Improvement's Triple Aim when you look at optimizing the patient experience, improving the population's health, and keeping costs per capita under control.”

Lean healthcare is all about using Lean principles to allow medical providers and organizations to provide better healthcare in a more welcoming and caring setting. It's not about trying to “turn the hospital into a factory,” although the lessons from a factory can make a hospital more of a caring place. I'm glad this excellent article recognized that.

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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. “making your practice a lean mean….”

    Before I left the UK a couple of my friends that I worked with as a consultant implementing lean manufacturing entered into the National Health Service (NHS) to help them implement lean ideas.

    They have now been there for almost 3 years and are enjoying their time as there is so much for them to do…

    Initialy their “bosses” were reluctant to let them loose within the hospitals themselves keeping them busy with improving suppliers designing and providing medical equipment, with their manufacturing background and years of lean experience they made some major improvements..

    However in the last year and a half they have finaly been let loose in the actual hospitals and have managed to get similar results to those reported in the article you quote above, in addition they have had success in increasing the number of operations that some surgeons are conducting and so on..

    The biggest problem in the UK is the lack of competiton, most of the people they work with lack the motivation to improve, there is no where else for the patient to go apart from to pay privately so they don’t care if the service is inefficient… they get paid the same no matter what happens!

    Changes are happening but it is frustrating to see the rate at which the changes happen..

    Have a look at my own blog and leave some comments to point me in the right direction….

    how to implement lean manufacturing
    .-= Tony ´s last blog ..Going to the Gemba =-.

  2. Thanks for the comment, Tony. To your comment:

    “most of the people they work with lack the motivation to improve,”

    Why is that? Most people who going into healthcare are HIGHLY motivated to provide better patient care. Maybe people have just gotten beaten down by bureaucracy over time? I’d hope that Lean would unleash a lot of pent-up creativity and initiative amongst NHS staff members. It’s the same hope in the U.S. where we do have competition, but people are likewise beaten down and frustrated. We have to do better, and it’s a management system thing that needs fixing…

    As to your comment here:

    It sounds like things are so dysfunctional, that any hope of meaningful Lean transformation isn’t worth the effort?


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