Today's edition of The New York Times has an outstanding article about Lean Healthcare and what Seattle Children's Hospital calls C.P.I. or Continuous Performance Improvement.
The article: “Factory Efficiency Comes to the Hospital“
I wish the headline had also addressed quality, waiting time, and staff engagement, but the article body does, at least. The article highlights Seattle Children's Hospital, as well as others, including members of the Healthcare Value Network (Park Nicollet, Akron Children's, and Paul Levy‘s Beth Israel Deaconess Medical Center), as well as Virginia Mason Medical Center. Yours truly is quoted in the article, as well.
I try not to judge an article by its cover headline. The online headline is a bit cringe-worthy, as it makes you wonder how people from outside manufacturing will read this (the general readership of the Times). It might sound like a negative thing – “What? You're turning the hospital into an assembly line? Oh no!”
In an interesting twist, the print edition headline is different, it reads:
“Factory Finesse, at the Hospital”
I like that headline better. What headline would you have given it, to more fully represent the breadth of improvements that come from Lean healthcare? Leave a comment at the end of the post.
The article highlights the role of Toyota and Lean in their C.P.I. program and there's actually a pretty good definition of Lean for being a mainstream media piece:
The main goals of the approach, known as kaizen, are to reduce waste and to increase value for customers through continuous small improvements.
I wish that definition had included “respect for people” element of the Toyota approach, but at least the definition covered reducing waste (as opposed to just cost cutting) as well as focusing on value and the customer.
Kaizen, is of course, a major part of the Lean and TPS approach.
Benefits of Lean in Healthcare
The article highlights many benefits of Lean:
Making sure nurses have supplies readily available, so they can spend more time with patients
The article gives a nice basic description of what we'd call a “two-bin kanban system,” a very simple and effective strategy. I had the chance to visit Seattle Children's in August of 2009 and I was very impressed with their supply chain processes and kanban systems (put in place by a VP who came from the high-tech manufacturing world).
Fully engaging staff leads to fewer mistakes, better outcomes, and lower cost
From the article:
And while a sick child isn't a Camry, Seattle Children's Hospital has found that checklists, standardization and nonstop brainstorming with front-line staff and customers can pay off.
“It turns out the highest-quality care also is the most cost-effective because we make fewer mistakes and create better outcomes,” says Patrick Hagan, the hospital's president.
Hagan outlined some other improvements in terms of cost and capacity:
- Cost per patient is DOWN 3.7% (think about that for a minute in this environment)
- The hospital is serving 38,000 patients a year, compared to 27,000 in 2004 (a 40% increase) without expanding or adding beds (this has saved them $180 million, they claim)
Thankfully, the article strikes a balance between quality and cost improvements, talking about how they go hand in hand:
“Some people think they have to choose between quality of care and saving money,” said Dr. David Chand, who attended the training and now uses C.P.I. methods at Akron Children's Hospital in Ohio. “C.P.I. improves both patient outcomes and the hospital's bottom line.”
Unfortunately, the article doesn't give really good quantifiable examples of quality improvement, but at least it was discussed.
Creativity over Capital
Akron Children's describes how they reduced waiting time for non-emergent MRIs from 25 days to just 1 or 2 days. Again, this was done without expensive capital spending — a $20,000 improvement project worked for them, allowing them to avoid a $3.5 million dollar construction project. These sorts of savings are being seen at leading Lean hospitals around the country – imagine the impact on our national health bill if we can spread this thinking!
The end of the article also mentions savings related to new construction at a new facility in Bellvue, WA:
The hospital was able to shave 30,000 square feet and $20 million off of the new building, which is to open July 20.
Both Sides of the Story (?)
Responsible journalism covers both sides of the story. Even with the overwhelming praise for Lean and C.P.I. methods in the article, you can always find somebody who doesn't like Lean — or they're willing to say they're opposed to Lean because it serves their purpose, perhaps.
In this case, it's the Minnesota Nurses Association, a group I've been trying to have a constructive debate with, but it's seeming more and more pointless (not surprising considering their misleading video that I blogged about the other day). You try to talk about Lean, and they fall back on complaints about greedy business people and how much money the hospital executives are making.
The union is quoted as saying:
She says that in an effort to reduce waste, consultants observed her and her colleagues and tried to determine the amount of time each of their tasks should take. But procedure times can't always be standardized, she says. For example, some children need to be calmed before IV's are inserted into their arms, or parents may need more information.
Now they may have a point here. Remember that the Toyota Way has two “equally important pillars”:
- Continuous improvement and waste reduction
- “Respect for humanity” (aka respect for people)
When things are done in the name of “lean” that ignore respect for people, we call that “L.A.M.E.” here on the Lean Blog (“Lean as Misguidedly Executed”).
If indeed the consultants were just hovering over the nurses, that's out-dated Taylorist time study, that's not Lean. You can collect time data, but it shouldn't be used as a quota or a mindless target. Lean thinkers realize there is variation in healthcare and that some patients will require more time, that should be built into the process and the staffing model.
So the nurse could be complaining about L.A.M.E. or she's misrepresenting it. Who knows.
The union also complains that Lean has led to “unsafe staffing levels,” but the hospitals disagree, saying:
Brian Lucas, a spokesman for Children's Hospitals and Clinics of Minnesota, says the lean efforts have been used to reduce unnecessary tasks and have not resulted in lower nurse-to-patient ratios. “To the contrary,” he said, “they have allowed nurses to spend more time delivering care to patients.”
I Got Quoted – and Not Horribly Misquoted!
The reporter, Julie Weed, reached out to me on Wednesday, looking for some quotes about the challenges with Lean – if this methodology is so popular and so effective, why isn't everyone doing it?
From the article:
Techniques like C.P.I. may indeed be hard for many hospitals to put into effect, says Mark Graban, a senior fellow at the Lean Enterprise Institute, a nonprofit research, education and publishing company. The process takes a large amount of time and requires a culture shift that many hospitals may not be able to accommodate or sustain. “If the leadership tries to force new ways of doing things, the staff may chafe under the successive changes,” he says.
There's always a risk of being misquoted and I don't think that happened here, thankfully. The reporter got the tone of my comments correct, too I think (I was afraid of seeming like a critic of Lean). Lean works amazing well in healthcare, but it requires a lot of leadership from all levels and it takes time to change mindsets. Lean concepts seem simple, but making this happen ain't easy.
The article has quotes from physicians, talking about how they came to believe in these ‘factory methods.' The article also mentions Joan Wellman, the consultant who started with Seattle Children's and their initial Lean / C.P.I. in the mid-90s. She's such a pioneer and it's great to see her get this much-deserved recognition. You might want to check out my podcast interview with Joan, she's great.
I'm curious to hear your comments about the article! Thanks to the NY Times for highlighting this exciting movement in healthcare improvement.
For those who are new to the blog, you can read more about Lean Healthcare in my book, Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction. The article focused quite a bit on staff-level improvements, but to learn more about how top leaders need to change their leadership styles, read the outstanding book from Dr. John Toussaint (published by LEI): On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry.