This is going to seem like a political rant, but I promise this is mainly a post about Lean and healthcare, or at least it's about dysfunctional parallels in both settings.
It used to said that President Ronald Reagan and Speaker Tip O'Neill would actually go have a drink together at the end of the day, even though they were pretty much 180 degrees opposed politically. Turns out it's a bit of political urban legend. Maybe that was just a mythical kinder, gentler time, as American politics has historically been bitter and nasty… like today.
As an experiment, do as I did the other day: watch Fox News for 60 minutes, then watch MSNBC for 60 minutes (especially in the evening opinion show times). You'd think there were two polar opposite Americas in existence from the vitriol from the right and the left. If you're on the right, watching MSNBC would make you think you were in “bizarro world,” where everything is opposite of your world. There's no middle ground, no compromise or “seeking first to understand” going on, it seems. Everyone is shouting past each other or just talking to those who already agree with them…
Look at the fight over the nomination (and now recess appointment) of Dr. Don Berwick to head Medicare/Medicaid (CMS). I'm not a fan of circumventing Congressional approval (when it's done by either party). Sadly, the extreme views come out about that procedural method (which is Constitutionally legal, but maybe bad form) and extreme views about Berwick himself. Dr. Berwick, who I support even with his comments about redistributing wealth, is painted by some, including Sarah Palin on Twitter, as a death-panel loving, socialized medicine obsessed, rationing monster. He seems to be no such thing. (Note: John Toussaint also supports Berwick).
Not to play the whole President George W. Bush “I saw President Putin's soul card”, but I've met Dr. Berwick briefly and he surely doesn't seem like Dr. Death Panel in his personality or based on his work at the IHI. Dr. Berwick is indeed pretty revered in the healthcare for his life-saving work and advocacy for quality and patient safety. Revered or radical? Two sides to that story, eh?
Dr. Berwick deeply understands that better quality and better processes in healthcare save lives AND it lowers cost. There's nothing the least bit evil about that. Dr. Berwick talks about making tough choices with our healthcare dollars (“rationing with our eyes open” instead of today's form of rationing, but he also talks about eliminating waste from healthcare. (post continues below the ad)
Regardless of political sides, most people have a blind spot toward the idea that you can actually improve healthcare efficiency without resorting to more rationing or killing people early. People ASSUME, it seems, that because hospitals are naturally as efficient as can be because they're are full of smart people, with great technology, and new buildings. Lean thinkers know this isn't true. Bad processes defeat all the great people, technology, and buildings every day.
I heard Dr. Berwick's Institute for Healthcare Improvement called a “healthcare efficiency organization” on the news. I thought they were mainly a quality improvement organization. But, again, there's the catch — better quality leads to lower costs and it's hard for many to see that. The term “efficiency” was said with an ominous tone of voice, as if IHI's mission is to deny people care just to save money. Ridiculous.
I'm not in favor of “socialized medicine,” but I support Dr. Berwick for the CMS job. Actually, “socialized medicine” is a term with such a vague and inconsistent definition around the world that it's a pretty meaningless statement to say I'm against it. I don't prefer a UK style system or a Canadian system, I'll put that much out there. But the U.S. system is far from perfect (as evidenced in this recent post from Jon Wetzel). So I don't fit easily into either political extreme… so who is representing me??
Extremes in Lean and Other Process Improvement Methodologies
Away from politics, we sometimes hear similar extremes about Lean, especially in healthcare. I'm squarely in the “pro-Lean healthcare” camp and there are some who run around saying “Lean doesn't work in healthcare.” Do I believe Lean *always* leads to good outcomes? No, of course not. The practices and principles of Lean are sound, but they're often very tough to implement since Lean goes against the culture of most organizations. I could run around with my fingers in my ears never wanting to hear about problems with Lean or what we call “LAME” here on the blog, but I don't. I would be an ideologue if I never admitted there were problems in Lean world (just as political ideologues would never admit their party is wrong).
Do the people who say “Lean NEVER works” really believe that extreme position? I'd hope not. They're probably just saying that to score points and to benefit their own methodology.
The Positive View of Lean
In a more specific case, let's look at Minnesota's Park Nicollet health system. They've been on the Lean journey for many years (and, conflict of interest disclosure, they're a member of the Healthcare Value Leaders Network that I work with). There have been many published accounts of how Lean has helped their organization and their patients.
Check out this great video (it's six minutes long, but worth it). Here's a 30-second ad version for the time-challenged. PN redesigned their cancer treatment in a VERY patient-centered way. They had patients involved in the design. Although the video doesn't talk about it, PN used a Lean 3P design process for this center (they presented about it at our recent Lean Healthcare Transformation Summit).
What a great story. There's the power of Lean to improve patient care and the patient experience. That's the best side of Lean, the “all is good” view — and I'm not criticizing PN for not telling “both sides of the story” in their video.
Patients are seeing an oncologist within 48 hours now (a “promise”) from PN. The UK NHS has a two week standard, by comparison. Park Nicollet patients are getting surgery within 10 days (compared to the UK NHS long-term “target” to get that wait down to ONE MONTH, the current goal being 18 WEEKS). In the new PN process, chemotherapy and testing and everything comes TO the patient, so the patient doesn't waste precious energy walking between campuses and departments. It's brilliant.
The Negative (and Distorted) View of Lean
Now, on the other extreme is the Minnesota Nurse's Union. I saw this video before my vacation, but I didn't want to get int the middle of a labor dispute that included a 1-day strike – the dispute has recently been solved (I guess) with a new contract.
The nurses, unfortunately, put up this very misleading “anti-Lean” video on YouTube, with all of the subtlety of a typical political attack ad. It's their editing and spinning of a Park Nicollet produced pro-Lean video.
If you only saw this video, you'd think Lean was evil and something that should be banned. Does the nurses' union really believe that? I hope not, but again they're trying to score political points with their extreme argument. They're confounding the issue by slamming PN executives for their high pay (a separate discussion).
The Lean approach and philosophy clearly does NOT put profit over safety, as the video states. The nurses' union plays the Toyota card, exploiting their recent quality problems (a design and engineering issue, not a production issue) to slam Lean and TPS as being BAD for quality. Hogwash. It's just like a politician on either side of the aisle making cheap demagogic point that sounds good to an uninformed audience, but it sounds good.
One could argue, at the other extreme, that opposing Lean is unconscionable because stopping a Lean program would likely prevent much needed quality and safety improvements. Again, neither extreme seems helpful. There's no point in people calling the union evil, I'm certainly not doing that. They're to some extent well intended (I'll give them the benefit of the doubt that they care about patient safety, as do hospital execs), but they clearly have a “more nurses is better” agenda because that also means more union dues.
The major issue is that nurses say they need MORE nurses to ensure safety. The other view would be that we need to reduce waste and improve processes so we can provide better quality and safer care without hiring more nurses (we have major nurse shortages, by the way, a trend that will only continue). The one side argues that hospitals are not as safe as they would be with more nurses. That might be true in the short-term (you'd have to look at real data and not generalize), giving current bad processes and waste in healthcare delivery. Lean often leads to productivity improvement, but sometimes data and patient needs lead to INCREASING staff in a Lean initiative (yes, I've seen that and recommended it at times). How many people do you need to get the work done the right way, in a way that's safe for everybody? That's the core question. Lean does not always stand for “Less Employees Are Needed.”
The Lean purists would say, for example, that inspection is bad, it's waste — we need to build in quality at the source. OK, but if your first step with Lean is moving the inspectors into other jobs, your customers are going to suffer if you haven't first fixed quality. So maybe in the short-term we *do* need more nurses to protect patients until we can improve the process – but I'm opposed to mandates in contracts or in state law (like California and others).
The union also twists the idea that you can see 50% more patients by taking waste out of the process (and the CEO even says “we're not trying to turn this into an assembly line”). The union implies that seeing 50% more patients mean you're working 50% harder. That doesn't seem possible when you have the view that healthcare MUST be already efficient (great people, great technology, great buildings).
People with Lean healthcare experience know that removing waste is good for patients, the staff, and the hospital. The hospital might make more profit (which the union seems to demonize), but as the CEO said, that profit is reinvested in patient care. The one point I agree with in the video that it's not the best use of funds to invest that profit in marble hallways and soaring atriums, but that's just me.
The original PN video also presents the idea of stopwatches being used to observe work – to identify “bumps in the road” and problems that interfere with care. But, the union twists that as being an inherently evil practice:
The stopwatches aren't there to make people work faster. If that's indeed happening (and I doubt it), then that's bad and it's classic Taylorism and that's clearly L.A.M.E. Again, two extreme sides to this story.
The final distortion is shown here:
Sigh. I guess this nurses' union, like some other unions, will just never see Lean as a positive force. That's sad and closed-minded, just as it would be if a Republican would never listen to a Democrat or vice versa. I blogged last year about a nurses' union in Canada that was IN FAVOR of Lean, so there's some hope.
Actually, the final distortion in the video is the strikers with their kids holding signs, as if that validates them as the good side (sort of like using puppies or babies in commercials). As if the management side doesn't also have children. Good grief. Just like a political attack ad.
The nurses' union didn't get their mandated staff ratios in the new contract, by the way.
Where is the Reasonable Middle Ground?
Is Lean always bad? Are Democrats always wrong? Feel free to ask those questions in reverse. I'd say no, however you ask those questions. The extreme position is never correct (oops!). The extreme position is hardly ever correct. Either way, when extreme views keep people from even hearing each other, yet alone talking, I really worry about the State of the Union (and I don't mean the “state of the labor movement”).
Does this trend of polarization continue and spiral out of control, or what is the balance against that? Sorry for such a long post — your thoughts??