Reader Questions: Lean and Process Improvement in Healthcare


I received some really good questions from a reader, Nick, who has recently crossed industries to bring his Lean Manufacturing experience into healthcare. Since I thought the questions might lead to a good blog post, I'm going to address them here. In his intro to me, Nick said: “I don't like to call myself a ‘consultant' (no offense) only because I work for the hospital and I find it carries a weight that is sometimes a bit of a burden.”

No offense taken. While Nick is an “internal consultant,” I work with hospitals as an outsider or an “external consultant.” Sadly, the term “consultant” often gets you glares or eye rolls from hospital staff…

Sadly, a consultant in healthcare often does one of two things:

  1. Lays people off (hence, the glares)
  2. Gives people answers and tells them what to do (hence, the eye rolls)

To the contrary, I'm a big believer in the “no layoffs due to Lean” policy and I'm always the one teaching methods that hospital staffers can use to improve their own work. I agree the word “consultant” has baggage, which is why I'd prefer “coach” or “advisor” (but not necessarily “sensei”).

Lean Program Structures

With regard to the conference, I saw that Scott & White had a presentation on their A3 process. I have heard quite a lot about their work, and was wondering if they mentioned at all how their PI department was structured. Specifically, do they work with consultants? Do they have internal PI guys like myself? Or do they have clinical staff doubling as PI staff?  Also, in your experience, which one of these models works best in working toward a lean organization?

I din't remember the exact numbers, but Scott & White has a relatively small central team that serves as lead educators and coaches. They have used an external consultant to teach them 3P, strategy deployment, and other methods (it's Altarum Institute, who co-presented with them at SHS). Scott & White typically pairs up a person with a clinical background with an engineer/manufacturing person. I think this is a really smart combination, as each person brings a different perspective to their improvement efforts. I've always thought that an internal central Lean team should be roughly a 50/50 mix of “insiders” and “outsiders.” The clinicians help the engineers learn and understand healthcare, while the engineers have a different thought process and experiences that they contribute.

Scott & White also has a program for training what they call “embedded coaches” in the organization. These are staff members who, in my description of it, work part time for a “fellowship” type period of time. Staff members enter and sometimes leave the program. Scott & White considers participation as an embedded coach to be a crucial development step for future leadership roles.

Data and Facts

Were there any examples where teams successfully used facts over numerical data during a lean project?

Nick is referring to a quote from Taiichi Ohno:

“Data is of course important in manufacturing, but I place the greatest emphasis on facts.”

See a blog post of mine about this idea.

Meaningful data for process improvement is often missing in healthcare settings. For example, if we are creating a value stream map of a patient's visit to the emergency room, we might have data on the overall average length of stay, but we probably don't have data on the components of that stay. How long do patients wait before triage? Are “door to doc” times actually accurate and meaningful if the clock doesn't start ticking until the patient registers? If so, that data is skewed because there might be a line waiting for registration.

Even if you have data, it's usually in the form of monthly reports that are lagging and hide too much information in the averages. That's why it's so important to go to the “gemba” or the point of patient care to observe the process first hand. Instead of just relying on averaged data, we'll observe an actual patient's journey through the E.D. We can collect data first hand, but we can gain and learn so much more with our eyes and ears (asking questions and talking with patients and staff).

Projects and Thinking

If you were to estimate, of the presentations/topics/speakers [at SHS]  who said they were using lean thinking,  about what percentage  of them were working toward a lean organization, and what percentage were “doing lean projects.” Additionally, about what percentage of them were improving the right  things, i.e. working toward becoming an ACO versus saving $5,000 on supplies because of 5S.

The percentage of presentations at the Society of Health Systems conference  that focused on management systems (rather than tools or a simple case study) has increased over the past four years that I've been attending. People are presenting about more hospital-wide issues instead of local department projects. We had sessions on the culture of Kaizen or continuous improvement, including my own, Lean space design, strategy deployment, and other high level topics. Other presentations were focused on important issues like patient flow in children's cancer treatment. See a PDF of the conference sessions, including the Lean Six Sigma track.

Top Down or Bottom Up?

Lastly, specific to your talk, in your opinion where should continuous improvement start? Is it better to start Bottom-up, or Top-down? Or does it not matter?

I fall back on the sage advice of John Shook, who says that Lean is “neither top down, nor bottom up” as a management system. We discuss this balance a lot in Healthcare Kaizen. It's pretty common for Kaizen and Lean efforts to start in a “bottom up” way, where people are choosing to work on things that matter for their patients and their department.

I like to use ThedaCare as an example of an organization that has this balance of “top down / bottom up.” ThedaCare has their Strategy Deployment process (as shown in this DVD) where the the senior leaders work in a collaborative way to define the strategy and “true north” objectives for the organization. Note, this is different than top-down “goal deployment.” There are some improvement events that are selected based on these true north objectives and goals that are set for the year. Front-line staff can initiate Kaizen initiatives that are aligned with those true north goals or they can work on things that just made work easier and better for the patient.

So, things often start “bottom up” but should evolve to a system that's both top down AND bottom up.

Thanks to Nick for the questions.

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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.


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