What’s Lean or What Works? Centralizing Hospital Functions
I had a chat with somebody from a hospital recently who asked about following one Lean principle and that leading to a conflict with another Lean principle.
Here was the gist of the discussion… she said that the hospital centralized its scheduling functions for different departments in a single location “because it was Lean.”
I asked, in the most polite tone I could muster, “In what way was that Lean?” (meaning “what Lean principle drove that decision?”).
I got sort of a blank stare in response.
She then said, “Well, we wanted to standardize the way scheduling was done.”
I asked, “Isn't standardization a separate issue from the location of the employees?”
If there is a general Lean principle that talks about centralization versus decentralization, I think it would be to decentralize functions like scheduling and registration. This is, like many Lean rules, a general rule of thumb that applies unless it doesn't make sense to do so (TPS as the “Thinking Production System“).
The old traditional mindset (seen especially in manufacturing) is to have “process centers” or a functional department layout — all of the grinding machines go in this department, all of the types of the turning machines go over there. This type of layout leads to big batches and poor flow.
One brilliant thing about Lean manufacturing is the creation of “production cells” that have all (or most) of the machines required to produce a particular product or product family. So we shift from a functional layout to a product-focused layout that will have better flow and shorter cycle times (and probably better quality as a result of the other two).
In the traditional mindset, the most important thing is the utilization of machines – keeping it high because it's thought that reduces the cost per part.
In a Lean approach, the most important thing is flow – which often leads to lower cost. You need “right sized” machines that fit into the production cells and these machines might be smaller than the big mega machines people put in the old process centers.
An example of putting capacity right in the flow in healthcare would be the hospital I visited in Sweden that put a small O.R. in a cardiac unit. The operating rooms (probably mostly for good reasons) are clustered together in a process center in the hospital.
But back to the scheduling situation… I think it matters less “what is Lean?” as it should be more about “what works?” and “how do we know what works?”
A centralized scheduling department would have some benefits:
- Higher utilization of people?
- Being easier to have people shift around as demand for scheduling phone calls was higher or lower for different departments?
- Easier for the scheduling people to learn from each other, improving their practices?
- Easier for the schedule function to be managed by a single functional manager?
But, having dedicated scheduling IN a department might have advantages:
- Better integration of scheduling into the department itself?
- More accurate scheduling based on learning how long certain appointments or procedures really take?
- More convenient for the patients if they would otherwise have to walk to a “scheduling department” for some reason?
I think you could still work on standardizing the scheduling process (if that was important) with people working in distributed locations. This is one reason why you still tend to have vertical management silos even when employees are distributed as part of departments or value streams.
The hospital was facing some sort of problem caused by centralizing scheduling. I could guess what they are, but I don't know exactly what the problems are (this was a short discussion we had as part of a larger group). If something's not working, follow the Plan-Do-Study-Adjust process… if they tried something (Plan-Do) and found that it didn't work well (Study), then Adjust rather than being stubborn about what Lean supposedly told you to do.
Do you see similar situations in your workplace?