Good Questions, But With Some Misunderstandings about Lean Healthcare
In 2009, I wrote about a nurses' union in New Brunswick that supported Lean because they realized this methodology could help reduce waiting times and improve working conditions. It's win/win.
Yet, as part of the recent politicized Lean healthcare brew-ha-ha in Saskatchewan (read more here), the Saskatchewan Union of Nurses (SUN) has been critical of the provinces' efforts — with what I think are some valid questions, mixed with a few misunderstandings about Lean. So, I'll address them here.
In an op-ed written by Tracy Zambrony, president of SUN, her headline is a good summary of what Lean advocates would say:
In this ongoing discussion, I saw somebody tweet that the only ones who say that Lean is a “panacea” or a “cure all” are the opponents or skeptics. It's a classic “straw man argument” (or an “Aunt Sally”) to argue against something your debate opponent isn't saying. So, one side implies the other side is saying Lean is a cure-all. But, both sides really agree on this. So, let's stop arguing and focus on healthcare improvement.
Zambrony is correct to say we can always step back and “rethink” an approach we're taking. That's the essence of the PDSA approach and that's Lean. It's also a very fair question to ask if they should have paid $40 million to a consultant. The “key issue” is one that I'd agree with:
“the implications of lean for the quality and safety of direct patient care.”
There's a reason the subtitle of my book Lean Hospitals is “Improving Quality, Patient Safety, and Employee Engagement” rather than “Cutting Costs, Improving Efficiency, and Hurting Quality.” While politicians might argue, we should all be focused on improving the dismal track record of healthcare quality and patient safety. If “Lean” efforts are actually (or perceived as) being only about efficiency or cost cutting, we have a problem.
No one doubts that lean has helped identify waste and make improvements. However, evidence of its effectiveness in improving direct patient care is weak and inconclusive, as the research literature makes clear.
I'm not a clinician and I don't write medical journal articles, but there are many publications in peer-reviewed journals that outline improvements to safety and quality. There are many other improvements that are real, but don't pass the muster of journals, but they're real. I have a list here and you can search Google or your favorite journals.
The clearest successes have been in areas of the health system that most resemble physical production, such as inventory management and process redesign to reduce unnecessary steps. Lean has also involved targeted quality and safety initiatives in which SUN members have been participants and leaders.
I think there's a misunderstanding there, that Lean applies best in areas that “most resemble physical production” (say, like a hospital lab or pharmacy). It sounds like Zambrony agrees that Saskatchewan is trying to apply Lean to quality and safety, but they aren't happy with the results? Side note on this – the NDP (opposition party) leader in Saskatchewan tried to blame Lean for data showing an increase in reported patient safety incidents, when it's actually a very reasonable assumption that the number of incidents could be down while the number reported is UP — this happens when the culture becomes more open and transparent and people are less afraid to report problems. It's POSSIBLE that the number of incidents is up, but this is really hard to measure in healthcare (which is part of the old culture and part of the current problem in measuring improvement).
Zambrony admits in her piece that people often don't speak up because of the fear of repercussions. That needs to change. A Lean culture would support that.
Zambrony also says:
But we need to make sure that lean principles are not applied rigidly or inappropriately.
Yes, great point. I'd agree with that. We should be careful when a consultant says something like, “We must always start with 5S” or “We must always calculate takt time for a process before we do anything else” or “it must ALWAYS be a moving assembly line to be Lean.”
The principle of “Just in time” has to be balanced by “Just in case,”
I think Zambrony is warning against not mindlessly cutting inventory to the point where we don't have enough supplies to do our job. Of course that would be dumb.
Cutting inventory for the sake of cutting inventory is a mistake that people sometimes make when they are just learning about Lean. Hospitals often have shortages of supplies and the “old approach” to management emphasized cost cutting and budgets (which might lead to shortages), rather than focusing on making sure people have what they need to do their work. When we set inventory levels for “just in time” or “kanban” inventory systems, the first goal is to make sure we always (or almost always, depending on the situation) have what we need to do the work without delay.
In a factory, the cost of running out of parts might be high, but Lean factories have amazing systems to make sure that “stock outs” and interruptions to the work rarely happen. In a hospital, if the cost of NOT having something is a patient DYING, then we'd err on the side of having too much. It's better to have a little extra inventory that might expire than it is to have a patient die due to a shortage. A factory might not like downtime or late customer deliveries, but it's usually not “life and death there.”
So, we can be reasonable with Lean in healthcare. Saskatchewan's $40 million consulting group are not “noobs” and they must understand all this, I'd assume.
and standardization, increased patient flow, and cost savings should not distract us from focusing on patient acuity and complexity, holistic care, and both preventative and post-discharge health management. Lean does not have all the answers.
Right, Lean should supply quality and safety, rather than being a distraction (healthcare's daily work already has enough distractions, as it is). Lean principles and management should be used to support these goals of dealing well with acuity and complexity (and variation), providing holistic care, etc. Lean does not have all the answers, sure, but Lean works best when it apply it toward answering the right questions.
Unlike supply management, the registered nursing process is not linear and predictable and cannot be reduced to bundles of tasks and rationalized on business principles. When lean moves from supporting the nursing process (by freeing up time and resources for direct patient care) to re-engineering it in its own image, it is inappropriate and unsafe and threatens to erode quality care by providers treating the “whole patient” and ensuring the continuity and co-ordination of care.
Lean should be used to support nurses and free up time. A nursing hour or nursing day is NOT as predictable as a repetitive 60-second job cycle in a Toyota plant. But, we can work with nurses to standardize what they can (there are elements of the work that are common and repeatable throughout the day), without making things overly rigid and inflexible.
Remember, it's the old management system that says “check your brain at the door,” not Lean. There's a reason Toyota calls it the “Thinking Production System.” Healthcare, before Lean, is often very siloed and arguably doesn't the “whole patient” well and the old approach doesn't have highly coordinated care. Those are problems that ThedaCare and others are addressing with Lean.
It is one thing for a retail outlet to fail to meet unanticipated demand. It is quite another for hemodialysis patients to be put at risk and harmed, or for hospitals to run out of linens or wound dressings, because the margin for error or uncertainty has been “leaned” out of supply chains.
Here's another case where the complaint is really about the old system of management.Before Lean, hospitals and clinics very often FAIL to meet unanticipated demand. Lean can help with this. Hospital units often run out of linens (because there are bad processes or there's been a cost-cutting focus). Lean addresses this and provides a new philosophy and management system. What Zambrony fears will be brought by Lean is probably already there!!
We need to solve those problems, not blame Lean for them. She points out other problems (or potential problems) — things that I'd describe as “L.A.M.E.” not Lean.
As discharges are rushed to increase patient flow, we see poor outcomes and costly readmissions. As efficiencies are found by scaling back high-touch surface cleaning in operating and emergency rooms, rising rates of hospital-acquired infection are the result. As untested model of care changes under the cover of lean reduce the capacity of registered nurses to adequately assess and monitor patients, safety and outcomes suffer.
It's not Lean to “rush” discharges. It's Lean to reduce delays that keep a patient there an extra night (and that extra night introduces more risk of harm in the old approach). ThedaCare and other hospitals are using Lean methods to reduce readmissions by, for example, having more consistent and more easily understood discharge instructions for patients. Lean can help.
It's not Lean to do a WORSE job of cleaning and disinfecting rooms. These rooms often get cleaned poorly before Lean, due to the lack of good process. Lean can help.
There are many published examples of Lean helping reduce infection rates. It's not Lean to cut nurses to the point that the patient care work can't be done. Lean is about having the RIGHT number of people doing the work. Lean can help.
She has doubts about how this will be implemented. That's great. She should be asking questions and putting the patients first.
Surely lean is not something that has to be uncritically accepted wholesale as the answer to every question. Engaging providers and patients must include being open to rethinking what we are doing along the way.
Who says Lean has to be “uncritically accepted” as the “answer to every question?” Only the critics… unless something is going very wrong in Saskatchewan. Everybody must be engaged and listened to. Everybody must be open, leaders and consultants included, to the cycle of Plan-Do-Study-Adjust.