After some supporters of the Saskatchewan Lean healthcare efforts reached out to me, I've been trying to follow everything that's being said and written – which is hard to do (just try a Google news search). There are many facets to this story, some of which are discussed well by John Shook and Bill Waddell in their blog posts.
Somebody from Saskatchewan complained to me via email that “Lean's gotten political.” Hmm… government-run healthcare system with elected politicians (and elected union officials to boot), it's always political. The rooster crows when the sun comes up, the politician gets political. No surprise.
Instead of Pushing Lean or Arguing with Each Other, Focus on Improvement
A lot of the discussion has been about “should we use Lean methods?” People are labeled as supporting Lean (often being accused, as I was, of supporting it only out of personal financial interests) and people are labeled as opposing or resisting Lean.
A lot of debate has been about people and politics, unfortunately, instead of being about improving things for the staff and the patients.
In the category of stuff I should just brush off and ignore… it's funny that a union official, an elected president who is paid by the union from dues that members are forced to pay, would complain that somebody (me) has a vested financial interest in something. He doth protest too much. He labels Lean a “scam.” Ah, politics. The union and the liberal NDP party have a vested interest in taking potshots at the conservative Saskatchewan Party (and vice versa). The NDP party has said that Lean is a cult and the Sask Party leader has demanded apologies. Good grief.
Instead of arguing with each other or arguing “should we learn and use Lean?,” the discussion should first be about improving healthcare. Should we improve healthcare? Yes? Can we improve healthcare? Yes! If so, how?
I'd like to think that's a non-partisan issue that everybody should be able to agree on – we have to improve healthcare. Saskatchewan has had a “Patient First” initiative. Maybe “Lean” should have just been under that banner instead of trumpeting Lean, Lean, Lean? Can everybody please grow up and focus on the patient? And focus on the nurses, physicians, and others who have to provide that care to patients?
People would probably agree that the current state of healthcare is bad in many states, provinces, and countries. This current state includes:
- Patients being harmed by preventable errors at unacceptable rates
- Inconsistent quality and patient outcomes
- Long waiting times for care
- Frustrating, stressful workplaces for nurses, physicians, and other healthcare staff
- Inadequate management systems and dysfunctional organizational cultures
- Cost cutting often traditionally focuses on layoffs
Again, this is the current state WITHOUT Lean. This is not a Saskatchewan problem or a Canadian problem. it's a global problem.
I hope there would be agreement that this all needs to be fixed.
The Debate Over How to Fix It
The question then comes down to, “So what do we do about it?”
Lean is one approach. It's not a silver bullet. It's not easy. Lean works in healthcare, but it's not guaranteed to work. There are other approaches and other fixes that people will propose. We can debate which one (or more likely multiple) strategies and improvements to adopt.
Lean is not an “American approach” (nor is it “Japanese” at this point). Lean in Canadian healthcare has nothing to do with fears of privatization and it's not about “turning them into an American healthcare system” for many reasons (one of which being that most American hospitals are NOT Lean yet).
The Saskatchewan government has had a Lean initiative for many years and I've met some of those leaders (including former Deputy Minister of Health Dan Florizone, who I interviewed here), but I don't really have any inside knowledge about what's going on there. Florizone was interviewed here recently, as well.
Who Should Help and How Much Should it Cost?
The government there has placed a $40 million (over four years) bet on the consulting services of John Black & Associates. Black is the author of a book (The Toyota Way to Healthcare Excellence: Increase Efficiency and Improve Quality with Lean) and played a key role in initiating the Lean transformation at the Virginia Mason Medical Center. He's rightfully credited as being a visionary and an innovator in Lean healthcare and Virginia Mason was named “Top Hospital of the Decade” for a reason for their improvements in patient safety, quality, and cost.
I respect John Black for the role he has played in bringing Lean to healthcare. All of us working in this space are standing on his shoulders.
But, back to politics… some complain that Black is an American. They complain that he flies in Japanese consultants who require translators. They complain about the $40 million. Some complain about his attitude. He did himself no favors (and didn't impress me) with this comment about how they'd regret not hiring him (even thought he “didn't want the job”):
“If you're not dead (in 20 years), you're going to be in one of your health-care systems here in bed, with a tube up your ass and one down your throat. You're going to be saying to yourself, ‘My God, I wish I would have asked John Black to come in and help improve my care,' ” he recalls saying before leaving one meeting. He thought he'd never hear from them again.
My God, I wish he hadn't said that. Leading with humility, anyone?
Some say “we should have spent that money on hiring more nurses,” but Lean thinkers would realize that adding more people might be, at best, a short-term countermeasure. If hospitals are truly understaffed (something I don't know without being there and without seeing data), they more nurses should be hired. But, looking at the long-term trends of an aging population and a retiring workforce, I'd argue that we need to get more efficient and productive — a better long-term countermeasure.
Some argue they should have hired a Canadian. That's for the Canadians and the politicians to decide. Some argue that they are using too many Japanese words (with the use of those words being part of the “cult-like” approach).
The “should we have spent the money?” and “should we use so many Japanese words? questions are very different than “should we embrace and practice Lean?”
What are the Results So Far?
Arguably, they are getting results with Lean in Saskatchewan. Beyond the training and the Rapid Process Improvement Workshops (both of those being means, not ends), Saskatchewan says the contract with John Black ($10 million a year) has already paid for itself with a projected $30 million savings in the construction cost of their planned Children's Hospital (through 3P and Lean Design efforts) — and it will probably be BETTER and more effective, not just cheaper.
Has it “already paid for itself?” In way, but not really (or not yet). For now, it's paper savings until the hospital is actually built and the money is not spent, but that seems like a reasonable savings projection based on the results of other hospitals using Lean design. Hospitals are building better buildings, cheaper, and faster. They're not bigger than they need to be, yet they're not inappropriately small. They need the needs of patients and staff. That's Lean.
But, I have a vested interest in saying that, don't I?
Update: This article includes a government claim that the Saskatchewan healthcare budget has increased less than in previous years and that it can be attributed (at least partially?) to Lean. So maybe they already have real savings.
DD: With this being a three per cent increase in health (spending) and last year, the 2013-14 budget had a 3.5 per cent increase in health, I think that does demonstrate that the work that we're doing with Lean has found efficiencies within the system. Normally, we're used to health increases of seven, eight, nine or 10 per cent a year and even at some pretty high increases in health budgets in the past, particularly through the late 1990s or early 2000s with significant increases in health budgets, we've seen positions that were lost — doctors and nurses that were cut, facilities and beds that were closed … (Because) we haven't had that same type of experience, I think (that) has shown Lean has been part of finding efficiencies and also of improving the quality of care that we've been able to offer patients in a more timely fashion.“
Better quality, more timely, lower cost. That's Lean.
So, did they have to spend $40 million on consultants? I don't know, maybe not. But that was the choice of the Saskatchewan leaders and they have to live with it (and face their voters if it doesn't work). The New York City HHC, consisting of 11 public hospitals, has had a $35 million contract with Simpler Consulting over multiple years and they have about the same number of employees. Saskatchewan Lean advocates have pointed out their annual spending on Lean is just 0.2% of their budget, but that doesn't include staff and leader time spend on Lean.
ROI matters to people… but we also have to consider the long-term value of training people. Lean talks about developing people AND improving the way work is done. Both things lead to results, both short-term and long-term (Toyota promotes long-term thinking as a primary principle). The ROI of the training and education that is taking place is harder to measure and value… but it should be considered.
But the Politics Sure is Annoying
As part of the politics, a Canadian union is doing what politicians do – spreading misinformation and lies about Lean.
They trot out the old, tired claim that unions always throw around:
Lean programs considered “management by stress” and used to justify layoffs while increasing workloads of remaining staff
There's plenty of stress BEFORE Lean. Lean gives us a fighting chance to reduce waste and free up time. The Lean workplaces I've been in are LESS stressful and they're calmer. Nurses get to spend MORE time on patient care. The total workload can't be increased beyond 60 minutes of work per hour and nurses are ALREADY being asked to do too much in an hour… so corners get cut (not the nurses' fault!) and errors are made.
Lean gives us a fighting chance to actually take the breaks we are entitled to, which is humane for the staff and better for the patients (less fatigue equals fewer errors).
The union also says:
Claims that Lean management produces savings have also been called into question. For exmaple, one Lean “success” at the Children's Hospital of Saskatchewan cost $30 million more than the original estimate.
Wait a minute. The government says they have SAVED $30 million. Either the union doesn't know the difference between “saved” and “cost more” or they are lying. Have the claims of savings been “called into question” by anyone other than the union's blog post? Or another union?
I'm not trying to make the union the enemy. We should all be working together on creating better workplace and improving patient care.
But politics get in the way?
Give Lean an Honest Look – Neither Blind Faith nor Blind Hatred & Distrust
If there are legitimate concerns that “they're not doing Lean right,” then I want to hear them. To discount them out of hand would be playing politics instead of being a good leader.
Yes, Lean is about respecting and engaging all people in improvement (which includes patients, as Saskatchewan is doing). If some managers are focused only on cost cutting, that can't be what John Black is teaching them and that's just an old habit they haven't broken yet. The visual display boards in their units have measures of safety, quality, waiting time, cost, and morale, so I know they aren't just focused on cost. But, if some managers are ONLY paying attention to cost, that should be called out and adjusted.
We should listen to the concerns and the leaders (and consultants) who are really there on the ground should listen and they should decide what, if any adjustments, should be made to their approach.
See a series of excellent videos that include nurses and patients talking about the improvements they are making with Lean in Saskatchewan. I wish them the best of luck on all levels and I hope they are very successful in their improvement work because that's what it's really all about. It's not about “implementing Lean,” it's about improving patient care and improving our health systems.
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