There have been plenty of headlines and updates since I first blogged about the controversy over Lean healthcare in the Canadian province of Saskatchewan (see my previous posts here).
From my outside perspective, there are some good things happening. I admire their adoption of a “patient safety alert system” and a blame-free culture (see Saskatoon Health Region CEO Maura Davies' comment about this on a recent post of mine).
Some of the controversy wasn't about Lean itself, but was focused on hiring on American as consultant and paying his group $40 million over four years. In late June, a few months after the controversy flared up, we saw this headline:
Deputy minister of health Max Hendricks said he foresees walking away early from the controversial $40-million, four-year agreement to train health-care workers across the province in lean leadership and management methods.
It's a sharp change of heart from six months ago, when health leaders said they would likely need the consultants' expertise for the full four years.
“We've learned a lot, and maybe it's time to take off the training wheels,” Hendricks said Friday.
The health minister has instructed Hendricks to review and renegotiate the contract “to ensure maximum value for money for the taxpayer.”
The positive spin is that John Black & Associates has done such a good job of teaching that they're not needed as much going forward. They are cutting the contract by $2.6 million, per this later article.
There are indications that the government is listening and adjusting their approach a bit (a good practice of Plan Do Study Adjust, or PDSA, thinking):
“People have complained. They've said, ‘We learned Japanese terms. We look at videos about the Toyota loom. We fold paper airplanes.' (The workshops are) meant to orient them and to demonstrate certain concepts, but I think that there's a way we could approach it that would fit better with our health-care system and our approach here in Saskatchewan,” Hendricks said.
Personally, I don't see how showing videos of Toyota weaving looms is engaging or relevant to folks in healthcare. It's possible to teach Lean without folding paper airplanes and we don't have to overdo it on Japanese jargon. They are adjusting the intro courses:
JBA will also shorten the introduction workshops 40,000 health care workers must take, and include more Saskatchewan content.
There has been a lot of back and forth about Lean in the op-ed pages of Saskatchewan newspapers. The papers don't always allow reader comments on these op-eds, but I'll share the columns and comment here. Debate is great. If bad things are happening in the name of “Lean,” then that should be called out. But, some of this back and forth is exhausting at times.
In his piece, he highlights complaints from nurses about being followed by people with stopwatches.
Yet the Saskatchewan Union of Nurses (SUN) says stopwatch toting lean administrators have been following operating room nurses to monitor their performance.
Does this really contribute to the improved patient care that lean is supposedly about?
“When we followed up, we asked (why stopwatches were required),” said Amber Alecxe, SUN's director of Patients and Family First and Government Relations. “We were told it was about charting flow.”
Lean doesn't require stopwatches. If we engage the people who do the work and ask them to identify barriers to flow, quality, and safety, they can point out those problems. We can have people shadow their peers to draw spaghetti diagrams and do time studies if that's helpful in identifying waste. I've written about this before (“You're the Time Study Man” and “Time & Motion Studies Are Not “Discredited,” Just How They Are Used“).
The use of stopwatches dates back to the days of “scientific management” and industrial engineering. Time studies can be threatening if we communicate badly or don't fully engage people.
Time studies can be helpful and actually be embraced by staff and nurses if we:
- Help them understand WHY the time studies are being done – not to make them work faster, but to identify problems, waste, harmful variation, barriers to providing safe, high quality, compassionate care.
- Make it clear that time studies and Lean won't lead to layoffs (and hold to that).
- Teach peers to shadow each other (as I've done and recommended) rather than having some outside expert or engineer do it.
- Let staff review the spaghetti diagrams and time studies and let them give input into improvements.
- Implement changes, based on the time studies, that make people's work easier and improve patient care.
The Mandryk column reports that nurses say that, with Lean, morale is worse, they have less time for clinical education, are more stressed, and less time for patient care. Something's not right here.
Zambory and Alecxe say the survey and general discussion with their nurses is producing stories of supplies being “leaned” out – vital respiratory equipment removed from emergency carts, catheters for nursing home patients that are cheaper, but more painful to insert, vaccines running out and more paperwork – not less.
And when nurses have brought up such concerns, some have been told by administration to “shut up” and stop complaining, Zambory said. The SUN president added the declining relations have really been more evident in the last year or so as the Sask. Party pushed its lean implementation.
If these allegations are true (supplies not being available, being told to shut up and stop complaining), there are some very deep problems and issues to resolve in Saskatchewan.
“Better patient care can't be measured by just a stopwatch.”
That's absolutely right.
Bonnie Brossart, CEO of the Saskatchewan Health Quality Council wrote a rebuttal to the Mandryk piece. She says:
“Without measuring time, we can't identify opportunities to make things better for patients.”
That's actually not completely true. Time studies and measurement are just one way of identifying problems and opportunities. If time studies are being done in a way that's antagonizing people, you could back off from that (or change the way the time studies are done).
“Concerns expressed by nurses [about paper airplane exercises and time studies] point to the need for leaders throughout our health-care system to do a better job communicating about lean.”
She's right that leaders need to listen (and certainly not tell people to shut up). But, sometimes “we need to communicate better” isn't the right countermeasure. American politicians say this all the time about unpopular laws (nationally and locally)… when people are opposed, they'll say “we just need to communicate better about what we're doing,” instead of changing what they're doing.
Dr. Mark Lemstra has written many op-eds that are critical of Lean and the Saskatchewan government.
In this op-ed, he points out that Virginia Mason Medical Center, for all of their success with Lean (an approach that John Black helped launch), doesn't rank highly in different national hospital rankings, such as U.S. News & World Report. Well, neither does ThedaCare. It's widely discussed how these national rankings have a built-in bias toward the big name academic medical centers and how patient safety data is a minuscule portion of the scores that lead to the ratings.
Lemstra ignores or doesn't share the data about VMMC's measurable results and ignores the fact that The Leapfrog Group named VMMC “Hospital of the Decade” for their improvement efforts.
In fact, a recent blog post from the CEO of Virginia Mason clarified that lean management is now correctly focusing on administrative tasks in that hospital, and not what happens between doctors or nurses and their patients.
I cannot find such a blog post on the Virginia Mason website. There's no evidence that it exists or that Dr. Kaplan said such a thing. Virginia Mason has certainly been using Lean to help improve what happens in patient care, including increasing the nursing time at the bedside from about 30% to 90%. See their blog posts about Lean and nursing care.
Lemstra writes again a few weeks later about Lean.
“Lean, and other industrial improvement methodologies, are increasingly touted as solutions to the quality and cost challenges in health care.
“However, despite infiltration of lean terminology into the vernacular of health care delivery, and the encroachment of exotic Kaizen quality improvement events into hospital conference rooms, results have often been disappointing.”
We've proven that Lean can work in healthcare, but that doesn't mean it's guaranteed to always work if there are misunderstandings, misapplications, a lack of leadership, etc.
Lemstra is right to point out that Lean is just one part of the solution for healthcare. Nobody is saying it's a cure all. I'm not. John Toussaint and the ThedaCare Center for Healthcare Value are not saying that.
Criticizing how Lean is apparently done in Saskatchewan is not the same as saying “Lean doesn't work here” or “Lean wouldn't work here,” as others are saying online.
Good summary to end his piece:
“If Saskatchewan must implement lean, it should follow Kaplan's advice by recognizing that it is only one tool of many – it must grow organically and include empowerment, respect and feedback from all staff members, and must be patient-centred.”
Gary Kaplan chimed in with his own rebuttal, including:
“Mark Lemstra stated that the health system I lead, Virginia Mason in Seattle, is now focusing its application of lean management on administrative tasks that don't affect patient care. Nothing could be further from the truth.”
Dr. Lemstra has a lot of good points to make without making up things about Dr. Kaplan.
Beyond also mentioning the Leapfrog Group accolades, Kaplan says:
“Virginia Mason received the Outstanding Patient Experience Award for the second consecutive year from Healthgrades, placing us among the top 10 per cent of U.S. hospitals for patient experience.”
There are good things happening at VMMC.
“Our work is focused on creating, for every patient, a perfect experience in an environment where team members are engaged and able to do their best work.”
Dr. Susan Shaw wrote a rebuttal to the Lemstra pieces. She correctly points out how Dr. Lemstra misrepresented Dr. Kaplan's views.
“Lemstra's column misrepresents Kaplan's view and uses it to reinforce his opinions – which seem unswayed by the evidence of Virginia Mason's success, turning from the brink of financial disaster to become a highly regarded organization…. And Lemstra errs in saying Kaplan's article was not peer reviewed: BMJ Quality and Safety is in fact a highly selective peer reviewed journal.”
People can and should disagree and debate issues of the day… but when you take things out of context and get key facts wrong, you don't do yourself any favors.
So what can we do, other than being a spectator in this arguing back and forth?
We can encourage people to read about (and practice) what Lean and the Toyota Production System are really all about. Share data and results. Look at evidence instead of slinging mud. Point out problems that should be corrected.
I hope this discussion helps Saskatchewan do a better job of improving patient care.
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