“Healthy Debate” About Lean in Healthcare & Emergency Departments
I was recently interviewed by one of the reporters who put together this web article in Canada:
“From the factory floor to the emergency department: Hospitals explore Lean method”
The article highlights Lean success stories and it also raises some interesting challenges and data that question the approach.
My friends at St. Boniface General Hospital in Winnipeg are cited as a positive example, with reductions in CT waiting time for patients.
Even though Lean methods are being used pretty much all across Canada:
However, critics argue lessons from a Japanese manufacturing system aren't transferable to health care and that Lean's benefits remain unproven. Saskatchewan instituted one of the largest tests when it began implementing Lean in health care institutions across the province. Four years in, it's revising its plan in the face of mixed reviews.
As I've written before, it seems pretty clear at this point that Lean CAN (and often DOES) have great benefits in healthcare (including patient safety and quality)… but that doesn't mean every single organization will be successful with Lean. Look at the results at ThedaCare, Virginia Mason, Seattle Children's (and others) and you see that Lean can lead to meaningful results. But, again, not everybody gets those results. So, we should ask “why?”
The article does a decent job of defining Lean. I posted a few comments on the article to try to clarify things (and there are some off-base comments, such as one comparing Lean to offshoring and outsourcing).
They define Lean as:
- “focused on rooting out waste” (but I'd add Lean is more focused on improving flow and increasing value than cutting)
- “targeting efficiency and the desires of the customer” (again, Lean is more concerned about flow and keeping the patient moving than it is worried about the efficiency of individual parts of the system)
- typically involving a “group of all levels of workers, from physicians and managers to administrative assistants and cleaning staff”
- “institutions are supposed to strive for continual improvements”
That's a better definition than many journalists come up with. The article, however, seems to focus a bit too much on projects instead of management systems and culture change. They do also rehash a bit of the Saskatchewan controversy over Lean.
“Now that Lean is being put into practice, we are seeing the primary focus is on creating efficiencies, waste reduction and budgetary savings only,” the Saskatchewan Union of Nurses said in a statement.
If that's true, I would complain about that as well. Lean's main focus should be on safety and quality, as part of a balanced scorecard view of improvement and goals.
A Study of Lean E.D. Improvements in Ontario
First off, I'll state for the record that I've visited and taught at many hospitals in Ontario. I've seen some of the improvement efforts that were labeled as “ED-PIP” or later just PIP (Process Improvement Program). Many of these hospitals instituted a “split flow” process that separated high acuity patients from low acuity. There were many other Lean methods and management practices put into place. Some of the training I've done has been in partnership with the consultants at KPMG Canada, the designers of and primary consultants for the Ontario hospitals.
From the article:
“Dozens of hospitals in Ontario have also used Lean, including Toronto's University Health Network,North York General Hospital and Windsor's Hotel-Dieu Grace. One of the most notable successes was using Lean to reduce wait times in the emergency department. At Hôtel-Dieu Grace, Lean helped significantly reduce emergency wait times, decreasing average length of stay from 3.6 hours to 2.8 hours, while increasing patient satisfaction. But a recent study found that Lean may not have deserved the credit. “Although the program reduced ED waiting times, it appeared that its benefits were diminished or disappeared when compared with that of control sites, which were exposed to system-wide initiatives such as public reporting and pay for performance,” it concludes.”
You can read the full PDF of the study here. You can also see this similar article that summarizes the findings: “Toyota approach not paying off for Ontario hospitals.”
It seems like there's not any debate about E.D. wait times falling — the question is about why. What deserves the credit for E.D. flow improvements?
No improvement ever takes place in a vacuum or a completely controlled setting. Even within a single hospital, it can be challenged to prove cause and effect between your efforts and results, because so many things are happening at once. Did your 5S program lead to reduced central line infections or was it due to one of the myriad of parallel initiatives and campaigns? You don't always know for sure.
The authors of the journal article are arguing that hospital E.D.s that did NOT use the ED-PIP program also saw improvement, so it was due to other systemic factors and things taking place across the province.
The lean intervention was not associated with a marginal decrease in ED length of stay compared with broader system-wide interventions.
One could ask if all of the hospitals in the “lean intervention” pool were equal. In programmatic approaches like this, some leaders and some hospitals are going to more enthusiastically work on initiatives like this. The journal says “sites for each [ED-PIP] wave were selected by the Ministry of Health according to expressions of interest.”
One could also ask if it's somehow harmful to teach people how to manage better, how to solve problems, and how to continuously improve, even if you can't prove the cause-and-effect between ED-PIP and waiting times? The journal authors admit “Our study did not address the effects of the lean program on front-line staff,” which is an important expected benefit with Lean.
Anyway, I did my best to read the journal article. I'm glad they did the study, as it's important to be data driven and to be a skeptical scientist, rather than just accepting things on blind faith. If you're more accustomed to reading academic / medical journal articles, I'm curious to hear your reactions.
Reader Comments & Fears
In the article, people understandably bring up concerns, more broadly, about Lean, including:
- Lean can't be about cutbacks (it shouldn't be, as Lean is a great alternative to layoffs)
- Lean shouldn't be just a fad
- The word “lean” has negative connotations (which I understand)
- Culture change is difficult
One comment on the article, from a pathologist, is eye opening:
Nobody has actually asked people who are under some sort of Lean-based program how they feel about their work. In my experience it removes autonomy and turns one into a cog worker. Not very good for morale. Many share my sentiments, but I cannot back it up with factual claims.
If “nobody has asked people” what they think about their work, that's “L.A.M.E.,” not Lean. Lean's intent, even in a factory, is not to turn people into interchangeable cogs who aren't listened to.
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At this point, Mark, I view any data coming out of Ontario with greater skepticism. If they implemented Lean with the same rigor that they implemented the WHO checklist, then there’s no point in wasting time on this article.
In the case of the the WHO checklist, the government sent out the checklist, and then mandated that hospitals publicly report their usage. Unsurprisingly, overnight adoption was between 90-100%, but their findings were that the checklist didn’t really have any impact. Of course, it was all self-reported and there was no actual assessment of the quality of the checklist use. More rigorous studies have found checklist completion at 4-54%.
As you noted, the pathologist’s remark makes it very clear that Lean hasn’t been implemented in that hospital. People resist change, and institutions magnify that effect because they have so much inertia. Darwin plays in heavily here, there are hospitals that will seriously implement Lean (methods, management, systems, culture, etc.) and those that will go bankrupt, and be purchased by other hospitals.
Yeah, I’m sure there is a big difference between “doing checklists” (to satisfy a requirement and get regulators off your back) versus really adopting the methods and culture change required to make checklists helpful.
If there is “L.A.M.E.” (Lean As Misguidedly Executed”) then there is also C.A.M.E. with Checklists??
How many of these Ontario ED-PIP hospitals were just implementing a program versus really embracing and adopting a holistic Lean culture and management system?
The ED is a great place to test whether Lean is a good fit for healthcare. I’ll put forward that Lean works best in stable and predictable environments.
Take a Lean guru from manufacturing into an ED waiting room and his or her head will likely explode! At any random moment on any random day, staff could be idle, overwhelmed, or even once in while, staff levels could be just right. Then there are all of the traveling bottlenecks through the ED including nurses, doctors, phlebotomy, lab, transport, inpatient beds, radiology, or seven other things.
I’ll also put forward that no hospital has enough resources to avoid backed flow from time-to-time.
Now that I’ve made the case that the ED is not a good place for Lean, there are numerous Lean tools that can be applied in the ED to respond to variation in demand and variation in support resources that will make things better. So yes, go and apply Lean tools! They will help, but then to make Lean work in an inherently unstable environment requires critical thinking, situation awareness, and both dynamic and strategic problem solving skills. These “thinking” skills take years to acquire and I think I remember somebody in Toyota saying that these skills take decades to master.
So I think quite frequently, people put Lean tools and even some Lean management concepts in place and are discouraged by the lackluster results. What is the answer? A way to accelerate true Lean thinking by leaders first and then staff. I frankly don’t know how to do this. Otherwise, leaders need to put in the time and be patient. Some of the organizations you mentioned are on their way. At least one of organizations you mentioned has found that in spite of all the successful Lean stuff they have put into place, they just aren’t there with leadership, so they are refocusing at that kind of stuff.
So two things: Lean has to be adapted for healthcare and doing Lean is going to take time even when done well.
I see great application of lean thinking in Emergency Departments all the time. NYCHHC, Akron Childrens, Lehigh Valley Health Network, MemorialCare, Salem Health. I could go on and on (and will if you want more examples). It works.
I was at Seattle Children’s during their LEAN implementation. I saw how a successful LEAN implementation looks first hand at a specialty hospital with physicians who provide services at both an academic medical center (University of WA) as well as Seattle Children’s. There were a ton of moving parts to the implementation, and it doesn’t start with overlaying LEAN on top of existing processes and culture. LEAN has to replace the process mentality (“I do this action to get this result), existing culture, traditional attitudes and instead focus on the entire value stream you are trying to improve – interactions and hand-offs between all departments and players in the overall flow of patients in the process – from the time they enter the front door to the time they leave the building and are billed for services…
Whether it is “regular” patient admissions, OR, or the ED – any one of them is just as good a place as any other to work on, but it has to be inclusive of all departments that work with and support value stream you are working on in order to be effective. And defining the value stream correctly is crucial. So, “putting LEAN” into the ED means including front desk/registration, patient access, triage, security, LAB, Radiology, interventional cardiology, external emergency services like ambulance providers and Fire Departments, Nursing staff, Physicians/PAs/Nurse Practitioners/Physician Specialists, the “scribes”, the housekeeping/clean up crew cleaning rooms between patients, supply chain staff/purchasing, any individuals responsible for making sure the rooms/ are equipped with the proper supplies, discharge staff, and patient accounting/insurance billing/collections.
At Seattle Children’s one illuminating example was a problem of the value stream defined as “referral for admission from an external provider to the hospital for specialty services (usually surgery) through discharge/billing for services from the hospital”. The value stream took (on average) 124 days, as I recall. Patients and their anxious families waited 3+ months (most of which was on the front end of the value stream) to get their child admitted and treated at the hospital. After LEAN (this effort took a little over 8 months to accomplish, by the way), that entire value stream was cut to 28 days (on average) (including the referral to Seattle Children’s, getting them into the hospital, the hospital stay/services rendered, recovery, discharge, and patient/insurance billing)! However, EVERY DEPARTMENT IN THE HOSPITAL AND even most REFERRAL PHYSICIANS had a role in the value stream LEAN effort.
LEAN is not a “project”. It is a “lifestyle” change for a hospital. It is not designed to cut costs or “waste”, but does eliminate wasted effort, redundant hand offs and bureaucracy. If that produces fear of change feel they will lose control, it is silly. The key lesson of LEAN is that any single person in the value stream has the power to stop it if they feel there is a problem and correct it immediately. That is true control, accountability, and self-authority. NO COGS.
“ED Wait Time Reduction” initiatives are the microcosm of my biggest concern with real-world Lean practitioners. A significant majority of the “successful” ED Lean initiatives I’ve seen didn’t make a significant impact at all in clinical outcomes or end-to-end patient experience. Many have just shifted the wait and waste somewhere else in the process (lab, radiology, in-patient, etc). If we don’t take the time to understand that the value stream extends beyond the four walls of the ED, we sub-optimize rather than improve flow.
Another interesting effect of ED Lean improvement came out of a Harvard study a few years ago. Researchers found that improving the efficiency of the ultrasound ordering process certainly reduced ED wait time, but also had the negative side effect of increasing the volume of ultrasound orders, even where they weren’t clinically appropriate. So patients spent less time in ED, but more time in non-value-added imaging time. The process was made easier, so people used it more. Despite the fact that it had no clinical benefit.
We have too many “Lean Experts” who know enough to actually be dangerous who would celebrate that project as a success.
Well said, Robert. We should all aim to be good systems thinkers and avoid sub optimization or point optimization.
Your example about ultrasounds adds unnecessary cost, as well.
Unnecessary CT scans add additional risk and downside to the radiation too.