“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:
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.
What are your thoughts? You can comment on their article or post your comments below.