Reflections on Almost 10 Years in Lean Healthcare
I often get asked, “How did you get into healthcare?” I was working on a chapter for a Lean healthcare compilation book that's being published in Holland and I wrote the following material that wasn't the right fit for that chapter, but I wanted to share below:
It has now been just about ten years since my interest in Lean healthcare was sparked by a visit to a hospital emergency room in Scottsdale, Arizona. Thankfully, I was there as a visitor, not a patient (no offense to the hospital, I'm just glad to not be a patient anywhere). At the time, I worked for Honeywell, a global manufacturing company, in a “Lean manufacturing” role. Within the Phoenix area, we had an informal network of Lean practitioners from different companies who met quarterly to discuss Lean and to do a “gemba walk” at one of our facilities.
In early 2005, we had the opportunity to visit Scottsdale Hospital to see how Lean was being applied in the emergency department. The efforts were being led by two women who had left Motorola, bringing their Lean and Six Sigma experience with them. I was impressed with what I saw and it opened my eyes to the potential of Lean in healthcare.
Although it was the very early days of Lean in healthcare, I tried reading as much as I could find on the internet about the challenges faced by hospitals and health systems and how Lean principles were being applied (or could be applied, as the hypothesis would be stated). This interest and research led to me taking a new job, with Johnson & Johnson, as part of a consulting group that helped introduce Lean to hospitals through training classes and project work.
In 2005, when I started that job, we still spent much of our time trying to convince people that Lean would be applicable to healthcare. Much of the early convincing took place in hospital laboratories, which was somewhat natural since labs are more like a high-tech factory than other parts of a hospital. Even if laboratory directors weren't interested, at that point, in Lean as a management system, they were greatly interested in the results that early adopters of Lean in labs had achieved, including 30 to 70% reductions in test turnaround times, improved productivity, and reduced error rates.
While there was a fair amount of interest from the labs and hospitals in “cost cutting,” our work at Johnson & Johnson was based on a commitment that nobody would lose their jobs as the result of Lean. To use Lean to drive layoffs would ensure that people would not participate in the Lean improvement process. Instead, we used Lean to reduce spending on supplies and reagents and to increase the volume of lab testing that could be done without hiring more staff. There was also great interest in improving quality – both through reducing turnaround times and reducing labeling errors and the like.
Over time, Lean became established as the new “best practice” in laboratory medicine. We then spent time, as others did, convincing other parts of the hospital that they could also use Lean methods and management practices to improve patient care and performance in many dimensions.
It's easy for healthcare professionals and leaders to focus on how they are different than manufacturing. Yes, it's true that healthcare is very different than manufacturing in many ways, but that means that we need to, if anything, figure out how to adapt Lean thinking to healthcare instead of making excuses that prevent us from trying.
Even as Lean spread within healthcare, different disciplines and departments would often focus on how they are different. If Lean had been adopted initially in the core clinical laboratory, the microbiology and histology areas might complain that they are different in their volumes and processes. Areas like the emergency department or radiology could argue they are different than lab because they directly interact with patients more often. But, we've found and proven, in practice, that Lean principles are robust enough to solve problems and improve the workplace in many different environments.
With all of the books, case studies, and journal articles published over the last ten years, we have moved beyond the early days when the primary question was, “Can Lean work in healthcare?” That question has been definitively answered as a resounding “yes.”
We now know Lean can work in healthcare, but the question today is more specific to our own organization – “can we make Lean work in our organization?” The answer to that question depends on the leadership that's present (or not present) throughout the organization. Lean can work, but that does not mean that it's guaranteed to work in any given situation. That's, perhaps, the challenge for the next decade… helping people understand what's necessary to increase the likelihood that Lean will be successful, meaningful, and sustainable in their own organization.
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I have been working as an medical interpreter in Columbus OH for the last year. I have observed how much waste time is spent waiting by the patients. Part of the 7 wastes is waiting. I do not complain, because even when I’m waiting with the patient, I’m still getting paid. However, I cannot stop thinking how much better the system would work if the process was designed as a manufacturing assembly where instead of the doctor moving from room to room was the patient who’d moved from one area to the other.
For example, check in –> vitals —> doctor examination –> discharge instructions. —> check out.
I know, one of your main points has been how much different Lean Healthcare is different from Lean manufacturing, yet wouldn’t be worth to change the system?
I would talk more about “improving patient flow” instead of calling it an “assembly line” (that’s just too loaded of a term to talk about assembly lines in medicine.
But we should learn lessons from assembly lines:
1) Ensuring good balanced flow between steps (balancing supply and demand and avoiding bottlenecks)
2) Ensuring things can be done right the first time (or, when not, we need a culture that allows people to report problems and work collaboratively to fix them)
3) Be customer focused and look at value, not just keeping busy
What a timely post! I’ve been reflecting back on the last five years that I’ve been in Healthcare. We know that Lean (and even Six Sigma) can and has been successful in Healthcare. Yet many hospitals still fail to do it well or even to it at all.
How do we increase the probability of success when implementing any process improvement methodology in Healthcare? I know the typical answers tend to fall around Sr. Leadership engagement/support/knowledge but that could be said for any company or industry.
Most of the engineers (by engineer I mean anyone who is practicing Lean or Six Sigma) I’ve worked with come into healthcare with strong process improvement skills but they get frustrated by the culture and language of the industry. Plus they have to get used to not being the Subject Matter Experts and facilitate the improvement versus owning it.
One strategy that may pay immediate dividends is to better prepare the non-clinical engineer to enter healthcare. We need a way to acclimatize the non-clinician to the clinical terminology, DRG’s, finances (charge master vs. reimbursed rate vs. actual cost) and general hospital operations. In essence I believe we need to on-board the non-clinical engineers so they can have a conversation with their clinician partner without having to Google every third word.
Thanks for your comment Mustafa. For a number of reasons, I’ve seen it be really effective to partner up a clinical person (with no or little Lean experience) with a non-clinical person (with lots of Lean experience).
They can learn from each other (especially terms and jargon) and work together to identify problems, build trust with people, and drive improvement.
I have seen healthcare organizations that are looking to lean processes to improve their services use their internal staff to become lean facilitators or program managers. I think that strategy has lots of merit, during the past 30 years I have spent in healthcare I have found it very difficult for health care leaders to take advice or direction from those who have not walked in their shoes. Especially nurses, they demand a lot of credibility from their leaders. Nurse are very smart individuals and can grasp the lean concepts very quickly, nurses are also great problem solvers and willing to learn, so a lean coach has a very motivated person to work with.
Yes, I’ve always said “It’s easier for a nurse (or pharmacist) to learn Lean than it is for me to learn nursing (or pharmacy).” That said, I think you need outside eyes to act questions and help challenge things and guide the process. But, Lean improvement in clinical areas should be owned and managed by the clinicians and the clinical leaders.