Dr. Gary Kaplan is the CEO of Seattle's Virginia Mason Medical Center, considered one of the world leaders in the adoption of Lean healthcare principles. He wrote the foreword for my book The Executive Guide to Healthcare Kaizen.
He co-authored a recent editorial in the BMJ Quality & Safety journal:
It serves as a bit of a counter, saying “Lean does work,” to the recent NEJM article where two doctors claimed that Lean is inappropriate for healthcare.
Both editorials are unfortunately free of data. We know that Dr. Kaplan has direct experience leading VMMC's Lean transformation and that VMMC does have results to report. It's unclear if the NEJM authors had any direct experience with Lean or L.A.M.E.
Dr. Kaplan wrote:
“Lean can be effective in healthcare as well as in manufacturing, with a growing literature supporting improved patient experience, quality, safety and efficiency. The existing research is far from complete but there are at least abundant examples as proof of concept that, under many circumstances, Lean can be effective.2-4“
Note that he says it can work in healthcare. I would say the same thing. It does work… it can work… but that doesn't make Lean easy or something that's guaranteed to succeed. A lack of leadership and other factors (such as not really understanding Lean) can lead to a lot of problems or failures.
Dr. Kaplan writes about some of the pitfalls to avoid, including:
“The first of these [pifalls] is the misinterpretation of Lean merely as a set of tools targeted at short-term gains. The tools of Lean are well known and include value stream maps, 5S and rapid quality improvement workshops. These tools are effective in the short term, but true transformation and sustainability require, in addition, aligned leadership, a supportive institutional culture and integrating the Lean tools as part of a comprehensive management system.1 Absent these latter elements, expectations for Lean improvement should be limited to small-scale targeted gains.”
As I've written about here, Lean is not just a set of tools. It's also a philosophy and a management system.
Dr. Kaplan is also right that Lean has to be focused on longer-term success and goals, not just short-term gains. Hospitals often go for short-term gains by laying off staff… Lean is an alternative to that. Principle #1 of the “Toyota Way” philosophy says to make decisions for the long-term, even at the expense of the short term.
One example of short-term thinking would be sending nurses home early to “save money” when census is low… when a Lean organization would choose to continue paying them that day so they can work on Kaizen improvements… arguably saving more money over time than sending them home would have realized. Read more about “flexing” and how that's not Lean.
Dr. Kaplan's editorial was in response to another piece in that issue that questioned if Lean provided benefits to patients:
“However, in this issue, Poksinska et al report that implementation of Lean management in 23 primary care centres in Sweden was not associated with improvements in the patient experience.5“
The authors of that piece are, rightfully, saying that healthcare organizations need to focus more on the patient (customer focus being a primary Lean philosophy and mindset). They are NOT saying Lean cannot impact the patient experience:
“Lean healthcare implementations seem to have a limited impact on improving patient satisfaction. Care providers need to pay more attention to integrating the patient's perspective in the application of Lean healthcare. Value needs to be defined and value streams need to be improved based on both the knowledge and clinical expertise of care providers, and the preferences and needs of patients.”
If organizations are only focused on cost cutting, that's not really Lean (see my recent post). If you're not focused on the patient as a customer, that's not really Lean.
Dr. Kaplan makes this point (and credit goes to BMJ for, unlike NEJM, printing two sides of a discussion in the same edition):
“…lack of improvement in patient satisfaction should not be seen as a failure of the Lean management system, but rather as the expected outcome when patient values and experience are not prioritised.
Nonetheless, the results of the study are provocative. No doubt all healthcare institutions identify patients as the first priority. However, do the needs of the patient truly come first? The results presented should provoke us all to re-evaluate our own priorities and, if we are applying Lean, to understand from which perspective waste is defined. In a sense, we would view the Lean implementation described in the Poksinska paper as a lost opportunity. The time and resources devoted to applying Lean to address the needs of the health system could be better used to improve value for the patients primarily, as well as all providers and staff. Cost-saving may then be expected to accrue from improved patient outcomes, and from better workforce engagement, productivity and efficiency.”
Cost savings is the end result of focusing on the patient, improving flow, improving quality, and creating a better workplace. Many organizations SAY that the patient (or patient safety) is the top priority, but that's too often just lip service.
My Healthcare Kaizen co-author's organization Franciscan St. Francis Health does focus on improving the patient experience. Their NICU has increased patient/family satisfaction (it's parents filling out the surveys) from about the 45th percentile to the 99th percentile. Their director credits the practice of Kaizen for this improvement – everybody identifying problems and working to fix them on a continuous basis.
Since journal articles matter, I'm working with Joe Swartz and the director of that unit to write an article that formally documents how they have used Lean and Kaizen to improve patient satisfaction. Again, that proves what's possible… but doesn't prove that it's easy or that every leader is able to make that happen.
We're close to selling out, but you can come visit Franciscan in April to visit the NICU (and other departments) and see what a culture of continuous improvement looks, sounds, and feels like.
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