Earlier this year, we had rantings from two doctors about Lean in the esteemed New England Journal of Medicine… except what they described didn't really sound like Lean (as I wrote about here and here – and also see Dr. John Toussaint's rebuttal). Also see this piece that I just discovered by Dr. Patty Gabow and Ken Snyder.
Now, there's a story written by an emergency medicine physician, Dr. Brad Cotton, that appears in a publication called “Emergency Medicine News” — FIRST PERSON: ‘We Fired Our Hospital'
What appears on the front page of their publication in the June 2016 edition isn't news — it's a first-hand story and an opinion piece. This is the “most trusted” name in “news” for emergency medicine professionals? Good grief.
In the article, Dr. Cotton describes the poor treatment he's received from a 40-something internal “Lean consultant” named Dean.
If what Dr. Cotton describes is true, I stand by him in his concerns.
But, there are things I'll be critical of here, about his writing and behavior.
In the story, Dr. Cotton describes a typically hectic E.D. scene where he's “six patients behind” and he's spent some time talking to a patient's mom in an attempt to comfort her and explain the situation… a perfectly human and caring response.
Then, Dr. Cotton describes an interaction that I'd hope would never happen… it's certainly not the way I'd act as a Lean consultant:
“And that's when Dean confronted me. “He wasn't your patient! You are six patients behind!” Dean was the hospital's MBA consultant for LEAN management.”
It's the least important detail here, but Lean is not an acronym.
More importantly, It's hard for me to imagine a Lean consultant getting upset at an ER doc about falling behind, etc. I generally don't see people operating that way. Does such behavior rank really high in the “respect for people” scale? Is that the right way to engage people in improvement?
It does strike me that Dr. Cotton constantly refers to Dean as an MBA. That's probably a statement of fact, but it implies that Dr. Cotton doesn't respect MBAs (although maybe they've treated him badly). The tone of this whole piece seems to reflect a lot of distrust and disconnect between physicians and management, which is really sad to see (and its fairly common).
Dr. Cotton continues:
“Last week I had embarrassed him in our department meeting by asking how applicable it was to take a process meant for assembly line production of cars and apply it to the very cognitive, very complex management of living human beings in the ED.”
Is Dr. Cotton being respectful and trying to work with Dean? This comes up all the time, the question about how patients aren't cars (as I've written about), but it's hardly “embarrassing” to have this pointed out. Maybe it was in Dr. Cotton's tone. And I wonder if it wasn't Dr. Cotton who was embarrassed in that exchange.
Hear Mark read this post (as part of this podcast):
It's also telling that Dr. Cotton doesn't understand that manufacturing can also be “very cognitive” and “very complex.” It bothers me when people look down their noses at manufacturing when they've usually never set foot in a factory. Is that respectful?
“I had also asked Dean what they do when the line runs too fast, and a scrap car is produced. Producing scrap was not an option for us, I had said.”
Dr. Cotton really exposes his ignorance about manufacturing. An assembly line runs at a steady pace. It's not possible to run the line “too fast.” That said, an assembly line is usually highly engineered to make sure each of the jobs is achievable within that “cycle time” or line rate.
Healthcare overburdens people all the time, which, again, is sad. Factories (at least Lean factories) don't do that.
There's not a “scrap car” produced. It's silly to think that a car is “scrapped” and thrown away. Again, ignorance about manufacturing there. What's more likely is that some sort of defect is found (and it's not because people were having to work too fast).
What happens is an employee “pulls the andon cord” to point out the problem. Management thanks them for this and then works together to resolve the problem — either a short-term fix or a root cause fix that prevents recurring problems from popping up again. That's exactly what we need MORE of in healthcare… being able to put quality first instead of pressuring people to work faster. Virginia Mason Medical Center, for examples, calls this their “Patient Safety Alert System” and it's that Lean concept put into practice in healthcare.
Dr. Cotton then writes about Dean, the consultant, coming into the ED as a patient having heart problems. Dr. Cotton implies that Dean is a drunk… something that's not very professional, not very respectful, and something not worthy of publication, even if “Dean” is not his real name.
Dr. Cotton recounts the lecture he supposedly gave to Dean:
“Dean, unlike like your cardiologist, who doesn't make my job harder, you do. It was the right thing to spend time talking with you while you were a patient. It was the right thing for me to take that kid over to his mom the other day. It could have been the last time he saw her.”
I agree with Dr. Cotton that Lean and a Lean consultant shouldn't make his job harder. I've written before about how what we might call “loving care” can be as important as the efficiency of care.
“We can't see four to five patients per hour, what with the acuity here and a 30 percent admit rate. The emergency medicine literature says we can't. Too fast means mistakes, and I can't just scrap mistakes — someone dies.”
Was Dean setting standards that couldn't be achieved? Was Dean (or management) pressuring people to work faster and telling them to put speed above clinical quality? If so, I'd be upset too. But, behavior like that isn't Lean, it's L.A.M.E. (or Lean As Misguidedly Executed). Prof. Bob Emiliani calls stuff like this “Fake Lean.”
Dr. Cotton and his colleagues felt disrespected and I couldn't blame them for that. He writes about how his group of emergency physicians “fired the hospital” (per his dramatic title) and walked away because they didn't like the conditions.
“Do we as a whole need to speak up and say there is a limit to how much we can tolerate and still remain professionals? It is past time to take emergency medicine back from the Deans, LEANs, and MBAs.”
Again, one of the core tenets of the Toyota Way management system and Lean is “respect for people.” In the Lean philosophy, we're supposed to work with people and not antagonize them. It makes me wonder what Dean's side of this story would be, though?
If consultants or MBAs or “C-suiters” (or “the suits” — I'm surprised Dr. Cotton didn't use that pejorative) aren't treating doctors professionally, that's not Lean. As a Toyota executive told me earlier this year, “If people are upset, it's not really Lean.”
But, maybe Dr. Cotton needs to think about respect, look in the mirror, and first heal himself? Does Dean, as the consultant?
As a Lean community, we should reflect and ask:
- Do situations like this happen?
- If so, why?
- What can we do about it? How can we pull the andon cord and prevent situations like this?
Photo via Flickr user KOMU News, used under Creative Commons license