This Time, the NEJM Publishes Something Positive About Lean

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You might remember the hubbub (a kerfuffle?) over the NEJM opinion piece written by Dr. Jerome Groopman and Dr. Pamela Hartzband. See my first post about their article. There are more links at the bottom of this post

Now, the “Perspective” section of the New England Journal of Medicine has published a piece titled “The Hard Work of Health Care Transformation by Dr. Richard Bohmer. Check it out.

Dr. Bohmer says “government and regulators influence” (or attempt to influence, I'd add) healthcare organizations through financial rewards and penalties, regulatory constraints, and attempts to encourage “performance-improvement activities through education, research, and measurement programs.” These approaches might help, but aren't sufficient.

Dr. Bohmer points out that healthcare executives are often attracted to structural and governance changes – these might include mergers and reorganizations. “Moving boxes” on the org chart and similar approaches “[appeal] to boards, CEOs, and consultants because big changes can be made rapidly.” But, these changes might also be insufficient.

What's required? Hard work.

“Organizations' delivery of care is ultimately governed by structures and processes at the ward, clinic, or practice level.”

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Lean is one of those methods that helps at this level of redesigning and improving the delivery of care.

Dr. Bohmer cites Virginia Mason Medical Center, one of the poster child organizations for the use of Lean and Toyota Production System methods and principles. They “constantly make small-scale changes to their structures and processes over long periods.” That sounds like Kaizen, or continuous improvement.

That classic Kaizen approach is basically described by Dr. Bohmer, when he writes, “Major change emerges from aggregation of marginal gains.”

As I've seen in my experience, these changes are undertaken by “multidisciplinary teams,” which is required since “patients routinely cross so many intra- and interorganizational boundaries that no single designer can create a highly functioning microsystem.”

In Lean, we call that approach “improving the value stream,” or the end-to-end patient flow, rather than just trying to improve every department, function, or silo. We're looking at the system, not just the pieces.

Dr. Bohmer writes of the “hard truths” of this approach to improvement, adding:

“Teams often redesign local structures and processes despite the lack of senior support, adequate data, capital, or a reimbursement system that rewards their efforts.”

A lack of senior leader support is frequently cited as a barrier to improvement. There's a balance to be found. Senior leaders shouldn't be diving into the details to give solutions for every problem, nor should they micromanage improvement efforts. Leaders have to create the environment and culture that allows improvement to happen. Executives need to be “servant leaders,” providing resources and breaking barriers when necessary.

Dr. Bohmer writes:

“And few redesigns get it 100% right the first time. In practice, health care transformation is a long series of local experiments.”

That's very true. I don't know any approach to improvement that guarantees getting it “100% right the first time.” In the Plan-Do-Study-Adjust (PDSA) approach to improvement, we're often happy with an initial 80% solution. We don't let perfect become the enemy of better, as they say.

In a culture of continuous improvement, we'll take “80% right” and build upon that to get closer and closer to 100% through continued experiments. “100% right” is the goal, even if we realize we might never get there.

Dr. Bohmer suggests there are “seven essential organizational elements that support orchestrated team-based redesign,” which I'll try to summarize below (and see his article for more detail):

  1. “Deploy many redesign teams concurrently — some permanent, some temporary.”
  2. “Redesign teams are typically led by clinicians, although managers are well represented.”
  3. “They aim to improve the quality and the efficiency of care simultaneously, and the organizations see no conflict between those goals.”
  4. “Invest heavily in leadership development, usually creating their own leadership programs rather than outsourcing them.”
  5. “Free leaders from some clinical duties to create sufficient time for this work.”
  6. “Transforming organizations have a routinized process” (a “standardized approach”) “for change.”
  7. “Internal support [resources]” with specific improvement skills, as opposed to relying only on external consultants.
  8. “Well-developed measurement systems” for clinical and financial performance, and while the data is imperfect, they “do the best they can with available information, recognizing that data will improve over time.”
  9. They treat “design change as a test of concept, rather than implementation of a known answer,” as clinicians related to that (and I'd add, so would a Lean thinker)
  10. “A senior oversight group is responsible for establishing teams, setting their priorities, monitoring their progress, addressing institutional barriers to change, and integrating multiple teams' work.”
  11. “Transformers have invested in creating a widely understood set of unifying values and norms.”

I counted more than seven common elements there.

Dr. Bohmer says there are different frameworks out there, but

“…what's most important is not which model — lean manufacturing, continuous improvement, six sigma — is chosen but that the process is internalized, repetitive, and consistent so that the same language is used throughout the organization and independent teams can undertake redesign autonomously.”

Makes perfect sense.

He closes the article with wise words:

“The short-term investments that are required can be surprisingly small, because most organizations already have many of the requisite human assets. The most substantial hurdle, it seems, is the change in mindset.”

Yes, changing mindsets is a huge challenge. Many organizations aren't even trying to do that, when they focus on the use of Lean tools or only training frontline staff.

In the related 10-minute podcast, Dr. Rohmer more specifically mentions the Lean and Toyota methodologies, further highlighting the Toyota idea that I've often talked and written about – the idea that everybody has two jobs… to do the work and to improve the work.

That's Lean. It's not easy. It's hard work. It takes time… but it can be effective.

I'm happy to see the NEJM acknowledge that as a counterpoint to the article by Groopman and Hartzband.

In my recent travels, I've heard Chief Medical Officers say that their physicians are often throwing the Groopman and Hartzband article at them as supposed “proof” that Lean isn't applicable in healthcare. I hope the CMOs can use this article to help respond to that ridiculous claim.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. To bad that the article is not more forthcoming about what it is that they are doing.From a strategic point of view the thinking is refreshingly new,however in my opinion is encumbered by older mindset.

    Hopefully they go along learnings will transpire that will eliminate Medical Errors from there system.


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