Journal Article Suggests Efficacy of Lean in U.S. Public Hospitals; Will Detractors Be Swayed?

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tl;dr summary: A journal article evidences Lean's effectiveness in healthcare, challenging skeptics. It finds that Lean adoption in U.S. public hospitals is linked to lower costs, along with better patient care and experiences. Success relies on leadership commitment, daily Lean practices, and proper training. However, study limitations and potential biases question its conclusive impact on skeptics.

How often have we heard Lean detractors say things like, “Lean doesn't work in healthcare”? That's demonstrably untrue. Lean is appropriate in healthcare. The methodology can be effective. That doesn't mean that it's easy or that it's guaranteed to show results — especially when Lean is bastardized into a cost-only focus and when it's done TO people instead of WITH them.

So it's always great to see published journal articles, since those have such currency in healthcare.

Lean Performance Indicators and Facilitators of Outcomes in U.S. Public Hospitals

This article has been making the rounds. Thanks to those of you who sent it to me.

Principal Findings: Lean adoption and implementation were associated with improved performance in U.S. public hospitals.

The findings also show hospitals that “adopted Lean” had these results:

  • Lower cost
  • More appropriate use of medical imaging
  • More timely care
  • Better patient experience

What are the drivers of these differences?

  • Leadership commitment to Lean (“leader buy in”… “starting with upper management”)
  • Daily management (including huddles, “gemba” walks, visual management, A3 problem solving, etc.)
  • Training and education in Lean

The article cites two examples of Lean healthcare success: Virginia Mason (where people tell me Lean is still very much part of the ongoing operations and culture) and Thedacare (where I am told Lean is now past tense and a matter of history, unfortunately).

Operational Definitions Matter

How did the researchers consider if a hospital “adopted” Lean? It's not a 0-or-1 binary yes/no factor. You could be “doing Lean” (a phrase used in the article) for just a year under the guidance of former Toyota people who have done great work with other health systems, or you could have five years “doing Lean” meaning just 5S or just huddles.

Whether a hospital “adopted Lean,” was based on:

“…the number of hospital units using Lean, degree of Lean training/education offered to frontline providers and managers, daily use of Lean practices, and level of leader commitment to Lean principles.”

What is the operational definition of “adopt”? Does “daily use” matter if people are going through the motions with huddles that don't really have an impact? How do they measure “commitment”? How do they determine how accurate and effective the Lean training is?

I share their hypotheses that Lean (done well, I'd add) would lead to better performance. I mean, that's the reason to “adopt” Lean.

Study Limitations

Even though the journal article discusses “going to the gemba,” the study methodology seems to rely on surveys being sent out. Does it confound the data if respondents overstate (or understate) the extent of their Lean adoption and the fidelity to true Lean principles?

I admire the intent, but one could poke holes in the approach that leads to the conclusion I'm happy to see.

The study showed “more than half of the public hospitals that responded to the NSL survey had adopted some form of Lean management.”

The phrase “some form of Lean management” creates a lot of grey area.

The “Study Limitations” section of the article also admits that correlation between “Lean adoption” (or “self-reportee Lean adoption”) and better results doesn't prove causation.

The article also admits the risk of “bias” in the way that executives answered the survey (or variation in how questions were interpreted).

As I've brought up already, the article admits they didn't (or probably couldn't) evaluate “quality [of implementation] as indicated by, for example, fidelity or adherence to Lean standard work.”

I'll acknowledge an elephant in the room: CLEAR (home of the authors) receives funding from organizations that have a vested interest in showing the effectiveness of Lean, including the software company KaiNexus that I am affiliated with.

Will This Article Convince the Skeptics?

I've seen, with my own eyes, how Lean done well — and consistently — can have a great impact on the measures that matter:

  • Safety
  • Quality
  • Delivery (Access)
  • Cost
  • Morale

I'm encouraged by the results of the study. So many people in healthcare want evidence from journals. Will this article convince them?

Or do the Lean skeptics, Lean detractors, and Lean supporters all continue down our paths of “confirmation bias”?

What would a full-bore Lean detractor, who says things like “Lean is inappropriate for healthcare and will never work!!!” say about this article?


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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.

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