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Engaging Physicians to Solve Real Problems in Healthcare

by Jack Billi
June 24, 2013

Engaging Physicians to Solve Real Problems in Healthcare

by Jack Billi
June 24, 2013 | Comments (7)

Healthcare grew up as a cottage industry, with notoriously weak process management and unclear responsibilities for costs. As healthcare organizations now strive to fix their broken processes and provide greater value (high quality care at a reasonable cost), one of the barriers often mentioned is ‘difficulty engaging physicians’ in lean improvement. 

I just returned from the Lean Healthcare Transformation Summit in Orlando. Lean thinking is spreading rapidly across healthcare organizations in the US and across the globe. Early adopters such as Virginia Mason and ThedaCare have powerfully demonstrated lean’s potential to transform healthcare. Over 200 organizations participated in the 2013 Summit, and we have a long way to go.

Physicians are natural “fixers” who love to solve problems and puzzles. Medical students are selected for this attribute, among others. Future physicians are trained to use the scientific method to diagnose and treat patients’ medical problems. They learn how to make direct observations of the patient, asking questions in a systematic manner, as part of the history and physical exam. Like lean practitioners, physicians are trained to “Grasp the Situation” by systematically observing the work and identifying problems in the gemba.

As physicians, we use scientific problem solving daily when we compare our patient’s findings with known syndromes and diseases, to create a hypothesis about the patient’s tentative diagnosis. We use root cause analysis in our “Impression”, including alternative explanations (“The jaundice might be caused by biliary obstruction or a reaction to a nausea drug”), and in developing a Plan of care (countermeasures). The hypothesis is tested (Do) and revised by further diagnostic testing or by response to treatment, a form of Check and Adjust. No physician I know would consider treating or performing surgery on a patient he or she had not personally examined. We must go to the gemba, so to speak.

So if lean thinking is just another version of what physicians do every day in taking care of patients, why don’t all doctors naturally gravitate to lean? Here are some common themes:

  • Like nurses, as physicians many of us have had to become "workaround artists" to get through our day. Doctors perform daily heroics to get their patients the care they need, despite being frequently frustrated by fragmented systems of care and broken processes. Doctors know that the ‘current state’ is deeply flawed, and some have lost hope that they can improve the work.
  • Some physicians have developed a deep-seated wariness of corporate improvement programs, having experienced flavor of the month cost efficiency and re-engineering programs. They may cynically believe that lean is just the latest cost cutting program imported from another industry, rather than a path to value creation.
  • Lean vocabulary is obscure to newcomers, and the term "standard work," if not properly explained, may be off-putting for physicians. Doctors value using critical thinking skills in service to their patients. They don’t want to practice cookbook medicine, or have someone outside of the profession (e.g., the government or an insurance company…) tell them how best to take care of their patients.

So what’s the prescription for engaging physicians?

Lean is practical to its core. Helping physicians “learn it by doing it” can help overcome resistance. When physicians can see for themselves that scientific problem-solving improves patients’ experience while making it easier for them to do their work, most become converts. For this reason I suggest always scoping a problem or project to ensure it includes some representation or telling of the physician’s pain with the current process.

The bad rap on standard work, I believe, reflects a misunderstanding of what it really is. If standard work is explained to physicians as the best way we know now to practice so as to reliably produce desired results, resistance will melt away. Standard work should be viewed as how we’ve designed our work to consistently deliver safe, effective care. Standard work makes it possible for physicians to apply their creativity to improving work methods. Without standard work, how would anyone know if a change is actually an improvement?

Since lean thinking is essentially the scientific method, practiced through iterative cycles of PDCA, physicians already have the mindset to be lean thinkers. We pride ourselves on practicing evidence-based medicine. Physicians are natural allies in a lean transformation. What’s not to like about a method that makes it easier for the doctor to do his or her job, and do it better? The challenge is to apply the same rigorous thinking we use to work up patient problems to solve the ongoing problems we experience in our organizations.

I wonder how many of my fellow physicians see it the same way?

The views expressed in this post do not necessarily represent the views or policies of The Lean Enterprise Institute.
Keywords:  healthcare,  PDCA
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7 Comments | Post a Comment
Heather Freeman June 26, 2013
3 People AGREE with this comment

Great post, Dr. Billi! 
Nurses have been held to "competency" and policy standards for many years, so standard work is a familiar concept. When nurses and physicians are working together to improve care, gaining agreement from physicians on a standard can be tricky.  But, as implied, just trying it is the most powerful way to make the case for standard work. 
An example: Our necrotizing enterocolitis (intestinal infection resulting in tissue death) rate in tiny babies was above the national average.  The literature boiled down to one intervention: having a standard feeding protocol.  Any standard.  It took 6 months to agree to a standard and implement.  After implementation, and many PDCA cycles, the NEC rate plummetted. 
Fast forward 2 years.  Our intraventricular hemorrhage (brain bleed) rate was higher than desired (we desire 0).  During their monthly "Clinical Consensus" meeting, the NICU physicians and NPs decided themselves that they needed standards for management of tiny babies at delivery. A standard was implemented in half the time and (after several PDCA cycles) the rate plummetted.
Our physicians saw the power of having an agreed upon and incrementally improved standard and embraced it. The hard part was getting through the first one.  

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D Chege June 26, 2013
This is a great article by Dr. Billi, I have participated in Lean projects where physicians were engaged and where they were not. When they are able to get engaged with a change and give their perspectives they were much more satisfied with the transition and outcomes. 

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Ann Brown June 26, 2013

These comments come from the "other side of the house" :)

Jack says "Doctors know that the ‘current state’ is deeply flawed, and some have lost hope that they can improve the work."

This is true ... and it can also be true of other clinical and non-clinical staff. Somehow we have created a polarized story that the physicians are disengaged and staff and administration are engaged and a great effort is required from administration to engage physicians. Physicians care about patients - administration doesn't.

I don't think it's that simple. And I don't believe physicians are disengaged - maybe from the organization, certainly not from the patient - and there are far easier sectors to work in than health care if you are an administrator that doesn't have the patient deep in your heart.

The three common themes are applicable across the organization. What works is when physicians and administration lead together and bring respect for all types of expertise. Together they can bring a better story - we all care. Change the story - change the pattern.

Lean asks everyone to step up.In Heather's examples, it is the clinical team that steps up. Sometimes it needs administration to work across the organization on systemic problems. Lean calls us to work together and focus on "managing complexity to achieve more valuable results for our patients" as Terry says.

Am I ranting?


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Terry Platchek June 26, 2013
2 People AGREE with this comment
As a fellow physician and colleague, I could not agree more with Dr. Billi! At its core, Lean is extraordinarily practical and my experience is that physicians will become highly engaged through successful participation in meaningful improvement. Done correctly, as Dr. Billi aptly describes, Lean emphasizes the same rigorous methodology to solve healthcare system problems that physicians are trained to use when diagnosing and treating disease. The methodology, namely the scientific method, is rooted in deep examination of the problem and respect for the insights of the providers having to deal with the problem again and again in the course of their work.

As medical knowledge grows and our treatment capabilities advance, our systems of care tend to become more and more complex. Lean is a organizational model that focuses on managing complexity to achieve more valuable results for our patients. Physicians are natural leaders in this continuous improvement journey.

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Jess Reyes June 26, 2013
2 People AGREE with this comment

My wife is a doctor and I have many that are close friends. They all use lean concepts and are some of the best at it. It is true that overall they are caution when their organizations launch lean as a formal program. It is still viewed as a business tool toted by business management to regulate the doctor's work rather than improve it. It is especially important that health care organizations present their programs from a customer/doctor perspective rather than one of cost management and efficency.

We are only now seeing just the tip of the iceberg of possiblities in this huge industry and others related to it.

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Jack Billi July 01, 2013
3 People AGREE with this comment
Author comments: thanks for the great feedback. Good points all. I agree with Jess on the importance of keeping the purpose focused on value, for both the workers (physicians, nurses, staff) and the patient -- not on cost reduction. Terry's comments show why he's a master at engaging clinicians -- he's helped Australian hospitals engage young physicians in improvement work early in their training. Heather's examples remind us why we work so hard on this -- improving our inconsistent clinical practices can save lives. Ann's observations ring true -- it's not as simple as disinterested physicians and engaged administration. The best improvements result when doctors, nurses, support staff, and administrators rally as a team to improve care. Their diverse perspectives lead to more realistic countermeasures. Together they can build consensus on the problem, how the work is done now, the root causes, and which experiment they'll run first.

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Mark Graban August 21, 2013

The points about "standard work" (or "standardized work," as Toyota tends to call it) are spot on and apply not just to doctors.

Standardized work doesn't mean "check your brain at the door" and it doesn't mean inflexible. People in many roles need to use judgment and critical thinking skills within the context of process and standard work.

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