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?