Dear Gemba Coach,
As Health Systems globally wrestle with skyrocketing healthcare costs, many hospitals are jumping on the lean bandwagon, hoping this will be the silver bullet that delivers improved outcomes at lower cost. Is this a valid justification for implementing lean in hospitals, or is the cost-saving rationale as a driver of the process doomed to failure?
Thank you for this thought-provoking question, although I’m a bit at a loss on where to start to try and answer, as I’m not sure we have the same understanding of “lean”. The lean ideal is indeed the complete elimination of waste, mainly to improve customer satisfaction and, yes, to get costs down – but experience shows time and time again that considering costs without putting customers first lead to bad, bad mistakes, all the more so when your customers are patients. Furthermore, to some extent, lean will indeed remove obstacles that hamper workflows, but as with costs, this is largely an outcome more than an input. Workflows are the result of what people do, particularly in a hospital where so many different professions and specialties are involved in treating one same patient. One of the foundational principle of lean was expressed by Kiichiro Toyoda’s belief that: “the ideal conditions for making things are created when machines, facilities, and people work together to add value without generating any waste.” As a result he conceived the methodologies to eliminate waste between operations. The Taylorist worldview (of people as essentially cogs in the machine) still rules and we tend to assume that the best way of achieving this is designing a better process and making people apply it. In lean, the gemba has taught us different: the challenge is indeed to make people, machines and facilities work together to see the waste they generate, understand the causes and progressively increase their value added.
Keeping these points in mind rather changes one’s perspective regarding your question. A couple of years ago I did a gemba walk in a large hospital. We started with a difficult discussion about the dismaying state of disrepair and general shoddiness of the emergency admissions. From working for years with health professionals I’ve come to accept there is a secret ingredient to treating patients successfully: trust. Increased trust heals patients. Less trust makes them sick. The first impression of the emergency entrance has a disproportionate effect both on patients’ trust and staff’s expectations of themselves.
As we argued, the full story came out that the hospital’s top executive had 1) invested massively in a new facility to centralize testing and sterilization and 2) the cost improvements were late in coming and so 3) there wasn’t a dime left to hire more cleaning personnel or pay for a coat of paint. Then they went on trying to convince me that the new modern facility had been designed in order to improve the workflows. They truly believed they were leaning the previously complex process by simplifying it. In actual practice, they were making the situation worse by throwing investment money at an issue without first understanding it.
So we walked the wards, looking at everything first from the patient’s perspective, and then from the nurses’ and doctors’ point of view. As we did that a thousand and one details jumped out, mostly about procedures not followed (for good reasons on the spot, but the procedure is there for a reason, it’s a hospital!), and of equipment looking dodgy (again, no money, but hey, it’s a hospital) and everywhere we heard stories of overworked understaffed wards (headcount reductions because of the financial situation, but… well, you get the idea). So, certainly, many problems are created outside the hospital’s control, but how about starting with the issues the hospital can fix (even if its management often doesn’t want to)?
Where do we start? Hospitals are so huge and complex. Ideally, we’d start head on with patient mortality – where it matters most, but in this specific case, it was politically untenable. The hospital Quality and Continuous Improvement director chose to start on a few issues he felt he could tackle:
- The general state of admissions areas and waiting areas for patients
- The working conditions in the treatment rooms
- The first incision in operating theatres
In these three cases it turned out the issue was not the process, but indeed how well professionals worked together. On the general maintenance or admissions area, improvement was a matter of talking to the ward managers about getting their teams or sub-teams together and seeing issues. They immediately had ideas to improve the situation, but every conversation started with a request for a budget. After some back and forth, it was decided that they would first do what they could on zero budget and, as a result of their improvement efforts, come up with a shopping list of things they really needed to replace. No magic bullet here, but over time, many areas of the hospital improved visibly. Staff learned to look at their environment with the patient’s eyes and organize themselves differently. The Quality director fought for small budgets where they were needed. As this process went on, trust was rebuilt and people realized they could do far more than they’d expected, even on very tight budgets.
As this first issue progressed, the poor state of treatment rooms became increasingly apparent, but there, the same method hit against the wall of “too much stuff, not enough staff.” Every storeroom was overflowing and made space control very difficult. The quality director’s challenge was “zero out of date” and teams tried hard. They also did their best to empty all surfaces to clean them thoroughly, but again there was so much stuff piled up that it was near impossible. As they looked into the matter it became apparent that the external platform hired to reduce the logistics costs did so by delivering wards from one week to two months of consumption of consumables. The challenge became “everything every day.” Now, this does sound like process improvement but in truth it was again nothing but a big teamwork issue and political fight, the logistics director simply not wanting to hear about it. She dug in her heals and flatly refused to see the huge waste she was creating by the method she chose to supply wards. Here, you see the core of the lean transformation, when each professional learns to see the waste they generate on upstream and downstream processes and start making a genuine effort to understand their colleagues problems.
In this case it became apparent that the key to treatment rooms control was not within the wards control but with logistics. It was a case of what you’re saying: outside the ward’s control. Yet, still way within the hospital’s control. In this case, the quality director had to confront the fact that the main barrier to progress was his own relationship with the logistic director. I don’t know where they’re at now, but last time I visited there were hopefuls signs of progress. It was still incredibly slow. Logistics continued to consider that ward problems were ward problems and logistics, logistics – which is exactly what happens when you lose sight of the patient and start considering costs as if they have an existence of their own and not respective to a purpose.
Which brings us to getting operating theaters started on time, an issue you’ll agree has a huge impact on overall costs since it impacts operating theatre utilization. On the basis of these previous experiences, the quality director now realized it was first a question of relationships, with surgeons this time. Rather than address this head on, he started by asking nurses to simply monitor on a visual form the daily hour of first incision and involved a few willing doctors in analyzing reasons for delays. This, again, proved to be an eye opener. With very few exceptions, few surgeons behaved as the late-because-I-was-playing-golf stereotype would suggest. What did happen is that very few trusted the planning system because of all the changes, rescheduling, double reservation and so on. Again, the hospital had tried to modernize its scheduling system by taking it out of the hands of the ward matrons and creating a computer system in that every one could access with their own priorities – including the medical secretaries. The result was absolute chaos. After months of failed experiments, they finally agreed that one matron would become a “master scheduler” in lean parlance – she’d handle the computer, come up with a proposed plan for the coming week and check with each surgeon in term with a “one amendment rule”: you could change one slot but not to (other than for patient issues). The completely surprising upshot was that surgeons were by and large happy with the proposed schedule so long as it didn’t change so that they could plan the rest of their week. This work led to gaining half an hour of operating theatre utilization per day.
Now, these examples are unique to this hospital and one of the frustrating aspects of lean is that there is no cookie cutter approach, no matter what consultants would like you to believer. This is the magic of the gemba – you have to take each case as it comes, with fresh eyes and open mind and try to figure out what is specific about the new situations even when you’ve seen it all before.
What I’m trying to say is that, effectively, you are right, if you try to remove obstacles that hamper workflows in such complex systems you’ll soon hit upon barriers over which you have no control. Agreed. But I don’t believe that’s what lean is about. Lean is about getting people to work together to look at their own workspace and try to see the wastes they create for their patients and their staff, and figure out the deeper causes without guilt or blame: most causes are technical decisions that might make sense in isolation but have unforeseen cross-impacts on others. In an environment as complex and interconnected as a hospital, understanding the ins-and-outs of technical choices is a key issue, and not an easy challenge.
So how can we work at making machines, facilities, and people work together to add value without generating any waste? The first step in healthcare seems to be building better relationships by going to the gemba and discussing what the ideal should be. Healthcare is vocational: doctors are there to cure people, nurses there to care for patients, and usually they’re more than happy to talk about eh gap between what is and what should be. Once a clearer image of shared success emerges, it’s then a matter of trying things until we find pragmatic solutions for problems. No magic bullet there either, as often every new idea hits a new constraint for someone no one had foreseen, but the revitalizing part of this work is seeing how many people you’d not thought of start putting their shoulder to the wheel and helping – I can’t tell you how much hope I get from seeing this time and time again.
But all of this requires a radical change of mind at the top. Rather than look for that silver bullet, for that brilliant new system-level design that will make all our problems go away, we must start getting interested in the “one second of waste” to use Tracey Richardson’s great image – all the small pebbled that get in the way of every operator doing there job well. I know it sounds incredible, but it’s by focusing on real work by real people that we will start to understand how all of this adds up into gigantic waste. On the other hand, most system-level solutions I’ve witnesses such as the centralize lab facility of the new theatre scheduling computer system never quite hit the spot (I’m not arguing against computer systems per se, and I’m a huge fan of patient records information and so on).
As my father is fond of saying, practicing lean is practicing helicopter thinking: we must constantly go from the most detailed (and landing a helicopter is particularly tricky) vision of the gemba to the high-level picture of the purpose of our processes in terms of what our products do for our customers and how we deliver it to them at the minimal cost. Lean starts with getting senior executives to realize how great a teacher the gemba can be and improving working together by solving specific issues across functions before worrying about fixing overall processes. In doing this, they’ll discover there is much, much they can accomplish within what is in their control by involving every one, every day.