My CEO has asked me to take a hard look at the lean program at our hospital – where should I start?

Dear Gemba Coach,

I am ops director of a large hospital. We have been doing lean for several years now, with a lean office of ten people involved in many projects in improving 5S, finding beds, test circuits, and so on, but lean doesn’t seem to “take”, and our financial situation is not improving. My CEO has asked me to take a hard look at the lean program – where should I start?

I’d suggest to start by reading again John Toussaint and Roger Gerard’s book On the Mend; I’m not being flippant, they’ve come up with one of the best definitions of lean I’ve seen so far:

• Focus on patients (not the hospital or staff) and design care around them.
• Identify value for the patient and get rid of everything else (waste).
• Minimize time to treatment and through its course.

And ask yourselves: are we following these three points?

Hospitals have their own specific context and they’re as far removed from an automotive assembly line as can be, so we need to be a little cautious in “applying” lean to the hospital context:

• First, the hospital’s “product” are suffering human beings – patients are moved around, manhandled, made to wait, and so on. The product is the customer. This is difficult because patients don’t see any value in all that’s happening to them. They just want to be fixed and get on with their lives. Instead they have to sit for hours, sleep in emergency ward corridors, have needles put into them, go through scary looking machinery and generally be treated like an inanimate object. Also, the magic ingredient in healthcare is confidence. According to this Wired article, the placebo effect is getting stronger! So, in terms of value, everything that you do in the ward that increases patient confidence is care, and everything you do (grotty looking emergency entrances, stroppy nurses, insensitive doctors, etc.) that undermines patient confidence is value destruction.
• Second, the hospital is a very complex place where a huge number of people have to come together to treat a patient – up to 18 or 20. Each of these specialties have different constraints, different traditions and different organizations, that have to come together somehow.
• Thirdly, hospitals I see are increasing victims of the spirit of the times in terms of financial pressure, and increasingly run by financiers who don’t understand the true nature of their costs: not replacing nurses when they’re ill is NOT going to keep costs down, but add overburden, which will lead to more mistakes and further costs. I know several hospitals that no longer have the budget to properly staff their wards, which generates both bad patient outcomes and a lot of staff resentment, but can find the financing to invest in new buildings, IS system migrations or even consultants to rationalize processes!

Facing Patient Issues

On the other hand, most people who choose to work in a hospital are determined to do good and help patients – that’s why they’re there. More often than not, they’re angry and frustrated because the complexity, the rules, and the bizarre behaviors of people stop them from doing so. Consequently, lean thinking applies very well in the hospital context, if we allow for a few specific learning difficulties.

1. A reluctance to face patient issues: more often than not, both doctors and nurses will be in strong denial about the reality of patient care. Faced with the practical difficulties of getting things done, humans being humans, hospital staff will often (1) refuse to measure patient incidents and (2) start negotiating basic rules such as separating clean from dirty, washing hands, not wearing jewelry etc. Chances  are everyone will agree on the need for kaizen on supporting processes, but not on patient front-line issues. However, fixing the laundry is NOT going to help you either treat patients better (and hence increase reputation and revenue) or keep costs down (by reducing nosocomial infections, and so keeping hospitalization times down).
2. A reluctance to share responsibility: the very complexity of hospital processes means that to improve any process, one has to get a number of professions to agree on their will to improve. A classic hospital game is to make sure nothing changes by using professional arguments to stop looking at bothersome issues; typically doctors will refuse to look at logistic problems, to self-measure their own outcomes, nurses will get all emotional and on their high horses at the slightest hint of criticism, logistics will explain that everything costs more and nothing can be done, etc. This is a true leadership test, both because of the number of specialties involved and because of the very set professional cultures of each of these specialties, and it takes some doing to overcome.
3. A bias for talking rather than doing: this might be very personal, but my experience with hospital workers is that they’re always happy to discuss things, as long as no immediate action is required. Meeting are endless and repeated, e-mails are long, detailed and cc-ed widely. The amount of coaxing needed to get anyone to actually do anything is an order of magnitude higher than any other environment I know, which slows down learning considerably as they often consider that talking is learning. Hmm.

As a consequence, most lean programs in hospital actually solve some issues, such as more reliable returns of lab tests, greater productivity in sterilization, and all sorts of logistics issues, but still the costs keep creeping up, patients are not better treated and every new project requires just the same amount of persuasiveness to get going: it’s kind of daunting.

Where to Start

What can be done? To begin with, I’d suggest to start with kaizen in each specialty, before touching cross specialty issues. Rather than try to fix logistics problems across departments, how about attempting to develop the kaizen spirit of each department head. This requires a change of mindset from the management group:

From:

Rationalization of processes projects across the hospital

To:

Patient-focused PDCA by each of the department heads.

It’s not that hard. I was recently visiting a mid-sized hospital, and discussing surgery management issues with the doctor in charge. He had identified overruns in time in surgery as an issue both for patients (usually because something went haywire) and for the overall cost of his unit. He realized that one or two more patient per theatre per day would have a dramatic impact on his costs. The problem, however, seemed impossible to tackle because of unavoidable variation from one patient to the next, and from one surgeon to the next. This is a typical case where stricter rules simply won’t help, and incentives will bias the system to sloppy work, so we need to be careful. On the other hand, this is a typical case where lean thinking applies naturally:

1. Formulate the challenge: patients should be out of the operating theatre at the scheduled time – each doctor being ask to set the scheduled time, so the challenge is more about developing surgeons on being more autonomous with their own scheduling.
2. The PDCA is about developing the leadership of the doctor in charge of surgery – NOT forcing a new “process” on surgeons.
3. Define OK versus Non-OK to specify finish operation in time. In this instance, to start with, within ten minutes can be considered as OK to start with. Also complications are difficult to see at surgery because they will be spotted in the wards (and we’re back to the cross-functional cooperation issue), but re-intervention is fairly clear: if a patient needs to be operated on again, this counts as NOK.
4. Visualize the schedule and measure every day the ratio of OK (on time) against NOK (more than ten minutes late) as well as counting re-operations.
5. For each NOK situation (as appears from the visual board or screen), the head surgeon can slip in the operating theatre and practice GOOD OBSERVATION and, later, GOOD DISCUSSION, to practice genchi genbutsu and try to get a sense of what really happens at the patient.
6. Agree a challenging NOK reduction target, such as -50% late finishes, and -50% re-interventions.
7. Through either workshops (all people for a few days) or quality circles (a few meeting for an hour every day), start listing possible factors of late finish and get agreement on the problem. Agree on ONE action – not more.
8. Try and measure, try and measure. Then move on to a SECOND action.
9. Draw conclusions and change the process when relevant.

It’s essential that actions should all be within the scope of the surgery: no involving outside sectors, at least at first. On the other hand, doctors can use check-lists, better coordination, better allocation of patients, better scheduling of patients (difficult patients up front, rather than at the end of the schedule – yes, if something goes wrong it throws everything off, but at least minds are fresh and problems can be seen early), and so forth. As the exercise develops, some notion of takt time can be introduced, as well as value streams and leveling (long, short, long, short) and on and on.

Back to your question: how do we assess a lean program? One, by its overall results of course, but I’ll allow that in a hospital this can be tricky. The underlying question is how do we define OK versus NOK lean activities?

This is probably very personal, but in the context of a hospital, I fell that an OK activity is defined by department head taking on board a PDCA cycle on a patient-focused topic. In a ideal situation, every department head is currently working with their staff at conducting a PDCA cycle in their area, on patient-driven issues. I’m fully confident that if this milestone is achieved, cross-functional kaizen will happen naturally and succeed far more easily.

With this target in mind you can now look at your hospital differently: how many area managers are we looking at? How many of them are truly conducting patient-centered PDCA (and I’m not even suggesting doing it well or successfully!)? The resulting ratio is a ready-and-ready assessment of your lean program – that begs the question: how do we get from where we are to all department heads involved?

Sure, when we grow up we can have proper hoshin kanri, value stream maps, Supervisor Standards, and so on. But to start with, let’s first focus on patient care and introducing staff to the excitement of the kaizen spirit. The biggest room remains the room for improvement!

[Editor’s note: Our latest book, Perfecting Patient Journeys, is a how-to field guide for healthcare leaders who want to make real and sustainable improvements in healthcare delivery using a hospital-proven improvement methodology for entire value streams. Please feel free to download excerpts and templates.]