Mark's note: Today's guest post is from Tony Manos (bio at the end of the post):
I was talking with a hospital CEO last week and we had a very wonderful conversation about all the great changes going on at her facilities. I was curious to get her opinion on a specific point. I asked her “Why aren't more hospitals and healthcare organizations embracing Lean?” As we all know there are some exceptional healthcare organizations that are doing wonderful things by utilizing Lean techniques and more importantly, Lean thinking. Many more are starting their journey, but why is it that for the most part, healthcare as an industry isn't moving faster with Lean?
Her basic reply was that healthcare tends to be reactionary. Many times things aren't put into motion until rules are imposed upon them. Take the recent insurance reform enacted by the federal government; there are many aspects of the changes that aren't very well defined and won't be imposed for years. Why would you work on improving something if it is just going to change later? Another aspect of her answer included that if you are so busy doing what you are supposed to do there is no time to add new things. I was very intrigued by this.
In order to frame the amount of effort I have encountered to move organizations along on their Lean journey I would say (half jokingly) “If you think it is hard to implement Lean on the shop floor than go to the office and it will be ten times harder.” Not because the concepts are hard to implement in an office or service setting. It is harder because of the people (meaning the resistance you may first encounter).
Then I would say “Try doing Lean in healthcare, it is ten times harder than that.” Once again, not so much about the concepts, I think it has to do more with the resistance to change. Then for fun, I say “Try it in Government, it is ten times harder there.” For my final nudge I say “Try it in Education; I don't have a scale that goes high enough.” Once again, this is just to give people a feel for what they might encounter.
I'm not saying that it is 100 times harder to implement Lean in all hospitals than it is on the manufacturing shop floor; that would be missing the point. Just realize that with the time and experience we have implementing Lean on the shop floor is much greater than in other areas. I remember seven years ago helping a hospital with their Lean implementation and they asked if there was a DVD they could watch for Value Stream Mapping. Of course at the time, there wasn't. What I realized then is that many organizations just want specific answers to their specific problems. They weren't willing to learn and apply Lean thinking, tools or techniques. I still run into this today.
Another way that I used to look at it is that healthcare was always about ten years behind manufacturing when it came to adopting new methods. Do you remember the 1980's? The big three automotive manufacturers realized that they had to improve the quality of their cars. There was a big push in general for all manufacturers to improve their quality. I noticed that it took about a decade for healthcare to grab this concept. Then in the 1990's many manufacturers starting Lean or maybe even six sigma programs. Where is healthcare now? They are lagging even farther behind accepting these ideas.
So my general conclusion is that we are not going to change healthcare overnight (contrary to what the government says). They will adopt Lean at their own pace. I just hope we can help them do this sooner rather than later.
Tony Manos is a Catalyst with Profero, Inc., where he provides professional consulting services, implementation, coaching and training to a wide variety of organizations, large and small, private and public, in many industries focusing on Lean Enterprise and Lean Healthcare.
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As you may know, here in the UK, many trusts, boards and hospitals in our National Health Service are starting to embrace Lean and it is interesting to note the quoted CEOs comment in this post about healthcare tending to be reactionary. I think that is probably truer in the UK than almost anywhere else. Clearly governments come and go as they are elected, each delivering a set of radical reforms to the NHS in line with their own particular ideology. The complexity and scale of the NHS goes way beyond that of almost any form of manufacturing or production and the debate on the impact of Lean in the service sectors continues, hopefully with a growing body of evidence to support it. Perhaps it is no surprise then that there is a very slow uptake of Lean in healthcare. Clearly imbedding Lean across an organization as large and complex as a PCT, Health Board or even a hospital is something which will take many years to establish. Why would you be keen to embark on what would typically be say a 10 year journey when a change in government is likely to occur, instantly rendering obsolete many of the change programmes you’ve initiated on the way?
Why would you be keen to embark on that journey? Because you give a crap, that’s why.
Thomas,
Another way to look at it is that if an organization has transformed toward lean and its way of thinking, it would be more effective in dealing with the changes when they come. So, lean thinking could make the organization better able to adapt, not to mention maximizing the processes currently in place.
I think it’s hard for us to fully appreciate the political dynamics of the NHS and the UK government. I think that’s a potential sea change every few years that goes well beyond the impact of an American privately-held hospital getting a new CEO.
Yes, but it’s no excuse to not give lean a shot.
There are a number of reasons why hospitals are slow to adopt and one of them is that they don’t have to …. yet.
Many mfg plants adopt lean because a major customer said they had to or the finances said they have to do something different for survival and as leaders explore what the “something” is lean floats to the top quickly.
Hospitals are still relatively insulated from competitive pressures, the need to innovate, and have been meeting bottom lines with a combination increased utilization, and ability to raise prices as part of the long-standing cost-shifting game.
This “success” model is rapidly falling apart now as utilization has peaked and medicare and medicaid reimbursements are falling faster than the other payors can swallow.
One more thing is that hospital leaders are trained and groomed to be anti-lean. The top MHA schools continue to produce new crops of empty suits steeped in mgmt by objective and lacking real operational expertise (Peter Drucker ridiculed the healthcare industry for needing a “special” degree for the industry).
The tide is turning but at the same time Lean has to earn a place at the table and while ThedaCare and others have achieved some notable improvement there is still not a consensus that you have to do Lean.
To Anonymous – I think that’s spot on. To extend the thought, look at ThedaCare. With all of their quality and cost improvements and bottom-line impact (doubling their operating margin), they are not going to grow like Toyota did and take over the U.S. healthcare market. Healthcare seems to be a somewhat local business with a bit of protectionism that protects those with high cost and poor quality.
The hospitals that are already big have the leverage to demand higher payments from private insurers, which lessens their need to improve.
Interestingly, ThedaCare *did* acquire another organization and they’ll create what will be their third hospital there in Wisconsin:
NEWS STORY LINK>
I should add that U Michigan among others seems to be very much on board with lean but not sure how much has penetrated their master’s program.
I too completely agree. I hear numerous reasons for not making timely changes… most of which do not hold up to scrutiny. The biggest reasons are the organizational cultures of management (command and contron) and of the professional disciplines (professional autonomy, barriers to interdisciplinary collaboration, etc.).
Most managers I interact with would agree that authoritarian/autocratic leadership styles are a big concern with trying to implement tranformational changes within healthcare… such as lean. Unfortunately, the same managers fail to see those same dysfunctional behaviors in themselves and how their own behaviors reinforce the dysfunctional culture within the organization.
I recall John Tousant’s comments when he presented to our organization that one of their implementation errors was not doing a readiness-to-change cultural survey beforehand. We have done the survey, yet management has barely made any headway in addressing the issues identified. We appear to be forging ahead with our Lean implementation without leaders appreciating that they have to manage differently for things to be successful (my personal opinion is that we really seem to be a LAME pathway).
PS: I loved Tony’s title “Catalyst”… I occasionally describe myself as a catalyst for change, but i’ve never seen anyone use it for their title.
Ron
Ron,
Tell me about this survey – the instrument, how it’s administered, etc. I’m very interested. Please email me at mwelch@spencerhospital.org.
Thanks
Hello,
I am a US Army Officer working in an engineering organization. You mentioned the difficulties of implementing lean for the government. Do you know of any good resources and/or people I could talk to about their experiences implementing lean for the government? We have a lot of inefficient processes in our operations and administrative sections and I want learn good ways to quantify the waste and implement the change.
John Kang
One starting point might be the Army’s website:
http://www.armyobt.army.mil/cpi-kc-tools-lean.html
Well said. Unfortunately organizational dynamics in general don’t accept new management ideas readily even when the evidence seems pretty obvious. Health care does seem to be even more difficult. I originally thought health care would be easier since they have an appreciation of the scientific method (when helps when you want to encourage evidence based management practices). But psychology and systems issues with health care organizations seem to trump that advantage.
John, one thing I’ve struggled to reconcile about healthcare (this is a very general statement) is that an industry/profession that claims to be so “evidence based” often uses the scientific method only when it suits them at the moment. It’s quite a bi-polar industry – they are evidence based, except when they are not.
While health care is making strides to become more evidence based (for example, methods and practices related to joint replacements or cardiac surgeries), the majority of things we do are based on “leading” and “best” practices. The majority of health care has no research to prove that one method/process is better than another. Even in areas that get more attention (e.g., drug trials), how often do you hear about how the results of trials are in question. And even when we have the evidence, often professionals are slow to change their practices (e.g., the number of physicians not following proven practice guidelines is unsettling high). I personally do not hear health care professionals boosting that they provide evidence based health care.
Lean is being implemented in hospitals. We are in the process where I work. This happens to be a Level 1 Trauma Center. They went so lean that we now don’t have enough nurses to care for patients and we run out of necessary supplies all the time. Would you like to be the lucky patient with a life threatening emergency. Hopefully there is a nurse with maybe more that six months experience to take care of you. Then hopefully we have the supplies that you may need.
Healthcare is unpredictable. It can change hour by hour. If you want assembly line healthcare then lean is the way to go.
Some nights I am happy that my patients and myself made it alive.
Oh by the way, I have over 25 years of hospital nursing. I’ve seen the changes and this has been the worst that I have encountered over the years. I am very happy that administration is giving themselves bonuses.
Luckily if a loved one of mine is ever in the hospital and errors are made due to the lean process and the wonderful computer systems that hospitals have, I know all the ways to sue their asses off.
I refuse to think that hospital executives could be that thick.
I’ve plenty of hospitals that did NOT use lean where nurses didn’t have enough supplies, etc. That’s the problem lean is trying to fix.
A crappy hospital and stupid hospital leaders… that has nothing to do with lean. You could give them magic beans and it wouldn’t work.
Please tell us what hospital so we can avoid it and go elsewhere. You’re posting anonymously, tell us where you are.
Sue:
That’s a pretty disturbing story. I hope that adequate supplies and staff can be provided where they are needed, that the problems can be addressed and the damage contained and turned around.
Womack’s team gave the name “lean” to what they saw at Toyota because it was characterized by SUCCESSFUL operation with remarkably low inventories, not just because inventories were low. There was much more to it than just low levels of inventory, however.
If a hospital is running out of stuff and hurting people it really doesn’t fit the model, even if it sounds like our common understanding of the word “lean” (as in, going hungry). The thing we study and try to understand is what Toyota was doing to achieve success; reducing staff and inventory of critical supplies to the point of failure is NOT the object.
It sounds really grim where you are working! I can hardly imagine. Good luck and good speed changing it if you can.
To Sue – Wow, I can’t even begin to wonder where things got off the rails at your hospital. What you’re describing is quite the opposite of Lean, as Andrew pointed out.
In hospitals I’ve worked with, inventory management is often way worse before Lean. Supplies are out of stock, nurses are running around scrambling – that’s not good.
The goal with Lean is not low inventory, but rather to have a better materials process that ensures that you always have what you need for patient care. The high level goals of Lean are quality, patient safety, waiting time, staff morale and cost. Cost is the end result of the quality and process improvements — the focus isn’t on cutting cost as in a regular management system.
Here is an example of a hospital (ThedaCare) that’s using lean to provide BETTER materials support to nurses, among other advantages and patient outcomes improvements:
http://www.youtube.com/watch?v=tGd0cEif-vY
The point is not to turn a hospital into an assembly line. But back to your concern about not having the supplies you need – go visit a Toyota plant or a good Lean factory and I’ll guarantee that everyone has what they need to get their job done — again, the opposite of what you’re describing.
Email me using the Contact menu in the top of the page. I’d be happy to send you a free copy of my book that you could take a look at and maybe give to your management – but maybe they are just clueless and beyond help.
If people don’t take time to learn about Lean, they are likely to go and do some really dumb things and just call it “Lean.”
What you described shouldn’t be happening at all.
Yes we have a Lean team and the consultants that go with it. I have worked ICU for the past 25 years and have to go to other units to find supplies. The pharmacy went lean and I have to wait up to an hour for critical drips for patients. Every shift I work i am asked if I would like to double. 5 months ago we had to rebid on our positions due to the lean process. So glad that they cut my hours. Unfortunately they did this process and data collection around the holidays when our census is usually at it lowest. Now we have to work off those numbers. The one thing the lean team did come up with is more management. On any weekday ( yes only weekdays) there are approximately 4 – 5 managers on duty for each nursing unit who do absolutely no patient care. They have to be figured into the budget thus cutting the nurses that do patient care. Before the lean team there was 2 – 3 managers per unit. GO LEAN.
The overtime is nice because I am paying for 2 children’s college tuition with it and hope to retire in the next 10 years. This will figure nicely for my high 3 in the retirement department.
I personally would think twice about being hospitalized, but then again I would receive adequate care due to my background. You on the other hand might want to think twice.
My work ethic is to do the best that I can for my patients for the 8 – 16 hours that I have them and then I go home. As far as the organization, I don’t give a rats ass.
Health care is not an exact science. The number of patients and the acuity of their needs fluctuate shift to shift. One major accident with several victims can wreck havoc on us. Some businesses can do lean (like in a factory), but the human factor is not something to mess with.
I do not have any qualms about working my ass off, but there is a limit. Lets make the cuts all around.
Maybe my hospital isn’t doing the lean process appropriately,but this is what they are calling it and it sucks. And they wonder why patient satisfaction has gone down.
Sue:
Sounds like a serious problem in management. If things are getting measurably worse on the course they are taking, a change of course is surely called for.
By the way, my first experience of something called “lean” was not unlike yours – a consultant was hired in, led projects that changed (disabled) processes and cut heads, leaving us completely unprepared for the next peak of activity. A train wreck. Fortunately, I’d seen enough at some neighboring organizations to know that this was not the real thing. We stuck with it, outlasted the consultant, and now have something that our customers, our employees, and our shareholders all appreciate.
How can you tell if it’s real? If the focus of the effort is making work easier, it might be real. When people set out to cut cost, but don’t understand the real work done on the shop floor or in the ICU (btw, only the people who actually work there really know), they run the risk of disabling critical processes when they take resources out. One of the key architects of lean asked “how can we make the work easier, so our people don’t have to sweat?” When we figured out that that was the starting point, OUR work got easier, too!
Your post prompted me to wonder how much of the problem lies in the schooling and training our Medical students get. I think we’ve trained the vast majority to be “toolheads” – they don’t know how to innovate for themselves, but first look around them for the best tool the industry around them has to offer (pharmaceutical and medical equipment especially) and use it even if it doesn’t quite do the job they want it to do. I know when I was a TA for the algebra based Physics course series at my local University, it was a challenge to get the pre-Med students to stop and think – they always wanted “The Formula” for every given problem!
I agree most med students are toolheads. They have to memorize vast amounts of information in a short period of time. The ability to do that doesn’t make you qualified.
Someone asked me what hospital I work for. I won’t give the name, but it is a major medical center and yes we made national in the recent past. It is not a for profit hospital.
Remember that toyota is a factory, healthcare is the human factor. In this day and age we need to stretch the health care dollar and yes cuts need to be made, but this time it went alittle to far.
I do want to make it clear that I do love what I do and I wouldn’t change jobs for anything, but I just want to have the supplies that I need (yes need and not want) and maybe not eat my dinner on the drive home from work. I don’t think thats asking for much.