After some supporters of the Saskatchewan Lean healthcare efforts reached out to me, I've been trying to follow everything that's being said and written – which is hard to do (just try a Google news search). There are many facets to this story, some of which are discussed well by John Shook and Bill Waddell in their blog posts.
All of these blog posts about Lean healthcare in Saskatchewan on a single day? That's more evidence that we're just a “cult” and a “scam,” eh? What do I mean by that? Read on…
Somebody from Saskatchewan complained to me via email that “Lean's gotten political.” Hmm… government-run healthcare system with elected politicians (and elected union officials to boot), it's always political. The rooster crows when the sun comes up, the politician gets political. No surprise.
Instead of Pushing Lean or Arguing with Each Other, Focus on Improvement
A lot of the discussion has been about “should we use Lean methods?” People are labeled as supporting Lean (often being accused, as I was, of supporting it only out of personal financial interests) and people are labeled as opposing or resisting Lean.
A lot of debate has been about people and politics, unfortunately, instead of being about improving things for the staff and the patients.
In the category of stuff I should just brush off and ignore… it's funny that a union official, an elected president who is paid by the union from dues that members are forced to pay, would complain that somebody (me) has a vested financial interest in something. He doth protest too much. He labels Lean a “scam.” Ah, politics. The union and the liberal NDP party have a vested interest in taking potshots at the conservative Saskatchewan Party (and vice versa). The NDP party has said that Lean is a cult and the Sask Party leader has demanded apologies. Good grief.
Instead of arguing with each other or arguing “should we learn and use Lean?,” the discussion should first be about improving healthcare. Should we improve healthcare? Yes? Can we improve healthcare? Yes! If so, how?
I'd like to think that's a non-partisan issue that everybody should be able to agree on – we have to improve healthcare. Saskatchewan has had a “Patient First” initiative. Maybe “Lean” should have just been under that banner instead of trumpeting Lean, Lean, Lean? Can everybody please grow up and focus on the patient? And focus on the nurses, physicians, and others who have to provide that care to patients?
People would probably agree that the current state of healthcare is bad in many states, provinces, and countries. This current state includes:
- Patients being harmed by preventable errors at unacceptable rates
- Inconsistent quality and patient outcomes
- Long waiting times for care
- Frustrating, stressful workplaces for nurses, physicians, and other healthcare staff
- Inadequate management systems and dysfunctional organizational cultures
- Cost cutting often traditionally focuses on layoffs
Again, this is the current state WITHOUT Lean. This is not a Saskatchewan problem or a Canadian problem. it's a global problem.
I hope there would be agreement that this all needs to be fixed.
The Debate Over How to Fix It
The question then comes down to, “So what do we do about it?”
Lean is one approach. It's not a silver bullet. It's not easy. Lean works in healthcare, but it's not guaranteed to work. There are other approaches and other fixes that people will propose. We can debate which one (or more likely multiple) strategies and improvements to adopt.
Lean is not an “American approach” (nor is it “Japanese” at this point). Lean in Canadian healthcare has nothing to do with fears of privatization and it's not about “turning them into an American healthcare system” for many reasons (one of which being that most American hospitals are NOT Lean yet).
The Saskatchewan government has had a Lean initiative for many years and I've met some of those leaders (including former Deputy Minister of Health Dan Florizone, who I interviewed here), but I don't really have any inside knowledge about what's going on there. Florizone was interviewed here recently, as well.
Who Should Help and How Much Should it Cost?
The government there has placed a $40 million (over four years) bet on the consulting services of John Black & Associates. Black is the author of a book (The Toyota Way to Healthcare Excellence: Increase Efficiency and Improve Quality with Lean) and played a key role in initiating the Lean transformation at the Virginia Mason Medical Center. He's rightfully credited as being a visionary and an innovator in Lean healthcare and Virginia Mason was named “Top Hospital of the Decade” for a reason for their improvements in patient safety, quality, and cost.
I respect John Black for the role he has played in bringing Lean to healthcare. All of us working in this space are standing on his shoulders.
But, back to politics… some complain that Black is an American. They complain that he flies in Japanese consultants who require translators. They complain about the $40 million. Some complain about his attitude. He did himself no favors (and didn't impress me) with this comment about how they'd regret not hiring him (even thought he “didn't want the job”):
“If you're not dead (in 20 years), you're going to be in one of your health-care systems here in bed, with a tube up your ass and one down your throat. You're going to be saying to yourself, ‘My God, I wish I would have asked John Black to come in and help improve my care,' ” he recalls saying before leaving one meeting. He thought he'd never hear from them again.
My God, I wish he hadn't said that. Leading with humility, anyone?
Some say “we should have spent that money on hiring more nurses,” but Lean thinkers would realize that adding more people might be, at best, a short-term countermeasure. If hospitals are truly understaffed (something I don't know without being there and without seeing data), they more nurses should be hired. But, looking at the long-term trends of an aging population and a retiring workforce, I'd argue that we need to get more efficient and productive — a better long-term countermeasure.
Some argue they should have hired a Canadian. That's for the Canadians and the politicians to decide. Some argue that they are using too many Japanese words (with the use of those words being part of the “cult-like” approach).
The “should we have spent the money?” and “should we use so many Japanese words? questions are very different than “should we embrace and practice Lean?”
What are the Results So Far?
Arguably, they are getting results with Lean in Saskatchewan. Beyond the training and the Rapid Process Improvement Workshops (both of those being means, not ends), Saskatchewan says the contract with John Black ($10 million a year) has already paid for itself with a projected $30 million savings in the construction cost of their planned Children's Hospital (through 3P and Lean Design efforts) — and it will probably be BETTER and more effective, not just cheaper.
Has it “already paid for itself?” In way, but not really (or not yet). For now, it's paper savings until the hospital is actually built and the money is not spent, but that seems like a reasonable savings projection based on the results of other hospitals using Lean design. Hospitals are building better buildings, cheaper, and faster. They're not bigger than they need to be, yet they're not inappropriately small. They need the needs of patients and staff. That's Lean.
But, I have a vested interest in saying that, don't I?
Update: This article includes a government claim that the Saskatchewan healthcare budget has increased less than in previous years and that it can be attributed (at least partially?) to Lean. So maybe they already have real savings.
DD: With this being a three per cent increase in health (spending) and last year, the 2013-14 budget had a 3.5 per cent increase in health, I think that does demonstrate that the work that we're doing with Lean has found efficiencies within the system. Normally, we're used to health increases of seven, eight, nine or 10 per cent a year and even at some pretty high increases in health budgets in the past, particularly through the late 1990s or early 2000s with significant increases in health budgets, we've seen positions that were lost — doctors and nurses that were cut, facilities and beds that were closed … (Because) we haven't had that same type of experience, I think (that) has shown Lean has been part of finding efficiencies and also of improving the quality of care that we've been able to offer patients in a more timely fashion.“
Better quality, more timely, lower cost. That's Lean.
So, did they have to spend $40 million on consultants? I don't know, maybe not. But that was the choice of the Saskatchewan leaders and they have to live with it (and face their voters if it doesn't work). The New York City HHC, consisting of 11 public hospitals, has had a $35 million contract with Simpler Consulting over multiple years and they have about the same number of employees. Saskatchewan Lean advocates have pointed out their annual spending on Lean is just 0.2% of their budget, but that doesn't include staff and leader time spend on Lean.
ROI matters to people… but we also have to consider the long-term value of training people. Lean talks about developing people AND improving the way work is done. Both things lead to results, both short-term and long-term (Toyota promotes long-term thinking as a primary principle). The ROI of the training and education that is taking place is harder to measure and value… but it should be considered.
But the Politics Sure is Annoying
As part of the politics, a Canadian union is doing what politicians do – spreading misinformation and lies about Lean.
They trot out the old, tired claim that unions always throw around:
Lean programs considered “management by stress” and used to justify layoffs while increasing workloads of remaining staff
There's plenty of stress BEFORE Lean. Lean gives us a fighting chance to reduce waste and free up time. The Lean workplaces I've been in are LESS stressful and they're calmer. Nurses get to spend MORE time on patient care. The total workload can't be increased beyond 60 minutes of work per hour and nurses are ALREADY being asked to do too much in an hour… so corners get cut (not the nurses' fault!) and errors are made.
Lean gives us a fighting chance to actually take the breaks we are entitled to, which is humane for the staff and better for the patients (less fatigue equals fewer errors).
The union also says:
Claims that Lean management produces savings have also been called into question. For exmaple, one Lean “success” at the Children's Hospital of Saskatchewan cost $30 million more than the original estimate.
Wait a minute. The government says they have SAVED $30 million. Either the union doesn't know the difference between “saved” and “cost more” or they are lying. Have the claims of savings been “called into question” by anyone other than the union's blog post? Or another union?
I'm not trying to make the union the enemy. We should all be working together on creating better workplace and improving patient care.
But politics get in the way?
Give Lean an Honest Look – Neither Blind Faith nor Blind Hatred & Distrust
If there are legitimate concerns that “they're not doing Lean right,” then I want to hear them. To discount them out of hand would be playing politics instead of being a good leader.
Yes, Lean is about respecting and engaging all people in improvement (which includes patients, as Saskatchewan is doing). If some managers are focused only on cost cutting, that can't be what John Black is teaching them and that's just an old habit they haven't broken yet. The visual display boards in their units have measures of safety, quality, waiting time, cost, and morale, so I know they aren't just focused on cost. But, if some managers are ONLY paying attention to cost, that should be called out and adjusted.
We should listen to the concerns and the leaders (and consultants) who are really there on the ground should listen and they should decide what, if any adjustments, should be made to their approach.
See a series of excellent videos that include nurses and patients talking about the improvements they are making with Lean in Saskatchewan. I wish them the best of luck on all levels and I hope they are very successful in their improvement work because that's what it's really all about. It's not about “implementing Lean,” it's about improving patient care and improving our health systems.
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I think it gets very tough when people take a topic like LEAN and jump on the bandwagon without fully explaining it to the people around them. It’s poor leadership.
As another example, one of the partners at my firm has recently decided to make PassivHaus his goal for his personal cottage. Which is great. Until he wants to make every single project in the office PassivHaus, which may not be the best solution for various types of architecture.
I was at a Healthcare Design Conference in Toronto last summer, and I was able to see various hospitals, all with patient-centered design, and what systems they used. Some used LEAN, some used bodies of research that have been around for decades, light creating courtyards for the emotional well-being of the staff involved. I don’t think they have to always be opposed, though courtyards increased the footsteps, which is counter LEAN, but all design strategies have a filter through which they need to be seen, and we need to be aware of that filter at all times.
I appreciated Dan Florizone’s reflections on the topic about not explaining it well being poor leadership or a “failure of leadership.”
He’s not a failed leader, I don’t think. To the contrary, that level of self reflection (realizing the problem is not always other people and could be himself) makes him a great leader.
Interesting points about Lean and architecture. Some say Lean is “all about reducing waste.” That’s not really true. Yeah, a courtyard might have more steps… but if those steps are better (more healing exposure to sunlight and natural environments), then maybe those steps are “value” not “waste.”
The goal of Lean is meeting the needs of customers/patients and helping us reach our long-term goals of organizational/provincial success and health.
I should have also linked to Paul Levy’s post from last Saturday.
I should have also added this data about Cleveland Clinic and spending on Lean (from the initial Sask. announcement about the Lean contract):
“For example, the Cleveland Clinic, which employs approximately the same number of people as Saskatchewan’s health system, invested $40 million in Lean and achieved $100 million in savings over five years as a result.”
I have yet to see a political argument that was productive. All we seem to be able to do is sit on our side and throw rocks at the other side. Sad.
Some political arguments do lead to changes that make the world a better (or worse) place.
But most of it is just gum flappin’
The NDP party tweeted and asked why “number of critical incidents doubled over 4 years. Why is patient safety getting worse under the Lean system?”
For one, I replied, it could be more accurate REPORTING of incidents. This was also stated in a tweet by a Sask. physician.
Or, you could call what’s likely a real phenomenon “spin” as the NDP politician did.
According to Health Minister Dustin Duncan, the results of the SUN survey — contained in a report from the Regina Qu’Appelle Health Region — could partly be attributed to a renewed commitment on behalf of health-care workers to report safety issues.
“The critical incident reports indicate that the system is becoming more vigilant about recording (these incidents),” Duncan told reporters.
“We need these incidents to be reported.”
Broten, however, called Duncan’s reasoning “offensive” and disrespectful to patients and their families.
“If I was a family member who lost my dad or a sibling because of a critical incident, I wouldn’t want spin about that,” he said.
Perhaps the NDP could learn a little more about root cause analysis. Their comment above is akin to relating the number of shark attacks off the coast of New England to the increase in ice cream sales in the summer. Guess what – they both go up at the same time. Do you suppose there is a direct relationship?
More articles
“Lean health consultant defends price tag; ‘Senseis’ carpool, ride bus”
With comments and reactions from John Black.
“‘Lean’ another in a lengthy list of ‘magic’ cures”
There are no easy magic cures.
My comment is delayed, but I see some problems with taking the government at its word while suggesting union members are spreading misinformation or lies about Lean, because that’s what politicians do.
You say at the same time you aren’t on the ground and don’t know the data (at least on some issues) so how do you know who’s spreading misinformation? Governments are made of politicians. Is a government’s claim of paper savings to be accepted at face value?
I appreciate your willingness to hear concerns about shortcomings. Perhaps it should be noted that nurses invited an opposition politician to hear theirs, but the meeting was reportedly kaiboshed by ‘higher-ups.’
Stephen – thanks for your comment. That’s a very fair criticism.
I guess my bias/tendency was to believe the Sask. government. They have a vested interest in this looking good (the Sask Party) or, I guess, in looking bad (the NDP). I wish it was as simple as them have a vested interest in the patients and staff!
If the government is lying about the success of Lean, they are accountable to the voters. If the union(s) is/are lying… well, I guess they are, in theory, accountable to their members.
I’m not a “union hater,” by the way (for what that’s worth). I have a more complicated view than most. I’m not “pro-union,” per se, but I don’t blame the UAW for all of GM’s woes, for example. I understand well why unions were formed “back in the day,” but I understand why workers at VW and Toyota (in the U.S.) would resist or say no to the union.
I agree we shouldn’t take anything at face value. I don’t take my American political leaders at face value nor do I blindly trust them (in either party).
I’ve been less than impressed with Larry Hubich, the president of a Sask. union. After he tweeted that Lean is a scam and a cult, I offered to send him links to medical journal articles about Lean. His response was, “No, I’m good.” So, I was probably feeling a bit pissy about that, honestly and I let that influence my comments more than it should have.
Here are my priorities:
1) The best care for patients
2) The best work environments for staff and physicians
3) The truth
4) Advocacy for Lean
The meeting you talk about was kiboshed by higher-ups in hospital management or the government??
Lean is all about encouraging people to raise concerns, to “pull the andon cord” (sorry for the Japanese term). We must be willing to listen to those concerns with an open mind.
Mark,
I was on-site (at the gemba) in saskatchewan as this was all happening this week. Don’t believe everything you hear on the radio, read in a newspaper (or a blog). Here’s the real deal:
http://wp.me/p3G1Li-c2
Mike
Thanks for sharing. I know there is a lot of good work going on up there. Did you hear any complaints at all? There’s often at least a shred of truth in rumors of instances of “Lean being done badly,” which like you say is often the result of leaders have old habits from having gone to “the wrong school.”
Mark,
What I saw when I was on site was good stuff. You and I know that cultural transformation is hard work. There are no shortages of opinions about the best course of action to take and how much it should cost. My advice is to not try to “out-squirt” a skunk. I also think the long term view is in order. I sometimes say “we make progress one funeral or retirement at a time”. I don’t mean we should be killing people off, but the long-term view and constancy of purpose requires patience, collaboration and choosing where to put our energy. Support and build the critical mass. Protect them from the nay-sayers, but don’t stoop to the politics and noise. I won’t waste an minute of my time on those who think the prevailing style of management (good old common sense) is the right course.
Mike
I always try to distinguish know-nothing naysayers (who don’t want to learn) like the union president who said “No, I’m good” when I offered to send him journal articles. We need to just ignore them, I guess.
But people who are skeptical or have honest problems to report… we have to listen to them. When somebody pulls the andon cord, there might not really be a problem, but we have to thank them and respect them for pulling the cord.
Yes, that’s a good point. You might find it of interest that one of the patients on the “patient panel” told a great story about how they were originally very skeptical and did not plan to stay for the entire event, and was then convinced (through the process) that this was the right course. Now this patient is a super advocate. So, it requires collaboration and willingness to participate from all sides.
I liked how Dan Florizone said:
We can’t blame people for not “buying in.” Giving them a chance to participate and really listening is key. That’s leadership, eh?
One nurse’s comments are here:
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