There have been plenty of headlines and updates since I first blogged about the controversy over Lean healthcare in the Canadian province of Saskatchewan (see my previous posts here).
From my outside perspective, there are some good things happening. I admire their adoption of a “patient safety alert system” and a blame-free culture (see Saskatoon Health Region CEO Maura Davies' comment about this on a recent post of mine).
Some of the controversy wasn't about Lean itself, but was focused on hiring on American as consultant and paying his group $40 million over four years. In late June, a few months after the controversy flared up, we saw this headline:
“Gov't scales back lean consultant contract“
Deputy minister of health Max Hendricks said he foresees walking away early from the controversial $40-million, four-year agreement to train health-care workers across the province in lean leadership and management methods.
It's a sharp change of heart from six months ago, when health leaders said they would likely need the consultants' expertise for the full four years.
“We've learned a lot, and maybe it's time to take off the training wheels,” Hendricks said Friday.
The health minister has instructed Hendricks to review and renegotiate the contract “to ensure maximum value for money for the taxpayer.”
The positive spin is that John Black & Associates has done such a good job of teaching that they're not needed as much going forward. They are cutting the contract by $2.6 million, per this later article.
There are indications that the government is listening and adjusting their approach a bit (a good practice of Plan Do Study Adjust, or PDSA, thinking):
“People have complained. They've said, ‘We learned Japanese terms. We look at videos about the Toyota loom. We fold paper airplanes.' (The workshops are) meant to orient them and to demonstrate certain concepts, but I think that there's a way we could approach it that would fit better with our health-care system and our approach here in Saskatchewan,” Hendricks said.
Personally, I don't see how showing videos of Toyota weaving looms is engaging or relevant to folks in healthcare. It's possible to teach Lean without folding paper airplanes and we don't have to overdo it on Japanese jargon. They are adjusting the intro courses:
JBA will also shorten the introduction workshops 40,000 health care workers must take, and include more Saskatchewan content.
Battling Op-Eds
There has been a lot of back and forth about Lean in the op-ed pages of Saskatchewan newspapers. The papers don't always allow reader comments on these op-eds, but I'll share the columns and comment here. Debate is great. If bad things are happening in the name of “Lean,” then that should be called out. But, some of this back and forth is exhausting at times.
Lean's stopwatches add to woes
Columnist Murray Mandryk, who I've talked to (and been quoted by) is a reasonable guy compared to some of the anti-Lean bomb throwers in Saskatchewan.
In his piece, he highlights complaints from nurses about being followed by people with stopwatches.
Yet the Saskatchewan Union of Nurses (SUN) says stopwatch toting lean administrators have been following operating room nurses to monitor their performance.
Does this really contribute to the improved patient care that lean is supposedly about?
“When we followed up, we asked (why stopwatches were required),” said Amber Alecxe, SUN's director of Patients and Family First and Government Relations. “We were told it was about charting flow.”
Lean doesn't require stopwatches. If we engage the people who do the work and ask them to identify barriers to flow, quality, and safety, they can point out those problems. We can have people shadow their peers to draw spaghetti diagrams and do time studies if that's helpful in identifying waste. I've written about this before (“You're the Time Study Man” and “Time & Motion Studies Are Not “Discredited,” Just How They Are Used“).
The use of stopwatches dates back to the days of “scientific management” and industrial engineering. Time studies can be threatening if we communicate badly or don't fully engage people.
Time studies can be helpful and actually be embraced by staff and nurses if we:
- Help them understand WHY the time studies are being done – not to make them work faster, but to identify problems, waste, harmful variation, barriers to providing safe, high quality, compassionate care.
- Make it clear that time studies and Lean won't lead to layoffs (and hold to that).
- Teach peers to shadow each other (as I've done and recommended) rather than having some outside expert or engineer do it.
- Let staff review the spaghetti diagrams and time studies and let them give input into improvements.
- Implement changes, based on the time studies, that make people's work easier and improve patient care.
The Mandryk column reports that nurses say that, with Lean, morale is worse, they have less time for clinical education, are more stressed, and less time for patient care. Something's not right here.
Zambory and Alecxe say the survey and general discussion with their nurses is producing stories of supplies being “leaned” out – vital respiratory equipment removed from emergency carts, catheters for nursing home patients that are cheaper, but more painful to insert, vaccines running out and more paperwork – not less.
And when nurses have brought up such concerns, some have been told by administration to “shut up” and stop complaining, Zambory said. The SUN president added the declining relations have really been more evident in the last year or so as the Sask. Party pushed its lean implementation.
If these allegations are true (supplies not being available, being told to shut up and stop complaining), there are some very deep problems and issues to resolve in Saskatchewan.
“Better patient care can't be measured by just a stopwatch.”
That's absolutely right.
Lean methods key to success
Bonnie Brossart, CEO of the Saskatchewan Health Quality Council wrote a rebuttal to the Mandryk piece. She says:
“Without measuring time, we can't identify opportunities to make things better for patients.”
That's actually not completely true. Time studies and measurement are just one way of identifying problems and opportunities. If time studies are being done in a way that's antagonizing people, you could back off from that (or change the way the time studies are done).
She writes:
“Concerns expressed by nurses [about paper airplane exercises and time studies] point to the need for leaders throughout our health-care system to do a better job communicating about lean.”
She's right that leaders need to listen (and certainly not tell people to shut up). But, sometimes “we need to communicate better” isn't the right countermeasure. American politicians say this all the time about unpopular laws (nationally and locally)… when people are opposed, they'll say “we just need to communicate better about what we're doing,” instead of changing what they're doing.
Lean value in health care limited
Dr. Mark Lemstra has written many op-eds that are critical of Lean and the Saskatchewan government.
In this op-ed, he points out that Virginia Mason Medical Center, for all of their success with Lean (an approach that John Black helped launch), doesn't rank highly in different national hospital rankings, such as U.S. News & World Report. Well, neither does ThedaCare. It's widely discussed how these national rankings have a built-in bias toward the big name academic medical centers and how patient safety data is a minuscule portion of the scores that lead to the ratings.
Lemstra ignores or doesn't share the data about VMMC's measurable results and ignores the fact that The Leapfrog Group named VMMC “Hospital of the Decade” for their improvement efforts.
Lemstra claims:
In fact, a recent blog post from the CEO of Virginia Mason clarified that lean management is now correctly focusing on administrative tasks in that hospital, and not what happens between doctors or nurses and their patients.
I cannot find such a blog post on the Virginia Mason website. There's no evidence that it exists or that Dr. Kaplan said such a thing. Virginia Mason has certainly been using Lean to help improve what happens in patient care, including increasing the nursing time at the bedside from about 30% to 90%. See their blog posts about Lean and nursing care.
Realize that lean is one of many tools
Lemstra writes again a few weeks later about Lean.
He quotes from a recent journal article (with a very reasonable title of “Why Lean doesn't work for everyone.”
“Lean, and other industrial improvement methodologies, are increasingly touted as solutions to the quality and cost challenges in health care.
“However, despite infiltration of lean terminology into the vernacular of health care delivery, and the encroachment of exotic Kaizen quality improvement events into hospital conference rooms, results have often been disappointing.”
Yeah, there have been disappointing results. We have instances of “L.A.M.E.” (or “fake Lean” as Bob Emiliani calls it) in healthcare, just as we see in other industries.
We've proven that Lean can work in healthcare, but that doesn't mean it's guaranteed to always work if there are misunderstandings, misapplications, a lack of leadership, etc.
Lemstra is right to point out that Lean is just one part of the solution for healthcare. Nobody is saying it's a cure all. I'm not. John Toussaint and the ThedaCare Center for Healthcare Value are not saying that.
Criticizing how Lean is apparently done in Saskatchewan is not the same as saying “Lean doesn't work here” or “Lean wouldn't work here,” as others are saying online.
Good summary to end his piece:
“If Saskatchewan must implement lean, it should follow Kaplan's advice by recognizing that it is only one tool of many – it must grow organically and include empowerment, respect and feedback from all staff members, and must be patient-centred.”
Best clinical care dictates all efforts
Gary Kaplan chimed in with his own rebuttal, including:
“Mark Lemstra stated that the health system I lead, Virginia Mason in Seattle, is now focusing its application of lean management on administrative tasks that don't affect patient care. Nothing could be further from the truth.”
Dr. Lemstra has a lot of good points to make without making up things about Dr. Kaplan.
Beyond also mentioning the Leapfrog Group accolades, Kaplan says:
“Virginia Mason received the Outstanding Patient Experience Award for the second consecutive year from Healthgrades, placing us among the top 10 per cent of U.S. hospitals for patient experience.”
There are good things happening at VMMC.
“Our work is focused on creating, for every patient, a perfect experience in an environment where team members are engaged and able to do their best work.”
Lean works
Dr. Susan Shaw wrote a rebuttal to the Lemstra pieces. She correctly points out how Dr. Lemstra misrepresented Dr. Kaplan's views.
She writes:
“Lemstra's column misrepresents Kaplan's view and uses it to reinforce his opinions – which seem unswayed by the evidence of Virginia Mason's success, turning from the brink of financial disaster to become a highly regarded organization…. And Lemstra errs in saying Kaplan's article was not peer reviewed: BMJ Quality and Safety is in fact a highly selective peer reviewed journal.”
People can and should disagree and debate issues of the day… but when you take things out of context and get key facts wrong, you don't do yourself any favors.
Final Thoughts
So what can we do, other than being a spectator in this arguing back and forth?
We can encourage people to read about (and practice) what Lean and the Toyota Production System are really all about. Share data and results. Look at evidence instead of slinging mud. Point out problems that should be corrected.
I hope this discussion helps Saskatchewan do a better job of improving patient care.
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From a friend on Facebook:
It is unfortunate that in education (high school, college), we are not taught the difference between batch-and-queue processing and flow, and recognize these as fundamental and distinctive characteristics of two different systems of management in organizations.
Anyone destined to work in an organization will encounter a management system based on batch or flow. People should know the difference between the two early-on, not late in their careers.
They should also know that flow, while far more challenging to do and do right, is preferred. Perhaps then the back-and-forth would be more productive and center on how to improve flow.
As far as what we can do, we have to respond to the core concern that Lean is perceived as zero-sum (win lose): good for you but bad for me (Fake Lean). We can help people understand that the “Respect for People” principle encodes non-zero-sum (win-win) thinking into every corner of Lean management.
http://www.leanprofessor.com/2014/05/11/evolution-rfp-principle/
I’m paraphrasing Shingo or Ohno (or both) when you look at the difference in approaches.
1) Traditional management gets upset when they see workers idle
2) Lean management gets upset when they see the product not flowing
The same is often true in hospitals. Managers look for employees who don’t look busy. They want everyone to be busy all the time. They send people home early if patient volumes are low (instead of engaging them in improvement).
Managers need to look for the tube of blood sitting in a batch. Look for the patient not flowing, sitting and waiting… and address things like that.
With better flow comes better quality (and vice versa) and that all leads to lower cost. That works better than old-fashioned “cost cutting” and I wish more people saw that.
Well said. And let’s think about that… Managers are used to doing 1), above, for years (often decades), and are rewarded for that. So it is a difficult change for most to make.
This is an example of where visual controls can be really useful in getting people to think and do things differently. They can help people make the transition; e.g. a sign that says:
OLD: Look for people who are idle
New: Look for processes that are idle
Thanks so much Mark for your continued contributions and sage advice. Every day I am both humbled and energized by the enormity of the ambition we have set in Saskatchewan to make care safer and better. We have a long road ahead of us, but it’s heartening to see several examples of safer care with shorter waits. As you have reminder your readers often, truly being Lean means being curious, committed, and courageous. Equally important is to learn from our mistakes and commit to improving every day.
$40M for 40,000 employees? If my math is correct, that is $1k/employee for training cost plus the cost for time out of standard for hourly employees. A big number in total but seems reasonable on a cost per employee basis.
The big issue is what they get for that $1K/employee cost. My big question is why aren’t leaders doing teaching once they have been taught? As an aside, I shake my head when I hear that people are having to learn Japanese terms. It will be interesting to see the impact and staying power of this engagement. I admire Saskatchewan Healthcare for being bold, good luck to them.
I read this with personal interest. I am from Saskatchewan and personally acquainted with some of the names mentioned or referenced in your post and links. I have also previously worked in companies that specifically designed digital and automation technology solutions for healthcare improvements.
I am curious about the initial diagnosis by Saskatchewan’s leadership that predicated the Lean transformation. Before supporting or refuting the benefits of Lean in Saskatchewan, I would first want to establish whether this was a stand-alone endeavor, or conversely if it was integrated with other improvement initiatives which may include:
– the adoption of an ISO 9000-based quality management system,
– implementation of Six Sigma projects to reduce variation and violations of process controls due to special or common causes,
– integration of facilities into compatible information technology networks and data centers,
– deployment of digital and automation technologies (i.e. digital imaging PACS, barcode/RFID controls for correct blood transfusions or drug prescriptions)
– overall employee engagement and adoption of objective goals, objectives, and standardized practices.
Lean is effective when managed according to its defined scope and expectations. If there are disconnects or misunderstandings, the root causes may be traced back to the inadequate implementation and deployment of complementary quality initiatives or ineffective employee engagement, the absence of which could threaten to obstruct or derail the gains expected from Lean.
If I were advising the Deputy Minister, I would provide the following recommendations:
– Establish a framework based on an ISO 9001 standard, and define the prioritized quality objectives (i.e. functionality, reliability, transparency, privacy, security, performance, etc.)
– Train, engage, and elicit the support of employees at all levels to participate in the definition and improvement in a constructive and respectful manner. Without employee commitment and alignment to relevant priorities, initiatives will fail.
– Conduct a series of Gap Analysis activities using various techniques (Value Stream, Problem Management, Corrective Action, Infrastructure, Capital Requests, etc.)
– Categorize the improvement initiatives and deploy the appropriate methods (Lean – efficiency and cost reduction, Six Sigma – reduce variation and process violations, etc.)
– Follow through with real objective evidence, and promote any “Quick Wins” and other small victories to build early success and justify further commitment and improvement.
– Share gains and efficiencies with staff to realize the benefits and improved working conditions.
Daniel –
Thanks for your comments.
I’m pretty familiar with ISO-9001 from my manufacturing days and I will respectfully disagree that the framework would be the least bit helpful.
Six Sigma might be helpful in certain situations, for certain problems, but that adds an additional level of complexity beyond Lean. I’d advise the Deputy Minister to take one thing at a time. I disagree with what you propose about Lean vs. Six Sigma. Lean environments, including Toyota and ThedaCare, do quite well as “reducing variation” and addressing “process violations” without Six Sigma methods. I’m not sure where you got the idea that Lean is only or primarily about “efficiency and cost reduction” – possibly from Michael George books, but he’s completely incorrect about that.
I would also advise, as I’ve written here, that the key is asking “what problems are we solving?” rather than asking “what methodology do we implement?”
It seems that the challenges of patient safety, quality, and cost are at the forefront and those are important issues. I agree that everybody needs to be engaged in the improvement process if all of these problems are going to be fixed.
I do agree that, in any situation, some quick wins and the demonstration of real benefits to patients, staff, taxpayers, etc. is very important.
Mark
Mark, thank you for posting and commenting. I appreciate the respectful dialogue and acknowledge your expertise in Lean for healthcare.
To your questions and comments:
– My characterizations of Lean and Six Sigma reflected an article in ASQ Six Sigma Forum Magazine by distinguished authors Ron Snee and Roger Hoerl. The title of the article is “Integrating Lean and Six Sigma – A Holistic Approach”, and the primary references cited are Joseph Juran and Michael George.
– I think we can agree to disagree on the merits and benefits of ISO 9001 and its impact on quality, cost, and delivery. I believe that effective management systems provide context and relationships between high-level objectives, plans, processes, documents and records, measures and key performance indicators, and actions for correction, prevention, continual improvement, and management review. I also believe that this type of framework could be constructively applied within a healthcare environment (just as Lean practices are transferable across industries and domains).
– As Lean and its methods are included within the ASQ Body of Knowledge for Six Sigma certification, a rejection of Six Sigma implicitly rejects Lean. These are not mutually exclusive practices.
– The methods for process controls predate both Six Sigma and Lean. They can and should be applied, irrespective of the label of the initiative. For example, a process control chart used to capture late deliveries should be used, whether the improvement initiative is characterized as Lean, Six Sigma, TQM, or whatever nomenclature is preferred.
– I respectfully disagree with the “one thing at a time” approach. A healthcare transformation incorporates clinical practices, biomedical engineering, medical documentation systems, administrative practices, transactions, information technology, medical inventories, and patient care and management systems. The optimal integration of processes, equipment, practitioner interactions, controlled environments, perishable products, and other attributes is a complex and dynamic configuration which requires a thoughtful and deliberate approach, appropriate to the context and culture of the public being served as well as those who prepare and deliver those services. Because of the interrelationships and interdependencies, attention must be provided to multiple elements of improvement in order to realize success in the initiative.
Hi –
Thanks again. Here is where I disagree.
Again, I think Michael George has created a false dichotomy of Lean and Six Sigma, creating a whole army of consultants who repeat the incorrect line of “Lean is for speed and Six Sigma is for quality.” If you read about Toyota from Toyota and their production system, they emphasize that it’s about flow and quality.
One can reject Six Sigma without rejecting Lean. One can use simple statistical tools (as Toyota does) but not use the Six Sigma formality of “belts,” etc. They are distinct. One can reject Lean and use Six Sigma, if they want. With all due respect to ASQ (and I’m a former member), they are factually incorrect if they think Lean and Six Sigma have been inherently merged into a single thing that they call Six Sigma. I’m sorry, but ASQ does not get to define Lean as being a part of Six Sigma. They have no right to do so.
Do you have any experience or case studies that support your theory that ISO-9001 would be helpful in healthcare? Or is that just a theory?
Lean can be a “thoughtful and deliberate” approach that can be quite transformative to a culture and an organization. It’s not the only methodology or Body of Knowledge that’s needed. But, my point is — if Lean is “simple” (as often said by Lean Sigma people) and an organization (in general) is struggling to incorporate it and engage people, how does adding the complexity of Six Sigma help?
Organizations can and probably should have parallel initiatives… but we can’t assume it can always be done successfully and effectively.
Mark
Mark,
Your perspectives on Michael George and ASQ are duly noted.
With respect to ISO 9001-based systems (which can include FDA Quality Systems Regulations), this type of quality management system is already widely adopted within the healthcare domain.
– Providers of pharmaceuticals and medical devices for commercial distribution are required by law to have a management system compliant with FDA Quality Systems Regulations (a.k.a. Good Manufacturing Practices) or its ISO equivalent (ISO 13485) outside of USA.
– In the US, DNV (Det Norske Veritas) has combined ISO 9001:2008 with the conditions for coverage and participations (CoPs) to permit Medicaid and Medicare participation. Lee Memorial Health System of Southwest Florida is one facility that has obtained this hybrid credential from DNV.
The US Government through NIST has also defined a set of healthcare criteria for its national Baldrige program for performance excellence. These management systems are intended to complement and support improvement initiatives.
The 2015 version of ISO 9001 is being revised to incorporate more attention to Risk Management. I expect that these changes would cascade and be propagated to its derivative standards within the next few years. This revision improves the relevance and applicability of ISO 9001 to healthcare priorities of cost, delivery, patient safety, privacy, other critical to quality attributes.
The best sources for testimonials would be the administrators of these particular programs (DNV, FDA, NIST), who could direct you to the success stories. I hope this helps to clarify the concern.
Here is that ASQ article that Daniel references.
Many points and figures are factually incorrect about Lean.
Lean and Six Sigma can co-exist. Six Sigma statistically methods are need to solve some complex problems. But when the Lean Sigma crowd says that Six Sigma is the only method of the two that reduces variation or improves yield… that’s just hogwash.
https://twitter.com/MarkGraban/status/502224294496043009
https://twitter.com/MarkGraban/status/502224992885432321
https://twitter.com/MarkGraban/status/502225498299064320
Here is a pretty balanced piece on the debate from a professor in Saskatoon:
Debate goes beyond lean itself
There’s a pot shot at John Black that’s a good line, but is a tad unfair and unnecessarily inflammatory.
“I’m not sure where you got the idea that Lean is only or primarily about “efficiency and cost reduction” – possibly from Michael George books, but he’s completely incorrect about that.”
I know where Daniel most likely heard of the principle of efficiency and cost reduction being the primary focus of LEAN. Our own premier, Brad Wall incorrectly stated this point in one of the many political responses in the media. It’s short sighted visions from our leaders that derail the process before it begins.
Efficiency and ultimately cost reductions aren’t the primary focus of LEAN, they are the BYPRODUCT of becoming LEAN.
This is one of many key points that get lost in the political debate that does nothing to help us become better.
We want to stop hurting our patients and provide them with the best and most effective level of care we can.
Lets try focusing on that when the LEAN debate comes up.
Agree that the focus should be on patients, safety, and quality, The rest will follow. When leaders, whether a premier or a hospital CEO in the U.S., they’d better understand what Lean is really about if they’re going to be talking about it.
The Sask. government has ended the JB&A contract early (Read Announcement).
A survey from the nurses’ union… how have they managed to give Lean such a bad name up there? Not patient centered? Not appropriate for healthcare?
mark, this doesn’t surprise me. I’m familiar with lean (more so with agile software development) and have 2 relatives working within the saskatchewan lean healthcare experiment. they are front line, treating patients in 2 different departments. over the last several years we’ve had some good discussions comparing what’s happening there with what I’ve seen in hi-tech. seems what they’re being asked to follow is an poorly conceived version of lean (at best) that is often contradictory to its ideals. amoung other things, real knowledge and influence ends at middle management and does not filter down as it should, creating animosity that overshadows the small successes. I’d guestimate the survey data is specific to the implementation, though because the general public has no way to tell the difference (nor do the people within the experiment for that matter), lean healthcare suffers as a result.
as a side note… I’m curious if you’ve had any direct contact with frontline workers there? I’ve often thought a person could build a great how-not-to case study out of their opinions and experience.
-neil
Hi Neil-
Thanks for your comment. I’ve trade emails with front-line staff from Saskatchewan. Mainly, it’s those who are relatively supportive of what the province is trying to do, even if they don’t like every detail of how it’s being done there.
I find it curious that the opposition party and the news there now refers to the program as “John Black Lean” instead of just Lean. That’s probably a more accurate, better descriptor.
When people complain that they’re not being listened to in a Lean initiative, that’s a sign of a real problem. It’s not just John Black, but also complaints about others, like the last comment on this post from Paul Levy:
http://runningahospital.blogspot.com/2012/07/you-dont-do-lean.html
This article cites a study that claims the total cost – consulting fees and staff time – are almost $50m.
It says nothing about the benefits of this work or the benefits of the time when frontline staff are paid to work on improvement.
But, the comments section shows how angry people are about what some call “a scam job” or they are just reacting to the ugly optics of such a big consulting contract.