Mark's Note: I asked my friend Sam Selay to write a blog post on this topic after some private discussions that we had. He agreed and shared this post. I've talked to many others who have run into similar roadblocks and frustrations when trying, with the best of intentions, to bring their Lean skills and experience into healthcare.
Sam was one of the contributing authors to the anthology “Practicing Lean,” which is now available through Apple iBooks, in addition to Amazon (Kindle and paperback), and Leanpub (eBook and audiobook). Here is his post:
In June, I was informed by my employer that the company had decided to go in a new direction. They said they would now build lean into their processes and enable process owners to be responsible for all continuous improvement functions. To date, I don't know many organizations that have been able to successfully embed lean into everyone's work and sustain it.
While this move left me unemployed, it could not have come at a better time. My kids had just started summer break from school and I got to spend the whole summer with them enjoying Southern California where I reside.
As I began exploring new opportunities in Lean, I used this as an opportunity to attempt to get into healthcare to practice Lean. Until this point, I had only practiced Lean in the Department of Defense, government, and manufacturing.
For me, I wanted to try to get into healthcare for several reasons: it's broken, errors are occurring, and costs are rising due to the poor quality of care. Some have gone as far to say that medical errors are now the third leading cause of death in the United States. Here is a report by Johns Hopkins on this subject, written in 2016. And Mark shares some other statistics here.
Additionally, being a 13-year United States Marine Corps veteran with 4 surgeries while on active duty, I can candidly say that there is room for improvement in healthcare for active duty and veterans through the Department of Veterans Affairs. I would one day like to help improve the Department of Veterans Affairs healthcare system through the deployment of Lean as a philosophy and management system. Whether it's healthcare in the private sector or government, there are great opportunities to use Lean to improve patient safety, quality of care, and service.
After applying to numerous Lean healthcare roles, I finally got an interview. The position seemed to be a good fit for what I was looking for. The position summary read: “Partners with managers and employees to facilitate, create and implement process and systems improvement (Lean Healthcare).” The job posting also went on to say the person in that role would “promote a true Lean culture.”
In the job posting, there was a line that didn't sit right with me. As it turned out, when I had the opportunity to ask questions about this, it completely painted the picture of what leadership's real expectations and focus were at their healthcare system.
“Willing to do diverse work to assist anyone or any team in the hospital to reduce waste in the lean sense, reduce defects, reduce cost in the traditional sense, improve productivity, increase revenue or volumes, and take time and complexity out of processes.”
Working in other settings, I have found that leaders care a lot about cost, efficiency, and productivity, even though safety, quality, and service are supposedly what the company cares most about, as outlined in numerous company documents and policies.
When I asked about this sentence, I was told that cost savings was leadership's top focus. The interviewer went on to inform me that the healthcare system has been cutting costs by laying staff off and increasing staff utilization to increase productivity, which resulted in a reduction in costs.
I was informed that I would be responsible for finding ways to further reduce costs through Lean. Laying off staff is NOT Lean. There comes a time when organizations must use layoffs to stay profitable. I was just part of a wave of layoffs, which included the whole Lean department.
The hospital can choose to cut costs through layoffs, but they should not be calling it “Lean.” Toyota, who is arguably the founder of Lean coming from the Toyota Production System, has emphasized that Lean is focused on improving flow and quality. In more recent years maximizing customer value has been a broader use of Lean.
The Lean Enterprise Institute has defined lean as creating more value for customers with fewer resources.
How then do layoffs and increasing staff utilization resemble anything close to Lean? While increasing utilization may reduce costs, it may hinder flow when there is a rush of patients. I don't think you would want your fire department at 100% utilization.
In fact, I'm currently living through three of California's largest fires in state history. My kids' school has been closed due to poor air quality. I'm thankful that the fire departments around the state have the capacity to support and fight these fires. What is going to happen when the ER at this hospital who's boasting at being at a high utilization rate has a surge of patients?
Prior to the completion of the interview, the conversation turned toward compensation. It was here that I learned that the pay range for the role was much lower than the rate I had been earning in previous roles outside of healthcare — close to 50% lower. This aligned with what I was told earlier about the focus on cost cutting. My perception of the low compensation is that the executives don't value Lean and didn't want to commit to a pay range that was commensurate to leaders in the healthcare system. I sensed that Lean was something that is “delegated” to someone else, or someone that is “beneath them.”
My experience interviewing with this healthcare system was a learning lesson. After that interview, I decided that I did not want to move forward with the role due to leadership not truly understanding that Lean is not only a set of tools that can be used to cut costs, but is also a philosophy and a management system.
I didn't understand how they got the idea that Lean's purpose was to cut costs. Also, to allude to what I just said, the low compensation for the role also indicated to me that the executives really didn't value Lean. They needed someone to find ways to cut costs and do other “Lean things” to hide the fact that they were really only focused on cost reduction.
Again, Lean can't be delegated it must be lead by senior leaders. To quote leadership author John Maxwell, “Everything rises and falls on leadership.”
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From the executive’s perspective, it does not matter what the true intent of any method or tool is. They exercise their prerogative as leaders to re-purpose them (e.g. Lean) to meet whatever need they have at any given time. It is their exclusive right to do so. The low compensation does not just reflect the low value placed on Lean, but also the low value placed on people who know about Lean – inclusive of the view that Lean is to be delegated, rather than led by executives. This is the common long-run pattern which the Lean movement has been largely unable to overcome in healthcare or any other industry, in large part because it has not understood, in detail, the complex interests and multi-faceted motivations of executives. Continuing disinterest in these facts is a detriment to both Lean and customers who would benefit from it.
Thanks Sam, This was an interesting read for me, I appreciate you sharing your experience and perspectives. I have been leading continuous improvement (CI) within financial services for 20 years now. I have always thought it would be more impactful and rewarding to apply my skills and experience in the healthcare industry, truly benefiting the people that matter most and not just the bottom line. My hope is to still have an opportunity someday to lead CI in healthcare, but more importantly, the ability to truly influence a healthy CI and Lean culture throughout the system.
Sam, thanks for the post, and good for you for asking penetrating questions to dig beneath the words in the job description, which didn’t sound too bad to me on the surface. Removing waste, defects and complexity can all contribute to improving safety, service, and quality, but you gave the interviewer the opportunity to show that that was just lip service. All of my lean experience (9 years) is in healthcare, including 3 years at the VA. With a few important exceptions, they have the same challenges as the other health systems where I’ve worked and learned to apply lean thinking. The environment is complex. Real transformation seems to depend on an executive leader who lives and breathes lean like the CEOs who have led the lean efforts at Virginia Mason, ThedaCare, Denver Health, and a relatively small number of others. I’d be happy to share my experience at the VA with you, and will reach out via LinkedIn.
As someone who has moved from manufacturing to financial services to federal government to healthcare, I certainly see the draw associated with wanting to apply your skillsets to an industry where you can fundamentally impact people’s lives in a very tangible way. But my only advice to someone trying to break into healthcare is pretty straightforward…. learn healthcare first.
While a focus on cost reduction may seem antithema for a patient-centric hospital, it’s a stark reality for many health systems. Many hospital have the luxury of relatively low rates of Medicare and non-reimbursement. That is an absolute luxury that many hospitals aren’t afforded. If you have a 60% Medicare/Medicaid patient base and tens of millions of dollars in non-reimbursed care annually, then margin matters. It matters just to keep the doors open so you can continue to treat those patients that need it the most. And that’s when Lean is needed the most. It’s needed to improve flow so staff don’t have to do so much NVA. It’s needed so Rx errors don’t happen. It’s needed to mitigate the need for 10s of millions of dollars in construction projects.
Not every hospital is in a lovely non-competitive suburban healthcare market. Not every hospital has a billion dollar endowment and can solve access problems by staffing pediatric intensivists around the clock. Dollars equal access. Access equals care for people who need it the most.
Secondly, learn healthcare so you don’t end up killing people. I’m not saying that to be glib. I’m saying that as a very real risk. Almost every former manufacturing lean practitioner in healthcare that I’ve ever met has done at least one ED Wait Time project. Whenever it comes up (or I see their poster at conferences), I always ask them the same question about their project. And I’ve never received an answer that made me confident that their “lean” project wasn’t going to have a significant negative clinical impact on patients. Lean capabilities on their own in healthcare aren’t enough. You need to learn the end-to-end patient value stream. You need to understand the healthcare revenue cycle. You need to have a basic understanding of population health. Otherwise you will spend years driving lean in your hospital without understanding the very real harm you may be doing.
Any lean practitioner that puts in the time and work, I will go out of my way to find them a job in healthcare. Lots of books out there (Hacking Healthcare is a great start). Lots of FQHC’s looking for pro bono consulting support. Lots of solid lean healthcare professionals that will donate their time to mentor you if you’re really committed.
Hi Robert, Thank you for the candid direction. Yes, I need to learn healthcare first. Yes, I agree that lean is needed to improve flow by removing waste to prevent errors and to avoid un-necessary construction projects.
I’ll take the necessary steps to position myself to work in the industry. Again, thank you for the advice!
Sam, please feel free to reach out if you need literally anything. As someone who has made that transition and have hired a lot of roles into healthcare, I’ve seen a lot of good and bad. When I first got contacted for my first healthcare role, she spent a lot of free time before/after work and during lunch sitting in ED/PCP waiting rooms to get a better feel for processes, flow, and variation. Also reviewed way too many healthcare project decks that were available online. Talked ti as many people working in healthcare as I could. The Rev Cycle element was one of the things I just didn’t spend enough time on before getting into healthcare. A lot of things that might make sense from a process perspective can actually negatively affect reimbursement. Who delivers the activity, where it happens, and in what sequence becomes more important because of that. You don’t need to be an expert. Just have to be able to ask the right questions. I’m relearning a lot of things in my new role down here.
Healthcare absolutely needs lean leaders who can figure out how to translate their skill sets into the unique hospital processes.
Rlkluttz@gmail.com
By the way, this is why reducing costs is a legitimate objective for many hospitals.
http://www.chicagobusiness.com/health-care/hospitals-shut-30-year-pace-us-no-end-sight
A rural town without a hospital means a lot of really bad things for a lot of really good people.
Who is saying cost isn’t a legitimate objective or concern for a hospital?
The problem is when it’s the primary (or only) goal. Especially when it’s short-term cost cutting that negatively affects quality and care.
It’s a different setting, but I have a veterinarian friend who has been learning about and practicing Lean. He’s owned a practice and has worked for a major national chain. In both contexts, he couldn’t think of a single metric that was not cost or financially driven. Yes, “patient safety” and medical error is a problem in veterinary medicine. Waiting times and customer satisfaction are things that should be part of a balanced scorecard… not just cost.