Management consultants and fads come and go but one that has persisted and is being applied more and more in healthcare is the application of Lean, writes Dr. Peter Lachman.
Based on the teaching of Deming, and developed by Toyota, the concepts and tools of Lean have cheerleaders and detractors. Every hospital will have had Lean projects. Lean tools abound- fishbone diagrams, process mapping, the 4 Whys and the 5S. But do they work and do they make a real difference? In Ireland, there are Lean Academies which aim to integrate Lean into the system of the hospitals where they are sited. However, the success of Lean has been varied.
A recent report from Sweden by Poksinska et al[i] in BMJ Quality and Safety reports on Lean programmes in primary care. These focussed on efficiency and value but seemingly from the perspective of the organisation rather than from that of the patient. They conclude that “Lean healthcare implementations seem to have a limited impact on improving patient satisfaction.” This may well be the experience of many providers who have done Lean projects – e.g. the Productive Ward or Operating Theatres series. Indeed, most Lean projects are aimed at efficiency and waste elimination for the process being improved. Poksinska et al. recommend that in all Lean programmes waste must be eliminated from the viewpoint of the customer, i.e. the patient, not from that of the organisation.
Poksinska et al. recommend that in all Lean programmes waste must be eliminated from the viewpoint of the customer, i.e. the patient, not from that of the organisation.
The defence of Lean is made in an editorial by Blackmore and Kaplan[ii] from Virginia Mason in Seattle. Virginia Mason is the “go to” hospital for Lean in the USA. One could ask why are there not more successful Lean hospitals. It is because there is a difference between Lean Management and Lean projects. Lean is more than the set of tools; it is about culture change and a total management system. Thus, Lean projects are not sufficient unless the whole organisation is focused around the value needed by the real customer, i.e. the patient. Blackmore and Kaplan are clear that “in the hierarchy of customers in healthcare, priority must be assigned first to the patient. Fundamentally, healthcare exists to serve patients.”
Lean allows prioritisation of patient values, generally safety and access and waiting times rather than cost. Reduction of cost is a by-product of a lean system and should not be the focus. Too often Lean is unsuccessful because there is a failure to understand that it is a new way of thinking, a new philosophy and one should not do Lean projects – rather the whole management approach needs to be Lean.
One should not be wedded to the tools but rather change the whole way we work, so that the patient is the reason to cut waste and be more efficient and the efficiency is a by-product of making the service value added at all stages for the patient. Providers will then benefit as they find the service is less wasteful, and they will be safer, more efficient and less costly. And person centred.
- [i] Poksinska BB, Fialkowska-Filipek M, Engström J Does Lean healthcare improve patient satisfaction? A mixed-method investigation into primary care BMJ Qual Saf 2017;26:95-103. http://qualitysafety.bmj.com/content/26/2/95
- [ii] Blackmore CC, Kaplan GS Lean and the perfect patient experience BMJ Qual Saf 2017;26:85-86 http://qualitysafety.bmj.com/content/26/2/85