Learn Through Lean

After celebrated success at Toyota, lean has made some forays into the health care industry, with some early successes.  Perhaps it makes sense for US hospitals to take a closer look at the Toyota Production System (TPS) because there was nothing wrong with their brakes after all.  No, that’s not the reason.  Fast forward to the Deficit Reduction Act war room, where legislators are busily hacking away at the Medicare and Medicaid programs.  Last time we checked, these were among the health care industries' biggest customers or payers.  While the lean/6-Sigma training necessary to empower employees and contractors does disrupt things to some extent, the payoff appears to be tangible; more importantly, we are facing lean fiscal times so a lean organization is an absolute necessity, no matter how achieved.

Those health care practitioners who have already ventured into lean seem to agree on one thing, that their successes are only truly successful to the extent they are systemic.  This means using lean tools, of course, and understanding the “system” dimension – one with much interconnectivity between and among departments.

But let’s be honest, those hospitals and other health care organizations that have already taken the plunge on a large scale, are now experiencing the same frustrations with lean that had plagued lean transformations in the auto industry. The problem is, lean advocates are so focused on “process improvement,” they often forget that for any process to improve, the people directly involved need to do their jobs better.  Another problem is that lean initiatives are often competing with other types of initiatives and training that compete for vital staff time.  Steven J. Spear explains that “unless everyone is completely clear about the tasks that must be done, exactly who should be doing them, and just how they should be performed, the potential for error will always be high.”  He further argues that lean applied to health care should be about creating a culture of “no ambiguity” and solving problems through quick experimentation.

For these reasons, we don’t necessarily see lean as an instant solution to hospital inefficiencies.  Instead, we see it as a structure for necessary learning and organizational change, which, based on early indications, will indeed bring the necessary results.  

Looking back, the first practitioners of lean in Toyota conceived of it as a way to develop “kaizen mentality” in every employee, rather than as way of applying “lean tools” to every process.  Kaizen is:

§         a Japanese word that roughly translates to “continuous improvement;” it pushes efficiency by asking each person to take personal responsibility for simplifying processes and techniques;

§         about waste management, i.e., getting rid of those things that make us inefficient, thus helping us to streamline our activities.

Lean thinking seems like a reasonable way to improve operations constantly disrupted by the challenges of organizing the work of a large number of staff with a great variety of patients in a very demanding environment.  Its dual focus on customer satisfaction and employee involvement also dovetails with most health care setting cultures.  

When the Rubber Meets the Road

When applied, over relatively short periods of time (six months to one year) early enthusiasm is likely to yield to frustration and then to cynicism.  For example, consider lean tool “5S”:

§         sort and eliminate

§         straighten

§         shine

§         standardize

§         sustain

In most units, the immediate reaction of improvement teams to 5S exercises is to mention the lack of storage space, and usually with good reason, since many floors have been designed without much consideration for storage.  And even where there is sufficient storage, it’s not unheard of for certain departments to hoard and often fail to account for necessary supplies.  All of this obviously hinders 5S progress.  

Just-in-time (JIT)

JIT, a lean tool, is helpful here, by locating waste and cutting it out of the process.  According to Blackburn, waste is "anything that does not add value to the product or service."  In order to satisfy the customer's needs, it is important to produce a product with value, but it is not important to include features that do not add value to said product.  This constitutes waste, and costs time and money.  Eliminating delays is an important part of eliminating waste, and with a faster production line free of waste, companies, including hospitals, will be able to produce the same value-based product or service faster than ever.  

For example, in many health care setting departments, the stock of medical supplies corresponds to a weekly delivery, which obviously floods the floor with products upon each delivery.  Daily delivery solves the space problem immediately, but would also mean far less stock on hand, which, in turn, means much greater reactivity from the treatment teams to any risk of supply failure.  This, in turn, calls for use of the “jidoka”, or “react at first defect” lean pillar, which means corrective action is taken at the very first risk of missing products.  

Stabilize the foundation

Learning occurs when basic stability has been achieved.  In a chaotic environment, any “improvement” activity can easily shift the burden to another element of the system, which will then collapse, often cancelling any initial positive results.  In lean, basic stability is absolutely essential to create the proper learning environment where employees and contractors can see clearly the impact of their actions – established and sustained by organized kaizen activities.  In fact, many practitioners have argued that successful lean implementations in health care are essentially about reducing ambiguity on the floors.  It is certainly a good first step, if nothing less.

What the heck is normal?

Clearly, the goal of Toyota/lean is to convert workers into problem-solvers, and doing so in complex environments such as hospitals is about educating people to stop going around problems, but fixing them immediately.  To do this, their working environment must enable them to see clearly what is a problem and what is not, or, in the spirit of Toyota-mantra, to identify abnormalities at a glance.  In practice, this is difficult in a hospital unit since there are a high number of activities going on at a given time, a high number of often rotating staff, surrounded by patients, family members and lots of illness, suffering, emergencies, questions and complaints.  Since many of the simplest tasks can become inordinately complicated, it can seem daunting to maintain “normal conditions.”  Plus tracking down the specific reasons for certain problems (e.g., bedsores) quickly can be discouraging because the reasons can be many and/or variable, thereby eliminating the possibility of a “blanket solution.”

For example, a great first task for those seeking stability is to liberate the corridors.  From a safety point of view, this makes obvious sense since any object, such as beds, trays, wheelchairs etc. can easily roll and block emergency exits in case of a fire or any other need to evacuate.  But many hospitals who have taken this step have been confronted by all sorts of material in the hallways, from laundry bins to wheelchairs to trolleys overstuffed with supplies.  Something as “simple” as clearing the corridors generally pushes back to inventory management, and monitoring/ordering of material.  Not only will any such drill-down efforts get the material out the corridors and into the storage rooms, it will boost quality by eliminating too much of some things, not enough of others, multiple holding points, hidden reserves, dangerous locations (top of shelves, corners, etc.), and dangerous out-of-date products.  In lean terms, the nursing managers and their teams will learn “leveling, which creates a sense of “normal conditions.”  Again this is a prerequisite for a productive learning environment, one that is capable of understanding what needs to be done and then doing something about it.

Other hospitals are value stream mapping their emergency rooms and testing centers.  This exercise yields average waiting time from triage to discharge.  Beyond quantitative information, this provides helpful information around improved: communication, standardization of activities and roles, physical placement of patients and providers for optimum flow, enhanced triaging, progressive inventory management, and so on.

Toyota Builds Cars, Hospitals Fix People

We could go on and on presenting different lean success stories, and how nicely it is transferring itself from the auto industry to the health care industry.  No, people aren’t cars, but that doesn’t mean that a kaizen way of thinking doesn’t have a place in the health care setting in terms of bringing the most progressive flow and quality concepts into an increasingly crowded physical plant.  It takes a true commitment to excellence, and the guts to fail to take on an enterprise-wide lean initiative in a confederation posing as an integrated organization, but everyone thought General Custer was crazy too.  Actually, he was.  OK, maybe you have to be a little crazy to freely throw around words like jidoka, but what could be cooler than getting a hospital to do better work with a lot less money?

One or another, we are all going to find out.