By Lawrence Marks, MD.
The application of lean to healthcare is most reasonable when healthcare is viewed from a broad perspective. The analogy between “making cars” and “caring for patients” becomes less valid as one delves into the more-granular aspects of healthcare.
Lean = Healthcare (broadly)
Lean X=X Healthcare (at the microlevel)
Personalized Medicine vs. Lean Health Care
There is growing interest in personalized medicine. Patients are increasingly being told that their care can be tailored to their specific situation. Enthusiasm for this approach is fueled in part by advances in genetics (e.g. defining tumor-specific abnormalities in the genome) and therapeutics (e.g. targeted therapies that exploit unique biochemical/genetic abnormalities in tumors). Further, this approach “sounds good” and plays well to our sense of individualism and empowerment.
Concurrently, lean health care is being promoted as a means to improve clinical operations and efficiency through standardization and the reduction of waste. Lean approaches gained much credibility as they were successfully applied by Toyota to generate uniquely reliable automobiles. Similar lean-based improvements have been seen by other manufacturers as well as in other industries such as aviation.
Lean has been less vigorously embraced by healthcare. There are several well-known successes (e.g. Virginia Mason, Thedacare) where lean has helped to improve operational efficiencies, increase financial performance and improve clinical outcomes. The standardization that comes with lean reduced inter-patient variations in care, appears to reduce errors, increases efficiency, and improve outcomes. In other words, exactly what was seen by Toyota. Nevertheless, it is very challenging to implement lean principles in healthcare. Indeed, the successes at Virginia Mason and Thedacare took many years to be attained, and were hindered by much resistance from providers and staff alike. This is all well described in the books “Transforming Healthcare” and “On the Mend” from these institutions. The popularity of these books, and manner in which these institutions are so widely admired for their achievements, is a reflection of the difficulties in bringing such lean-based change to healthcare.
Physicians and other care-providers are typically strong-willed and opinionated. The concept of standardization (fundamental to lean) is often seen by providers as an affront to their medical judgment, competence and professionalism. “We are not making cars, we are curing cancer” is a representative refrain voiced by opponents of lean.
Who is right? Like most things, the truth is somewhere in the middle. Health care providers indeed are not making cars, and inter-patient differences are almost certainly larger than the inter-car differences. Nevertheless, viewed from a fairly high level, patients and cars are very similar. In our radiation oncology clinic, we typically evaluate and care for over 100 patients per day, with a wide variety of ailments. There are many inter-patient differences that need to be considered on an individual basis, with corresponding modifications to their radiation doses, field sizes, etc. Nevertheless, there are many commonalities that span across all patients. At the time of initial consultation, essentially all patients will have (in the same order) an evaluation by a nurse, a history and physician examination by a physician, review of pertinent medical records, a recommendation for treatment (or not), and a series of appointments made for future activities. Sure there are differences in the details of these various components, but the broad structure can be readily standardized. Similarly, just prior to receiving a radiation treatment, essentially all patients will disrobe, get onto a table in the radiation treatment room, be positioned and aligned as needed, imaged to assume correct positioning, and then treated.
Therefore, lean concepts such as standardizaton can usually be readily applied to the broad aspects of patient care. However, as one delves more deeply into the details of any individual patient’s treatments, the presence of (necessary) inter-patient variation makes the application of standardization more challenging.
The successful implementation of lean in healthcare requires that we accept that there are inter-patient differences and that the provider’s input as to how to address these differences is still needed. Indeed, the goal of lean in healthcare is to standardize what can be standardized, so that the providers can spend their time focusing on those important inter-patient differences. In fact, it is those inter-patient differences that makes healthcare so interesting, challenging, and rewarding. Used properly, lean can liberate providers to relish the most interesting aspects of their work. Personalized medicine and lean healthcare are synergistic.