By: Lukasz Mazur, PhD and Marianne Jackson, MD:
I have recently participated on a conference call with Lean Healthcare experts around the country during which it was debated if we really have a unifying definition of “what is Lean Healthcare?” Initially, this came to me as a surprise as we healthcare professionals have been applying Lean for more than a decade now. Yet, with reflection and speaking with my colleagues, I tend to think we are actually not clear “what is Lean Healthcare?”
To explore this intriguing question I asked my dear friend – Marianne Jackson, MD – one of the Lean Healthcare implementation leaders at University of North Carolina to help us understand “what is Lean Healthcare”. She shared with me a presentation she recently gave to the UNC Joint Committee on Quality.
“As an industry, Healthcare lags behind many others in delivering quality. How do we know?
Ask yourself: Your mother is having a 3 hour surgery today – how is your day different from usual? What’s on your mind? Now ask yourself, your mother has a 3 hour flight to San Francisco. Is your day equally changed? How about it if it’s you having the surgery or the flight? Which one makes us more nervous – why?
In 1999 and 2001 the Institute of Medicine reported on the harms including deaths caused by hospitalizations and it developed the now very familiar aims that define quality in the delivery of healthcare services – we aim to deliver care that is Safe, Effective, Efficient, Timely, Patient Centered and Equitable. Nationally, we struggle and are hardly better at what we do a decade later. Stated reasons for the difficulties have included the complexity of healthcare organizations, misaligned financial reimbursement incentives, out-dated acute care models applied to serving chronic disease populations, lack of team-based training on quality and safety and rapidly advancing technologies.
This is not the story we have to tell. Instead we can give you a picture of an approach to quality and safety that should give you hope. It’s a story from our Cancer hospital that has adopted a management approach to Quality and Safety called Lean – well developed in manufacturing, applied in other industries and spread to healthcare beginning in about 2001, first in Seattle at Virginia Mason hospital , and in Wisconsin at Theda Care and begun in UNC radiation oncology by Dr. Larry Marks in 2009. Lean is known for many things, but we maintain it is about RESPECT – for people, for resources, for time, money, health, talent, effort and innovation – or in a nutshell – Quality and Safety. Eliminating waste is an act of respect. It is based on the fundamental principles that to provide quality and safety you have to know what you do, how you do it, by whom and in what order and that you can do it reliably every time, without error and with confidence. It states that if you have your processes down, your outcomes will follow – like a three point shooter making the shot: whether he scores, is always and only a result of his lining up and making the throw with precision.
No one knows how to improve workplace processes better than the people who do the work. HARNESSING EVERY WORKER’S IDEAS for continuous improvement leads to better and better processes. It is also based on the understanding of James Reason’s Swiss Cheese model that states that eliminating error requires rigorous examination of our organizational structures, our supervision, workplace conditions and human factors. This does not require a detailed knowledge of all the Lean tools or the Japanese terms – that often detracts and distracts improvement work. Rather, with good facilitation, frontline nurses, schedulers, residents and staff can provide and spread the ideas for quality improvement and learn experientially how to solve problems.
There is one more aspect of this story you need to appreciate – and that has been the role of LEADERSHIP. This is a story about a passionate group of physicians, PhD’s, engineers, nurses, administrators, and staff that are working together to create a culture of safety and respect. THIS WORK TAKES TIME AND PERSISTENT EFFORT, not just using the elevator speech at every conversation, but using every opportunity to spread the culture of safety and respect. It requires hospital LEADERSHIP to make crystal clear the quality goals of the organization and then allow managers to develop their staff to work to meet those goals with ideas, problem solving projects and collaborative teams investigating through experimentation the best solutions. This work requires LEADERSHIP that has the humility to learn from others – other industries (like aviation), other professions like engineers or theatrical directors or restaurant chefs) and above all to learn from their own staff and patients.”
Here is how I interpret what Marianne tries to tell us.
Marianne emphasize RESPECT FOR PEOPLE, need for HARNESSING EVERY WORKER’S IDEAS, and LEADERSHIP because, without it, virtually no significant organizational change can succeed, nor can a Lean-like functioning organization (once created) be maintained. This is true in essentially all types of organizations; e.g. from industries to sports teams. The same is true in medical environments.
Marianne tells us that “no one knows how to improve workplace processes better than the people who do the work”. She emphasizes that leaders must a) set clear vision and goals for culture of quality and safety; b) continually reinforce the need for the staff to cooperate with each other, understand and work to improve their workflow; c) become fully committed to Lean principles so improvement efforts can be implemented, coordinated and sustained over time.
She also tells us that Lean Healthcare TAKES TIME AND PERSISTENT EFFORT. Over-time, all staff need to similarly commit to a vision of quality, reliability and value creation that comes with Lean Healthcare. This might take a long time as these concepts have not always been given the highest priority. The true potential of Lean Healthcare can only be realized if all staff buy-in, both in theory and action via active participation. A less-than-complete participation might still yield improvements, but they will not be optimal. Further, even if reliability and value are achieved, a widespread personal commitment to continuous improvement efforts is needed for sustainability. Entropy is a strong ever-present concept. Systems decay, and often become obsolete as practice evolves. Sustainability requires the continued concerted efforts from all staff.
So, what is Lean Healthcare? Perhaps, we could define it as function of RESPECT FOR PEOPLE, HARNESSING EVERY WORKER’S IDEAS, and LEADERSHIP. We would love to hear your opinion about how to define Lean Healthcare. Please comment!