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Mike Richman

Health Care

Lean, Health Care, and Quality

Does lean in health care make sense?

Published: Wednesday, November 3, 2010 - 07:50

A recent article appearing in the Quality Digest Daily e-newsletter (“Why Lean? Why Now?” by Dean Bliss http://www.qualitydigest.com/inside/health-care-news/why-lean-why-now.html) discusses the value of lean in a health care setting. In his editorial, Bliss writes about the manufacturing origins of lean and why he believes that lean tools translate so well into a health care environment.

If you scroll down to the “comments” section at the bottom of the article on our site, you’ll see an exchange between two Quality Digest columnists, Tripp Babbitt and Mark Graban (with some additional feedback from reader Chet Marchwinski). Babbitt and Graban often take opposing views on certain aspects of quality improvement, particularly relating to lean. Their comments on this particular article uncover a longstanding argument, namely, can lean tools be successfully adapted from manufacturing environments and applied to service industries such as health care?

Process improvement specialists are an imitative sort, and in many (but not all) of these cases, imitation is the sincerest form of flattery. “Benchmarking” is a hallowed tradition, practiced by practitioners of practically every stripe. It therefore makes sense that lean tools, first pioneered by Toyota within a manufacturing setting, would be adapted by organizations in various sectors, including service industries. Certainly, health care, in which success is often measured in lives (not just dollars) saved, was ripe for a lean revolution, and in a sense, that has happened in recent years.

The core of the argument isn’t the inherent value of lean; that’s pretty well established. My sense is that proponents seeking to define lean more narrowly feel that the practical results within manufacturing, such as a lessening of rejected parts, don’t apply to service, in which improvement often has to do with “softer” metrics like customer wait times. Those that support a wider view of lean believe that the methodology’s underlying philosophy dictates that pretty much anything and everything can be improved through a relentless focus on waste, however that phrase is defined for a particular process.

So, like many long-running debates within the quality industry, this one can be looked at as a matter of semantics. What constitutes waste, after all? Must it be a rejected product or part, or can it also be unnecessary time, steps, or effort? Can linked health care processes “flow” in the same manner as assembling an automobile or fabricating a semiconductor?

I don’t know the answers, but it’s fascinating to hear the experts duke it out. Their points are enlightening and well taken, and provide great food for thought. So what do you think? Is lean well suited to health care environments, or is it best left to manufacturing? If so, why? If not, why?


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Mike Richman


An important debate

This is an important debate. An interview with the chief executive of one of the UK’s leading ‘lean’ healthcare initiatives reveals the intervention problems being experienced. While they have done lots of training and some rapid improvement events have borne fruit, interventions break down and it has proved difficult to maintain changes and gain acceptance at local levels. By her own account, it was difficult to show real results after a year and in their first improved service costs rose. Read the interview here:


And in another UK health organisation (Gwent), often cited as a ground-breaker for lean, the lean team has been disbanded. My conversations with leaders there indicated that clinicians had difficulty engaging with lean practitioners.

I have no experience in health-care organisations but what I see in every financial services organisation I work with, that is ‘doing lean’, is this: reported improvements based on cost/activity metrics which don’t fall through to the bottom line. I wrote about this phenomenon here:

In short, standardised work and activity management in financial services leads to an illusion of improvement and actually makes service and costs worse.

We see similar phenomena in health care. For example this blog cited work in a pharmacy as an example of lean at work (moving high-frequency items closer to the picker, as one might in manufacturing logistics), and one of the contributors to the blog argued how this missed the point: studying a pharmacy led to the realisation that the real problems lay elsewhere.
See: http://www.leanblog.org/2010/05/a-glimpse-into-a-3p-lean-space-design-pr...

In my view the heart of the problem is the lean practitioners’ unquestioning belief in the universality of Toyota’s tools, thus interventions begin with the application of tools rather than understanding the real problems.

Professor John Seddon

Yes, it IS important

Mr. Seddon-

Yes, this IS an important issue. So I am struggling to understand why you would chime in with what you admit here is zero experience in healthcare. What do finance examples or Starbucks have to do with this discussion? Well, they highlight that Lean is sometimes misapplied (or misportrayed in the media). Your links don't prove that Lean doesn't work.

Your American colleague Tripp Babbitt said, in the other Quality Digest post, that I "lack evidence." Quite the contrary - there are many examples where Lean works well in healthcare - including publications in peer reviewed medical journals, like Health Affairs, where the bar for "proof" of Lean working is quite high. To those, like Tripp, who say that Lean might be "dangerous" for healthcare - you are the ones with no proof. What you are bringing to the table is your own anxiety, prejudice, and opinion. You are speaking with data or having a fact-based discussion on this issue.

Your one example from my blog is your speculation based on a gemba that neither of us has been to. You can jump to conclusions that they were doing it wrong, if you wish. You say "we see" but you have not been to the gemba. Mr. Ohno should have taught you about the importance of that, yes -- to go and see and to speak with facts?

You are incorrect (and insulting) to imply that all who practice and teach Lean are "toolheads" (again, your word). You, sir, are NOT the only one out there saying that Lean is about more than tools (although you may think you invented the notion or learned it directly from Taiichi Ohno in Japan, as you imply). What I *do* believe in is the universality of Toyota’s principles, philosophy, and management system (especially the parts based on the Deming approach). Again, you say hospitals are likely just applying tools - I believe that is incorrect and I'd like to know where you get your data.

The "debate" is clear:

1) I have evidence (and first hand experience) that Lean can work in healthcare. I can separate in my mind that Lean is sometimes misunderstood and implemented with a tools-only copy-first mindset. That doesn't invalidate Lean principles, as taught by Ohno and modern-day Toyota people.
2) You paint with a broad brush and smear all "Lean" people and you have no evidence to back your blanket claims that Lean never works or that Lean is "a wicked disease."

You are fear mongering and you're doing so in a very obviously self serving way (that the answer is Vanguard).

As I've told Tripp - if your method is that good, then please have at it. Hospitals need help. I'd never bash your methodology if you could prove that it works. Why you spend so much time bashing Lean is beyond me, except for that it seems to be your marketing strategy.

It's quite sad, in my opinion.

Efficiency is not Efficacy


Whether Lean or Six Sigma or the more current Lean Six Sigma, there aim is still more focused on efficiency. But efficiency is not always effectiveness or better . . . efficacy (= efficiency AND effectiveness).

W. Edwards Deming said that we need to reinvent management. We have (for the most part) not done this. We have managed to focus our attention on the front-line and miss the thinking changes that must occur in management. Lean and Six Sigma have no human change methodologies that are key to transforming our thinking or, more importantly, management thinking.

By addressing ALL elements of the system (structure, work design, measures, technology, management thinking, etc.) we wind up with a completely different service organization. By redesigning the work and the thinking whole new possibilities open themselves up to a company.

Until we address the fundamental thinking problems that prevent a huge shift in improvement, we will be mired in either in mediocrity (doing the wrong things, righter in Russ Ackoff terms) or making things worse. The big loss is we get little innovation which helps fuel our economy and jobs.

Please define 'thinking'

Every time that I try to read your responses to questions regarding Vanguard, etc., I find myself stumping a toe at your liberal use of the word 'thinking'- a use that is not accompanied by a solid definition within its context.

You say that Deming called for reinventing management, but what does that mean? Does that involve changing the manager's response to a situation or stimulus confronting the process? If so, then your argument is one supporting command and control: one that has managers promoting a predetermined, 'best' outcome of a process. Once applied across the culture of the organization, perhaps this becomes a new thinking which you are talking about.

However, until you define thinking in a more rigorous way, your arguments will continue to appear as repetitive 'cut & paste' text from someone else's sales brochure.

Best regards.

Define Thinking

The place to start would be the management biases that have created the design of work that we wee in business today. We believe that a better way is to move from command control to a systems thinking approach. http://newsystemsthinking.com/about_command_v_systems.asp I have posted many things on this and the positive influence this mindset helps in looking at organizations from a different perspective. From here new thinking can develop and grow.

You didn't invent that notion, either

By the way, ThedaCare (in Wisconsin) is just one organization that is working to address ALL elements of the system (structure, work design, measures, technology, management thinking, etc.). Your post implies that you have a monopoly on this thinking and understanding...

Sharp practice & LEAN intimidation @ the SHARPS end of practice?

When 98%+ of ALL Lean projects fail (according to commentators within the Lean community) http://www.evolvingexcellence.com/blog/2006/01/pogo_was_talkin.html (I suspect actually it is 100%) you can hardly be surprised at our incredulity at claims for LEAN in hospitals.
More specific is the way that LEAN is trying to CONTROL and LIMIT the story for example in the HBR a blog article called ‘Getting Physicians to Buy in to Lean Health Care’ http://blogs.hbr.org/cs/2010/03/getting_physicians_to_buy_in_t.html they highlighted that 'the initiative encountered stiff resistance ... the vast majority of physicians found the methods confusing or irrelevant and harshly questioned whether techniques pioneered in the auto industry were applicable in health care'.
Mark Graban responded that the person criticizing must be false 'I'm not sure who is behind your user name or pseudonym. You can contact me through my blog if you'd like to discuss this offline'. I am speculating that the reason that this is done offline is that other people do not have to see the negative criticisms of LEAN.
And in another Harvard Business Review critique of LEAN http://runningahospital.blogspot.com/2009/08/please-call-me-next-time.html you tried to smear them by suggesting that the HBR was related to another medical organization.

Mark Graban said...
It's a bit puzzling that HBR is technically and tangentially part of the same organization as BIDMC, correct? Too bad they did that to you.
AUGUST 10, 2009 8:32 AM
Paul Levy said...
No, Mark, that is not correct. We have nothing to do with HBR or HBS.

I have many more examples if anybody would like to contact me for them ...

What is wrong with you?

Yes that will sound like a personal attack, I really have to question your reading comprehension skills.

In the Paul Levy blog, he was complaining that he was misquoted by HBR. I said that was too bad since they are all Harvard affiliated (in a way) and that discussion had nothing to do with Lean.

So who is trying to do the "smearing" here??


Methinks you protest too much

When the NY Times ran an article about LEAN in hospitals called 'Factory Efficiency Comes to the Hospital' One nurse in the article argued against LEAN
'She says that in an effort to reduce waste, consultants observed her and her colleagues and tried to determine the amount of time each of their tasks should take. But procedure times can’t always be standardized, she says. For example, some children need to be calmed before IV’s are inserted into their arms, or parents may need more information'
The union went on strike for one day worried over the danger that this standardization might pose only to be accused of harboring a 'deep-seated resentment against business and profit that blurs their thinking (or they feel the need to attack lean to further their union agenda)'

Regarding strike

Admin is posting comment on behalf of MGRABAN:


MGRABAN reply: "It is incorrect to imply that the nurses in Minnesota went on strike because of Lean. They made Lean an issue in their negotiations with management, but you have to take into consideration that things are sometimes said by both sides in a labor negotiation that aren't necessarily accurate or objective.


The core of this long-standing argument comes down to Tripp and his colleagues taking an example of "lean done badly" or what Bob Emiliani calls "fake lean" or I call "L.A.M.E." and then assuming that ALL lean efforts have those mentalities and mindsets of old top-down Taylorist thinking embedded in them.


Tripp and his colleagues are right to criticize instances where standardized work is coercive and inflexible, but that hardly means Lean is always that way."

Personal Insults and Attacks


In one post you claim personal insults and attacks from Vanguard. Yet you continue to be the one with the personal attacks. I have an email folder full of them from you and they are all personal attacks. Clean it up.