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Mark Graban

Health Care

Three Reasons the General Public Doesn’t Think Health Care Can Improve

1+2+3 = Awesome?

Published: Monday, September 27, 2010 - 05:00

Lean thinkers see the waste in health care when they are at the hospital gemba. I think this is true whether you are a lean person who is new to health care or if you’re a long-time hospital person who has learned lean. Experts (doctors) ranging from John Toussaint to Patricia Gabow to Don Berwick all estimate that between 30 to 50 percent of health care spending is waste.


It seems that, often, when you take this sort of discussion to the general public, people react emotionally as if “reducing waste” equates to not providing people the care they deserve—they think lean health care is about taking away, instead of reducing cost and improving quality. I think this happens even outside of charged political circles. Why is that?

I have a theory.

Some of the common waste is described in this article about a new Master’s Degree program at Dartmouth:

“Disney knows precisely how to gauge the wait for rides at its theme parks. Major airlines know how to maintain near-perfect safety records on their aircraft. But hospitals? Most don’t know how to avoid making patients wait—some just build bigger waiting rooms.

“Medical centers spend increasing amounts of money on patients, but don’t necessarily deliver better care.

“And estimates suggest that each year in the United States there are 15 million incidents of medical harm, some of which result in injury or death.

“Now, a new master’s degree program at Dartmouth College is intended to bring more of the business of safety, cost-effectiveness, and efficiency into medicine.”

My theory is that the general public puts a lot of faith in our health care system. Blame TV or the movies, I guess. Would they think that a program such as Dartmouth’s is even needed?

I think people find it hard to believe the 30 to 50 percent waste estimates because they assume health care is fundamentally pretty perfect, or that it should be. It breaks down into three categories… because we have the following, we should already have perfect waste-free health care delivery:

1. We have highly trained, motivated people who care a great deal about patients

2. We have relatively new, modern hospital buildings

3. We have amazing health care technology (equipment, software, and medical knowledge)


So what could go wrong, given those three aspects? Yet, lean thinkers know that the overall system just doesn’t work. It’s probably hard for the general public to see that 1+2+3 = a lot of waste when they would likely assume 1+2+3 = awesome.

So when errors occur, the general public wants to blame and punish individuals—assuming they must be bad people working in an awesome system. When cost is high, people want to blame the greedy or the incompetent. People tend not to look at the overall system, they wouldn’t expect the problem is bad processes, not bad people. The general public assumes quality is good, when the data show otherwise.

It’s safe to say there are indeed a lot of great aspects about modern health care (see 1, 2, and 3, above). But we don’t get the high quality and patient safety we deserve and we, in the United States, certainly spend way more than we have to—and this high spending is partly due to waste, not due to 1, 2, and 3.

Do you think the public shares that perspective that I described above? Does that common (and arguably incorrect) view get in the way of the public calling for real systemic improvement that reduces cost and improves quality and safety? If so, how can we change the perception that 1+2+3 automatically equals awesome?


About The Author

Mark Graban’s picture

Mark Graban

Mark Graban is an author, educator, podcaster, and speaker in lean and continuous improvement strategies through his company Constancy Inc. He is a senior advisor to the technology company KaiNexus, the founder of LeanBlog.org, and the author of Lean Hospitals, Healthcare Kaizen (with Joseph E. Swartz), both recipients of the Shingo Publication Award. Mark’s most recent books are Measures of Success and The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation.



I think the public has heard of major healthcare errors (like Dennis Quaid's twins), but my impression is that people think it's always an anomaly (a bad person) as opposed to continual systemic risk. We all too easily and quickly blame a bad person and don't clamor for the process to be improved.

If the public is aware of bad quality, they certainly are clamoring loudly for healthcare quality to improve.

Maybe people tolerate the waiting because they assume quality would suffer if the doctor went faster, although we know (with lean) that efficiency and quality (and cost) go hand in hand.

Everyone Knows Healthcare is Slow and Error-prone

Anyone who has sat in a doctor's office or an emergency department waiting room knows healthcare is slow. Everyone knows someone who has had some sort of complication from treatment or surgery. Or they've read an article about wrong site brain surgeries (three times in the same hospital) or some other atrocity.

The public knows, but they don't think they have the power to change it.
Healthcare has to want to change. It's happening at some forward thinking hospitals like Virginia-Mason, Mayo Clinic, Cleveland Clinic and others, but it's not happening fast enough.

ED wait times, according to Press Ganey are still four hours, unchanged over the last decade. 10 years after To Err is Human found healthcare to be the eighth leading cause of accidental death, a Joint Commission article asked: "Is it better?" The physician's answer: "We don't know, because we don't really measure it." The public should ask: "Why not?" What get's measured, gets better, but healthcare isn't measuring as well as it could. There are measures, but most clinicians tell me that these numbers are underreported by a wide margin.

A few states now require hospitals to publicly report their errors, mistakes and mortalities. Every state needs to require it. And the public needs to demand it.

Healthcare has to want to get far faster, better and cheaper if it's going to pick up its part of the additional costs of universal healthcare. There's an estimated trillion dollars in waste, rework and unnecessary treatments that are waiting to be eliminated. Hospitals have to save $112 Billion ($2.5 million/hospital/year).

The methods and tools of Lean Six Sigma are easy, getting people motivated to use them to serve patients is much more difficult.

Jay Arthur is the author of Lean Six Sigma for Hospitals, McGraw-Hill, 2011. To find out more attend one of my free Lean Six Sigma for Healthcare webinars: www.qimacros.com/webinars/webinar-dates.html.

The Healthcare System is really fragmented sub-systems...

Trained, motivated people in new facilities with new technology are also working in the fast food industry. That's another industry that doesn't have a stellar reputation with customers. The problem in healthcare - just ask anyone who recently sat in an emergency room or waiting room - is a problem with incentives. There is no one who really believes they gain by improving the customer's experience or retaining the customer. Instead, doctors battle insurance companies. The insurance companies battle back. Hospitals, labs, drug companies, doctors and insurance companies don't treat people like customers. Large employers are seen as the "customers" for group health insurance plans. Employees at those companies have little control over the cost of their insurance plans or the relationship those insurance companies have with the doctors and hospitals. Insurance plans for small companies and individuals do not allow a reduction in coverage (and premium) if the insured agrees to waive certain types of claims. For example, an insurance company won't offer a policy that excludes maternity, drug treatment and diabetes coverage, even if I say I'm willing to exclude those things from my policy. Similarly, I cannot get a quote for health insurance that covers only cancer and heart disease, even if I agree to pay for sore throats, broken arms and annual physicals.

Improving some work processes to drive out waste and variation is possible in healthcare. Expecting those improvements to accrue to the financial and customer service experiences is flawed because the "customer" hasn't been identified correctly within the "system." Worse, the customer isn't the one paying the bills! Think lunch insurance!