What the world (of healthcare) needs now...

“Lean” is a fad in healthcare management. It* appeared in the field about a decade ago and enjoyed a period of frothy excitement for about that long. I confess to having partaken in the celebration during 2009-2010. Real Lean is a system of management that came out of manufacturing. It is asserted that its techniques are applicable in all human activity and, therefore, in healthcare. Since hospital managers started buying this, consultants began to repackage their healthcare management expertise with Lean labels and to sell it with Lean jargon. And out of that part of the story came a lot of fake Lean. We will ignore that here. By "Lean" I mean the Toyota Productions System (TPS) à la Ohno, Liker, John Black, etc.

Lately, the hype has begun to reach its limits. Sober experience has revealed that some bits of Lean work in healthcare (i.e. hospital care), or more to the point, Lean works in some bits of healthcare. Otherwise not. But the momentum of fads is such that not working is not an option. We must have it! Indeed, the tale of implementing TPS is full of adrenaline soaked tales of Sensei Samurai kicking resistant doctors out the door. As actual implementations have shown that what can be done by Lean in a hospital is pretty innocuous. “Five S” or making the place clean and tidy. Process “flow” streamlines assembly of instrument trays for OR. Meal delivery. And so on.

But the party is far from over. Waiting in the wings is the promise that Lean can do great things for real healthcare, what providers do for patients. I have been calling this Diagnosis-Treatment-Care, DTC. More can be done than we do now. Lean offers something of which the healthcare analogy is evidence based medicine or care. But Lean’s version is at best only analogous to EBM/C. There are aspects of DTC healthcare that cannot be touched by real Lean. For the essence of real Lean requires the fundamental assumption of manufacturing efficiency: high volume production and repeatability. Human beings are not repeatable, or not repeatable enough for Lean to apply.

I expect to post here a series of considerations that will show why “Healthcare providers are right to be wary, but wrong to reject Lean”.

Today, I want to write down what is needed for the improvement of healthcare management, both in the parts where Lean can be applied and where it goes beyond into DTC. The need can be summarized as four management abilities.

But by no means should it be supposed that I think that it would be easy or even practically possible to ensure that our managers have these abilities. There are many ways in which fostering these abilities is attempted in organizations daily. Some approaches work better than others, often or usually depending on specifics. In future,  I might offer some ideas on how to make progress in these things, but now I only want to make a context in which the potential role of Lean can be understood.

1. Honesty

The ability to form judgements and choose actions that serve the interests of the organisation beyond preferences.

A major impediment to process improvement in healthcare is the existence of perverse resistance and the unethical pursuit of personal advantage. The one word label on this ability might be “Ethics” or “Service”. The problem is that, currently, professional prerogatives granted to secure a safe atmosphere for clinical judgement are abused to defy common sense or even decency.

2. Experience

The ability to recognize significant types, patterns, or trends, emerging as aspects of normal process functioning.

This is often called “domain knowledge”. It is the skill of seeing what is needed and them knowing what knowledge to apply in a given situation. With the maturing or “greying” of the Boomer generation, we are actually in a golden age of experience. Our organizations will soon be operated and managed by a cohort of people who have much less exposure to how things work, how people work, and what can be done and cannot be done. Experience teaches humility.

3. Intelligence

The ability to perceive, as connected with their causes, the important parts and processes that compose an emerging moment.

There are kinds of intelligence. The kind needed for the management and encouragement of the process improvement is as rare as any other kind. But our organizations now give leadership roles to people without considering this need. This may be a self-perpetuating vicious circle, that calls for the first ability: to serve organizational interests rather than only one’s own.

3. Knowledge

The ability to recall relevant facts, measures, statistics, paradigms, methods, or algorithms.

Process improvement requires special and general knowledge, of general science and general mathematics more than of art and literature. But they need to know some history too, at least of healthcare and hospitals. Also the techniques of Lean and other process improvement methodologies. The potential for computer simulations, and why it is not the same as putting data into spreadsheets. And so on.

 

*I.e. "healthcare Lean". Of course, as an approach to manufacturing, it has roots that go back to the two stages of post- and pre-WWII Japan (Toyota), through the great gurus Juran and Deming, the genius of Henry Ford’s assembly line, to the "Scientific Management" of Taylor and the Gilbreths, the mid-19thC managerial revolution, 18thC mass production (Whitney) and so on. Juran's history of Quality has a very relevant chapter on Moses! And even in healthcare, there were some early outliers. Frank Gilbreth “invented” the OR nurse as an efficiency move in 1914; in 1915 Henry Ford built a hospital to apply his ideas… it operates today!

 

What is the Patient Centered revolution?

The ever-faithful rising and setting of the Sun in its daily course across the sky is one of the most beautiful and gloriously magnificent phenomena of nature. From the most hidden reaches of pre-history, humans have adored the sky-climbing Sun as a God of fire and life. The earliest scientists began by carefully recording for centuries its eternal path around the Earth. And even when the religious tone abated in favor of viewing the Sun as “the greater light to rule the day”, its stately movement through our skies kept it firmly the focus of intense scientific investigation.

So, when Nikołaj Kopernik (Copernicus) suggested that the most obvious fact about the Sun was an illusion - that the Sun does not go around the Earth, but the Earth revolves around the Sun - he was not believed. In fact, it was such a bizarre suggestion, easily refuted by anyone who cared to look out the window, that, despite his prestige as a great scholar and Cardinal of the Catholic Church, almost no one, outside a couple of young disciples and the astronomers and ecclesiastical think tanks in Rome, took him seriously for a very long time.

Of course, times have changed. And almost everyone nowadays believes Copernicus’ revolutionary notion that the Earth goes around the Sun idea is obviously true, an elementary fact of science, no matter how the sky looks.

As hospital based healthcare providers, we are invited to participate in a kind of “Copernican revolution” in how we think about our patients and the care they receive from us. This revolution is not proved by the laws of physics or astronomy, but it is based in logic and on sound principles of health and medicine. And it is not a new concept -- we are responding to a call that has been growing for many decades, more than a century. But we have not been taking it seriously, or not in the right way. And yet it is the foundation for rightly understanding our commitment to patient centered care.

Hospitals are not mere bystanders in the health history of the people we call “patients”, but they must learn to see themselves as existing for the other. First, then, let us review how the situation looks “out the window”.

There is no denying the “obvious fact” that hospitals are the centre of healthcare. Patients who get sick and need healthcare do wonder whether they will have to go to the hospital. They go first to their Primary Care physician, to find out. They may not have to go, but the hospital is always at the centre of gravity in whatever they do to get well. Or at least that is how it can seem to someone who works in a hospital.

After all, we only see patients who in fact did have to come to us. The other ones, who do not come to us, we are sure exist, but we don’t know much about them. Patients who don’t come to the hospital ... What kind of patient is that? They sound almost like “escapees”!

If we study a bit how healthcare is spread throughout our society, we soon learn that hospitals are not the only institutions that patients have access to. Besides the GPs mentioned already, there are various kinds of health-related clinics and offices. There are places that tend to diseases of the eyes, feet, elbows, and waistlines. There are labs to test almost everything. And there are dozens of “Institutes”, “Academies” and “Homes” that offer to do things that may or may not actually help a patient. Many of these may be found in a hospital. Some may have recently left a hospital setting. Others may be lobbying to be allowed in. A few are found both in hospitals and spread around the community. But what we see in the end is the immovably obvious “truth” that, ultimately, whatever the “exceptions”: patient care revolves around the hospital. Doesn’t that sort of “egotistical” statement make you feel uneasy?

Of course, hospitals are only places, where people and equipment are gathered together for the convenience of the patients. It is the expertise of healthcare providers that make Hospitals the centre of things. Patients don’t revolve around hospitals, they revolve around providers. When you put it like that - patients revolve around providers - the sense of creepiness really intensifies.

None of us, in our democratic culture that worships autonomy and equality, feels comfortable when one class of people revolves around another. And I put it this way to make you uncomfortable. It is precisely this kind of unequal situation that leads to revolutions. And, as health care workers and providers, you are in a position to make the revolution happen first. You can make it a conceptual revolution - one that affects attitudes and influences institutions without leading to protests, confrontations, and accusations.

We must begin with a reassessment of how we perceive our relationship, as providers, to those we serve with our knowledge and skills. By our own values and stated commitments, it is they who should be at the centre of our activities.

Better Healthcare

Healthcare is an activity, a human action, performed in the interest of another human being, for the restoration of some aspect of the health of the other. That the actions of healthcare have this clear goal, allows them to be and to be judged as more or less effective in reaching it. In this sense, they can be better, no better, or worse.

Experience and experimentation have discovered and established specific ways in which healthcare actions can be shaped and conducted so as, reliably, to have more probability of ending in the desired effects. These ways are each described in formal clinical protocols, procedures, care maps, etc. Application of these procedures offers further and refining experience. Through this continual critical observation, ineffective features are removed and, perhaps, more effective features are added. The probability gradually increases that a given action or series of steps will produce a desired outcome. Thus, later procedures are better than those initially introduced.