“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!
