Twenty years ago, the Institute of Medicine rocked our world with To Err is Human (1999), a report that suggested that nearly 100,000 people die every year due to unintentional medical error, and a new age in healthcare quality improvement was born. It wasn't long before "lean" was introduced, a management philosophy that had proven successful in the automotive industry that focuses on the elimination of waste and inefficiency. Hospitals and healthcare systems across the country soon began implementing lean in an effort to improve the quality and safety of care.
Since then, there have been mixed reviews about whether lean has truly been successful in healthcare. Although there have been multiple anecdotal reports of sustained improvement through a lean approach, there has yet to be any empirical study that proves this to be the case (Daultani, Chaudhuri, & Kumar, 2015).
Healthcare professionals often point to this lack of evidence as proof that lean doesn't work in our industry, because "we are different", and sadly, many have come to perceive lean to be a four-letter word. Engineers and other lean practitioners suggest that it is exactly that thought process that is preventing lean from being successful in the first place, and that its application in healthcare is no different than in any other industry.
Lean brings some excellent problem-solving tools that can be applied to many aspects of healthcare, and a focus on improving efficiency and eliminating waste is much needed. A lean approach helps clinicians to see the impact of their workflow on patient care in other departments and is definitely applicable to the production side of healthcare, such as food services and supply chain.
However, we will never be successful at implementing lean if we don't all agree that healthcare is different than any other industry, and therefore, requires a novel approach. This is not because we think we are better, or more special, than any other profession; it's just the reality of the nature of the services we provide.
Five Reasons Lean is Different in Healthcare
Healthcare is the only industry where the product and the customer are the same. People are the "widget" healthcare, and no two people are alike. Five patients with the same diagnosis will likely all have different issues that need to be addressed, because we are rarely treating just one problem. A clinician's goal is to provide individualized care to each patient, while lean teaches us to standardize. To truly meet every patient's needs, we need to do both, at the same time.
Clinicians are scientists, whose entire thought process has been predicated on the scientific method for centuries. Nurses built further upon this problem-solving method with the development of the nursing process more than a half century ago: assess, plan, implement, and evaluate (APIE). Lean facilitators can quickly alienate a group of clinicians by suggesting that PDSA and DMAIC are brand new concepts to people who apply the exact same problem-solving process to patient care every day. Clinicians will either be offended at the suggestion that they don't already know how to problem solve or be frustrated with the “new” terminology and ignore (or even sabotage) the facilitator's efforts. We should help clinicians apply the principles they are already familiar with to system processes as expertly as they already do to patient care.
Lean thinking is linear, and although it is applicable to many aspects of healthcare, it does not always apply to the process of actual patient care. Improvement in care requires more than just one approach and should be heavily based in evidence-based medicine. Unfortunately, this is a variable that is often excluded from lean projects. We are a very heavily regulated industry, and because lean focuses on including the frontline in improvement and keeping team sizes small, standards can be easily overlooked. This doesn't mean that we should exclude the frontline or have huge improvement teams; it just requires us to incorporate efforts to uncover all applicable standards during preparation, which can be an exhaustive task if an organization-wide process to accomplish this has not been previously established.
Lean practitioners often speak about focusing on process and not practice. This is because most lean professionals are not clinicians and are therefore not qualified to make recommendations on practice. But to those of us who understand both sides, there is no line. If you improve the speed and efficiency of delivering medications from the pharmacy to the patient's location, but the physician did not order the most appropriate medication, or the nurse didn't educate the patient properly before administering it, then the improvement efforts don't really matter. We have to focus on both process and practice, at the same time.
Nothing makes a lean facilitator shake their head more than the statement, "I don't have time for improvement." Executives sigh when they hear this, and lament that nobody ever thinks they have enough time. Although it's true that many people who work in a healthcare organization do have the time, and just need some help to find it, this is not the case for the frontline clinicians and managers who are usually the recipients of the "change". Let me be very clear here: they really do not have the time. Clinician burnout is a reality, and it is not happening because physicians, nurses, and other members of the care team are a bunch of whiners. They are hardworking, dedicated professionals who are already unable to get everything accomplished in one shift. Frontline nurse managers often have an unreasonable span of control, with direct oversight of 75+ FTEs, an expectation that they will participate in direct patient care whenever necessary, and the never-ending struggle to manage daily staffing. Something has got to give, and it needs to start with a true understanding of actual workloads.
Don't make lean a four-letter word in your organization. Although lean management brings excellent tools and process improvement techniques that we very much need in healthcare, we also need to accept that healthcare is different. If we all appreciate the skills that everyone brings to the table, and agree that it's OK to be different, then perhaps we can move forward and transform our healthcare system, together.
Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: The National Academies Press. Daultani, Y., Chaudhuri, A., & Kumar, S. (2015).
A decade of lean in healthcare: Current state and future directions. Global Business Review, 16(6), 1082-1099.