The recent debate on lean in health care, and specifically hospitals is heating up. Two Quality Digest Articles Why Lean? Why Now? and a follow-up story by the publisher of Quality Digest Lean Health Care and Quality.
I did a bit of research on the subject and it appears the a couple of months back the Minnesota Nurses Association has been very vocal in their distaste for Lean and standardization. I am right there with them.
Time features lean transformation at Seattle Children’s, debate ensues is very telling. The promotion of standardization is at issue.
“The two pillars of lean are continuous improvement and respect for people. However, there are aspects of lean that can ring alarm bells among employees who do not yet have a wholistic appreciation for lean. The first is standardized work. In lean, first you standardize, then you improve. Improving a non-standard process is like remodeling a house built on quicksand. It won’t do you much good in the long run.”
Lean continues to promote its application to service industry and hospitals. They believe (as in manufacturing) that standardized work is the place to begin improvement. This completely ignores the variety of demand that service and in particular hospitals get.
The Minnesota Nurse’s Union (or any other union) has right to voice there displeasure as this is a bad place to begin. The comment in the above article from Mark Graban of LEI (Lean Enterprise Institute) says nurses are “interested in talking about the hospital CEO’s paychecks than Lean.” Another comment says nurses are only interested in patient rations. My feeling is that nurses are over-worked by poorly designed systems that management has put in place using flawed thinking.
If we continue to standardize work in hospitals without accounting for the variety nurses and hospitals get from patients we will make things worse for patients, nurses, doctors and the bottom-line.
The system needs to be redesigned around the work by management, nurses, doctors and others working together to improve the system. This all begins by management changing their thinking around the design and management of work. Once management understands by seeing the damage of their thinking in a normative way can real changes impact the work.
Unfortunately, too few administrators spend time in the work. A checklist to be sure management shows up every once in awhile is hardly a solution. Decisions need to be made with the work with an understanding of it. The problem here is not the nurses, it is the management thinking.
Respect for people in service is not having someone stand over you with a stop watch like a machine or compliance to standard work that can’t cope with variety nurses get from patients.
Nurses should stand firm against any improvement initiative that doesn’t address the thinking problems of management.
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Tripp Babbitt is a columnist (Quality Digest, PSNews and IQPC), speaker, and consultant to private and public service industry.
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Why do you assume all laen implementations are bad? Why do you assume all standardized work is top-down, coercive, and inflexible?
There are many hospitals doing it the right way, based on Ohno’s teachings and “Respect for People.”
Why do you ignore any of the good things that are happening? Your “research” via google shows a few problems. My real experience includes the faces of nurses who are THRILLED that lean means they finally have a voice in their hospital and that leaders are finally understanding the fire fighting that goes on every day. Lean is leading to many good things in hospitals around the world. It’s worth mentioning that in the name of balance.
You asked for evidence Starbucks baristas complaining about what is done to them, now nurses strike against lean efforts. What kind of proof do you need? If this is good, please send me the bad.
Which ones and please don’t say Theda care or this hospital with the striking nurses. Respect for people? I consider nurses people.
Again, standard work is not the place to begin improvement efforts in service.
I don’t see what Starbucks has to do with this.
Do you have proof that the nurses in MN went on strike “because of lean”? That’s a dubious claim.
Of course nurses are people. Many nurses love Lean because they are able to have control over their own workspace and processes. With lean, hospitals and support systems provide what the nurses need to provide the best patient care.
Case in point, this article (written by nurses from Virginia Mason):
“Creating an Environment for Caring
Using Lean Principles of the Virginia
Mason Production System”
http://www.ncbi.nlm.nih.gov/pubmed/17563521
I will email you a PDF if you want.
Your definition of “standard work” as top-down, coercive, and inflexible is not the definition of “standardized work” that we’re talking about in healthcare.
Nurses and other front-line staff look at patient needs and first observe their own workplace – identifying things they can fix and what help they need from the hospital (like a better materials management system). Nurses write standardized work that’s not restrictive or constraining — they decide the best practices for patient care.
You see “standard work” as a problem because you define it wrong.
Mark-
“The MN Nurses’ Union really seems more interested in talking about the hospital CEO’s paychecks than Lean. There’s 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). This quote appears that you take a pretty hard line.
Also, it seems that maybe variety is a problem in health care:
“Nellie Munn, a registered nurse at the Minneapolis campus of Children’s Hospitals and Clinics of Minnesota, thinks that many of the changes instituted by her hospital are inappropriate. 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.”
Top-down, Coercive and inflexible is only the beginning. Standard work as a starting point ignores variety.
So I’ll assume you don’t want me to send that PDF and that you’re not interested in anything that disproves your biases against Lean?
Give us an example, given your healthcare experience, of what you mean by your oft-repeated phrase that standardized work ignores variety?? One specific example please?
You can send it over, I’ll have a look. I just have a hard time tracking down what is right or wrong in your mind on lean. I need a score card to differentiate lean and LAME. They are closely resembled.
My biases against lean are from experience . . . and your biases for lean?
My bias for Lean are from experience. Article on the way.
According to the LEAN community (Not me) 98%+ LEAN projects fail http://bit.ly/9UX06i then this is REAL LEAN.
Which makes REAL LEAN = LAME.
You can’t claim the 1.5% success rate (questionable at best) as REAL LEAN when the rump of LEAN is a failed method.
MNA is interested in one thing…more profits to further their political agenda. Look at their priorities. They hide behind patient ratios, etc…but when it comes down to contract negotiations it’s all about the money.
LEAN is a good process. The problem with LEAN in hospitals is that clinical staff “think” their work is so diverse that they can’t standardize. It’s not…a patient is a patient..their individual care may be be different, but how you give meds, turn, toilet, start and IV is all pretty standard.
Again, this is just another way to hide from doing what could be productive and better for the patients and organizations. But oh my gosh why would unions want to do what’s right for the organizations all their members work for in order to pay their union dues.
Howard- The “98%” number you are referencing has nothing to do with a failure rate of “lean projects.”
The number cited in that blog post comes from a famous Jeff Liker quote where he said while 50% of auto suppliers were talking about lean, only 2% were really doing it. Liker sets the bar high, where “really doing it” means a full culture change to Lean/TPS.
So the difference between “98% of auto suppliers don’t make a full lean cultural transformation” and “98% of lean projects” is a huge leap and, I’d propose, a serious misunderstanding of what Bill Waddell wrote on his blog.
I have to agree that this drive to bring ‘lean’ into our hospitals is a big mistake. They are taking a set of tools that evolve from a specific approach to manufacturing and applying them in a totally inappropriate environment.
I was in a meeting with the senior executive of one of our British Columbia health authorities recently. They were bemoaning the lack of success of their large lean initiative and who were they blaming? The doctors and nurses of course; they were just being stubborn and not buying in; what could we do to ‘whip them into shape’ (their words, not mine)? When we told them to start by stopping the lean initiative and looking instead at their system, the meeting came to a rapid end.
The problem is that lean has become the current money-maker for armies of consultants who find a willing ear among hard-pressed healthcare executives who are looking for any quick-fix nostrum. In the meantime, frontline staff are having their work disrupted and resentment is rising.
No Mark you misdirection will not work here. The QUOTE was from Clifford Ransom on the board of directors for the Shingo prize.
QUOTE:
‘I keep using the Clifford Ransom numbers – 98%+ lean failure rate – which most folks seem to think jives with our feel for the situation. The mantra we spout far too readily to explain away this debacle tends to fall collectively under the heading of senior management character flaws’
The blog carried on:
‘Simply pointing to Toyota and saying they are lean and they make a lot of money is not enough to expect senior managers to leap headlong into lean. In fact, many managers such as those at Delphi, did make a leap and did many of the things we lean advocates told them to do – and failed’
Use systems thinking, but don’t use a stopwatch to understand the processing times? Seems contradictory. How do you propose someone understands the system without accurate processing times?
Time studies date back to the early 20th century with Gilbreth and Taylor. While it is a tool used by people that implement Lean concepts, its purpose in process definition and data analysis reaches far beyond Lean.
Good video by the Minnesota Nurses Association.
http://www.youtube.com/watch?v=UbPOO1hNX10&feature=player_embedded
If management doesn’t change too, improvement efforts have little chance of success. Patients suffer more from the command and control design of systems than nursing errors.
Howard – it’s not “misdirection.”
Here are Cliff Ransom’s comments from an LEI webinar transcript:
He is clearly not talking about projects, he’s talking about the companies that “get it” at a high level and complete lean culture standpoint. He’s not saying only 2 to 3% of “lean projects” fail.
http://www.lean.org/events/dec_18_webinar_downloadable_transcript.pdf
“As I look at companies, I think that 85 % of the companies that I come across, and I probably look at 150 companies a year, and have working knowledge of [lean], I don’t know, 1,000, 85% of them are clueless. Another 10% of them know what words to use and what
phrases to use but aren’t really doing it. And I think there’s really only 5% who practice the art skillfully in a world class master practitioner kind of way. I’m actually mellowing in my old age. I used to say only 2 to 3% of companies did it.”
I meant above to say that Ransom didn’t mean “…only 2 to 3% of projects SUCCEED…”
I’ll point out why what you say is very wrong Mark.
The blog is discussing Ransom’s comments and they are being very specific about their meaning.
‘98%+ LEAN FAILURE RATE – which most folks seem to think jives with our feel for the situation’
‘Senior managers don’t understand lean and have not taken the time to learn it’
‘Simply pointing to Toyota and saying they are lean and they make a lot of money is not enough to expect senior managers to leap headlong into lean’
‘In fact, many managers such as those at Delphi, did make a leap and did many of the things we lean advocates told them to do – and failed’
‘What I know for sure is that far too many companies have bought exactly what we are selling and saw little or nothing at the bottom line for the problem to be senior management’
They end their blog (their INTERPRETATION of Ransom) by writing that ‘Like Pogo said, “We have met the enemy and it is us.”
You rant and rave against LAME without understanding that LAME is what is in your head. It is REAL LEAN.
Here is my dimes worth.
An example of applying lean tools in a hospital
http://www.leansystems.org/cart.php?page=top_12_lean_tools#press
On the quick-changeover card?
Is that a quick changeover of body parts?
You know Heart Lung and Liver?
Mr. Babbitt,
It was nice of you to quote my article on the challenges of adopting lean in a healthcare environment (http://rk2blog.com/2010/07/12/times-features-lean-transformation-at-seattle-childrens-debate-ensues/).
However, it’s possible you misunderstood and, perhaps inadvertently, exemplified the point.
My point was, it’s possible to look at one attribute of lean in isolation and assume, erroneously, that the entire approach is bad. In fact, lean is an integrated system that produces benefits for patients and providers. It simply requires an investment of time and effort to understand and appreciate. I encourage you and your readers to make that investment.
Thanks,
Mark
Mark T.-
Quick changeover applies VERY well to the operating room.
http://www.google.com/search?sourceid=chrome&ie=UTF-8&q=hospital+quick+changeover+operating
Before lean, typically all of the work to prep for Patient #2 is done after Patient #1 is out of the room. This means a long time (maybe 45 minutes) before the next case starts (Patient #2).
Doing some work in advance (using “external setup”) means the time for room changeover can be reduced maybe to 15 minutes. This is a form of standardized work actually.
The patients don’t wait as long and the hospital can potentially do one or two more cases per day in the same O.R. capacity, which has a very positive financial impact on the hospital.
You are a dangerous man Mr. Graban.
Have you disposed of medical equipment to be replaced by the wrench?
How is it dangerous to prevent delays in getting surgical case started? How in the world is it dangerous to engage the nurses and O.R. techs and team to figure out how to do their work better? Quick changeover has nothing to do with how the surgeon does surgery.
You’re just throwing around insults now.
Mark Taylor’s post is flippant and not necessarily helpful but he appears to be getting at something.
I had a look at the link Mark Taylor posted. It takes you through to a small pack of cards that display manufacturing TOOLS.
You appear to say whenever challenged that you seek understanding before deploying standardization and manufacturing tools. Then when digging a little deeper find that you go straight into using Lean manufacturing TOOLS.
What you say and do are in constant contradiction.
I never said I just dive into using tools. You’re putting words into my mouth and you are making assumptions about how I work. He asked about the method and I described use of the method and a bit about the problem that’s being addressed. I’m done here. Last time I’m commenting on this post or this blog.
Mark Taylor-
Although I agree there are dangerous aspects to lean in health care, let’s not attack a person. It is counterproductive to the conversation.
Everyone-
I have had to delete a few new comments and sent emails to those pro and con to the issue at hand. Disagreement is expected, personal attacks and insults are not. Thank you.
A truly fascinating debate. From where I am standing you have here, what I would call violent agreement.
Am I the ONLY person who can clearly see (contentiously apparently) that lean and systems thinking ARE one and the same??
Maybe learning my lean ways with a very difficult to please japanese supplier development engineer?
Both are about following the value, and reducing and eliminating waste by changing the way we work.
Both are totally derived from Toyota and Deming.
Both require both bottom up and top down engagement to work and both achieve that by using the brains of the people doing the work. (when done right)
I am sure someone will try and correct me, but I know both work, because they are both the same.
Now, I have a suggestion: Lean is great, Systems thinking is great – its working wonders in the UK in our public services. However sooner or later some wise wag will get hold of this systems approach, use it as the latest mgmt fad and suddenly systems thinking will end up with same issues that “lean” has encountered. Ie numptys following a list of tools to solve problems you didnt have. I suggest we listen and LEARN from each other to stop that happening and get ourselves aligned to solving the actual issues.
(and some of you should grow up too.)
Don’t want to debate or argue over real lean vs. fake lean. What I will say is that most lean transformations that fail do so because they never get the respect for people tenet. the nurses in our org have embraced standard work, and now the real improvement can begin.
Final Comment:
The most interesting comments are those that say lean and systems thinking are the same thing. I have done both and they are not.
In many organizations, the focus on efficiency misses the larger areas for improvement . . . management thinking. Systems are developed by the prevailing management thinking about the design and management of work. When thinking doesn’t change, the system doesn’t change or changes marginally. Worse, when management thinking doesn’t change we quickly or eventually revert back to old ways.
The Vanguard Method addresses this in each intervention as well as identified the important differences between service and manufacturing. The difference is dramatic improvement when we understand the differences and embrace the human change methodologies refined through interventions of the Vanguard Method.
Dr. Deming told us that survival is optional. The rest is up to you.
I am an RN and have taken part in two lean processes. The first being a 5s and the second an RPI. The 5s progran was much needed and made good common sense. It’s focus was arranging and making accessible much needed medical equipment.
The second lean process being an RPI was a terrible experience. The leaders saught to standardize patients. All patients had to meet a time requirment regardless of preexisting conditions or complications. The leaders had no functional or clinical knowledge in the area of expertise they saught to implement their changes. Staff, like myself were encouraged to participate but our suggestions were shot down repeatedly.
In the end productivty was being increased and staffing numbers being reduced.
Furthermore, since during our RPI one of the outcomes is a merging of two departments. The staff that is to join our department lacks the experience and skill set that it takes to care for our paticular patients needs. This is only acquired through experience taking care of critically ill patients. The leaders of this lean enterprise believe this skill set can be obtained by Nurses in one department training these RN’s joining the department.
There has been no clear objective layed out for how this training is to be accomplished. The RN’s who are being relied upon to train are upset and can see no value added to the patient. It is worth noting that physicians are equally distressed and do not feel confident in the care their patients will be recieving from these individuals.
To address the aspect of staff inquiring into high wages paid out to CEO’s and top wage earners of hospitals. I see this done for numerous reasons. One being many hospitals are saying they are in financial distress. That being the case the salaries and bonuses paid out to these top individuals do not reflect this. Also many of these hospitals are not for profit and as such recieve tax adjustments accordingly. This being the case how does one reconcile such high compensation in these organizations.
All the while they are continually cutting nursing. This is done by not replacing staff that leaves the facility. The situation is further exacerbated by erasing accuity levels. Hence, the staffs productivity is increased by taking the same number of patients. This is what standardization does to a facility. Patients no longer are individuals but a diagnosis that is only permitted a certain amount of staffs time.
There is absulutely no value added to a patient.
This information should scare any potential patient seeking care. Myself, friends and co-workers who have been in the medical field for sometime are well aware of the risks patients are being exposed to when they enter a facility. We also know that one of us will follow each other on admit to a facility so that individual can have an advocate in the event that we cannot do so for ourselves. We are well aware of what standards of care are.
Unfortunatley many Medical facilities bank on the fact that patients have little or no medical knowledge. They do not know what standards of care should be. In this aspect facilities play the odds of getting away with substandard care without being detected.
True value added would be putting more resources into bedside care. If this is done through cutting down on over inflatted compensation packages given to higher management I am all for it.
Katie-
Thanks for the insight and detail in your experiences with nursing. Privately, many nurses have sent me alarming feedback.
Lean in itself shouldn’t present a problem . . . but it does because we are not addressing the “thinking” problems in the design and management of work. Management designed the poor system and (unfortunately) they are short-term thinkers that take an industrialized design to hospitals. This is the failure.
Ultimately, too many administrators around to cut costs when the way to cut costs is improve service in hospitals. There are definitely some egregious practices in hospitals and service in general when bonuses are paid while cutting staff. Nurses to the value work, managers can only enable and management doesn’t do much of that.
Management is too focused on their prize. The system loses with the short-term, “every man for himself” focus. Hospitals need staff and management to work together to improve the design of the work. Too much attention to staff, management has to change too.
@Mark Graban
So,my hospital is scrambling to implement LEAN, the level of disrespect for nurses is unfathomable. I have been a nurse for 25 + years and we have taken a HUGE step back with LEAN, it sucks.
Suggest you have someone proof-read your blog for spelling errors before you hit “post”
Thank you Doctor.
My columns are edited – for a clean copy go there. Where can I find a legible prescription?
How do you standardize care during a code?
Where does the extra time it takes come from for double and triple checks. Nurses aren’t fans of it either but it is for our accreditation with MD Anderson that makes the rules about having more than one nurse double check the chemo orders before administering. It’s the patients health we are doing it for. You can’t standardize the teaching needed before you give the chemo and you will never be able to standardize the amount of time needed for all the questions from that moment on. One day it will he you or your loved one.
Lean is a management system which seeks to create a culture of problem solvers who are empowered to make changes to their work which in turn will create better processes for both the customer and employee. This is only accomplished when leadership changes the way they lead and everyone in the organization changes the way they look at problems and problem solve. Without a fundamental shift in management, Lean implementation will be difficult and uncomfortable. I would argue that this is not true Lean implementation, it is a strategy to find a “quick fix”.
I’m sure there are countless examples of hospitals that don’t appreciate Lean and those that absolutely love it. I would argue that there are much deeper reasons behind both and blaming Lean in itself is not the right path to take. One could replace Lean with any number of other programs/processes (TQM, MBO, etc.) and get the same result. Some organizations will love it, others will hate it. These opinions will be based largely on how the system is implemented. Do we “Do To” or “Do With”?? Big difference.
Now, the argument about standardized work is odd to me. How do we as clinicians deliver our care? We follow care pathways, we research the best processes for treating diseases, we follow very detailed protocols, we make people very famous and wealthy when they publish breakthrough treatments that we all adopt as the best way to treat “you name it”. Yet we balk at the idea of standardizing how we chart, where supplies go, how we turn over rooms and the numerous other processes that we use to support our patient care providers. What am I missing??
I think we can all agree that creating the most efficient systems for our patients and team members is what we are all after. Lean is one way to accomplish this and has been very successful in many organizations that have gone about implementation the right way and looked at Lean as a system and not simply a set of tools.
There is something missing from most improvement programs I have seen. They don’t address the fundamental change in thinking that needs to happen in staff, administration and support groups. A key element is engaging those that have use the standardized process participate in its development. When employees using a process don’t have input they don’t understand why they are doing something – they wind up just following the procedure developed by others. The process police looking over their shoulder for compliance. If someone is not following they either do not understand why they do something or possibly have a better way – ignoring either is dangerous. You don’t want to have employees doing mindless things when movements and thinking should be purposeful.
The concept of one best way is a myth – everything can be improved. End-to-end delivery of service needs thinking from all staff not just the rich and famous ones coming up with treatments. What if you are given a protocol that doesn’t work or has negative observed consequences? Do you just follow the procedure anyway?
Healthcare demands everyone being a skeptic and treating new things with this skepticism. This requires knowledgable employees in all areas that are constantly aware and not blindly following standard work.
Remind me to never visit a hospital where people who think like you govern. Every time I’m seen for a health issue I want to receive consistent, standard care. People who support this article do not want to standardize because they don’t want to improve. They want to just get a check and thrive in chaos.
What people want is not consistent, standard care – they want the hospital to give them unique service appropriate for their condition.