Can Lean redesign stick in health care?

There were some useful insights about how hospitals work and what is required to improve them when Dan Jones and Marc Taylor from the Lean Enterprise Academy visited the Fund recently. Dan is the author of several best-selling books on Lean, a methodology developed by Toyota which aims to improve flow while minimising waste, and he has been working in health care for the past few years as a ‘Lean missionary’. He has been puzzling over why it is difficult to make Lean redesign stick in health care.

One reason is that operational managers in hospitals are often sucked in to hundreds of improvement projects, meetings and other activities – often the result of centrally set requirements. This means, as Henry Mintzberg observed some years ago, that clinical work is disconnected from management.

Meanwhile on the shop floor, care is often not planned, leading to blockages and problems with flow. These are caused by the design of the system rather than by unpredictable spikes in activity. For example, GP home visits – and subsequent transport to hospital for patients – take place at the end of the day, so patients arrive at the same time. Another example is arranging the bulk of elective admissions for the busiest emergency days.

Hospitals work on a heartbeat set by the pace at which work arrives, which may be 15 to 20 minutes in A&E or two to three hours on wards. This makes the system very sensitive to variations in flow. The lack of a plan for a patient’s journey through that system leads to a significant amount of variation, almost all of which causes delay. When things go wrong the patient requires a rapid intervention – but many of the people who could do this may not understand how the system works or may be busy on other activities – including working on improvement projects. This leads to work-arounds and fixes but does not deal with the fundamental issues.

Hospitals have to be protected from the need to carry out hundreds of projects. Staff, frontline supervisors and managers need to plan care and have mechanisms to escalate problems when they arise. Senior managers need to be available to assist in unblocking the problems and identifying where the process needs more significant redesign. All of this needs to happen at the heart of the hospital. The use of visual control systems, real-time information (white boards will do) and operational managers who are trained in solving problems in the system and who walk the floor are also important. Improvement then becomes something that happens as part of everyday work, rather than in separate projects, and this means that clinical and managerial work can be brought together.

What is striking is that the Lean approach challenges quite a lot of common assumptions about how improvement takes place and what makes a difference to complex systems. The final conclusion from Dan’s work is that, in many NHS organisations, there remains an important gap in skills and knowledge about effective Lean operations management. Chief Executives need to embrace Lean fully, rather than experiment with it around the edges, if they want to reap the rewards and commit to the training and support needed at all levels to deliver it well.

Find out more about the Lean methodology on the Lean Enterprise Academy website.