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.

Comments

I have spent the last 10 years in the health service watch Lean not stick - it is completely glueless! Other service improvement methodologies are available - see John Seddons work at: systemsthinking.co.uk

Working with colleagues in North America the Forton Group identified three key issues that most Lean thinkers exclude:
1 Staff engagement:in both the current future states
2 Leadership throughout the organisation (not just heroic leadership at the top)
3 Better 360 communications - 21st century comms are NOT just 2-way - they're factorial
If you want materials to stick, you need the right glue

The difficulty for lean is that with its origins in manufacturing, the kinds of things people try to do with it fit poorly with the demands, variety and complex branching flows in healthcare. I am an engineer, an apostle of lean in manufacturing, but I'm not doing it in healthcare for the reasons you give and the poor fit - not because lean is "wrong". You also mention the skills issue - but people aren't stupid. There is also an intervention issue - teaching it as skills or tools can miss the point of a change in thinking, where Deming and Toyota started.

We have a huge task to do in health, and rather than regret the failings of a method from the other world of manufacturing, we need to nurture and grow the best of what is already happening.

That's why, when I discovered an innovation by GPs which transforms their service, I picked it up with both hands. And we're running with the ball called Patient Access as fast as possible. The outcomes are staggering - for patients, doctors and the NHS.
patient-access.org.uk

Lean has a very important role to play in health services to deliver operational efficiency. I agree with Dan Jones' analysis that there is a knowledge and skills gap here. I also agree that we do not see lean being embraced. The experimental approach that Dan Jones identifies may be because in some organisations we lack organisational development strategies that can embrace the enabling tools such as lean into a coherent approach. We need to be dead clear on what the transformational interventions are that our front line staff require to do their job and then provide the formal teaching and in service support to help them develop and practice. You just cannot do this on a whim with a couple of folk gathered together on a part-time or temporary basis and Dan Jones is right to say that this is not experimental, this has to been core business for the organisation.

From what I know there are NHS organisations that have done this and they can demonstrate the impact - why are others so slow to take it up.

Having studied Lean methodology and its applicability to healthcare organisations for a number of years, I have to agree with the first three respondents. The concept of Lean as a service improvement tool is fantastic in other industries, but like other manufacturing/engineering methods that are being adopted in health for example, PRINCE2 project management, it just doesn't fit the complex health environment as it is. Work needs to be done to adapt and develop the core principles of Lean, so that it is more relevant to health care organisations and the staff that are tasked with implementing the interventions.

While efficiencies have a flow on benefit for patients, no patient wants to be counted as "throughput" on a production line. We don't want to be 'processed' (no matter how efficiently). We want to be part of the process.

The culture change that Lean demands is based on efficiencies in the the flow of production. It fails to include the human values that are essential in a high stress, high turnover environment of hospitals where the outcome has to be measured in clinical and personal as well as financial terms. Even the CEO of the Toyota company had to admit that, in the pursuit of efficiency, some quality issues were overlooked costing the company millions in vehicle recalls.

The key issue when looking at lean is NOT to take the manufacturing approach, as other comments make clear. There are too many 'lean' consultants who sell manufacturing based lean approaches into service organisations.

Kathy - take a look at the Vanguard in Health blog to see how lean principles can be applied in health and social care, based very much on human values. vanguardinhealth.blogspot.co.uk/2012/05/does-going-lean-going-wrong.html

To all NHS managers, if you don't know what 'failure demand' is, you need to know.

Getting Doctors involved in Lean makes a great deal of difference to its success as evidenced by the work of David Ben Tovim at Flinders in Adelaide (also of the Lean Academy has shown warwick.ac.uk/fac/cross_fac/slim/cases/flinders/, how ever as I have said elsewhere (British Journal of Healthcare Management 2003 Modelling Demand a rejoinder 9(2) 67-71) the difference in health is that the patient is the product, so any methods that do not adjust for this will be problematic once it moves away from the competent innovator to the routine provider.

The NHS Institute for Innovation and Improvement have shown with the Productive Series that with a bit of demystification and reframing for the audience the principles of lean alongside other service improvement methodologies are entirely applicable, and with the approprite strategic alignment lead to some fantastic front line, bottom up quality and financial improvements.

Take a look at the case studies
institute.nhs.uk/quality_and_value/productivity_series/the_productive_series.html

As for not sticking, The Productive Series was developed in 2005 following a call from nurses that what they required was time to be freed up - hence the Releasing Time to Care strapline.

7 years on the NHS is in a position where 70% of wards are implementing this programme (with high implementation in the subsequent Productive Mental Health and Theatre programmes... the implementation position in the rapidly transforming Community arena is slightly slower but good progress is being made). There is also massive international adoption of the programmes - i.e. were exporting to Oz, NZ, US etc.

In MSP terms we completed the tranches of 'programme development', 'stakeholder engagement' and 'building capacity and capability' and are just beginning to see the benefits.

I think some of the problem with public sector is that as leaders we don't normally wait for this to happen with large scale programmes, are too impatient, want quick results or there is a change of political focus to the next shiny new thing. This just leads to disengagement and confusion at the frontline.

With a constantly changing NHS structure maintining some of the stability within programmes (lean or otherwise) might not be a bad thing!

Before our Trust started working with Marc Baker and his colleague Ian Taylor from Lean Enterprise Academy I thought I knew a fair bit about LEAN and was trying to "make it stick" in the organisation. Having worked closely with LEA now for 2 years I realise that I knew nothing really about how the principles need to be applied in healthcare. What I had learned about was a set of tools which we were using at departmental and ward level to achieve isolated areas of improvement that showed no effect at Trust level. What I've learned from working with LEA is that healthcare is (as Dan Jones observed at the Lean Summit last year) in fact an operational management free zone. Because of this our patients struggle to get through our processes and systems and probably rarely get what they need both on time and in full. For the last 2 years we've worked with LEA to begin to put in place some operational management. Visual Hospital allows us to see at hospital level what's going on with each patient with regard to readiness for discharge or transfer (or if in fact a patient is ready to move on but delayed). This information is used throughout the day to manage the demand for discharge (ie patients who are ready to go) thereby satisfying the demand for admission. Coupled with this Plan for Every Patient on wards, assessment areas and in A&E will ensure that there is on arrival or admission a visual plan of the interventions likely to be required up to discharge/transfer and based on this an estimated discharge date/time. The plan is regularly checked against actual - the aim being on time and in full.
In 2 years we've come a long way in our attempt to introduce true operational management in our hospitals through Visual Hospital and Plan for Every Patient and have reduced medical length of stay by 28%. A by product of this has been a cost out saving in the region of £2million through ward closure.
We've still a long way to go but I believe we can demonstrate how Lean redesign can stick in healthcare - if you approach it in the right way.
If you've not read it "making hospitals work" by Marc Baker and Ian Taylor is an excellent introduction to a different way of thinking about Lean in healthcare.

Just to support Stewart Brock's comment - I think Kathy is firing at the wrong target. My Mum is just about to have a cataract done and she is very clear that she wants to be processed efficiently and effectively thank you very much and she wants it with dignity, to be addressed properly, to be informed of what is going on and for her dignity to be maintained - these are not contradictory terms but mutually supporting. There is no issue of lean discounting patient experience, in fact it should be driven by it as timeliness is one of the key quality domains of healthcare. I cannot agree with Andrea's comment that healthcare is too complex - and I think Tania's description of applied lean methodology in Calderdale and Huddersfield shows that it can (and must!) be done. Terminologies are always difficult - just look at the issues associated with the technical language in and around healthcare that - but there are ways of finding words that can get you through without losing the core principles and techniques of lean (just struggling with the term 'component innovator' for a minute back there).

Good to see a discussion like this developing. Not sure we have really got the nub of why CEOs are not taking this on and laying out how they will incorporate improvement methodologies of all hues, frankly, into their organisational development/change management strategies. What can be done to change this?

I agree with some of the comments about consultants from manufacturing trying to apply the same principles in healthcare and creating chaos.

From what I have read, however, my understanding is that LEA’s approach is vastly different. Their “core tenet" as they call it, seems to be a "patient centred approach to re-design and that it’s been the underlying principle of all their work in healthcare”,

They do have a website leanuk.org/health/default.htm and a blog lean-health.blogspot.com where I first found out about their approach.

What strikes me by this article is the persistence with which Lean doesn't stick. In 2006 Cliff Ransom (a lean consultant) speculated on a '98% lean failure rate'. And that wasn't even in health.

Professor John Seddon has articulated the causes for this persistent failure in 'Rethinking Lean Service'. He describes a movement that has misunderstood what made the Toyota Production System so impressive.

Lean became a movement focused upon re-using tools and techniques practised to solve problems on the factory floor, but not suited to services environments. The tragedy is that these same tools keep being thrown at different types of service organisation, only to provide short-term gains that quickly die, or drive increased dysfunction.

So Lean is very poor at adequately describing and understanding services organisations. Everywhere it sees a factory production line, instead of a hospital filled with people. Standardization is great if you make a car. Reducing variation is wonderful if you are drilling a 1 mm hole. But people are not holes and hospitals are not production lines. Just look to HMRC to see this 'factory logic' in action. Services as industrialized design.

Perhaps the final problem is that Lean does nothing to address the people aspect of change.

Howard Clark – The Systems Thinking Review

I started this journey in 1993 as a young NHS manager with a new keen Trust CX fresh from the automotive industry. It was a fascinating 5 years - real progress in some areas but lots of frustrations and learning - but ultimately his tenure was not long enough to embed it. Therein perhaps lies the CX take up issue - if you're going to do this seriously it needs an extended period of real leadership focus and time. And we know most CXs might expect a tenure more in keeping with a premiership football manager. As a FT NED, I think we need boards to own this agenda so we can ensure it outlives any particular senior leader. Now days I actually also teach an MBA module called 'lean in healthcare' - and find most of what we talk about is contextualising the approach [as always in complex organisational interventions] but without losing the insights [which obviously can work with the right leadership and OD approach as seen at Flinders etc]. Hence we end up with 'lean whole systems.' Interestingly we have also found in our consulting projects outside healthcare that a wider whole systems view is needed to deliver benefits.

Lean is an approach to operations management developed to solve the problem of making cars at the rate of demand. Even if the NHS had the same problems (which it does not), Lean would still have a problem sticking because it is not a method for changing thinking. As the blog states "the Lean approach challenges quite a lot of common assumptions about how improvement takes place". True but it does nothing to change these assumptions, that requires a different method and here's the rub - when people in organisations learn how to think differently (about the nature of the problems which need to be solved and the nature of the solutions) they no longer need to 'go lean'. After all, how do you think the people who invented lean came to invent it?

The lesson here is not that we need to make lean work. It is that we need to change thinking. Others have mentioned it and I can declare an interest - I work at Vanguard - but the Vanguard Method is the only method which I am aware of which has a proven track record in changing thinking within (and across) organisations.

I concur with Alistair Mitchell-Baker about the need for contextualisation. I think we need our CEOs to have or encourage their organisations to have clearly defined OD strategies that understand this and therefore have the flexibility to use a variety of improvement tools and technologies (Lean, Check, ToC, Six sigma) according to context. They are not mutually exclusive to any organisation, you just have to think carefully about when and where you need to deploy them. The point is that we really need to use them and we really need to help our front line staff down on the wards to develop the necessary skills and knowledge in deploying them to their every day work. It is more than changing thinking, it needs to be a change in how we work together with patients to change delivery of healthcare. It is not a one solution fits all environment, but the principles of process management that lean offers, for example, can be used effectively to improve patient care.

Read your contribution to a debate on the future of secondary care You seemed to suggest we had too many well paid doctors. From my perspective the real problem is that pay is too low in comparison with other sectors of the economy. All my fellow cambridge graduates enjoy much better pay without the rigours and stresses of medicine if we go down the low pay low prestige route we will no longer attract quality applicants as most of us are not members of the landed gentry My advice to aspiring docs is always the same - try the City first

I'm amazed that people still think the Toyota Production System (TPS) applies to healthcare when Toyota system have developed a 'medical system' for their motor vehicles .. it is called Total Productive Maintenance or TPM!

Anyone who wishes clarification can read my article 'Can Lean Save the NHS' (Google sites: Quality Transforms)