Over the past months I have been working rather intensely with a Canadian healthcare organization, the Victorian Order of Nurses (VON). This work has made very clear in my mind two things: first, that healthcare is in need of lean thinking and culture (I am sure not a surprise to anyone); second, that lean is an “end state” but not a change methodology.
Lean, as we all know, is the elimination of waste, designing processes to meet customer needs, and a culture of continuous improvement. But, too many organizations have reduced lean implementation to the simplicity of using an A3 report, doing 5S, or doing some very targeted and small scale problem solving using PDCA, DMAIC or other problem solving methodology. While all these are good things, none of them transform the culture or major work processes of the organization. They address a fragment of the system, not the whole-system. Whole-System Architecture, a combination of socio-technical systems design, appreciative inquiry, re-engineering, and other methods, does exactly that. Fortunately, at VON, I have the opportunity to once again look at and redesign the whole-system of the organization. It has been very gratifying.
Judith Shamian, the CEO of VON, recently published the following guest blog post by yours truly.
Can Healthcare Learn from Lean?
Guest Article by Lawrence M. Miller
Management fads come and go and leaders of organizations are frequently guilty of jumping on the bandwagon of the next set of buzz words. Now comes the repackaging of the Toyota Production System in the name of lean management or lean culture. On the one hand healthcare managers may reject it as something that fits on an assembly line, but does not fit in a professional service organization. On the other hand, there may be principles, some wisdom, that if we seek to understand, we may be creative and find ways to improve our service to our clients.
Over the coming months VON will seek to apply the following principles to our own work with the simple goal of improving the client experience and the experience of our funders.
Flow and the Elimination of Waste:
Some years ago I was working with Honda America Manufacturing as they developed their manufacturing plants in North America. I learned something important from them. The brains of Honda managers were wired differently than the brains of other manufacturing managers with whom I had worked. Their instinct was to think horizontally, to think about the flow of materials without regard to walls or silos created by internal departments or even the legal walls that separate companies. They viewed the flow of work through the eyes of the customer who catches the end product and has no interest in whether a problem occurred in department A or B. Every day Honda engineers were in supplier locations, seeking to assist their suppliers to improve the flow.
Every interruption to flow is bad. Materials and information, when they move horizontally, without piling up on pallets or in bins, are good. Small piles are good. Big piles are bad. Delays in the flow must be eliminated. Stuff standing is waste. Stuff piling up as inventory is waste. Waiting, delays are waste. Eliminate all delays and rework. Optimize the flow!
To optimize the flow decisions cannot constantly be going up and down levels of the organization. This takes time and represents delays and interruptions in the process. For this reason, as well as others, employees must be truly empowered to make decisions “on-the-spot” and must be respected as the “world’s greatest experts” in their work.
High performing teams or individuals appear natural when their performance flows with seemingly little effort. Athletes experience flow, or what they may call, “being in the zone.” A musician may say she is in “the groove.” Flow for an individual is complete focus, absorption in a task, when all energies move with ease and without interruption. Rather than feeling great exertion, the work feels natural and exhilarating. Mihaly Csikszentmihalyi described flow as the psychology of optimal experience. If you type well, you experience flow, the uninterrupted movement of your fingers. If you play a musical instrument well you experience flow. And, our organizations can experience a collective flow as we work together as a well conducted orchestra, moving to the rhythm of our clients.
Can this principle of flow and the elimination of waste be applied to healthcare? Of course it can. Every waiting room in a hospital is much the same as in-process inventory, input sitting on pallets or bins, waiting to move to a point of adding value. In healthcare, every delay and interruptions in the process are not only waste, they increase the risk to the patient. From the moment a patient feels a pain in their stomach to the exact moment when the right care is delivered to the patient, every moment is a wasteful and risk creating moment. But, healthcare organizations and clients, have come to believe that waiting, being sent from one office to another, from one phone call to another, are all necessary to the process of getting care. But they are not necessary. They are symptoms of poorly designed processes and the failure to apply the right principles.
At VON, as well as at all healthcare organizations, we must seek continuous improvement by eliminating walls, delays, and rework that create interruptions in the patient experience.
Respect for People
Mr. Toyoda, the founder of Toyota said that employees have only two responsibilities: first, to be there, every day, on time; second, to stop the line. That is right. Every hourly employee working on the assembly line is authorized, empowered, and instructed to stop the entire production line on which thousands of other workers are employed. When this is explained to managers of traditional manufacturing plants, they don’t believe you. They think this is impossible. You would have chaos if every employee could stop an entire production line! Within their paradigm and their culture, they are right. But, it is a different paradigm and different culture.
At Toyota, when an employee sees a quality problem, immediately and without delay, every employee, manager and engineer seeks to solve that problem. And, then the work resumes. Quality problems are not passed on to others.
As parents, most of us have witnessed the effect of giving your child responsibility. It gives them pride and they generally rise to the occasion and act in a way that is worthy of respect. Showing respect tends to result in behavior that is worthy of respect. Honda refers to their employees, their “associates,” who work on the line as “the world’s greatest experts” in their work and it is the job of managers to assure that they are, in fact, the world’s greatest experts in their work. If you are doing your job as a manager you will have employees worthy of respect.
If an auto manufacturing plant can practice respect for people, how obvious it should be that a healthcare organization, a nursing organization, should equally demonstrate respect for people. Nurses enter the profession for the highest motives, to serve others. They are worthy of respect, as are our patients and funders.
But, what exactly does this principle mean in an organization like VON? It means that the work of nurses must be designed to respect their ability to make on-the-spot decisions to serve their clients in the best possible way. It means the organization should provide the opportunity for continual learning and development of their skills. It means that we must involve them in the design of the work process and organization that will enable them to provide quality care. We are, after all, an organization of nurses.
Of course there are other principles – continuous improvement, customer focus, managing by the facts, and others. Each of these principles appears simple on the surface. However, it is meditating on their meaning, their implications for daily life in our organization that will return benefits. There is no one right or simple answer to applying lean to healthcare, any more than there is one simple answer to the pursuit of human health.
Healthcare is a complex system. Complex systems are hard to change by pulling on specific or detailed levers. There are too many of them, all interacting with one another. However, complex systems are changed by the adoption of new principles and the determined and sustained application of those principles.
Healthcare organizations must gain dramatic improvements in both the efficiency and effectiveness of healthcare services. Lean thinking can be one source that improvement.