Reconstituting lean[2139]

Copyright 2017 by Kelley School of Business, Indiana University. For reprints, call HBS Publishing at (800) 545-7685. BH863
Business Horizons (2018) 61, 13—22
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Reconstituting lean in healthcare: From
waste elimination toward ‘queue-less’
patient-focused care
Richard J. Schonberger
177 107th Avenue NE, #2101, Bellevue, WA 98004, U.S.A.
KEYWORDS
Lean healthcare;
Patient focus;
Lean practices;
Quick response;
Healthcare strategy;
Lean management
Abstract With ultra-short sightlines to its patient-customers, healthcare should
pursue lean in its own way rather than follow the often wayward lean practices of
manufacturing, a sector in which few people ever see real customers. Because of the
distance in manufacturing from end customers, this sector’s lean practices usually
focus inward on operational efficiency through waste elimination. The nature of
healthcare–—with customers up close and immediate–—calls for elevating its lean
efforts toward customer-focused lean effectiveness: flexibly quick response along
the multiple flow paths leading to and involving patients. This article illustrates that
approach to lean by drawing from a case study in which widely scattered heart attack
patients were transported to a central treatment hospital in a system-wide, highly
coordinated program of quick response. This article shows that the keys to
success–—including high rates of saving lives and lean healthcare in general–—boil
down to just five lean methodologies, each focused on quick response. Lean
healthcare, when practiced in this way, becomes deserving of status as a fixture
in strategic management of the enterprise.
# 2017 Kelley School of Business, Indiana University. Published by Elsevier Inc. All
rights reserved.
1. Lean lessons from manufacturing: A would loosen up my stiff and sore shoulder, she
asked what kind of work I did. In my response, I
poor fit in healthcare
mentioned research and writing, including on the
topic of lean management. “Is lean management in
A few years ago, I was in treatment at my health
use here?” I asked. Nodding, she replied impishly:
organization’s physical therapy department. As
“You said a bad word.”
Jennie, my PT, showed me some stretches that
I could not fully disagree. In this article, I explore
the misapplication of lean manufacturing to health-
care, discuss reasons why lean’s essential focus on
E-mail address: sainc17@centurylink.net the customer (i.e., patients) should be leading to
0007-6813/$ — see front matter # 2017 Kelley School of Business, Indiana University. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.bushor.2017.09.001
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14 R.J. Schonberger
better results similar to those achieved with lean in
manufacturing, and point to the most effective of
lean’s methodologies in this quest.
This could be seen as an opinion piece, especially
since my contentions run counter to some of the
current thinking in the still young and evolving area
of lean healthcare (see Table 1 regarding some of
what led to this article). For several reasons, how-
ever, my stance regarding the need for healthcare
to develop its own approach to lean as opposed to
relying on ineffectual lessons from lean application
in manufacturing stands on more than mere opin-
ion:
I am aware of convincing hard data evidence
indicating that lean has not been working out
well in manufacturing (Schonberger, 2016). Inas-
much as healthcare has taken most of its lean
lessons from manufacturing, healthcare would
seem not to be expected to do any better.
On the other hand, healthcare interacts with its
customers up close, which gives immediacy to
lean’s most essential pursuit of delivering flexibly
quick response to customers. In contrast, most
people in manufacturing rarely see a real cus-
tomer, if at all. Such narrow vision tends to
localize most lean efforts within the operations
realm.
Healthcare treats numerous patients concurrent-
ly. In contrast, most manufacturers process their
catalog of product models or customer orders
sequentially, which means long, un-lean wait
times to receive their goods.
Healthcare’s high level of customer visibility
should lead it to downplay waste reduction,
which has been treated in manufacturing as
lean’s essence. Waste reduction makes up a fine
Table 1. Why I wrote this article
A number of factors led me to undertake this article.
Among them is my involvement in advances in
manufacturing management. In this area, I have
isolated effective manufacturing practices from those
that are not effective or that have proven to be flashes
in the pan. I have also conducted sporadic research on
how mistakes and weaknesses in lean manufacturing
are being echoed in healthcare. Due largely to their
distance from customers, manufacturers have done a
poor job of directing their lean efforts toward
effectiveness in the eyes of the customer. There are
good reasons why healthcare can and should do what is
necessary to reverse that state of affairs.
tool set, but it has a low-level, operations-
oriented ring to it. In its place, healthcare should
put quick customer response on the lean pedes-
tal, with queue-less response and time to care as
catchy, just-right-for-healthcare alternative
phrases.
A standout example, impressively saving pa-
tients’ lives, comes from an article by Shah,
Goldstein, Unger, and Henry (2008). It is a case
study of a comprehensive set of practices–—
seen by its authors as following four lean
principles–—for getting heart attack patients from
all over the state of Minnesota to Minneapolis for
emergency treatment at the Minneapolis Heart
Institute (MHI), snuffing out queuing delays along
the way.
Key elements of the MHI-directed processes are
taken up in this article, reoriented here around
five method-specific lean practices rather than
couched in abstract lean principles as in the
original case study. I advance these methodolo-
gies as a spare, specific, and easy-to-understand
way forward in the cause of quick-response/
queue-less lean in healthcare.
Through these approaches that emphasize health-
care’s tight linkages to patients, lean healthcare
may become a truly positive force and alter the
negative views of it by insiders such as Jennie–—and
more importantly, though perhaps less vocally, by
nurses, physicians, and administrators. Following
sections elaborate on these points, while bringing
in various arguments on lean’s potential and
obstacles to its fruition.
2. Living up to lean’s potential in
healthcare
After a late start, lean implementations today are
flourishing in health centers globally (Aherne
Whelton, 2010; Bisgaard, 2009; Protzman, Mayzell,
Kerpchar, 2011). Oft-cited U.S. examples include
Seattle Children’s Hospital, ThedaCare with multi-
ple locations in Northwestern Wisconsin, and Virgin-
ia Mason with a main hospital complex and network
of clinics in greater Seattle. Virginia Mason’s promi-
nence in the practice of lean (Kenney, 2011) has
made it a go-to location for lean healthcare tour-
ism. As an example pertaining to lean healthcare
internationally, Saint Goran’s hospital in Stockholm,
Sweden, has been called “a temple to ‘lean man-
agement’” (‘A Hospital Case,’ 2013, p. 75).
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Reconstituting lean in healthcare: From waste elimination toward ‘queue-less’ patient-focused care 15
2.1. Why shouldn’t healthcare learn lean
from manufacturing?
Healthcare has taken its lean lessons from
manufacturing, with car assembly often serving as
a lean model, albeit a dubious one. For example,
early in Virginia Mason’s lean journey, it sent three
dozen top employees to Japan “to study and work in
an automobile factory” (Kenney, 2011, p. 15). How-
ever,itishardtoseemuchleaninactionatacarplant
amid the robots, conveyors, and other automation.
Moreover, lean manufacturing is at least as well
developed outside of automotive as within it. In this
light, the best choices to see lean in action–—and
learn from it–—are in sectors where production is less
complex, less automated, and less gigantic.
Virginia Mason probably found that out before
sending people to Japan, since it first sent a team to
Wiremold in Pennsylvania (Kenney, 2011), an easy-
to-grasp lean showcase (Byrne, 1995) and 1999
Shingo Prize recipient. Moreover, unlike carmakers,
Wiremold is a high variety, low volume producer
(made-to-order power strips for construction sites),
characteristics it has in common with healthcare.
While Virginia Mason had to fly its team cross-
country to visit Wiremold, ThedaCare in Appleton,
Wisconsin found a manufacturer only 22 miles away
with lean practices it could relate to and learn from.
In 2002, ThedaCare CEO John Toussaint made an
eye-opening visit to the Ariens Co. plant in nearby
Brillion. Daily at Ariens, a producer of snow blowers
and lawnmowers, 35 cells assemble every seasonal
product sold (Hall, 2004). Dr. Toussaint may have
realized that this ability to produce many product
models in parallel, rather than sequentially,
and in relatively close sync with market demand,
is akin to healthcare’s need to care for multiple
patients simultaneously.1
In the mainstream,
however, manufacturers have long resisted
parallel processing, including many of those es-
teemed for their leanness. Some of this resistance
may be starting to fade, inasmuch as the customer-
effectiveness attributes of parallel (i.e., concur-
rent) production has begun to receive attention in
manufacturing-management publications (e.g.,
Schonberger, 2014a).
On the surface, lean-efficient factories would
seem to be useful models for healthcare. The most
advanced examples have minimal throughput
times, inventories, flow distances, setup times,
and interruptions. Orders flow quickly rather than
stumble spasmodically from receiving docks to
1
Parallel vs. sequential processes in the healthcare context is
discussed in Protzman et al. (2011).
shipping. But such efficiencies are gained in large
part by smoothing the erratic demand patterns of
customers. As a case in point, the typical output of
car assembly in the U.S. is 3 months of unsold
vehicles in dealers’ lots (Young, 2014). Applying
this scenario to a hospital, patients might experi-
ence a smooth flow of care throughout the process,
but only after waiting for months while suffering
unaddressed medical complications.
2.2. Lean healthcare’s skeptics
Some have suggested that the expected benefits of
lean in healthcare have not been satisfactorily
demonstrated or have been minimal. One article,
“Lean in Healthcare: The Unfilled Promise?”
(Radnor, Holweg, Waring, 2012), reported on four
case studies in applying lean within the National
Health Service in the U.K. Of two principle conclu-
sions, the first is that the lean applications were
producing “small-scale and localized productivity
gains,” the result of being mired at a lean ‘tools’
level (Radnor et al., 2012, p. 364). Second, even if
lean was scaled upward to a systems level, it would
be unlikely to yield impressive results. That, the
authors said, is because “healthcare is predomi-
nantly designed to be capacity-led,” and therefore
is unlikely to free up resources or influence de-
mands for care (Radnor et al., 2012, p. 364).
Both points seem well off the mark. Rather, lean
in healthcare seems particularly well suited to
freeing up capacity and, when done right, yields
impressive results at a systems level. Those effects
are amply demonstrated in the Shah et al. (2008)
article, the centerpiece of which is a case study on
saving lives of heart-attack patients from all over
Minnesota who are taken to MHI of Abbot North-
western Hospital for treatment. In the article, the
program and its outstanding results are implicitly
shown to be attributable to effective application of
lean management. Why implicitly? Please see the
explanation in Table 2.
Shah et al. noted that the MHI program, in its
focus on front-office, customer-processing health-
care, faced the difficulties of highly complex inter-
acting sources of variability, which is characteristic
of lean at a systems level (Shah et al., 2008). That,
they pointed out, is in contrast to the simpler
healthcare context of back-office processing, which
they likened to lean in manufacturing in that
customers are remote and orders are capable of
being batched. Moreover, the MHI program operates
at a systems level in that its higher-order focus is on
saving lives. The program also involves many
community hospitals, transporting ambulances
and helicopters, and a large cast of care team
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16 R.J. Schonberger
Table 2. The MHI program: Is it lean?
It is not clear from the case study that the MHI’s
leaders thought of their program in lean terms. As to
that, a modification of the ‘duck test’ comes to mind:
If it looks like a lean implementation and acts like a
lean implementation, it is a lean implementation. In
this regard, the MHI program qualifies as lean.
The authors saw the program as lean in that it matches
a set of four lean principles laid down by Spear
(1999). The first of the four, standard work (standard
process protocols), dominates, as is apparent in nearly
all aspects, from the roles of patient transport and
community hospitals to the treatment sequence in
Minneapolis.
They chose lean principles as their level of abstraction
because “We did not observe . . . common lean
practices/tools associated with process
improvement.” But a read of the case study 8 years
later by a different set of eyes does reveal common
lean practices, five of which are detailed in the body of
this article.
members, all contributing to an extensive and
highly coordinated program.
Further, the program frees up resources even
though heart attack instances are highly unpredict-
able and require spasms of costly system capacity.
Within those spasms, though, the program’s high
degree of system-wide coordination features
largely queue-free sequences of care with little
of the usual stage-to-stage, stand-by-and-wait
characteristics of emergency care. As compared
with norms, the program treats more patients
with better results using equal-to-fewer costly
resources.
This is not to say there is no idleness. At times
when heart-attack incidences are below average
(i.e., half the time), nurses, physicians, rooms,
equipment, and transport resources cannot be busy
in their top priority tasks of processing heart attack
patients. This is not to say, however, that this extra
time necessarily goes to waste. Idle time between
incidences is available for important catch-up
charting and reporting work, cleaning and organi-
zation that otherwise would fall to the wayside, and
studying and updating skills.
2.3. Making time for continuous
improvement
Notably, in lean terms, there will be time for con-
tinuous-improvement activities, which include re-
cording and analyzing everything that goes wrong
and which, according to Tucker and Edmondson
(2003), are either errors or problems. Errors are
defined as inaccuracies or unnecessary actions oc-
curring within a task. Problems, on the other hand,
are disruptions and setbacks that upset task com-
pletion. Based on intensive observation of high-
performing nurses’ behaviors in the context of fac-
tors in hospital work “that inhibit system change,”
Tucker and Edmondson (2003, p. 57) found that
people “are unaware of their own errors while
making them.” When serious, errors are likely to
show up later, oftentimes much later.
On the contrary, the MHI program seems likely to
reveal human errors sooner rather than later. Since
each pair of process steps is tightly linked, an error
will often be caught by the person(s) at the next
step well before the consequences multiply and the
trail of causes grows cold.
Tucker and Edmondson (2003, p. 57) observed
that, in contrast to errors, people “are well aware
of problems they encounter.” The authors
found, however, that the nurses studied were so
independently minded that they tended to resolve
problems on their own, rather than having the
problems–—along with their own sometimes hasty
solutions–—documented so that best practices could
be determined and built as fixtures into their
hospitals’ protocols. Moreover, the nursing units
were designed to maximize efficiency, which tends
to deny slack time to work out and document
problem solutions.
Historically, efficiency has been the name of the
game in manufacturing, and despite lean-
management’s mantra of customer-responsiveness,
lean efficiency typically still gets priority over lean
effectiveness. That is, in the typical lean-
manufacturing model, production schedules are
smoothed and balanced so that production associ-
ates keep busy making product and so that equip-
ment has high rates of utilization. The rub is that
the smoothed schedules are at odds with high vari-
ability of demands and usage of end-customers
(Schonberger, 2013a, 2013b, 2014a).
2.4. How the MHI program works
Countering the dominant emphasis on efficiency,
the MHI program prioritizes for effectiveness, as
measured by quick response and saved lives. Ex-
cerpts from the case study set the stage for showing
how lessons from the MHI program can be extended
to enhance lean efforts elsewhere in healthcare:
[When] initial transport is by ambulance to the
community hospital . . . the patient remains
on the ambulance gurney while necessary tests
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Table 3. Lean methodologies well suited for healthcare
Methodology Application
Quick setup Choreographed methods for quick, error-free setups and changeovers involving
physical and human resources
Visual management Prominent identifiers of correct locations and quantities of materials, devices, and
implements
Kanban (queue limitation) Setting quantitative limits on waiting times, both for human and physical entities
Cross training/job rotation Every position having one or more certified backup staffers, with multi-skilling
maintained through job rotation
Value-stream organization A facility set up in product-focused or customer-focused (or both) units–—in lean lingo, a
and layout work cell (small) or a focused factory (big)
and treatments are performed at the commu-
nity hospital, rather than being transferred to a
hospital bed, which would add unnecessary
movement and time to the process. (Shah
et al., 2008, p. 776)
All necessary drugs and supplies are packaged
in an easily accessible kit, which also includes a
checklist of all protocol activities. The same
checklist appears on posters displayed in each
community hospital ED [emergency depart-
ment], as well as on pocket cards carried by
ED physicians and transport personnel. All
patient-related data, including records of drug
dosages and test results, are recorded on a one-
page form that stays with the patient through-
out the process. (Shah et al., 2008, p. 776)
Further are direct quotes from parties within the
process:
The helicopter pilot has to do a hot load [blades
rotating] because it’s faster . . . We have to
have the MHI cardiologist scrubbed and in the
room when the patient gets here. I can’t ask
[the community hospital] to beat themselves
up getting the patient here and then see the
patient waiting for the doctor. (Shah et al.,
2008, p. 776)
Before, the IV tubing inserted at the commu-
nity hospital often had to be changed at MHI to
accommodate new needs later in the process.
The community hospital nurse didn’t see these
problems because they came up later, after
the patient was handed off to someone else.
Now, the IV tubing style is defined in the
protocol, and it’s in their kit, and what they
insert at the community hospital works for
MHI, saving time and not repeating another’s
work. (Shah et al., 2008, p. 776)
As to outcomes, Shah et al. (2008, p. 765) com-
mented that “few if any U.S. hospitals have been
able to improve performance to the level achieved
by our study.” Namely, the MHI met a targeted time
of less than 2 hours 80% of the time for patients
transported fewer than 60 miles and 50% for those
transported 60—210 miles. Those percentages com-
pare with only 16% for U.S. hospitals as a group. In
saving lives, the MHI’s mortality rate was 4.4%
compared to 8%—15% in most U.S. hospitals.
Clearly, these are not “small-scale and localized
productivity gains” (Radnor et al., 2012, p. 364).
Rather, the program aimed at, and was highly
successful with, two overriding and interlocking per-
formance parameters: time (quick response) and
quality (saving lives)–—factors that would stand up
asdominantsuccessindicators inmostanycustomer-
service endeavor, particularly healthcare.
Besides those general observations, the workings
of the MHI program can be seen to build on specific
lean practices or methods (the two terms are used
interchangeably), considered next.
3. Lean healthcare in method-specific
terms
Table 3 summarizes five lean methodologies that
describe the workings of the MHI program and its
outcomes, and support the view that those same
lean methods should serve in many or most other
healthcare contexts. These methods, all focused on
quick-response, are extra-relevant in healthcare,
given its customer-facing nature and high impor-
tance of immediacy. Each is discussed next using
MHI case-study particulars as supportive arguments.
3.1. Quick setup
In manufacturing, the typical context is a single
machine, such as a punch press in which setting it up
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18 R.J. Schonberger
quickly entails modifying dies to be the same height
and staging them next to the machine instead of in
remote racks. In healthcare, quick setup can be
directed broadly toward a multifunctional proce-
dure, thus to ensure no-fuss, no-delay, no-problem
engagement of rooms, medical devices, supplies,
and clinical-care teams. A fitting example is the
standardized preparatory steps in the MHI program,
which, given the geographical dispersion of its heart
attack patients, look to be more impressive than
most of the localized quick-setup paragons in
manufacturing.
3.2. Visual management
Visual management, employing 5S (five ways of
keeping things clean and orderly) can ensure that
supplies are where they are supposed to be (exam-
ples from the MHI case study include checklists,
poster displays, pocket cards, and one-page patient
data forms that accompany patients throughout
processing). More than that, visual management
can significantly alter human behaviors for the
better.
One example dates back to a time when lean was
scarcely mentioned in the same sentence with
healthcare: 1992 at Northwest Hospital, Seattle.
Debby, a critical care nurse, had been attending
training conducted by Daniel Sloan, a local
consultant specializing in quality management
methods. Armed with that training, Debby tackled
a festering problem: No one, she said, could re-
member a surgery starting on time. One or another
surgical team member was always late. The natural
attitude seemed to be, ‘Not much need for me to be
on time, since we’re never on time anyway’
(Sloan Torpey, 1995).2
Debby’s solution was to clear out a small supply
room in the surgical suite and turn it into ‘Debby’s
Dugout,’ which she set up with a large white board
annotated with names of surgical team members
and scheduled start times for each surgery. A check
mark went beside the name of anyone who was late.
The result–—no more late surgeries–—was almost
immediate. The shame and opprobrium from being
singled out for bad behavior can have that effect,
especially when, as in this case, more than incon-
venience is at stake. In this case, the rippling
effects of one late surgery pushed back others, with
patients the worse for it–—to say nothing of the costs
of poor usage of valued resources.
2
Protzman (2011, p. 239) says that surgeons are chronically
late for surgeries “because the patients are never ready [and] it
becomes a ‘Catch-22’ type problem.”
The lean practices at work in Debby’s Dugout also
included quick setup, largely achieved by nothing
more than having everyone present. This practice
would not, however, ensure that needed supplies
and devices are on hand, another commonplace
obstacle that can delay the start of surgery, bring
it to a halt, or degrade the quality of the effort.
Such causes of delay call for kanban.
3.3. Kanban
The Japanese term kanban translates well in
English as ‘queue limitation,’ as that is its purpose
and effect. It establishes a maximum allowable
on-hand quantity (queue limit or kanban number)
of anything that can be queued and sets replen-
ishment in motion whenever the amount on hand
falls below it. The method can bring about auto-
matic replenishment, which eliminates tying up
nursing and other staff searching for supplies. A
form of it often referred to in writings on lean
healthcare is the two-bin system, explained in an
example from Children’s Hospital in Seattle
(Weed, 2010):
Two years ago, the supply system [at Child-
ren’s] was so unreliable that Susanne Mat-
thews, a nurse in the intensive care unit,
would stockpile stuff–—catheters in the closet,
surgical dressings in patients’ dresser drawers,
and clamps in the nurse’s office. . . . “Nurses
get very anxious when we can’t get our hands
on the tools we need for our patients . . . so we
grabbed them when we saw them, and stashed
them away.” This, in turn, made the shortages
more acute.
On a busy day last month in the I.C.U., it took
Ms. Matthews just a few seconds to find the
specialized tubing she needed to deliver medi-
cine to an infant recovering from heart surgery.
The tubing was nearby in a fully stocked rack,
thanks to a new supply system instituted by the
hospital early last year, following practices
typically used in manufacturing or retailing,
not healthcare.
There are two bins of each item; when one bin
is empty, the second is pulled forward. Empty
bins go to the central office and the bar codes
are scanned to generate a new order. The
hospital stockroom is now half its original size,
and fewer supplies are discarded for exceeding
their expiration dates.
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That kanban was so late in coming to healthcare is in
part owed to the sector’s place among the last to
adopt electronic tagging of goods, despite a few
early publicized successes, such as one dating back
to 1986. As The Wall Street Journal described it
(Rundle, 1997), supply managers at St. Alexius Med-
ical Center in Bismarck, North Dakota, came up with
home-grown scanning equipment that worked well.
However, since few manufacturers were using
barcodes, the supply team applied their own stick-
ers to incoming items. In following months, they set
up 100 barcode scanning locations, including nurs-
ing stations, pharmacy, dialysis center, operating
rooms, and the print shop. These efforts resulted in
far more reliable provisioning with far less invest-
ment in stockroom inventory, achieving 13 to 16 in-
ventory turns per year, up from the typical low
single digits.
Today, most producers of medical materials
employ electronic tagging, often via RFID (radio-
frequency identification) tags, which overcome
various limitations of barcoding. Among high-
impact applications is RFID tagging of medications
going from the pharmacy to patient rooms, thus to
stamp out deliveries of wrong medications at the
wrong times to the wrong patient. Kit Check, a
provider of RFID software, claimed that on January
1, 2015, “Sentara Virginia Beach General Hospital
applied the one-millionth Kit Check RFID medica-
tion tag” (MacDonald, 2014).
3.4. Cross-training
Cross-training is a pillar of lean management. A
common starting point is for each associate on a
production line or in a work cell to be capable of
working one position to the right and one to the left.
Next, cross-training can extend to other production
lines, and then to non-production work such as
fetching materials or driving a fork truck. Though
the MHI case study does not refer to cross-training,
it seems likely that non-clinical staff, and some
nurses and physicians, too, are cross-trained so that
when a key person is busy or missing, planned and
unplanned events can proceed promptly–—obviating
slow-downs or halts in processing heart attack pa-
tients.
3.5. Value stream-focused resources
The MHI program is organized solely around heart
attack patients, which reduces or eliminates com-
plexities that would otherwise render staff, equip-
ment, and rooms as non-available at critical times.
3.6. Lean healthcare revisited
These five lean methodologies or practices are
likely to free up costly space, equipment, supplies,
and human resources that commonly go under-
used, particularly in healthcare, because of poor
readiness, chaotic supply areas, search delays,
needed skills missing, and unfocused resources.
While each functions well enough alone, they are
mutually reinforcing and work particularly well as a
complementary set.
4. The lean management jungle
Still, for reasons other than those from the Radnor
et al. (2012) article, elevating lean healthcare to a
systems level may not yield sustainably impressive
results. For one, the term lean itself has become
problematic. An internet search for “lean contro-
versies” brings up little else than hits relating to
the widely discussed book from the women’s
movement, Lean In (Sandberg, 2013). Aside from
Sandberg’s book, the public generally thinks of lean
in relation to diet or body mass (i.e., the well-
known and disagreeable phrase “lean and mean”).
The term ‘lean’ is also widely used in the financial
community to describe companies in retrenchment,
typically calling for staff reductions. One example
of that usage is an article headlined, “Lean Compa-
nies Ready to Cut”–—that is, cut people, products,
and more (Linebaugh, 2011).
And then there is the matter of lean lingo over-
load. The book Lean Lexicon, now in its fifth edition,
contains “207 terms from A3 Report to Yokoten,”
and includes 14 new terms added since the fourth
edition. Japanese words are liberally sprinkled in
(Lean Enterprise Institute, 2014). As healthcare
professionals are confronted in lean classes by these
long lists of lean elements and terminology, push-
back seems likely on the grounds that it takes time
away from primary work in treating patients and
staying informed about latest advances in medi-
cine. Among published examples of such resistance
to lean are the following:
In June, 2010, Nellie Munn (2010a, 2010b), a
nurse at Children’s Hospitals and Clinics of Min-
nesota in Minneapolis, led a 1-day strike by the
Minnesota Nurses Association against six area
healthcare corporations. Ms. Munn said that hired
consultants, in efforts to reduce waste, were
using timing methods to standardize nurses’
tasks. In protesting perceived staff reductions
resulting from the consultants’ work, the strikers
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20 R.J. Schonberger
blamed lean methods and maintained that the
cuts created unsafe conditions for patients.
More citations critical of lean in healthcare are
found in “Lean Blog” (Graban, 2014), a reference
to a 4-year, $40 million commitment by Canada’s
Saskatchewan province to train healthcare work-
ers across the province in lean methods. Graban
(also author of Lean Hospitals [2012]) agreed
with some of the critiques emanating mostly from
op-ed columns in the province’s newspapers and
refuted others, some of which he refers to as
coming from “anti-lean bomb throwers.” He
agreed, for example, that “showing videos of
Toyota weaving looms,” “folding paper air-
planes,” and heavy use of Japanese jargon by
U.S. consultants under training contracts are
overwrought.
Regarding the contention about small-scale results
of lean at a tools-level, it is a viewpoint that lean
consultants have been passing back and forth to
each other for years. However, the point is
muddled, because the usual lists of tools (see
Table 4) do not differentiate between methods
of studying processes (problem finding, for exam-
ple, mapping the healthcare value streams) and
those that change practices (problem solving,
such as quick, mishap-free setup), which, as Shah
et al. (2008) put it, “are easily observable and
measurable” lean indicators. Over past decades,
the trend in manufacturing has been toward a
lean agenda short on actual implementations
within the processes and long on professional-
grade people engaged, to a fault, in process anal-
ysis, lean planning, and lean readiness. Such
overkill can be viewed as un-lean and wasteful
of valued resources. Lean in healthcare, emulating
manufacturing, may be bent on the same
trajectory.
Table 4. Think or do
Lean methodologies subdivide logically into those that
study and analyze processes to pinpoint process
deficiencies versus those that change processes for the
better. Among the former are value-add/non-
value-add analysis, value-stream mapping, spaghetti
charting, intensive observation, cost analysis, time
study, and process simulation and modeling. Those
that act on or in the process include one-piece flow,
quick changeover, kanban, visual workplace,
product-family focused organizations, load leveling,
point-of-use deliveries, process-capable equipment,
right-sized equipment, activity-based costing, stack
(trouble) lights, line-stop authority, and more.
5. Patient-centered lean
effectiveness as strategy
The remainder of this article is aimed at deeper
treatments of what I think are the two most
salient lean-in-healthcare issues arising in this
article. First is how and why healthcare should
be pursuing lean’s foundational objective of quick
response and doing so as a permanent element
of healthcare strategy, as opposed to manufactur-
ing’s lean formula of focusing inwardly on waste
and operational efficiency. Second is capitalizing
upon healthcare’s natural lean advantage and
urgency, namely, its intimate linkage with patients
whose needs are often immediate. The two issues
are intertwined.
5.1. Quick response: A primary lean-
healthcare mission
Standing out among champions of customer-focused
operations management is Rajan Suri (1998, 2010),
whose books call for measuring effectiveness by
total elapsed time to final customers (see also
Schonberger, 2014b). Suri referred to his ideas as
quick response manufacturing (QRM) in an effort to
distance them from the shortcomings of lean
manufacturing, employing the phrase “It’s about
time.” Although QRM’s publications, conferences,
and consulting activities (centered at the University
of Wisconsin) have made inroads, the dominant lean
regime in manufacturing–—and by imitation in ser-
vices–—remains, myopically, in the realm of efficient
operations.
For all this and more, lean’s foundational
concept of customer-pull has tended, in practice,
to lose traction (Schonberger, 2012). Lean is seen
in upper echelons as a worthy efficiency-gaining
effort that, as with other such “alphabet soup
initiatives . . . du jour” throughout the years
(Collins, 2001), is to be delegated to the operations
staff. Before long, that passing interest from senior
executives filters downward, resulting in reduced
lean training, fewer process-changing lean imple-
mentations, and, likely, a return to pre-lean
practices generally referred to pejoratively as
batch-and-queue production. The concern is that
loss of high-level support for lean, endemic in
manufacturing, is being echoed in healthcare:
Since patient-centered performance is always
the top-most concern, attention to the lean
agenda is likely to subside, especially when viewed
primarily in terms of waste reduction. The chal-
lenge for healthcare, then, is to upgrade lean so
that it is seen as a prescription for enhancing
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patient care, that being the main point of this
article.
To be sure, lean healthcare seems to have
stayed on the front burner at a few healthcare
facilities (e.g., Virginia Mason), in part because the
public relations value is unmatched and free. The
flywheel effect also encourages these facilities to
maintain lean healthcare, in that successes gener-
ate their own continuing momentum (Collins,
2001). For the majority of healthcare organizations
though, ever shifting regulatory and legislative
imperatives–—plus increasing cost and measure-
ment pressures–—quietly divert attention away
from lean.
This is not a call for rejection of waste
elimination, which plays a beneficial role in lean
healthcare (Protzman et al., 2011) as well as in
manufacturing. Nor does it deny that lean endeav-
ors (despite the flaws) have yielded considerable
beneficial results, in healthcare and elsewhere.
Rather, it is a call for elevating lean’s profile, by
recognizing lean’s key pursuit: delivering ever
quicker responses, greater flexibility, and higher
quality and safety along the flow paths, which is
especially fitting in customer-facing healthcare
where these attributes are of the essence.
Redefining lean healthcare in these kinds of terms
is an essential element in its transformation into an
enduring healthcare strategy.
5.2. Quick response with time to care
Time to care concepts (Simmons, 2011) have been
taken up by many hospitals in the U.K. (e.g.,
National Health Service, Scotland) and beyond
(e.g., Manitoba Health). Time to care makes good
sense in lean terms, given healthcare’s short
sightlines to impatient customers. Were lean
healthcare promoted, defined, and perhaps re-
named as ‘time to care,’ it should resonate at all
levels. Everyone–—clinical staff, administrators,
back-office functionaries, buyers of supplies and
devices, janitors–—readily sees timely patient care
as their institution’s dominating mission. No other
single error or obstacle to patient care stands out so
much as being too late, too slow, too hurried, or too
otherwise engaged. Lean-as-time-to-care would
aim squarely at those conditions, doing so with
the five practices summarized in Section 3. Those
best practices had been generally recognized as
fundamental in lean manufacturing’s early years,
but have tended in the past 2 decades to be treated
as just some of many, and most of those many
consist more of problem-analysis than problem
resolution.
6. Delivery of lean healthcare: A
summary
The points that have been discussed in this article
may be summarized in three main points. First and
most important, healthcare should take full advan-
tage of its intimate connection with patients–—its
customers. The term lean may need to be discarded
in favor of words and actions that everyone, includ-
ing patients, can positively relate to: quick re-
sponse, queue-less service, time-to-care, etc. Or,
as Seattle Children’s Hospital has done, healthcare
should rebrand lean as continuous process improve-
ment (CPI), which for many years has been a favored
term and common acronym in the quality manage-
ment community.
Second, healthcare should place high priority on
methodologies that change the processes, do so in
ways that achieve quicker response–—quick setup,
visual management, queue limitation (kanban),
cross training, and patient-focused organization–—
and spend less time and effort on those that study or
analyze the processes. Studying processes with
value-stream mapping, the five whys, value-add/
non-value-add analysis, and the like have their
usefulness, but are overused to the point of being
treated as necessary in any lean implementation, or
in some cases, almost as ends rather than means.
Third, with a better name and a firm focus on
quick response, lean could and should become an
end customer-oriented fixture in strategic manage-
ment of the organization. This may be a difficult
challenge in manufacturing, in which customers
reside at the far end of the bullwhip. In healthcare,
the jobs of those in most senior positions are linked
through multiple measures to patient responsive-
ness and outcomes. On that basis, lean as time-to-
care and quick response should be seen at all eche-
lons as long-term strategy and not just flurries of
passing improvement projects.
A few months after my physical-therapy session
with Jennie, I was back at her department for
further treatment, but assigned to a different PT.
While walking to my new PT’s alcove, the exuberant
Jennie, clear across the room, spotted me, got my
attention, and yelled out, “Now I like lean!” Maybe
she had served on a kaizen project or something. I
never did find out.
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