Does Lean Work?
Eric K. Wei, MD, MBA, Erik Berg, MD
I. History of Lean Healthcare
Lean strategies are currently being widely applied in hospital systems across the world. Originally conceived by Toyota in the 1950’s, the key principles and tools of lean methodology received much fanfare and spread to other industries, including healthcare. The core ideas of lean involve decreasing waste and increasing value from the customer or patient’s perspective. Early lean adopters in healthcare, such as Virginia Mason Medical Center and ThedaCare, generated enthusiasm for more widespread implementation.
Subsequently, many Emergency Departments (EDs) across the US and the world have adopted lean strategies to tackle common ED problems such as overcrowding. In a 2009 survey of US hospitals, 53% reported using lean approaches and 60% of those hospitals had employed lean in the ED.
II. Lean Takes a Hit
Despite the widespread adoption of lean, there is scant evidence in the healthcare literature to support the use of lean. The results from two recent studies from Canada, including the first large-scale controlled study of a lean intervention and results from the “largest lean healthcare transformation in the world,” failed to show significant benefit.
In 2008, the Canadian province of Ontario launched a province-wide “ER Wait Times Strategy” designed to reduce total length of stay. In collaboration with the Health Ministry, researchers from the Institute for Clinical Evaluative Sciences designed an evaluation of 36 EDs who received the lean intervention and compared them to 63 control EDs with both groups incentivized by pay for performance goals. Although 36 EDs in the lean intervention group saw decreases in their median LOS, when compared to control EDs, there were no differences.
On a larger-scale, the Ministry of Health in Saskatchewan sought to implement lean methodology across the province's entire healthcare system starting in 2008 with a $40 million (CAD) lean consultant contract. Results of surveys sent to both patients and healthcare staff found that the lean interventions failed to help patient satisfaction or health outcomes, and hurt worker satisfaction. Multiple articles in the lay press have criticized the lean initiative quoting reports that for each Canadian dollar (CAD) saved, it cost the Ministry of Health $1,511 (CAD) and the consulting contract was cut 9-months short despite the Health Ministry believing that the lean investment saved the province $130 million (CAD).
III. Lean or L.A.M.E.?
Multiple review articles conclude that the results of lean interventions in healthcare settings are mixed and many of the interventions that show initial improvements regress back to baseline over time.5 Defenders of lean have coined the acronym L.A.M.E. (Lean as Misguidedly Executed) to describe improper implementation of lean leading to failed initiatives. However, it is not as simple as saying every failed lean implementation was because it was executed incorrectly. Creating change in organizations and culture is extremely difficult and sustaining changes is even harder.
One of the keys to successful implementation of lean is having leadership engaged and creating the appropriate environment to allow lean methodologies to occur. This means having hospital executives, physician and nursing leaders, and managers support the creation of multidisciplinary teams consisting of frontline staff and empowering these teams to analyze their daily work, identify waste and their root causes, and come up with the solutions to improve the work. Lean is a management philosophy, not just a collection of tools. The tools work with the philosophy of driving out waste. Management must support front line staff to incorporate lean practices in their daily work.
Another key and one of the biggest barriers to any quality improvement project is culture change. Proposed change often elicits a defensive response. Lean helps break down staff resistance by being inclusive and engaging all stakeholders to be part of the solution. Having members of the multidisciplinary teams be homegrown champions who are on the frontline doing the work, actively engaging their colleagues, reinforcing rapid cycle PDSA (Plan, Do, Study, Act) implementations, and providing feedback to the teams is critical to success.
A third key is to be aware of and prepare for barriers to implementation. Lean cannot be perceived as standing for “Less Employees Are Needed” or cutting “fat”, as there will be resistance to participation when employees think they will be laid off as a result of improved processes. Leadership needs to be sincere in reassuring staff that gained efficiencies will be reinvested in further improvement activity and providing even more value to the patient.
Toyota taught us that those closest to the process of creating value for the customer best know how to improve the process, and thus create more value for the customer. So, it is not surprising that paying for an outside consultant to come in and implement lean to improve healthcare processes was not successful in Saskatchewan and was not superior to other improvement strategies in Ontario.
Lean is one of many process improvement methodologies—all have their advantages and disadvantages. It is also not surprising that the pay for performance intervention in Ontario provided enough incentive for all EDs to improve their wait times regardless of receiving lean consultation. If you adequately incentivize decision makers, they will figure out formal or informal process improvement techniques to achieve a goal.
Lean is a powerful set of tools and philosophy that when applied correctly to the right problems, can help healthcare organizations reduce waste and increase value from the perspective of the patient. This can help EDs improve the Quality and Safety of the care they provide and achieve high reliability. Just don’t expect lean to be a magic bullet that can be purchased to solve all your hospital/ED’s problems.
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