Lean thinking in healthcare

Hospital leaders need to reach out to quality and safety leaders in other industries, including aviation and manufacturing, says Mark Graban.


Even after the Supreme Court's ruling on the fate of “Obama Care,” we should recall the formal name of the law: the Patient Protection and Affordable Care Act. Most of the health reform discussion has been about the cost of healthcare, losing sight of the urgent need to fix the ongoing crisis of quality and patient safety. More healthcare organizations need to adopt the “lean” management philosophy to “bend the cost curve” and save lives, as some innovators have proven over the last ten years.

The most highly touted aspects of the PPACA include attempts to protect patients by increasing their access to health insurance. A 2009 Harvard Medical School study estimated that 45,000 Americans die each year due to a lack of coverage. Access to an affordable insurance card is an important first step, but patients still need to be able to book an appointment with their physician to get the care they need.

In Massachusetts, under “Romney Care,” patient waiting times have increased for non-urgent primary care or specialist office appointments because “doctors offices are full to capacity,” said Dr. David John, chief of emergency care at Caritas Carney Hospital in Boston in a 2011 article. If we have a greater number of insured calling on the same number of doctors, people will have to wait longer unless medical offices can find ways to increase their capacity. Massachusetts emergency room visits have increased, the opposite of what was predicted with reform.

Even if patients can get appointments or get admitted to a hospital, the care they receive is fraught with dangers that often go under reported by the media and under appreciated by the public. The Department of Health and Human Services reported, in 2008, that 80,000 Medicare patients die each year due to preventable medical errors. Other studies estimate that 90,000 patients are killed annually by hospital-acquired infections, a problem that is increasingly viewed as avoidable when best practices and proper hygiene guidelines are followed. Ironically, we are granting easier access to a very dangerous system.

The good news is that the system need not be dangerous and some leading hospitals are demonstrating that patient safety and healthcare can be dramatically improved - while simultaneously reducing costs. Preventable medical errors cannot be outlawed by Congress. Instead, as Dr. Donald M. Berwick, the former administrator for Medicare and Medicaid stated, “Successful redesign of healthcare is a community by community task… only each local community actually has the knowledge and the skills to define what is locally right.”

Healthcare organizations like ThedaCare, located near Green Bay, Wisconsin, have worked with local industry leaders to learn and adapt a process improvement and management system called “lean,” based on the famed Toyota Production System. Plant managers and manufacturing CEOs taught, inspired, and coached ThedaCare as they started the hard work of healthcare improvement.

ThedaCare’s results are the envy of the rest of the country. For example, patients with chest pain are better protected by more timely treatment for their heart attacks (waiting just 45 minutes compared to 91 minutes in 2005). As they say, “time is muscle,” and the faster care saves lives and reduces damage to patients’ hearts – which speeds recovery times and reduces treatment costs.

These results come not from working faster, but from preventing the delays that occur with handoffs and communication between different roles and departments. Staff members study the way care is provided and they are fully engaged in fixing processes through weeklong “rapid improvement events” and a method called “continuous daily improvement” for smaller fixes. ThedaCare has demonstrated gains in patient access, quality and safety, and cost in areas ranging from cardiac surgery care, outpatient orthopedics, inpatient, and primary care.

Dr. Richard Shannon, of the University of Pennsylvania, has led efforts to reduce certain types of deadly hospital infections by 90 percent. Beyond the obvious benefit to patients, the hospital saves millions each year and reduces the hospital stay for patients who would have previously gotten infections by 17 days, freeing up beds for other patients (a change that typically leads to reduced emergency room waiting times, as well). Reducing infections is a far more affordable way to create bed space compared to the construction of a new hospital tower.

The safety and quality problem is not the result of a lack of medical knowledge. Almost every hospital and healthcare professional knows what is supposed to happen to protect patients, including disinfecting your hands before and after every patient contact and repositioning at-risk patients every two hours to prevent bed sores. Yet, in many hospitals, these proven best practices are not followed consistently. The most common excuse is a staff member or manager saying, “we don’t have time.” Our hospitals know what to do – they just aren’t doing it. This is a systems problem, not a problem caused by bad individuals.

Hospitals using the lean methodology have everybody working together to reduce waste that otherwise eats up the day of harried nurses and staff. When staff are running around searching for supplies, equipment and information, they don’t have time to provide ideal patient care. While some might say the hospitals are understaffed, it’s often not realistic to increase costs by hiring more people (if you can even find them, given the shortages of key medical professionals). The smarter approach is to free up staff time through process improvement, as Dr. Shannon frees up beds at the University of Pennsylvania. Lean hospitals have more time for patient care, so patient satisfaction and health outcomes improve.

Hospital leaders need to realize that, for all of the strengths and talents of their organization, we can't solve problems by using the same kind of thinking we used when we created them. It’s time to reach out to quality and safety leaders in other industries, including aviation and manufacturing. It’s easy to shun these proven methods by saying, “we are different.” Yes, healthcare is different. Lives are on the line and families are shattered when a preventable medical error kills a patient. That’s all the more reason to adapt, spread, and share what works – the lean management system.

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Mark Graban is a consultant, author, keynote speaker and blogger in the world of “lean” healthcare. In June 2011, Mark joined the software company KaiNexus as their Chief Improvement Officer, to help further their mission of “making improvement easier” in healthcare organizations, while continuing his other consulting and speaking activities.

He is the author of the book Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement (Productivity Press), which was selected for a 2009 Shingo Research and Professional Publication Award. Mark has also co-authored a new book, titled Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvements, released in June 2012.