In August of 2012 the provincial government of Saskatchewan signed an agreement with a consulting company to assist in the implementation of the Lean quality improvement system throughout healthcare system. This deal, which will cost up to 38 million dollars, will see Lean quality improvement consultants working to imbed the Lean system in the culture of Saskatchewan healthcare over the next 4 years. Is this initiative going to revolutionize healthcare in the province? Or is it just the flavor of the week? As part of my administration rotation I recently took part in a week long Rapid Process Improvement Workshop (RPIW) to check it out.
For the uninitiated, an RPIW is an intensive week long investigation into a process that engages a group of employees to try multiple ways to improve it. By the end of the week an improved process is in its first states of implementation. RPIW’s are a cornerstone of Lean’s continuous incremental improvement approach to QI.
What is Lean?
Lean is a quality improvement system that was developed in the Japanese factories of Toyota. From what I have been told, the system has been widely implemented by manufacturing companies. The promotional videos that were shown at the one day “Intro to Kaizen” session I attended as well as the first day of the RPIW told the story of how Sackichi Toyoda (original spelling) developed the technique, first with looms and later with vehicles. Little mention was made of Toyota’s recent quality issues. More attention was placed upon the successful implementation of lean at Virginia Mason in Seattle. As with any system transformation effort, Lean has a notable focus on the essential nature of culture change.
As the popularity of Lean and similar approaches to health care improvement have risen, so too have the $$$’s put into them. Judging by the number of consultants touting their expertise with these systems on the web, there must be a strong market for them. There is even a Lean blog, complete with a podcast, written by a Lean healthcare consultant. But is there any evidence that these systems work?
Does Lean work?
The anecdotal evidence is spectacular. Just google “Lean success stories in healthcare” and you can be regaled with its many successes. You can also find explanations for the failures. Common refrains include a lack of CEO commitment or resources. Is there real, solid evidence that this stuff is effective? Not so much.
Vest and Gamm (2009 – open access) did a review of the peer-reviewed literature on Six Sigma, Lean and Hardwiring Excellence. 8 studies on the Lean methodology met their inclusion criteria. In general, the studies that they found universally reported success indicating either that Lean is always successful (very unlikely) or that there is substantial reporting and publication bias (very likely). They also found that the studies that were published:
routinely omitted statistical analysis, violated statistical test assumptions, failed to adjust for confounding, introduced selection bias, and through failure to include a comparison group cannot exclude other external events as potential sources of invalidity.
A more recent review (2010 – not open access) that included more literature reached similar conclusions in addition to noting the lack of focus on clinically important outcomes and lack of reports on cost-effectiveness.
While this literature paints a relatively bleak view of Lean’s potential efficacy, I do not think it is enough to dismiss the concept. There is an extremely limited number of peer-reviewed reports available from which to draw a conclusion. While it is unfortunate that quality improvement has not yet been married to research to any significant extent, it is not surprising. Most of these initiatives are taking place in hospitals that would gain little from investing additional resources to formally study what they are doing. Additionally, methodologically robust QI research is hard! Hopefully more academics will get involved in studying these projects as lean continues to pick up steam.
How was my experience with Lean?
I had a wonderful RPIW week. My team was engaged and supportive, the scope of our tasks was reasonable, and I quite enjoyed doing this sort of thing for a change. The small group work reminded me of my days in Victoria working on team projects for my masters degree. Our team consisted mostly of nurses and care aids from the areas of the hospital that were involved in the processes that we were examining. There was also a patient representative. One of the hired consultants oversaw the work of our team. The rest of the team was composed of employees that were completing their training as “Lean Leaders” and a support person from the health region’s newly formed “Kaizen Promotion Office.” Ultimately, I think that the process changes that we came up with will improve efficiency and the patient experience if they are implemented effectively.
What do I think of Lean?
The rest of this post is solely opinion based on my own experience with Lean in my health region. While it is as anecdotal as the rest of the reports on the internet, I’d like to think that I have somewhat more credibility because I have no conflicts of interest and my background includes years studying leadership and system transformation. The positives and the negatives:
1 – System-wide commitment
It is promising that the provincial government has committed whole-heartedly to implementing Lean. Their public commitment of substantial resources and the long timeline that they have given the effort have made their position clear. Based on the heavy involvement of upper administration in the RPIW week, it seems like there is also buy-in from our institution’s administration group. It will be interesting to see how well this is maintained, but for now I consider it a definite positive.
2 – Accountability
I was unable to observe or participate in any of the accountability aspects of my RPIW. However, I did note that several of my team members were planning to continue our team’s work over the next few weeks to implement the process changes and that there was a system to ensure that all employees received the necessary training. That there was an administrator assigned to “own” the process and be accountable for its implementation (or lack of implementation) was also promising. Having accountability built in to the process is a definite plus.
3 – Excitement
The excitement of the participants during the reports on their teams’ activities on Friday of the RPIW week was palpable. There was smiling, there was laughing, there was the feeling that we had all been a part of doing something good. That energy is the single biggest reason why I think this lean thing has a shot. The facilitators did a fantastic job of celebrating the successes of the teams. While I have no evidence to confirm this, I think the majority of the participants left as believers in the Lean process and will do their best to implement their own changes and support the work of future teams. In my mind, this is the beginning of the culture changes that Lean will require to take it from fad to fab.
1 – Japanese Terminology
While I appreciate that Lean originated as a Japanese methodology and that this using Japanese terms pays respect to that, I do not comprehend how it was okay to change the name of the system (I’m pretty sure “Lean” is not a Japanese term) but not the other important words. I also understand that some of the words do not have a simple English equivalent. In this case, I’m okay with preserving the Japanese name. However, many of them do.
For example, in Lean “waste” is known as “muda.” During RPIW’s people in brightly colored t-shirts wander around and point at things saying “Muda,” “Muda,” “Oooo, Muda!” when they find inefficiency. To the outsider this makes no sense. They see their colleagues walking around speaking Japanese and think that this whole “Lean thing” is “pretty strange.”
Why does this matter? I think that it is important because the more foreign something seems the more difficult it is going to be to get everyone in the system to buy-in. Prior to participating in an RPIW I had no idea what they were talking about. Had they pointed and said “Waste” I would have agreed. Instead I looked at them funny and wondered why they were wearing such colorful t-shirts (I would describe ours as fluorescent orange).
Having two words for the same thing is “Muda.” Let’s Lean this up, use the English words where possible and, in doing so, make Lean more accessible to the many people that have not done an RPIW and do not speak Japanese.
2 – Japanese Sensei
The introduction and conclusion of the RPIW week included a speech by a Japanese Sensei that was translated for the crowd. I am unsure why this is still necessary when Lean has been implemented effectively in so many north American hospitals. Surely, these successful hospitals have trained masterful Lean leaders that could give us a speech in our own language. And their flights would be cheaper too.
Again, while I realize that the Japanese invented Lean, I think these speeches would have been more effective given to us in English by someone with extensive experience with Lean in healthcare that better understands our context and culture. Just because Canadians invented hockey doesn’t mean all hockey coaches need to or should be Canadian. Lean is at a point where there are many experts capable of coaching and I suspect that a controversial change message would be better received coming from someone that we can easily relate to.
3 – Training Outsiders
While this was less of a problem on my RPIW team than some of the others, I noted that each of the RPIW teams seemed to have almost as many “outsiders” as they did employees involved in the processes that were being examined. By outsiders I do not mean the consultant or support people, but individuals participating as part of their training as a Lean leader or who were brought in from other health regions or organizations to “experience Lean.” While I recognize the need to include these individuals to help spread the work on Lean that is being done in Saskatoon across the province, I think their involvement limits the success of the interventions. This is problematic as if the RPIW’s are unsuccessful the involved participants are likely to be turned off of Lean and the development of a “Lean culture” will be inhibited.
I think outsiders inhibit the success of these RPIW’s in two ways:
-They do not understand the process or the implications their changes will have on the people involved. This could lead to changes that the employees involved with not be open to. Some would argue that a set of “fresh eyes” looking at a process will see things that the people involved will not. I would agree with this statement, but it seemed to me that there were too many sets of “fresh eyes” in some of the groups and not enough of the employees that are going to be able to sell the process to their colleagues when the outsiders leave.
-The entire premise of Lean is about engaging the employees that are involved in the process to improve it themselves. This is important because top-down changes are met with much more resistance bottom-up changes. Additionally, involving more of the employees (as opposed to more outsiders) would allow those involved to sell the changes that they have made to their colleagues during the implementation phase when they are back working in the new process.
Conclusions on Lean
So is it a fad? Or a healthcare revolution?
I’m going to cop out on this one and say that I think that it has the potential to be both. If the government of the day (or even its mood) changes and commitment to Lean wavers, I expect that any gains that have been made will quickly be lost. On the other hand, if institutional commitment is preserved and reinforced through personnel decisions, strong accountability measures, ongoing demonstration of improvements, and financial support, I could see Lean becoming entrenched into the culture of our hospitals and improving both efficiency and patient care over the long term.
In the end, I offer the same thought on Lean as I did when a nurse asked me about it when it was first announced:
Nurse: “What do you think of all of this lean business?”
Me: “I think it’s better than what we’re doing now.”
Nurse: “What are we doing now?”
Me: “I have no idea.”
Thanks for reading! If you think this is worth a read please share it on facebook, tweet it, retweet it and e-mail it to your friends. You can follow my blog through the many ways outlined at the top of the column on the right. Within the next couple of weeks expect to see a new medical post on agitated patients as well as a couple of requested mentorship posts that I haven’t gotten around to writing yet. Author recruitment efforts have also yielded a few leads and there may be some “guest posts” from potential new contributors/partners up soon!
Peer Review: Dr. Mark Wahba & Dr. James Stempien
Addendum (15/3/14): Recently the NDP has been attacking the cost of the Lean program in Saskatchewan. As noted above, I do not think this program is perfect, but I think that’s the wrong aspect to criticize. To put the $40 million that is being spent over 4 years ($10 million/year) into perspective, that is 0.2% of Saskatchewan’s $4.84 billion healthcare budget. I do not think that is an unreasonable amount to spend on quality improvement.