confessions of an eclectic pragmatist

Let's get serious about waste in healthcare


With Lean back in the news, and taking center stage during the election,  I think it's time we talked about it. For me, the most disheartening part of the political discourse is the taking and defending of entrenched positions. Where we need nuance and subtlety, we get knee-jerk responses designed to provoke reaction rather than invite curiosity. Perhaps we can emerge from our corners to take a look at Lean with some hopefully useful rather than reactionary critiques.

Lean, in the classic sense, is mostly about waste and it's very popular today to discuss waste in the context of healthcare improvement. Much of the time, we are discussing the classic wastes identified by Taiichi Ohno of Toyota: transportation, inventory, motion, waiting, overprocessing, overproduction, and defects or errors. Or, if we don't like the Lean approach taken in Saskatchewan, we talk about the waste of money in hiring consultants and traveling out to see what other industries do and the "ridiculous" notion that something from car manufacturing could apply in healthcare - which kind of misses the point for me. There is much to critique about the path we've taken, but not this. Healthcare is rife with opportunities to identify and drive out these classic forms of waste and we are fools if we think we can't learn from other industries or outside perspectives.

So what would I challenge? At least 3 things:

1) Despite all the talk to the contrary, we've taken a very mechanistic "Lean as tools" approach. If you actually take the time to understand what Toyota did, you will realize that it is a management approach more than a set of tools that made the difference. People avoid the management side, it's messy and uncomfortable and challenges those in positions of power to change just about everything they do. Mark Graban has created a fantastic Storify that summarizes some key Deming insights into leadership. My personal favorite: "Management by walking around is hardly effective either. The reason is that someone in management, walking around, has little idea about what questions to ask, and usually does not pause long enough at any spot to get the right answer" - turns out "going to gemba" isn't so simple after all. 

2) We overestimate Lean's applicability in healthcare. We are not very sophisticated in our understanding of how and why Lean works in healthcare and where and why it might struggle. For me, Lean works nearly perfectly to address areas of service and care with high throughput, highly repetitive tasks, and low involvement or engagement of the patient, client, or family. Think the lab, materials management, admission, surgical processes like room turnover, imaging...for me these are the places to take a Lean approach with some confidence. 

Robert A. Gardner’s The Process-Focused Organization: A Transition Strategy for Success, ASQ Quality Press, 2004, pages 28-31.

Robert A. Gardner’s The Process-Focused Organization: A Transition Strategy for Success, ASQ Quality Press, 2004, pages 28-31.

But what happens when we try and apply these methods in situations where processes are more subtle and involvement or engagement of the person receiving the service is high? This classic diagram from ASQ highlights the issue.

In much of healthcare, the customer and what is being transformed in that middle section are one in the same. This has some serious implications and is a very special situation compared to other service industries, never mind manufacturing. I could be wrong, but I think healthcare, social care, and education are unique in this matter. We also tend to totally ignore the need for processes to be adaptable (point #3 under process evaluation in the diagram above) - in the focus on reliability, we miss that resilience is often more appropriate in complex systems. 

3) We tinker at the margins by avoiding what I will call the wicked wastes. Similar to Zimmerman's wicked questions which are used to expose the assumptions we hold about an issue or situation in Complex Adaptive Systems work, wicked wastes surface potentially challenging differences in our mental models. Wicked wastes can't be designed out without some seriously hard work aka long and difficult conversations.

This is a work in progress, provoked by Paul Batalden, and likely incomplete, but let's consider some potentially wicked wastes:

  • power structures - that's right, the good old hierarchy. The deeply embedded mental model that preserves the concept of the "physician's lounge", maintains processes designed to keep patients and families out of the loop (pay to access your chart, no family in the OR or procedure room), and generally impedes good communication within and across professions and groups involved in delivering health care.
  • cherished myths -  "care happens in the interaction between a single provider and a patient", "the doctor knows best",  "patients and families don't want to be involved in decision making", "if we just try harder, things will improve", "if we just add people, space, resources, time - our quality issues will vanish", "there is one right way to improve"...take your pick
  • an inability to shift our focus upstream - there is an underlying assumption that the structure is right, it just needs it to be faster and more reliable. We continue to pour enormous resources into optimizing the acute care system and ignoring the primary, public, and preventive care system.
  • persistently siloed thinking - organizationally, professionally, but also in improvement methods, we seem unable to get our heads around true integration. 
  • business models that constrain value-based design - direct from Batalden, this one is a it possible that the granddaddy of waste reduction might actually generate waste if applied inappropriately? You better believe it.
  • avoidance of key discussions regarding values conflicts - professional advocacy that clashes with improvement or true patient-centered care for that matter. The tension between espoused organizational values (safety, patient-centered care, collaboration) and observed organizational values (productivity).
  • overuse -  not overproduction which presumes that you are doing more than enough of a right thing but the waste of doing the wrong thing altogether.

I would suggest we approach our very complex challenges in this very complex system with some humility and be willing to bring to bear all the approaches, tools, and strategies that could help - this means being eclectic and pragmatic. And courageous. And curious. I promise it won't be a waste of our time if we try.