A critical look at lean thinking in healthcare

Preceding inter-views had investigated the extent to which hospitals hadfollowed a rigorous philosophy, such as Lean Thinking. Both wish to have it acknowledged that this was aretrospective analysis and that their thinking has continued todevelop; moreover, they would stress the importance of achange of mindset in adopting such methods. A pictureemerged in which both saw that PDSA plan, do, study, act was the only improvement methodology that had bedded downto any extent in the NHS culture. PDSA is a traditionalmanufacturing improvement method in which new ideas arefirst planned P then implemented, or done D , studied S andthen applied A , tested further or discarded, depending on thefindings.

Interestingly, both improvement specialists articulated theirown methods in terms of a central, strongly heuristicmethodologyconsistent with PDSA. However, when it cameto deciding what measures to take in the next PDSA iteration,each would consider the next move from a variety ofperspectives, using Lean, other philosophies, and trends show-ing up in statistical process control charts. In summary, there is evidence of widespread familiarity withLean, and accumulating evidence of benefit when it is applied,especially in the areas of safety, delay and cost-effective delivery ofcare.

A Methodology for Supporting Lean Healthcare

However, there is evidence that even those advisingclinicians and management would apply their own judgementwhen selecting Lean approaches alongside other approacheswithin a broader methodology, such as PDSA. Ironically, onemight argue that this is exactly what Ohno6 originally advo-catedbut such a discussion is beyond the scope of this paper.

Hopp and Spearman1 p. Qualitatively, the industrialimprovement scene is characterised by champions who promotemethods and promulgate success stories within an appealingintellectual framework, requiring buy-in and commitment toimplement change within that framework.

As Hill andWilkinson25 observed with respect to TQM, the original gurusof quality management have been long on prescription butshorter on analysis and, moreover, have differed amongthemselves. The uptake of improvement methods into healthcare has notalways been smooth. Blumenthal and Kilo26 reported on the UShealthcare scene: It remains too easy for health care organisa-tions to talk a good game. Moreover, the messages ofmixed methods being combined under a single banner, ofrhetoric winning over reality, and a mixed message over impact,recur in that literature, too.

Many of these general observations resonate strongly with thehealthcare scene we have just described, where there is strongevidence of the activity of champions, the role of success storiesand the promotion of how to guides. The historical experienceof improvement methods in industry and healthcare raises someconcerns about the extent to which what is hailed as Lean isgenuinely Lean in practice. Finally, we must recognise that there isa tension between the rigour of an academic approach especiallyin terms of controlled trials and the improvement ideal, whichstarts with what exists in real life and seeks to improve upon thatwithin the context of everyday practice.

Our contention is that the improvement agenda has beendriven by champions and by analogy with the industrial and.


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Figure 1 Pathway of movement of patients through a haematuria clinic from waiting on arrival1 to departure. The intuitive link between valuestreams and patient pathways is compelling, and in fact, it isexactly this link that drove Ben-Tovim et al19 through the studyin which they report their own, successful, improvementprocess. Moreover, examples of benefit are now common.

However, it is more difficult to see exactly what has happenedto the founding concept of value. Given that clinicians havedeveloped many ways of measuring value-type concepts, suchas quality, it is worth examining how the simple concept ofvalue to the customer is faring in the world of healthcare. Thestaggering, global, scale and complexity of healthcare provisionset healthcare naturally apart from manufacturing, perhapsfrom all other service sectors. Although dual lines of authority,clinical and managerial, need not be a unique factor, they arecertainly a sensitive issue at present,29 but it is perhaps in therealm of the customer that differences are most obvious.


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Shah and Robinsons30 classification of medical device usersshows several levels of users, including carers and healthcareworkers, each exhibiting characteristics that might make themanalogous to the customer. By extension, there are many peoplewho might, at the same time and with the same particularpatient in mind, have a role as customer for that product orservice, and hold widely different views as to the value of thatproduct or service.

Alongside the personal customers are thosewho specify or procure31 attempting to buy the best value formany services to achieve the maximum health gain for thosemost in need. A case study is offered to demonstrate the potential forclashes due to different concepts of quality.

In May , one ofthe authors TY ran a workshop on industrial methods in theNHS to explore how a cross-disciplinary team of managers,doctors and nurses might apply improvement thinking. A LeanConsultant was duly hired to gather information, part of whichwas obtained during an observation of a haematuria outpatient.

A Methodology for Supporting Lean Healthcare

The patientpathway is captured in fig 1, and the Lean Consultant timed afew patients through the system see table 1. The clinic starts smoothly, but a queue builds as the clinicproceeds because patients wait to see the Consultant. Both theConsultant and the clinic Manager attended the workshop, anda critical contrast of views emerged as to how best to Lean thesystem, in this case for those patients diagnosed as not havingcancer. The Manager, who came from a nursing background,took the view that the clinic had performed its purpose by thisstage and that waiting time could be eliminated by givingpatients the good news that they did not have cancer andsending them on their way.

The Consultant, on the other hand,felt that the problem of diagnosis remainedeven in the light ofa negative finding for cancerand therefore wanted to ensure afurther consultation, even if this meant a queue building up. One wonders what choice patients might have madeandwhether that choice might have changed with diagnosis. The question of what steps to take to improve the cliniccannot be resolved until the question of value is resolved. Thosewho value smooth and fast throughput will lean one way, whilethose who value as complete a medical response as possible willlean another.

From this case study, it is clear that there are atleast two dimensions of patient-centred value, namely onebased around the responsiveness of the system and another thataddresses clinical priorities.


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  • Lean thinking was used in a highly prescriptive way, limited to the application of shop floor tools , e. Over the years, lean thinking evolved beyond applying Toyota's shop floor tools. The introduction of these principles placed customer value and waste reduction at the centre of lean thinking, but also fuelled the argument that process improvement and customer value came at the expense of working conditions of employees.

    While the use of original lean instruments remains extensive, lean theory nowadays extends beyond its original operational aspects to include human behavioural aspects and the interface between these two. It is now argued that for any lean effort to succeed, both a quality system operational and a quality culture sociotechnical are needed [ 9 , 12—14 ]. Value is defined as the capability to deliver exactly the customized product or service a customer wants with minimal time between the moment the customer asks for that product or service and the actual delivery at an appropriate price [ 11 ].

    Value adding activities contribute directly to creating a product or service a customer wants.

    Non-value adding activities do not and are called waste. Of course, waste needs to be removed or avoided. On an operational level, standard organizing tools like value stream mapping and 5S are available to create value for an overview see reference [ 10 ]. Application of these instruments seems reasonably straightforward and they are discussed in most papers on lean thinking. Using them, hospitals have reduced waste in inventory, reduced waiting times WTs and improved productivity [ 15—17 ]. In some cases, these process improvements directly contributed to better quality care. In better organized wards for example, complications and infections may go down [ 18 ].

    A well-known consequence of improving a single process is that problems shift to adjacent processes. In mental health care, timely out-patient follow-up after in-patient treatment is a well-known problem that causes patients to stay admitted longer, even in well-organized wards. That is why lean emphasizes a systemic, holistic view of process improvement.

    Application of lean thinking may initially focus on improving a single process the ward but needs to rapidly diffuse to the total value system the ward and the following out-patient treatment , otherwise problems are not solved completely and will occur elsewhere in the system. On an operational level, improvements are mainly achieved by reducing unwanted variation in processes. Variation is the degree of difference in the same process when repeated. Some variation is needed: surgical procedures are never done exactly twice; psychologists never have exactly the same consult with a patient twice.

    This is called natural variability. Natural variability is needed to effectively deal with individual differences between patients and their needs and deliver patient centred care. Artificial variability, on the other hand, is related to controllable factors in the design and management of health care systems [ 19 , 20 ].

    Counter-intuitively, artificial variability how we have designed our health care system may have a greater influence on health outcomes than natural variability. McManus et al. The fact that lean tools explicitly focus on removing non-value added activities artificial variability may explain some of the positive results that have been reported.

    A critical look at Lean Thinking in healthcare. - PubMed - NCBI

    Lean interventions have the potential to make jobs more simple and repetitive or turn them into jobs that require more thinking, planning and responsibility. These changes affect those who execute these processes making jobs too simple or repetitive, for example, may lead to resistance and anxiety. Sociotechnical systems theory studies these interaction between social human behavioural and technical elements technologies [ 22 ]. The emphasis on lean as operational, process-oriented concept has directed attention away from these sociotechnical aspects.

    Despite this, the sociotechnical influence of lean thinking on workers has been subject to explicit criticism. Much of this criticism has centred on the question how a technical system that explicitly promotes standardized repetitive work can still be attractive and motivating to workers.

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    A common opinion is that even though lean organizations have some practices that seek to promote worker well-being e. From a sociotechnical perspective, application of lean tools automatically triggers further dynamics. Standardization, for example, makes jobs more simple and repetitive.

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