A few weeks ago while receiving physical therapy for an injured rotator cuff, Martina, my PT asked what I do for a living. I said I write books and do lectures on quality lean management, and so on. Is this hospital involved with the lean movement, I asked? Nodding, she replied impishly, "You said a bad word."
Lean got a late start in healthcare, but by now is active in medical centers throughout the United States, Canada, the U.K., and other countries. Healthcare has imported lean's methodologies from the manufacturing sector, which in the 1980s had imported just-in-time (JIT) production from Japan in the 1980s, then in the 1990s renamed it lean manufacturing. Wrong-headed tendencies in lean implementations in the industrial sector are, unfortunately, being carried over into healthcare. Sensible corrective measures are needed to ensure that lean in healthcare is steered toward where it has its greatest potential-in serving the patient-rather than merely as a methodology for drumming out wastes. By redefining lean in patient-serving terms, lean gains stature throughout the healthcare community and beyond, such that it may become ingrained, rather than another passing management fancy.
Over JIT/lean's three decades of existence in the West, it has been re-defined, appended and amended to the point where, in some cases, its least important features have risen to prominence over what is meaningful to customers, clients, patients. In manufacturing this is somewhat understandable, given that customers are largely out of sight, out of mind. Healthcare, on the other hand, is customer-facing. These differences should offer advantages in lean's application in the healthcare sector, as I'll attempt to explain.
Although lean is generally heralded as a success story in manufacturing, my own many-year hard-data research (the "leanness studies") reveals dominant patterns of good progress followed by back-sliding. Why lean implementations tend to falter centers, I think, on temporal high-level attention to it. Manufacturing executives, induced to seeing lean in operations terms, delegate it down the hierarchy. The lean community has failed to make it clear that lean's main effects are not operational so much as competitive and strategic.
That is, lean's primary role and outcomes are delivering ever quicker, more flexible, higher quality, higher value response to customer needs, demands, orders and usage. Rather than seeing lean for these essential effects, industry has been persuaded-by latter-day books, articles and consultants-that lean is mainly about reduction or elimination of the "seven wastes." In turn, healthcare, too, has adopted waste elimination as lean's mantra. That won't do.
Waste reduction is poorly cast as lean's essence. It is one of lean's tools for studying processes, but not one of the key methodologies that change the processes from fat to lean. The latter include product-family/customer-family organization of processes (e.g., into flow-oriented cells), quick setup, small lot sizes, kanban, quality at the source, cross-training and job rotation, continuous replenishment, cross-docking, trouble lights, lean accounting and more.
Waste reduction, on the other hand, is akin to spaghetti diagrams, the five whys, value-stream mapping, and value-add/non-value-add analysis-all worthy methods but that look at, not change the process. Twenty-five years ago, much less time was spent studying and analyzing processes; instead, companies extensively trained employees in product-family/customer-family organization and layout, quick setup, and so forth, then said go do it.
In getting it done, lean delivers quick response-short waits and waiting lines-as the dominant effect, with flexibility and quality as close partners. Given the norm-that customer demands are highly variable, both in type and quantity-quick response requires flexibility so as to be immediately ready for the next order or customer. Lean provides that through redundancy in the form of extra equipment and people; or fast changeover of equipment and a cross-trained or on-call work force. Fast response depends equally on high quality. Otherwise, response is slowed or stopped for rework. Or abandoned entirely: the customer went elsewhere for service, or the patient died waiting. Value, in the eyes of the customer, may be seen largely as the sum of quick (time is money), flexible, high-quality response.
There are reasons why, over time, waste reduction has been elevated to its high status among lean methodologies: It is easily taught to operations people, who can readily recognize and measure the wastes, and devise ways to reduce them. And it works: It does make operations leaner, including quicker and more flexible with better quality and value.
But if lean is to thrive and survive, waste reduction cannot be the driver and must be downgraded to its proper role as a useful enabler. In its place, upgraded to prominence, is lean defined and promoted for its competitive and strategic purpose, namely, to deliver flexibly quick, high-quality, high-value service everywhere along the value chain to final using customers, clients, or patients. Seen this way, lean positions itself to become a permanent strategy of the organization.
Martina, my physical therapist, had a not unusual reaction when I mentioned my interest in lean. To many health professionals, lean in its waste-reduction guise may be viewed as a pedestrian imposition, and that their training time would be better spent on patient health matters. At my next appointment I'll explain to Martina what lean really is. Maybe she'll pass that information along to her colleagues.
Richard J. Schonberger is an independent researcher, author and speaker from Bellevue, Wash. He is the author of Best Practices in Lean Six Sigma Process Improvement: A Deeper Look . . . with Telling Evidence from the Leanness Studies.