Lean HealthcareThe Dark Side of Lean

Giving Lean Healthcare a Bad Name

By Jon Miller Published on June 5th, 2006

We’re giving Lean healthcare a bad name in Jean’s world. Jean is a nurse at a hospital where Lean healthcare practices based on the Toyota Production System are being implemented. At Jean’s hospital, it sounds like they are making a mess of it. She found this blog through the article What’s So Bad About Assembly Line Healthcare? and posted a comment explaining in her terms exactly what is so bad about Lean healthcare.
She also agrees with Darius Mehri’s assessment of Lean work as dehumanizing in her comment posted today.
Since Jean’s hospital is not a Gemba client, we can not take sole responsibility for this awful experience Jean and her peers are having with Lean healthcare. However, I think WE all can take responsibility to ensure that when we practice Lean it is in ways that respect people, and that we have courage to speak against the use of Lean in ways that does not, as Jean is.
Healthcare in the U.S.A. is in enough trouble without Lean implementations creating hostile work environments for nurses, physicians and staff at hospitals. We need the experience and problem solving skills of everyone if we are going to fix healthcare. Any of us who work as consultants in Lean healthcare need to reflect on the work we do and ask ourselves if we are guilty of giving Lean healthcare a bad name in Jean’s world.

  1. jean

    June 6, 2006 - 8:01 am

    I appreciate your response and the willingness to promote lean. From the nurse’s perspective, patient care is not an assembly line process and while lean has and can offer worthwhile suggestions to elevate the quality of care at a reasonable price, your logic is flawed on several issues. Lean and its cadre failed to recognize those practices in place that were good. Many acts are established through practice as a better way to do things because they evolved as the practice of nursing as evolved with its own set of standards for nursing care. Instead, we were made to feel that people from the outside, who have their own power issues, were brought into make radical changes because they know more about patient care than nurses do. The reason healthcare costs are out of control is not because were are sloppy in our routines. It is because managemnt is not only top heavy and narcisistic, it is consumed by profit and not really involved in nursing. If lean really wanted to eliminate waste and start reducing health care costs , it might question and examine the extraordinary amount of plastics and paper products that are used by manufacturers of medical products. The nonrecyclable waste is staggering. We all share the guilt in this country addicted to oil and the medical vendors who suck up these resources in the name of pretty packaging. Lastly, our hospital failed to recognize the value of input from the most common worker on up who toil daily at a task and can tell anyone who asks how it can be done cheaper and faster with little change. And while you distance your self from the bad lean enforcers and well paid consultants who have a mortgage payment due, you fail to realize that you all wear the same uniform. How well are you hired consultants screened?

  2. Jon Miller

    June 6, 2006 - 8:35 am

    Hello Jean,
    I meant no disrespect to your profession or to anyone working in healthcare by the term “assembly line healthcare”. I was merely trying to call attention to the good work being done with eye surgery in India.
    Your point that nursing is not where the focus of cost reduction in healthcare should be is a valuable insight. As consultants, we are sometimes guilty of relying on our “tried and true” approach instead of taking time to fully grasp the situation based on the big picture.
    Most Lean consultants in healthcare today are coming from a manufacturing background, so this is understandable though not excusable.
    We’re a small company and we grow only as fast as we can find the best people possible. We screen very carefully. With all due respect, we at Gemba are not bad enforcers. We really don’t wear the same uniform as the consultants at your hospital. You would have to meet us to know.
    Thank you for opening our eyes.

  3. Matt

    June 6, 2006 - 10:49 am

    I feel compelled to respond here, because I have witnessed a couple of lean efforts at hospitals from afar. I am not in healthcare, but in engineering and manufacturing. However, my wife is an MD and my sister is an RN, and I watch the lean healthcare efforts carefully, because I am trying to learn more about implementation in such a complex environment.
    One thing I noticed in Jean’s comment is typical of lean efforts in most hospitals and most other companies. That is, when lean is introduced, nearly every party/group denies ownership of the “big” problems, and then points to other groups who “need more improvement than we do”. That may or may not be true, and I cannot judge Jean’s situation. However, it is imperative that each individual and each group accept the fact that they can improve, and work from there. Each group needs to get their “house” in order before addressing the problems of other groups.
    The successful lean implementations (especially in hospitals) have put as a priority to bring all of the groups together toward a common goal, and have been successful because the leaders have carefully and inoffensively removed the “blame culture.”

  4. Jim Sady

    June 6, 2006 - 11:00 am

    As a comment to this posting I would suggest looking into alternatives to Lean consulting. There are a number of Lean training packages that provide a great alternative that allow nurses to use their healthcare experience while getting the Lean consulting tools. I personally think it is a great combination and takes care of the outsider issue.
    Best regards,

  5. Mark Graban

    June 6, 2006 - 9:01 pm

    Any consultant, whether they come from manufacturing or not, should understand the lean/TPS concept of “respect for people.” Any consultant who doesn’t understand that should be thrown out on their ear, from a factory or a hospital.
    When I do work in hospitals, we emphasize that lean is about improving things for patients and employees. It’s about reducing waste and solving the problems that plague nurses each and every day, finding real root cause solutions to put those fires out for good. Lean, done right, gives nurses more time to provide direct patient care, to “let nurses be nurses” and they love it.

  6. Jim Sady

    June 6, 2006 - 9:20 pm

    I agree with you 100% that is why I support using these tools. Again, it comes down to the most appropiate people to deliver this knowledge and this should be within the professional field.
    Best regards,

  7. Bill Waddell

    June 6, 2006 - 11:17 pm

    The situation is not unique to lean healthcare. Mark and I have both written about companies that have done pretty crappy things in the name of lean. Sometimes it is the product of a self proclaimed lean expert/consultant who is wholly unqualified.
    More often it is the result of senior management using a few lean tools to do the same nonsense they has always done – namely, to put pressure on front line people to do more work in less time, rather than to eliminte legitimate waste.
    Whenever this happens, it leaves the people in the organization with a sour taste for lean and sets lean back. Jean’s experience has nothing to do with lean’s applicability to healthcare or anything esle. It is just another example of poor management.
    Jean wrote “If lean really wanted to eliminate waste and start reducing health care costs …” Jean, lean really does want to do precisely that. It is your management that has a different agenda.

  8. jean

    August 12, 2006 - 4:18 pm

    Since your kind response in June, my workplace has descended into a kind of black space. Without telling any family secrets, those who did not “heil” lean have found other employment. I think we, as a staff are beginning to feel like chicken pluckers in the Golden Plump Place where Faster is always better. The morale in our place of work has been sliding down and has recently picked up speed as the true depth of lean is being revealed to us. I do not know what Toyota does to halt the subliminal disconnect of hearts and body that is happening in our place. Last week a co-worker said she felt like an evil black vapor was loosed upon our place. We are all good nurses and are dedicated to the healing arts. We cannot figure out what we did to warrant the pattern of abuse, in the classic description, that mocks what we have spent our lives preserving. Yes, it is pitty pat to say that malcontents focus blame on sometning else rather than face up to the challenge of lean. I say that they simply do not understand what is happening. We all now would like lean to go away. As it is failing in our place, the pressure to make it succeed lest the venders of lean lose business selling the “concept”, the pressure to “do it” has increased so many fold that a day at work is like that picture “The Scream” for eight hours. There is no joy in the hallways, no laughter (I suppose laughing slows down the Line), no one wants to stay late or do anything extra that use to come just from the joy of working in an Operating Room. I do not know where this will end. I only have three more years until I can retire. It is going to be a long three years.

  9. Simon

    September 24, 2006 - 4:26 am

    Dear Jean, I was distressed to read about your experience at the hands of the “mean lean” brigade. This is a salutary warning for those in healthcare who desperately want the golden eggs but don’t understand how to get them. Six years ago I started a service improvement initiative based on three goals – what I call the Three Wins. First, the quality of care that the patient gets; second the quality of life of the dedicated professionals (like you and me) who convert cash into care; and lastly the performance. What we found was that focussing on improving the working environment and job satisfaction were critical – get that right and quality improves and get both those right and the savings start flowing. This is how Toyota did it and this is how we did it. What is interesting is we didn’t hear about “lean” until after we had done it. I don’t use the term “lean” – I use the term value stream design because that is what we did. If what you have said is the general feeling of the majority of staff in your organisation then the “lean” transformation will fail – just as many others have failed before if they have been driven top down and by executives who have not changed their mindset from “slash and burn” thinking. Value stream design is a mindset change and a set of methods and tools; you need both – either alone will not work.

  10. Jean

    October 1, 2006 - 2:14 pm

    Thank you for the response. I have decided that I no longer want to be a victim grumbling about the oppression, depression and suppression. I just do not know where to start.

  11. Patrick

    November 30, 2006 - 6:46 pm

    I found Lean to be a transformation of spirit, one of focus on our patients and doing all that we can to see they receive good value. Successful lean implementations see that 30% to 40% of health care processes are wasteful and that time with the patient can be improved by thoughtful Kaizen events that allow the employees to improve the workplace by eliminating that waste. It sounds to me that Lean was imposed on Jean, not brought to her in a caring and compassionate way. In a successful lean implementation, she should be gaining more time to spend with patients. Please don’t let one bad experience sour you against a tool that values patients if implemented correctly. Jean, do a search for Lean Virginia Mason or Lean Park Nicollet and see what successful implementations mean for patients. Nurses are one valuable part of a huge process that patients find themselves in.

  12. jean

    January 13, 2007 - 6:58 am

    Any process that reduces waste is good. I failed to read in any Lean Park Nicollet sites how they supported staff and kept morale up during rapid changes. In any process, Lean included, great stewardship of staff should be primary. After all, bed side nursing will never be a lights out factory no matter how reduced the surroundings.

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