Method to Lean-ness: Big Benefits Only Possible from Big Changes

By Matt Skoufalos

In the endless search for cost savings and process improvement in health care, one of the more popular areas of interest to emerge within the past 20 years is lean methodology. Credited with driving nearly $100 million in cost savings at the UMass Memorial Health Care System and a turnaround of more than $127 million at Denver Health, the idea of continuous process improvement can return anywhere from three to nine times the cost of investing in it. Results like those are head-turning, but experts in the field say they’re only achievable by those who are willing to commit to full-scale system change. In the age of larger and larger health systems, the scope of the rewards that are possible may be equaled only by the size of the institutions that take them on.

John Toussaint, CEO of Catalysis Inc. in Appleton, Wisconsin, said much of the thinking associated with lean methodology is often incompletely expressed, misunderstood or adopted piecemeal. There is no implementation of lean principles in that the approach doesn’t have a discrete end or a single execution, he said. Rather, it is an ongoing continuous improvement process that can take a variety of forms as it’s absorbed into institutional culture.

“You never really ‘implement’ lean,” Toussaint said; “you use the principles to, over time, change the way you think about your business. It works really well, but it’s not as easy as it sounds.”

The concept of lean methodology emerged into Western consciousness from studies of the Toyota automotive production system in the late 1980s, but it didn’t find its applications in health care until some 20 years later. As Toussaint notes, “nobody really knew if you could use the principles of great manufacturing companies and apply them to health care.” What its adherents did codify was a core set of principles for the identification of waste in production systems, and suggested they might have an application in the field of health care.

As outlined by Sorin T. Teich and Fady F. Faddoul in the April 2013 edition of Rambam Maimonides Medical Journal, these areas of waste are:

1. Overproduction – producing something in excess, earlier, or faster than the next process needs it.

2. Inventory – the cost of managing a large supply inventory may not be obvious at first glance; beside consumption follow-up and space required to store, there is a need to follow expiration dates and to constantly ensure that the items in the inventory are not technologically obsolete. It was already shown that the overall cost of smaller and more frequent shipments is lower than a large-volume purchase for which a discount was provided.

3. Motion – a lot of walking waste can arise from poor design of the working area.

4. Transportation – in health care this can be evident when moving patients, lab tests, information, etc.

5. Over-processing – there are times when material provided to the customers (patients) mandated by regulations can be confusing. For example, multiple insurance claim forms, including ones that are not bills, can confuse the inexperienced “novice.”

6. Defects – there are many examples for these defects that can be related to poor labeling of tests, incomplete information in patients’ charts or in instructions provided to referrals, etc.

7. Waiting – there is not much need to explain why waiting a few hours in line is a wasteful activity.

8. Under-utilizing staff – under-use is not only time-dependent but also involves deeper levels such as not sharing knowledge or not taking advantage of someone’s skills and creativity; under-use typically shows in hierarchical structures and not using teams.

Addressing system issues like these doesn’t start at the manufacturing floor, however – it starts at the C-suite, with principles, behaviors and systems. Toussaint said most institutions gloss over in their approach to going lean, “and that’s why they have their problems.”

“Lean has a toolbox, but we underline sustainable behaviors related to the method,” he said. “We’re talking about the change of the culture of the organization. Where the leadership really understands the difference between tools and cultural change, that’s where you get the breakthrough types of results.”

Leadership style and actions in a lean company are “quite opposite” the style and actions in a traditional, autocratic health care system, Toussaint said: instead of telling people what to do, lean principles are focused on building systems that deliver the desired results every time. In a health care industry that has multiple levels of senior and executive management, it often requires banishing egos from positions of influence in favor of wholesale system change. That’s not easy to achieve without a top-down commitment to certain leadership styles within the broader framework of an organization.

“For lean principles to accomplish a complete transformation of a complex organization, that’s going to be very difficult to do unless the leadership is committed to making the personal change that’s required,” Toussaint said. “Where we see failure is where the top leadership handing it off to someone else.”

The challenge of shifting the thinking at the top of an organizational pyramid is also compounded by the fact that many health care CEOs don’t stay with a company long enough realize the potential of lean principles. Building excellence is a continuous goal, and required consistency at the top over a period of years to drive the system changes that lean principles can yield, Toussaint said. Further, with the constant shuffling of leaders, each new appointee implements a flavor-of-the-month style “versus being committed to this journey of excellence,” he said. And the promise of savings or efficiencies that lean thinking offers are often sold by consultancies who look to drive short-term gains among their clients and then cash out.

“Most organizations try to skip the behaviors, principles, and systems” because many leaders believe “change is great as long, as I don’t have to,” Toussaint said. They’ll say, “Why don’t we just open the toolbox, get out a couple of tools, and leave it at that?”

“I think a lot of people are in that boat now and they need to step back and deeply reflect on what they’re trying to accomplish,” he said. “If they’re working to build capability to identify and solve problems every day, they need to back up and examine these core elements of organizational change.”

Toussaint has identified five key personal changes that leaders who seek to drive a culture of improvement may adopt in order to realize the best results of lean methodologies. They are: willingness, humility, curiosity, perseverance and self-discipline.

The first of these, willingness, means that leaders must face the same critical eye with which they regard the entirety of the institution, assuming responsibility for “poor patient outcomes, as well as staff and physician burnout,” Toussaint wrote in an August 2017 article.

“To facilitate willingness, we encourage leaders to commit to 10 minutes of self-reflection weekly, telling them to ask themselves, ‘What in my actions this week led to better thinking on behalf of my team about problems?’ ” Toussaint wrote. “Did my questions unleash the thinking capacity of my team, or did I blame them for not following up on my specific ideas?”

Humility involves leaders knowing when to defer to another member of the team, especially if their expertise exceeds those of the people above them in the institutional hierarchy.

“Effective leaders know they do not have all the answers and are willing to ‘go see’ – to be present where the actual work is done – and to respect workers by asking open-ended questions and seeking input,” Toussaint wrote. “Leaders should therefore proactively examine their interactions with others and ask themselves, ‘Did I ask questions that elicited the best thinking of the person or team with whom I interacted? Were there implied answers in my questions?’ ”

Curiosity requires a genuine interest in problem-solving over dogmatic processes; again, being willing to “go see” the interactions at different organizational levels.

Perseverance requires the ability to believe “that no problem is unsolvable,” he wrote; it speaks to “psychological resilience and the persistence to attack any personal problem,” which again builds on the concepts of humility and willingness.

Leaders can stay true to the course of continuous improvement by opening themselves up to criticism and being able to receive honest feedback from an objective observer.

Finally, self-discipline involves the idea that leaders follow the same systems they instill for their entire institutions without absolving themselves from criticism. This approach “reduces second-guessing regarding what others need, allows for better-informed decision-making and problem-solving on the fly,” Toussaint wrote.

Without leadership, discipline, and support from the top down, an organization can’t really drive the lasting changes that sustain the benefits of being lean, said Dennis Delisle, an adjunct assistant professor at the Thomas Jefferson University College of Population Health in Philadelphia, Pennsylvania.

“Someone who doesn’t understand anything will challenge the hard-wired assumptions about why things are the way they are, but you have to understand people who work the process, because they are the experts.”

Delisle said that connecting the personnel of an institution to the work they do and the people with whom they interact helps identify the problems that lean thinking can correct. To identify the things that aren’t working requires understanding the patient experience at every stage of his or her journey within a system.

“If you go into a process, it’s understanding that process from everybody’s perspective who touches the patient, or a component of the process,” Delisle said. “You might talk to a triage nurse, attending physician, the charge nurse, the registrar, the environmental service nurse. Based on the patient’s experience and input, it starts to really form where opportunities are.”
The process of identifying those hiccups within the system subsequently reveals “the highest opportunity to solve the problems,” Delisle

said. When staff members throughout the institution are cultivated to recognize these issues, they’re also often inspired to ideate sustainably solutions to the same problems more so than a consultant who isn’t native to the institution, he said.

“Someone who doesn’t understand anything will challenge the hard-wired assumptions about why things are the way they are, but you have to understand people who work the process, because they are the experts,” Delisle said. “Lead with questions, not solutions, because nine times out of 10, a process expert will come up with a much better solution than you would because they understand what the problems are that they’re trying to solve.”

When Jefferson recently underwent a large EMR implementation, Delisle’s job was to speed the process by leveraging “purpose, process and people,” he said: managing governance committees, team and departmental meetings, and empowering staff to solve problems at their own levels. By supporting staff in doing their own jobs and providing clarity around their roles and responsibilities, the professionals with which Delisle worked were able to reduce unnecessary meetings, tasks and activities – the waste within the system.

These tools can be used to target specific aims – lowering rates of hospital-acquired infections, improving the quality of health outcomes – only “once you understand what you’re trying to do,” Delisle said. After identifying these aims, it becomes easier to streamline activities and add tasks in pursuit of a common goal. But as lean adherents search for ways to drive ROI from the adaptation of those principles, qualitative results are frequently easier to identify than the hard savings or throughput numbers around which the data-driven industry typically revolves.

In short, the perspective of seeking ROI can be lost in the opportunities and benefits that come from building a more sustainable institutional culture of excellence, Delisle said; much of the tangible results that follow are related to building better systems that then produce better results.

“When you have clarity around your purpose and you align processes, workflows, goals and responsibilities, expectations, the organization will become inherently more efficient,” Delisle said. “That does have an ROI because you’re able to do better with less, not just more with less. Often [observers] look for hard-dollar savings on the budget when there’s a lot tied to empowerment, which leads to retention and recruitment: soft benefits that you can extrapolate as well as operational efficiencies that are quantifiable.”

“If you don’t start from the base of what is the philosophy you have towards a lean management system, it’s really just a collection of management tools that you apply ad hoc as wanted or as needed,” he said.