How Lean methodologies in healthcare can add value and improve the patient experience
Thomas PalopoliInternational Project Consultant at Roche
How Lean methodologies in healthcare can add value and improve the patient experience25 November 2020
Regardless of the industry, the underlying philosophy of Lean does not change: define value and relentlessly pursue perfection in delivering that value
In healthcare, the customer is the patient and the value is the patient’s clinical status and outcome
Within a Lean environment, standardization reduces variation to create a solid foundation from which to improve, which inevitably improves the quality of patient care and increases patient satisfaction
Although Lean methodologies have their origin in the automobile industry, Lean applied to healthcare can improve the patient experience, while eliminating waste and reducing financial costs.
In this insightful interview, Lean expert Thomas Palopoli, shares why healthcare may be the best industry to apply Lean methodologies, how to overcome the greatest challenges in implementing Lean, and 4 key starting steps for leaders who wish to transform their organization to Lean.
Lean: Define value and deliver that value
Regardless of the industry, the underlying principle of Lean does not change: Define value and relentlessly pursue perfection in delivering that value”
HT: What can the healthcare industry learn from the automotive industry when it comes to Lean management practices?
Tom Palopoli: First, it is important to recognize that regardless of the industry to which it is applied, the underlying philosophy of Lean does not change. It always revolves around the relentless & continuous drive to improve the flow of value to each customer through the engagement and respect for those that do the work.
The automotive industry is simply the soil that the system grew and matured. The many concepts, methods and tools commonly applied in a Lean environment, such as “just in time” or “built-in-quality”, are a means to that end and apply to any human effort. From making toast to performing open-heart surgery, the same philosophy applies – define value and relentlessly pursue perfection in delivering that value.
The healthcare industry can learn to establish this drive towards perfection and apply the proven tools and methodologies to incredibly complex systems to achieve brilliant results.
HT: Do you find Lean methodologies in healthcare fit well?
Tom Palopoli: Absolutely. In many ways, Lean fits better in healthcare than it does in manufacturing or other industries. The reason is passion.
It is sometimes difficult to be passionate about delivering value in manufacturing. Sure, you want to provide your customers with the best possible product at the lowest possible cost, but you cannot really compare the passion of those securing bolts with the passion of healthcare workers healing patients.
Lean provides pathways to direct that passion.
Understanding the Lean methodology in healthcare
HT: What are some of the misapplications or misunderstandings of Lean methodologies?
Thomas Palopoli: The biggest one I have encountered is that Lean means less people.
To be clear, you certainly do not want more people performing a task than is required, but you also do not want less than is required. Either way is highly disrespectful to those people, and in the case of healthcare it is disrespectful to the patients we serve.
Quite often I will hear something like, “We are already too Lean, we don’t have enough people!” There is nothing Lean about that!
In fact, the term Lean itself was coined to describe the way Toyota builds cars with less of everything – less parts, less space, less cost, less defects, less steps, and yes, less people. However, that does not mean “less than required to safely and effectively perform a task”. It means they are relentlessly engaging their people to figure out ways to do everything safer and better.
Moreover, if you enlist the entire workforce to eliminate waste and improve flow you must not lay people off as a result. Otherwise, they will (rightfully) never participate and engage, and remember respect for people is at the heart of any Lean enterprise.
Respect for people is at the heart of any Lean enterprise.”
The impact of Lean methodologies in healthcare on the patient experience
HT: How can Lean thinking lead to an improved patient experience?
Thomas Palopoli: Lean thinking implies the relentless focus on value as defined by the customer. In healthcare, that is the patient.
Certainly there are very complex internal customer / supplier relationships in the delivery of healthcare, but we must never lose sight of the patient as the ultimate customer.
While traditional thinking often gets us focusing on how to facilitate waste in the system, such as providing comfortable chairs and a nice television in a waiting room, the Lean enterprise is relentlessly trying to eliminate the need for a waiting room altogether!
The Lean enterprise focuses on ensuring healthcare providers have what they need, when they need it, where they need it so they can respond immediately to patient needs and dedicate their time to healing them.
Consider the typical emergency room visit. How much time do we, as patients or family members, spend waiting, wondering and worrying rather than being treated?
The Lean enterprise laser focuses on why we are there and works to safely and systematically eliminate everything else – to continuously pursue perfection in that specific care delivery model.
That is improving patient experience at its utmost.
HT: Does Lean potentially eliminate the warm patient experience?
Thomas Palopoli: If applied correctly, the exact opposite is true. I would much rather a nurse spend time holding someone’s hand in comfort or properly communicating to worried family members than searching for supplies that should be readily available.
That is often a misconception – Lean does not create robots, Lean facilitates and expands creativity and compassion.
Many Lean tools and methodologies are designed to eliminate frustration and time wasted so you can focus on healing others while ensuring a warm patient & family experience.
The link between Lean methodologies in healthcare and value-based care
HT: The Lean methodology puts the patient at the center and aims to remove any non necessities that get in the way of giving the patient what is needed, when needed. This is very similar to the aims of a Value-Based Healthcare (VBHC) model. How would you describe the link between Lean and VBHC?
Thomas Palopoli: The first step in creating a Lean thinking organization is to define value from the perspective of the customer. The entire organization needs to be relentlessly focused on improving the flow of that value to each customer.
For healthcare, that customer is the patient, and the value, at the very foundational level of healthcare delivery, is the patient’s clinical status and outcome.
VBHC is the effort to align the healthcare delivery model, including financial incentives, with delivering these outcomes and ultimately to keep people healthy. This may seem obvious and that it should already be the case, but the healthcare industry is a very complex system, with multiple reimbursement models, regulatory requirements and sometimes conflicting agendas and incentives.
Unfortunately in this complex web of reimbursement models and associated incentives, what the patient values most is sometimes misaligned or even in conflict with the system.
It isn’t that the healthcare providers do not care or do not want to do the right thing for the patients, it’s that the “invisible hand” of these misaligned incentives guides behaviours and care pathways, resulting in waste and reactionary medicine.
For example, let’s say you get paid for each specific procedure you perform. You will naturally (and perhaps subconsciously) look to perform as many of them as you can. There is very little incentive to explore methods to make the procedure itself unnecessary by keeping the patient healthy to begin with.
VBHC works to align those incentives through shifting from volume-based to value-based payment systems. This aligns very well with the Lean business model, where value, as defined by the customer, is at the heart of everything you do. It naturally follows that a Lean thinking organization would work to align the healthcare industry with value as the patient defines it.
The VBHC concept reminds me of something a Lean teacher told me long ago. A traditional lawn mower manufacturing company that is adept at continuous improvement would work to create efficiencies by eliminating waste in their operations. However, a Lean lawn mower manufacturer would do that in addition to developing grass seed that only grows a certain length, eliminating the need for a lawn mower to begin with.
In the same way, a Lean healthcare system would both work to eliminate waste in their healing systems while simultaneously working to keep people healthy.
For healthcare, that customer is the patient, and the value, at the very foundational level of healthcare delivery, is the patient’s clinical status and outcome.”
Overcoming the challenges of implementing Lean methodologies in healthcare
HT: What are some of the challenges of applying Lean in healthcare?
Thomas Palopoli: Ironically, one of the challenges of applying Lean in healthcare is the very passion that also helps so much!
There are often certain personality types that enter the healthcare industry, especially in direct clinical care settings. They are practitioners of a specialized craft and are very independent thinkers and workers. They often have their own way of performing tasks or facilitating processes.
This challenges a fundamental principle required to be successful with Lean, which is standardization. Within a Lean environment, you standardize everything you can to reduce variation and create a solid foundation from which to improve. As you can imagine, this foundational principle can sometimes create conflict and resistance.
I have found traditional organizations sometimes display a culture of what I call, “accommodation and optionality”. For example, some healthcare workers consider established processes, such as bedside reporting, to be at least partially optional.
There needs to be mechanisms in place to review and continuously improve established processes. That’s not to say that those that do the work should not be involved in developing the standards – they absolutely should. However, once established, it is important that standards are followed. Otherwise, we really have no idea how effective the standards are and improvements are very difficult to sustain. It is like building a structure on sand, the foundation is constantly shifting.
This optionality also creates a secondary effect, where associates spend a significant amount of their time accommodating other’s optionality. In other words, they have become experts at workarounds.
In healthcare these issues are exacerbated due to the inherent variation that is an integral part of the work. Every patient is different and requires a different clinical and social approach. Emotions are often running high. Families are involved. It is all very chaotic.
However, the important message to convey is that this inherent variation is exactly why we must reduce the chaos wherever we are able. It makes standardization that much more important!
HT: What is the most difficult part of implementing Lean principles?
Thomas Palopoli: Culture. Lean is a definite culture change and every organization has a unique, ingrained culture already in place. Everyone is subconsciously comfortable with it, even if it is ineffective or frustrating. They know their place and understand the different roles. Change, even change for the better, creates uncertainty and it is uncomfortable.
In addition, many Lean principles are somewhat counterintuitive. For example, it is human nature to want to produce work in batches rather than practice single piece flow. Physicians may do this with their orders, i.e. see multiple patients and then enter all the orders at once.
This is terrible for throughput and quality (and safety!), but it is difficult for people to stop optimizing the individual task and consider the entire system when making these decisions.
HT: Why do you think that there is a high failure rate of Lean enterprise transformation?
Thomas Palopoli: I think this is the direct result of the challenge of culture change.
Lean is too often superficially applied and inevitably, performance and behaviors slide back to its original condition. Senior leadership must not just agree to “do Lean”, they must embrace & lead the change.
Also with “failure” it is important to keep in mind that Lean is about cycles of learning and growing the people in your organization. More important than achieving a relatively short term goal or objective, I want to know, did the organization learn and grow? Dust yourself off, try again.
Sometimes we learn more from failure than success if we allow ourselves.
HT: What needs to happen at the cultural level for Lean to succeed?
Thomas Palopoli: Culture is essentially a collection of common behavior and thought patterns.
The key to changing culture is to put in place systems that require different behaviors & thinking and strictly monitor them for adherence to create new habits.
For example, putting in place a system to visually display & manage performance at all levels of the organization each day, including getting senior leaders out on the floor where value is created (called the “gemba” in Japanese), creates a new pattern of behavior and thinking – a routine of improvement and coaching.
If you do that every day for several weeks, you will create new habits and notice a slow shift in culture. You will realize that this new system is now part of the ingrained behaviors and with the proper guidance from a Lean coach, their thinking will shift. They will be seeing waste everywhere and the Lean cultural momentum will take hold.
Key starting steps to implement Lean methodologies in healthcare
HT: What would be the 3-4 key starting steps needed for a healthcare organization to implement a Lean model.
|1.||Assess the current system and engage your workforce:
The first thing I look for in an organization undergoing a Lean cultural transformation is their current method(s) to manage performance and engage those that do the work to solve day-to-day problems. This type of visual system serves as the standard work for the front-line leader while engaging leaders at all levels of the organization in ensuring high levels of accountability and support. Without this basic management infrastructure, creating a sustainable cultural shift will be very difficult.
|2.||Become proficient at rapid improvement methodologies: While an organization is establishing this visual daily management system, I recommend they become very proficient at rapid improvement methodologies. Traditional organizations often have several improvement efforts underway, that of course is not a new concept. However I have found these efforts consist largely of weekly or bi-weekly improvement-type meetings, sometimes even monthly “check-ins” reviewing performance and discussing action plans. While these multi-week or monthly efforts have their place, all too often shifting priorities and resource availability see these efforts achieve sub-optimal results or the entire effort may even fade away over time. People are on vacation, items are not completed, the meetings start late or it just takes the first 15 minutes or so to reorient everyone on the project itself. To prevent this, organizations must learn how to support intense, focused improvement efforts that achieve results very quickly. Action is the priority, and with this intense activity will come frequent cycles of learning. As one hospital president I worked with used to say, “Fail fast. Learn quickly. Try again.”|
|3.||Define your organization’s long term goals and devise a strategic plan to achieve them: As an organization becomes more adept at managing performance each day and rapid cycle improvement, they need to leverage this infrastructure to focus the organization on achieving their long-term vision. What are the “true-north” goals of the organization? What are they key performance indicators that must be achieved? What breakthrough initiatives must be accomplished to ensure success? This strategic planning process serves as the standard work for executives & senior leaders and aligns the organization.|
|4.||Focus on people development: Finally, throughout all these efforts, the development of the people in the organization must be central. Lean is a leadership and people development system more than a process improvement methodology. People are an organization’s most valuable resource, and the key to unlocking brilliant, world-class results is engaging everyone to pull in one direction and collaborate to achieve their goals.|
I would like to add that if an organization has the opportunity to create a new system – whether it is a new inpatient unit, a new surgical center or a new laboratory – I highly recommend they engage skilled Lean practitioners to facilitate the Lean design of the new area prior to beginning construction. It is well worth the investment to do it right the first time than to have to live with monuments of waste that inhibit the flow of value once the construction is completed.
Lean is not a method for process improvement, but the way to administer business
HT: Why do you think Lean practices are not part of healthcare education?
Thomas Palopoli: For healthcare management education, there are certainly more and more components of Lean introduced. I have worked with several administrative fellows and interns fresh out of university that were quite aware of Lean in healthcare.
Unfortunately, Lean in this context is often taught as a method of process improvement, without an understanding that Lean is much more a people development system and complete business system than a process improvement methodology.
A good example of this is comparing or grouping Lean thinking with quality improvement methods like Six-Sigma. Six-Sigma is an excellent process improvement methodology for improving some things, particularly complex problems requiring high-levels of expertise to facilitate. However, Six-Sigma falls underneath the overall enterprise cultural umbrella we call “Lean”; Lean and Six-Sigma are not simply different approaches to the same thing.
This is common in all industries by the way; Lean may be a chapter in an MBA program without anyone realizing Lean is the way to administer business, not simply a way to improve the current state through kaizen events or other traditional Lean tools.
For clinical staff, their education is rightfully focused on their specific role directly healing patients. However, I have found them to be highly trained problem solvers. At a fundamental level, that is what they do with patients – understand the current condition, establish root cause and develop & execute action plans to achieve a desired future condition.
It is often useful to ask clinical teams to consider their processes as they would a sick patient and work to “heal” it! Therefore, in many ways, clinical education prepares direct patient care professionals to participate in Lean transformations directly and very effectively.
HT: What is the latest trend in Lean?
Thomas Palopoli: Over the last 25 years there has been a gradual shift in Lean thinking. Initially it was not fully understood that a comprehensive Lean management system was required to fully realize the Lean enterprise.
Applying Lean tools to a traditional management system did not create a sustained culture change. In fact, the first thing I recommend an organization do is establish a visual, tiered management system that is reviewed each day that includes executive level engagement at the front lines of patient care (i.e. leader gemba walks).
This combined with a robust system of rapid cycle improvement, strategic planning, and focused people development will establish a rewarding environment that facilitates excellent performance levels and creates a culture of continuous improvement. Let the traditional Lean tools and methods cascade out of this system.
Thomas Palopoli is an International Project Consultant for Global Roche Healthcare Consulting, where he supports Roche Healthcare Consulting in North America. Thomas has 25 years experience as a Lean transformation consultant and he is responsible for the designing, developing and deploying healthcare transformation consulting services for Roche in the United States. His focus is on improving the delivery of value along the patient care journey through the application of a full array of continuous improvement tools and techniques