Going Lean: The Rise of the Lean Health Care Model

When a new kind of health care model burst onto the scene more than two decades ago promising techniques that gave better patient care, created less work for nurses and physicians, and saved organizations money, the reaction was decidedly lukewarm. The promises sounded great, but the origins of what we now know as lean production principles were based on factory work with cars, not the decidedly different work of caring for human beings.

Based on Toyota Motor Corporation’s streamlined production approach (coined the Toyota Production System), hospital workers found the idea of implementing manufacturing principles into a hospital setting jarring.

Building cars isn’t the same as caring for a complex human being, but the end goal is the same—a customer-driven, high-quality end result with as little waste of money and resources as possible. Lean proponents say each organization has to run efficiently and precisely because the satisfaction and safety of customers is the priority.

“One of the biggest hurdles is the recognition that lean isn’t a method for building cars, but for building a better management system and process improvement methodology,” says lean expert Mark Graban, author of The Executive Guide to Healthcare Kaizen: Leadership for a Continuously Learning and Improving Organization and author of LeanBlog.org.

“It’s an improvement of quality, better workplaces, reducing wait time and cost,” says Graban. “It seems like common sense, but health care organizations are complex.” Lean is not a Band-Aid fix for a larger problem. “Lean gets people engaged in fixing the end-to-end patient flow,” says Graban of the hospital-based lean practices. “For an emergency department visit, that is from the time someone calls 911 to the time they are sent home.”

How Does Lean Go from Cars to People?

Also known as “kaizen,” the process of lean is a customer-focused production process centered on constantly improving the start-to-finish (or end-to-end) flow of production. Whether it’s a patient or someone buying a car, consumer satisfaction with the end product is the goal.

“There’s lots of pressure on health care to reduce costs,” says Graban. But there’s always the worry that reducing costs results in substandard patient care and lost health care jobs.

Although lean has been around in health care since the Virginia Mason Medical Center in Seattle officially implemented lean programs in 2002, it is not industry-wide because, quite simply, it’s a lot of work.

Charleen Tachibana, RN, is senior vice president, chief nursing officer, and hospital administrator for Virginia Mason Medical Center, the first health care facility in the country to adopt lean practices and now one the leaders in training professionals in the lean process. In 2001, the organization began compiling a new strategic plan and investigating other effective management systems. When they could find nothing satisfactory in a health care setting, they turned to a totally different industry, car manufacturing, which had made news for its revolutionary process, to see if any of their industry practices could be applied to hospitals, says Tachibana.

After a year of investigation, Virginia Mason announced the changes to the staff’s uncertain  reception. “The vast majority were in the middle,” Tachibana recalls. Wanting to take a wait-and-see approach, the staff was willing, but hesitant. “Part of the work wasn’t the tools and production methods, it was how do you handle change,” says Tachibana.

What Is Lean?

Sometimes, it’s just hard to understand something when you know nothing about it. Lean is simply an improvement method that aims to minimize waste and maximize value. Health care organizations like Virginia Mason and Beth Israel Deaconess Medical Center in Boston (where they implemented a “House of Lean” model) quickly realized the methods could transfer easily to a health care setting.

But lean isn’t about making everything faster with fewer people to do more work. Lean is about efficiency and quality, say proponents. For a health care consumer, that means a better health care experience in less time and with less waste. For nurses, lean means a more efficient work process, so they can get more done in less time so they have more time to spend with patients. And that’s where most nurses are happy with lean—they reconnect with patients and remember the very reason most of them got into health care in the first place.

Why Turn to Lean?

Alice Lee, vice president of business transformation at Beth Israel Deaconess Medical Center, first learned about lean principles when she was approached to look at the organization’s business processes with fresh eyes. While researching practices in other industries, Lee discovered lean principles appealed to her business sense. “Back then, lean got little to no attention,” says Lee. “People in health care were not thinking in the same ways as those in industry.”

After visiting manufacturing facilities, Lee says it soon became clear to her how the end-to-end flow approach suited a hospital. Applying the tactics to Beth Israel would lead to an environment that was less burdensome for nurses especially and that would understand and remedy those existing burdens.

“Lean is very, very, very customer-focused, “ says Graban. “But it also helps people in health care rediscover their sense of purpose. Lean as an approach is very respectful of people doing work.”

Tachibana says Virginia Mason had direct goals in mind. “Our goal was to get nurses in with patients and to increase patient time,” says Tachibana. “What is adding value in what we do and what is not adding value?” At Virginia Mason, the changes were incremental, so they were both easier to adopt and easier to adjust to. “We started on one floor or with one shift until we had it where we wanted it,” explains Tachibana. “Then you can think of ‘how do you spread this.’ There was a series of changes that fed to a higher goal.”

What Is Lean Like in Real Use?

What does a lean process look like? At Virginia Mason, lean means a Patient Safety Alert System allows any employee to “stop the line,” or make a report and cease any activity, if they ever see something that is likely to harm a patient.  In another organization, IV trays were cluttered with several tools that were never used. By redesigning and streamlining the trays, staff found them easier and faster to use.

At Virginia Mason, Tachibana says staff-designed changes made for a better process and invested the staff in the outcomes. They were given a week at what’s called a Rapid Process Improvement Workshop, to redesign a process. Once implemented, improvements were measured at regular intervals. Moving some essential supplies to patient rooms gave nurses more time with patients. Changing a sign-off procedure to be in the patient’s room with the patient’s input not only reduced hand-off times by two-thirds, but also engaged the patient and the family in a way that was immensely more satisfying to them.

When an organization adapts to lean models, innovation is encouraged, but it’s also standardized. So while another organization might welcome innovation and suggestions, staff don’t always have the resources or authority to implement the suggestions or track follow-up with measurements.

“The production system provides structure and methods,” says Tachibana. “It has an interesting impact in that it liberates the culture. People can get more innovative.”

So while some improvement processes might focus on one problem, lean principles discover how to provide the right support and resources every step of the way. And while some might say lean only aims to treat more patients in the same amount of time and thereby creates more work and more pressure, Graban says the opposite is true. Instead of working harder, he says, lean principles encourage working smarter.

Alexandra Zaremba, RN, manager of the short-stay surgical unit at Virginia Mason, and Rowena Ponischil, RN, MSN, director of the cardiac telemetry unit at Virginia Mason, have both seen the transition to lean over the past decade.

“This took a lot of growing pains, and it didn’t happen overnight,” says Ponischil.

But the changes made the nurses feel supported by the leadership, says Zaremba. “It gave a voice to the nursing staff,” she says. “And then they felt empowered and supported.”

Eventually, Zaremba noticed something different when new charting procedures required her to do the chart in the patient’s room, not at the end of her shift. “I was interacting more with patients,” she says. “I was talking to them and meeting them on an emotional level.”

Chikodiri Gibson, RN, MSN, MBA, DNPs, APN, CNS (Adult Acute Care), and senior associate director of behavioral health at HHC Kings County Hospital in New York, says even the most minor change can reap huge benefits. Having never experienced lean models before coming to Kings County Hospital, Gibson says the ideas were new to her, but the process of identifying a problem and understanding the real root causes made sense to her.

Gibson recalls one change that involved rearranging the nurses’ stations. Nurses couldn’t find what they needed and patients were being delayed when they were ready to leave the hospital because it took so much time to find anything, she says. “We started one unit at a time, and everything is labeled and nice and clean and neat,” she explains. “Nurses are happier, patients are happier, and now nurses have more time to spend with patients,” says Gibson. “We moved it to every unit now, and no matter what nurses’ station you go to in the hospital, it all looks the same and you can find what you need.”

Involving More than Managers

No matter how great a project is, the magic of implementing lean is creating a culture where everyone in the organization makes a change. Engaging everybody, even patients, to fix the smaller problems not only highlights problems that might have been overlooked, but also makes everyone involved and invested in its outcome.

“Whenever we do design work of process, space, or roles, we bring patients in to participate on the design team, and they always teach us something,” says Lee. “This has really been a wonderful way to convey to patients that we are trying to make this better.”

Ponischil agrees. “We want to create a product that is good for the patient, not what we think is good for the patient,” she says.

John Toussaint, CEO of ThedaCare Center for Healthcare Value and author of On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry and Potent Medicine: The Collaborative Cure for Healthcare, recalls the overhaul brought about by one patient’s letter. An obstetric patent wrote Toussaint a critical letter about her bad experience giving birth at the facility. Toussaint, who agreed that a poor information flow was at the root of the problem, invited the woman to a week-long improvement event to see what changes a team of staff, physicians, patients, and nurses could make to the process that encompasses the time from a baby’s birth to the time he or she visits the doctor for the first visit.

“Our process involved 140 steps, and we reduced it to 70 steps,” says Toussaint. “We ran experiments to see if the doctor would get all the information needed, and we were 100% reliable every time. We started at 40% reliable. It was a dramatic improvement.” The diverse group, some of whom were cynical about lean methods, were focused around one thing and that created a better experience for the patient, says Toussaint.

Giving the reasons for change also helps. “You have to get that down to an individual person who asks, ‘Why should I change,’” says Tachibana. “The greatest gift of this is that people are engaged in improving their own work. They know what works and what doesn’t.”

“It’s not uncommon for a department to provide 25% more care without adding equipment or people,” Graban says. “You can take care of more patients in a shorter time without shortchanging the care. Patients are happier, but they are safer, too.”

That could mean redesigned space that allows fewer steps or fewer trips to get equipment or even paperwork that is designed to reduce duplication and enhance accuracy.

Convincing People to Go Lean Is Tough

Why do people resist lean? In busy hospitals and health care organizations, learning something new eats up time that no one has to give. Even nurses in the thick of the lean process say the work can seem counter-intuitive. When you have done something one way for so long, it is a struggle to change.

Talk of being more efficient inevitably leads to concerns of reducing staff. “People do get nervous,” says Graban. “Sadly, the traditional way hospitals cut costs is by laying off people. Lean is one of the best alternatives to layoffs.”

How Do You Keep Lean Going?

Lean doesn’t work without commitment and dedication to a long-reaching goal. Because hospital staff changes frequently, organizations are constantly acclimating new people to the lean culture. “When CEOs and managers behave in this style, it reinforces that ‘this is the way we do things here,’” says Graban. “It has to be reinforced in a lot of ways that this is the new normal.”

Beth Israel’s hiring approach begins right from the first encounter, such as an online assessment, and Lee says that is what makes lean challenging. “How do we hire people with the mindset of those who are able to work in a lean environment?” she asks. “We have 2,000 new people come in every year. That means we have 2,000 opportunities to get it right or get it wrong.”

A Lean Future?

What is the future of lean? Graban points out that with any manufacturing process, change happens in fits and starts over the course of decades, not months.

An initial wave of interest spurs others to dabble in the process, says Graban, and of that group, some will embrace it and others will give up on it. When an organization has success, other groups will take a fresh look at the process and learn from the deeper understanding the other organizations gained from experience.

Lee doesn’t pretend that lean is simplistic or quick.

“We are 10 years in,” says Lee. “This work is hard, and initially there is a lot of resistance. It’s uncommon to find a hospital not doing something with lean now. Who is going to stay the course? And who will stay the course when the course gets tough? It takes daily perseverance.”

Lee says keeping an eye to the future and on the end goal helps staff persevere as the health care climate evolves and changes with time. “This takes a constancy of purpose,” says Lee. “You have to believe there is no option but to improve the current condition. If you don’t, you resort back to chaos.”

When lean practices become part of the new culture, Graban says the results are tangible and intangible. “I think the most exciting things are the moments when you see pride on the people in the health care field,” says Graban. “To see them get re-energized about the work they are doing and why they got into health care.”

Zaremba says the changes have made her unit tight. “It’s the teamwork approach,” she says. “We are responsible for each other, and we have the spirit of one team.”

And Toussaint says the measurable results are inevitable if you follow lean principles correctly. “If you do it right, three things will happen,” he explains. “Staff morale improves, quality of care process improves, and costs go down. People recognize that this is a way to fix the system.”

Julia Quinn-Szcesuil is a freelance writer based in Bolton, Massachusetts.