3 reasons your lean efforts will fail, unless...

Many hospitals and clinics are using Lean tools in efforts to improve their performance, as the need to drive to greater value and efficiencies continues to increase.

Yet, only a few healthcare organizations have successfully embarked on their journey toward becoming Lean. Most healthcare organizations fail along the way, only to achieve limited and short-lived success, while leaving behind disillusionment with yet another failed management fad. Many organizations even established in-house teams staffed with Green Belts and Black Belts in Lean Six Sigma but to no avail. According to a somewhat dated Wall Street Journal article, about 60% of process improvement efforts fail, while other estimates of failure rates are somewhere between 50% and 90%. So what is causing such poor results when only a few healthcare organizations have been to demonstrate significant and lasting results with Lean and/or Six Sigma?

There are three fundamental reasons for why process improvement efforts based on Lean and/or Six Sigma fail.
- Lack of understanding
- Lack of commitment
- Lack of proper execution

This assessment may seem trivial but the path toward becoming an efficient, customer-centric, high-reliability and value-centric organization is anything but that. It is worth analyzing each of these three reasons in more detail.

Lack of understanding

The lack of understanding is especially problematic for Lean, a management philosophy and set of tools distilled and codified from the Toyota Production System and the Toyota Way. Consequently, the origins, foundation and principles of Lean are often misunderstood and, thus, not correctly applied. This is serious problem for all industries but especially for healthcare, where many believe that there is nothing to be learned from other industries. I recently read two blogs, one from Mark Graban and one from Christoph Roser that address the issue of what Lean really is. Its definition is not as clear-cut as many may think. Furthermore, Bruce Hamilton, a.k.a. the Old Lean Dude, recently posted a blog commenting on the fact that "we segment various aspects of continuous improvement in our attempt to break a big system down into digestible pieces". He goes on to say that we often forget to look at the whole thing, not just waste or some other aspect of Lean independent from the other Lean aspects. Because of the lack of understanding of Lean's history and foundation, there are many perceptions of what Lean is, most of which are incorrect or incomplete.

First, many healthcare organizations embark on their Lean journey by focusing on the wrong things. Since Lean is usually associated with removing waste and doing more with less, the common and erroneous misperception is that Lean is only about reducing cost and increasing productivity. This misconception makes labor and supply costs easy targets, as they usually make up the bulk of a healthcare organization's operating expenses. Efforts to become Lean quickly fail when it becomes obvious to everyone on the frontlines that elimination of employees and/or reducing salaries and benefits is one of the main desired outcomes. Few will look forward to improving him or herself out of a job, so a cost reduction goal is a non-starter for becoming Lean.

Second, many efforts toward becoming Lean are pursued in a fragmented manner, leading to sub-optimization of individual departments, as opposed to optimization of the entire organization. All too often, I read proud accounts about how an individual laboratory, pharmacy, Emergency Department or Surgery Department has improved its performance through Lean. While these efforts are commendable and probably beneficial, they fail to take the physics of the entire healthcare enterprise into consideration. To use two analogies for clarification, the weakest link determines the strength of the entire chain and the narrowest section of a pipeline determines the flow rate of the entire pipeline.

We have all experienced the impact of bottlenecks on busy highways when the number of lanes drops from three to two or one due to a merge or accident. Traffic comes to a near standstill and all lanes start to back up. To make matters worse, these back ups persist long after the original cause has been removed.

Similarly, the greatest bottleneck in the healthcare delivery system determines patient throughput and/or information flow rates. Unfortunately, most Lean projects fail to take such health system-wide patient flow, workflow or information flow bottlenecks into account and may be trying to improve the performance of a non-bottleneck, which will hardly yield meaningful benefits. A successful pursuit of Lean depends, therefore, on looking at the entire healthcare organization and the interdependencies between departments and resources. These should not be optimized individually but, instead, optimization of patient throughput should focus on the organization as a whole.

Third, many pursue their journey toward becoming Lean in a rigid, cook book-like and linear fashion that usually leaves the human element, i.e., front line staff, and organizational learning out of the equation. This algorithmic, one-size-fits-all approach is usually applied in this manner due to the way in which Lean and Six Sigma are frequently being taught. Lean and Six Sigma courses often do not address how to best engage front line staff in improvement efforts, how management needs to change its behaviors or the importance of organizational learning to becoming a continuously adapting, innovating and improving organization. Moreover, Lean tools such as value stream mapping, smoothing patient flows, 5S, control charts, etc., are often confused with and used as solutions instead of being used to make problems visible throughout the entire healthcare organization.

The Toyota Production System and the Toyota Way, from which Lean is derived, evolved over a long time and much of it out of necessity. When Toyota started to produce cars after World War II, Japan was a poor and crowded country with no natural resources. Materials to build cars had to be imported, while space and capital were scarce. Unlike its American rivals at the time, there was neither the money nor the space to afford large inventories and wasting precious materials was a luxury Toyota could not afford. So, Toyota had to learn to produce good cars while operating under substantial constraints.

To address these challenges, Toyota - in particular Taiichi Ohno and Shigeo Shingo - experimented with insights borrowed from Frederick Winslow Taylor (standardization), Henry Ford (flow), Training Within Industry during World War II (standardization), Edwards Deming (quality, Profound Knowledge), Joseph Juran (quality) and Sakichi Toyoda (automation with a human touch).

It has taken Toyota decades to learn how to build high quality, affordable cars quickly and efficiently and, even today, it still will not claim to have all the answers. The company continues to learn to adapt and achieve its goals under ever changing conditions and fierce competition.

So what does this mean for healthcare organizations? As John Shook, CEO of the Lean Enterprise Institute, recently stated so eloquently, "Lean is about building organizations that learn to learn how to create better value". Unfortunately, many blindly copy what Toyota has done without taking into account their own organization's unique abilities, constraints, market conditions and customer characteristics. This is one of the reasons Lean often fails to produce profound and lasting benefits. Instead, healthcare leaders should focus on finding their own unique solutions to their problems using Lean Thinking and Lean principles as guides.

- Treat all members of the organization with respect. Encourage, empower and engage everyone at all levels to identify and solve problems, to work well with others across the organization and to learn together how to continuously provide better value.
- Understand the customer and learn how to best serve them and provide them with better value.
- Establish even patient and information flows and reduce unevenness in these flows. This often overlooked and ignored objective of Lean is key to creating a more streamlined, efficient and effective healthcare environment.
- Reduce overburdening of staff and equipment to reduce burnout or wear-and-tear, and, thus, decrease the risk of harm to patients and frontline staff. This too is an often overlooked objective of Lean and healthcare futurist Ian Morrison, has reported the problem of improvement fatigue among healthcare workers a few times.
- Eliminate waste and inefficiencies.

Lack of commitment

Much has been written and said about how important it is for senior management to stay actively engaged in and committed to continuous improvement efforts. All too often, senior management team members focus on strategies, budgets and running their organization by the numbers, without developing a personal and firsthand knowledge of what really goes on in the frontlines where people care for patients. Edwards Deming called this Profound Knowledge. In addition, improvement projects are frequently delegated down the ranks or to a dedicated group of Lean/Six Sigma belts. Failure of senior management to become and stay an integral part of the continuous improvement efforts – and spend a substantive amount of time on the front lines - will quickly cause such projects to lose momentum and the organization to lose interest and faith.

Lack of proper execution

To truly transform their organization into a lean, agile and high reliability organization, healthcare executives must follow the spirit and key principles of Lean and other improvement methods as outlined previously. The journey toward becoming Lean is like a long voyage into unchartered territory, during which profound knowledge about customers, the organization and ever changing market conditions is developed. It is not a quick fix or shortcut to a well-defined destination. Failure to do so will lead to isolated and short-lived benefits, while leaving behind exhausted and disillusioned organizations that survived yet another management fad.

Paul Schilstra is President and founder of primeASCENT, LLC, a healthcare consulting firm that focuses on helping healthcare providers pursue operational excellence. He has over 25 years of domestic and international experience in healthcare, having previously served in a number of executive positions at global companies. He can be reached at paul.schilstra@primeascent.com.

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