John Toussaint’s Monthly Reflections – New Research Shows Lean Thinking is Making a Difference in Healthcare

I am sure at some point in your career you have had to make the argument that lean thinking will work in your healthcare organization. The first time I had this conversation was with my senior executive team some 20 years ago. At that time, I knew we needed to do better but I also did not know what I did not know about lean. I took it on faith that the same method my mentors espoused, which had brought greatness to manufacturing, would work the same in my complex health care organization. It was an uphill battle with my team to garner their support. How has it been with yours? Here is some good news that may help. View this message on YouTube.

A new extensive research paper titled Lean Management and Hospital Performance: Adoption vs. Implementation, based on data from 1200 U.S. hospitals, published by Steve Shortell MBA PHD and his colleagues at U.C. Berkeley, now shows how healthcare organizations extensively practicing lean thinking, meaning the method is demonstrated in most hospital departments and outpatient clinics, perform better than hospitals not practicing lean. In fact, the lean hospitals have lower adjusted inpatient expense per discharge. Armed with this knowledge you now should get support in the finance department. These health systems also have better HCAHPS scores, so marketing and patient experience leaders will have reason to get on board. The lean hospitals also had lower 30-day readmission rates. You can avoid Medicare penalties. That should make your CEO happy because your hospital will not show up negatively in the newspaper. Finally, these health systems had better results for the appropriate use of imaging. That means less wasteful, better value care, which is what employers are clamoring for.

What the study did not show was better clinical quality performance on such measures as risk- adjusted mortality rates. I have been wondering about this result because my experience as CEO was there were significant improvements in quality. Anecdotally at places like UMass Memorial in Worcester, Massachusetts and others practicing lean thinking, there have been as much as 30% improvements in year over year actual vs. expected mortality, the ultimate quality outcome measure.

One reason may be that efforts focused on improving performance in targeted units, departments, or programs do not quickly improve the organization-wide performance measures that are publicly available and examined in this study. As others have suggested some of the publicly available quality measures may not be the best measures of quality of care and may not be sufficiently “sensitive” to the types of changes that lean organizations make to improve care quality.

The paper concludes that lean is more than tools and we need to think of it as a transformational management system that is based on a set of principles and behaviors, as the Shingo Model describes. Clearly research determining the long-term effects on clinical outcomes is in order but in the meantime, we finally have a solid argument for bosses, peers, and subordinates that lean thinking, when practiced system wide, works in healthcare to lower cost, improve efficiency, deliver better value, and improve customer satisfaction. Hooray!!

But back to the bug. I received great feedback from some of you on COVID after my last letter and we published the results here. There is light at the end of the tunnel with the new Johnson and Johnson vaccine being FDA approved but we still have hospitals full of patients with COVID and states opening bars will only increase that number. So, we all still must hunker down for a while yet.

Teams have been hit especially hard at Mt. Sinai Morningside hospital in New York City. The staff are exhausted the second wave has pounded them. Winter and the slow roll out of vaccinations has compounded the pain. But the lean management system has been their saving grace and allowed them to unleash the creativity of every staff member to solve problems.

Dr. Lucy Xenophon, the Chief Transformation Officer, and her team have built an elegant information flow system that complements the lean management system. Information is displayed on large TV Screens and updated every few minutes via the electronic health record and other legacy software. This allows the managers and team members to huddle in the command center each morning and throughout the day to decide where to focus their effort and resources that day. They know how many patients are in the ED with COVID, how many beds are available where, and where they have bottlenecks to flow. Using this system, they increased the number of patient discharges by 1500 over a single year. We published the full article in the NEJM Catalyst, and you can read it here. You can also listen to a podcast by Dr. Xenophon here.

I would love to know how you are improving hospital and clinic flow during the pandemic. Share what you have been learning with me at john.toussaint@createvalue.org.