Learning Lean

A friend of mine, published this diagram today on his Facebook wall.  (I’m not sure where it is from or who developed it, but it seems to be linked to ‘Big Up the NHS’, apologies if I have that wrong).

It compares South Tees Hospital in the North East of England with Virginia Mason Medical Centre (VMMC), in Seattle who have been contracted to support NHS improvement in England to learn about and implement lean healthcare.  You might notice the scale differences in terms of volume and bed numbers between the two organisations in the example, not to mention the geographical difference.

When I first heard of the potential deal with Virginia Mason Medical Centre (VMMC) and the Trust Development Authority (TDA) to support the implementation of lean by way of the Virginia Mason Production System (VMPS) in a number of trusts in England; my first reaction was; brilliant, how can I get a job in one of those Trusts? (post PhD obvs!) What an opportunity.   My second reaction a few moments later was, similar to the diagram above was why VMMC? They only have 300ish beds and they are on the other side of the world. How will their challenges compare with Leeds Teaching Hospitals or other large hospitals like them (such as South Tees) or indeed any of the other organisations selected to take part (Surrey and Sussex Healthcare; Barking, Havering and Redbridge; Shrewsbury and Telford; Coventry and Warwickshire)?

VMMC has a well-deserved reputation, steady leadership, some research evidence of their work, results and a steady stream of visitors from the UK (I wrote about Jeremy Hunt’s visit here). They have lots to share and lots for us to learn from, great safety work; the compact and what lean leadership looks like, oft quoted results; so in many ways they are an excellent choice. But a little niggle started in my brain, because there are many healthcare places doing lean and reaping the results or otherwise, and learning from when it goes well and when it goes not so well…. Does we really need support from Seattle? From an organisation with only 300ish beds? Really? Does their brand, results, knowledge and reputation mean that much?

For example, why not Thedacare in Appleton, Wisconsin,  again not so many beds…but does size really matter, to learn about learning lean?  They have the Thedacare Centre for Healthcare Value to help share the learning or we could learn from those involved in the much bigger lean healthcare work in Saskatchewan province in Canada. Who else is there? There is the ubiquitous IHI….ok so they tend not to use lean as their overriding approach, preferring a more purist Deming approach to improvement science. Still, they are overly qualified, have a superb reputation, and could do the job. In addition, they have a track record of helping healthcare organisations, e.g. in the NHS in Scotland with some lauded results….and importantly, at scale. However, all these examples still need a few trans-Atlantic flights and there has been little rigorous and independent evaluation. That has not to say we should not learn from the USA, we must pinch with pride the best ideas, approaches and learning to improve care.

VMMC has a record of improving financials, as well as safety, notoriously more difficult to demonstrate in healthcare. Maybe this has something to do with the choice, given that the financial performance figures for NHS English providers in the first three months of this financial year show a deficit of £930m in Q1 of 2015-16 – bigger than entire deficit for previous year. But then….for lean organisations, financial improvement is the expected by-product of quality being ‘free’ rather than the aim….so I truly hope deficit reduction is not the ‘major’ evaluation criteria for if these lean healthcare experiments ‘work’….(I hope there will be evaluation….!)

In Europe, there is also a lot of learning about lean healthcare… an awful lot more than there was a decade ago. For example there is the work and learning from the large scale roll-out of Productive Ward (based on lean developed by the NHS Institute for Improvement and Innovation, ex-Toyota employees management consultancy KM&T and McKinsey), some of which is captured in this evaluation about Productive Ward in Ireland. There is also learning, experience and expertise for sharing from those who have attempted lean work in healthcare and discovered just how hard it is in a NHS context, not just a healthcare one. Places such as the Wirral, Bolton, Stockport, Blood and Transplant, the Lean Healthcare Academy, Portsmouth, Barnsley, Calderdale, Blackpool, the NE of England, with the North East Transformation System (also developed through a relationship with VMPS) and many more both within healthcare and outside. There is as much learning from these NHS organisations and their staff on how not to do lean healthcare and what ‘fake’ lean looks like as there is about what do to well and how to integrate it with other quality improvement work and governance. (Including at Leeds actually, who worked with KM&T for quite a while doing lean work and so I hope the VMMC work will build on top of this initial work and learning). In addition, there are numerous UK based academics and management consultancies who can help.

Thing is, whilst knowledge, expertise and experience is helpful, in a way it does not matter who comes to help, or from how far away, or what their organisational configuration or size is; the external support cannot do the work, and they cannot guarantee success. Only the organisation and its stakeholders, patients, employees, commissioners, regulators can learn to change themselves for the better and have the tenacity, resilience and persistence to keep going in their context. I feel that much of lean is learnt through doing. The external support whether it comes from the other side of the world or round the corner can only facilitate encourage, coach and create supportive environments, not do.

An organisation on a lean journey is likened to a climb up Everest with the organisation encountering many problems on the way and many opportunities to turn around and tempting chances to change course.  Even with help to carry your bags and plan your route, you still have to climb up yourself, no one else can climb for you and no-one can control the environmental conditions and weather.   A lean transformation might take over 20 years in some of these very large NHS organisations. It may be very easy to become impatient and slip into the delivery of LAME/Fake lean, even unintentionally, or in reaction to urgent stakeholder demands, or whilst facing new pressures such as organisational reconfiguration or financial or reputational ruin or as leadership intentions and strategy changes. Some might even do lean as the latest policy fad, waiting for the contract with VMMC to be over and move on to the next new ‘improvement’ fashion or return to less progressive management methods.

I truly hope these five English NHS organisations can stay the course, even as people change within the organisations and within their stakeholder groups and as policy continues to evolve. This huge lean healthcare experiment offers opportunity of a lifetime to learn from VMMC, one of the best, and learn how to scale and adapt what they have done in a 300ish-bedded hospital in Seattle for their own organisations, wherever they are in England and whatever size they may be. This will not only support the delivery better care for patients, but more importantly support the organisations to learn how to keep adapting lean for their context and delivering safer and better prevention, care and support for patients and the public in the future in a self-sustaining way. Hopefully, they too will then inspire and support other aspiring lean healthcare organisations, even if they are the other side of the world or sized differently to ensure even more patients benefit. This, for me anyway, is the long-term promise of learning lean.

NB apols for those links that are £walled

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