Why does lean ‘fail’ in some healthcare organisations?

This was the question posed by Dr John Toussaint* on Twitter earlier this week.

Big question, and in my view the answers are probably as relevant to organisations outside of healthcare as those in it. It is also an important question, given the resources committed by organisations to ‘do’ lean, the opportunity cost of those resources and the potential learning from asking it, that might help us understand more about delivering value for patients effectively whilst being respectful of staff and the communities we serve.

So, what are my thoughts? Here are some of my reasons for lean ‘failures’ (in no particular order):

Rivers and rocks

You are possibly familiar with Ohno’s rivers and rocks analogy, where a cross-section of a river is used to illustrate how higher water levels hide rocks in a river bed and a lean approach seeks to lower water levels (inventory/waste) and in doing so the rocks become visible, allowing the rocks (problems) to be removed rather than worked around. The problem is, many seem to expect organisations using lean to have magically removed all the rocks by the end of day 2 or 3 and seem to think that problems and challenges thrown up through error identification and inventory reduction mean lean isn’t ‘working’.

Show me the money

Waste is removed using lean, in all its forms, transportation, inventory etc. But, these are not all cashable, and removing waste in itself, in healthcare anyway, tends to release capacity or reduce overburden, more so than reducing stock usage and wastage and thereby releasing cash. In industry, spare capacity can often be converted into revenue through the sales of more product on top of reduced costs from defect correction. But, in healthcare the use of fixed volume, fixed price contracts or fixed total spend across a population, can often mean this conversion is less possible for providers, meaning the only other way to turn freed up capacity into cash, (if this is an expectation rather than a safety, quality, morale or productivity gain), is through capacity reduction, thus potentially jobs. Who wants to improve themselves out of a job?

It’s too hard

It is hard, very hard at times. It’s hard to keep the energy, enthusiasm,when it at times seems so relentless, and after the initial full steam ahead, improvement can become a little more, well, boring. The attention to detail needed, the careful specific work to keep testing and adaption, the ongoing communication and influencing. It is easier to imagine sometimes to just go and do something else, something more exciting, with even brighter post-it’s or new gadgets and technology…. but then remind yourself why and it is worth it (but see reason number 5).

Leadership, leadership, leadership

Do I need to say more? The biggest risk for me, is when leaders, especially board level leaders lose interest, find other priorities, introduce another improvement approach on top of the lean approach confusing matters, don’t walk the talk, or find new jobs/retire without succession planning, not just for their role, but their successors role as well (if an internal appointment) and fail to find full sponsorship and understanding of the the lean work as they depart.

Why are we doing this again?

Perhaps the biggest reason, it fails simply because the organisation forgets why it was learning to be lean in the first place… to improve care for patients… and starts to believe their own hype and focuses on executing lean instead delivering value.

These are just my first thoughts, other reasons are failure to adapt to local context; too many initiatives driven through silos competing with lean; failure to respect staff and patients and improve together, too reliant on the internal/external change team; thinking lean is all about tools and training, failure to pay attention to organisational culture and so on.

I haven’t researched this area in any great depth, unlike Prof Bob Emiliani who has spent a good chunk of his career looking at the failure modes of lean. It is worth checking out his bookstore and blogs. What are your thoughts? Why do you think lean sometimes ‘fails’?

*Dr. Toussaint is the former CEO of Thedacare In Wisconsin, USA who set up and established lean there with the help of a number of folk using an adaptation of the Danaher business system, about 15 years ago. When I worked at Bolton FT on their lean programme, Thedacare was one of our inspirations and a group of staff went out to visit them and took part in some rapid improvement events with them. Dr .Toussaint has since set up the lean healthcare organisation, Catalysis.


About joyfurnival

Interested in TQM, lean, Quality Improvement, Healthcare, Regulation, Accreditation, Inspection Improvement Science, QI, improvement capability.
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