Lean Healthcare Jitterbug

Two steps forward, one step back.  Lean healthcare initiatives have really been taking off at several locations around the country.  Costs are being reduced, mistakes reduced, efficiency increased, and quality of care increased.  There are even lean healthcare programs at the AME Annual Conference later this year. 

Many of us have been trying to figure out if lean healthcare will gain sufficient prominence and acceptance fast enough to head off a draconian injection of government bureaucracy in the mistaken belief that it will reduce costs... while improving benefits, quality, and access.  Fellow blogger Mark Graban at the Lean Blog is involved with lean healthcare initiatives himself, and several of his posts discuss that application of lean.

But, alas, even in the midst of this strong interest, some simply don't get it.  Paul Levy, President and CEO of Beth Israel Deaconess Medical Center in Boston, has his own blog called Running A Hospital.  His posts provide a rather unique look at the hospital business, albeit from the executive perspective.   Last Friday he wrote about his hospital's latest JCAHO (the Joint Commission that audits and certifies hospitals) report, and even linked to the entire text of the report so his audience, and employees and customers, could review it.  Pretty bold, as the JCAHO is notoriously tough and the results are often not very flattering.  I applaud him for that... the transparency and openness is refreshing.

Mark Graban also read the text of the report, and was troubled by a couple items, which he commented on in response to Levy's post.

I have to ask though, and this coming from someone relatively new to healthcare from the manufacturing industry. How can management let obviously unsafe conditions, like unsecured gas containers, go unchecked? Why does this require an outside inspection to uncover?

Why not be more proactive in your improvement efforts? How do you plan on holding managers accountable to make sure safety problems like that are audited on a continuous basis so they are never again found by outside inspectors?

Very valid points.  Most of us in the manufacturing world also have numerous audits... ISO, cGMP, fire department, etc.  On an ongoing basis, and especially prior to such audits, everything is crutinized for compliance.  Paul Levy responds to Mark's comment as follows.

I think it would be an unusual manufacturing plant, covering about 3 million square feet with about 10,000 workers, to not have any safety violations or other problems. That being said, we do audits and surveys ourselves, and we do hold managers accountable. We are always looking for better ways to do that, and we are borrowing techniques from other industries.

Not offered as an excuse, but just part of the explanation: Please remember that this is not a manufacturing process, with constant production of a constrained set of identical products. Remember, too, that a key component of our workforce (i.e, the doctors) are not employees and are therefore not subject to the kind of direction and supervision of employed staff.

Actually I've worked in very large manufacturing plants, and with the proper procedures and accountability something like unsecured gas cylinders would never occur.  Yes there would be problems, but they'd usually be gray-area interpretations that would be discussed and worked out.  But it's his last statement that really digs into me a bit.  That side of me to is sometimes made to feel like a knuckle-dragging manufacturing grunt.

Please remember that this is not a manufacturing process, with constant production of a constrained set of identical products.

It has been a very, very long time since I've seen such a manufacturing process.  Do any still exist?  Toyota can build up to ten different vehicles on the same production line, with hundreds of permutations.  Job shops can create anything, sometimes just once.  Constant production?  Where?  Mark tries to tactfully point this out, with more patience than I would have had.

It's good that your hospital is learning from other industries, but please don't diminish the challenges of manufacturing. It's a rare factory that just cranks out the same products over and over.

But, your other comment comes across as somewhat demeaning to the simple manufacturing business. It certainly doesn't seem like a valid explanation that "we have complex processes." Would Intel use that as an excuse, considering they have probably the most complex and high-tech manufacturing processes in the world?

And then Levy's response.  I do give him credit for discussing this on his public forum.

The difference is between producing say, 12 or even 20 identical products, really well over and over -- and producing highly personalized and individualized medical services 600,000 times one at a time.  I don't mean it to sound at all demeaning to any manufacturer, but this is solving a quality control problem of a different order of magnitude.

Ok, he took it up to 20 products.  Still a few short of the hundreds or even thousands of permutations most of deal with.  The manufacturing world has the luxury of problems that don't generally result in fatal outcomes... well I guess I better take that back.  A recent defibrillator recall and the Ford Pinto come to mind.  But the medical world definitely has a couple luxuries as well: several centuries of increasing knowledge on a single product (hey, if he can call a car a single product, I can call a human a single product!) instead of a complete model change every couple years.

If he really wants a challenge perhaps he should try to run a veterinary hospital.  Just a few dozen more species, all radically different... now that's more like manufacturing!  No wonder vet school is more competitive than med school!

UPDATE:  See Mark's post on the subject here, as well as the "banter" between Mark and Paul in the comments.

Comments

[Mark Graban]

Levy does sometimes mention Lean as something that the hospital is working on:

http://runningahospital.blogspot.com/search?q=lean

"d. Achieve significant productivity improvements required to reach the 07 budgeted cost/case and cost/visit and to prepare for FY08 budget by:
1. Implementing LEAN initiatives in 5 key areas with a focus on reducing costs and enhancing revenue;"

I don't think we should beat up on them too much for trying... but it's too bad that Lean is seen as cost and productivity. At least they see the revenue potential, but what about quality and safety? Lean can lead to major improvements in those areas, with the right approach.

I'll pick on them more for making excuses ("well, we're a big, complex facility, so we're bound to have some unsecured tanks") than for anything else.

I'm going to have a post later tonight, something I had written over the weekend, but am going to update based on my interaction through their blog comments.

[anon]

So, while Mark and Paul argue about it, did anyone actually fix the problem?

[Paul Todd]

This is a pretty unproductive conversation. You're never going to convince a medical professional that making products - any products - is in the same league as treating someone with a gunshot wound or leukemia. Let's not waste time trying.

It's natural that as manufacturing types we take offense at the notion that what we do is simple or easy, but rather than engage in a game of "My job is harder than your job", let's just be thankful that healthcare is thinking in terms of process improvement.

Part of the hurdle involved in most lean efforts is overcoming the idea that "My department/plant/company is different and what you've done in the past won't work here." It's human nature to see the difficulties in a new endeavor, and healthcare professionals are no different. Let's recognize that and move on.

[anon]

There's quite a leap from thinking about process improvement to actually doing it!!

It was the CEO who played the "we're more complicated" game, Mark was just asking some fair questions. Mark did get suckered into some of that back and forth, but I think the CEO Paul was being least productive. Like Kevin said, Mark was being pretty patient!

[Mark Graban]

Here's my post, most of which was written before my comments exchange with Paul Levy:

http://www.leanblog.org/2007/08/managements-job-is-to-be-proactive.html

[Paul Levy]

I have been trying to post a comment in reply, but it keeps getting filtered out by your less-than-perfect spam filter.

[Kevin]

Paul,
The spam filter just asks you to write down five letters in a row; I haven't heard of any other issues.

I am very interested in your perspective, so feel free to reply or to send me an email using the contact link on the left and I'll update the post. The discussion between you and Mark is very interesting.
-Kevin

[Mark Graban]

Paul's comment is posted on my site, it's up now.