“Be kind and generous, strive to create a warm, homelike atmosphere,” Sakichi Toyoda Sakichi Toyoda was born in the year of Canada’s confederation, 1867. He invented of a variety of automatic looms during the period between 1890 and 1924. His inventions revolutionized the textile industry. In 1926 he founded the Toyoda Automatic Loom Works, Ltd. This company evolved into Toyota Corporation, a global automobile manufacturing giant. Mr. Toyoda had strong views about how best to run a company. His goal was to create an educated and united workforce that embraced his core principles. These precepts were codified by his son Kiichiro and published on October 30, 1935, 5 years after his death. He viewed these tenets as “moral standards” and they remain Toyota Corporation’s guiding principles. It’s not hard to get behind Mr. Toyoda’s 5-point philosophy (shown above) and most, if not all, of the tenets are relevant to the optimal running of a hospital. However, The Canadian health care system has primarily focused on one derivative of the Toyoda philosophy, which centres on reduction of waste. This approach has come to be called the Lean methodology. However, Lean was not one of Toyoda’s original tenets (although he certainly eschewed waste). This blog is inspired in part by the prevalence and fervour with which Lean has been embraced and in part by a recent article which suggests that the yield of Lean, as applied to health care, may not be as great as one might have hoped. Let’s review some basic facts about Lean: The term Lean is a recent addition to our lexicon, purportedly derived from John Krafcik’s 1988 article, "Triumph of the Lean Production System," Sloan Management Review 30 (1): 41–52.) Lean is defined in Wikipedia as: “A production philosophy that considers the expenditure of resources in any aspect other than the direct creation of value for the end customer to be wasteful, and thus a target for elimination. Working from the perspective of the client who consumes a product or service, "value" is any action or process that a customer would be willing to pay for.” (Wikipedia). Lean’s approach to optimize efficiency and reduce waste is given the acronym PDCA (plan, do, check, act). There is little to dislike in this strategy. However, a single approach is not optimal for all problems. Moreover, the Lean approach was designed for manufacturing, do we know it works in health care? It may be optimal to take a PDCA approach to enhance processes in the admitting office or in managing the physical plan of a hospital; but that does not necessarily mean this is the best (or at least not the only) approach to more complex issues, such as how best to achieve optimal flow with minimum rates of cancellation in the operating room or reduce waiting time in Emergency Departments. So how does Lean function when tested in the Canadian healthcare system? A recent report by Vermeulen et al sounds a cautionary note (Vermeulen et al). Vermeulen’s et al noted that Lean has been enthusiastically embraced by many Ontario hospitals and that resources and time have been spent implementing this system. However, in a paper in the Ann Emerg Med. (2014;-:1-12) they noted that “… although many studies report improvements in waiting times before and after lean-type interventions, none are randomized and none compare changes in performance with concurrent comparison sites”. Kudos to this team for performing a careful evaluation of the impact of Lean methodology. Their study addressed the following question: Can an emergency department (ED) process improvement program based on lean principles improve ED efficiency? Context: They examined the effects of Lean vs. conventional management on ED waiting times in Ontario. This is a hot topic in light of the undeniable congestion and delays in our emergency care system. In 2006, a report commissioned by the Ontario government proposed strategies to decrease emergency department delays/congestion. The following year the government indicated that it intended to reduce emergency room waiting times. In April 2008 Ontario’ s Emergency Department Wait Time Strategy was published” (emergency report). The Ontario ED process improvement program was launched in 2009 and rolled out in 3 waves, with increasing numbers of centres participating in Lean in each wave (and thus fewer non-Lean centres as the program rolled out). In wave 1 there were 5 Lean sites and 39 controls whereas by the end of wave 3 there were 15 Lean sites versus only 7 controls sites. It must be stressed participation was based on a statement of interest by the sites and thus the program was not randomized. Study design: The study used a retrospective cohort design and compared delays (wait times) for unscheduled Emergency room visits at sites where Lean was used. They looked at the impact of Lean by comparing waits in the ED before and after Lean implementation. More importantly they compared changes in ED waits in Lean centres versus control sites. The study was conducted in Ontario from April 1, 2007, to June 30, 2011. The Lean improvement program had structure and required resources. Dedicated hospital improvement teams were created (composed of senior leaders, managers, and staff from a variety of departments). These groups identified improvement opportunities to enhance patient flow. A 7-month implementation period was specified, which included diagnostic, solution design, pilot and control, and ultimately a rollout phases. The resources (beyond staff time) included “ an external lean coach to train and mentor improvement teams at each hospital, on-site support from lean management experts, training on the program methodology and tools for implementation, data management tools to track and report performance, linkages across sites to facilitate peer-to-peer mentoring, and forums for teaching and sharing progress “. In addition, Lean program required backfilling of positions that were previously held by staff redeployed to lead the Lean program. Key to understanding the study, not all Ontario Emergency Departments participated in Lean implementation; however even non-Lean centres were affected by the government’s overall ER Wait Time Strategy, which included public reporting of ED wait times. The primary outcomes analyzed in this study were 90th percentile and median ED length of stay, 90th percentile and median time to physician attention, and percentage of admitted and non-admitted patient missing provincial ED length-of-stay targets. Regardless whether a hospital was in the Lean program or not the provincial ED length-of-stay targets were < 8 hours for admitted patients and higher-acuity (Canadian Triage and Acuity Scale (CTAS levels 1-3) non-admitted patients, and < 4 hours for non-admitted patients triaged as lower acuity (CTAS level 4-5). Results: The unique value of this study was that the authors examined the question whether Lean methodology was effective not simply by comparing before vs after Lean intervention at centres that used the methodology; they also compared Lean vs non-Lean centres. While Lean appeared to have some benefit when looked at simply as before vs after at centres where Lean was implemented there was no benefit of Lean when comparison was made to control centres (see Figure below). Lack of benefit of Lean intervention when Lean centres were compared with Control Centres: In this Forest plot one can see the major findings. The lack of benefit of Lean vs conventional intervention is evident from the paucity of measures that fall significantly to the left of the 0 on the horizontal access (which would have indicated improvement). An interesting finding, which is perhaps intuitive, is that sites with the best performance pre-intervention (ie shortest wait times) had the least improvement in wait times with intervention. Limitations: The authors acknowledge that this lack of benefit may have been confounded by the simultaneous implementation of public reporting of ED wait times and pay for performance measures by the ministry of health and long term care (MOHLTC). Both of these factors would tend to drive hospital to shorten ED waits, regardless of the use of Lean. In addition, some sites did their own version of Lean without being part of the program. Thus the Lean intervention was shooting at a moving target. Nonetheless, the changes are not impressive for the amount of energy and money expended. Cost: Lean is not cheap. The government of Saskatchewan has an extensive Lean program and recently reduced its 4-year, $40-million contract with John Black and Associates, a U.S. Lean consultancy company, by ~ nine months (lean contract). Dan Florizone, deputy education minister and deputy minister responsible for Lean is reported to have said, “We have a need to become more self-sufficient in our Lean deployment. It’s really about weaning ourselves off consultants.” (digital commons). The authors note that while the costs of “this particular program were not available, Lean initiatives in general are not inexpensive, given need for external consultants, data collection tools, and staff time that must be assigned to quality improvement teams.” They conclude: “These findings demonstrate the value of using rigorous methods to evaluate the true effect of complex health system performance improvement initiative” My suggestion would be that we use Lean methodology (or any such tool) carefully and evaluate its benefits before rolling it out broadly. Mr. Toyoda did not use Lean to design his cars; although he may well have used some of these principles to increase efficiency of his assembly line and warehouse. I would argue that likewise, many higher-level functions in health care may not be optimally handled by Lean methodology. Indeed, when I visited the Toyota Corp’s web site and reviewed the Toyota Production system (TPS), I did not find reference to the Lean Methodology (Toyota Philosophy), However, the same website did devote significant time discussing Mr. Toyoda’s 5 tenets for running a successful business and these strike me as being more philosophically aligned to the complexity of running a hospital than Lean’s more waste-reduction focused approach. Thoughts about Lean at KGH based upon conversations with senior leadership:
- KGH’s strategy makes explicit reference to “lean” and other process excellence strategies –so that (our) notion is that there is no panacea and instead we advocate focusing on continuous improvement with alignment of effort to strategy and with measurement of whether there is desired or expected outcome.”
- It is also only as good as the ‘experience’ of those leading and or involved.
- Lean processes are improving and the study may not fully capture the current sate of the art
- Change or improvements will only occur if people actively involved in the trenches get engaged and want to see change.
Conclusions: Like many tools, Lean is best used in certain situations and is not the only tool in our chest. Lean is a valid approach to problem solving; however, it is not the best approach to solving all problems. Adherence to the Lean approach should not be construed as a litmus test for one’s commitment to improving healthcare. Innovation by physicians, nurses, pharmacists and other allied health workers (i.e. the folks who are at the coal-face), should remain central to health care reform. Our patients should be part of the innovation team and they will tell us when we get it right. I would suggest in the meantime that we consider the totality of Mr. Toyoda’s advice and commit to making hospitals have a warm and homelike atmosphere and fully engage our colleagues in a process of “endless creativity” to improve the care we deliver. Further reading: Check out the Healthy-Debate Blog by Vanessa Milne, Sachin Pendharkar & Gord Winkel for additional thoughts about the Lean Methodology and its use in the Canadian health care context: Healthy Debate