Mark Graban, the author of Lean Hospitals – we read the brand new second edition of this book – worked as improvement and change manager in companies like General Motors, Dell and Honeywell. In 2005 he became Lean healthcare consultant for ValuMetrix. In that role, he coached Lean teams in many hospitals in North America and the United Kingdom.

Coach
The word ‘coach’ is deliberately chosen here. As Graban emphasizes repeatedly, consultants (and in a later phase internal Lean managers) must not give answers, but should guide an improvement team by asking questions, so that the people in it will learn to develop their own solutions.

To have success with Lean, you need an organization in which information about what to improve moves down, and ideas about how to improve move up. If you implement Lean in that way, it works also outside manufacturing, says Graban, since the behavior and needs of people in all organizations are more or less the same.

Graban proves to be familiar with the whole body of Lean knowledge, and is an active member of the well-known Lean Enterprise Institute. In June 2011, he became chief improvement officer at KaiNexus. This company makes web-based software, to make information about improvement projects available to everyone in a healthcare organization.

Translation
Graban speaks the language of healthcare professionals. In his very readable book, he translates the tools and practices of Lean into everyday situations and challenges in hospitals. A large number of improvement cases in (US-) hospitals is added for clarification. This will certainly help to make doctors and nurses enthusiastic. Basically, the whole book can be seen as a call to experiment at your ‘Gemba’ (shopfloor) with Lean!

None of the tools or approaches is discussed in detail. This book should be seen as an introduction to Lean and a very good one, since nearly all aspects of this improvement method pass in review. Writing such a book is not an easy task, since Lean consists of many interconnected principles and tools. Lean should change what we do, how we manage it, and even what we believe, says Graban.

System
Lean is not applying some tools like Kanban, but should be an integrated improvement system. To succeed, also the organizational part should be addressed. Only then you will be able to create more value for the customer (the patient) with less resources and less costs.

The fact that Lean is a system is also the reason why Graban thinks it is not a good idea to start with one tool, for example 5S, and implement this throughout your entire hospital.

Lean tools should be an aid to solve problems in the workplace and to reduce waste, with would otherwise interfere with patient care. Therefore it is far better to start simultaneously with the tools and the organizational part of Lean, be it restricted to one value stream or one department. So start small, but broad.

Many hospitals begin for example with Lean in their laboratory. If you do that, it is a good idea to have for example a nurse in an improvement team. Not only is she the voice of the customer, he or she can also help to spread Lean further.

Title: Lean Hospitals

Subtitle:  Improving Quality, Patient Safety, and Employee Engagement

Author:   Mark Graban
Additional information:  Second edition (2012), 245 pages, published by CRC Press.

Pro’s and Con’s:

++      A very well balanced and clear introduction to Lean in hospitals

+        Lean concepts are translated to practical situations in hospitals
+        Tools like 5S and Kanban are positioned as part of an integrated Lean system
+        Also Lean management and organization is discussed
+        Practical line of approach
+        Many case descriptions

+-       Restricted to hospitals, nursing homes are not discussed.

-         Clinical pathways are not discussed*
-         Making a business case is not worked out commercially*

*) Mark Graban reacts on these two points (clinical patwways and making a business case) in his blog about Lean in hospitals↗
    Graban's blog↗ also provides links to order the book, which costs about $46.

Time to care
To have success with Lean, first it should be made clear that although jobs and roles might change, improvements will not lead to layoffs, says Graban.

On the contrary, Lean should improve existing j obs, for example by leveling the amount of work over the day. Peak loads are not only bad for humans, these also reduce the throughput in a hospital. In addition, time which is freed by removing wasteful steps can be used to better serve the patients, which includes explaining medical procedures and relieving their anxiety. To stress that, the Lean teaching program of the National Health Care in the UK is called Releasing time to care.

Error prove
No problem is a problem if you want to apply Lean, since problems are opportunities for improvement. Therefore there should be room to come out with problems, or to admit that you (nearly) made a mistake.

When something goes severely wrong in a hospital, news reports often contain quotes that blame individuals. Often, these persons did indeed something wrong, like for example pre-labeling empty bottles, and filling them later with the wrong medicine. People should act responsible and can be held accountable if they deliberately violate rules.  In the book some extreme cases are mentioned with experienced health practitioners who even ended up in jail.  

But there is also another side: often it is the system which makes it possible that people make errors, even if they have the best intentions. Therefore it is one of the objectives of Lean to make work methods as error prove (Poka Yoke) as possible.

A good metric for the ‘Leanness’ of a hospital might be the number of warnings signs, states Graban. The fewer warning messages are needed, the better.  Each sign is an indicator of a process problem of which the root cause has not been addressed yet. Why? Because if you can’t make an error or if that mistake has never happened before, the warning sign wouldn’t be there!

Lean manager
It is the task of a lean manager in a hospital to:

1. get each person to take initiative to solve problems and to improve their own job.
2. ensure that each person’s job contributes to provide care and/or add value for the patient.

The central thought within Lean is that people improve their own work, to create increasingly more value. Managers are only guiding, helping and coaching them to do that. Because everyone should know what things have the highest priority, objectives should be cascaded downwards, so that each person knows how he or she can contribute personally.

Graban explains this Lean management concept in a nutshell. If you are a manager in a hospital I would advise as further reading:  “Managing to Learn” by John Shook (also advised by Graban), “Toyota Kata” by Mike Rother, and “The Lean manager”, written by father and son Ballé.  Another good book is “The Birth of Lean”, because this explains that Lean is essentially a scientific approach, with lots of trial-and-error.

       ^  ThedaCare in Wisconsin, discussed earlier in On the Mend, is also mentioned
           as example in Lean Hospitals. Here, a Kaizen event group in ThedaCare studies
           the layout of a work unit. 

Practical
What I liked in particular of Lean hospitals is the practical line of approach. The book is full of real-life examples and anecdotes, which clarify and inspire. Learning from eachother is a good idea. To exchange best practices, in the US Healthcare Value Networks are formed.

However, Graban stresses repeatedly that you should not copy practices of others, but experiment – within safe boundaries - to discover what works in your own situation.

Standardize
To know what is ‘better’, you should first standardize the current work as ‘proven care’. Not all the work, but only the most critical tasks. The people doing the work should also know why complying to the standardized steps is important. During the second world war, this concept was already part of the Training Within Industry program!

Besides being standardized, work should be organized in such a way – using visual management tools - that any problem becomes readily apparent.  When this occurs, a problem-solving process starts immediately to find the root cause. The aim is to improve the standardized way of working. Hypothetical solutions are tested by rapid experimentation.  

Value added
The principal goal of Lean is to increase the rate and amount in which value is added to ‘products’ (patients, laboratory samples etcetera). This raises quality, but simultaneously the costs and needed resources are reduced.

Keeping inventory low can attribute to that, but that should never become the primary objective. The same holds true for the illustrious idea to create a One Piece Flow, with patients and laboratory samples streaming through the hospital without buffers and waiting times. This is not an absolute target, but more a direction giver!

Besides these practical guidelines the book also contains useful tips for managers, for example for when they visit their Gemba. One example: It is far better to say “this process seems to have a lot of wasted motion” then “you are walking too much”. Always remember that it is the process which is wrong, not the person executing it.       

Business case
Since the book is meant as an introduction for healthcare professionals, not all aspects of Lean are discussed in detail. Therefore it is logical that supplementing methods like Six Sigma are only discussed briefly. However, it is remarkable that the Theory of Constraints, applied in several English and Dutch hospitals,  is not mentioned at all.

A real shortcoming in my eyes is that the concept of clinical pathways is not discussed.
In addition, I missed a chapter about making a business case for Lean healthcare, since this book will be read by many executives. The first chapter does explain which problems hospitals are facing today, and how Lean might help. Mark Graban states correctly that managers should make it very clear that Lean will not be used to drive layoffs. Otherwise resistance will occur, and you will not get the involvement you need. This raises however the question how a hospital – which cannot simply grow like a manufacturer - can reap commercial fruits of Lean improvements.  Sometimes, process improvement can be an alternative for otherwise needed investments . However, if Lean ‘only’ leads for example to beds becoming free, as a result of a shorter length of stay, then the commercial advantage is not so clear. How to fill these extra beds? A related problem is the current reimbursement system, which peculiarly enough pays for the number of operations, not for the health value added to patients. Healthcare needs lean accounting!

To conclude: Lean Hospitals is a very good book to start with if you want to learn about the possibilities of Lean in healthcare.

Need help to implement Lean? Here's a list of our sponsors/advertisers of the site-section Lean.

Referral to this article on the internet?
Use as link: http://www.business-improvement.eu/lean/Lean_Hospitals.php