This Doctor is Upset, But It Doesn’t Really Sound Like Lean | Mark Graban |

Emergency Medicine News

“[…] it’s a first-hand story and an opinion piece. […]  Dr. Cotton describes the poor treatment he’s received from a 40-something internal “Lean consultant” named Dean. […] Dr. Cotton describes a typically hectic E.D. scene where he’s “six patients behind” and he’s spent some time talking to a patient’s mom in an attempt to comfort her and explain the situation… a perfectly human and caring response. Then, Dr. Cotton describes an interaction that I’d hope would never happen[…]: ‘And that’s when Dean confronted me. ‘He wasn’t your patient! You are six patients behind!” Dean was the hospital’s MBA consultant for LEAN management.”

Sourced through Today, 9:12 AM

Michel Baudin‘s comments:

I think what happened to Dr. Cotton is primarily the result of 25 years of Lean bandwagon jumping. Ever since the name was coined, all sorts of consultants and gurus have rebranded their offerings as “Lean,” misleading their audiences and living off the reputation of the Toyota Production System.

Given the absence of consensus on a Lean body of knowledge or control on the appellation, this was inevitable. But this process has besmirched the “Lean” label, and I am not sure it is salvageable.

Dr. Cotton seems to have it in for MBAs, which Mark may think unfair because he has one. Mark’s saving grace, however, is that he is also a mechanical engineer.

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Medical Taylorism, Lean, and Toyota | P.Hartzband and J. Groopman | New England Journal of Medicine

Seen today in the New England Journal of Medicine, under the signature of Harvard Medical School professors Pamela Hartzband and Jerome Groopman:

“The TPS is a set of principles designed for the manufacture of inanimate objects in a factory. We accurately depict two essential elements of this system that are directly derived from Taylorism: standardization and time efficiency. In his classic study of the application of Toyota principles to the manufacture of cars in the United States, Paul Adler describes how ‘Each job was analyzed down to its constituent gestures, and the sequence of movements was refined and optimized for maximum performance. Every task was planned in great detail, and each worker was expected to perform that task in the prescribed manner.’ Adler refers to ‘the intelligent interpretation and application of Taylor’s time and motion studies’ as key to its success. He states, ‘The reference to Taylor may be jarring, but it fits.’

[…] Other medical professionals who, like us, have experienced the toxic effects of obsessive standardization and time efficiency in the care of patients have expressed concerns similar to ours. In an era of accountability, we believe that those who advocate the application of Lean principles to medical care must take responsibility for the unintended consequences resulting from these elements shared by Taylorism and Toyota practices.”

Michel Baudin‘s comments:

The authors base their claim that the Toyota Production System (TPS) is “derived from Taylorism” from the writings of Paul Adler, a business school professor at USC who has written many papers over the past 40 years, a few of which touched on TPS and NUMMI, the first plant to apply this system in the US and now operated by Tesla. I met Paul Adler at Stanford in the late 1980s, and found his insights on NUMMI quite valuable. It was also clear to me that Paul Adler was not an engineer, that TPS, to him was one interest out of many, and that his knowledge of the subject was only at the business school level, as reflected, for example in an expression like “Taylor’s time and motion studies.” Taylor did time studies; Frank and Lilian Gilbreth, motion studies with, as stated in other posts, very different objectives.

This distinction, perhaps too subtle for business schools, is of paramount importance to anyone who wants to understand TPS, which owes much more to the Gilbreth’s work than to Taylor’s. Taylor wanted to prevent workers from slacking off; the Gilbreths, to observe the way work was being done and make it easier. And the medical profession has a good reason to remember Frank and Lilian Gilbreth: the way operating rooms function today is based on the analysis and recommendations they made 100 years ago.

Health systems learn to be lean | Jodi Schwartz | Argus Leader

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Without adding staff, the Avera Medical Group gynecologic oncologist spends 10 more minutes with each patient than he used to and leaves work two hours earlier.

‘We were often stressed at our clinic and running late,’ he said. ‘Patients sometimes had to wait, and I was always behind on documentation.'”


Michel Baudin‘s comments:

See Mark Graban’s blog post about this article. It is a case he has been following, and is featured in the 2nd edition of Lean Hospitals.

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880 Saskatchewan health care leaders study Lean at Virginia Mason | The StarPhoenix

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“Close to 900 health workers will make the pilgrimage to Seattle in search of factory efficiency for hospitals. Take a look inside at the origins of the world’s biggest health quality experiment. […] With Virginia Mason as their model, the treks are part of a sweeping overhaul of how the provincial health system is managed. […]More than a decade into a journey that’s never really finished, Virginia Mason now makes it its business to teach health care leaders from all over the world about the Virginia Mason Production System.”

Michel Baudin‘s comments:

This Canadian newspaper article is the most detailed account I have seen of the “Virginia Mason Production System.” Virginia Mason Medical Center is a Seattle hospital that has been converting to Lean since 2001and now has a business unit teaching others what it has done.

100 years ago, industrial engineer Frank Gilbreth developed the operating room procedures that are standard today, so it’s not the first time hospitals learn from manufacturing.

What this article gives is examples of the changes that were made at Virginia Mason, in particular the application of 3P (“Production Preparation Process”), involving patients in the design of new care units, and simulating with full scale mockups.

Other specifics include building design features to support maintenance and upgrades without disrupting care, the use of the two-bin system to manage medication supplies, and visual management.

And the article also touts the results that Virginia Mason achieved through this effort, in terms of both improved care and economic performance.

The StartPhoenix is a Saskatchewan newspaper, and the article also tells readers about the cost to taxpayers of the effort to emulate Virginia Mason in the entire health system of the province.

Most striking is the $39M contract over four years given to the Seattle consulting firm that helped Virginia Mason. As this translates to tens of people working full time on the project, it looks more like engineering than consulting.

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Don’t ‘Lean’ on Me, Hospital Workers Say | Labor Notes

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“A sign in the newborn intensive care unit invited nurses to suggest changes that would speed up their work.

One popular suggestion: replace a sticky combination lock with swipe-card entry. But that would cost too much.

Instead, on a consultant’s recommendation, supplies were rearranged. Blue masking tape outlines now show where each item is supposed to go. A sign lists the “five S’s” of workplace organization (sorting, straightening, cleaning (shine), standardizing, and service). Each shift, one nurse is supposed to check them off.”

– See more at:

Michel Baudin‘s insight:

I had seen articles bashing Lean from a union perspective in manufacturing, but this is the first one I see about hospitals.

On the one hand, the author thinks that the work processes cannot be improved, and that the only way outcomes can be is by new equipment or more people. On the other hand, the “improvements” she describes are definitely L.A.M.E. (Lean As Mistakenly Implemented) rather than Lean: 5S as the most visible change, curtailment of communications between outgoing and incoming nurses as shift change, or reduction in the skill level of heart monitor operators, etc.

If that is what “Lean Health Care” boils down to, she has a point. But what about the use of Kanbans to manage supplies, as described in the “Par versus Kanban” article I scooped on 8/13?

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3 Reasons You Need to Include Employee Engagement in Your Lean Improvement Efforts | Becker’s Hospital Review

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“Done well, the Lean quality improvement philosophy can transform a healthcare organization when it comes to safety, quality, patient satisfaction and overall efficiency. So why aren’t healthcare leaders including employee engagement in the Lean mix? Here are three reasons you should.

1. Employee engagement needs to be on your radar screen daily.
Now more than ever, employee engagement is a game changer in healthcare. Every commitment we’re making to patients, our communities, the board, etc. depends on having engaged employees to deliver the services we are promising; therefore, engagement needs to be a recurring thought — not an afterthought…”

Michel Baudin‘s insight:

Makes you wonder what kind of “Lean effort” is not based on employee engagement from the start…

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Par Versus Kanban: Managing Variable Usage | Lean Hospital Group

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The great majority of hospitals in the United States manage hospital supplies using what is called the Par Level method. One of the strengths of this method, it is claimed, is that it works well in the face of variable usage.



Michel Baudin‘s insight:

If you have always wanted to know how hospitals managed their inventory of medicines, the article will both tell you the traditional method they have been using, and how the Kanban system can outperform it.

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The Virginia Mason Production System | Hospital Impact

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“Virginia Mason Medical Center in Seattle was the first in the nation to adapt the Toyota Production System as the framework for managing a medical center. We call our version the Virginia Mason Production System (VMPS). It is our management method to identify and eliminate waste and inefficiency in the numerous processes that are part of the healthcare experience.

By streamlining repetitive and low-touch aspects of care delivery, our physicians, nurses and other clinical staff members are freed to spend more time talking with, listening to and treating patients. We are discovering it is possible to provide high-quality care with lower resource utilization.”

Michel Baudin‘s insight:

This blog post by the CEO of Virginia Mason sheds some light on the specifics of the “Virginia Mason Production System.” He confirms that the focus has been on administrative tasks to allow doctors and nurses to spend more time with patients, rather than on what happens while the doctor or the nurse is with the patient.

What he describes involves breaking down communications and administrative transactions in “small lots,” organizing groups of contiguous rooms into “cells,” and reassigning tasks to better leverage available skills.

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Visitors see ‘lean’ during RUH tour | Star Phoenix

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 Technology is often touted as the cure for many of our modern afflictions.Funny, then, that a whiteboard in the staff room could make such a difference in how the city’s busiest emergency department runs.”It’s very low-tech,” says Jon Schmid, the registered nurse manager for Royal UniversityHospital’s emergency department. “But the impact it has on our organization is huge.”…

Michel Baudin‘s insight:

The text of the article is informative, particularly about the use of a white board, but the picture does not show this white board. In fact, it seems unrelated to the article, as if the newspaper just slapped on a stock photo from a hospital.

As it is, however, this photo is a good reason for the quotes around the word “Lean.” It is an encyclopedia of work space design mistakes, with work surfaces at uneven and ergonomically inappropriate heights, causing people to stoop, or even squat to access the refrigerator. Not to mention empty space in the center and chairs.

Workspace design mistakes

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Lean in administration at St. Luke’s Internal Medicine | David C. Pate

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TEAMwork is St. Luke’s application of lean principles. It’s our management operating system. TEAMwork stands for timely, effective, accountable, measureable work. And it’s making its way through St. Luke’s Health System as we gain on our Triple Aim of better health, better care, and lower costs.

Starting last summer, SLIM embarked on a top-to-bottom examination of how it conducted its work. They wanted to eliminate waste by tapping into the potential and knowledge of every member of the clinic team and build a culture of continuous improvement.



Michel Baudin‘s insight:

The improvements described are all about supplies and the handling of patients by nurses and administrative staff.

There is not a word about any changes to the work of doctors themselves or involvement by doctors in the improvement process. What form might that take? I don’t know, but, the last industrial engineers to work on health care before Lean were Frank and Lillian Gilbreth 100 years ago, and their focus was the work of surgeons inside operating rooms, not patient handling before and after they see a doctor.

The result of their work was the now standard mode of operation in which the surgeon calls for tools that are handed to him by nurses. It seems hard to believe today but, earlier, surgeons would actually leave patients to fetch tools.

Following in the Gilbreths’ footsteps today would mean for Lean Health Care to get involved with the core of the activity: what doctors do with patients.

In manufacturing, successful Lean implementations start with the work of production on the shop floor, not with the logistics upstream and downstream from production. First you worry about line layout, work station design, and the jobs of production operators. Then you move on to keeping them supplied and shipping their output.

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