Dan Jones reflects on the use of lean to revolutionise healthcare around the world
I t is still unclear whether lean thinking will turn out to be a wave or a fundamental driver for change in healthcare, not just in this country but across the world.
The prognosis is positive. One of the most significant things this government has done is to fundamentally change the
goal posts on the NHS – making hospitals responsible for their own finances and introducing an element of competition for patients, test results etc. Hospitals are not only competing against each other but also against new polyclinics and local treatment centres.
This provides a fertile ground for the real adoption of lean.
The early days of lean in healthcare have also followed a very familiar pattern. Initial enthusiasm for lean was built on rapid improvement events. Staff have experienced the liberation of being able to change things quickly, instead of seeing every idea killed off by endless consultation.
They also begin to see how broken the processes are in which they work, while they clear away a lot of low hanging fruit.
Lean actually starts with experiments taking a series of activities and turning them into a process; for instance, a new process for managing the flows through the pathology lab. This means seeing real demand and capacity, understanding current performance and the patient’s experience of the process and the variability of each step, which is critical if we really want to link them. But this is just the start.
Traditional management systems organise knowledge, careers and resources vertically in functions, departments and budgets. This is the right thing to do. However, the fundamental insight from lean thinking is that customer value is created by the actions of lots of different people across many departments and organisations.
Linking these together into a seamless end-to-end process or value stream reveals literally hundreds of opportunities for streamlining the flow, eliminating non value creating steps and aligning the rate of flow with customer demand.
Improving the performance of the organisation is the direct result of making these end-to-end value streams flow. The management challenge is to see and manage these horizontal value streams at the same time as organising knowledge in vertical departments.
Although healthcare initially appears very complex, in fact most patients travel down one of only a few value streams through a hospital or a healthcare system. In a hospital two entry points – accident and emergency and elective – feed five basic value streams – medical, surgical, outpatients, children and gynaecology. However, many types of patient share each of these primary value streams, and enabling them to flow involves synchronising many more subsidiary (but equally important) value streams so that the right people, records, beds, tests, porters, supplies etc are in place at the right time.
The consequences of this situation, where no one is responsible for these end-to-end value streams, was brilliantly revealed in the Gerry Robinson TV programmes. The great disappointment was that he offered no method for solving
these problems. Many people now recognise that lean is actually a management system as well as a set of principles for understanding value from the customer’s perspective and for designing end-toend value streams.
Management processes turn out to be as broken as operations, and they have a pervasive influence right across the hospital.
For example, strategy and planning processes typically mirror the political fight for resources at the national level. Every department holds its cards close to its chest as it bargains for extra resources. A lean policy management process on the other hand achieves the organisation’s strategic objectives through process improvements planned by each value stream manager, based on a very clear knowledge of the resources required.
Another example is the procurement and replenishment process. Walk round any ward or theatre, open the cupboards and you will find tens of thousands of pounds of stock hidden away.
If supplies to wards and from suppliers into the hospital were replenished daily as Toyota do it should be possible to reduce the purchase spend of the hospital by a third. Multiplied across the NHS the savings would be huge.
