Lean and compassionate care

Two hot topics in Dutch healthcare are 'lean thinking' and 'compassionate care' (menslievende zorg). We agree that they are related, but we have little understanding how. Therefore some thoughts about this from the perspective of lean thinking, based on: value, respect, time pressure and system thinking.

Value
Conceptually lean and compassion come together in the concept of value. Lean thinking means that every activity and process is viewed from the question: what value does it add? Compassionate care is a core value of our existence as a hospital and therefore a natural question to ask when improving processes: is this process compassionate? If not, why not?

If an acceleration of a process or standardization or another change is at the expense of compassionate care it is basically not an improvement.
 
Respect
One of the two core values of Toyota is: respect (besides Kaizen). Respect for customers, employees, supply chain partners and society. This translates, among others, that everyone is well equipped for their tasks and that everyone is challenged to perform a little better tomorrow. Respect is a  core value from lean thinking that relates well to compassionate care.

Time pressure and system thinking
Why is care (sometimes / often?) given less compassionate than we would like?  The academic hospital UMC Utrecht performed a study that is published in Journal for Nurses (Tijdschrift voor Verpleegkundigen), April 2009, 4. A quote from p.45:

"Nurses experienced obstructing factors to practice compassionate care. Time pressure was the main factor. Interviewees indicate that it's no excuse, but the amount of duties and hectic of the situation and basic care gets priority over the relationship with the patient."

Lean thinking focuses on reducing non-value adding activities, which can reduce the workload. One of the core principles is: hijunka. It aims to evenly distribute the workload throughout the day and the week. Health professionals often speak of running and standing still as their day rythm. It is conceivable that it is particularly difficult to provide compassionate care during peek levels of workload. Evenly distributing the workload with fewer disruptions can lead to more attention to patients

Compassionate care addresses directly the intrinsic motivation of individual care providers. Lean thinking can add: why does the system lead to inadequate compassionate care for our patients?

Example why there is no 'flow'

Recently I visited a PA lab and one of the analysts gave an example of a lack of flow:

Why does it take several weeks for the results of a smear for "cervical cancer' to get back to you? (Partly) because the smear is delivered only once a week by a courier from the pharmacies to the hospital. Then a big batch comes in. If you have bad luck it takes up to a week between the visit to your general practicioner and the the test getting into the hospital.

The hospital then has a week to process the whole batch (because it must be completed before the next batch comes in). If you have bad luck it takes another one week before your test gets into the process and you have waited for two weeks with, untill now, not one action that added value.

Why are the tests deliverd by courier in batches? Previously this did not happen, the general practicioners used to sent it by mail, which was literally a smear. A while ago, however, a new and better technique was introduced with tubes that do not fit through the letterbox. The GP therefore can not mail it anymore. Therefore, he (or an assistant) has to bring it to the pharmacy (which often also takes several days by the way), and a courier has to pick it up there again.

Suggestion of the analyst: ask the manufacturer of the tubes to create a smaller tube type that will allow to be mailed daily again, taking out more then two weeks of processing time.

His story shows nicely how you can look at processes from a (one-piece-) flow perspective. It shows the problem of batching, it uses root-cause analysis with '5 x why?" and reduction of unnecessary steps. A good example also how poor flow (weekly courier) leads to more bad flow (one week to process the tests).

Symposium lean thinking in healthcare - highlights

June 11 the symposium "lean thinking in health care" took place in the St. Elisabeth Hospital in Tilburg in the Netherlands. 230 participants from 20 hospitals and several research institutions, a packed auditorium.

Besides managers and staf many caregivers (almost half) and a remarkable level of energy. Was there at the first symposium last year an atmosphere of "could lean thinking be something for us?" this year it was' how can we work on it? ". Also, there was a lot of exchange of experiences with lean principles and tools. The application is increasing rapidly in the various hospitals.

In his book "The Toyota Way" Jeffrey Liker describes 14 principles that Toyota has developed over the years. He divided them into four pillars (roughly translated):

• Long-term philosophy that leads to greater value
• Improve processes: more flow and less waste 
• People excel through respect and challenge
• Countinuous, steady, improvement

I looked back at the program of last year, and noticed how the focus on the application of the principles in the care last year was mainly in the 2nd pillar: the improvement of processes. This year shows a different picture: a lot of attention to continuous improvement and the human side is well represented. Value also is represented in the form of the relationship between lean thinking and "loving care". It would therefore appear that the principles of Toyota are not only applied more in healthcare, but also the application evolves and gets richer.  A development that gives confidence that lean thinking can contribute to a sustainable development of healthcare.