Book: If Disney ran your hospital

I finally got around to start reading the book “If Disney ran your hospital’ by Fred Lee. I have heard a lot about it last year, and I am curious whether it can help our lean journey. Or will my predisposition be confirmed that the approach to care will be too simplistic, as if we should just entertain the patients more? Well, the first chapter did not disappoint me. Fred Lee has worked in a hospital for a long time and his mother, sister, partner, and daughter are nurses. One can feel that he is used to think from a care perspective. The most important connection with ‘lean thinking’ is in the first place his reflection on ‘value’, the core of lean thinking.

Fred reflects on the value that is of importance to gain patients’ loyalty. The elements care providers have to pay special attention to in order to accomplish this loyalty are:
- Be alert on peoples needs, before they ask for it (initiative)
- Help each other (teamwork)
- Recognize the feelings of people (empathy)
- Respect the dignity and privacy of others (courtesy)
- Explain what is happening (communication)

Intuitive this list gives me a good feeling. However, does it offer new points of application for the care we are giving at this moment?

Lean thinking and compassionate care

Recently O&I published an interview (in Dutch) with Jacob Caron, Orthopedic Surgeon and chairman of the medical staff of the St. Elisabeth Hospital in Tilburg in the Netherlands. Jacob talks about the relation between 'lean thinking' and 'compassionate care'. A reflection on several quotes using the 14 principles of The Toyota Way.

"...it's typical of 'lean thinking''  not to think from big, future plans, but to initiate change process from problems and issues in the current processes. By staying close to the existing processes, changes are kept small."

Principle 5: Build a culture of stopping to fix problems, to get quality right the first time

Fixing problems directly can only be done by the people that encounter the problems. That implies that every team member considers improving a normal part of every days' work. By keeping lean thinking small you bring it into the zone of influence of teams.

"... this approach creates a deep learning process that leads to sustainable change, because the change process does not limit itself to fighting fires, but is aimed at adressing the root causes"

Principle 14: Become a learning organization through relentless reflection and continuous improvement

Relentless reflection is confronting. Our (health care) culture tends not to show that you have a problem. To learn deeply, people need to be able to make themselves vulnerable so that root causes can be addressed and more fundamental change processes can take place. Trust is a basic condition. To create a culture of trust is very demanding of leadership.

"...it's important to anchor the 'lean thinking' philosophy in a long term vision on excellent care. This vision must include the core values of the hospital and gives direction to the process of continuous improvement that 'lean thinking' initiates. The St. Elisabeth Hospital chooses as a core value: 'compassionate care'.

Principle 1: Base your management decisions on a long-term philosophy, even at the expense of short-term financial goals

The long term philosophy will need to be so well connected to what the hospital stands for and what the environment needs that it will also provide direction in difficult times. In good times buffers need to be created that enable to hold on to the principles in the more difficult times.

It might seem contradictory that the earlier quote he stated that lean thinking does not start from a big future plan, and here he states that a long term philosophy is important. The difference is that, for me, a future plan is not value drive, but control driven. It's oriented at what is not. A long term philosophy is based on values and that provides direction to take decision in the here and now. It's oriented on what is. A future plan takes away initiative from most and gives it to a few. A long term philosophy can and increase initiative.

"Administration and leaders must stay connected to the primary processes and let that feed the vision."

Principle 12: Go and see for yourself to thoroughly understand the situation

Going to the source to base decisions on observations and experience from the work floor. This is extra difficult in health care, because many actions literally take place behind closed doors and because many steps are not taking place right after another (and many should not be). That makes it the more important to do effort to go to the source in health care. For example by attending daily or weekly (short) gatherings of teams that reflect on the day or week.

"In summary, 'lean thinking' creates space for compassionate care if the change process is anchored in a long term philosophy on excellent care. Compassionate care is part of the core value that is being optimized with 'lean health care'."

Principle 1: Base your management decisions on a long-term philosophy, even at the expense of short-term financial goals

"You need to understand your patient, what he wants and expects. Try then, each time again, to meet that expectation perfectly."

Principle 14: Become a learning organization through relentless reflection and continuous improvement

By connecting the first and the last principle it becomes full circle: relentless reflection on the way value is created, related to the changing expectations and values of patients, feeds the continuous, steadily improvements to deliver better value.

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?