How do you start with lean?

I am frequently asked how to make a start with lean and how to determine the objectives when starting with lean. First of, lean is an improvement strategy. So there are no lean objectives. There are only team, division or hospital related objectives. The lean principles, instruments and way of thinking, can be used to accomplish these objectives. Where to start, thus depends on what you want to accomplish with a team, division or hospital. 

Are your issues for example:

• A declining number of patients?
• Enough patients, financially healthy, but we want to improve quality and service delivery, because this is our vision and/or we want to achieve stronger patient loyalty?
• The workload is too high; the work of the care providers does not provide enough fulfillment anymore?
• We see the world changing, and are worried whether we are able to change rapidly enough to keep up with these changes? We want to become more flexible and improve on a systematic basis.

Are you making a start with lean only to solve short term problems? The use of a few relevant instruments will be sufficient. Or do you desire to develop your team or organization on the long run? Do you want to work on the DNA of your organization? Your answers to these questions are relevant for how to make a start with lean.  

Pitfall of lean

Lean is one of the most widely used and proven management approaches. Yet, also with lean applications there are many organizations that do not achieve a real lean journey. Projects might deliver results, but they rarely lead to a sustainable development. After a while the attention drops away. What are the pitfalls of lean? A first exploration.

What characterizes the (popular) literature on lean? The approaches are largely based on a rational, predictable approach to organizations. Read the most common lean method another time:

1. Determine value
2. Identify the value stream
3. Create 'flow'
4. Let the customer 'pull'
5. Continuously improve
(Womack en Jones, Lean Thinking)

Step 1. Determine value
Could it be that different caregivers often think differently about what is of value to a patient? And that patients themselves have a completely different view? Hoe do you handle a great diversity of views? An example:

A department realized that they offer a poor service by giving their patient their date to be operated just shortly before the operation. Therefore they started a project to offer every patient their operation date directly in the outpatient clinic when the operation is decided. A nice improvement. Yet something felt not right. A later study showed that 95% of the patients indeed highly appreciated the new service. 5% however is very nervous before the operation and can't sleep anymore as soon as they have the date. They prefer to be called as shortly to the operation as possible. Determining value is often more nuanced than at first glance.

Step 3. Create 'flow'
Could it be that many forms of waste are related to historical patterns and relationships? That it can be threatening when this is analysed? Or that in itself rational process improvements create uncertainties for stakeholders? An example:

An outpatient clinic had problems with no shows, pressure of phone calls from patients and GPs requiring priority, much work with rescheduling sessions, and surprisingly enough, also many unused appointment slots. A major cause appeared to be that they used various types of appointments on fixed times in the sessions. E.g. always a new patient at 9am, 9.40am, 10.20am. This offers insufficient flexibility because every week there is a different numer of patients requiring a specific type of appointment. Just stop using fixed slots and plan flexible. The group of doctors however did not allow this. Why did they use fixed slots? Because they wanted to be sure that every specialist sees an equal number of new patients, thereby ensuring that each specialist contributes the same to the group. This had gone wrong in the past. From a flow perspective, the current planning method is a (minor) disaster and there are other solutions, but they would not let go because they feared that the old quarrel would come back.

Step 5. Continuously improve
What are your experiences when you suggests an apparantly good idea? Is it often not put to practice as quickly as you can imagine? An example:

On an outpatient clinic the relations had gone from bad to worse. There was much dissatisfaction. They saw many things they did not like, but they were not able to improve them. Interviews revealed that the assistents perceived that the specialists hold all the power and blocked any improvement. The specialists however said they had many good ideas, but they needed the assistants to realize them. Since the specialists did not have any formal power over the assistents they were not able to influence them. The specialists felt powerless.

With a sense of reality
The examples are not intended to indicate that the lean principles do not apply there. To the contrary. Lean however pays little attention to the non-rational side of change processes. Even thoug they often determine the progress. In the words of Marcel Boonen, manager of a care department: "after the logic starts the confusion".

With a lot of external pressures (higher management, program management, etc.) the rational approach can deliver results. Continuous improvement, a cultural change is something different. Lean thinking can not be implemented. For the non-rational side, to reach inside, other interventions are needed. This starts with the recognition of different views on value and problems and investigating them with a sense of reality. As a secretary once spontaneously shouted during an improvement session:

Do you mean that from now on you are going to take our ideas seriously!?