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?

What is your first association with lean?

Often I ask people what their first association is with lean. I invite you to answer that question for yourself. What is your first association with lean?

................. .............

The answers I get usually are synonyms  for 'reducing waste' or 'improving efficiency'. That was also my first association when I started to dive into lean. By now I regret it. My first association is now 'value'. I'd state that if you don't take 'value' as the starting point of lean, your efforts sooner or later will work against you. A personal anecdote:

As a physiotherapist, my mother often treated people at their homes. When I came out of school, I often went with her. One day, we visited a woman that was not able anymore to move her fingers well. My mother asked her what she would like to do again with her hands. She said shet would love to play bridge again with her friends. My mother asked whether she had a deck of cards in the house en I got them. Then my mother invented exercises with the cards.

Care providers connect to a person asking a personal question. They try to understand what is of value for this person. It does not make much sense to reduce waste if this process is not well understood. It can be useful to consider two types of value:

1. The reason why someone asks a question to a care provider. What's happening to me? What should I do? Why? Activities that help answer those type of questions add value, for example a consultation, diagnostic research and an operation.
2. That what is important for a patient during the process. Comforting a restless patient, touching a confused patient, giving attention during vulnerable moments. These are not activities that help answer the questions that the patient came for to the hospital, but at that moment they are of value.

If we reduce waste without first understanding value we start of the wrong side. The risk is real that reducing waste will become a goal in itself. Perhaps the biggest risk of introducing lean is becoming anorexic. Few people working in healthcare have a passion for reducing waste. They want to be of meaning to other people. From that motivation, they are willing to improve processes and to reduce waste so that they can spend more time on valuable activities. But in that order.

I'd state that the effects of lean should not be measured by how much waste is reduced, but how much more or better value is created.

What was your first association with lean? How does that relate to value? I invite you to share your association!

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.

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!?

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?