Article: 'Approach to efficiency is not well thought through'

Recently, an article ‘Approach to efficiency in healthcare is not well thought through’ (Aanpak effieicny in de zorg is ondoordacht) appeared in 'Medisch Contact' by W.H. van Harten, E.W. Hans en W.A.M. van Lent. In this article, they assess the business methods of the last years in Dutch hospitals, including lean management. They conclude that the methods are often accidentally or fashionably chosen. They also argue that there is little scientific evidence for the methods. Click here to read the whole article (in Dutch).

What I like about the article is the long-term perspective with which they look at the application of the methods. I also l and that they base this on the current problems of individual hospitals and they thus emphasize the importance of customization. Their final conclusion is:

“The variety of combinations of organizational development, type of problems and available methods requires a customized solution. Approaches that stress a culture of continuous improvement and that leave room for personal interpretation, such as lean management, seem therefore to offer currently the most perspective and besides that, they are easy to maintain. And that is very important, because introduction takes years in large organizations.”

I illustrate a few statements about the various methods:

“Theory of constraints (TOC): Addressing the most pressing problems in health care processes sounds sympathetic and will lead to results when there is only one bottleneck. Processes are usually complex, various departments are involved and there are connections between bottlenecks.”

Indeed, that is also my experience. Although, the methodology provides some good methods. In my experience it can be complementary to lean thinking.

“Six Sigma: This approach consists of two elements that can stand at odds with health care: the virtually 100% reliability that is rarely realized in medical processes and the hierarchical ‘belt-qualification’ that will, especially in the egalitarian Dutch organizations, face difficulties in the introduction.”

Indeed. Six Sigma is appropriate for only a limited number of processes. Currently, this is useless for most of the processes. Moreover, the approach does not fit in our culture. I do see several hospitals pursuing a sort of mix of lean and sig sigma and I am curious about the results.

The following is said about lean:

“Lean management: the philosophy behind lean management is rooted in the auto-industry (Toyota) and is about the elimination of waste, the application of  techniques to improve the quality of the processes and to add more value for the customer. Creating and implementing improvements takes place at the work floor. Value adding, reduction of waste, direct observation and continuous improvement are key terms. It takes decades to implement an approach into the entire organization: success stories, based on a project of one year are therefore not reliable and are not representative for an organization-wide implementation. In the literature, we found 24 techniques that are rallied under LM. This gives the method a toolbox character and offers opportunities for adaptation to the care environment.”

I agree with their criticisms on the success stories on project management that never cross the full depth of lean. I also agree  that the way lean is used and published often gets a toolbox character. I believe however that this is a pity, because in this way the essence of lean thinking is ignored and in this way it can never deliver a sustainable contribution for an organization. This is the reason why this web log is called ‘lean thinking’, to emphasize that it is a way of thinking and the tools are only of secondary importance. They interpret the toolbox character as positive, because a toolbox means that you can determine for every case which tools you need. And that is of course the power of lean. It has principles that can inspire you  and a wide range of techniques that you can use depending on the situation.

Finally, they argue:

“Our experience is that when a method is imposed in a hospital with many self-employed professionals, in a a dogmatic and forced way, that this will rather lead to resistance (or pseudo-cooperative) than to successful (local) decisiveness.”

This seems obvious, but apparently it is not. I consider lean thinking and the principles of the Toyota Way as a source of inspiration that can help us to improve our organization and our processes. Because they are essentially different from one another, they provide innovative insights. This means that a serious translation is needed for the health care. Once the introduction of the principles and methodologies have become an goal itself, the current practices get out of sight and any right-thinking professional will start to offer resistance. And that is a good thing!

As for the title 'Approach to efficiency in healthcare is not well thought through' I can only speak for ourselves (the Elisabeth Hospital). In our hospital, lean thinking was applied independently by  various departments in 2006. The departments were very enthusiastic and the approach seemed valuable. Extensive discussions were held and also other approaches were considered. We came to a pilot of four departments in 2007. This was evaluated in 2008 and lean was chosen to experiment further (but not yet as the central improvement approach).

Meanwhile, a V-team was created with four medical specialists and three managers who examine and foster the development of the principles in our hospital The V-team includes the chairman of the Medical Staff and the Chairman of the Policy Commission. We organized a symposium and work conferences and all (medical) managers have followed a course of Toyota. Based on these experiences we, as a hospital, have embraced lean thinking in 2010 formally as a source of inspiration and have connected it to our own developments (with as main focus: compassionate care).  I have the impression that we certainly did think it well through before we chose to apply the lean principles.

How do you experience this? Do you feel addressed by the statement that hospitals choose their approach not very thoughtful?