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Evidence that Lean CLEAR-ly Works in Healthcare

Posted by Mark Graban

Mar 30, 2021 1:14:00 PM

Dr. John Toussaint has long been one of the world's leading practitioners and advocates in the world of Lean healthcare, so it's always great to see what he has to say and share. 

John recently shared an email newsletter that also included this video message:


Many physicians and other healthcare leaders understand the need for data and evidence. That's their habit, and it's a good habit, especially when we are talking about new medications, new treatments, and new vaccines.

When it comes to Lean management, it gets more complicated. It's not really possible to set up placebo double-blind controlled experiments when it comes to Lean practices. You know you're doing them because you hypothesize that these methods will work, or you can work to make them work.

Sometimes people in healthcare will ask to see the evidence that Lean management is better, even though they didn't use such evidence to choose their existing management system (if it's a "system" at all). A collection of mindsets and practices doesn't make a management system any more than a pile of car parts creates a working car.

One academic research group working to create and compile evidence about the positive effects of Lean in healthcare is CLEAR (the Center for Lean Engagement & Research in Healthcare) based at the University of California, Berkeley. I've done two podcast interviews with one of the co-directors, Prof. Stephen Shortell, from that group you can listen to here and here.

They have published some new research that shows healthcare organizations that use Lean methods have lower costs and better outcomes. You can read a summary via the Catalysis blog, or you can read the full article here:

Lean Management and Hospital Performance: Adoption vs. Implementation

Here’s a summary of the results:

"Hospital adoption of Lean was associated with higher Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience scores (b = 3.35, p < 0.0001) on a scale of 100–300 but none of the other nine performance measures.

The degree of Lean implementation measured by the number of units throughout the hospital using Lean was associated with lower adjusted inpatient expense per admission (b = -38.67; p < 0.001), lower 30-day unplanned readmission rate (b = -0.01, p < 0.007), a score above the national average on the appropriate use of imaging—a measure of low-value care (odds ratio = 1.04, p < 0.042), and higher HCAHPS patient experience scores (b = 0.12, p < 0.012). The degree of Lean implementation was not associated with any of the other six performance measures."

In my experience, "using Lean" is not a simple binary yes-no determination. There's more of a spectrum of how many Lean mindsets and methods you are using. Is it an integrated system, and how consistent is your use of Lean practices? It's not easy to determine on a scale of 1-10. That makes research like this challenging (and above my pay grade).

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Their conclusions:

"Lean is an organization-wide sociotechnical performance improvement system."

Yes, I agree with that strongly. Lean is not just a bunch of technical tools. The "socio" piece refers to how we act and how we behave in a workplace—that's the culture and Lean management system.

"As such, the actual degree of implementation throughout the organization as opposed to mere adoption is, based on the present findings, more likely to be associated with positive hospital performance on at least some measures."

So, again, determining the "actual degree of implementation," as they put it, suggests, like I said, more than a yes-no adoption question. It's easy, though, for a hospital or a department to SAY they are using Lean when they aren't necessarily really doing so.

Catalysis has shared the full-text PDF on their website—they have a collaboration with CLEAR.

I agree with one of their conclusions:

"...[the results show that] the idea that adopting Lean as a targeted intervention or program is insufficient—rather, adopting and implementing Lean as an overall comprehensive sociotechnical management and leadership system requiring widespread and ongoing implementation overtime is needed to achieve positive changes in hospital-wide performance."

Again, you can't just use random tools or do sporadic projects. Lean has to be adopted more holistically and more consistently, hence the challenge.

I also agree with their assessment that Lean shouldn't be turned merely into a cost-cutting exercise:

"... the view that Lean applications in health care should not be restricted to cutting costs."

A truly Lean-thinking organization focuses on Safety, Quality, and Patient Flow. When those factors are improved, they lead to lower costs. There's a catch-22—if organizations are (incorrectly) focusing on Lean as cost-cutting, these organizations won't see a positive impact on safety or quality outcomes. If people are "doing Lean wrong," then their outcomes are a self-fulfilling prophecy. If I were a hospital leader, I'd worry less about what other organizations are doing with Lean and more about what my organization was doing and working toward.

So how is evidence like this received in your organization? Does it satisfy those who are demanding evidence? There's been evidence out there, long before this formal research effort and paper, that demonstrates that Lean can be effective in healthcare. That shouldn't be a serious question here in 2021.

Does that evidence, anecdotal or formal, mean that Lean is easy or that Lean will work in your organization? Of course not. Adopting Lean requires a lot of effort over time—it's not as simple as buying and installing a new type of MRI machine because evidence shows that it's less expensive and provides better quality.

When people see research, do they still make excuses about their organization being different or more complicated? Will logical and rational evidence ever fully convince people, given that humans are complex and emotional or organizational politics often overwhelm what's rational?

What do you say about those questions or the article?

Topics: Lean Healthcare

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