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Some more skepticism about Lean-based approaches for healthcare institutions


Lean-based system as made famous in Japan.

Michael I. Harrison, Ph.D., of the Agency for Healthcare Research and Quality, writes in NEJM Catalyst about the limitations of Lean-based approaches to healthcare institutions’ management.

He writes that “according to current research, Lean promises more than it has delivered. It is possible that published research studies are lagging practice, where there are some reports of Lean-driven breakthroughs in quality and value and even Lean-based culture change. But a positive publication bias may actually be leading the research literature to overestimate Lean’s potential.’’

Among his other observations:

  • “To ensure appropriate care for chronically ill patients, and to promote population health, organizations need to redefine some traditional operating objectives and performance standards and develop new or radically redesigned care processes, such as team-based primary care. As Lean experts and users concentrate on making current processes more efficient, they may devote insufficient attention and energy to developing new goals and care delivery designs.
  • “Except in tightly integrated systems, coordination of medical care requires cooperation across fragmented medical services. Health promotion calls for joint action by medical, social, and educational services. It takes time and concerted effort to build teams that bridge boundaries between care sites and entire organizations. But Lean projects typically rely on teams made up of members of the same organization, who already share objectives and operating assumptions.
  • “Radically transforming taken-for-granted assumptions, values, and work procedures goes far beyond targeting selected processes for improvement. To change culture, leaders must articulate an overarching organizational change strategy and align diverse programs and improvement initiatives with that strategy. Strategic and behavior change must be implemented and reinforced through the appropriate use of performance measures, incentives, training, and staffing. Lean thinkers call for culture change, but popular Lean improvement techniques alone do not provide sufficient change levers to promote it.’’

To read Mr. Harrison’s article, please hit this link.


‘Lean methodologies overrated’?


Front entrance of Virginia Mason’s main building.

A Seattle hospital system has  long been taking a “systems approach” in improving healthcare quality and cutting costs, looking to emulate some of Toyota’s practices.

Virginia Mason Health System has been lauded as being an exemplar of “Lean” methodology, based on eliminating waste and focusing on always adding more value.

But a blogger for Med Page Today who (rather timidly) uses the nom de plume of “Skeptical Scalpel” says Lean may be grossly overrated. He/she writes:

“Attempts to incorporate Lean into healthcare have met with varying degrees of success. I blogged about this 6 years ago and pointed out that a literature review done back then found ‘significant gaps in the [Lean and Six Sigma] healthcare quality improvement literature and very weak evidence that [Lean and Six Sigma] improve healthcare quality.’

Randomized prospective trials of Lean in medicine are lacking. A recent “paper from the Journal of the American College of Radiology found only seven studies on the use of Lean in radiology and they showed ‘high rates of systematic bias and imprecision.’ The authors concluded there was ‘a pressing need to conduct high-quality studies in order to realize the true potential of these quality improvement methodologies [Lean and Six Sigma] in healthcare and radiology.’

“In 2010, Toyota had recalled more than 9 million vehicles for various defects. Nothing has improved. So far this year, Toyota has recalled over 11,654,000 vehicles….”

“Having adopted Lean methodology in 2002, Virginia Mason is not really a new story. How is it doing?

“About as well as Toyota.

“In May of this year, the Joint Commission paid a surprise visit to Virginia Mason Medical Center and found 29 instances where the hospital was out of compliance with standards. The Seattle Times wrote that among the problems were not having an adequate infection prevention and control plan, failure to store medication safely, and failure to provide a ‘care, treatment, services and an environment that pose[d] no risk of an immediate threat to health or safety.”‘


“{I}f Lean works so well in healthcare, can anyone tell me: how does a hospital that has been practicing Lean methodology for 14 years achieve 29 Joint Commission citations?”

To read the whole blog entry, please hit this link.


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