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Dean Bliss

Health Care

Why Lean? Why Now?

Health care reform offers an opportunity for improvement using lean tools and techniques

Published: Thursday, October 28, 2010 - 12:24


ealth care reform, insurance changes, more insured patients, never events, changing reimbursements, accountable care organizations, medical home—what does it all mean? How do we react? How do we keep up with all the changes? The questions are many, and the answers are few, so what do we do?

The listed above is just a glimpse of the changing environment of health care. Much of it is coming from legislation over which we have little control. The easy thing to do would be to play the victim, but the results may be undesirable—cost woes, access reduction, financial loss. The smart thing may be to approach the changes head on. A reasonable objective is for organizations to address what they can control and get better every day.

That’s where lean comes in. Most health care stakeholders know that the lean philosophy, tools, and techniques originated from the Toyota Production System, which is in the business of making cars, not treating patients. But the concepts and techniques can navigate to any type of business, including health care, as the examples from ThedaCare, Virginia Mason, and others have shown.

What does this have to do with health care reform? If an organization can improve from the inside by reducing waste and improving efficiency, capacity to see more patients, and quality, it will be in a better position to absorb the reforms and continue to do business. As quality improves, never events are reduced. As efficiency improves, the ability to see more patients improves. As resources are more efficiently used, costs can be kept under control.

Bringing the lean philosophy to an organization takes time. It takes building a culture that says, “Everyone, everywhere in the organization, will improve every day.” There must be leadership, creative thinking, and problem solving at all levels. All stakeholders must understand why something is done, what services the organization provides, and how they can best deliver those services. Training in the tools and techniques of lean are necessary.

It’s sounds like a daunting undertaking, but when an organization gets involved in improvement, momentum starts to build, and everyone in the organization can see the weaknesses in the processes and is equipped and empowered to correct them. That’s when an organization can make quantum leaps in quality, efficiency, patient access, and staff satisfaction. Patients are happier and more satisfied. Providers are freed from mundane and wasteful tasks and can spend more time with their patients. The bottom line of the financial statements can also be improved substantially.

The tools of lean are easy to learn. The methodology is not rocket science—or more appropriately for health care, brain surgery. That’s one of the best features of lean: With a little training, everyone can apply it. Once someone is taught how to see the waste in a process, he will see it everywhere. The challenge is to apply leadership, priorities, and resources to the identified problems to ensure that the right tools are used to find and fix the root cause of a problem, and that the work is then organized to eliminate the problem.

I’m often asked if lean really works in health care. “We know it’s a manufacturing thing,” I hear. My response is to give example after example of health care organizations that have seen tremendous results from the use of the lean philosophy, and not just in clinical areas. Areas such as finance, human resources, scheduling, and purchasing can benefit from the tools and philosophy of lean. It works, and it works everywhere. Especially now, with health care reform looming, we need to apply it, and we need to start now.

This article first appeared in the October issue of the National Association for Healthcare Quality’s NAHQ e-news


About The Author

Dean Bliss

Dean Bliss is a senior lean Six Sigma health care coach for the Altarum Institute, a nonprofit health systems research and consulting organization based in Ann Arbor, Michigan.


Here's why not Lean and not Now!

There can be no denying that recently there has been a massive increase in the Lean marketing machine touting for more Healthcare business. It does seem that as experiments in one field fails, there is an attempt to shift it to a new field of exploration. Recently we have seen Lean in HMRC tax services in the UK hit the news headlines:
2010 - http://bit.ly/9Gyf4T
Also recently Lean experimentation in cafe's has hit the headlines.
2009 - http://bit.ly/1sEvJk
2010 - http://bit.ly/aumcRO
The things that join these Lean failures together is the very thing that Dean Bliss appears to be calling for in hospitals the 'tools and techniques of lean' which he describes as necessary.
Professor John Seddon has written compellingly about the problems associated with Lean tools. He has collected all of his articles together here:
In particular this easy to listen to podcast called 'Rethinking Lean Service' provides an alternative analysis of Lean

Your evidence

SYSTEMSTHINKER - the notion that you and Tripp share that lean can be "dangerous" (your words) for healthcare -- is this a theory or a fear or do you have evidence and examples? If you do have examples, it's time to step forward with them.

Conflicts of interest

Can we please have a rule here about stating your conflict of interest, since Howard (SYSTEMSTHINKER) works for John Seddon....

Did you even read Dean's piece? He talks about philosophy and management system... this is ridiculous.

98% + Lean projects fail

Happy to declare the relationship between Seddon and the Systems Thinking Review (http://www.thesystemsthinkingreview.co.uk/)
Even happy to declare that I have an MSc in Lean Operations (2 years and lots of money and hard study). Every word that I say about Lean downgrades the value of that qualification. Imagine.
If you don't take my word for it try reading a Lean post in 2006 that declares that 98% + of Lean projects fail.
The exact words are:
'98%+ lean failure rate - which most folks seem to think jives with our feel for the situation'
Every time Lean is criticized you attack them, smear them, rubbish their arguments.
I have links to a long list of articles in the press that criticize Lean or highlight failures and every single one of them has comments that claim that these are all LAME.
LAME or just real Lean in action.

A clear pattern

Howard- there is a clear pattern here: John Seddon uses insults and personal attacks against the entire lean community (or against individuals) and then when people disagree on the merits of the discussion or point out conflicts of interest, you scream that you're being smeared and attacked.

LEAN as a FAILED methodology

I now have a long list of articles which suggest tactics designed to smear, undermine and intimidate those who dare to be critics of LEAN.
In one comment you call a Nursing union arrogant for refusing to talk to you (when you have nothing to do with the hospital).
Seddon has criticized LEAN http://bit.ly/bNyB50 because he keeps encountering LEANs trail of destruction (e.g. a selection http://bbc.in/HQmDc - http://bbc.in/a9FBD7 - http://bbc.in/a9FBD7 - http://bit.ly/cAw1mD - http://bbc.in/cu3HB4 - http://bit.ly/8XwOYI - http://nyti.ms/9nPFxN) of its (self-proclaimed) 98%+ FAILURE rate http://bit.ly/9UX06i
When you consider all of those frontline workers subjected to your tools and suffering from standardization, Sedddon calling those who apply lean tools 'TOOLHEADS' or arguing that LEAN is a 'WICKED DISEASE' seems reasonable and appropriate.
Your bias is that you run a blog that makes money from advertising LEAN tools and techniques and Seddons reasonable criticisms considering a (lean blog reported) 98%+ FAILURE RATE OF LEAN http://bit.ly/9UX0 hits your bottom line.

I'd give up too

You lack evidence and don't want to be challenged. Hospitals need to know what they are getting into, lives are at stake. Before drinking the Kool-aid . . . test it.


Tripp - you are the only that lacks evidence that Lean is "dangerous" (as you say) or that it doesn't work.

There is countless evidence data and evidence published all over the place that Lean can work in healthcare, especially when it is treated as a philosophy and a management system instead of being just a bunch of tools.

If you had evidence or experience to share, I would listen. I'm still waiting.


Tripp - there's clearly no satisfying you here, so I give up. No amount of evidence or data is going to convince you that lean works outside of the factory floor, even with differences between functions and industries.

It's worth, however, noting for other readers your financial relationship with Vanguard UK, since you so graciously endorsed their model as the only thing that works. Conflict of interest much? I, like Chet, work for LEI. I don't hide that relationship.

If your Vanguard method really works that well, then have it at. Good luck. I hope you help a lot of hospitals improve quality and safety. I don't see how you're recruiting people to help you with your online discourse, but maybe you know better than me about how to transform an industry.

I'm still curious if you will respond to Chet's question (and mine) asking you to clarify your allegation that the numbers in On the Mend are suspect?

What suspect data?

Tripp -- OK, one thing at a time... since you're making an accusation that "On the Mend" has "suspect data," what specifically are you calling suspect?

The Stats problem

Many different things and there are no perfect data . . . understood. Here are a couple:

1. An understanding that there was not any reward or incentive to manipulate the data. If executives or managers were rewarded for the numbers manipulation can easily come into play. I asked you this question and you said you didn't know. Yet you promote the book and all that is in it.

2. There are no data on control charts. The writers assail six sigma in the book, but the one useful thing that six sigma has in the SPC charts. The book itself, displays no knowledge of variation. Deming and Shewhart left us a great way to look at data. If you put the Theda Care employee satisfaction survey (page 170) on a XmovR chart you will see that there is no improvement is ee satisfaction all points with in the limits, chart it yourself. The lack of charts tells me a lot that is wrong with the approach. How do you improve a system without knowledge of special and common causes of variation and the importance in taking the right or wrong action?

You claim to know about Deming and his teachings and promote a book devoid of one of his most important contributions.

3. Operational definitions. How things are or aren't counted make a difference. I have no idea whether the same operational definitions that were used in the baseline data applied to the "improvement" data. I do know that when I get into the work that I usually find things mis-categorized, just by pulling them out does not constitute improvement. I would say that in most improvement efforts that I have been involved that operational definitions have a tendency to change.

4. These writers don't explain what is wrong with the data. Ever talk to a scientist? He can tell you what is wrong with his findings regarding an experiment. Same thing applies to data. I see some things like the footnote on page 3 that gives me a range of data results for a time period (not relevant to Theda Care's data and its timeline), but no chart indicating limits for the HHS data.

I suspect other problems but peer reviewed or not, most physicians don't work with data in this way. They may know medicine, but most don't understand variation or the use and misuse of data.

There are others but I can't and won't fix all that is wrong and suspect with lean manufacturing approaches in service industry.

About the data


Does your organization (or any that you've seen) publish such statements affirming that employees and managers weren't manipulated into fudging the numbers that are published? Good grief. You are setting the bar ridiculously high and asking someone to prove something that likely can't be proven to your liking anyway (if they affirm the numbers aren't fudged, you'll simply choose not to believe them). It's pretty damn cynical of you to assume the numbers are all manipulated. That makes me feel sorry for you, honestly.

Does any book out there publish results in control chart format? I have long advocated for this in my book and on my blog. I agree that would be helpful to represent the data that way, but I'm happy to support "On the Mend", as it offers a lot of good ideas for the benefit of healthcare or society.

You seemed pretty tortured over all of this and about lean in general. Again, I'd suggest going forth and prospering with your method. If it's a better approach, you will win. Your argument aside, a lot of good things are happening with lean in healthcare and most people are willing to recognize that.

To your other points, are you criticizing me personally or the book? I thought we were talking about ThedaCare and whether their data is valid. That's the topic at hand.


Problems with Lean in Healthcare and Hospitals

I am in the process of reading "On the Mend" which is written by John Toussaint of Theda Care and I am still seeing the fundamental thinking problems associated with a "lean" approach to Health Care or any other service industry. This has nothing to do with some of the suspect data given as proof at the beginning of the book, but more the close association directed with manufacturing tools and thinking.

Specifically, in Chapter 3 there is a conclusion that the "5 Whys" leads to the need for a standardized process. How did we get there? This is the manufacturing bend that most service organizations take. If standardization is good for manufacturing . . . then it must be good for service. Service has different problems and one constantly ignored by the manufacturing lean folks is variety of demand in service is greater than manufacturing. Health care (and more specifically hospitals) has great variety in demands, patients with more than one associated chronic and/or acute condition need care that can absorb this variety in the design of the work. Standardization often keeps variety from being absorbed. A 5 Why or any questioning exercise should conclude with a clear picture of the problem, not a preconceived notion about a solution.

Both Toussaint and Don Berwick (CMS) continue to make manufacturing overtones for service and leave (at a minimum) on the table better solutions to redesigning the work. Other than the variety problem noted earlier, the service agent and customer are part of the delivery in service. In practical terms, this means the customer sets the nominal value. Whereas, in manufacturing we are concerned with things like model, color and how many.

Further, there is no consistent "lean method" ask 100 different lean people a question and you are likely to get a 100 different answers. Lean folks claim that many are doing lean wrong, which begs the question . . . who is doing it right?


Please cite the data you are challenging and explain. I think it’s time for you to substantiate such an allegation or retract it.

By the way, re-read On the Mend pages 28, 52, 67, 71, 93-98, 135-136, 154, 171-174, where standardized work as applied to healthcare is fully explained. You’ll see that unlike your mistaken characterization of it as an inflexible one-best-way approach, standardized work is always being improved.

I’d like to point out that asking the “5 Whys” in Chapter 3, an exercise you questioned because it led to a team’s realization that a standard process was needed, was part of a very successful effort to reduce the waiting time for people suffering heart attack symptoms.

I’d argue that having an efficient standardized process for treating heart attacks is a good thing if every step in the process adds value from the patients’ point of view — immediate EKG in a dedicated room, all medication stored in a kit that a nurse grabs as she enters the room, immediate vital signs taken by another nurse, immediate paging of a catheter team if the ER doctor sees a heart attack on the EKG, etc. This is what ThedaCare did. And it is continuously improving the process, beginning from the baseline of the current standardized process.

You failed to note that on p.42, also in Chapter 3, that doctors believe that because a standardized process is now followed for every person complaining of chest pains, more people having heart attacks are being identified and treated, especially women and others having atypical symptoms.

Perhaps you haven’t gotten to page 112. The authors explain what can’t be standardized about medicine. They call it “middle flow” and it’s the time doctors actually examine patients and discuss treatment. Every patient is different so there is no attempt to make every doctor behave the same way. However, much of what happen before and after examination – making the appointment, taking vital signs, running follow-up tests, making follow-up appointments – can be improved by standardized work as well as other lean concepts.

In healthcare, the customer should not be viewed as merely “part of the delivery” as you imply; that’s a dangerous approach. The customer (patient) should be the focus of delivery processes. In fact, lean healthcare designs care around the patient as a true system approach should. (Full disclosure: I work at the Lean Enterprise Institute, publisher of On the Mend. You are invited to read what respected healthcare and process improvement experts have said about the book at:
http://www.lean.org/BookStore/ProductDetails.cfm?SelectedProductId=275&P... )

March on out

I addressed the data part.

With regards to the 5 Whys. So, are you saying it is OK to question with the solution already in your hand? Why don't you just start with standardized work like the rest of the toolheads/LAME (found one Mark).

As I said in my post on this matter of standardized work, starting there is problematic. All hospitals have different demands and looking for standard work may lead to the inability of the system to absorb variety. Hospitals (especially) that can build systems to absorb variety. Starting with standard work is just wrong and could make matters worse if we are busy seeking compliance. The fact they don't understand variation (previous reply) adds to the (messyness) of this approach.

The most important discovery of the book, was that management remained unchanged (page 81). They recognize this as a problem, John Seddon recognized this years ago, if they were aware of him they wouldn't have gotten here without change in thinking for leadership. The Vanguard Method is completely set up to change thinking something lean lacks and in service is critical especially in hospitals. Yes, I am partners with them and glad to be. Instead Lean advocates service use A4s (manufacturing) and have little check boxes for executives and managers to show up in the work now and then (Mark had this in a presentation). This may be one of the reasons they have trouble mixing coffee for Starbucks. The approach lacks the systemic approach needed.

I'll get back to the book at some point, but I didn't find it either compelling or breakthrough.

Varietal Interlude

Could you please provide a model of 'absorbed variety' in any business setting?

Thanks in advance.

100 ways?

Tripp - your old cut and paste talking point was that Lean was "codified" in an extreme, unevolving way. You speak of Lean as this centrally-controlled monolith... but now you're trying to claim there is no consistent method. Which is it? Clearly, there is no "cookbook" for how to implement Lean. If there were, you'd criticize that. There are consistent Lean principles -- it's easier to define "what Lean is" and "what Lean is not" than it is to define precise roadmap that doesn't exist.

Many are "doing Lean wrong" because they don't understand or don't embrace core concepts like "respect for people" or they blindly copy tools. Neither Berwick nor Toussaint are advocating the blind copying of tools. They are being inspired by manufacturing quality, which is often at a higher level than healthcare.

Who is doing is right? Clearly, ThedaCare is one of those organizations (based on their peer-reviewed data) and yet they'd be the first to admit that they aren't perfect and they don't have it all figured it.

Codification and more tools

Here is a quote from the article "Areas such as finance, human resources, scheduling, and purchasing can benefit from the tools and philosophy of lean." I don't see the evidence for this and quite the contrary have seen more harm than good in service. May be the LAME/toolheads but even a gun comes with a warning. You say you can't control every Tom, Dick and Harry that puts up a lean consultancy which really scares me in healthcare, because here they come straight from manufacturing (a fallen industry) with their tool kits ready to remedy health care like manufacturing. I can only hope not.

The codification has to do with the tools approach that you now say is wrong (a waffle, it is the political season). So, you must be the "lean expert," but many lean consultants are using the tools approach. Can you promise that LEI will discontinue the lean manufacturing tools training for service?

Theda care (page 50) applies the 8 Wastes taken directly from TPS, service has different problems. The biggest is variety of demands. If I start with 8 Wastes, are there others? It starts a pre-conceived notion of what wastes exists . . . what if there are others that manufacturing doesn't account for? They never account for the waste associated with what is between the managers' or workers' ears and how that may affect the work. There is more to being efficient, you must be effective. This means everything has to be looked at not just 8 manufacturing wastes.

Which leaves us with a question for the tools being taught . . . where are the new tools that came from learning service problems? I have yet to see one new, service-only tool come from understanding service problems from the lean community.

I do see one group, in the UK (Vanguard) applying new thinking that is starting to create another gap that the US will have to overcome. While we are fighting over tools, they are getting way ahead. Japan gave us payback for WWII, do we have to get whipped by the British in service too? Payback for the Revolutionary war, I suppose.