Lean principles were born out of manufacturing applications but have been creatively applied across a variety of industries. Healthcare is one industry that has witnessed a lot of creative lean thinking in the recent years. Lean process improvement in healthcare is certainly possible as long as you recognize the unique elements of a healthcare environment.
Here are some of the unique elements for you to consider as you drive your team to improve results and change processes.
Patient pathways add a level of complexity based on findings at each step in the patient’s care
We all want to create value stream maps and then describe the perfectly streamlined future state. The challenge here is that a patient entering a hospital will go through a number of different paths depending on what happens with every interaction.
The intake information leads to a test; the test result suggests a conversation with a specialist, but that specialist isn’t immediately available; the pain becomes unbearable, so the patient receives a new medication; the patient has an allergic reaction … You get the idea.
The lean principles of mapping the process and making direct observations of the process steps in action are still valid. Just be sure to look at the process multiple ways to be sure you have a solid understanding of what can be improved and standardized.
Patients have emotions, which will impact decisions
Imagine that during a routine check, the doctor discovered something abnormal. The next step in the process would be to arrange a biopsy. The doctor could schedule the biopsy to be conducted immediately, which would be the fastest path to information and subsequent treatment. But, what if the patient is at this appointment alone and is in an emotional state and wants support? The patient shares that he/she would rather have a family member present. That immediately changes the process from what might look ideal on paper.
The process can still follow a natural flow of steps, but the timing of when things happen might have a lot of variability. The need for flexibility in the process is critical to allow for the patient to be emotionally ready for the next level of treatment.
Planned time with the patient needs to be flexible
Because of the factors described above, the healthcare practitioner needs to be flexible about what time they may need to spend to move the patient to the next step. It could be that there are unexpected steps, or a series of questions that the patient wants answered.
Here’s a real example with which I’m familiar, as it was my wife’s actual experience. Imagine that you go to a doctor’s office for a strange pain in your wrist, and you think it is internal and could even be a blood clot. The doctor gives a quick poke and twist and decides that you simply need an ace bandage for your sprain, and walks out the door. The problem is that you really want more conversation and you’re not convinced about the diagnosis because you have not done anything to injure your wrist, yet you’re left to call back if it doesn’t feel better in a few days.
We didn’t know what that doctor’s motivation was to move on so quickly, but it is clear by his behavior that he was trying to minimize time with the patient. When designing process steps and estimating time required at each step, be sure to build in flexibility so that the practitioners can do what is required.
By the way, in my wife’s real example it actually WAS a blood clot that was confirmed only after another similar blood clot appeared in her leg a couple weeks later when the same doctor finally agreed to send her to radiology for the proper test. Had the doctor taken the proper time to confirm the blood clot in her wrist during the first visit, he could have started the correct treatment and provided a higher quality of care.
On another side note, we later learned that many doctor’s offices have their doctors on a salary plan that motivates them to burn through a high volume of patients (and also incents them to prescribe tests or meds). This might work well for auto dealers but to treat doctors as commissioned sales persons is frightening!
Compensation is a management system that motivates behavior and, like any management system, needs to align with the other outcomes you want. If you are trying to improve patient care and recognize more time with patients correlates with better decisions and better care, then a compensation structure that rewards the physician for maximizing the number of patients he or she sees in an hour will create quite a conflict with the goal of allowing the optimum amount of time to improve decisions.
Gain both physician and administrative buy-in
Like any organization, there are multiple functions that have a say in how processes are followed. If administrators make decisions about process changes without involving the doctors, then the chance of implementing the changes is quite low. Similarly, if doctors decide things would be better a certain way and simply make the change without the right involvement by administrators, they will create friction.
This is not unlike any other organization. It is important to note that these groups are typically high-powered thinkers who are quite busy, and so the chance of process changes sticking is quite low unless you can gain buy-in first.
Inventory management matters
You might not think of a hospital or doctors office as a facility with a lot of inventory, but there are quite a few critical items. Think of medical supplies that have a shelf life but also must be available. This situation lends itself to some basic analytics and some good inventory management strategies.
The lean principle of pull fits well here, and kanban can certainly be used for any item that does not have shelf life concerns. For those that do have a shelf life, you can review the cost of a stock-out vs cost of carrying the item and then make reasonable minimum inventory decisions. As long as you follow first-in-first-out (FIFO), you should be fine.
A widget in a production process doesn’t care if it gets moved from area to area, if it gets multiple tests done on it, or if it has to wait for a machine to become available. A patient, on the other hand, does care. The patient is not a widget, but a human being with all the complex dynamics that we, as people, experience. The approach in healthcare therefore needs to be modified to take this into consideration for a successfully optimized process AND a successful experience for the patient.
People do have a say in where they choose to receive services, and hospitals and doctors offices have begun to pay attention to the number of patients who are coming because they have heard positive buzz about other peoples’ experiences. For the healthcare industry to change its perception about how they treat their patients, they have to begin to apply all of the lean principles in a way that also enhances the patient experience. Those that treat patients like widgets will be perceived as cold patient factories. Those that make their patients feel like they really care will begin to see more people coming to them for service.
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