Many approaches to improving value in our health system focus on specific issues involving care delivery models such as optimizing primary care, coordinating care transitions, facilitating the care of the high need/high use patients, or reducing unnecessary readmissions. While improvement in specific areas will yield benefits for certain patients and populations, broad, all-encompassing improvements in quality and cost across the health care continuum will require more fundamental and comprehensive system transformation.
System transformations will require a disciplined and structured approach that is broadly applicable and easily implemented across all components and all processes within the complex health care system. Ideally, the approach would utilize the talents of the entire health care workforce, involve patients and their families, and focus on eliminating waste while retaining the value-added components of care.
Toyota Production System or “Lean” offers one such approach that has the capacity to hit the target on improved quality, lower costs, and increased employee and patient engagement. The power of Lean lies in both its philosophy and its robust tool set which takes aim at eliminating waste from the customer (in our case the patient) perspective.
First, Build People
Toyota built its improvement philosophy on the pillars of respect for people and continuous improvement — something health care should have an understanding of. Both Lean’s foundational pillar of respect for people and Toyota’s principle of first building people and then cars can invigorate the health care workforce.
The respect for people is also manifested in the belief in and reliance on every employee to be a problem solver. The Lean tools are elegantly simple and democratize problem solving. Every employee from a frontline clerk with a high school education to a department chair can understand a spaghetti diagram. The foundational pillar of continuous improvement relies on iteratively removing waste. The two pillars are linked by the idea that waste is disrespectful to humanity, workers, and for us, our patients.
The robust tool set includes tools for prioritization and alignment, tools to see and eliminate waste, tools for quality and structure. Leadership sets the priorities and staff solves the problems that they encounter every day as they do their work. Often people create “work-arounds” in trying to solve the barriers that exist in any process. These “work-arounds” are a source of waste and add new barriers that impede smooth process flow. Lean experts estimate that 60-90 percent of every process is waste.
The eight categories of waste described in Lean include overproduction, waiting, unnecessary transport, over-processing, excess inventory, unnecessary movement, unused human talent, and defects. Most of our health care institutions do not have a systematic and disciplined approach to identifying and eliminating waste. Some institutions may even think that they have very little waste, but using the Lean tools it is easy to uncover significant waste in the eight categories in any health care setting.
We have even institutionalized some wastes: think about the many large, luxurious waiting rooms we have built instead of eliminating the waste of waiting. Clearly, for patients and their families defects are the most devastating of the eight wastes causing harm and even patient death.
Benefits Of Lean Adoption
Over a decade ago a few health care systems saw the power of Lean. Virginia Mason, Thedacare, and Denver Health were early adopters of the system. The documentation of the substantial impact on cost, quality, and employee engagement of their efforts and that of others has led to increasing adoption of Lean. For example, Denver Health realized $195 million of financial benefits, including savings and increased productivity, from Lean while achieving the lowest ratio of observed to expected mortality rates among members of the University HealthSystem Consortium.
Health systems, hospitals, physician practices, and government departments, including the Centers for Medicare and Medicaid Services (CMS), are adopting Lean. By adopting Lean, CMS is decreasing contract modification cycle time by more than 50 percent, achieving a 95 percent reduction in post implementation information technology change requests in national quality programs, and saving thousands of hours of staff time by decreasing or eliminating meetings. One publishing company has released 30 books on Lean health care in the last year — clearly Lean is “in.”
Spreading The Lean Model
Despite this growing interest, full implementation of Lean has been spotty across the components of the health care system. Even in institutions where it is being been used, its breadth and pace are often limited. In this area of system transformation, as in many clinical areas, we face the problem of slow spread of proven approaches. Are there ways to accelerate the use of Lean to enable a broad, comprehensive approach to higher quality and lower cost? We believe there are.
One approach is to rigorously document the power of Lean to reduce cost and improve quality. The reports by the President’s Council on Advisors on Science and Technology and by Institute of Medicine, which discuss the power of system engineering and Lean are excellent examples of documentation, endorsement, and dissemination.
Dissemination will also require journals in all health care disciplines to publish outcomes and lessons from Lean implementation in the health care sector. Trade groups, specialty societies, state governments, and federal agencies could highlight the benefits they have achieved through implementation of Lean. Organizations and entities that have successfully adopted Lean could offer training, as some are doing.
Consultants, in partnership with experienced Lean teachers, could offer guided implementation to accelerate the depth and breadth of Lean use across the health system. We need an accelerated pace of training of Lean leaders who can help drive culture change in health care organizations. Philanthropic and federal granting agencies could also include robust Lean efforts as a funding priority.
CMS through its CMS Innovation Center models and State Innovation Model grants could move toward greater emphasis on systematic approaches like Lean that yield broad health system improvements. Through learning collaboratives of participants such as Accountable Care Organizations, CMS is beginning to implement systematic approaches to improvement, including Lean, and is fostering a shared learning environment to increase the pace of innovation and spread.
As with other approaches that have the potential to move our health care system toward higher quality and lower cost, the widespread adoption and effective implementation of Lean will require time and a multipronged approach. However, we believe the time and effort invested has the potential to greatly reduce waste across all components of the health care system, markedly improve quality and reduce cost, and engage our workforce and patients in a way that values and rewards them. Lean is a respectful, disciplined and powerful approach to achieve the broad, comprehensive and important change that our health system needs.
The views expressed in this article represent the authors and not necessarily the policy or views of the Centers for Medicare and Medicaid Services.