In 2008, I had lunch with a physician from one of the region’s larger hospitals. He had recently seen a Toyota-based “lean” approach dramatically reduce infection rates in his hospital but predicted that it would never really take hold as a movement in healthcare. It could work in isolated arenas where it was championed by strong individuals, he argued, but it was too much of a culture change for the industry as a whole to embrace.
At the time, I didn’t know if he was right. The field of Lean Healthcare was very young. There were only two books and a handful of articles available on the topic. I could count on one hand the number of blogs or conferences or training programs that touched on the subject. Working for five years with the Pittsburgh Regional Healthcare Initiative (PRHI), I had seen a Toyota/Lean approach improve quality and safety, boost patient and staff satisfaction and save money in settings all across the care continuum. But the ability of physicians and hospital administrators to grasp its full potential on an organization- or industry-wide basis was still up in the air.
That same year, in 2008, I was recruited to lead a lean transformation at St Clair Hospital, and in the last three years the field of Lean Healthcare has exploded. I now have an entire shelf in my office devoted to books on the subject, my pick of several conferences to attend each year, and I can no longer keep up with all the blogs, online resources, and LinkedIn discussion groups dedicated to using Toyota thinking in healthcare.
This year, as hospitals wonder not whether they will lose revenue with the coming reform, but how much they will lose, the Toyota Production System is having its day in healthcare. Evolved from the rubble of post-war Japan, there was no room for waste of any kind at Toyota, so the company developed just-in-time production, tightly standardized work to achieve reliable outcomes, and invested heavily in training a workforce that would continuously ferret out and eliminate waste wherever it sprouted.
Looking ahead, the way to meet the demands of an increasingly exacting payer community and the needs of patients with high service expectations is not to cut costs across the board, but to follow a Toyota-style path of identifying and reducing any activity that does not provide a direct service to your customer or patient.
After the dramatic turnaround of our Emergency Department at St Clair Hospital, in which we used Toyota/Lean methods to redesign patient flow (bringing our overall patient satisfaction from the 61st percentile nationally to the 99th percentile in a single year), we turned to dozens of other improvement efforts all over our hospital. Some have been high level—affecting the entire hospital—like creating a dedicated Observation Unit for patients awaiting diagnosis. Others have been as simple as reducing the number of times a nurse has to leave a patient’s room by providing pill crushers for every room. Most exciting, however, is that having trained over 50% of our workforce (1,000+ employees) over the last three years in the basics of Toyota/Lean thinking, we see more and more improvements cropping up in every department. Some originate with leaders, but many come from frontline staff.
In our impatience we may look for the quick fix—the one big change that will give us back millions of dollars in cost, or an hour a day in lost time for our staff. But Toyota races like the tortoise. Those huge strokes of waste-cutting are rare, and most organizations have found them by now. What is left are the hundreds of small annoyances that riddle our complex healthcare delivery systems. The little errors and inefficiencies in our days that drain away the capacity to serve patients a few seconds or minutes at a time: the missing medication, the ambiguous job instructions, the ineligible chart, the incomplete shift report, the complicated phone tree. To plug those hundreds of drainage holes takes a disciplined organizational culture of relentless and continuous improvement with all hands on deck. One administrator or manager couldn’t possibly find all those holes, let alone know how to plug them effectively. Every employee’s critical eyes and creativity need to be harnessed in reducing waste.
When I look ahead, this is what I see. Armies of caregivers and support staff, equipped with disciplined ways of understanding and improving their work, and supported by a leadership who understand that Lean Healthcare is not a program, but a culture. A culture ideally suited for our time.
Tania Lyon holds a PhD in sociology from Princeton University and is the Director of Organizational Performance Improvement at St. Clair Hospital. For more information visit www.stclair.org.