What Happened To Lean Healthcare?

By Gerrit Van Wyk.

Toyota patient care.

Quite a few years ago, we had a problem with operating room (OR) time for surgery at the hospital I worked. The hospital, supposedly, was the first of its kind built according to lean principles and procedures in Canada. During my conversation with management, I pointed out that Toyota factories at the time worked three 8-hour shifts a day, 7 days a week, whereas operating rooms in our lean hospital worked only one 8 hour shift a day, 5 days a week. Comparatively speaking, the resources in that part of our hospital stood unused about 75% of the time, which is a tremendous waste, and lean aficionados will tell you lean tries to make procedures more efficient by removing waste. My suggestions about how to use those resources better was met with stony silence, and my OR time was reduced without further comment. Personally, I’m agnostic about lean, but that experience was not a good advertisement for the Toyota Production System.

After World War 2, the Toyota Motor Corporation realized it could not compete with American companies through mass production, but could use their unique low volume production to their advantage. They sent out people to gather information, and from the feedback stitched together a unique style of production. They already had experience of small lot production and stopping production to fix mistakes, and added; standardization, time and motion studies, and data analysis from Taylor’s scientific management, the use of interchangeable parts and a moving assembly line from Ford, just in time restocking from supermarkets, the idea of constant improvement from quality gurus, timed production from the Focke Wulf aircraft factory in Germany, and a management structure copied from General Motors. What one can see is the Toyota Production System, or lean as it is called in the West, wasn’t planned but emerged from a diverse group of ideas and practices, and even today is not written down in a manual.

What is missed in the West is the system was built on a foundation of Japanese culture, which, at the time, consisted of vertical group hierarchies determining rank and interactions, lifelong commitment to the company, and reward by seniority. As Hofstede’s research showed, Western culture is the exact opposite in all dimensions. The lean craze in the West missed the point that grafting a flexible system that is not a formula rigidly onto a completely different culture is a problem.

There is a story, or myth, about a hospital in the US with financial problems. The president of the board was flying somewhere, and ended up lamenting his problems to a lean consultant who happened to be seated next to him. The consultant whipped out his laptop and showed him lean could fix his problem, and in a jiffy, he was hired to help. A group of senior managers was mandated to study the new approach, and sent to Japan on a mission, and on their return transformed their hospital, supposedly successfully, although that’s a matter of opinion, by leaning it.

In 2010 the government of a Canadian province announced healthcare would by transformed into a lean manufacturing process. Government appointments were made, the same American consultant was hired, and his team fanned out over the province, but soon ran into trouble. He made it clear anyone opposing the project was an enemy and non-commissioned officers in management took it seriously, flushing out and hounding anchor draggers, driving them to quit, or be fired if needed. All that did was drive resistance underground, and eventually opposition from voters and medical professionals became so loud, the government announced the training wheels can come off, and the consultant’s contract was terminated. An effort was made to spin and sell the episode as a success by torturing data to confess, but no matter which way it was bent, it wouldn’t, and a promised academic review was quietly swept under the carpet when it became clear the outcome wouldn’t be pretty. After four years of turmoil, none of the promised savings were realized.

The first problem was, not enough thinking went into the idea treating humans is conceptually the same as building automobiles. A motor vehicle is a simple collection of parts that if assembled correctly, enables the vehicle to move. Health care is a service industry meaning humans with complex health problems interacting in a very complex social world. The two could not be more different. You can describe the parts of a motor vehicle and how they fit together in a manual, but trying to do so for humans and human interaction is impossible. Controlling a manufacturing process is not the same as trying to control human social interactions.

A second mistake was the consultant and people who hired him assumed Americans and Canadians are culturally the same. They are not. And that health care in the US is no different from that in Canada. It couldn’t be more different. Instead of pausing, reflecting, and adapting when things started going wrong, everyone tried to do more of the same, harder. It destroyed the morale of employees, who afterwards felt health care was in a worse position than before. In theory implementation was to be driven bottom up through employee contributions, in practice, as in other leaned industries, it was top-down do as you’re told.

A third problem is healthcare in Canada is a sociopolitical hot potato, or the third rail as Simpson called it; touch it and be ready to be electrocuted. The consultants and planners didn’t take account of that either. Failure, politically, is not an option, hence the spin to cover up the results afterwards. The reason a lot of hospital resources, like the OR in my story, radiology and laboratory equipment, etc., are grossly underutilized in Canada is a lack of funding, that funding is distributed politically, and that in turn cannot be discussed. If we used those resources fully, as in a lean factory, the controversial conversation about diverting funding to private institutions would disappear. In a sense, politically, lean healthcare was doomed to fail from the beginning.

One would think we would reflect on what went wrong and learn from it, but like the recent COVID mess, it was brushed off and the rush was on to repeat a mistake of the same kind. There is a lot to learn from what happened; the fact health care is complex and not simple like an automobile, leading and managing a complex social system like health care is different from leading and managing a manufacturing company, prepackaged solutions don’t survive in different ecologies from what they were designed for, you won’t change anything without ongoing respectful dialogue with the people who do the work, and politicians, leaders, planners and consultants are not heroes but part of the problem.

Lean, like a malnourished patient, slowly withered away and was eventually replaced by another rushed initiative without enough time spent to think it through. The more things change the more they remain the same, while health workers are blown about in another change tornado. No wonder they are burnt out, depressed, demoralized, and leave the profession as soon as they can. Looking to add more bodies to beat up in the same way makes no sense. We can and must do better than that, and there are excellent ways to do so. All they need is a chance, and, because this is Canada, political support. Ashby’s Law says you cannot manage complexity with simplistic solutions. Let’s step away from the mechanistic approaches that keep failing, acknowledge what we are dealing with is complex, and then tackle the problem with approaches appropriate for that complexity.