Editorial

Citation

Bowerman, J. (2007), "Editorial", Leadership in Health Services, Vol. 20 No. 4. https://doi.org/10.1108/lhs.2007.21120daa.001

Editorial

Welcome to the LHS special issue. This issue has been dedicated to contributions that discuss Lean and other related Quality Programs as they help to reduce or eliminate waste specifically in health delivery systems. Our interest in the concept of Lean was piqued as a result of Michael Balle and Anne Regnier’s article on the subject in LHS, Vol. 20 No. 1. Here, the writers describe how the process of lean has been used to build a learning environment on the part of the nursing staff and transform a Paris hospital. Next, a conference on the subject in Manchester in the early months of 2006 which was attended by two of our editors meant that they were able to speak to a number of working health care professionals who were actively involved in implementing lean initiatives in their workplaces, and who wanted to share their learning experiences with others.

Some of the papers in this issue originate from the Manchester conference. As such, they may not all be papers with an academic or professorial tone. Rather, in the form of stories, they represent the practical issues working staff have to deal with when they either personally initiate research or else lead initiatives intended to reduce or eliminate duplication. Thus they have immediate knowledge sharing value and should be of immediate and practical interest to those readers implementing lean initiatives or else thinking about them.

The concept of lean originates from the auto manufacturing environment of Toyota. For those of us who would prefer a less scientifically technical and more generous world, it is therefore viewed with some suspicion, especially when it comes to dealing with people who are sick, who are human beings rather than machine components, and whose lives are not about profit. However, it is safe to say that lean is viewed here not as a means to greater profitability, but rather as a means of helping patients in the health care system receive faster and more efficient treatment. In human terms this means translating waste in the form of duplication and unnecessary procedures into resources, so that more can be spread over an ever increasing population of need – so that people who are sick can be treated faster – in less time. With ever-increasing pressures on the delivery of health services, the application of leaner practices can only mean that ideally we can do more with less – minimize waste, eliminate patient backlogs, and treat more patients in a more timely and ultimately humane manner.

From this perspective, lean initiatives are leading initiatives, with enormous implications for professional practice and healthcare outcomes. Focusing on what the patient feels to be of value, all activities and processes within the system must be closely examined to determine whether they contribute to this end. To the extent that they may add cost or time without contributing to the end goal means that they become potential targets for elimination.

Balle and Regnier emphasize that “lean is well adapted to solve the operational problems presented by organizing the work of a large number of staff with a great variety of patients in a very demanding environment” (LHS, Vol. 20 No. 1, p. 33). This is certainly the case for modern health care organizations, which are large and complex, located within ever increasingly critical external environments, and under enormous pressure to change. And like all complex organizations, hospitals and health care services each have their unique cultures dominated by professions with their own histories, particular sets of practices and legislative boundaries. Lean requirements mean that interacting individuals from different professions, often operating within different systems and interacting within one large system, start to assess their own practices. Hence they become reflective practitioners, noting where the areas of overlap are, where the flows of patient care are interrupted, and where they can work together more effectively. As Balle notes, lean is first and foremost a system that must be constructed by the actors themselves. Lean is not a tool box of quick fixes. Nor is it about applying piecemeal applications of industrial practices to the various components of the medical environment. It requires an understanding of the big picture and the necessary awareness of how one’s role fits into that picture. The system becomes one of active learning, where the potential benefits are that patients experience greater safety and shorter lead times, and the health professions themselves achieve better understanding and greater mastery of their own practices (LHS, Vol. 20 No. 1, p. 33-4).

To be sure they may be some disadvantages to the introduction of lean initiatives in the health care field. For health care professionals already burned out as a result of the never ending pressure of constant change implemented by “external powers that be”, they may be viewed as just another change fad. But as potentially exciting initiatives involving folks themselves with real time for reflection and assessment, they could be just the “breath of fresh air” that this industry so sorely needs. In part it depends on how the change is led and managed.

As a case in point, David Fillingham’s article on the Bolton Hospitals National Health Services Trust reminds us that leading a major lean initiative is a long term patient outcome improvement project anticipated to last over a ten to twenty year time period and perhaps even longer. In the Bolton Trust, the lean initiative has been systematized as the Bolton Improved Care Service. Using a process known as Rapid Improvement Events (RIEs), (to this reader reminiscent of GE’s WorkOuts), Fillingham explains that “week long, hands-on change activities – involving more than 650 frontline staff over a two year period – sit within a rolling seven week cycle of planning, executing and following up change which piece by piece build better end to end processes for patient journeys”. Such a process allows change as a journey of never ending improvement to become embedded within the organizational culture, thus overcoming the natural change inertia afflicting organizations. These reflective activities help to prevent the organizational difficulties and inefficiencies that so often occur when a change in one part of the system adversely affects another part, thus cancelling out any potential benefits. Fillingham reminds us that Lean is not costly in terms of money, but it does require time to be built into the system for reflection, ongoing assessment and review – all components of a learning organization, thus bringing us back to Balle’s and Regnier’s main point that lean first and foremost is a system of thinking and learning. It is the ultimate in continuous improvement. What is special about the Bolton case study is not just the lean process itself but in addition, that the CEO is so supportive in setting the environment for the ongoing change initiatives to occur.

Providing a more limited perspective on the unnecessary duplication of medical administrative practices but certainly within the spirit of lean, Jenkinson et al. document how both junior doctors and nurses are required to take generic patient medical histories. This group of medical consultants point out that such duplication does not necessarily lead to better outcomes for the patients and that the nurses record more accurate patient histories. In the interests of efficiency therefore, their recommendation is for doctors to discontinue this generic practice. What makes this paper particularly interesting is that it is written by medical professionals, not administrators or professional researchers. It therefore could be said to represent a degree of self interest. At the same time any initiative that encourages more accurate medical history from patients and unnecessary duplication of activities between professional staff is certainly worthy of further research.

The paper presented by Bamford and Lodge documents a research initiative in the spirit of lean conducted in the Pennine Acute Hospitals NHS Trust. Using action research, the paper focuses on how the transformation to the use of electronic waiting lists and a logical approach to their management has led to much shorter wait times for patients. The paper speaks of the difficulty in bringing changes about in a system replete with change fatigue, and the need to involve the front line staff in change initiatives early in the process. Documenting lessons learned, what went well and what went not so well, the paper reminds us that senior level support for these kinds of major change initiatives tends to be present only when a national target is introduced, and is a timely reminder once more of the overriding importance of leadership in embedding continuous improvement within an organization.

Finally, Antony et al. present us with more of a general research paper on six sigma and its application to health care. Six Sigma is a variation of lean because of its emphasis on the reduction of process variation. In this case, the authors walk us through an explanation of what six sigma is, demonstrate its applicability to health care as a means of increasing customer and client satisfaction, while at the same time providing excellent service levels at minimal cost. Once again we are reminded of the importance of senior management and leadership buy-in for continuous improvement initiatives, and the importance of involving front line staff through ongoing training programs to bring about culture change.

The concept of lean is undoubtedly a hot topic in the field of management science today, and has particular relevance to the messy and very human world of health care today. To achieve greater efficiencies, provide more people with better care faster and more efficiently, at less cost, is surely the dream of every health care administrator. Lean first came to importance through Toyota which started out small but which came to the fore as the biggest and best automobile company in the world because it was able to apply the lean process to its manufacturing plant so effectively. It was and remains a learning company committed to continuous improvement and revolutionary rather than incremental change. In a recent HBR interview with Katsuaki Watanabe, President of Toyota (HBR July-August 2007, pp. 74-83), Watanabe notes that “when people are heading in the right direction, the small movements and the major ones will stay aligned”. He says “there’s no genius in our company. We just do whatever we believe is right, trying every day to improve every little bit and piece” (p. 83). The idea of continuous improvement through Lean or Six Sigma in the world of health care may not be quite so straight forward. Given the complexity of health care organizational cultures, incremental improvements may be all we can hope to achieve. However, as the articles in this issue demonstrate, lean initiatives hold great promise for changing the culture of health care organizations and the improved delivery of health care services to their clients.

Jennifer Bowerman