Lean in healthcare: The unfilled promise?
Introduction
There is a growing pressure on public services around the world to increase their efficiency by adopting concepts and methodologies more commonly associated with private enterprise and manufacturing. A recent review on the use of such methodologies in the public sector revealed that 51% of publications focused on Lean, a further 13% on Business Process Reengineering, with 35% stating their use in health services (Radnor, 2010). In short, Lean seeks to reconfigure organisational processes to reduce waste and enhance productivity based upon the application of specialist analytical tools and techniques coupled with creating a culture of continuous improvement (Womack & Jones, 1996). Lean projects in healthcare have become widespread: Brandao de Souza (2009) show that most have occurred in the USA (57%), with the UK growing at a fast pace (29%), followed by Australia at 4%. Cases such as the Virginia Mason Medical Center in Seattle (USA), Flinders in Australia and the Royal Bolton NHS Foundation Trust in the UK have become celebrated examples of Lean implementation in healthcare settings. In these and other cases there is growing evidence of the potential impact on quality, cost and time, and satisfaction of both staff and customers. Many of the results reported have been in terms of tangible outputs such as reduction in waiting times, increases in quality through a reduction of errors, reduction in costs, as well as intangibles ones such as increased employee motivation and increased customer satisfaction (Radnor & Boaden, 2008).
It is worth considering, however, that this ‘efficiency agenda’ is not new and that since 1970s and 80s various attempts have been made across the world to contain healthcare spending and improve service performance, including major structural reforms in commissioning (Ham, 1997). One of the most prominent and widely debated developments has been the expansion of management practices in the organisation of clinical services (Alford, 1975). Reflecting the ethos of New Public Management (Hood, 1991), the managerialisation of healthcare is widely based upon the introduction of ‘private sector personnel, models and techniques’ (Pettigrew, Ferlie, & McKee, 1992). This translation of private sector management practices into healthcare has been described by many commentators as representing challenging, even countervailing powers to established healthcare professionals (Alford, 1975). In the UK National Health Service (NHS) for instance, a multitude of specialist management domains have been introduced to transform established organisational and professional working practices regarded as wasteful, unproductive or unsafe. This includes performance management (Scrivens, 1988), Business Process Engineering (BPR) (McNulty & Ferlie, 2002), quality assurance (Pollitt, 1993), risk management (Waring, 2005) and knowledge management (Currie, Waring, & Finn, 2008). It is within this context that the recent introduction of Lean Healthcare can be seen as a further attempt to reorganise and rationalise healthcare services through the translation of management practices found within the commercial sector (Waring & Bishop, 2010). It is worth noting, that in many of these instances the impact on organisational performance, and indeed professional practice, has often been less than anticipated. Research attests to the persistence of deeply institutionalised forces that complicate and constrain reform (Currie and Suhomlinova, 2006, Pettigrew et al., 1992). This includes competing or contradictory political, regulatory or commissioning priorities; the persistence of powerful professional groups as manifest in specialist expertise, established ways of working, and defined jurisdictional boundaries; and high degrees of organisational complexity between both clinical specialities and service sectors that make the management of change difficult and contingent.
This marks the starting point of our paper, asking to what degree Lean has been successfully transferred into healthcare. We report on four multi-level longitudinal case studies within one region of the English NHS (three Hospital Trusts and one Mental Health Trust), where we essentially assessed what works, what did not, and why. We compare our findings to the general evolution of Lean in private organisations in order to draw out the differences related to the respective contexts over time, and to assess the validity of Lean as context-free improvement methodology.
Section snippets
Lean thinking
Originating from the Toyota Motor Corporation, Lean (also referred to as the Toyota Production System, TPS) is considered to be a radical alternative to the traditional method of mass production and batching principles for maximising operational efficiency, quality, speed and cost (Holweg, 2007). The development of Lean Production has been widely discussed, and shall not be recounted here (Fujimoto, 1999, Hines et al., 2004, Holweg, 2007, Ohno, 1988, Womack et al., 1990). Instead we briefly
Method
Our exploratory study looked further into how Lean is applied in healthcare organisations, and to determine the contextual factors that modulate implementation. A case study approach was taken to assess simultaneously the organisational dynamics of Lean at multiple levels and in multiple settings. Four public healthcare organisations within one English NHS region were identified that each had embarked on a Lean implementation in one or several parts of their organisation – either as part of
Findings
We present our findings using both overall observations that span across the four cases, as well as representative quotes. Before considering these in detail it is worth giving an overview of the purported impact of the Lean activity for each of the Trusts. For Pottery the impact reported included reduced waiting times, improved services for the patient, clearer understanding of the care pathways, removal of duplicated processes, tidying up of areas through the use of tools like 5S’s, enhanced
Discussion
Our findings highlight several important aspects of implementing Lean in healthcare. First, there are clear differences in how those implementing Lean define the customer and the subsequent creation of customer value; second there was a disjointed approach to implementing Lean across the organisation; third Lean was widely articulated as a tool-based approach; fourth, implementations projects tended to ‘hit a glass ceiling’. These findings are also supported by the literature which shows that
Outlook
Reflecting upon the recent White Paper (Department of Health, 2010), it might be speculated that to some degree these two critical breaches might be resolved in the English NHS. The paper sets out a vision of a ‘liberated NHS’ that places patients in the ‘driving seat’ of care planning and delivery. On the one hand, it devolves commissioning responsibilities to consortia of GPs who, through engaging more fully with their patients, become the purchasers of care. Although this will not completely
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