How Do We Show Benefits from Improvement Activities?

BenefitDr Leanne Hayward, a trainee in psychiatry, published a review of Lean approaches in the International Journal of Clinical Leadership in 2012. I can’t post a link to the whole paper, as it’s pay per view unless you have institutional access, but the abstract is available.

The paper is an interesting review of the development of Lean in health services, and in mental health. The policy focus is on the NHS in England and Wales, but many of the documents mentioned are relevant to other health systems, including Scotland. I didn’t agree with the detail of some of the descriptions of the various approaches – Lean, six sigma, TQM, PDSA cycles, and the divisions that Dr Hayward noted – but that doesn’t affect the overall value of the paper.

Dr Hayward points out that doctors, and many other health care professionals, are used to considering randomised controlled trial (RCT) as the gold standard for evidence. This is a problem for Lean approaches, as RCTs would be difficult – or impossible – to undertake, particularly given the enormous differences in time scales between rapid cycle improvement, and inevitably time consuming and expensive RCTs.

Dr Hayward goes beyond this to suggest ways of producing evidence that might be accepted – realist evaluation, and case studies, she notes, are possible methods, although there seem to be few examples of them in mental health. Being part of a wider evaluation framework could also be worthwhile, she suggests.

The paper has an interesting discussion of objections to the use of Lean in mental health – it’s too complicated, there are too many agencies involved, diagnoses change, it’s too reductionist, and so on. Dr Hayward challenges this by pointing out existing uses of Lean methods in mental health, including 5S, PDSA cycles, and integrated care pathways.

If you can access it, the paper is well worth reading in full. The main message is that there are few papers in traditional academic journals that report on Lean – and as Dr Hayward points out, cases studies that make it in to publication tend to be positive in any case. It’s important that those of us who are involved in Lean work take the point, and seek to document work – even when a project runs in to problems.

Photo courtesy of Stuart Miles at

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