The basic facts are clear – the provincial Government saw significant challenges in its health care system, These seem to have been the usual suspects – an ageing population, more people living longer with long-term conditions, more acute admissions and greater difficulty in moving people back out of hospital. So, in an attempt to increase efficiency and improve quality, the government embarked on a hugely ambitious plan to use Lean at scale.
They agreed a large contract – variously reported as $30 million, $33 million and $40 million – with a consultancy firm to train 880 Lean Leaders, and to support Lean implementation. The local newspapers, and various blogs and websites, document a stormy course with opposition and dissent at various levels. Some of the blogs also document problems in the wider system, with labour disputes, financial cuts and concerns about privatisation of health care, which is probably an important context for later worries.
Many of the criticisms are familiar from other health care use of Lean – people aren’t cars, you can’t apply industrial ideas to health care, there’s no waste anyway – and similar critcisms. I’ve discussed some of these ideas in previous posts, and none are inherently unreasonable: you can’t expect people to accept Lean as an idea until they see it working, and it’s natural that people are concerned about the potential for changes to their work. When you’re already under pressure, it can feel counterintuitive to spend money on quality improvement work. There’s a great example in the Canadian news reports of someone using a standard work form to explain to people how to use a coffee machine: this was held up to ridicule, and used as an example of misuse of techniques by people who did not favour Lean. None of this is particularly surprising.
There’s another tone to the discussions, however, that centres on methods of implementation. There are claims of a ‘militaristic’ approach to implementation. At a distance, it’s difficult to know what this means, and exactly how Lean methods were used, although some of the claims are that changes in some projects were being forced on staff, and dissent from proposed solutions was not permitted (see for example the claims in the debate recorded in the Saskatchewan Hansard on Thursday October 23rd, 2014 ). There was a barrage of criticism from Trade Unions, staff groups and opposition politicians, and the provincial government pulled the plug on the contract early, saying that enough Lean Leaders had been trained to make the system self-perpetuating. This could be true, but it also sounds like the sort of thing governments say when they’re extracting themselves from a perceived problem.
What can we take from all this? It’s difficult to know precisely what went wrong in the barrage of claim and counter-claim – hopefully objective work will be published which examines the failures and successes in this story.
There have been some sequelae, however. Dr Visvanthan, a urologist in the area, commented in the Leader-Post,
‘…our health-care system remains burdened with waste: long wait times, redundant or useless testing, and fragmented care delivery.
Whether or not we apply the lean label to our efforts, we desperately need to improve health-care delivery. It’s time to separate the politics of lean from its potential.’
Regina Qu’Appelle Health Region, which I’ve used as an example in some earlier posts, is planning to continue to use Lean, despite criticisms of the implementation that were reported in the October 24th debate (mentioned above). A Regina Qu’Appelle Director is quoted as saying that they will ‘continue the improvement journey’.
No doubt some of the concerns expressed in the debate are fundamental disagreements with the use of Lean in health care, but the responses above suggest that the underlying problems are still there to address, and that at least some areas plan to continue with Lean at their own pace, because of positive outcomes.
Without a definitive and objective review, it’s challenging to know what to take from all this. On the face of it, it seems a sensible approach: if some Lean work is good, then a lot of Lean work must be great, you might feel. Most of the reports suggest that the external consultants were technically very competent in Lean, and had supported projects elsewhere without incident, so lack of knowledge seems unlikely to be a problem. The issues may be about context, preparation, style, scale and sustainability.
On context, this was a system already in turmoil. There were major pressures on staff, and perceived – and probably actual – staff shortages. The health service was already subject to considerable political attention. This is similar to most health care systems, and people often start to think about quality when there are problems in the system, so this is not a show stopper. The various blog posts suggest, however, that many staff believed the focus of Lean work to be on cost savings rather than on quality. When you start from this basis, it can be very difficult to take staff with you.
Preparation is essential. In earlier posts, I’ve touched on the research evidence that Lean – or any improvement method – has the greatest chance of working when there is management support, and organisational alignment. There was a single political decision that committed many areas to work on Lean simultaneously, and there may have been very limited previous experience or knowledge of Lean in at least some of the areas affected. My experience is that services usually want to look at Lean for a while before deciding if it is right for them. If Lean was imposed on the entire system, that may not have happened, reducing ownership and commitment.
Style is more difficult to assess, given that the information and debate became so politicised. Some of the accounts suggest that methods and systems were required to be implemented. There were some criticisms of the focus on Rapid Process Improvement Workshops (RPIW), rather than on wider quality improvement. Working out the solutions before the problems are identified, if it occurred, does seem at odds with promoting ownership and engagement. Respect for staff and patients is a foundation of Lean work: after all, it is the front line staff who develop, test and maintain the service changes.
The next challenge is scale. I have no knowledge of the capacity of the consultants in this project, but training over 800 Lean Leaders is an enormous challenge. According to the various websites, the method used to train Lean Leaders was an industry standard process of taking part in an RPIW and then taking on a formal role in two coached RPIWs, combined with classroom teaching. If the ‘880 Lean Leaders’ figure given in many of the press reports is right, then for 880 people to take part in two training RPIWs, you need almost 900 workshops. Saskatchewan is a big place, but that is a lot of workshops. The organisation for which I work took over three years to train 20 Lean Leaders, and that felt difficult – the amount of effort to train almost 900 leaders would be enormous.
Training at large volume also has the considerable challenge that, to generate this number of workshops, the answer to the question ‘how can we improve this?‘ has to become ‘ by running an RPIW’. This, in turn, can feed in to the concern, expressed in an internal health service memo discussed in the Saskatchewan Parliament, that only RPIWs are promoted. It may also give the inadvertent impression that Lean improvement can only happen as part of a big event, or with the involvement of staff with a great deal of training – neither of which are accurate. When teaching Lean methods, you encourage staff to pick up methods and use them in their day to day work, as well as in specific improvement events. If people believe that only experts can ‘do’ Lean, then there is a danger that changes may become pickled in aspic: the new process should only be kept until staff work out a better way of doing something, and you don’t want people to feel that a technocracy is needed to approve change.
Finally, some of the websites imply that no local coaches were being trained. I do not know if this is correct, but if so it has the obvious problem of leaving services dependent on external providers who also control the materials used. This makes it difficult to make local adaptions, and can again decrease the feeling of local ownership.
Consider what learning can be taken from this: for me, the main message from the limited information available is that implementing Lean at scale is difficult, and that context, capacity, ownership and sustainability are all important. We knew this already, but the Saskatchewan experience demonstrates the need to get as many of these right as possible, to maximise the benefits from improvement work.
Photo courtesy of domdeen, at freedigitalphotos.net