Five Reasons Not To Spend Money on Quality Improvements

MoneyQuality improvements don’t have to cost money.

I’ve been reading two older books, both by Hiroyuki Hirano. Hirano is best know for his work on 5S, and his book ‘5 Pillars of the Visual Workplace‘. The two earlier books, ‘JIT Is Flow’, by Hirano and Makoto Furuya, and ‘JIT Factory Revolution’ are both valuable in their own right.

‘JIT’ stands for ‘Just in Time’, a core part of the Toyota Production System, and widely used in other management systems as well. I’m not going to dwell on Just in Time in this post – more on that in a later entry – but I do want to pick up some points that caught my eye.

Hirano and Furuya stress the importance of improving systems before you work on facilities. Their examples are from industry, where it can be enormously expensive to change machines and move production lines, but the principle is equally relevant in health and social care.  Hirano and Furyua go on to argue that you should not spend money on quality improvement. This reads, initially, as if it is an absolute pronouncement: when you read the context and the rest of the two books, however, it becomes clear that, like exhortations to ‘Zero Inventory’, it’s a way of making a point, rather than a commandment that needs to be taken literally..

So, what are the reasons for avoiding spending money on improvement? Taking their books, and my personal experience, I offer these reasons:

1. Improve the system first: It’s easy to generate big, expensive solutions. I’ve written about these tendencies in two previous posts ‘With Lean, How Big is Too Big’, and ‘Lean: Perfection or Incremental Improvement’. These solutions can be great, but sometimes they are an alternative to action. In some projects, the answer is always just over the hill, with the next innovation, the next piece of software or the next office relocation. These can be a barrier to making real changes, right now. If people start from the assumption that they have to improve services within their current resources, then it’s more difficult to rely on a deus ex machina solution. You have to fix it as far as you can yourself, and just now, not next year.

If you can improve the system, make the service function better for patients and staff, and make it stick, then the final improvements, that may need financial investment, become much more apparent.

2. Don’t buy more of the same: The obvious answer, if there is money on the table, is to buy more of what you have. Staff are very busy, everyone is working hard, but you still can’t get things done, so the answer must be more staff, more machines, or more rooms. Sometimes more of something is needed, but it’s very uncommon to have no improvements that can be made first.

For example, we worked with a service that wanted more rooms. When the service measured room occupancy during working hours, it averaged under 40%.  The main issue was how people flowed through the service, not the room numbers themselves (although there was an issue about large, fixed pieces of equipment that could only be used in specific rooms).

Another service wanted additional community staff. Early observations identified drags on staff time associated with unnecessary and duplicated administrative processes, communication delays and travel problems. Staff changed these systems, released time to spend with patients, decreased waiting times and decided they did not need an additional staff member at that time.

The point is not that people working in a service can’t change  it – all the changes that happened were designed by the staff – but rather that first impressions of the nature of a problem may not be complete.

3. Release staff creativity: people working in health and social care are extraordinarily creative, when given the opportunity. In a recent piece of work, a survey of patients on the run up to the Rapid Process Improvement Workshop (RPIW) found that there was a problem with the relative location of a waiting room and treatment room. Patients were attending a service where, because of its nature, other people attending would have a rough idea of why the person was there, and therefore of they type of news they might receive.In this case, the waiting room was directly opposite a short corridor to the treatment room. People on one side of the waiting room could see the person emerging, and could often guess from their demeanour the news they had received. This was embarrassing and upsetting for both the person leaving, and for the person waiting.

As one of the staff providing technical support for the RPIW, I fell into the trap of looking for a structural solution. I assumed we were going to have to move a door. A staff member working in the service listened to the same problem. She noted that the waiting room was very rarely more than half full. She then walked to the waiting room and removed the chairs on the side of the room that could see in to the treatment room corridor. The chairs were reused in a different area. The staff member, once given permission to change things, solved a problem that could easily have resulted in expensive building works. In the long run, you would want to see if you really needed a waiting area at all, but this was a pragmatic and inventive solution to an immediate problem.

4. Reveal flow problems: Improving the system begins to reveal previously concealed flow problems. In the out-patient service example above, about 20% of the people attending a particular clinic went on to undergo a procedure. This part of their attendance was not seen as a problem: it seemed to work fairly well, and there were much longer waits at other stages in the process. When flow was improved, however, it became clear that there were significant delays in the procedure stage. These were partly related to the rate at which people came in to that part of the process, and partly related to the set up time. Set up had not appeared to be an issue, because the flow was so unpredictable. When flow improved and smoothed, the set up delays in the treatment process became much more obvious. Going straight to a solution with more rooms and more staff would not have identified the problems in this process, and so allowed them to be addressed.

5. Encourage attention to value: Removing money from the equation, at least initially, can help focus on value. Value in Lean healthcare is something that gets the patient closer to their destination (see this post for a discussion of value). Focusing on value helps to boil a problem down to its essence. What do patients want? How do we achieve that? What stands in the way of delivery? It is easy to mistake activity for value, and to feel that the answer must be more activity. Focusing on value, and on the core requirements, helps to avoid expensive projects that fix perceived rather than actual problems. There are always things to spend money on, but we need to identify the nature of value first.

This does not mean that quality improvement never costs money, any more than ‘Zero Inventory’ means that we can literally run a service with no inventory at all. The staff time for improvement work has a cost of its own, and sometimes we really do need more staff, more equipment, more space – but the time to decide that and to invest, is once we understand the process in detail, have aligned it to value, and have identified precisely what added value the investment will deliver.

Photo courtesy of Mr GC at

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