Dan Jones at Medical Grand Rounds

Dan Jones continued his visit as our Judith and Robert Melzer Visiting Professor in Health Care Quality and Patient Safety with an appearance at Medical Grand Rounds. You see Dan here with his friend and colleague Jim Womack.

The topic was "Realizing the potential of Lean thinking in healthcare." I'll try to hit the highlights.

Joking that, after visiting our hospital, "I'm encouraged because your problems are the same I see everywhere else," Dan set forth the challenge as one of delivering more and better service to patients for less money. He noted that progress in the quality movement can be viewed an complimentary to implementation of Lean approaches. Whereas the quality movement strives to define best practice interventions and to eliminate variation and errors, Lean focuses on the context of the flow of work to eliminate delays for patients, wasted effort for staff, and unnecessary costs. The two movements share a common sceintific-evidence based methodology.

Lean, says Dan, begins with engaging the staff in improving work, liberating the potential to take action. But, he warns, point improvements are hard to sustain without an end-to-end perspective and management systems to support them. There is a need to manage an interdependent process throughout an organization. This requires a different level of engagement, in that making the system more "fragile" and subject to interruption is an inherent characteristic of the lean approach.

Dan illustrated the hospital environment as a set of processes (see above). Usually, nobody can see the whole set of interactions, "but we need to be able to do that," or each segment will just react to events rather than working on the greater good. In the example he gave us, he showed an analysis of patient flow from the emergency room through to discharge. "If demand is generally predictable, why are there so many delays" he asked, "both at the front end in the ER and at the back end, waiting for discharges?"

Based on his work at many hospitals, he noted that there are pioneers who have make progress in each segment of the care process. "Yet, the big opportunity is leveraging the gains of that work by linking the entire system together. The challenge, now that we see the hospital as a collection of processes, and we know how to improve most of them, is to connect all the pieces together."

After a detailed review of one particular case, Dan laid out the conditions for successful implementation of this kind of integrated approach:

There has to be a will to act.
Someone has to be the value stream manager, the person who takes end-to-end responsibility.
That person works to establish the foundations of progress: stability and visibility.
That person has to gain agreement from the team on the right actions, based upon the facts on the ground.
That person has to have the backing from senior officials to resolve conflicts that arise between departments and the overall value stream objectives.
That person, has to be able to deliver results, and yet has to do so with no authority over resources (just like the engineers at Toyota.)

Our doctors and students were engaged and very interested in all of this. Many had been primed by previous activities and instruction from Mark Zeidel, our Chief of Medicine. But, I think the fact that this is a whole new way of thinking about care delivery was evident to the audience. It is an approach that will take lots more practice and thoughtful planning and priority setting for hospital-wide implementation.