Saturday, March 15, 2014

Saskatchewan leaders take sides on Lean

I want to make clear that I am not taking sides in the internal political debates of another country, but I think it is instructive for all to watch a current scuffle in Saskatchewan.

Several years ago, the provincial government began an effort to adopt the Lean process improvement philosophy in the health care facilities across the province.  This was to require a large investment of time, money, and other resources.  Those of us in the health care world who have participated in Lean roll-outs--and have seen the value that it offers in increasing efficiency and quality--were impressed by the vision and commitment of the government.  We knew, as did they, that this kind of cultural transformation would take years, and we admired a government that had a long-term view of the return on the taxpayers' investment.

Over the months, consultants have been brought in to conduct training and offer support, and staff members in the various institutions have become more and more familiar with the philosophy and with the techniques and approaches used to create true front-line driven process improvement.

But the size of the investment has now raised concerns.  This article in the StarPhoenix summarizes the dueling points of view:

Under fire from the Opposition, Premier Brad Wall defended the provincial government's spending on the "lean" health quality management system.
"The overall amount is a significant investment and when we made the decision in cabinet, we're a government that looks at these things from the perspective of thrift and value and it was a long discussion."

The premier said the province is recouping its investment.

"We sought the very best and made the difficult decision to do this because of the dividends. What we're able to show is that between the savings just on the design of the children's hospital, on the design of the new Moose Jaw hospital, on the blood management system, we've recovered the entire costs of the four-year program, never mind all of the efficiencies that we have found," Wall said.

Opposition Leader Cam Broten took aim at the government over the issue during question period Thursday in Regina.

"There are good components to 'lean' . . . but this government has taken the 'lean' process and allowed it to become fat, allowed it to become a cash cow for consultants," Broten told reporters.

He said $40 million doesn't represent the total cost of "lean" in the province, since regional health authorities and other ministries also have "lean" contracts.

"I think it's gone overboard," Broten said. "I've looked at some of the Twitter feeds of health administrators who are paid to champion these kinds of things. It sounds like they're in a cult, the way that they pursue this type of language, over the top. We have to allow common sense to have its place."

This is an important debate with ramifications beyond this province.  I know from my visits and conversations elsewhere that people in health care throughout Canada are watching the Saskatchewan experience closely.  I think its fair to say that its success would be a signal throughout the country that it is possible to increase quality and safety and service levels and improve operating efficiency.

So how to resolve the political debate? I'm not taking sides, but it seems to me that this is too important an issue to have a "he-said-she-said" type of debate. Two ideas come to mind to help resolve the issue.  First, the government should be utterly transparent with regard to process improvement successes and failures during the roll-out.  Where successes have occurred, document what was achieved and how the stories of those advances are shared throughout the province and therefore contribute to the spread of good ideas.  Where failures have occurred, explain what has been learned from those experiments.

Second, bring in a (volunteer) group of outside experts to review the steps taken by the government and offer an objective appraisal of the roll-out.  Provide that report to the public and allow the government to explain how it will take those expert opinions into account going forward.


Mark Graban said...

I've read a lot of the articles and op ed pieces from the Saskatchewan news online.

It seems there are two debates - one old and one new.

1) Does Lean apply in healthcare settings? There are many who trot out the old argument that "patients aren't cars, so Lean doesn't apply." But, that argument is easily debunked if you look at the good things that are happening with Lean healthcare around the world, including Canada

2) Should an organization pay huge fees to a consulting group? Much of the uproar is about $40 million in consulting fees (an average of $3500 a day)... is this really necessary? The Canadians are, also, sensitive about an American consultant coming to help (which leads to the nonsense objection of "We don't want to turn our system into the American system," which is, of course, not what Lean is about.

I had a friend up there complain that this had all been politicized. Well, it seems like it goes with the territory when it's a government health system and government spending on the consultant.

I wish them all the best in improving patient care and improving the health system with Lean.

Shelli Chernesky said...

I cannot reply on the blog....get past 50 words and it stops. This journalist is clueless! Quality Healthcare Delivery and Lean Six Sigma are beneficial as a framework for employees to work by. These elements are not just for cars and will not change the Canadian Healthcare delivery to look like the American's. These processes promotes efficiency and quality. Sure our profession is driven by ethics to do what is right for the patient with evidence-based processes....So why not add to the system with fail-safe procedures (poka yoke) and eliminating waste (muda). This work culture change promotes quality and best practice....with cost savings. Be honest our healthcare costs are through the roof! As healthcare employees we need to focus on quality for cost saving overall. Plus...In those busy times at work....been in critical care for 27 years....the need to stop and make sure you are doing the write procedure or using a check-off to maintain best practice with a central line insertion reduces harm to the patient. We are human we make mistakes! These are poka-yoke tactics. Too bad home didn't consult me. I would have done the job for less..being family and all!

Mark Graban said...

Yes, Lean can work. Yes, John Black was an early Lean healthcare innovator with his important work at Virginia Mason Medical Center (as an outside consultant).

But, arguably a big factor in the success of VMMC (and other examples like ThedaCare or Denver Health) was that the CEO and other senior leaders were directly leading the culture change and were willing to put in the hard work required to make Lean really take root.

Does the leadership in Saskatchewan have the same involvement and commitment?

Does John Black's model work as well across an entire province compared to one relatively small hospital in Seattle?

Time will tell. The leaders (political and hospital) in Saskatchewan have placed a BIG bet here and are probably putting their careers on the line by placing it. I hope it works out.

Daniel Jones said...

I visited Saskatchewan last September looking for a Candian healthcare example for my Keynote for AME in Toronto. As I said in my LEI Lean Post at I was impressed by what I saw, not just in health but using lean across government. If they succeed in what they are trying to do it will be a very important example from which the rest of us will be able to learn a lot. They have also been very open about what they are doing - which you can see from their videos at

But I agree that there should be rigorus evaluation of the claimed savings and what worked and what did not. Although it is a lot of money is it really out of line with what other healthcare pioneers have spent on external and later internal consultants as they got going? The question I always have about these big consulting engagements is could the same results be achieved for less money. This will also be an important question to answer before others follow this example.

Mark Graban said...

"Although it is a lot of money is it really out of line with what other healthcare pioneers have spent on external and later internal consultants as they got going?"

From the initial Saskatchewan announcement, they reference Cleveland Clinic spending a similar amount of money to launch Lean:

"For example, the Cleveland Clinic, which employs approximately the same number of people as Saskatchewan's health system, invested $40 million in Lean and achieved $100 million in savings over five years as a result."

But I'm not sure if Cleveland Clinic is really considered a national or world leader in Lean. What results have they gotten from that investment other than "cost savings"?

And, as Dan asks, could they have done it without the large investment?

They've placed a big bet on this approach... annual batches of $10m each, renewable each year.

Daniel Jones said...

How does this compare with the costs and results at Thedacare and Virginia Mason?

Mark Graban said...

I'm not sure if either hospital has ever disclosed that amount spent on consultants. VMMC used John Black & Associates and ThedaCare used Simpler (and still does, to some extent, I believe).

NYC HHC, as a public entity, had to disclose the cost of their consulting contract with Simpler, which was $5M per year, per this document.

Lee RN said...

I was, unfortunately, a patient in Sask healthcare. What should have been a 72 hour admission turned into a 12 week stay full of missed diagnoses and leaving me permanently disabled. How 'lean' is that, eh? You want to know how wonderful SK healthcare REALLY is--talk to the patients.
I am an ER/ICU retired RN from USA.

Don Sharpe said...

Hi Paul,

I know one of the managers who's been involved in transitioning SaskHealth into LEAN.
It hasn't been without difficulty, but she says it's already paying off with happier staff who feel they are more engaged and she believes it's also directly responsible for a reduction in sick time.

I've ventured into the fray here in Alberta with a project to use LEAN concepts to reduce risks and improve patient flow in Hospital Ambulance Bays.

If you have a few minutes, please read an interview I gave to Healthcare Design magazine in their March issue.

If you have any comments or questions on the research please contact me.