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Letters: Are Lean Management Principles Going Astray in Health Care?


I was receiving PT for a shoulder problem. Jenna, my physical therapist, asked if I injured it working. I said no, my work involves writing and lecturing on Lean management, quality, and things related. Has Lean made it to this health center? I asked. Nodding, she replied impishly, “You said a bad word.”

After a late start in health care, Lean has cut a wide swath in the sector. Health care took its Lean lessons from industry, which had imported just-in-time (JIT) production from Japan in the 1980s, then renamed it Lean manufacturing in the 1990s. Off-the-mark tendencies for Lean as applied in manufacturing have, unfortunately, been carried over into health care. Sensible corrective measures are needed to ensure that Lean in health care does not suffer pain and an early death. Actually, the metaphor is apt in that Lean’s most beneficial outcome is reduction of wait times, and when it comes to health care, long wait times surely can and do kill people.

Since Lean’s introduction in the West three decades ago, it has been redefined, amended, and appended to the point some its lesser features have trumped what is meaningful to patients. Manufacturing has the excuse that end customers are nowhere in sight. Health care, on the other hand, is customer-facing. Lean’s customer-centered primary effects should make it doubly suitable in the health-care sector.

Although Lean manufacturing generally is viewed as a success story, my own multiyear “Leanness studies” reveal dominant patterns of good results followed by backsliding. A likely reason: Most present Lean in operational terms, so manufacturing executives delegate it down the hierarchy to the operations contingent. The same is generally the case where Lean has been applied in health care.

Corrective action calls for making it clear that Lean’s main effects are not operational so much as competitive and strategic. That is, the primary role and outcomes are delivering ever-quicker, more flexible, higher-quality, higher-value response to customer needs, demands, orders, and usage. Rather than seeing Lean this way, industry generally has adopted the view that Lean mainly is about reduction of the “seven wastes.” Falling in line, health care, too, has adopted waste elimination as Lean’s mantra.

That won’t do.

Rather than being Lean’s essence, waste reduction is akin to spaghetti diagrams, the five whys, value-stream mapping, and non-value-add analysis. All are worthy ways of framing the Lean pursuit but are not among the methodologies that act on the processes to change them from fat to lean. Over the years, some have done a better job implementing Lean, spending less time on framing and more on training employees in organization by product family or customer family, quick setup, cross-training/job rotation, trouble lights, and more, then saying, “Go do it.”

In getting it done, Lean delivers quick response as the dominant customer-sensitive effect: Nearly every change that Lean elicits reduces waiting times and waiting lines, and the sum total of those reductions through the processes can speed up customer response by an order of magnitude.

In delivering quick response in any setting, Lean relies on flexibility and quality. Given the norm—that customer demands and needs are highly variable, both in type and quantity—quick response requires flexibility so as to ensure immediate readiness for the next customer or need. Lean provides flexibility through a cross-trained or on-call workforce, plus fast-change or standby equipment. As for quality, without it, response is slowed or stopped for rework. Or abandoned entirely, with the customer seeking service elsewhere. Or the patient dies waiting.

There are reasons why waste reduction has been elevated to its high status—in some quarters, almost as the definition of Lean: operations people can readily learn to recognize and measure the wastes, and devise ways to reduce them. And it works—it does make operations quicker and more flexible, with better quality and value.

But if Lean is to maintain good health, waste reduction cannot be the driver and must be seen as a useful enabler. Lean must be defined and promoted for its strategic purpose—delivering flexibly quick, high-quality service everywhere along the value chain to patients. Seen this way, Lean can implant itself as a permanent organizational strategy.

Jenna, my physical therapist, may have been like many in health care, viewing Lean as something of a pedestrian imposition, and that training time would be better spent on patient care. At a more recent visit to PT with a different therapist, I spotted Jenna across the room. She called over to me and said, “I changed my mind. Now I like Lean!” That’s great, I thought. She’s happily chasing down wastes. Now, if only the facility’s leadership can come to understand Lean’s customer-side purpose and build it in as a fixed element of strategic management.

Richard J. Schonberger, PhD, president of Schonberger & Associates in Seattle, is the author of more than 170 articles and papers, as well as several books.

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