LEAN was created in a manufacturing assembly line world where processes are linear. Clinical care is not linear, but functions as a four-dimensional web. A Value Stream Map of a clinical care process looks more like a maelstrom than a stream.  Can “Lean” apply? Can it add value?

The classic Dartmouth Atlas of Health Care described the extreme variability in American health care. Daily clinical experience defines  the persistence and consistency of that variability at a microsystem level. Can “Lean” apply? Can it add value? Some variability is appropriate and necessary.  Would patient outcomes improve? Would care be less costly and more efficient? Would physicians (and other clinicians) be less frustrated, if there were less variability, more consistency? Can “Lean” help?

We tried it…….The Value Stream Maps were maelstroms. The inputs were extremely variable. The rigor of Lean however, did help. The specific topics we addressed: Central-line Blood Stream Infections and Implementation of Sedation Vacations.

Comments from our experience:

1)  A Kaizen is an excellent process to provide focus. Many departments address a single problem intensively….Breaks down silos.

2)  The structure of the Kaizen forces output: not another week-long meeting of only talk. Example: we actually achieved agreement to implement an order set that we had worked on for four years. Even the physicians agreed.

3)  The support and when possible involvement of upper management is critical. Barriers disappear when the boss says, “Do it”. Involvement also helps upper management see much more clearly what the rest of us live through daily.

4)  The Kaizen highlights needs for change(s) that no one would agree to previously (even when identified). When presented through the Kaizen process, both staff and management see the needs.  Eyes open. The Kaizen also helps define a method to implement the changes needed.

5)  The Kaizen forces inter-group communication. Example: one of our biggest challenges was to define Sedation Vacation. Each person/ each department “knew” what a sedation vacation was; what each person/ each department “knew” however, was different. No surprise we had never succeeded in implementing the process effectively or consistently. The Kaizen forced a definition which then allowed us to proceed with implementation

6)  Caveat: The outcomes of a Kaizen may not be what the Kaizen designer anticipates. Have we decreased our central line infections? Not yet, but we now have institutional commitment to count them.  (We also have many other institutional commitments to improve the central line management process).   Have we decreased our ventilator associated pneumonia rates?  Not yet, but we do have agreement on an automatic process to implement care that should decrease those rates.

7)  Caveat: If you plan to effect clinical care you must involve physicians. A Kaizen is a long week for a physician. Find ways to involve the physicians essential to the process at critical moments in the discussion, rather than all week.

8)  Caveat: Clinical process improvement never ends. The Kaizen provides a “jump start”. To address all the issues identified, work continues long after the Kaizen week. To truly effect outcomes, that work is absolutely necessary.

9)  Caveat: A Kaizen and “Lean” processes cannot convert a four dimensional web into a linear process. However, it can identify and begin to address inconsistencies, remove unnecessary steps and rework, define process needs, and remove some of the tangle of the web. Clinical care can improve.

“Lean” can help.

This week’s blog was written by Shirley E. Dearborn, M.D. Dr Dearborn is a board certified pediatrician with INTEGRIS Health in Oklahoma City, where she has been the physician champion for several Kaizen events. She has served as a primary care pediatrician in a multi-specialty group, transitioned to an administrative role and has functioned as a full time medical director for medical groups, health plans, hospitals, and as an independent consultant. Dr Dearborn has always maintained an interest in clinical quality improvement and believes that to improve healthcare we must not only find better medical solutions, but also find better ways to effectively and consistently implement those solutions.