In the wake of the recent Lean Healthcare Summit that took place in Johannesburg, the CEO of the Lean Institute Africa (LIA), Dr Anton Grütter, discusses the summit’s outcomes and the LIA’s plan to establish a learning network of hospitals.

After visiting the ThedaCare Center for Healthcare Value in Wisconsin in February 2015 to observe how the ThedaCare performance system has applied Lean Management to the healthcare context, the CEO at ThedaCare, Dr John Toussaint, and I agreed that we needed to collaborate. ThedaCare’s mission of disseminating their successful methodology to the rest of the world by helping healthcare organisations to start and sustain their improvement systems, coupled with our need to fulfil our mission of improving healthcare in the public sector, led to us exploring ways of collaborating; and a way of getting that going was to have a Lean Healthcare Summit in South Africa with John as the keynote speaker.

The purpose of the summit was for John to explain first-hand how the ThedaCare model works and what is required of the different role players inside and outside of the organisation to make it work. He’s successfully documented how they’ve managed to make ThedaCare work in several books and numerous articles, which serve as the world-wide model that other organisations can aspire to.

Enabling continuous improvement

During the summit, one question that was put to John was: “Quality is measured against standards that come down from government, not through continuous improvement – how do you get around that?” This is an example of how people often misunderstand what Lean is about. The Lean Management system comes down to the Deming PDSA (Plan, Do, Study, Act) Cycle of gaining valuable learning and knowledge for the continual improvement of the process. The PDSA Cycle is applied throughout the way in which the Lean Management system works, both on the ground in the smallest improvement project all the way up to strategy. Obviously it gets done very differently at different levels and in different contexts, but it all comes down to having a plan that is in effect a hypothesis of how change can improve service delivery.

The National Core Standards are the government’s plan for establishing minimum standards of what healthcare institutions should have and do. However, just having a plan and implementing it is not going to improve anything unless you actually have a systematic method to check whether it is working, and take corrective action if it is not. That’s what needs strengthening in the way the National Core Standards are used.

In the Lean Management System you cycle through this and have a standard operating procedure to do a particular task. You continuously improve on that, but not while you’re doing the normal work, because then you have to do it according to the standard. You essentially need to take time out to systematically improve via an experiment of the new method of what you think will work better, and if it works better then you change the standard operating procedure and apply that in your normal work. In the Lean world we regard standards as extremely important, but as only one part of the whole PDSA cycle.

Using Lean Management to avoid improving in silos

Early on in John’s presentation he had two slides which explained how to avoid improving in silos. In the first slide the vertical silos were in front of the horizontal processes because traditional management is hierarchically organised according to department or function. In the next slide he had the horizontal processes in the foreground to illustrate how Lean Management changes your focus from the hierarchy in organisations to focus on flow of patients through the process.

One of the big challenges that organisations on a lean transformation journey need to go through is to figure out how to improve work horizontally according to the process, which requires collaboration across the silos. While you can’t do away with functional organisation, especially in a large organisation, you need to learn how to work horizontally across those boundaries. It comes down to being process-focused; the organisation needs to start thinking in terms of processes and doing improvement of the normal work in those processes.

Processes extend outside the organisation, so it’s very important that suppliers, like referring doctors and pathology laboratories, are involved in improving work together. For example, Toyota provided Lean Coaching support to their suppliers, in many cases for free, simply because they realised that it’s worth their while to develop them in order to get good inputs into their operations.

Moving to patient-centred care

The first principle of Lean Management is to create value for the end customer, in healthcare that translates into patient-centred care. During John’s presentation he had an interesting formulation of value, which is quality divided by cost. Basically, you want to improve the quality of service to your patients while reducing costs at the same time.

There’s a lot of misconception about Lean being only about efficiency and cost-cutting, which isn’t the case. For example, ThedaCare increased the staff-to-patient ratio with their collaborative care model. But because the improved healthcare led to reduced readmission rates and shorter stays, overall they created better value and their margins tripled. So it’s a case of understanding what you need to do to deliver good value, and if you get that right in your particular work context then money will follow, or in the public sector, the service delivery backlog will be reduced.

Transforming the leadership role

Improving HR, ICT or supply chains on their own are not going to change the world. But if you put those things together in an integrated management system, as has been described in John’s book Management on the Mend, then it can work very well.

From the outset it all has to do with leadership. There’s traditional leadership and then there’s Lean leadership. Traditional leadership is when people look up to the leaders who are charismatic and who manage to inspire people. Lean leadership is all of those things, but more importantly, it is also about creating an environment where staff problem solving skills are developed, while taking responsibility for the custodianship of the Lean Management System. So it’s not so much about the leader, but rather the leader developing the system so that when the leader walks away the system is still left standing.

To build this new management system personal transformation is required where the leadership behaviour has to change from telling people what to do to developing people. This is very challenging because it doesn’t fit with the current culture in the public sector, and a good many private sector companies as well. This transformation needs an investment mind-set to develop people, because it takes time and leaders have to persevere through the setbacks. You have to keep on watering that plant until it has time to bear the fruit, which is years. Too often I’ve seen people move on before the roots are strong enough to survive.

Developing a best-practice learning network of hospitals

Following the Lean Healthcare Summit, in collaboration with ThedaCare, we started engaging with those healthcare organisations that expressed an interest in learning to implement the Thedacare model locally. We’ve had lots of positive feedback and interest from individuals and organisations, including a provincial health department and organisations in the private sector.

Starting from 2016, we envision developing a learning network of hospitals in three phases: the first is a gemba walk visit to ThedaCare, which translates to “go see”, where senior decision makers can go and get insights into how the model can work. The second phase is for a core group of coaches to go through the ThedaCare coaching development programme. The third phase is adapting and implementing the model back home in the participating organisations.

Any healthcare organisations that are interested in joining this network are welcome to contact LIA to find out more.

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