Lean forward: Mark Graban on how kaizen can improve quality of care and patient safety, and build strong organizations
Mark Graban is an internationally-recognized expert in the field of “lean healthcare.” He is a consultant, keynote speaker and the author of two books, including the most recently published, “Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvements,” as well as the popular Lean Blog. In 2011, he joined the software company KaiNexus as Chief Improvement Officer to help further its mission of making improvement easier in healthcare organizations. In this interview, he discusses how the principles of kaizen make the healthcare industry (and world) a better place.
Dodge: Can you start by giving us a general overview of kaizen, what it means and how it relates to lean?
Graban: Kaizen is a Japanese word that means “good change” or is translated to mean “improvement.” The word kaizen is typically used in the context of continuous improvement, one of the two core pillars of the Toyota Way management system. Those two pillars are continuous improvement and respect for people. The ideas go hand-in-hand. We are driven to improve because we respect our customers or our patients. We are also driven to engage our employees in that improvement because we respect them, their capabilities, and their desire or ability to participate in ongoing improvement. That’s what takes improvement out of realm of being something just for experts or just being about projects. And in that lean culture, improvement is something everyone can and should be participating in. As leaders we have to create a culture, an environment, where that’s welcomed and encouraged.
Dodge: Critics say lean is based in manufacturing, and therefore of limited value to hospitals and other healthcare organizations. Can kaizen realistically be applied to the healthcare setting?
Graban: People are sometimes hesitant to take good practices from any outside industry. Sometimes the fear of approaches from manufacturing comes from a misunderstanding of the concepts. You’ll hear comments like, “don’t turn our hospital into a factory.”
Of course we’re not trying to turn a hospital into a factory. We’re trying to make the hospital the best it can be. Hospitals and healthcare settings have this caring aspect, so that it’s not just about clinical healthcare but creating a caring environment for the whole patient. There is a very emotional connection in healthcare. We want to be maximizing that—not somehow drumming it out of system.
People think of factories as cold, robotic, mechanistic environments, but we’re using lean in healthcare to free up time for nurses and staff. So instead of dealing with all the firefighting and workarounds and hoop jumping, they’re trading that wasted time for more patient contact—which leads to better emotional connections with patients—answering patients’ questions, alleviating their fear or anxiety about a procedure or about their recovery. Freeing up nurses’ time can lead to achieving better quality and patient safety measures. It leads to fewer bed sores, fewer falls, fewer hospital acquired infections, things that tend to occur because nurses and other hospital staff are swamped—they’re dealing with too much waste, and they don’t have enough time to be there with patients, to respond to their call light, to be there in the proper way without having to cut corners. That’s what lean is trying to help create.
You’ll also hear some comments about lean resulting in “assembly line medicine,” that it’s just going to squeeze the amount of time they have with each patient. But look at what’s happening with lean in the primary care setting: If you eliminate the waste from a doctor’s day, you actually get the great outcome of getting more time to spend with each patient and seeing more patients per hour. The traditional, old-style approach to production improvement says do your work faster, which leads to less time with patients. Whereas lean focuses on eliminating waste, so you can spend more time on things that really matter, including patient appointments and visits. Lean is a very different mindset and philosophy than the “improvements” that have traditionally taken place in healthcare.
Dodge: Can kaizen and lean approaches lead to layoffs? How would you address this with people who have that perception?
Graban: That’s a very understandable reaction and understandable in some organizations. Cost-cutting in healthcare, unfortunately, has usually focused on headcount reduction. But lean process improvement and kaizen give people an alternative. And the best lean cultures out there have some version of “a no-layoffs due to lean” policy, and that would include leading health systems like ThedaCare in Wisconsin and Denver Health. There are a growing number of hospitals that are making a conscious pledge to their employees that says if we improve productivity in an area, your job function may change, but your career here in this organization is protected. You see lots of different strategies for redeploying employees, creating opportunities, providing training and new job skills, or offering lateral transfers into other areas. That’s part of the commitment: If you collaborate with us on improvement, we’ll make sure you and your colleagues aren’t harmed through involuntary severances.
Here’s an example of how that works. With the financial crisis and then in the aftermath of the tsunami in Japan, Toyota in the past few years has made very conscious efforts to not layoff any full-time employees, even temporarily. Staff was paid to work on training, improvement projects and even to do community service projects. Those are great team-building and leadership development activities— and just part of Toyota’s loyalty-building with their employees and commitment to the community.
Dodge: There are a lot of areas where lean and kaizen can have a positive effect. For example, changing processes sometimes means changing the hospital’s floor layout, right?
Graban: Right. Changing the physical space leads to a lot of waste reduction. There’s a lean methodology called 5S where nurses and the entire team work together with a lean facilitator to help make sure that they’re spending less time searching for equipment, supplies, medications and information. That might mean rearranging utility rooms or adding cabinets, locked boxes or mobile carts to be able to keep medications closer to the patient’s bedside. Coming back to a factory example, whenever I tour a Toyota plant with people from healthcare, they’re amazed by all of the almost magical support systems that are in place to help make sure assembly line workers always have what they need, when they need it, where they need it and in the right quantities. Before lean, unfortunately, healthcare workers didn’t get that level of support. They were left to fight fires and fend for themselves. Using 5S can help eliminate a lot of that waste. When you get the chance to renovate or build new space, you can start with a clean sheet of paper. That’s where there’s a lot of great activity going on with lean design. Building it from scratch in a way that best supports the staff to eliminate waste and maximize patient care.
Dodge: We’ve talked a lot about the people and the processes. How do you think technology plays a role?
Graban: The benefits of technology are that you can really keep people connected across multiple departments, multiple shifts and multiple locations within a health system. The very traditional methods of kaizen that I’ve practiced and wrote about in the book Healthcare Kaizen would typically involve things like bulletin boards and note cards. That can be incredibly effective within a localized team, but healthcare organizations are becoming so big and complex. The benefit of doing this on the Web is that people in a hospital on the west side of town now have visibility into what that hospital on the east side of town is doing. One pharmacy can share improvements with another. Technology can either replace or supplement those older, more manual methods for tracking improvement. Communication and tracking functions happen best through software. Being able to quickly tabulate the impact on safety, quality, cost, time savings—that’s something technology does really well. It saves a lot of time that people might otherwise spend adding that up manually through different reports.
This is something we’ve been working on at KaiNexus, a software and technology company that supports and helps organizations manage kaizen and continuous improvement. Our founder and CEO was an emergency department physician. When he was a resident at Vanderbilt, he was exposed to the concepts of kaizen. Because they were in the midst of making everything electronic, it was just natural they’d have a computer system to help track improvement ideas, to keep people informed, to track results of what they were doing. They built a homegrown tool that eventually became commercialized and licensed into KaiNexus.
Dodge: The concept of Kaizen was written about nearly 25 years ago and is only now starting to get play in the healthcare industry. Where do you see it going from here?
Graban: Interesting question. Masaaki Imai’s book, Kaizen, was published in 1986. And in 1989, Dr. Donald Berwick, who is well known for founding the Institute for Healthcare Improvement (IHI) and for serving as the administrator for the Centers for Medicare and Medicaid Services, wrote an opinion piece in the New England Journal of Medicine talking about the need for kaizen in the healthcare setting. He used the word, he cited Imai’s book, he talked about the need for a culture of continuous improvement in healthcare, and he cited W. Edwards Deming and the need to stop blaming individuals for problems and start looking at things more systemically. I was floored when I discovered that article. Sadly no single opinion piece was enough to create a groundswell for kaizen to become the norm in healthcare. Fortunately, IHI, the Lean Enterprise Institute, the ThedaCare Center for Healthcare Value and a lot of the leading healthcare organizations out there are very much talking about the need for this continuous improvement culture. It is not just a bunch of projects or tools or tips or tricks. I’m optimistic we’re going to see more of it.
At same time, it’s not easy to embrace a culture of continuous improvement. It requires changes in leadership behaviors starting at the top, from senior leadership to frontline managers. Sometimes there are too many ingrained behaviors that prevent people from getting started with continuous improvement or that can keep them from maintaining it. People won’t argue with you that continuous improvement should happen, but that doesn’t mean everyone is putting in the serious work to make it a reality.
Look at how Toyota makes time for improvement. They pay people to come in early or stay late to work on their improvement ideas. People are motivated by that not just for the overtime but because they want to make their workplace safer, less frustrating—or, in healthcare, better for patients. Clearly having people work on improvement is beneficial to Toyota. It’s not only giving a return on the organization but also helping develop their employees by building enthusiasm and morale. There are so many benefits.
Dodge: Implementing the kaizen philosophy sounds like a wonderful opportunity to engage staff, regardless of the industry.
Graban: Exactly. We see people using kaizen in so many different industries. Starbucks has been teaching lean methods at its stores, teaching store managers, baristas and store partners how to implement kaizen and continuous improvement. It’s great to see how that’s spreading. In fact, a couple weeks ago KaiNexus signed our first non-healthcare customer—a trucking and logistics company. It’s universal that people want to participate in improvement. We need a culture and methodology to make sure we’re turning that goal into reality.
Mark Graban blogs and tweets regularly on lean and kaizen. Follow him @MarkGraban.