Expert Interview Series: Mark Graban of

Mark Graban President of Constancy, Inc. will conduct an Expert Interview Series

Mark Graban is an internationally-recognized expert in the field of “Lean Healthcare,” as a consultant, author, keynote speaker, and blogger.

We recently talked to Mark about what going Lean entails and how it can be applied to healthcare and laboratory settings. Here’s what he had to say:

Can you give us an overview of what Lean Healthcare is?

Lean healthcare is the adaptation of “Lean Manufacturing,” which is based upon the Toyota Production System, or TPS. Lean healthcare is an improvement methodology that engages all people in a scientific problem solving process.

Lean is also a management system and a particular organizational culture with certain characteristics. The Lean culture and philosophy includes a focus on the customer (the patient), a respect for people doing the work, a primary focus on safety and quality, and the need to better design, manage and improve processes as a path to success, instead of the old way of cutting costs and blaming people for errors.

Lean principles are pretty simple and straightforward, but it can be very different from the way healthcare organizations are typically led. For example, Lean organizations engage everybody in continuous improvement, making it safe for them to speak up about problems and working together with them to implement their ideas, a practice we call “Kaizen.”

How did you become such an advocate for Lean Healthcare?

My background is engineering and business, so I did “Lean Manufacturing” work for the first 10 years of my career. I was fortunate to be exposed to the idea of Lean in healthcare when I had a chance to visit a Scottsdale, Ariz. hospital in 2004 that was using Lean to improve their emergency department and patient flow. Thankfully, I was there for a local networking group, not because I was sick or injured.

From that initial eye-opening moment, I was also fortunate to receive a call from a Johnson & Johnson consulting group in 2005 when my wife and I had to move for her new job and I was on the job market. Being able to work for J&J with hospitals quickly cemented my passion for healthcare being a very important place to teach and practice Lean.

What are some of the major challenges facing hospitals today?

From a patient perspective, you might face an unacceptable level of risk – being harmed or even killed as the result of preventable medical errors. These errors, including medical errors, wrong-site surgeries, bedsores and the like are most often caused by process or system-related problems – not by so-called “bad apples.” Various estimates suggest that roughly 200,000 Americans die each year due to medical error and this is a global problem. To me, this has to be the biggest priority for hospitals, but there often isn’t a lot of transparency or acceptance of the problem.

Patients might also face long waiting times, such as waiting for an appointment, waiting to be seen in the emergency department, waiting to be discharged once they are ready to go home. Lean hospitals focus on improving flow – not by asking staff to move faster or work harder, but by improving processes and eliminating delays and miscommunications.

Patients also, of course, complain about high costs and confusing billing. From the hospital perspective, they are facing low margins that result from higher costs and lower reimbursement from the government and private payers. Some hospitals face staffing shortages, which can create quality problems, which then hurts the hospital’s reputation or, more often, directly hurts their reimbursement and bottom line. We have to break this cycle and Lean is a great alternative.

Why do you believe the Lean model is an ideal solution for these challenges?

It’s not a matter of belief or faith at this point. It’s been proven that Lean methods can help improve patient care, service to patients and financial performance for the hospital. Lean provides a new way of thinking about our work, including different ways to study and improve patient care and hospital processes. It provides concrete methods that are more effective than the old approaches of trying to cut costs through layoffs or trying to improve quality by firing those who make mistakes.

Lean has been effective in hospitals around the world … but proving that it works (as documented in Chapter 1 of my book Lean Hospitals, available as a free PDF download) doesn’t mean that it’s easy to adopt Lean or that it’s always going to be successfully adopted.

Can you offer one of your favorite success stories or examples of the Lean model being applied in a hospital setting? What were the results?

One of my favorite examples was working with a children’s hospital to reduce waiting times for outpatient MRI procedures. Kids were typically waiting about 12 weeks for an appointment, which delays care and increases stress. As a consultant, I taught Lean principles and worked with a dedicated team of nurses, MRI techs and others. I showed them how to study their work, from the scheduling process to the daily work of bringing a patient in from the waiting room.

They identified barriers to flow and they figured out how to increase capacity by making better use of MRI time during the day (preventing idle time between scans). By the end of that year, they had reduced waiting times from 12 weeks to about three weeks and they have sustained that improvement and that level of performance for about eight years.

What I love about that example is that it was meaningful improvement for the patients and families, and it was meaningful to the staff who had previously thought improvement was impossible.

How easy is it for organizations to implement Lean practices? Where should they begin when attempting to go Lean?

It can sometimes be easy to use Lean to make a local improvement, through a project or a “Rapid Improvement Event.” It can be very difficult, sometimes, to get an organization to dedicate time for staff and managers to participate in the improvement process, however. It’s easy to give people some training about Lean, but it’s much more difficult to change the management style and the culture of the organization.

Many “Lean programs” never really take off, or get canceled, because executives never understood Lean and the role they needed to play. If an organization thinks Lean is about “fixing the employees,” instead of everybody changing their approach and mindsets, then the effort is probably doomed or won’t be sustainable.

I’d argue that the best way to start with Lean is to use the basic Kaizen methodology to engage employees in solving small problems in their work areas. If departments can’t engage people in simple improvements, there’s probably less hope of implementing larger changes for more complex problems. Start small, build capabilities and confidence, and then move forward from that.

What are the most common mistakes you see organizations making when trying to adopt lean methodologies? What are best practices for avoiding these missteps?

I’ve already touched on some of the risks and mistakes.

Some other mistakes include only using Lean to focus on speed, efficiency, or cost, when quality and safety problems are enormous and Lean methods have much to contribute in those areas. Another mistake would be thinking Lean is just about tools and focusing on implementing tools instead of solving problems that matter to all stakeholders.

I think a “best practice” for avoiding these would be to educate executives and leaders at all levels about Lean and their role (and how they need to change). The most successful Lean transformation stories have hospital CEOs who were directly driving the culture change, and those CEOs had mentors from their board or the community.

What are the risks to healthcare organizations that fail to evolve?

The risks include not being able to compete in a fast-changing healthcare environment. Hospitals that want to remain independent might not be able to do so, being forced to merge or consolidate unless they can use Lean to compete better. There would also be continued risk to patients without major improvement and a risk that hospitals won’t be a “workplace of choice” for talented healthcare professionals.

Ultimately, a hospital is defined by its employees. Lean supports the notion of “take care of the staff, so they can take care of the patients.” Creating a better, less frustrating, more engaging workplace leads to many benefits for everybody involved. An organization that has everybody engaged in improvement will be better equipped to navigate challenging times – and who knows what is coming in these next four years?

How can Lean be applied to a laboratory setting?

Hospital labs were some of the early adopters of Lean practices. Lean can be used to re-arrange the physical layout of the lab to improve flow and reduce turnaround times for test results. It’s a classic situation of working smarter, not harder. Reducing batch sizes (from the point of specimen collection through the reporting of results) can reduce turnaround times 50 to 70 percent.

It also means a Lean lab can do much more volume of work without adding staff. The key thing to remember is that working in a Lean lab is easier, not harder. People are less stressed when they’ve had a chance to redesign their workflows – flow improves, quality improvements, and the quality of work life improves. It’s very powerful to see … and we need more of it throughout healthcare.

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