TY - JOUR
AU - Reimer, Laura, E
AB - Abstract Continuous improvement efforts, recognized in much literature as Lean management techniques have been used in efforts to improve efficiency in democratic health care contexts for some time to varying degrees of success. The complexity of the health care system is magnified by the sheer number of processes and sub processes required to deliver value within a bureaucratic environment, while maintaining some level of compassionate and personalized care. There is inherent tension between what is required to be efficient and what is required to be caring and this conflict presses against Lean practice at the level of delivery. Administration and care intersect at the point of the patient’s experience. In order to achieve the dual goals of improved value and lower costs, the application of Lean thinking for meaningful health care reform must acknowledge the fundamental dichotomy between the impersonal tasks required to provide health services, and human interactions. Meaningful health care reform requires an acknowledgement of this distinction, currently not recognized in literature. While administrative process improvements are necessary, they are insufficient to achieve a sustainable and caring health care system. Lean thinking must be applied differently for administrative processes and patient care encounters, because these are fundamentally different processes. In this way, Lean principles will effectively contribute to sustainable health system improvements. Lean management, health care, health reform, quality improvement, patient experience, health care policy Relationship-centered health care as a Lean intervention Continuous reform to improve outcomes while reducing the cost of providing care has become one of the hallmarks of public health care policy. While Lean management has become a popular approach to public service reform, including in health care, it seems that there is a general fatigue among policy-makers that has left health care (and other public organizations) with accusations of defective and ineffective Lean implementation. Leading scholars [1] of Lean management have argued that Lean implementation has been defective because there has been a consistent focus on the technical tools of implementation without an overarching business logic to validate the implementation. This paper extends this thesis to suggest that within the purposes of health care are dual logics to validate implementation: there is a technical or administrative component, but there is also care and concern. That is, we agree that ‘Lean does have the potential to have a substantial impact upon public services reform [but]…it is only a tool.’ [1 p. 267] For health care, this care and concern, communicated through relationship-centered encounters, provides the overarching logic to the system and contains the ‘missing’ keys to making Lean management work in health care reform. Several jurisdictions, including a number in Canada, have publicly and enthusiastically embraced Lean management as the method of choice for modernizing health care delivery, with varying degrees of success [2–6]. Improvements in many key areas proceed at a glacial pace, while other institutions have decided to rescind their decision to implement Lean for no apparent reason other than the politically unpalatable pace of change [1, 7, 8]. The complexity of the health care system is magnified by the sheer number of processes and sub processes required to deliver value within a bureaucratic environment while maintaining some level of compassionate and personalized care. Meaningful health care reform requires an acknowledgement of this distinction in both theory and practice. Health care administration involves tasks and processes readily amenable to the processes and tasks of Lean methodology as popularized in the Lean literature [9–11]. However, while administrative process improvements are necessary, they have proven insufficient for the reform needed in struggling modern health organizations [2–7]. We argue simply that Lean thinking is applicable to both administrative and patient care encounters but leaders must recognize that these are fundamentally different yet fully complementary health care processes. Administration and care intersect at the point of the patient’s experience, and it is here that reform offered by the Lean pillars is most critical [12]. We posit that this distinction is missing in the continuous improvement (Lean) research and literature, and may be one of the undisclosed reasons why some politicians and administrators tend toward the abandonment of Lean reform in favor of faster, money saving reforms [1, 7, 8]. There is inherent tension between what is required to be efficient and what is required to be caring; a conflict that presses against Lean practice at the level of delivery. In order to achieve the dual political goals of improved value and lower costs, the application of Lean thinking for meaningful health care reform must acknowledge the juxtaposition of impersonal tasks and the human relational interactions so critical to a positive health care experience [13]. Then, and only then, Lean and its principles of respect for people and continuous improvement leverages the strength of professionals to deliver the improved health systems that patients, practitioners, policy-makers, and politicians seek (This paper is intended to raise for discussion the complementarity and philosophical compatibility of person-centered care approaches and Lean. We do not propose to address the details of implementation, such as practitioner engagement or culture change. While interesting and relevant, these are topics that require depth of research and of discussion beyond the scope of this paper). Table 1 compares the application of Lean pillars and philosophy to tasks or processes, and to care interactions. This comparison, we believe, illustrates the ways in which the strengths of Lean can facilitate relationship-centered, and not just impersonal, task-focused health care. Table 1 Comparison of Lean philosophy in Administrative and Care interactions . Administrative . Care . Focus of interventions Process and task oriented Relationship oriented Pillars Respect for persons Engagement of stakeholders in improvement projects Engagement of patient in care decisions Continuous improvement Seeking perfection, culture of change and improvement Continual communication to understand and achieve patient values Customer Patient; also colleagues adjacent in value streams Patient Lean Principles Value: Defined by primary customer e.g. fast turnaround, sufficient supplies, achieved through elimination of waste e.g. positive health outcomes, prompt attention to needs Value stream: Set of all specific actions required to deliver value Delivering health services: e.g. getting a room ready for an admission; following a standardized care map or pathway Achieving the patient’s health goals: e.g. a quick appointment, a diagnosis, a treatment Flow: value moves promptly to the customer Supplies are restocked as soon as they are used; invoices are paid as soon as they are received Patient receives the required attention as soon as they need it Pull Responding to need identified by previous step in process Patient need informs services provided Perfection Evaluation via measurement and rethinking to achieve improvement Evaluation via diagnostic tests, therapeutic relationship to determine what can be improved and how Effect Efficiency, cost savings Less waiting therefore more efficient, demonstrating respect for the patient’s time, better health outcomes as defined by the patient Tools e.g. Standardization, visual management Dignity, harm reduction, Hospital Home Teams . Administrative . Care . Focus of interventions Process and task oriented Relationship oriented Pillars Respect for persons Engagement of stakeholders in improvement projects Engagement of patient in care decisions Continuous improvement Seeking perfection, culture of change and improvement Continual communication to understand and achieve patient values Customer Patient; also colleagues adjacent in value streams Patient Lean Principles Value: Defined by primary customer e.g. fast turnaround, sufficient supplies, achieved through elimination of waste e.g. positive health outcomes, prompt attention to needs Value stream: Set of all specific actions required to deliver value Delivering health services: e.g. getting a room ready for an admission; following a standardized care map or pathway Achieving the patient’s health goals: e.g. a quick appointment, a diagnosis, a treatment Flow: value moves promptly to the customer Supplies are restocked as soon as they are used; invoices are paid as soon as they are received Patient receives the required attention as soon as they need it Pull Responding to need identified by previous step in process Patient need informs services provided Perfection Evaluation via measurement and rethinking to achieve improvement Evaluation via diagnostic tests, therapeutic relationship to determine what can be improved and how Effect Efficiency, cost savings Less waiting therefore more efficient, demonstrating respect for the patient’s time, better health outcomes as defined by the patient Tools e.g. Standardization, visual management Dignity, harm reduction, Hospital Home Teams Table 1 Comparison of Lean philosophy in Administrative and Care interactions . Administrative . Care . Focus of interventions Process and task oriented Relationship oriented Pillars Respect for persons Engagement of stakeholders in improvement projects Engagement of patient in care decisions Continuous improvement Seeking perfection, culture of change and improvement Continual communication to understand and achieve patient values Customer Patient; also colleagues adjacent in value streams Patient Lean Principles Value: Defined by primary customer e.g. fast turnaround, sufficient supplies, achieved through elimination of waste e.g. positive health outcomes, prompt attention to needs Value stream: Set of all specific actions required to deliver value Delivering health services: e.g. getting a room ready for an admission; following a standardized care map or pathway Achieving the patient’s health goals: e.g. a quick appointment, a diagnosis, a treatment Flow: value moves promptly to the customer Supplies are restocked as soon as they are used; invoices are paid as soon as they are received Patient receives the required attention as soon as they need it Pull Responding to need identified by previous step in process Patient need informs services provided Perfection Evaluation via measurement and rethinking to achieve improvement Evaluation via diagnostic tests, therapeutic relationship to determine what can be improved and how Effect Efficiency, cost savings Less waiting therefore more efficient, demonstrating respect for the patient’s time, better health outcomes as defined by the patient Tools e.g. Standardization, visual management Dignity, harm reduction, Hospital Home Teams . Administrative . Care . Focus of interventions Process and task oriented Relationship oriented Pillars Respect for persons Engagement of stakeholders in improvement projects Engagement of patient in care decisions Continuous improvement Seeking perfection, culture of change and improvement Continual communication to understand and achieve patient values Customer Patient; also colleagues adjacent in value streams Patient Lean Principles Value: Defined by primary customer e.g. fast turnaround, sufficient supplies, achieved through elimination of waste e.g. positive health outcomes, prompt attention to needs Value stream: Set of all specific actions required to deliver value Delivering health services: e.g. getting a room ready for an admission; following a standardized care map or pathway Achieving the patient’s health goals: e.g. a quick appointment, a diagnosis, a treatment Flow: value moves promptly to the customer Supplies are restocked as soon as they are used; invoices are paid as soon as they are received Patient receives the required attention as soon as they need it Pull Responding to need identified by previous step in process Patient need informs services provided Perfection Evaluation via measurement and rethinking to achieve improvement Evaluation via diagnostic tests, therapeutic relationship to determine what can be improved and how Effect Efficiency, cost savings Less waiting therefore more efficient, demonstrating respect for the patient’s time, better health outcomes as defined by the patient Tools e.g. Standardization, visual management Dignity, harm reduction, Hospital Home Teams Applying Lean management in health care For the purposes of this discussion, we will take administration to mean any technical, procedural, or supporting aspect of health care that is not a personal encounter between a patient and a care provider or support person. For example, stocking supplies, processing diagnostic tests, reconciling financial statements, and human resources functions are tasks that do not require direct interactions with patients, although they do support health care. These are administrative functions; impersonal and process-oriented, with objective measures of success. A care encounter, on the other hand, is any direct contact with a patient. Processes such as booking appointments, determining a treatment plan, and obtaining consent for a procedure require direct and often intimate connections between an individual patient and someone working within the health care system. Successful care encounters must be led by a keen desire to communicate caring, determined by the capacity of the people involved to form a positive or effective relationship, and facilitated by the infrastructure of a man-made system to uphold the values of the patient involved. Discussion of care encounters is absent from Lean literature, and this paper offers to fill that gap by asserting how critical they are to successful Lean implementations. The goal of Lean is to ‘sustainably deliver value fast’ [10, p. 9], according to value defined by the customer. One of the complicating factors of health care delivery is the confusion between patient and customer [4, 8]. The task for Lean analysts is to identify precisely what provides a valued and improvable service, according to the recipient of that service. Care encounters exemplify the principle of respect for persons, where the quest for continuous improvement can be a matter of life and death. Accurately determining who the customer is stands at the core of Lean thinking [8, 14, 15]. The ‘patient’, or primary customer, refers to individuals requiring health services. In addition to the patient, there are many supporting customers [14, 15]. Each person or department along the pathway of care is a supporting customer in the continuum of a patient’s care, even when they do not have direct contact with the patient. Understanding how value is perceived by the customer (primary or supporting), and the distinction between administrative and care customers, is critical to the success of the incremental systemic improvements that add up to Lean transformation. Finally, there are specific terms that belong to the practice and philosophy of Lean itself. Three terms are generic to Lean management discussions: ‘value stream’, ‘flow’, and ‘pull’. Value stream refers to the mapping of the current state of the organization and designing a future state for the steps that take a product or service from its beginning through to the customer. Flow refers to the manner in which work (both care and administration in this case) progresses through a system. Pull refers to the system that ‘pulls’ its required service process from the needs of the customer. Lean philosophy and its pillars of respect for persons and continuous improvement are undoubtedly applicable to health care. The common purpose of health care systems, both public and private, and the intention of people who work within them, is to support and improve the good health outcomes of individuals and communities. Value streams in health care Health care interactions are inherently value-laden, and take many forms. For care encounters, the value stream is different and much more challenging than for administrative processes. These are far less predictable than administrative, task-focused activities. Customers of health care are a heterogeneous group for whom value is intensely personal, so each patient’s value is different, and is co-produced by the patient and health care provider together. The patient’s needs pull on resources, but the particular resource required will depend on individually-defined value, making it difficult to have all possible contingencies at the ready. For one patient, value may be achieved by survival of a devastating accident. For another, it may mean a comfortable death. One patient could prefer the privacy of a one-on-one examination, while the next values the opportunity to contribute to education by allowing medical students to be present. These are not tasks that can easily be mapped and measured in the same ways as disembodied administrative processes [1, 9]. The countless individual value streams make anticipating what might be needed for a given patient difficult, but do not preclude adoption of the core philosophy in the patient care realm. Indeed, the pillars of Lean are perfectly suited to the care side of the system. Respect for persons and continuous improvement remain commendable mainstays for the goal of sustainably delivering value fast, so that Lean emerges as meaningful for health care. On a micro- level, patient-centered care takes cues from the individual seeking/receiving care and approaches all interventions from the view that best represents their ideal of value [16–18]. As in administration, connecting with the customer is the only way to understand value from their perspective. This means treating the patient as a member of the health care team, recognizing that only they can truly know their own experience of care, and empowering them to make important decisions, armed with all relevant information. This is already entrenched in common practices like obtaining an informed consent before proceeding with any intervention, or new approaches such as providing a recording of personalized instructions upon discharge [20]. On a macro-level, patient input is now being sought more deliberately than ever in administrative aspects of health such as planning and quality improvement activities [19, 21]. There is a recognition that a first-hand understanding of the patient experience is critical to delivering value, which is best achieved through purposeful and respectful engagement of the customer in the ways they prefer [21]. In this way, Lean management can work when care and administration are recognized as complementary, Lean-able components of health care. Continuous improvement in care means ongoing monitoring and evaluation of processes and outcomes. With care interactions, the measures of success are subjective and individualized. The treatment of a patient at risk for a heart attack can vary greatly, depending on many individual factors, such as the patient’s age, the clinical presentation, and, importantly, the patient’s quality of life [22]. This means ongoing monitoring to ensure the individual’s goals of care are understood and being met through the elimination of non-value-added activities like waiting, or unwanted treatments, both of which can be identified through the Lean lens. Relationship-centered care in action Relationship- or person-centered philosophies, which make a deliberate effort to keep the patient as the focus of every interaction in care, fall well under the umbrella of Lean systems. Dignity in Care, for example, is one Canadian quality of care movement that safeguards core values like kindness, humanity and respect, and supports a culture of compassion [23]. The language of this philosophy is remarkably similar to Lean. At its core, it encourages health care providers to ask a simple question at every patient encounter: What do I need to know about you as a person in order to give you the best care possible? The answer to this question is the patient’s ‘value stream’. It sets in motion a process of ‘pulling’ in relevant and necessary resources in ways that add value and remove burden from the patient. Similarly, harm reduction strategies in public health ensure that individuals are treated with respect regardless of their personal circumstances, health practices as determined by the patient are supported, and the negative impact of the individual’s circumstances and lifestyle are acknowledged without perpetuating stigma or paternalistic assumptions about what might be best for them [24]. Again, these strategies help the system ‘flow’ by identifying value-added resources and pulling on them according to the needs of the patient. Tools for enhancing care interactions clearly support respect for persons and continuous improvement, and generally meet the principles of Lean. Hospital Home Teams, also known as Virtual Wards [25], clearly reflect the application of the traditional Lean toolkit on care interactions. These are care teams assigned to patients with complex needs. The individual’s ‘value stream’ is mapped and resources such as home care and mental health services are identified and set up to ‘flow’ to the patient according to need, rather than forcing the patient to come to the system. The patient ‘pulls’ on an extensive but tailored set of services as needed to support them in the community according to their personal values. Regular evaluation provides opportunities to understand and work toward the ideal set of services for that individual (perfection). This model has been shown to improve outcomes for some patients, and avoid hospital admissions for others [25]. Each of these tools supports the inherent worth of each patient by empowering them to determine what constitutes value, and then marshaling the system to deliver that value. The net benefit is that the patient (as the customer) receives the value they have defined. The individuality of value streams in care interactions ensure care is personalized rather than standardized. Standard care may make administration more efficient, but it runs the risk of the patient having a dehumanizing experience. The outcome of Lean, when it is applied in ways that are faithful to the philosophy of respect and improvement, will result in better experiences, and better health outcomes. Built in to each interaction is a transparency and inclusivity that continuously assesses the patient’s experience and adjusts as necessary. ‘Flow’ and ‘pull’ can be achieved, and perfection sought, but only through the establishment of an effective caring relationship between the patient and caregiver/system. In this way, the continuous improvement pillar is operationalized in caring interactions while maintaining the improvement and efficiency required for hospital administration. Administration is task oriented and transactional when compared with the caring side of health care. The impersonal nature and generality of administrative value streams makes them amenable to broad and diffusible improvement, and particularly attractive for Lean practitioners. For many administrative processes in health care, the patient-as-customer is distant, and admittedly somewhat irrelevant. For many administrative elements of health care, the customer is staff, caregivers, budgets, and boards. ‘Value streams’ in this context are complex with many intermediary customers that do not deliver services to patients. The creation of processes that flow from one value-added activity to the next can transform labor-intensive and wasteful activities into choreographed efficiencies. When the next step in the ‘value stream’ is predictable and well-understood, needs can be anticipated and processes readied to respond in a timely way. In Lean terms, inputs like surgical supplies, linens, intravenous pumps and operating tables add value by being available and in working order when needed. As discussed above, there is a complementarity of process and relationship-focused applications of Lean. Table 1 depicts the major pillars and principles of Lean applied to administrative processes and to care encounters. One can readily see how the mindful address of administration AND care encounters meet the Lean principles and offer the formula for a more humane and caring health care system, while ensuring efficiency and effectiveness in administrative matters. Conclusion Systematic application of relationship-centered care approaches are consistent with Lean philosophy. Systematic application of Lean principles in the administrative realm arguably reduce waste by saving both time and money, but without consideration of an improved patient experience, a full consideration of the goals of health care are not met. The simultaneous application of Lean management to both administration and person-centered care will also demonstrate respect for the patient, and yield a better experience—both of which are preferred outcomes for policy-makers and especially for patients and health care professionals. The singular focus on the low-hanging fruit of tasks and processes for improvement do not and have not produced sustainable health care systems. It seems that the conflation of Lean with efficiency has essentially exempted the relational, care interactions from Lean projects. This has been identified as ‘defective’ by leading scholars in the field [1]. There are tools and techniques that have been shown to work well in these contexts. Care, on the other hand, is cluttered and complex, and it requires individualization, which often needs more time, not less. In this way Lean management means that success is measured differently for administration than for care. In this paper we have argued that for Lean to succeed in health care practice as it is theoretically intended to do, the two distinct but interrelated sides of health care must be recognized in any Lean approach to health care reform. Lean principles applied with careful recognition of patient care as separate from administrative processes uphold the pillars of respect for people and continuous improvement. For administrative tasks and processes, Lean management gives rise to efficiency through the elimination of non-value-added steps. While this is good for public sector quantitative measures, it does not provide the caring and relationship at the core of public health purposes. However, patient care encounters, which indirectly benefit from administrative applications of Lean thinking, can themselves be directly improved with relationship-focused strategies and tools that are consistent with Lean philosophy. The inherent subjectivity of each patient’s definition of value demands an individualized approach to health care within which care meets the patient’s personal needs through the caring, relational side of health care. While the technical administrative focus of Lean origins may be a reason that Lean has not traditionally been used to directly target improvements in the relational side of health care, patient-centered care is compatible with Lean thinking and will benefit from and reflect its core principles. We argue simply that Lean thinking, while applicable to both administrative processes and patient care encounters must be applied differently for each, because these are fundamentally different health care processes. Then, and only then, Lean and its principles of respect for people and continuous improvement will leverage the strength of health care professionals to deliver the improved health systems that patients, practitioners, policy-makers, and politicians seek. 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Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
TI - Relationship-centered health care as a Lean intervention
JO - International Journal for Quality in Health Care
DO - 10.1093/intqhc/mzx156
DA - 2017-12-01
UR - https://www.deepdyve.com/lp/oxford-university-press/relationship-centered-health-care-as-a-lean-intervention-C9Ad6GSxf0
SP - 1020
VL - 29
IS - 8
DP - DeepDyve
ER -