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Organisational matters

A critical look at Lean Thinking in healthcare


T P Young,1 S I McClean2
1

School of Information Systems,


Computing and Mathematics,
Brunel University, Uxbridge, UK;
2
School of Computing and
Information Engineering, Faculty
of Computing and Engineering,
University of Ulster at Coleraine,
Coleraine, UK
Correspondence to:
Professor T P Young, School of
Information Systems, Computing
and Mathematics, St Johns
Building, Brunel University,
Uxbridge UB8 3PH, UK;
terry.young@brunel.ac.uk
Accepted 9 December 2007

ABSTRACT
Background: With healthcare, Lean Thinking encounters
a world, not devoid of value, but awash with
sophisticated and mutually unconnected concepts of
value.
Design: Given a shortage of systematic analysis in the
literature, this paper provides a preliminary analysis of
areas where the read-across from other sectors to
healthcare is relatively well understood, based on a broad
review of its impact on care delivery. It further proposes
areas where conceptual development is needed. In
particular, healthcare, with its many measures of value,
presents an unusual challenge to the central Lean driver
of value to the customer.
Conclusion: We conclude that there is scope for
methodological development, perhaps by defining three
themes associated with valuethe operational, the
clinical and the experiential.

The last century saw revolutions in production and


operations management (see Hopp and Spearman,1
for an historical overview, and Berwick2 3 and
Locock4 for healthcare perspectives). Of these,
Lean Thinking emerged with Taiichi Ohno at
Toyota.58 Laursen et al9 describe how a broad
family of quality improvement concepts impacted
first on operations management, with service
management following from around 1984, and
medical management from around 1996. They
further identify Lean Thinking as formally emerging in operations around 1992, in service around
1996, and in the medical arena in the early 2000s.
Lean offers five stages of improvement, founded
on the concept of value to the customer, created by
the producer, and defined in terms of specific
products with specific capability offered at specific
prices through a dialogue with specific customers.8 Value stream mapping identifies waste in
the end-to-end process (as activities that do not
add value), while the concept of flow stipulates that
products move smoothly from process to process
without waiting or waste. Flow may be a physical
mattersuch as realigning machinery in a factoryas shown with the five Ss (sort, straighten/
simplify, shine, standardise, sustain) system
adopted by the NHS.10 However, it also embraces
the idea that a system accepts each product variant
as it comes along. Flow eliminates obvious waste
(for instance, repeat activities or remedial work)
and hidden waste (such as the cost of managing
inventories, queues, delay or travel). Customer pull
creates a new production dynamic away from
batches and queues. Finally, the search for perfection is a reminder that Lean embraces a continuousimprovement mentality. With global healthcare
expenditure soaring above $3.2 trillion,11 12 and
with healthcare systems increasingly challenged to
382

deliver better care to more people using less


resource, the quest to explore the promises of
Lean Thinking is compelling.
The first half of this paper reviews the scene and
notes the profound gap between the medical
approach of randomised trials and other academic
methodologies on the one hand, and that of the
improvement methodologies on the other. The
second half provides a preliminary analysis of the
many views of value driving healthcare delivery
and proposes a framework to consolidate the scene.

IMPACT OF LEAN THINKING ON UK HEALTHCARE


A short experiment using the keyword NHS on
Google, followed by the phrase Lean Thinking
using the search within results function revealed
565 hits (experiment performed January 19 2006).
Searching within the results, with the string NHS
Trust, reduced the hits to 239, and listed a wide
range of newsletters, websites and other grey
literature related to Lean Thinking in hospitals,
ambulance services, PCTs, Strategic Health
Authorities and other NHS networks. The
Modernisation Agency proposed a set of 10 critical
improvements,13 in which the impact of Lean
Thinking can be seen. For instance, Change No. 5
(Avoid unnecessary follow-ups) is classical Lean
elimination of waste to save an estimated 100
million in follow-up DNAs (Did Not Attend).
The literature, academic and grey, has grown
considerably since the start of 2006. For instance,
repeating the January 2006 experiment reported
above on 17 October 2007 increased the hits to
37 100 (as opposed to 565) and the NHS Trust
hits to 554 (as opposed to 239). Typical of the
guides now available is that produced by Warwick
Business School.14 Evidence of effectiveness generally takes the form of case studies. Spear,15 for
instance, provides evidence of safer, higher-quality,
more cost-effective care through a series of
examples. The NHS Confederation commissioned
a report,16 17 with a set of exemplar improvements,
while Ben-Tovim18 19 reports from Flinders Medical
Centre in Australia. Findings from these sources
include the following:
c delays from emergency care to surgery reduced
to 1.7 days from 2.4 days and bureaucracy cut
by 24%;
c reduction in the number of steps in the
pathology process from 309 to 57 and reduction
in turnaround time from 2430 h to 3 h;
c a hospital halved the number of insurancerelated safety incident reports over 3 years, and
has moved healthily into profit without staff
cuts on the Lean journey.
The practice of Lean and other manufacturing
philosophies in the NHS was clarified when one of
the authors (TY) was invited to share in two

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Organisational matters

Figure 1

Pathway of movement of patients through a haematuria clinic from waiting on arrival1 to departure.12

interviews by David Bensley, Operational Research Programme


Manager at the Department of Health, who was leading a study
into hospital improvement on behalf of the Department of
Health and the NHS Modernisation Agency. Preceding interviews had investigated the extent to which hospitals had
followed a rigorous philosophy, such as Lean Thinking. Two
NHS process improvement experts, Dr Kate Silvester20 on 8
October 2004 and Paul Walley21 on 18 October 2004, were then
interviewed. (Both wish to have it acknowledged that this was a
retrospective analysis and that their thinking has continued to
develop; moreover, they would stress the importance of a
change of mindset in adopting such methods.) A picture
emerged in which both saw that PDSA (plan, do, study, act)
was the only improvement methodology that had bedded down
to any extent in the NHS culture. PDSA is a traditional
manufacturing improvement method in which new ideas are
first planned (P) then implemented, or done (D), studied (S) and
then applied (A), tested further or discarded, depending on the
findings.21 22
Interestingly, both improvement specialists articulated their
own methods in terms of a central, strongly heuristic
methodologyconsistent with PDSA. However, when it came
to deciding what measures to take in the next PDSA iteration,
each would consider the next move from a variety of
perspectives, using Lean, other philosophies, and trends showing up in statistical process control charts.23
In summary, there is evidence of widespread familiarity with
Lean, and accumulating evidence of benefit when it is applied,
especially in the areas of safety, delay and cost-effective delivery of
care. However, there is evidence that even those advising
clinicians and management would apply their own judgement
when selecting Lean approaches alongside other approaches
within a broader methodology, such as PDSA. Ironically, one
might argue that this is exactly what Ohno6 originally advocatedbut such a discussion is beyond the scope of this paper.
So, how has Lean been applied, and what is to be the prime
driver of value?
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INDUSTRIAL AND ACADEMIC VIEWS OF IMPROVEMENT


METHODS
Industrial and academic methods have produced very different
corpuses of literature24 (p. 396). Hopp and Spearman1 (p. 42)
capture something of this dichotomy between the industrial
and commercial worlds: It is apparent that business schools
and corporations have swung far apart since the Ford and
Carnegie studies of 1959 . . . Qualitatively, the industrial
improvement scene is characterised by champions who promote
methods and promulgate success stories within an appealing
intellectual framework, requiring buy-in and commitment to
implement change within that framework. As Hill and
Wilkinson25 observed with respect to TQM, the original gurus
of quality management have been long on prescription but
shorter on analysis and, moreover, have differed among
themselves.
The uptake of improvement methods into healthcare has not
always been smooth. Blumenthal and Kilo26 reported on the US
healthcare scene: It remains too easy for health care organisations to talk a good game . . . and yet to leave their daily
operations virtually unchanged. Moreover, the messages of
mixed methods being combined under a single banner, of
rhetoric winning over reality, and a mixed message over impact,
recur in that literature, too.27 28
Many of these general observations resonate strongly with the
healthcare scene we have just described, where there is strong
evidence of the activity of champions, the role of success stories
and the promotion of how to guides. The historical experience
of improvement methods in industry and healthcare raises some
concerns about the extent to which what is hailed as Lean is
genuinely Lean in practice. Finally, we must recognise that there is
a tension between the rigour of an academic approach (especially
in terms of controlled trials) and the improvement ideal, which
starts with what exists in real life and seeks to improve upon that
within the context of everyday practice.
Our contention is that the improvement agenda has been
driven by champions and by analogy with the industrial and
383

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Organisational matters
service-sector experience. The intuitive link between value
streams and patient pathways is compelling, and in fact, it is
exactly this link that drove Ben-Tovim et al19 through the study
in which they report their own, successful, improvement
process. Moreover, examples of benefit are now common.
However, it is more difficult to see exactly what has happened
to the founding concept of value. Given that clinicians have
developed many ways of measuring value-type concepts, such
as quality, it is worth examining how the simple concept of
value to the customer is faring in the world of healthcare.

VALUE IN HEALTHCARE
That Lean can continue systematically and dramatically to
improve a sector as significant as healthcare is still a matter of
belief, rather than proof, and there are some obvious reasons
why healthcare may differ crucially from other sectors. The
staggering, global, scale and complexity of healthcare provision
set healthcare naturally apart from manufacturing, perhaps
from all other service sectors. Although dual lines of authority,
clinical and managerial, need not be a unique factor, they are
certainly a sensitive issue at present,29 but it is perhaps in the
realm of the customer that differences are most obvious.
Shah and Robinsons30 classification of medical device users
shows several levels of users, including carers and healthcare
workers, each exhibiting characteristics that might make them
analogous to the customer. By extension, there are many people
who might, at the same time and with the same particular
patient in mind, have a role as customer for that product or
service, and hold widely different views as to the value of that
product or service. Alongside the personal customers are those
who specify or procure31 attempting to buy the best value for
many services to achieve the maximum health gain for those
most in need.32 In the UK and US, such parties represent an
organised attempt by a private or public sector purchaser to
ensure quality and to improve health outcomes.33 Some
communities have been considering value-type questions for a
long time, and there are sizeable literatures around the sociology
of healthcare and, of course, the business of defining and
measuring clinical and healthcare quality.
A case study is offered to demonstrate the potential for
clashes due to different concepts of quality. In May 2001, one of
the authors (TY) ran a workshop on industrial methods in the
NHS to explore how a cross-disciplinary team of managers,
doctors and nurses might apply improvement thinking. A Lean
Consultant was duly hired to gather information, part of which
was obtained during an observation of a haematuria outpatient

clinic on the afternoon of 24 February 2001. The patient


pathway is captured in fig 1, and the Lean Consultant timed a
few patients through the system (see table 1).
The clinic starts smoothly, but a queue builds as the clinic
proceeds because patients wait to see the Consultant. Both the
Consultant and the clinic Manager attended the workshop, and
a critical contrast of views emerged as to how best to Lean the
system, in this case for those patients diagnosed as not having
cancer. The Manager, who came from a nursing background,
took the view that the clinic had performed its purpose by this
stage and that waiting time could be eliminated by giving
patients the good news that they did not have cancer and
sending them on their way. The Consultant, on the other hand,
felt that the problem of diagnosis remainedeven in the light of
a negative finding for cancerand therefore wanted to ensure a
further consultation, even if this meant a queue building up.
One wonders what choice patients might have madeand
whether that choice might have changed with diagnosis.
The question of what steps to take to improve the clinic
cannot be resolved until the question of value is resolved. Those
who value smooth and fast throughput will lean one way, while
those who value as complete a medical response as possible will
lean another. From this case study, it is clear that there are at
least two dimensions of patient-centred value, namely one
based around the responsiveness of the system and another that
addresses clinical priorities.

DISCUSSION
Once we move beyond the concept of value-to-a-singlecustomer, we encounter a bewildering array of value-concepts,
reflected in a plethora of quality measures and frameworks. For
instance, Ellis and Whittington34 propose nine dimensions of
healthcare quality; the Dartmouth Clinical Improvement
model35 appeals to a four-point Clinical Value Compass (functional status, cost, satisfaction and clinical audit); while
Brown36 proposes a different set (access, effectiveness, safety
and satisfaction); and Lohr and Harris-Wehling37 analyse
services in terms of their ability to align knowledge with
outcomes. Another community addresses the quality of life.
The Barthel score, for example, may be used to assess the
mobility of a patient on discharge from a hospital. It is an
interesting example, since, while it is widely referred to, there is
considerable debate about its validity,3840 and it is not clear how
it fits alongside other measures.41 Measures related to patient
experiences may even include patient-defined criteria.42

Table 1 Summary of Lean Consultants observations related to patient movements around the clinic illustrated in fig 1
Patient delay observed (1, 2, 3, etc) (min)
Location

Activity

Later

1
2
3
4
5
6
7
8
9
10
11
12

Sit down on arrival


Change
Fill out form
Got to toilet
Sit down to await theatre
In theatre
Go to toilet
Change
Sit down to await consultant
In cubicle with urology nurse
In cubicle with consultant
Leave

0
5
10
3
1
11
5
9
1
3
9

0
10
5
5
0
11
6
8
1
2
4

0
5
5
2
0
7
1
5
5
0
5

0
5
5
2
9
18
4
3
7
2
4
2

0
5
5
2
0
10
3
5
60
2
5

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Organisational matters
Some unification of these various concepts may be possible by
considering value in terms of utility. The quality adjusted life
year (QALY) is a convenient way of calibrating health states
onto a single scale from 1 (perfect health) to 0 (worst imaginable
health state, usually death), discounted over the appropriate
period of health improvement or loss.4345 This measure can be
used to compare the outcome improvements effected by quite
different interventions, and critically the measure provides a
means of economic evaluation. For our purposes, the fact that
QALYs focus heavily on outcomes means that the experiential
elements of a process may not be captured. For instance,
Berwick and Weinstein46 discovered that women felt that as
much as half the value of an ultrasound scan was to have the
picture of their unborn babya benefit not traditionally
reflected in QALYs.
Even this limited and rather arbitrary survey shows that there
is no single customer with a simple view of value that can drive
Lean Thinking in healthcare, but that the field is full of
advanced views of value that have yet to be interconnected in a
systematic way.
The first major attempt to link some clinical values with
some other value-concepts in healthcare is reported by the
Institute of Medicine,47 which has proposed 10 rules for the
delivery of care. This endorses a multifaceted view of value,
while suggesting that there is a manageable limit to the
number of facets. What the rules do not do is to specify the
trade-off between them when time, money, or access to other
resources forces the case. Moreover, one might argue that
there are some other, unspoken, desirable values, such as
access or affordability that would feature highly for most
people. The Institute of Medicine48 also proposed six criteria
for quality assessment, namely that treatment be safe,
effective, patient centred, timely, efficient and equitable.
More recently, Gray48 suggests there are five important value
perspectives to consider (the payers, the patients, the
clinicians, the managers and industrys). Mainstream Lean
literature is alert to these issues,49 but the healthcare paradigm
is particularly difficult in this respect. However, there is some
evidence that patients do better when they value the
experience more.50 51
The reason this matters is that most choices in healthcare
service design include unintended outcomes. Until we have a
connect-up view of value, it is impossible to know whether
some aspect of waste-saving outweighs some other loss, or
depth of diagnosis, for instance. It is critical, therefore, to find
the minimum set of values required to proceed with Lean
Thinking; to understand how this value set connects to existing
value-concepts in healthcare; and to determine how value gains
in one dimension equate to losses in another. It is possible that
Lean is genuinely virtuous in all dimensions, but without a
framework it will be impossible to know.
A proposal that is consistent with all of the above is that
there are at least three critical dimensions to value:
c Clinical: The prime clinical value is to achieve the best
patient outcome (and is likely to be shared by clinicians and
patients alike).
c Operational: The prime operational value is likely to be the
effectiveness of the service, measured primarily in terms of
cost (including that which is lost through delay and poor
quality). Clearly, this matters most to service providers and
their managers, although clinicians and patients will also
buy into this view of value. Our contention is that most, if
not all, Lean Healthcare has been driven by an Operational
view of value.
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Experiential: Clearly patients value (or otherwise) their


experiences of care, as will carers and those working in
healthcare systems, either through their ability to empathise
with patients, or in their own right.
Crossing from one theme to anotheror attempting to tradeoff benefit in one dimension with disbenefit in anothermay
be possible.52 The fact that the NHS53 in the UK will pay up to
30 000 per QALY may provide a boundary limit in converting
clinical to operational values. Interestingly, Santry54 reports that
even this limit may be too high, authorising the unaffordable.
While reducing everything to money may seem rather crude, at
least it enables one to envisage how the argument may be
developed. Finally, we all manage to evaluate experiential
elements of our lives, and, indeed, willingness to pay55 is a wellunderstood concept that links experiential to monetary values.
Pulling all this together under a patient-centred paradigm
may, indeed, be possible, but it will require either patients to
develop more, and specialised, knowledge in these fields, or
careful attention to be paid to the way in which patients are
protected by other stakeholders who come to represent them.
c

CONCLUSIONS
The way in which Lean Thinking is being adopted in healthcare
appears to follow a trajectory consistent with the way in which
other industrial methodologies have been taken up in other
sectors, where uptake is mixed, and practice may be pragmatic
rather than pure.
Having briefly reviewed the attempts to distil out a smaller
set of common values, we propose that there are three key
themes, or dimensions, to value in healthcare: the clinical, the
operational, and the experiential. Moreover, since all three are
subject to economic evaluation, it should, in principle, be
possible to undertake a comparative analysis between benefits
along these separate axes.
For Lean, however, the absence of a single customer with a
compelling view of value is perhaps the most important feature
of healthcare, and consideration of value within the many
customer communities reveals a complex and fragmented
scene. We contend that having demonstrated value in the
sector, Lean must now engage with these many value concepts
in a rigorous and, if possible, homogeneous fashion.
Acknowledgements: The authors wish to thank P Hines (Cardiff University), K Young
(Warwick University) and N Proudlove (Manchester Business School) for helpful
comments, and T Grocott (Kings College London), J Hobart (Derriford Hospital),
R Lilford (Birmingham University) and the referees, for helpful pointers to the literature.
They especially wish to thank D Bensley and the Department of Health for access to
the Improvement Partnership for Hospitals Evaluation interviews. K Silvester and
P Walley have also been very supportive in preparing this paper, and we thank them
for their help. Finally, TY would like to thank M Feneley (University College London
Hospitals) and G Sutton (Sutton Kaizen Consulting) for data and help with the
haematuria example. L Steuten, with her excellent proofreading, along with J Eatock
and C Weekes, with their help with the references, have provided invaluable support
at Brunel University. The views expressed are entirely those of the authors.
Funding: This work has not been supported by any specific programme. However,
much of this thinking has benefited from the involvement of TY in the MATCH
Programme (EPSRC Grant GR/S29874/01) and SMcC and TY in the RIGHT proposal
and programme (EPSRC Grant EP/E019900/01).
Competing interests: TY has received fees and research funding for work on process
improvement, simulation and information technology in relation to healthcare.

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Qual Saf Health Care 2008;17:382386. doi:10.1136/qshc.2006.020131

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A critical look at Lean Thinking in healthcare


T P Young and S I McClean
Qual Saf Health Care 2008 17: 382-386

doi: 10.1136/qshc.2006.020131
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