Public hospitals are too Lean


The San Francisco Department of Public Health is paying Rona Consulting Group, an out-of-state consulting firm, $1.3 million of taxpayer dollars to implement a program called “Lean,” allegedly to improve patient services. The “Lean” program is based on the Japanese Toyota automobile production model.

Hospital quality improvement schemes such as the Lean promise decreased waiting times, improved communication, more satisfied patients, and safer care. Quality care should also decrease the incidence of hospital-acquired conditions so that patients leave the hospital without getting new infections, falling, or getting pressure ulcers such as “bed sores.”

Hospital administrators are telling health care workers and patients that Lean will achieve these widely shared goals. Yet despite years of efforts, there is no evidence that it works, and growing concern that resources must be increased rather than prescribing the Lean diet to an already starving public health infrastructure.

Health care should be based on the best available science — not corporate sales. The Lean program encourages the hospital staff to consider its workplace as a factory shop floor, and to consider their patients and work as a product. The competition for well-insured patients and improved satisfaction for reimbursement has caused hospital administrators and Lean consultants to propose surgical clinics that resemble Nordstrom or the Hyatt Regency.

Lean’s management methodology, based on Toyota’s selected Japanese words, is used to mystify and dazzle. Instead of the pharmacy window, we are told that all staff must go to the “gemba,” which the consultants (not the dictionary) say is Japanese for “where the work happens.” Many highly paid hospital administrators and even clinical staff have been re-named as “kaizen promotion office” leaders. Those who have completed advanced training are awarded a “black belt.” The use of Japanese terms is clearly meant to add a sense of authority.

Evidence-based medicine and nursing have been examining high-quality studies of the effectiveness of improvement schemes such as Lean. According to “Guiding Inpatient Quality Improvement: A Systematic Review of Lean” (The Joint Commission, 2012), “the true impact of these approaches is difficult to judge, given that the lack of rigorous evaluation or clearly sustained improvements provides little evidence supporting broad adoption.” This leads to very expensive, wishful thinking. When consultants are paid from $4,700 to $25,000 a day from public funds intended to construct a seismically sound hospital (see “Toyota work methods applied at General Hospital” San Francisco Bay Guardian, May 7, 2014) it seems important to consider what randomized controlled trials tell us. The taxpayers have a right to know what to expect from this scheme, but there are no controlled scientific studies to tell us.

Despite more than 10 years of multiple published studies, very few consulting firms even report statistics. Those that do show weak evidence of effectiveness, and none show sustained improvement. If Lean were a medication, it would never receive approval from the Food and Drug Administration, as we don’t know if it helps or hurts the care of patients. As it is, hospitals are performing a single-group intervention study without ethical approval or consent from the workers and the patients.

Hospitals should be providing their patients with the best care, not the cheapest. Even if Lean didn’t come with a price tag to taxpayers ranging in millions of dollars for consultants to do the work that administrators should be doing, the underlying notion of speed is dangerous in health care. Public health patients are even more vulnerable with increased prevalence of poverty-related co-morbidities, from diabetes to tuberculosis. If there were a way to more quickly cure our population of its many ills, we would embrace Lean.

Nobody likes to wait around, but the human connection between caregiver and patient takes time. Efficiency should not be valued over safety. Furthermore, many patients would be unhappy to learn that they are being viewed as inanimate products on an assembly line. Nor does it please health workers to think of themselves as robots.

Hospital safety under Lean is being modeled after the same automobile corporation that was just forced to pay $1.2 billion for concealing safety defects (“Toyota Is Fined $1.2 Billion for Concealing Safety Defects” New York Times, March 19, 2014). The safety defects were implicated in unintended acceleration of some Toyota vehicles that led to injury and death. Speed was certainly not helpful in that situation. Perhaps DPH should critically examine Lean before prescribing a diet to our vulnerable safety-net patients. Maybe we need more, not faster, health care workers.

Ed Kinchley has worked for DPH for 30 years, after spending nine years in Japan.