Blog Posts

Toyota Production System

Why Lean Fails: Commitment Is Key

Posted on Tue, Aug 11, 2015
Why Lean Fails: Commitment Is Key

This is Part 1 of a two-part series about the challenges implementing Lean processes.

By Joseph Twanmoh MD, MBA, FACEP, FAAEM

Virginia Mason Hospital and Medical Center in Seattle is the poster child for Lean in healthcare. Consisting of a 336-bed hospital, multiple clinics and multispecialty group practice, Virginia Mason was named Leapfrog Group’s top hospital of the decade. But it wasn’t always that way.

In 1998, Virginia Mason was losing money. In 2000, its board of directors decided that change was needed, and a new CEO was hired. Coincidentally, Boeing, also based in Seattle was 7 to 8 years into deploying the Toyota Production System, the foundation of Lean process improvement methodology. In 2002, Virginia Mason began its Lean journey. The hospital’s leaders took their first trip to Japan to study from Toyota and they return every year for two-week intensive study missions.

The hospital’s success stories include:

  • ED Redesign: Like many emergency departments, Virginia Mason’s was frequently closed to ambulances. Using Lean, low-acuity patients were identified and quickly discharged, saving beds for those more acutely ill. As a result, ambulance diversion was decreased by 90 percent.
  • The Patient Safety Alert (PSA) system: The PSA system requires all staff to immediately report any threats to patient safety and stop any activity that could cause further harm. Investigations are immediately launched to correct the problem. Prior to the PSA system, safety complaints took months to be resolved. Between 2002 and 2009, more than 14,000 safety alerts were reported. Now, most safety concerns are processed in 24 hours. Patient safety has improved and professional liability claims have dropped.
  • Cancer Center Redesign: Previously, oncology patients traveled throughout the hospital for chemotherapy. Now, treatment is brought directly to the patient in his or her private room. For the patient, a 10-hour visit has been reduced to two hours.
  • Nursing Workflow Redesign: In many hospitals, nurses spend about 65 percent of their time in non-direct patient care. Using Lean, nurses and techs work as teams geographically located near their patients. Supplies were reorganized to be closer to the patients and care teams. Virginia Mason’s nursing teams now spend 90 percent of their time on direct patient care, instead of just 35 percent as before.
  • Hyperbaric Medicine Redesign: When the Center for Hyperbaric Medicine appeared to outgrow its existing space, the original solution was a new building with larger chambers. Lean teams were able to design and build a new hyperbaric center in existing hospital space, saving $2 million in construction costs.

Have you been using Lean at your hospital but not getting these types of results? You’ve read about Lean and maybe even taken a Lean certification course. Why has Virginia Mason been so successful with Lean where others have not? While the questions seem straightforward, the answers are not. The short answers revolve around Lean implementation, differences between manufacturing and healthcare, and inherent Lean limitations.

Lean: The Early Years

Lean is a term used to describe the Toyota Production System. From the ashes of post-World War II Japan, where Japanese industry was literally in rubble, Toyota rose from a seemingly insignificant motorcar company to one of the world’s most profitable and respected auto manufacturers. Toyota sent engineers to the United States to study the automotive industry. One of those engineers was Taiichi Ohno, considered the father of the Toyota Production System. He realized that Japan could not possibly compete with the US using the same American methods of mass production. Obsessed with waste, he instead challenged his engineers to develop more efficient systems. Thus, the Toyota Production System was born.

The Toyota Production System is based on the Toyota Way, consisting of the Four Ps and 14 Principles.

The four Ps are:
  • Philosophy
  • Process
  • People and Partners
  • Problem Solving

Toyota’s philosophy is to add value to their customers, society, community and associates. Toyota strongly believes in process; that the right process will yield the right results. Conversely, you can’t get the correct results with the wrong process. Toyota believes in investing in people and partners. The company believes that it has an obligation to develop and grow both its associates and partners, such as suppliers and key business relationships. Lastly, Toyota believes in problem solving – that improvement should be continuous and that the pursuit of quality is never ending.

Toyota places these four Ps and 14 principles into a pyramid, which is symbolic. The base of the pyramid is Philosophy, the next layer is Process, followed by People and Partners, with the top being problem solving. Toyota believes that you cannot operate at the top of the pyramid without having a solid foundation and base.

Lean Pyramid
Image courtesy of Toyota Production System

Not Leaping for Lean?

This graphic reveals the first reason Lean so often fails in healthcare. When Lean was implemented at your hospital, how much time was spent on philosophy? Did everyone in the institution understand that it’s necessary to place the needs of the customer – the patient and his family – first in designing processes? Did you show respect for direct caregivers by creating work environments that are safe and rewarding?

Toyota has a phrase: Treat each line worker as a surgeon. The line worker has the most important job, directly making the product. Their work environments should be clean, well-organized, and safe to minimize errors and maximize efficiency. Is that the situation at your hospital? Are your rooms adequately stocked? Is equipment readily available and in good working condition? Is your computer system user friendly to minimize wasted time and errors? Did your senior leadership go to Japan to study at Toyota? Likely, the answer to these questions are no.

The first failure with Lean in healthcare is a lack of leadership commitment. Too often it’s viewed and used simply as a tool to cut costs or solve a problem. Remember, Toyota believes that you cannot operate at the top of the pyramid (problem solve) without a secure foundation (philosophy and process).

When leaders are not fully committed to the mission, it’s a signal to the rank-and-file. People simply will not follow when leaders aren’t committed. Imagine a general who isn’t committed to his mission. Do you think the troops will give 100 percent effort? When leaders pay lip service to Lean, it becomes readily apparent.

Dr. Twanmoh is the Director of Health Systems Innovation for EmCare's North Division and the Senior Vice President for the MS2 Group, a healthcare consulting firm that specializes in patient flow optimization and readmission reduction, creating sustainable solutions for hospital clients. With more than 20 years of experience as a medical director and board-certified emergency physician, Dr. Twanmoh understands both strategy and operations, keeping the big picture in mind when re-engineering patient flow. Certified in Lean and with expertise in change management, he has applied those techniques to seek innovative solutions to improve patient outcomes and service delivery.   Having worked for an independent physician-owned emergency medicine practice, contract management groups, and as faculty in an academic institution, Dr. Twanmoh has a deep understanding of the challenges and opportunities facing physicians in each of those employment arrangements. A graduate of Rutgers-Robert Wood Johnson Medical School, he received his MBA at the Johns Hopkins University Carey Business School. Dr. Twanmoh is a Fellow in both the American Academy of Emergency Medicine and American College of Emergency Physicians.  He is a past-president of the Maryland Chapter of the American College of Emergency Physicians and serves on the Emergency Medicine Practice Committee for the American College of Emergency Physicians and is the co-chair of the Operations Management Committee for the American Academy of Emergency Medicine.