A Remarkable Story

The most surprising and rewarding thing last year was seeing how lean is transforming the patient journeys through what is thought to be the oldest hospital in Europe, founded on the 23rd of June 1288! In the cellar of the Santa Maria Nuova e Bonifazio Hospital in the centre of Florence, Italy they still have the slab where Leonardo de Vinci carried out his secret dissections to understand the workings of the human body. This hospital also published the first manual detailing how hospitals should be designed and managed. La Tavole del Regolamento, published in 1783, was the bible for how hospitals should be run until modern times. Now they are one of the most impressive pioneers of lean healthcare.

Their lean story began six years ago when Luigi Marroni, a senior executive heading Fiat’s global tractor operations, was asked to become the Director of the regional healthcare system in Florence, his home town. From the beginning he told them lean would be part of their journey to modernise these ancient institutions. Six years later a thoroughly modernised interior is taking shape inside these beautifully restored historic buildings and his growing team of lean engineers led by Dr. Maria Teresa Mechi are transforming the way doctors and nurses work within them. They also have four other hospitals and the responsibility for the entire regional public health system, so they will be busy for many years.

What is so refreshingly different about their approach is that they look at the hospital as a whole organisation and understand exactly the importance of using lean to improve the overall performance of the hospital and its bottom line. But they also understand very clearly the importance of looking at the fine grained detail of how doctors, nurses and other hospital staff work together to progress patients through the hospital. And one of the first things they did was to organise and recruit managers (many of them clinicians and senior nurses) to run each of the major patient flows from end-to-end. Of course they did training sessions and workshops — but only in the context of the problems they were trying to solve.

The other important difference is that they scoured the world for lean knowledge and brought this back to develop their own internal lean capabilities, rather than relying on external consultants, which never lasts, to do a lot of the work for them. We met at our first Global Lean Healthcare Summit in 2007 and in subsequent visits discussed their early experiments with value stream organisation and management. But their progress really accelerated when they came to see the lean work done by the old miners’ hospital in Caerphilly in Wales and when they read Making Hospitals Work and attended our two day workshop, which explained the method Caerphilly used. They went straight back to Florence and implemented what they had seen.

They also decided to organise a public conference in Florence in December to raise awareness of lean healthcare across their organisation and across Italy. We brought a team of experts from the UK and were stunned to listen to story after story from doctors and nurses talking about their lean projects in the different hospitals in Florence and in other hospitals in Italy. The seeds of the right way to introduce lean healthcare have been well and truly sown in Italy thanks to their example. We look forward to following and supporting their efforts in the years to come.

I draw three lessons from this example and from other hospitals I visited around the world last year. First new ideas need new leadership. Without Luigi’s vision and his experience of what it takes to make lean really work in other circumstances, none of this would have happened. [n my experience clinicians and nurses have little problem with evidence based lean — indeed they see it as common sense. They often ask why management does not just make it happen!

However at least in the UK they have become used to initiative after initiative being consulted to death, to literally hundreds of new improvement projects being given to already overloaded staff to do in addition to their already overloaded day jobs and to management endlessly distracted by fire-fighting. At the same time managers who learned to play the highly political process of negotiating for the resources from the politicians and who are skilled at administering and policing the spending of these budgets do not have the skills and experience to run a service delivery business that must pay its way. New leadership from outside healthcare and probably outside the public sector is needed to break this impasse.

Second, all improvement work needs to start from a clear and shared analysis of the quality, effectiveness and safety problems which contribute to the cost problems facing each healthcare organisation, as well as an investigation of the root causes. Surprisingly this is not common practice. Ideally we would use evidence based medicine to define best practice interventions to eliminate variation and errors. We would also use evidence based lean management to improve the flow of work to eliminate delays for patients, wasted effort for staff and unnecessary costs for the hospital. But point improvements, whether to address quality problems or to lean parts of the patient journey are almost impossible to sustain in isolation.

Quality and lean are two sides of the same coin. They need to be used in tandem. We would use the scientific method for prioritizing which problems to work on, eliminating the generic root causes of these problems and carefully planning how to implement countermeasures that will stop the problem ever occurring again. We would also use lean principles and tools to link best practice activities into integrated patient journeys from initial consultation to discharge and beyond. We would use visual management to establish stability in the work flow, to see variances and to reveal problems. And we would develop the problem solving skills of staff through learning by doing.

Third the end-to-end patient journey, plus the key support processes, must become the focus of attention for management. Because so much of managers’ time is taken up with meetings and fire-fighting not enough of their time is spent on the front line seeing what is really going on (as opposed to what they think should be going on), unblocking decisions and actions that are holding this up and helping staff to resolve their own problems quickly. It can rightly be summed up in the Toyota mantra of “Go and See”, ‘Ask Why” while generating ‘Respect for People” trying to do a good job right first time on time.

Yours sincerely
Professor Daniel T Jones