Lean thinking to mind the gap in healthcare management.

We congratulate your team for your initiative to improve healthcare delivery to stroke patients1. The participation of multidisciplinary staff working at Gemba (where the work is done) is an excellent approach, discussing the strengths and weaknesses of care delivery, anticipating threats and looking for opportunities. We agree entirely with your views on quick-fixes, which may create work-arounds that do not address underlying issues. It is like prescribing a medication without a clear diagnosis or understanding of the problem. Healthcare management is strategic; in many areas of healthcare delivery, treatment efficacy and also safety take place outside the boundaries of pharmakinetics or procedures. Stroke patients are a good example. We know about rt-PA as a hyperacute ischaemic treatment, but in order for the medication to work safely, we engage in looking into each patient’s 5 R’s (right medication, right dose, right time, right route, right patient). In the United States, it has been estimated that over 98 thousand patients per year have died of medical errors2. One way to reduce this toll is to start with education about management and quality improvement, which is neglected in the Medicine curriculum. We need to mind the gap, and to move from intuitive “gut feelings”, to a logical, data-driven, stance in healthcare management. Lean thinking, derived from Toyota’s Production System, has been adopted in many healthcare setting with success. Lean thinking is not a set of tools, but is rather a more philosophical approach towards management, founded on the concepts of relentless elimination of waste and continuous improvement. For example, eight broad types of waste have been identified, often summarized with the acronym DOWNTIME: Defect (give a wrong medication), Overproduction (ask for exams that are not needed), Waiting (a patient waiting for consultation, a surgical team waiting for an operating room), No use of staff (not listening to employee’s suggestions), Transportation (patients need to go to several places), Inventory (expired medication), Motion (employee walks to distant areas to get supply), and Extra processing (generate duplicate documents). The Institute of Healthcare Improvement has developed a tool3 to help in identifying wastes in a hospital. Your group is on the Lean journey, not wasting the collective intelligence and looking to improve your work. We believe this effort is worthwhile, as it can provide more efficient and safer care for your patients as well as an improved work environment for your staff.