Lean and the perfect patient experience.

To cite: Blackmore CC, Kaplan GS. BMJ Qual Saf Published Online First: [please include Day Month Year] doi:10.1136/bmjqs-2016005273 The term Lean means different things to different people. At Virginia Mason, it is applied to the management system based on the systematic identification and elimination of waste, defined as any activity that does not add value from the standpoint of the customer. First developed in manufacturing, and championed by the Toyota Motor Corporation, efforts to introduce Lean into healthcare have been met with some scepticism. ‘People are not cars’ has been the refrain of those unwilling to view healthcare as made up of processes that produce products and services, and that is thus amenable to improvement. Healthcare, of course, is different from manufacturing, in that it is not simply the final product that is important to the customers, but also the patient and family experience of care. Also adding complexity in healthcare is the presence of multiple customers, the patient most importantly, and the healthcare providers and staff, and the healthcare institution itself. In addition, in most healthcare systems, there is a disconnect between those who pay for healthcare and the patients who receive it, thus generating an additional healthcare customer or stakeholder, the source of funding, whether it be the government, employer or insurance company. Clearly, the application of Lean in the healthcare setting is complex. Successful application of Lean to healthcare requires avoidance of several pitfalls. The first of these is the misinterpretation of Lean merely as a set of tools targeted at short-term gains. The tools of Lean are well known and include value stream maps, 5S and rapid quality improvement workshops. These tools are effective in the short term, but true transformation and sustainability require, in addition, aligned leadership, a supportive institutional culture and integrating the Lean tools as part of a comprehensive management system. Absent these latter elements, expectations for Lean improvement should be limited to small-scale targeted gains. Second, in the hierarchy of customers in healthcare, priority must be assigned first to the patient. Fundamentally, healthcare exists to serve patients. It, then, is foundational that waste must first be defined from the perspective of the patient. For example, much of the value to a patient in a primary care visit lies in the direct interaction between the provider and patient. Therefore, Lean improvements in the primary care visit should first focus on maximising this interaction, increasing its length, eliminating distractions and delegating simple tasks (ie, data entry, blood pressure measurement) to others. The needs of the other customers in healthcare are important, but must be secondary to those of the patient. For example, though increasing throughput may be important to some of the customers in healthcare, this is a secondary goal and should not be addressed at the expense of the provider– patient interaction. Third, Lean enables systematic improvement towards specific targets, with the choice of targets therefore determining the improvement plan and overall impact of the work. From the patient perspective, quality, safety, access and the care experience are most important, and these then must be the primary targets for the Lean approach. Too often, Lean is treated simply as a cost-cutting or efficiency approach, mitigating the opportunity to improve overall care. Furthermore, cost control may not be the top priority for frontline staff who are motivated to work in healthcare by a desire to focus on patient needs. A primary focus on cost may alienate these key participants in the patient care process and limit improvements. Conversely, using Lean to address quality EDITORIAL