Posted by: Knightbird | July 10, 2010

A Sad Moment

Mark Graban reported in about the vastly improved Park Nicollet Cancer Center. Patients were involved in the actual design of the Center, which is the new lean way of designing facilities.  I will write about this later. The Clearview Cancer Center in Huntsville, Alabama was designed with lean principles in mind, although it is not clear from the literature that patients participated in the design. Clearview has achieved phenomenal results. The plain and simple result is that lean design for cancer centers focus on the patient journey, and eliminating some of the waste they encounter. It works when executed properly. Lean works when executed properly, with employee empowerment, delegation of authority to accomplishment improvements, training in the tools of lean, and accountability for continuously improving processes.

Mark also reported on a campaign by Minnesota Nurses to discredit Park Nicolet’s lean transformation.  In public advertisements, the Nurses do what so many opponents of lean do, they implied that a management system used by an automobile company, and a foreign one at that, is totally inappropriate for a hospital and patient care. Never mind that Ford and General Motors pioneered much of our modern command and control, budget based management systems that are currently used in hospitals. The Nurses then misrepresented certain Lean tools, like the use of a stopwatch to time processes. They also used Toyota’s recent troubles as an argument that the management system does not work.

I had my own “Minnesota Nurses” (and management} in my health care system at Chugachmiut. After I had managed to change our headquarters office to a lean culture, I began to look at our health care system. We had conducted a number of health care Kaizen, including 2 I talked about under “TheSnoopy Dance” blog. I began to ask the health care division for data. In particular, I wanted to know the number of patients our providers were seeing on a daily, weekly and annual basis. My health care division director said they would have to gather the data. This went on for months and I finally made it an order. Within a couple of weeks I had a very rough report of the number of patients we say. Our Seward Clinic averaged 12-13 patients a day with a variance from 0 – 31. 2 of the 5 mid-level providers at the clinic saw a majority of the patients, and in the year I reviewed the data, they were seeing an average of 4.5 patients daily. Our Village Clinics say a similar number of patients on a daily basis. I quickly worked the numbers.

Imagine my surprise. Data in Alaska indicated that the average mid-level provider saw 19 patients daily, and handled radio medical traffic from other Village Clinics as well. Our providers were asking for another mid-level provider on staff to handle the extraordinary workload. Instead, I saw a need to downsize. Since we had a vacancy at that time, and another resignation occurring in a few months. I let the division director know that I would not be authorizing replacements for the 2 vacant positions and to determine a work schedule that involved all 3 remaining mid-level providers at Seward in direct patient care. Well, the brown stuff hit the proverbial fan. The division director and providers started contacting the Village Health aides and told them that this act of mine would destroy our health care system. They contacted the tribal chiefs with the same message, and the contacted the board of directors. They asked to come speak to the board in person. I ordered my division director to keep the providers at their duty station and not come to Anchorage for the meeting. Of course they disobeyed and some of them came anyway. I asked the board not to allow them to speak to the board. Mind you, the division director and providers had not made any effort during their months of political activity to explain how patient care would suffer, or why we needed 7 providers for 1,350 patients. The board recognized that the division director and providers worked for me, and needed to make their arguments to me. Because they realized their arguments were not sound, they chose the political solution, which typically involves scaring the patients with anecdotal arguments, instead of sound reasoning. After being rebuffed by the board, all of my providers eventually quit and were gone within 30 days. We were left to operate with itinerants for about a year until we were able to hire new providers. I was disappointed with our providers abandoning their patients, especially after almost every provider candidate we interviewed afterwards told us they would need a period of 3 months or more to ensure that their patients were taken care of.

Chugachmiut now has a full time MD and Physicians Assistant. They do an excellent job seeing our patients. In fact, I had budgeted for a third midlevel position, and the 2 providers didn’t feel it was necessary to fill it. They felt, as I did, that we could use itinerants when necessary. We now do.

Our patient care has improved substantially. The complaints have slowed to a trickle, and my clinical staff reports a very high patient satisfaction level with our service. The Minnesota Nurses need to think of their patients before they dismiss lean health care.

In the meantime, we have been able to dedicate resources saved to our dental program, among others, with great success. We actually have one of our Villages see all of their dental restorative work completed (no cavities). We are on maintenance with that Village.

A health care system is just that, a “system” and a complex one at that. No one part of the system can work well unless they work together. If one segment of the system is taking a lions share of the resources through political means, it leads to more waste.


  1. Not having been in the middle of the Minnesota Nurses Association hoopla I wondered if the nurses didn’t understand the true nature of lean, didn’t want to, or both. If they did truly understand it they wouldn’t have been pointing the finger at lean, because it is a very compassionate philosophy. “No one loses employment because of lean improvements” is a key tenet. Also, quality patient care is a top priority, so understaffing at the expense of patient care would not be an issue, if lean is applied appropriately. In the end, it’s clear that they don’t understand that one of the aims of lean is to remove the obstacles (waste) that prevent them from delivering the best patient care possible. Perhaps it wasn’t explained to them this way. But, if the learner hasn’t learned, the teacher hasn’t taught.

    The stopwatch thing was also clearly off-mark. If Park Nicollet is having lean facilitators, or others outside of the areas being studied doing the time observations, then I could see why they felt as they did. If they are doing their own time observations in an effort to identify their waste and remove it to improve patient care, as it should be done, this also should not be an issue.

    We can only speculate, but the obvious disconnect is sad…

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