Engaging Physician in Lean Transformation

8 Comment(s) | Posted | by Marianne Jackson, MD, MPH |

Immersed as I am now in Lean literature and methodology, it is sometimes hard to recall my first reactions as a physician to the words Standardization and Compliance. I am reminded, however, of my negative reflexes when I see the responses of physicians who attend Lean educational sessions. Those who are following along contentedly through Value Stream Mapping and A3s suddenly throw up walls of defensiveness when they hear Standardization and Compliance.

The response of Quality Assurance staff and facilitators often is to become frustrated and critical of us physicians for being too conservative and wedded to our autonomy. They may proceed with improvement efforts without physician participation. I'd like to explore the physician context and in so doing, suggest means for introducing Standardization and Compliance in ways that physicians can accept because physician engagement is critical to the success of the majority of Lean Healthcare transformations.

Lean has only been aggressively adapted to the healthcare market for about a decade. We promoters understand it to be an integrated approach to improving processes and systems using the innovations of all of the workers who touch the process, top to bottom and bottom to top. Prior to Lean, quality initiatives came strictly from the top and often from outside the hospital walls. Regulatory agencies developed and imposed "standards" and only negative indicators of poor outcomes such as infection rates, low APGAR scores and returns to OR without the input of those who provided the care.

Enforcement of "standards" or compliance was given to the Quality Control Officer (intimidating language) whose job it was to comb through charts finding the omissions, failures and faults in order to display them for the Medical Staff for review and report to the Board. Such statistical methods applied to very small sample sizes and minimally meaningful indicators created anger and rejection of the process among medical staff. For example, a physician who had saved a life by diagnosing a post-operative bleed, who took the patient back to the OR was "dinged" and judged as culpable by the indicators. Many of these practices continue today. If an error is caught in a non-Lean regulatory environment, what are the incentives to identify and disclose it if you are going to be penalized?

Physicians work with many sharply competing incentives. Reduce costs, see more patients, make no errors, document to satisfy even the harshest malpractice lawyer, be compassionate, spend more time with all patients, screen for seatbelt or tobacco use, complete required authorizations for HMO's, coordinate care with all providers, and be prepared to respond to any emergencies. We will resist Standards if they feel like another burdensome injunction to "remember to do" one more thing that is going to be measured.

On being introduced to Lean, physicians are likely to think of it is a means of meeting current reporting requirements while we know it can have much greater impact. I saw a recent example at Scotland Memorial Hospital in Laurinburg. Surgeons began using Lean to investigate why they had deficiencies in meeting SCIPS DVT prophylaxis indicators and why orders for heparin were omitted. When they went on a Gemba walk they discovered the many wastes in their whole pre-operative admission process. They discovered how Lean methodology could be used to simplify, not burden their practices. They discovered how standardization is about having resources, routines and safeguards in place that protect their practice of medicine. Simple examples of standards and routines include having laboratory results reported in an accurate and timely manner, for having outside records available prior to consults, for medication refills ready for signing after checking for allergies, for check lists for pre surgical authorizations and registrations. These examples and others can demonstrate how standardized work can avoid errors, redundancy, waiting, and rework while simplifying medical practice but not constraining it.

To engage physicians, emphasize that Lean Methodology is devoted to establishing processes throughout an organization that reliably support the physician’s efforts. Demonstrate how standardization links the physicians' work to those who come before and after in the sequence. Compliance with standard work is a means of confidently controlling the mundane work and focusing the physician's efforts on the exceptional and unusual cases. Physicians will see that the processes associated with standard work assist them to provide individualized care and responsiveness to unpredictable need.

For assurance, we should emphasize what Lean is not - it is not a means of controlling, policing or punishing. It is not a set of Do's to remember. It is not a denial of individual patient or physician needs. It is not strictly an efficiency tool. And it is not the enemy of innovation. Atul Gawande, MD, in his outstanding book "Better" examines several stories of clinics and practitioners whose outstanding outcomes are many percentage points above the expected. He challenges us to look at that variability for the sources of true excellence. Compliance with standards by everyone in the workflow is not going to eliminate all variability or stifle innovation but it will provide an unprecedented level of support and stability to highly competent physicians who will be able to focus on excellence.

We physicians are not necessarily resistant or obstructionist when it comes to Lean or quality improvement efforts. The Lean transformations of Virginia Mason and Theda Care were led by physicians. Engaging physicians is critical for success in Lean Healthcare. As a facilitator, sensei or change agent, success will be when you find the ways to align the Lean principles with the physicians' goals - they are not incompatible. The true transformation in the medical culture will be achieved when this alignment results in trust and cooperation among all providers of patients' care.


  1. Rachel Baker's avatar
    Rachel Baker
    | Permalink
    If all health care workers, including physicians, could take a week vacation in Japan to learn the Toyota Production System, there would likely be a massive lean movement. Perhaps a key way to engage physicians is to share success stories from the perspective of other physicians, like yourself. First answering the common question of "what's in it for me?" will help in getting physician buy-in. Physicians, like most of us, will support activities that will make their job easier.
  2. Emily's avatar
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    I couldn't agree more with the author's points. Doctors must be an integral part of the standardization process. If there is no by-in by the physicians, compliance will not happen. They must understand why this is beneficial to them and to the care they give (and like Rachel said...maybe a trip to Japan would help).
  3. Lauren's avatar
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    I also agree with the author's points and believe Lean can be very helpful in healthcare. However, the author does not address key barriers to engaging physicians in Lean:

    1. Time. The Lean process takes a lot of time. Most organizations use a "Kaizen" approach, meaning that they have a Lean event/rapid cycle improvement event that spans a few days. Even in organizations where physicians are salaried employees, there may be resistance to allow the physicians to take time away from patients to participate in Lean events because, ultimately, the organization is not generating revenue during that time.

    2. Other staff are also involved. As part of the Lean process, entire teams take a look at processes and determine where there are non-value added steps and then remove those steps. However, as health care processes normally involve staff of all levels (i.e. nurses, front desk staff, physicians, etc.), numerous staff play a role in developing the new standard process. There may be conflict or resistance between physicians and other staff if disagreement on the best process occurs. It is not as easy as the author makes it seem to develop these new standard processes.
  4. LeVelton Thomas's avatar
    LeVelton Thomas
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    I agree with the author, that physicians should be involved in the standardization process. Physicians are an important part of the hospital, and their cooperation/buy-in is integral in any large scale system-wide changes. A history of being hard to work with and autonomous, should not deter or preclude physicians from being included in future decision-making within the hospital or any other organization. Like Emily stated, if physicians do not feel like they were included in the process, they are less likely to comply with the new standards/procedures.
  5. Paige's avatar
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    While this system is not easy to implement (the points Lauren makes above) it is one that will strengthen the operations of the facility utilizing it. Creating a culture of physician engagement in developing new and improve procedures is a challenge, but if this step can occur, their input can lead to improved patient outcomes and increased revenue. Just like any improvement strategy, it takes time, personnel and effort to implement.
  6. K. Lee's avatar
    K. Lee
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    This article provides excellent ways to frame Lean practices and improvements in order to achieve physician buy-in. I have little doubt that a physician's autonomy constantly feels threatened by many components of health care, both old (e.g. dealing with insurance) and new (e.g. reimbursement bundling). Some of this threat is good since, after all, physicians do not work in a vacuum but instead in an industry where they must interact with many other providers and deal with patients' personal information and maybe even their lives. Lean can easily be seen as one more requirement to meet or one more thing that comes between physicians and their patients. However, the true purpose of Lean does not fall in either category. Rather, Lean has the potential to remove obstacles, simplify the many processes in the day of a physician, and ensure a standard of care that the physician's setting of practice expects of itself.
  7. J's avatar
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    Never heard about Lean, sounds interesting!
  8. Lee's avatar
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    The successful lean events I've experienced all involved buy in and participation from all levels of the process to include (most importantly) the physicians. I completely empathize with the ideas that "quality improvements" that are brought with a sledge hammer from the "outside" are sometimes more destructive and typically not well adopted. Change is best received when driven from those working the process from the lowest skilled to the highest skilled people involved. While change can be intimidating (especially for physicians) for those who are the most powerful in the process, once people realize that the point is not to drive more work, but more efficient work, these types of activities can be great for the organization.

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