Obstacles to lean in healthcare: Mindsets and the nature of work

The ideas and principles from lean management are now widely being adopted within the health care sector. The interest in lean from managers and policy makers, however, appear to contrast the realized benefits. An analysis of cases reported in literature and three Danish healthcare cases show that organizations within health care most often only implement a limited set of tools and methods from the lean tool-box. This form of lean implementation leads to very limited productivity gains in the health care organizations. Lean implementations focus on peripheral activities in the health care organizations for example laboratory work, logistical issues for patient e.g. emergency room layout, billing processes, and logistics of medical supplies. At first glance an explanation could be found in the conservative nature of the medical community which needs substantial scientific evidence to change behavior. This is of course not true as new modes of treatment are rapidly implemented when their effect has been documented. The health care sector therefore presents a paradox: Why can changes in treatment be implemented without problems, when lean and thereby changes in work processes are so difficult? This paper will try to answer the paradox and research question by analyzing health care work from two dimensions: 1) The nature of the work and 2) Rationality and validity of healthcare professionals. The two dimensions will then be related to lean. Firstly, it is observed that the nature of the work in health care, i.e., care for patients, is difficult to standardize thus creating difficulties in creating a stable and predictable flow which is a key prerequisite for lean. Many processes concerning patient treatment are complex and unique depending on the actual condition of the patient and also involving many different professions. Due to this inherent variability in dealing with patients no treatment will be completely alike as many activities within health care are dependent on the professional judgment concerning the optimal treatment by, e.g., doctors and nurses. Secondly, within our case studies in hospitals we find the existence of different mind-sets or rationality/logic in the different health care professions. Doctors tend to emphasize and focus on successful treatment of whatever condition the patient has. Truth is established through scientific validity such as the double blind experiment. Nurses, on the other hand, tend to focus on patient care and well-being of the patient. Psychology and human understanding are central drivers. Laboratory technicians (and other technicians as well) focus on maintaining a high level of productivity and accuracy in the different analyses being carried out. Secretaries will often focus on supporting doctors and nurses, by maintaining an efficient flow within the department. These different rationalities and logics create barriers for the successful implementation of lean both the lean project and subsequent continuous improvement.