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Jim Womack’s challenge to the healthcare community

June 17, 2011

Last week, with clarity and simplicity, Jim Womack exposed the principal dilemma facing healthcare providers as they seek to become lean organizations:  Value streams in healthcare flow horizontally and yet healthcare organizations are arranged in vertical silos.  So how, with patients being passed from one silo to the next, can we ever trigger the virtuous cycle of improving quality and decreasing cost that we see in so many other industries?

It’s a theoretical question with unexpectedly practical implications for healthcare delivery in this country and it’s the kind of fundamental, thought-provoking one often hears from this guru of lean production.

Jim might prefer not to be called a guru — the term has gained negative connotations in the business world — but his clarity of thought is guru-like, in the classic sense of the word.  “Go see, ask why, show respect” is Jim’s mantra, a phrase coined by Fujio Cho, the current chairman of Toyota.

Consistent with his mantra, Jim has gone to see many, many times and, speaking in a packed ballroom at the Westin Seattle, he used his opening keynote at the second annual Lean Healthcare Transformation Summit to ask why, respectfully, providers have yet to solve this basic problem.

Value streams flow horizontally.  This is true everywhere, not just in healthcare.  Yet, healthcare providers are organized into vertical silos.  These silos go by many names: units, departments, professions, cost centers.  A patient might be admitted to the healthcare system in one silo, discharged from another, and find herself passed from one to the next in-between.

Vertical organization presents grave challenges for an increasingly complex healthcare delivery system: failed handoffs that lead to high cost, medical mistakes, and suboptimal outcomes for the patient.

Within this structure, the best one can hope to achieve is point optimization when, in fact, what’s needed is optimization of the whole value stream from end to end.

Jim illustrated the problem with a simple graphic, recreated below (captions added).

The problem is vastly more difficult to solve in the real world than it is in PowerPoint.  There is no way to select vertical rectangles in a complex healthcare organization and simply “send to back.”

Of course, some healthcare providers are indeed able to optimize horizontal value streams.  A provider with a narrow sub-specialty and predictable demand can optimize the value stream from end to end.  Orthodontists seem particularly adept at this.  It may also be possible for other professional practices specializing in a single procedure: orthopedists specializing in knee replacements, urologists specializing in vasectomies, and so on.

So, is the answer for everyone in healthcare to specialize in a single procedure?  No, because not every diagnosis can be addressed with a single procedure.  Most medicine is a team effort and always will be.

In fact, achieving horizontal flow in a narrow subspecialty is not solving the problem of applying lean in healthcare at all.

Here’s why.  Lean production is often described as separate and distinct from mass production, a new way to solve an old problem.  But, in fact, mass production is a subset of lean production, a special case of lean production made possible when customers demand one product in massive quantities.

In 1909, Henry Ford famously told his management team, “Any customer can have a car painted any color that he wants so long as it is black.”  When the customer demands one product in massive quantities, mass production, one could say, is the lean solution.  But when customer demand is lumpy, fragmented, specialized, and ever-changing, as it is in healthcare and most other industries today, mass production is no longer optimal.  It is the solution to the wrong problem.

So what is the answer?  As of today, no one has stepped forward, not even Jim Womack.  However, Jim saved us some time by sharing a couple incorrect answers to the question.  For example, obliterating departments and professions is not the answer.  Healthcare value streams are not automobile assembly lines.  You cannot cross-train an anesthesiologist to perform brain surgery.  You just can’t.  According to Jim, anyone seeking to organize a hospital solely along horizontal lines will soon fall victim to “the counterattack of the verticals.”  Professions need to exist, they will always exist and they will always be vertical.

Neither is the answer to create matrix organizations.  According to Jim, “Matrices simply create conflicts of horizontal versus vertical authority.”  Matrix mayhem.

So what is the answer?  No one knows but, according to Dr. Womack, “what we need is not assertion, it is experimentation.”  Jim Womack’s challenge to the healthcare community is to experiment and, if your experiment yields the solution, Jim promises, you will be prominently featured in his next book.

One Comment leave one →
  1. June 23, 2011 4:48 am

    There have been some experiments in the UK and US (and maybe Canada too) on a role called the “Value Stream Manager.”

    See one of the presentations from a 2009 lean healthcare event in the UK:

    Gaining agreement to act: the role of the value stream manager
    Maria Purse, Emergency Value Stream Manager, Portsmouth Hospitals NHS Trust
    PDF Presentation
    Video Presentation

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