If you are a regular peruser of LMJ’s news page, or spend some time on news sites, you’ll have noticed a recurring trend: that of opposition to implementation of lean programmes in public hospitals.

We’ve covered it with reaction to San Francisco hospitals going lean, with lean being brought in to the NHS, with Canadian hospitals, and a rare positive story of lean in rural Indian hospitals.

The ongoing saga in the Canadian province of Saskatchewan has been bubbling away for nearly a year. The province decided to take on credit-crunch budget cuts with a lean programme in its public hospitals. The idea of having to spend money to make money-or in this case save money, was clearly lost. The government has been accused of crony-ism and a lack of transparency in its awarding the lucrative contract to Seattle-based John Black and associates.

And when you see the financial figures involved it is hard not to see the points of the naysayers. Public funds-those lauded taxpayers dollars which are in such short demand- have been spent on paying the high salaries of consultants to bid for contracts they were almost sure of already getting and such tasks as flying Japanese senseis to visit and teach.

While a proper trained lean teacher is always best, the lack of forethought and awareness in this situation of a private firm and government body not understanding when working in the public sector, budgets are tight and mindsets have to change to a frugal outlook, is truly alarming. It shows, at best, a perverse closed mindedness to the concerns of those unfamiliar with lean and an inability or non-desire to educate, and, at worst, a corruption of the ideas of efficiency and a self-serving attitude.

We spend a lot of time at the LMJ trying to educate people about the theories behind lean.
Where newspaper writers see a way of cost cutting (read: job losses) and a quick salacious headline about budgets in the healthcare sector, we know it’s really about encouraging efficiency.

But we here in Britain have undergone five years of austerity, with our beloved National Health Service (NHS) at the forefront of these cuts and freezes.

The New Year saw record queues and waiting times as – a key clue to any lean analysts out there – millions went to their A&E rather than GP out of frustration at unhelpful opening hours and long waits that just don’t sit with our lifestyles. Especially not the millennials, who have been raised on the internet and Amazon next-day delivery. The healthcare system was in crisis, the tabloids yelled. Third world healthcare, others yelled.

So where do we go from this? The situation stands with a healthcare system being used as a prop in a hotly contested election, in the midst of never-ending financial uncertainty, and record numbers of patient admissions.

The cause? The NHS hasn’t modernised as quickly as it needs to and hasn’t been given the proper tools to. Staff are overworked and haven’t the time for training let alone huddles.


When LMJ travelled to Florida for the AME conference in November 2014 it was lucky enough to tour the world famous Mayo Clinic with a group of other lean enthusiasts. Amongst this group were several nurses from Ontario, Canada who worked in a large public hospital.

These nurses, passionate about their work, were relatively new to lean and were hoping for inspiration as we toured. As they went round the facility their eyes widened at the state of the hospital; the lack of patients having to wait in corridors for a free room, bureaucracy that was designed to be helpful rather than a hindrance and management systems that actually worked.

It wasn’t just the shiny floors and order they weren’t used to; they whispered in amazement amongst themselves and looked sheepish as the positive, motivated and highly organised staff of the Mayo Clinic accurately took their appreciation as congratulation

If their anecdotal musings on the state of healthcare is to believed, then clearly we need an overhaul. And what better overhaul than making the system more efficient? David Ben-Tovim says in his article this month healthcare workers are notoriously difficult to engage in new programmes; they are the masters of passive resistance. And it’s understandable: the job they do is far too important to society to attend seminars and management workshops unless it has a proper and proven outcome.

Does this resistance come back to the arguments Nathan Wilson expounded upon in his recent article (“The language of lean”, LMJ January/February 2015) where he spoke of his colleagues indifference, and at time hostility, when he brought back lean? That institution, like a hospital was a public sector –the UK’s Ministry of Justice- with similar staff cultures and gripes –lower pay than the private sector, lack of incentives, a poorly managed system burdened in paperwork and the dreaded bureaucracy- and the staff responded in poor measure to his attempts to implement lean.

They hated the jargon, they were needlessly confused by Japanese terms; they wanted clear-cut solutions in English- minor trials of their work-day fixed. No grandiose promises of cultural change, just a working environment which wasn’t as stressful. The cultural change would occur on its own if these problems were fixed and the daily grind in the office became easier.

But with the hospitals it’s a little different: we expect the civil service to be a laborious home of red tape, but we want our hospitals to be able to cope with anything. We put our doctors and nurses on a pedestal and treat them terribly when they fail. The outrage at the implementation of lean, whether it’s the San Francisco General Hospital in California or the NHS in England.

So where is lean going wrong? It’s not treating the public sector perceptively enough. It’s not adapting itself to the sensitivities of the situation. And it is most definitely not playing the game with the media. You cannot expect people who want to be angry about a subject to be calmed when you throw Japanese terms at them that just sound pretentious and out of step. If you want lean to work in the healthcare –notably public healthcare, not the endless money of private healthcare- you have to speak to your audience.

A nurse on a low income who has been doing her job for twenty years, does not want yet another management drive. We need to learn to sell lean. The efficiencies it brings-lean will make your life easier; lean will be a way of making those short-staffed shifts easier to cope with. Pinna and Belpanno’s article (“Using 5S in a paediatric hospitals”, LMJ March 2015) came illustrated with before and after images of a nurse’s toolkit and equipment shelves. Helpfully leaned. The effect was instant-the nurses were spending half as much time looking for things as they were before. The syringes, medications and other paraphernalia were where they were supposed to be and the hospital was a better run organisation for it. Patients benefited.

This is what we need lean in healthcare to show. Not million dollar contracts awarded to consultants, not lean experts using Japanese phrases in media interviews to hostile journalists (as one particularly cringe-inducing consultant did in the coverage of the San Francisco Hospital debacle) which had her framed in the interview as out of step and elitist.

It’s as we have spoken before of in LMJ, lean needs to learn to sell itself. Its cloistered days of manufacturing are over. If it hopes to grow and be seen as worthwhile to society at large it needs to adapt and learn from what the customer wants. They do not want buzzwords and complicated terminology. They do not want a culture based on efficiency, which seems to have a surfeit of consultants.

The NHS’s own institute for innovation and development’s lean page defines lean as “an improvement approach to improve flow and eliminate waste that was developed by Toyota. Lean is basically about getting the right things to the right place, at the right time, in the right quantities, while minimising waste and being flexible and open to change.” There it is. Simple. And yet misunderstood.

With our ageing populations and other social demographics, healthcare will become more and more important. The baby boomers will be sure to prove cantankerous in old age and a force to be reckoned with-we need efficiency and lean in our healthcare. We just need to do it cleverer. And retake the controls of the story away from the press and back in to those who know the way to make it the obvious solution.

We would love to hear what you think. Agree? Outraged? Get in contact with a.putwain@hennikgroup.com to share your thoughts.