Public health: how lean management can help

The Covid-19 figures in Brazil catch our attention. By April 2021, approximately 14.7 million people had been infected (World Health Organization) and 4 million sought care in the public and/or private health network, with a Unified Health System used by more than 80% of the population and 14.4% of Brazilians unemployed in the first quarter of 2021, according to IBGE's Continuous National Household Sample Survey, 2.9% more than in the last quarter of 2020.

The figures above indicate that Brazilians could be in an even more precarious situation without a Unified Health System. The new coronavirus tested, as in other countries, the local health system and showed the importance of keeping it structured for possible emergency situations.

SUS, the Unified Health System, is one of the few health systems in the world that provides free care to each and every citizen, regardless of nationality. Before SUS existed, medical and hospital care was guaranteed only to those who had formal employment, through the Ministry of Social Security and Social Assistance. Had SUS not been implemented, today, in the midst of the pandemic, the more than 14 million unemployed Brazilians would currently have no health coverage. In the midst of a crisis, wages were cut, contracts were suspended and many people stopped paying for health plans, increasing the flow of patients in public hospitals.

Despite the challenge SUS faced of mobilizing the necessary resources and providing care for everyone during the pandemic across such a large territory and with various limitations, it was possible to see the effects of a social justice policy when severe cases began to be prioritized; at the same time, non-urgent consultations, tests, therapies and surgeries were postponed in order to avoid crowding and new infections. In this way, the service was decentralized through field hospitals, thus delivering more beds in places where there are few health facilities.

Even with all this mobilization to guarantee health care as the disease advanced in Brazil, the Unified Health System revealed gaps between what was provided for in the 1988 Constitution and what is actually practiced in Brazil. The Constitution aims at comprehensive care and popular participation, respecting the principles of universality, comprehensiveness and equality. Despite being rated as one of the best in the world, SUS still has opportunities to improve its performance. Through the lean management philosophy, which aims at reducing waste, redesigning flows and improving the patient experience, these gaps can be analyzed through projects that apply these concepts, which can help institutions become more efficient and come ever closer to what was established in the Constitution.

Lean management in SUS

The lean system was born at Toyota, in Japan, in the postwar period, with a great deal of persistence, discipline and determination, since it faced many adversities due to market constraints that forced the company to produce many varieties in small quantities. The most important objective of this system was to increase efficiency through the consistent and complete elimination of waste. The lean concept starts from the principle that if a process brings no benefit to the end customer, it does not need to exist or should at least be minimized.

Always seeking to reduce the waste of resources, improve quality and maximize the value delivered to the customer, lean management aims at process excellence. It was with this objective that, in 2017, the Ministry of Health, together with the National Council of Health Secretaries (CONASS) and the National Council of Municipal Health Secretariats (CONASEMS), launched the “Lean in Emergency Departments” project, a program that aimed to reduce overcrowding in the emergency departments of Brazil's public hospitals using the lean methodology.

With lean management, the culture of continuous improvement was put into practice in the hospital environment, eliminating process errors, poor quality of care, long waiting times and low bed turnover, giving the public health system agility and efficiency in hospital emergency processes. The positive results of implementing lean in the Unified Health System, such as treating a larger number of patients without increasing human and physical resources, shorter waiting times, greater effectiveness in outcomes and greater satisfaction among patients, families and hospital staff, sparked the interest of other departments.

The same procedure was adopted in surgical centers for elective surgeries. The results were not long in coming: within a few months, a significant improvement in flows was observed. Before lean management was implemented, approximately three patients were operated on per day per room. After the methodology was introduced, that number rose to six surgeries per room. Within a 12-month period, these hospitals were able to operate on a significantly larger number of patients with the same health resources and investments, drastically reducing the SUS waiting list for surgeries.

With the arrival of the pandemic, SUS was directly affected, and it had to meet greater demand with the same resources, redefine process flows, segregate patients to prevent transmission of the virus, and deal with the shortage of ventilators while staff were learning about this new disease and trying to stay motivated and keep saving lives.

During our experiences here at Lean Institute Brasil, we have observed that public hospitals that went through a lean transformation before the pandemic were able to apply the knowledge they had acquired and organize themselves more quickly to fight Covid-19; in other words, they responded quickly to the changing scenario.

Some lean management practices that made a difference in these institutions were:

• Going to the gemba to see what was really happening in order to learn.
• Holding daily rounds under in-person distancing restrictions to keep the team aligned and sharing the same purpose.
• Creating a crisis committee for immediate decision-making with an autonomous cross-functional team for the activity.
• Designing and implementing patient-focused process flows.
• Controlling materials and medicines by implementing kanban and standardized work.

Regarding primary health care, it is important to point out that, in the near future, investment in management must be a central item on the ministry's agenda; only then will the country be able to have a system with structural changes that deliver better qualification and supply of health services.

Black Swan, a concept that does not apply to the new coronavirus

It is a fact that, from a risk-analysis standpoint, Brazil is likely to face a series of economic challenges at least until 2022. Those who are able to change their attitudes in response to change will find it easier to get out of future problems, and adapting to the environment in order to evolve will be an important attitude. According to the theory of Evolution proposed by Darwin, natural selection holds that the fittest organisms survive. It is precisely at this point that the concept of antifragility, by Nassim Nicholas Taleb, also applies: being antifragile will lighten the negative consequences of Covid-19.

Another theory of Nassim Taleb's that has been associated with the new virus is that of the Black Swan, but in his participation in the XP Expert event, Taleb rejected the use of the term Black Swan to classify Covid-19. According to the economist, the pandemic was always predictable; human history is full of very similar cases, such as the Black Death, smallpox and cholera, among so many others that have ravaged the planet in other times. In his talk, Taleb explains that the Black Swan theory applies only to unexpected, rare events with consequences of great proportions for people and companies. “How can the pandemic be considered a Black Swan if we have had several examples like this in the past?” he said.

Therefore, if the Unified Health System has weaknesses, and if the pandemic and health difficulties are not rare cases and may happen again, we should follow as soon as possible the example of the institutions that were able to respond better to adversity by implementing lean management.

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