Lean healthcare on the front lines

Like many of you, I'm in lockdown. No gemba walks for a while. I've been talking with lean hospital leaders I know, and, although we can't do much to help directly, we can still listen to them and cheer them on. 

With time to think, I've been asking myself — how does lean thinking make a difference on the front lines? How can it help when you are overwhelmed, both materially and emotionally, by a crisis like this one? As we salute the courage and dedication of healthcare professionals around the world, I'd like to share some immediate reactions that we can analyze once we get through this and begin our hansei. 

A key part of keeping your emotional balance as events unfold is staying ahead of the curve. The lean approach in hospitals is a strategy for maintaining continuity of care — and for looking at all the risks of disruption of care. Practicing this outlook daily in peacetime is immensely useful in wartime, because it helps keep executives focused on the next point to be won, even if you lose a few. Constantly looking at the wave of work overload and suffering and looking at the horizon helps the team balance its focus on the now against what comes next. There can be no plan, because we are plunged into the unknown. But being able to see things coming somewhat in advance makes all the difference in the team's confidence in its ability to cope. 

Lean thinking starts with a focus on patient and staff safety. This is frightening, because this virus is new, largely unknown and easily spread. We were all caught with our pants down in terms of protective equipment, such as masks and hand sanitizer, treatment equipment, such as ventilators, and testing capacity. There are few tests available, and the ones that exist are not that reliable. Patients are scared, families cannot see their loved ones because of the lockdown, and caregivers bravely carry on with the fear of catching the virus. 

While everyone works hard to solve the logistical problems of keeping critical equipment and supplies flowing, we also see the importance of emotional safety. Exhausted people tend to make mistakes, and even the best have a limit at which they lose their cool and either yell at the wrong person or make a not-very-smart decision. Not overreacting to these incidents and learning to comfort people when they are discouraged is a critical skill for keeping everyone on track — everyone understands and thinks “I could be next”. Maintaining an atmosphere of psychological safety through calm and presence — something lean teaches with its relentless focus on “why?” rather than “who?” — is essential. 

After safety comes logistics. Facing the COVID-19 wave is an enormous exercise in flexibility. Beds need to be redirected to patients diagnosed with COVID-19. Protective equipment needs to be procured and distributed. Staff need to be retrained. Meanwhile, the rest of the activities carry on in hospitals that were already overwhelmed before the crisis. Right now, ERs are almost empty, as people are afraid to go to the hospital and avoid showing up for minor injuries, but we dread the moment when the postponed treatments will need to happen. The 4M approach of lean thinking helps us deal with such a monumental realignment of resources by framing problems in terms of: 

• Manpower: who is the best person to lead on this problem and whom do they need to talk to? What is their way of thinking? Who needs support and where? Who is overloaded but not asking for help and will probably be the next to snap? 
• Machines: while all this is happening, the rest of the hospital needs to keep running — this means taking time to continue working with the infrastructure teams to understand how the changes will impact the most deeply rooted systems. 
• Materials: everyone is currently focused on masks, but the lockdown of society outside the hospital will have huge and unexpected consequences on supply chains. By looking daily at the hospital's inventory situation, we are already discovering surprising out-of-stock items (in addition to the usual wrong information in the computer). 
• Methods: methods are challenged for every caregiver because, first, the virus is new, and, second, materials and equipment are lacking, so nothing can be done the proper way for now. How do we rediscover the core of the method and ignore the bureaucratic work around it? How do we stay focused on rationality? 

Lean leaders understand problems and problem solving and can deliberately get their teams to focus on new problems: let's look at the new problems and how we can tackle them in new ways. By expressly focusing on the changes and their practical implications, lean leaders help their teams deal with what they need to learn and face the hard questions about which rules and regulations can be broken and which must be kept at all costs. 

Masks, for example, are a crisis for everyone. Masks are critical protective equipment for the front line — and there aren't enough for everyone. One hospital I know accepted local help from a seamstress to make cloth masks. Cloth masks are not enough for staff who are providing direct care to COVID-19 patients and will never pass the strict medical supply protocols. On the other hand, many jobs in the hospital — from administrative or information staff to security guards — require far less proximity to possible carriers of the virus, and any mask can help stop the droplets that carry the virus. These situations will happen more and more as supply chains become unbalanced. The key is not to get stuck in a YES/NO framework, but to ask questions about the WHAT/WHEN/WHERE conditions to see where substitute products can help and where they can't. 

Solving the logistical problems is the only way to truly support the teams, but unfortunately, as we know, logistics doesn't solve itself at the snap of a finger. Meanwhile, teams face work in ways they are not used to — and understandably feel distressed about it. Beyond the fear of contracting the virus, they constantly fear doing the wrong thing and facing potential accusations of negligence later on. They also seek approval or permission from central structures, which are simply too slow and too far from the gemba to respond. 

Lean leaders can support their teams by understanding their concerns and constantly discussing the dividing line between the part of the protocols that can be changed and the part that can't. A vivid lesson from this first month of the pandemic is that, even outside hospitals and other businesses, we have created systems so interconnected that you need an incredible amount of bureaucratic work to do anything. Everything needs a code to be released, a form to be filled out, and so on. In addition, we have discovered the hard way how IT systems allow these decisions to be centralized by normalizing them within the system — and the impossibility of changing things on the spot. Teams need help with this to rediscover their autonomy safely — as well as to rediscover the things we cannot give up, regardless of immediate pressure. 

The conclusion of lean hospital leaders is that lean thinking, especially the experience of daily logistics and the practice of framing problems with front-line teams, really helps you stay one step ahead of the tsunami. But the wave is coming, and we know we won't be able to keep  everything running — it's already happening in some places. What we have found is that, faced with painful setbacks, people focus on: 1) solving a problem they already know and know how to solve (which may not be effective against the new, real problem); 2) becoming overwhelmed by everyone's feelings; or 3) denying everything, hoping that by doing things as usual, it will all simply go away. 

Lean thinking helps us with: 

• Sideration: the problem we see on the horizon may not happen after all, but if we see it, there is a good chance it will catch up with us. So let's do something now. Let's sew some cloth masks and hope we won't need to use them. Forcing yourself to face problems pulls you out of the denial reflex, which makes you bury your head in the sand, and forces you to do something to prepare. You may be preparing for the wrong problem, but at least the teams are working and learning, which will help them respond with more flexibility and confidence to the real problem when it arrives.
• Problem solving: solve the right problem, solve the right problem, solve the right problem. Yes, we are in a panic. Yes, people are clamoring for quick decisions. Still, look up from the containment work, look around and ask yourself and your teams: are we solving the right problem? This shouldn't paralyze you until you have the right answers, but it should encourage you to take a deep breath and take mental pauses to avoid following others down the wrong path out of panic and making mistakes that are too costly. In a real crisis, serious mistakes have worse consequences — the first rule of problem solving in a crisis is don't make things worse. 
• Acknowledging emotions: this is a life-threatening crisis across all of society. People will panic. They will go mad and lash out, hide or collapse. They will become obsessed with their own thinking and become unable to listen to others  or accept other points of view. They will freeze and become unable to make the simplest decisions. Things will go wrong in the most absurd ways possible. Acknowledging strong emotions such as fear, fury or anger against the system that comes from simple frustration is the best known way to reboot the frontal cortex and get people thinking again. We will have low times, but also occasional moments of extraordinary, all-round courage and unexpected, amazing insights, and we will feel the strength of team spirit against impossible odds. Emotions are not “out there”. They are a fundamental part of the problem. We need to communicate early and often about the changes and create spaces for people to ask questions and express their feelings. 

On a final note, command and control is a seductive mirage in severe crises. Yes, people look for a leader who gives strong commands. But on the other hand, those in charge also panic and give contradictory, meaningless instructions that, overall, contribute to the “through the looking glass” feeling of plunging into chaos. The wartime feeling will lead to increased control in bureaucracies: instructions, controls and permissions. On the other hand, what lean teaches us, and what we can confirm today, is that teamwork in obeya rooms to support initiatives and voluntary contributions is the key to bringing together effective solutions. For example, as key materials start to run short, we can ask local business leaders to create substitution initiatives, as manufacturers in Taiwan did to produce masks quickly. These two contradictory trends will soon collide, and we can do our part to keep fighting the command-and-control reflex of bureaucracies when they feel threatened by a loss of control, as they do now. 

Discovering the right contagion factors and developing the appropriate logistics chains are the only true remedies for this mess. But we need to figure all this out while keeping people working in frightening, unusual and difficult situations. Lean thinking helps us 1) understand the psychological safety needs of patients and staff in order to 2) be able to solve the right problem with smart solutions by coordinating local initiatives while 3) keeping the hospital's key equipment running. When people understand what they do best, see a clearer path to success and are confident they are being heard, they will perform better. Learning to lead this way in a crisis is exactly what lean trains you to do.