Prior to studying medicine, I trained and worked as a mechanical engineer. I was responsible for manufacturing processes and used many tools to guarantee efficiency and quality. I assumed that this structured world of protocols and measurement was similar in all high risk businesses. After I started my medical training, it quickly became apparent that healthcare was a very different industry.
As an engineer I learned the theories of Lean, statistical process control and theory of constraints. But more importantly, I applied these every day to solve problems related to process design, quality control, scheduling, supply and demand, and finance. I worked in multi-disciplinary teams and together we designed and ran small experiments in our manufacturing processes to ensure that our products were continually improving.
In medicine, I often feel much more alone. We are taught to take individual responsibility for our decisions, despite knowing that we will often be unable to predict the effects of these decisions. I discuss issues with my physician colleagues, but rarely do I work with multi-disciplinary groups that include nurses or managers.
I was taught that the best way to prevent errors was to work hard, to be knowledgeable and to follow the standards defined by generations of physicians before me. Patients would die, that was inevitable, but I would be protected from the consequences unless I had egregiously deviated from these norms. Residency would be tough, but if I succeeded I would earn entitlement.
Evidence-based medicine is the current philosophy, enabling us to make decisions based on the results of clinical trials. But large numbers of patients and long follow-up periods are required to identify clinically significant outcomes. The results of these studies are often out of date by the time that they’re published, and the expense of these trials has put us at the mercy of the large corporate interests who can afford to fund them. Furthermore these trials rarely advise us on how to do what we need to do. Evidence-based medicine in it’s current form is not sufficient to address the daily needs of clinicians and patients.
For me the most striking anomaly is that despite all that we have learned, we still don’t routinely measure our daily work, we can’t predict when our processes are out of control, and we are not comfortable with experimentation in the way that we deliver our care. We need less entitlement and more measurable outcomes.
Many people have been shouting for the need for efficiency and quality, and their voices are being heard. We have come a long way from the time that I started my medical training. We accept that measuring patient outcomes is necessary and that we need to save money. Lean is no longer viewed as synonymous with car factories and inappropriate for healthcare. There are hospitals that have used Lean concepts to improve the care that they deliver.
However, there remains a long journey ahead of us. We need to apply the tools that we have available to achieve higher quality and financial sustainability. But it is my hope that we can do much more than this. Healthcare is a complex industry. Some solutions have been developed that will be adopted by other industries to address complex issues that they have. It is my hope that one day pilots will be touring hospitals to see how we simplify complexity, rather than the other way around.