Volume 192 - Issue 5
Making cars and making health care: a critical review
Authors: David I Ben-Tovim, Duncan Stuart, Maarten Kamp and Paul Cullen
Med J Aust 2010; 192 (5): 295-296. || doi: 10.5694/j.1326-5377.2010.tb03520.x
Published online: 1 March 2010
Published online: 1 March 2010
To the Editor: We read with some dismay the article by Winch and Henderson1 critically reviewing the introduction into health care of process improvement methods pioneered in manufacturing and service industries. We take issue with the article at several points.
While the article is titled a “critical review”, it has more of the character of a personal view. For instance, the authors single out “lean thinking” for particular criticism, but the examples cited are in fact a mixture of business process re-engineering, hospital or health system restructuring, and total quality management. These differ substantially from lean thinking, but this is not acknowledged in the text. Then the authors claim that lean thinking has been accepted “somewhat uncritically”, but this is not so. The current peer-reviewed literature contains a number of articles critical of lean health care that have not been referenced by Winch and Henderson (for example, an article by Young and McClean2).
The authors’ principal argument is that fragmentation of health care delivery reduces the quality of care provided. We agree. They then argue that process redesign increases the fragmentation and impairs quality of care, but we reject this view. The process redesign programs we have been involved with have been aimed at increasing the time that staff can spend with patients. They explicitly involve staff in designing systems that will deliver this. Rather than trying to “[reduce] the richness of professional health care practice to impoverished snippets of work”,1 we are trying to put broken care processes back together.
The authors close by implying that process redesign may “add to the problems of hospital misadventure . . . rather than solve them”, but they provide no evidence for this assertion. In fact, the existing evidence points the opposite way. For example, a recent report from the ThedaCare group in the United States showed a reduction in mortality after coronary artery bypass grafting from 4% to effectively zero as a result of process improvement.3
Here in Australia, the Flinders Medical Centre in Adelaide has seen a striking reduction in serious adverse events after implementing a process redesign program based on lean thinking.4 Interest in process redesign is increasing in health care. All improvement methods benefit from critical discussion, but critiques that are also well supported by evidence are likely to be the most influential.
Competing interests
David Ben-Tovim has undertaken work with Flinders Partners, the consulting arm of Flinders University, assisting the Victorian Department of Health with implementing their Redesigning Hospital Care Program. All fee income is directed to a university trust fund. He has been paid by the International Quality and Productivity Center, the Institute for International Research and Conferenz to provide patient flow master classes and for travel expenses to participate in professional meetings.
References
- Winch S, Henderson AJ. Making cars and making health care: a critical review. Med J Aust 2009; 191: 28-29. 0_CBBEJEJD
- Young TP, McClean SI. A critical look at Lean Thinking in healthcare. Qual Saf Health Care 2008; 17: 382-386. 0_CBBFCCAD
- Toussaint J. Writing the new playbook for US health care: lessons from Wisconsin. Health Aff (Millwood) 2009; 28: 1343-1350. 0_i1091868
- Ben-Tovim DI, Bassham JE, Bennett DM, et al. Redesigning care at the Flinders Medical Centre: clinical process redesign using “lean thinking”. Med J Aust 2008; 188 (6 Suppl): S27-S31. 0_i1091870