Where is the Lean?

While information about lean healthcare is rapidly expanding, from books to conferences to blogs, long-term care predictably remains largely absent from the conversations and resources. This is unfortunate on many levels, as the field would not only benefit from embracing the core value of respect for all people, but it also has so many fewer resources than other sectors of healthcare already and desperately needs to utilize those resources more effectively and efficiently.

First, a look at a few reasons why LTC is once again lagging behind the healthcare industry:

1) Long-term care organizations invest less in innovation. This unfortunate reality may have as much to do with scale as interest, but the end result is stark. According to a recent survey, 64% of large healthcare organizations have a Chief Innovation Officer— a position virtually unheard of in long-term care organizations. Meanwhile, most acute care organizations have adopted EMRs, while– though it’s difficult to know exact market penetration (itself a sign of lack of interest)– LTC implementation of EMRs may be as low as 6% (2012), though likely closer to the 50-60% range (2013 in MD). Even the resources that are spent– for instance, LeadingAge’s Innovation Fund— rarely result in replicated projects.

2) Long-term care organizations, more so than others in healthcare, rely on rigid, hierarchical management philosophies and strong command and control styles of operations. This not only stifles line staff involvement in change operations, but creates a culture of doing only what you are told to do and an atmosphere where fear of standing out leads to conservative and reactive action.

3) Long-term care is governed by a punitive system of survey and certification that values documentation of work and the following of rigid policies and procedures over quality outcomes and resident satisfaction. Because many problems are buried deeply within the established system, it is much easier to rely on blaming of individuals rather than fixing systems. (Indeed, I’ve had many surveyors demand to see records of disciplinary action when errors have occurred despite evidence of systemic root causes.)

4) Metrics of performance are based largely on payment realities (census, PPDs, case mix) rather than satisfaction, effectiveness of operations or continued improvement. Additionally, trade organizations representing communities focus on eternal realities, like Medicaid funding shortfalls, rather than driving more efficient deployment of existing resources.

5) Many nursing homes exist in a perpetual state of near or semi crisis, fueled by unconscionably low wages and high turnover of line staff, insufficient labor, organization- and industry-wide financial strain, and near-constant threat of adverse regulatory and legal action.


In a recent article in the Gerontologist, Bishop et al notes:

Frontline service production in some traditional nursing homes exhibits many of the features of a classic “low road” enterprise, where management attempts to keep labor costs as low as possible through fragmented jobs and close supervision (Handel & Gittleman, 2004). Nursing home direct care jobs have few skill requirements, minimal selectivity in hiring, cursory initial orientation and on-the-job training, low wages and benefits, and supervision focused on completion of defined tasks (Bishop et al., 2008). Nursing assistants describe the work itself as repetitive, taxing, and demeaning. Workers are treated as unreliable and easily replaceable. High turnover justifies low on-the-job investment in workers’ skills, because internally trained workers are likely to leave for better opportunities.

Some culture-change adopters will point to their organizations’ success in overcoming some of these challenges. However, as Lopez (2006) noted in “Culture Change Management in Long-Term Care: A Shop-Floor View,”

resource limitations also forced management to adopt a series of punitive personnel policies that actively undercut the rhetoric and aims of culture change, turning culture change into a rhetorical device for shifting blame for care problems from structural resource limitations onto the attitudes of nursing aides.”

We’ve found this to be the case more often than not, with culture change-oriented organizations blissfully unaware of how their embrace of culture change principles is only skin-deep.

Where Lean Comes In

Building a lean culture offers many, connected benefits, from designing systems that support residents to valuing, respecting and trusting front-line staff to make improvements that bring benefits for everyone:

  • Creating or sustaining a culture of respect for people: Lean requires organizations to rethink the value of line staff, trusting those staff as both the experts and the agents of improvement.
  • Focusing on value: Lean thinking helps identify waste that is endemic in long-term care from poor inventory management to convoluted admission practices to absurd meal delivery systems.
  • Placing the resident first: Lean is, by nature, resident-centered. Using tools like VOC (voice of the customer), value stream mapping, and gemba visits, Lean helps identify areas where organizations are wasting resources or failing to meet needs.
  • QAPI-ready: Lean, especially when combined with six sigma, is a perfect method to drive QAPI programs, fully meeting CMS QAPI requirements and indeed building the very culture QAPI envisioned.
  • Operational edge: Lean helps organizations use the resources they already have to do better work. It leads to higher resident and staff satisfaction, higher census, reduced turnover time and better leveraging of human and capital resources.

The Affordable Care Act will continue to put pressure on long term care organizations to perform better, smarter, and more efficiently. Lean is the best way to make all of these things happen at once.


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