How Lean is Too Lean?

My background is in science. The thought of getting a business degree never occurred to me. I have picked up a few business buzzwords over my years in healthcare. One of the most prevalent examples of MBA-Speak is Lean. This four-letter word is sprinkled liberally in job postings throughout all sectors of the economy.

What is Lean? In plain English, it’s reducing waste as much as possible. Lean was derived from the Toyota Management System and has been applied to other industries, including healthcare. While Lean is a structured philosophy that is more bottom-up than top-down, companies have often corrupted the process to mean that they don’t hire staff until it’s absolutely necessary to do so. They don’t order supplies until needed – “just in time” delivery. Warehouse space is kept to a minimum. 

While Lean may serve its purpose in good times, it has been a disaster in the era of COVID-19. Consider the impacts of Lean in healthcare:

• Human Resources. Nursing and allied health staff are hired in numbers that are necessary to maintain accreditation. Twelve-hour shifts were sold to nurses as flexibility; “three days on, four days off – such a deal!” When staff got redeployed to care for pandemic patients, this flexibility fell apart fast. Staffing reached crisis levels when nurses, doctors, and other front-line staff such as respiratory therapists wound up in hospital beds or quit their jobs due to burnout. Hospitals put out the call to retirees to gown and mask up. Some (bless them!) did so. Large hospital systems used traveler nurses to maintain staffing levels, often offering large sign-on bonuses and generous salaries – more than what the regular staff received.
• Personal Protective Equipment (PPE). Supply chain folks made sure they had enough on hand for normal patient census. However, when COVID-19 patients started flooding into emergency rooms, PPE ran out quickly.  Other countries supply most PPE, so shipments were delayed. American medical supply houses also followed “Lean” principles, so their warehouses were quickly depleted of masks and gowns. Hospital staff were reusing masks, face shields, and gowns beyond their useful lifespans. Some nurses in supply-strapped hospitals were using large garbage bags as gowns. Hand sanitizer was nearly impossible to find. 
• Hospitals in General. Hospitals had to postpone elective surgeries to stretch staff and supplies. These procedures, from plastic surgeries to overnight sleep studies, are key revenue-generators. When elective surgeries are canceled, a hospital’s bottom line can rapidly turn red. 
• Rural Hospitals. Even though I work in a major metropolitan area, I grew up in rural upstate New York. The counties bordering Lake Ontario east of Rochester have one hospital each. Residents there go to Rochester or Syracuse for procedures such as heart valve replacements. The rural hospitals deliver babies and stabilize emergency patients for transfer to the cities. COVID-19 swamped these hospitals’ already limited intensive care unit capacity. The aforementioned supply chain issue affected independent rural hospitals disproportionately, as they didn’t have the bulk purchasing power of large hospital chains. The combination of staff who may have quit or become traveler nurses and the limitation on elective procedures induced a downward spiral. Some rural hospitals, especially in hard-hit areas of the southern US, have closed their sliding glass doors for good. Others may have been bought by larger chains that may have little or no connection to the region.
• Patients. Preventive care has always been the poor orphan of the US healthcare system. The pandemic only made matters worse. Folks were scared to enter clinics or hospitals for routine mammograms or colonoscopies. Elective echocardiograms or cardiac catheterizations were also postponed. Some of these people wound up requiring more extensive or emergency surgeries down the road than if they’d had their tests performed earlier. Early detection saves lives. 

Reserve capacity is necessary to sustain any system against shocks. So-called “Lean” management failed healthcare miserably during the pandemic. It may be time to rethink this strategy to prevent future crises.