Decentralization of Healthcare: An Example of a Key Lean Flow Principle in Action

Decentralization can take many forms. It can mean moving to many smaller factories rather than one large “scale factory.” 3D fabrication is an example of having many distributed, local mini-factories rather than one large plant that then has to transport things hither and yon.

It can mean 1-thing at-a-time processes rather than creating a big batches. It can mean pushing decision-making and problem-solving from a few senior leaders to the frontlines.

In healthcare, this can take the form of distributing healthcare assets rather than relying on massive hospital “factories” that process patients using “batch and queue” methods. New technologies are a big opportunity to make this change as long as hospital administrators, doctors, patients and politicians also change their mindsets from the centralized, big batch, large scale model to a decentralized, individualized, local and frontline-driven approach.

An example is the Cleveland Clinic, a large U.S. healthcare group that is trying to move from an approach that has many people having to visit and often stay at a central site, to a more distributed model.

Today, hospitals are where patients go for consultations with specialists, and where specialists, with the help of medical technicians and pricey machinery, diagnose their ills. They are also the main setting for surgery and medical interventions such as chemotherapy; and where sick people go for monitoring and care. But high-speed internet, remote-monitoring technology and the crunching of vast amounts of data are about to change all that. In the coming years a big chunk of those activities—and nearly all the monitoring and care—could move elsewhere.

“When I think of the hospital of the future, I think of a bunch of people sitting in a room full of screens and phones,” says Toby Cosgrove, the Cleveland Clinic’s head. In such a vision, a hospital would resemble an air-traffic control tower, from which medical teams would monitor patients near and far to a standard until recently only possible in an ICU. The institution itself would house only emergency cases and the priciest equipment. The only in-hospital consultations would be those requiring the expertise of several specialists working in a team. Patients inside the building would be cared for better. But fewer people would be admitted, as hospitals coordinated care remotely and led population-wide efforts to keep people well.

Picturing what hospitals could be, if the various obstacles are overcome, means abandoning long-held assumptions about the delivery of care, the role of the patient and what makes a good doctor. The first is what should happen where. “A hospital can also be at home,” says Lord Ara Darzi, a surgeon and professor at Imperial College London, a university that runs teaching hospitals. Just as online banking made life more convenient for consumers and freed up branch staff for complex queries, online health care could mean fewer people need to come to hospitals to be cared for by them. Last year half of consultations offered by Kaiser Permanente, an integrated American health-care firm that runs many hospitals, were virtual, with medical professionals communicating with patients by phone, e-mail or videoconference.

The main limitations today, says Kari Gali, a pediatric nurse-practitioner for the Cleveland Clinic who takes such video-calls, are that she cannot look into children’s ears or listen to their chests. As these and more sophisticated diagnostics, including blood tests and virtual imaging, become available remotely, more patients could receive hospital-quality care without leaving home. Gupta Strategists, a Dutch research company, reckons that around 45% of care now given in Dutch hospitals could be done better at home.

Shifting almost all dialysis and chemotherapy out of hospitals is further off, but is on the way. And with better remote monitoring some chronically ill patients who now need to be in hospitals will be able to stay at home, only coming in when their conditions deteriorate. Moving care outside institutions will both save money and raise standards, by making patients more comfortable and reducing infection rates.

The next iteration of the hospital, however, is tantalizingly within reach—and it is more the coordinating node in a network than a self-contained institution. “We have reached the peak of bringing patients to the healing centres—our hospitals,” says Samuel Smits of Gupta. “We are on the brink of bringing the healing to patients.” (From The Economist, April 8th 2017.)

The more things change (such as information technology) the more important it is to focus on the fundamentals of what makes processes effective. The notion of delivering value “where and when it is needed” is now much more possible but only if professionals in all areas understand enduring lean principles. Increasingly, it is not manufacturing people who need to practice lean, but people who may have never thought they needed to understand what they may have considered as relevant only to operations types.

2 Comments on “Decentralization of Healthcare: An Example of a Key Lean Flow Principle in Action”

  1. Rod Morgan says:

    Hi Bruce! Thank you for taking the time to prepare this thoughtful article and associated references. It is important that healthcare be “revisioned” (as opposed to revised). I remember our early days of Six Sigma at Bombardier and the emphasis on understanding capability and “fixing” versus “designing” decisions. I am a firm believer that we are beyond “fixing”… we do still need to “stabilize the patient” but capability to meet current and well as future demand will require a redesign. Keep spreading the word, Bruce!

    • brucem says:

      I agree. New technologies enable new approaches, but without new thinking we are simply enabling old approaches with new toys.

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