Elsevier

Social Science & Medicine

Volume 71, Issue 7, October 2010, Pages 1332-1340
Social Science & Medicine

Lean healthcare: Rhetoric, ritual and resistance,⋆⋆

https://doi.org/10.1016/j.socscimed.2010.06.028Get rights and content

Abstract

This paper presents an ethnographic account of the implementation of Lean service redesign methodologies in one UK NHS hospital operating department. It is suggested that this popular management ‘technology’, with its emphasis on creating value streams and reducing waste, has the potential to transform the social organisation of healthcare work. The paper locates Lean healthcare within wider debates related to the standardisation of clinical practice, the re-configuration of occupational boundaries and the stratification of clinical communities. Drawing on the ‘technologies-in-practice’ perspective the study is attentive to the interaction of both the intent to transform work and the response of clinicians to this intent as an ongoing and situated social practice. In developing this analysis this article explores three dimensions of social practice to consider the way Lean is interpreted and articulated (rhetoric), enacted in social practice (ritual), and experienced in the context of prevailing lines of power (resistance). Through these interlinked analytical lenses the paper suggests the interaction of Lean and clinical practice remains contingent and open to negotiation. In particular, Lean follows in a line of service improvements that bring to the fore tensions between clinicians and service leaders around the social organisation of healthcare work. The paper concludes that Lean might not be the easy remedy for making both efficiency and effectiveness improvements in healthcare.

Introduction

In the current global economic climate, governments look for ways to contain or reduce public healthcare spending, while simultaneously assuring levels of service and, in some cases, extending provision to marginalised groups. Policy makers and service leaders are therefore attracted to management philosophies that, for other industries, offer more productive and cost-effective ways of organising and delivering services. One prominent example is the popular application of process re-engineering methodologies, such as Lean Thinking and Six Sigma (Radnor & Boaden, 2008). These are characterised as reducing waste and adding customer value through re-configuring organisational processes (Womack & Jones, 2003). Over the last decade there has been growing international interest in the idea of Lean Healthcare, exemplified by the work of bodies such as US Institute for Healthcare Improvement and the UK Institute for Innovation and Improvement.

The introduction of Lean healthcare resurfaces longstanding debates around the changing organisation of healthcare work. For over three decades scholars have examined the impact of reform on clinical practice. Managers and corporate rationalisers have been widely interpreted as ‘countervailing powers’, challenging the dominance of groups such as medicine (Alford, 1975, Harrison and Pollitt, 1995, Hunter, 1994, Light, 1995). More broadly it is suggested that the ‘logic’ of managerialism had come to replace the ‘logic’ of professionalism in the social organisation of healthcare (Kitchener, 2000). Contemporary healthcare reforms illustrate this trend in three areas. The first relates to the proliferation, and management co-option of, evidence-based guidelines and audit regimes, which highlight the standardisation, bureaucratisation and re-regulation of clinical practice (Allen, 2009, Harrison, 2002, Timmermans and Berg, 2003a, Timmermans and Berg, 2003b). The second relates to the re-configuration of clinical work, especially professional boundaries, to deliver more patient-centred, evidence-based services, including new forms of clinical specialisation (Martin, Currie, & Finn, 2009). The third relates to the re-stratification of professional groups as clinical leaders are co-opted in managerial roles to direct the process of change (Coburn et al., 1997, Friedson, 1994, Kitchener, 2000). In combination these changes raise questions about the creeping managerialisation of healthcare, the negotiation of jurisdictional boundaries, new forms of governance and emerging ‘hybrid’ identities (Llewellyn, 2001, McDonald et al., 2008, Sheaff et al., 2004, Waring and Currie, 2009)

Lean Healthcare contributes to these three trends, representing a new focal point in the reorganisation of healthcare work. It exemplifies efforts to establish unambiguous evidence of service performance on which service leaders can seek to further rationalise and streamline clinical practices, which in turn involves the re-configuration of established working practices and new forms of clinical leadership. Our paper investigates the implementation of Lean within the English National Health Service (NHS), specifically the hospital operating department, to understand whether and how this particular management approach interacts and transforms established ways of working. It contributes to these wider debates, and offers a critical appraisal of Lean as the current fashion in healthcare reform. In developing our analysis, we look to new ways of understanding the interplay between Lean and clinical practice and draw upon the ‘technologies-in-practice’ approach (Timmermans & Berg, 2003a). This considers how technologies such as Lean interact with and are co-constructed in relation to other social actors and practices within in a given social–cultural context. Our work is therefore attentive to the way both Lean and clinical practice are constructed in relation to each other in a situated and ongoing process of organisational change.

Section snippets

Lean healthcare

Process re-engineering methodologies, such as Lean and Six Sigma, have become international management phenomenon. Without engaging in a detailed social history, such methodologies follow in a long history of systems management and quality improvement with their own distinct genealogies, such as scientific management and Total Quality Management (TQM) (Deming, 2000). With its origins in the Toyota Production Systems (TPS), ‘Lean Thinking’ has become particularly popular (Liker, 2004, Womack and

Lean-ing on clinical practice

In developing a socio-cultural perspective, analysis in other sectors points to some of the consequences of Lean outside of those conveyed in managerialist visions. Research has illustrated how its introduction can change social relations in the workplace as managers seek to remove demarcations between areas of production (Gerrahan & Stewart, 1992); it is often accompanied by an extension of surveillance as peers are encouraged to monitor each other’s work (Moody, 1997); and productivity gains

The study

The paper is based on an ethnographic study of the implementation of ‘Lean Thinking’ within the hospital operating department. The research was initiated in 2008 in two NHS hospitals and continues to be developed in two further hospitals as new service re-configuration programmes are introduced. Across all research sites, service re-configuration projects were identified that were explicitly based on the philosophy of Lean and TPS. Our research found, however, variations in these projects

Rhetoric

Our first analytical theme foregrounds the role of rhetoric within organisational practice or the way language is used in an interactive space to persuade others (Farrell, 1999). Classical principles of rhetoric include the appeals to reason (logos), emotion (pathos) and values (ethos), but more broadly it is attentive to where, how and when arguments are articulated. A focus on rhetoric highlights the contribution of persuasion to the negotiation of social order, the social construction of

Conclusions

At the outset we suggest Lean healthcare might represent a new development in the reorganisation of healthcare work. In this paper we have investigated its implementation in one operating department and found that in several ways it has the potential to contribute to the three lines of change outlined above, including the use of evidence-based guidelines, the re-configuration of occupational boundaries and new forms of clinical leadership. Firstly, Lean emphasises the importance of determining

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    The research was funded by the Economic and Social Research Council [RES-061-25-0040].

    ⋆⋆

    The authors would like to thank reviewers for their comments and suggestions in developing this work.

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