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Envisioning a Cohesive Health Care System

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Kate McGovern
February 11, 2022

Challenges in public administration range from the minor to the momentous. The COVID-19 pandemic certainly falls in the latter category. As a Lean practitioner, I assessed our response through that particular lens. It is timely to broaden the topic to examine health care in the United States from a Lean perspective.

Lean is an organizational management system. Originally developed in manufacturing, it focuses on eliminating waste and improving customer value. More than a set of tools, it is a perspective and a discipline. In previous columns, I recommended Lean techniques to improve government services. I urged states to implement sustainable Lean programs to facilitate the deployment of American Rescue Plan Act (ARPA) funds.

Lean practitioners are systems thinkers. Viewing a system as a whole, we seek to integrate functions across silos to maximize value, quality and efficiency. It is not a one-and-done redesign—it is an ongoing cycle of improvement. Such concepts are equally applicable to organizations in the public, private and non-profit sectors and to broader societal systems.

The task of applying Lean principles to health care is difficult because the United States does not have a health care system. U.S. health care is delivered by a multitude of disparate parts, among public, private and non-profit institutions and individual providers. In contrast, as Dr. Michael Fine defines: “A health care system is an organized set of services and products made available to the entire population and designed to achieve a predetermined set of outcomes.”

Prior to envisioning a cohesive health care system, Lean concepts can be used to examine the disparate parts. It is timely to start with the public health component.

As the pandemic spread in the United States in March 2020, economist Robert Reich wrote, “The dirty little secret, which will soon become apparent to all, is that there is no real public health system in the United States.” Later, journalist Ed Yong reported, “More Americans have been killed by the new coronavirus than the influenza pandemic of 1918, despite a century of intervening medical advancement.”

The unlean state of public health

Most Lean projects begin with an analysis of the current state. Three indicators of organizational dysfunction can be identified with the Japanese terms used by Lean practitioners. Consider the waste (muda), variability (mura) and over burden (muri) in public health administration:

Muda: (waste) is an unnecessary use of resources including time, people and materials.

  • Layers of overlapping jurisdictions and responsibilities. Journalist Fareed Zakaria noted the limitations of “America’s crazy quilt patchwork of authority with thousands of state, local and tribal public health departments” which are “proving a nightmare when tackling an epidemic that knows no borders.”
  • Multiple systems of redundant data collection. Resolve to Save Lives reported, “Unlike many other countries such as Germany, Senegal, South Korea and Uganda, the United States does not have standard, national data on the virus and its control.”

Mura: (unevenness or variability)

  • A reactive “cycle of panic and neglect.” Citing crisis-driven responses going back to cholera in the 1830s to HIV in the 1980s, journalist Ed Yong reported that interest lapsed once an immediate threat had abated. He concluded, “progress is always undone; promise, always unfulfilled.”  
    • The capacity of state and local health departments varies widely, with many functions dependent upon grants from the Centers for Disease Control (CDC). Dr. David Himmelstein compared the arrangement to having the military apply for grants to fund its ongoing responsibilities.

Muri (overburden) is exacerbated by dealing with muda and muri.

  • Layers of bureaucracy impede responses by state, local and federal entities—an overburden of time and energy expended on coordination efforts.
  • Reliance on grant funding burdens each entity with the need to staff grant seeking and reporting—an overburden of staff for work peripheral to the mission.

Can public health administration be leaned?

Yes. Lean practitioners have taught managers and employees in public health departments how to streamline program administration. Waste is reduced, and programmatic quality is improved. Hospitals use Lean to improve administrative efficiency and patient care. Yet, such incremental measures alone cannot address the need for a cohesive health care system.  

What would a cohesive health care system look like?

Seeking to design an integrated system, Dr. Michael Fine studied models in other countries. Drawing on a model used in Finland, he recommended a system of municipal health centers, each serving 10,000 people. The centers would provide 90% of the area’s health care needs, including medical, dental, behavioral and preventive care. Staff would include social workers, counselors, nutritionists and physical therapists. It would be open evenings and weekends. It would be responsible for ensuring all immunizations and screenings for the entire population of that community were up to date. Services would include recovery and wellness programs.

The integrated model meets the Lean criteria: more efficient, better customer value. It could be at the core of a functional, cost-effective and humane health care system.

Upcoming columns will examine the muda in the health care funding stream and the mura and muri that result.


Author: Kate McGovern, MPA, Ph.D. is a Lean trainer and practitioner in the public sector. Formerly a professor for the State of NH, Kate is an instructor at College Unbound and a consultant with Daniel Penn Associates. She is the author of A Public Sector Journey to Lean: Fighting Muda in Times of Muri. [email protected] @KateMcGovern_

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