In a newly revised book, Lean consultant John Black says he had a difficult time working on Saskatchewan's health care system, encountering intense criticism of his work and attitudes that he characterized as "nationalist, if not racist".

The book, The Toyota Way to Healthcare Excellence (2nd Ed.), is a textbook on Black's work on Lean, an efficiency strategy that Lean was contracted to implement in the province in 2012. Originally designed to make car manufacturers more efficient, the Lean model has since been adopted by the healthcare sector as a way to cut costs and avoid medical mistakes.

In the book, Black writes that he was caught off guard when Lean became a "political football" between the Saskatchewan Party and the opposition NDP. As the politicians sparred, accusations of government waste and reliance on Japanese consultants started flying.

At one point, according to Black, the Ministry of Health asked him to stop using the Japanese members of his team — a request he found shocking.

"No other client in JBA's [John Black and Associates] history had ever singled out any of our consultants based on gender, race, ethnicity, or nationality," he wrote. "The objections aired in public forums often carried distinctly nationalist, if not racist, overtones."

On Wednesday, Saskatchewan's health minister Dustin Duncan said he did ask Black to make some adjustments to the consultants he was using. Duncan said he was looking to trim costs associated with flying in consultants from overseas.

"So was there an opportunity, because he had consultants based in Seattle, Houston and Florida — which had a smaller cost than flying someone overseas — could he accommodate us in those requests as much as possible?" Duncan said. The minister also disagreed with Black's characterization that the province was singling out consultants based on ethnicity.

In his book, Black took issue with comments that the Lean initiative wasted money, especially on Japanese-based consultants.

"The fact of the matter is that the province paid no more to bring in our Japanese consultants than it did to bring in our consultant from Florida," he wrote. "But few seemed interested in the facts."

In his latest book, John Black writes about his challenges implementing Lean in Saskatchewan. (CBC)

Media 'noise'

In his book Black criticized media reports on the Lean program calling some articles "silly" and "mockable".

"Conflict sells more newspapers than good news," he wrote. "By late 2014, the Saskatoon StarPhoenix was running negative articles and editorials almost daily — without ever addressing the millions Lean had saved, let alone the improvements for patients and workers."

Black said that the situation could have been avoided if more positive messages on Lean's work had been brought to the forefront.

"More proactive communication of positive results, internally and to the public, would have helped silence some, if not all, of that noise," he said.

What next?

In Black's view, Lean has been a success in Saskatchewan and has significantly reduced the number of medical errors across the province, since it was implemented.

He is concerned, however, that Lean may fall by the wayside, especially in rural areas that have only started applying the system.

"Provincewide, the implementation may still be at risk," he wrote. "Some regions and facilities are struggling mightily to catch up, with neither consultants nor sufficient Lean leaders to support them."

Black wrote that he is concerned that the premature canceling of his contract with the province may put the Lean system in jeopardy.

"After only three years of guidance ... can the province successfully drive Lean forward?" he asked. "Our original plan was to educate 800 Lean leaders; as of March 2015, about 300 had completed their certification — which may not be enough to carry forward in a system with more than a dozen administrations, more than 200 widely scattered facilities, and 44,000 people."

Duncan said the fact the province ended Black's contract a couple of months earlier than intended doesn't mean the province is finished improving its health care system through the Lean strategy.

"I don't think that means that our use of continuous improvement in Lean and healthcare will be jeopardized," he said.