NOTES FROM THE GEMBA – Aloïs, a Bordeaux-based home care provider, applies Lean Thinking to ensure continuity of care, support employees, and grow sustainably while prioritizing patient needs and staff wellbeing.

Words: Catherine Chabiron

Arnaud Barde is the founder of Aloïs, an organization created in 2014 to provide home care to the severely disabled in Bordeaux, France. Arnaud has been promoting the adoption of Lean Thinking at Aloïs from the very start – I have recounted his early steps here – so I thought I’d head back to Bordeaux to see how the organization is faring a few years later.

Arnaud confirms that growth has been consistent, and significant. The 2024 turnover is 68% higher than it was in 2018. The margin, largely influenced by the home hourly rate established by the Departmental Council Healthcare Board (the payer), has also seen improvement. Home care was deemed essential for managing non-Covid patients when hospitals were overwhelmed with Covid-19 cases, leading to adjustments in the hourly rates.

PROTECTING PATIENTS: CONTINUITY OF CARE

As we walk into Aloïs’s new offices in Bordeaux, one information on the visual management board strikes me: their service rate continues to be at the top level. Out of the 14,250 contracted hours in April 2025, only 34 (0.23%), could not be fulfilled and the patients’ parents had to step in for a few hours each. “This is something very important for us,” Arnaud says. “We never let a patient down. Most of them are very severely handicapped, and they count on us.”

Home care services do not require a high level of training and education, and employees are typically paid rather low wages. At the same time, this is a very demanding job, both physically and mentally, and even Aloïs experiences employee turnover and absenteeism. So how do they manage it, given the difficulties inherent to the job?

First, each patient is under the responsibility of a dedicated area coordinator, who has a very intimate and comprehensive understanding of all the cases within her area. Each coordinator, therefore, is able to gauge their needs, understand the criticality of their situation, and prioritize assistance as needed.

Secondly, Aloïs was the first company in Bordeaux to offer an on-call service: top care assistants are scheduled a maximum of one on-call day per week, with a bonus. Arnaud introduced this constraint to shift the problem-solving burden onto support functions rather than care assistants.

If the usual care assistant is sick or late (half of the care assistants do not own a car and use public transportation), the area coordinator will first check whether any of the carers already attending that patient is available. If not, the on-call team is called upon. If this fails, the coordinator will do the job herself. Currently, the total hours worked by the coordinators barely reach 10 to 30 hours a month between the six of them, compared to 300 hours a month they worked a few years back. Arnaud himself is trained to do the job, should this last level of escalation be necessary.

One last, key element: if the service failure exceeds four hours for any given patient, the team sits down for a problem-solving session.

A PLAN FOR EVERY PATIENT

Aloïs has signed in 65 patients and Arnaud is a firm believer in a plan-for-every-client approach. “We need to develop the concept a bit more, but we have collected very detailed information for each patient, describing for each of them the context, the needs, the things we need to pay attention to, the risks, and so on,” he explains.

Improving the service each client receives is the organization’s main concern. They always start the weekly meeting with a patient incident. T., for example, is tracheotomized and requires 24/7 assistance (with two people needed during toilet time). T. complained that his carers acted as if he was a nuisance when he asked to be repositioned several times during the night. Even though Aloïs is very careful not to recruit night workers without testing them first on a daytime activity, there is a real risk that, as routine sets in, the assistants will take advantage of the situation to sleep and will have to be woken up to provide the service they are paid for.

Options were discussed within the management team. Send a reminder to the assistants? Organize on-site audits? Ensure night workers are not working somewhere else during the day?

The constant search for continuity of care heavily relies on both the area coordinators’ and Arnaud’s visits to the patient gemba. The coordinator directly manages the first steps of any new care assistant and will regularly follow-up from there. Arnaud, in turn, visits each of his 65 patients at the pace of one a week. But he admits: “Although I check in detail with the patient how he or she feels about the care we provide, this is more a follow-up visit than a gemba observation”.

So, he developed a new, more genuine genchi genbutsu approach, together with Noémie, Aloïs’s occupational therapist, and the area coordinator in charge. One such gemba visit turned out to be a real 5S exercise, when they identified all the useful consumables and equipment scattered in the accommodation and grouped them in one central spot, with the patient’s approval. Arnaud sees two advantages to this new approach. “I follow up the issues with the area coordinator; this encourages them to do their own gemba with their patients once or twice a month. And I take advantage of the gemba visit to show appreciation to the carer and say thank you,” he tells me.

PROTECTING CARE ASSISTANTS

Aloïs currently employs 140 care workers, and Arnaud’s second biggest concern is to ensure they work in the best possible conditions.

Home care involves physically demanding tasks, such as lifting or bending over, making workplace accidents a concern. To address this, Arnaud hired occupational therapist Noemie and arranged a dojo to offer carers training on proper postures and professional positioning.

Noemie is keen to tells me how she sees her work. “It’s a two-fold approach: increase the patients’ autonomy, while making the job of care assistants easier,” she explains. She eagerly shows me pictures of a training session. “We can even emulate the patient’s actual environment. Sometimes, there is very little space to move around the bed, and this can result in carers adopting bad postures,” she says.

Noemie recalls a recent training session. While she was busy explaining the risks of a transfer (carrying the patient from bed to chair, using a patient lift), the carers in charge of S. pointed out that their top concern with that patient was performing endotracheal suctioning (ETS). The patient’s room is so cramped that they had to twist while bending over, and this was where most of the risks and the actual wounds came from.

Noemie has developed quite the array of training modules, both for the new carers and the senior ones. Coming soon, a new one on hygiene and cooking, to be delivered by the coordinators in pairs. She is also developing a training module on cognitive and motor problems, to improve the support patients receive at home. And, of course, there is a recurrent training in endotracheal suctioning (ETS). Developing stronger ETS capabilities enables Aloïs to take over complex cases and to be more reactive in case a carer needs to be replaced at short notice.

Taking care of care providers also means ensuring they know their schedule well in advance. Arnaud sees the monthly schedule as a production plan, prepared by coordinators and sent out by the 22nd of the previous month. “Not the 23rd or 24th, because I want the care assistants to understand their schedule early,” he says. His goal is a 95% complete schedule by this date. They have improved from a 60% to 80% completion rate, reducing unassigned hours from 2,000 to 200-500 by the 22nd. An early schedule helps carers manage their own medical appointments, leave, and personal lives. Additionally, Aloïs offers care assistants meetings with a social worker to discuss personal issues.

BEST IN TOWN STRATEGY

Akio Toyoda, former President of Toyota Motor Corporation, framed Toyota car dealers’ mission worldwide with those simple words: Best in Town. To quote him: “If we aim for Best in the World, what does it mean? But Best in the Town is easy to understand. I want us to focus on one customer at a time, one by one.”

Arnaud's initial ambition had been to create a network of home care agencies for vulnerable people. With Lean, he repeatedly favoured quality and customer proximity over “blind” growth and geographical dispersion. I see his work and most of his decisions as a Best in Town approach and I ask him and his team how others perceive Aloïs’s performance.  

Local medical authorities in Bordeaux seem to agree, according to Arnaud. He tells me that one doctor who follows up on patients after they leave hospital once told them Aloïs does a more thorough job than its competitors. The Departmental Council recognizes their capability in handling complex cases and is granting them a bonus of €3/hour to manage human resources development: training has increased from 200 hours in 2023 to 1,000 hours in 2024, with the same workforce. The ETS trainer at Pellegrin Hospital once told them: “You are the best at tracheal support.” A severely disabled patient, who had been with Aloïs for five years, died two months after hiring a competitor whose staff wasn’t properly trained in ETS.

Their main competitors are large national companies with multiple agencies. They invest significantly in consumer advertising and commercial targeting of medical authorities. Consequently, when Noémie and a coordinator visit prescribers (doctors, social workers, legal representatives, occupational therapists, etc) to discuss Aloïs services, they are occasionally told, “We've never heard of you,” even though the area coordinator’s real-life stories soon resonate with them.

“The service rate level, the on-call system, the proximity of area coordinators, and the local network maintained for service continuity are well-received features,” Noemie says. Coordinators establish good relationships with everyone involved in their patient’s care, including doctors, nurses, carers, family members, and associations. They can assist patients or carers with administrative tasks, such as completing forms or registering at the local library.

Competition analysis also confirms that Aloïs’s coordinators spend more time on the gemba, whereas competitors tend to focus on office-based HR paperwork. Initial visits to create the Plan for Every Client are conducted by the area coordinator, ensuring they remain closely connected to the field and retain knowledge and expertise if a carer leaves.

Arnaud says: “We conduct thorough needs assessments when visiting prospects, leading to high sign-up rates.” He then laughs: “Early in my career, fresh off sales training, I confidently tried selling Aloïs to a prospect who initially declined. A month later, he agreed but told me I had acted like a shoe salesman. Now, we focus on understanding client needs during visits and mention Aloïs only if specifically asked.”

When they are competing with others, however, Aloïs’ teams suggest that the prospect ask their competitor two questions: what their service rate is, and what happens if their care assistant is suddenly unavailable. This usually does the trick.

DOING MORE WITH LESS

Aloïs’s plan is to exceed 200,000 contracted hours in 2026 with the same support function staff (in 2024, their totaled 163,170 contracted hours). The teams are discussing how to decrease the time spent on the scheduling for the following month or on the painful monthly collection of information needed to feed the wages calculation. They also plan to improve how they assign carers to patients, to reduce transportation time. All carers are employees of Aloïs and are paid, whether or not they are assigned to a patient. The teams are consequently planning to improve the way they assign carers to patients, to reduce both the transportation time and the number of hours paid but not worked.

Lean resonates deeply with Arnaud, who has travelled several times to Japan for TPS tours. “The point is not to grow through massive recruitment drives or investment, but by making better use of our current resources. That’s why my mission is to develop our people’s individual and collective know-how.”

_{Catherine will share her lessons learned from her many gemba walks at the Lean Global Connection 2025. You can register for free here.}