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 Process Redesign
for Health Care
Using Lean
Thinking
A Guide for Improving Patient Flow and
the Quality and Safety of Care
Process Redesign
for Health Care
Using Lean
Thinking
A Guide for Improving Patient Flow and
the Quality and Safety of Care

David I. Ben-Tovim
CRC Press
Taylor & Francis Group
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Library of Congress Cataloging‑in‑Publication Data

Names: Ben-Tovim, D. I., author.

Title: Process redesign for health care using lean thinking : a guide for
improving patient flow and the quality and safety of care / David
Ben-Tovim.
Description: Boca Raton : Taylor & Francis, 2017.
Identifiers: LCCN 2016044986| ISBN 9781138196094 (pbk. : alk. paper) | ISBN
9781138630864 (hbk : alk. paper) | ISBN 9781315303956 (ebook)
Subjects: | MESH: Delivery of Health Care--organization & administration |
Quality Assurance, Health Care--methods | Total Quality Management |
Efficiency, Organizational | Organizational Culture | Case Reports
Classification: LCC RA971 | NLM W 84.1 | DDC 362.1068--dc23
LC record available at https://lccn.loc.gov/2016044986

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For Josephine, without her constant support and encouragement,
and her enduring belief in the value of the work, none of this
would have been possible. With all my love and thanks.
Contents

1 Introduction: An Accidental Redesigner.......................................................................1

Process Mapping................................................................................................................. 1
The Modernization Agency................................................................................................. 2
Why Redesign?................................................................................................................... 3
Learning about Lean........................................................................................................... 3
A Decade Later................................................................................................................... 4

SECTION I CONTEXT AND METHOD

2 Craft, Flow, Mass..........................................................................................................7
British Manufacturing: The Extension of the Craft Work System....................................... 7
The American Method of Production................................................................................. 8
Henry Ford and Highland Park.......................................................................................... 8
The Rouge, Production Villages, and Excess Inventory....................................................... 9
Alfred Sloan........................................................................................................................ 9
Dreamliner or Bad Dream.................................................................................................10
3 Taiichi Ohno and the Birth of Lean............................................................................11
Why Is Lean Thinking Important for Health Care?......................................................... 12
Toyota and Taiichi Ohno............................................................................................. 12
Waste and Flow............................................................................................................ 12
Work and Waste............................................................................................................13
Kanban.........................................................................................................................13
Supermarket..................................................................................................................14
Push and Pull................................................................................................................15
Workers as Problem Solvers: The Challenge for Managers.............................................15
4 The Principles of Lean Thinking.................................................................................17
The Process Viewpoint: The Golden Thread of Lean..........................................................17
The Lean Principles............................................................................................................18
Principle 1: Specify Value from the Viewpoint of the End-Customer............................18
Patients: The End-Customer.....................................................................................19
Value, the Intermediate Process, and the Direct Customer...................................... 20
Principle 2: Identify the Value Stream for Each Product Family....................................21
Thinking in Journeys............................................................................................... 22
Principle 3: Eliminate Waste and Make the Product Flow; the Eight Wastes............... 23
Wastes 1 and 2: Waiting and Queuing.................................................................... 23

vii
viii ◾ Contents

Waste 3: Rework...................................................................................................... 24
Wastes 4 and 5: Transportation and Motion............................................................ 24
Wastes 6 and 7: Overprocessing and Overproduction.............................................. 24
Waste 8: Neglecting Skills and Talents.....................................................................25
Flow..........................................................................................................................25
Principle 4: So That the Customer Can Pull..................................................................25
Principle 5: As You Manage toward Perfection............................................................. 26
5 Health Care Is Not Manufacturing.............................................................................27
Placing an Order: Customers and Raw Materials.............................................................. 27
Deterioration.................................................................................................................... 28
Redesign Double Vision.................................................................................................... 28
Health Care Is Complicated............................................................................................. 29
Adaptive Problems........................................................................................................ 29
6 Knowledge Work.........................................................................................................31
The Nature of Knowledge Work....................................................................................... 32
Supervised but Not Subordinated..................................................................................... 32
Knowledge Workers Own Their Knowledge Capital.........................................................33
Machines Extend Knowledge Work, Not Replace It......................................................... 34
Design and Redesign........................................................................................................ 34
7 Redesigning Care: Authorization, Permission, Teams, and Governance....................37
Authorization.................................................................................................................... 38
Permission........................................................................................................................ 39
The Redesign Team........................................................................................................... 39
Governance....................................................................................................................... 40
8 The Virtuous Circle of Process Redesign and the Health Care A3..............................43
9 Identifying the Problem..............................................................................................47
Primary Purpose, Problems, and Concerns........................................................................47
What Kind of Problem and Where to Start?..................................................................... 48
Evidence........................................................................................................................... 48
Keep It Simple, Be Prepared to Be Surprised.................................................................... 49
10 Defining the Scope......................................................................................................51
The Benefits of Starting with Scope...................................................................................51
Sphere of Influence............................................................................................................53
Scope and Scoping: An Evolving Task...............................................................................55
11 Diagnosis (1): Mapping...............................................................................................57
The Big Picture and the Big Picture Map...........................................................................57
The Process of Big Picture Mapping: A Social Intervention...............................................59
Setting Up and Undertaking a Big Picture Mapping........................................................ 60
Closing the Session........................................................................................................... 62
12 Diagnosis (2): Direct Observation...............................................................................63
External or Internal Redesign Capacity?........................................................................... 63
The Structure of the Learning to See Phase...................................................................... 64
 Contents ◾ ix

What Do the Visionaries Need to Look for?................................................................ 64

Follow the Raw Material as It Is Transformed...............................................................65
Tracking the Machine.................................................................................................. 66
Analysis............................................................................................................................ 69

13 Identifying the Real Problem......................................................................................71

Root Cause Analysis, the Five Whys, and Effect-and-Cause Analysis............................... 71

14 Measurement...............................................................................................................73
Measurement for Redesign—Types of Measurement........................................................ 73
Qualitative and Quantitative Measures........................................................................ 73
Parametric and Nonparametric Measures................................................................ 75
Computers or Paper and Pencil................................................................................ 75
The Basic Triad of Analysis Design....................................................................................76
The Run Chart............................................................................................................. 77
Measurement Focus: Time, Money, and Outcomes.......................................................... 79
Measuring Processes or Outcomes............................................................................... 80
Summary.......................................................................................................................... 80

15 Goals, the Scientific Method, and the Future State.....................................................81

Experiments and the Plan–Do–Study–Act Cycle............................................................. 82
Goals................................................................................................................................ 83

16 Strategies (1): Value Stream, Batching, and Flow Improvement.................................85

Making the Process Visible............................................................................................... 86
Splitting into Value Streams............................................................................................. 87
Short and Long............................................................................................................ 87
Planned and Unplanned............................................................................................... 88
Splitting, Segmenting................................................................................................... 88
High Volume............................................................................................................... 90
Flow.................................................................................................................................. 90
Takt Time.....................................................................................................................91
Take............................................................................................................................. 92
Batching........................................................................................................................... 92
Improving Flow: Eliminate, Combine, Reduce, and Simplify.......................................... 94
Redundancy................................................................................................................. 95

17 Strategies (2): Targeted Interventions—5S, Visual Management,

and Visual Systems......................................................................................................97
5S..................................................................................................................................... 97
Take the Doors Off, Support the Processes, and Standardize Where Possible................... 98
Visual Management.......................................................................................................... 99
Visual Systems: Symbols, Signs, and Signals................................................................ 99
Status......................................................................................................................... 100
Direct......................................................................................................................... 100
Affordance.................................................................................................................. 100
Commands.................................................................................................................101
The Ideal Visual Management System.............................................................................102
x ◾ Contents

18 Strategies (3): Queues, Prioritizing, Capacity, and Demand.....................................103

Acknowledging Erlang—The Calling Population............................................................104
Queue Discipline.............................................................................................................106
Unplanned Work and FIFO........................................................................................106
Long-Term Queues......................................................................................................107
Shortest Service Time Queue Discipline.....................................................................107
Mixing Planned and Unplanned Work: Minimizing Impact on the
Short-Term Queue—Intrusions and Buffer Slots.........................................................108
Slot Time Adjustment.................................................................................................109
Partial Booking and the Infinite Queue......................................................................110
Managing Long-Term Queues ........................................................................................ 111
Queues and Priorities—Little’s Law in Action.................................................................112
Little’s Law and the Impact of Prioritization...............................................................113
Analysis of Capacity and Demand...................................................................................114
Erlang Variables.......................................................................................................... 115
Utilization at 85% and Above; Exponential Delay...........................................................117
Exponential Growth in Queue Length with Small Changes in the
Number of Arrivals.....................................................................................................118
Pre-emption and Impossible Jobs................................................................................ 119
19 Embedding and Sustaining.......................................................................................123
Measure, Monitor, and Evaluate..................................................................................... 123
The Frontline Managers.................................................................................................. 124
Constancy of Purpose......................................................................................................125

SECTION II CASE STUDIES: MAKING IT WORK

20 Redesigning Emergency Department Flows: Case Study..........................................129
The Problem....................................................................................................................129
Evidence..................................................................................................................... 130
Scoping........................................................................................................................... 130
Diagnosis.........................................................................................................................131
Big Picture Mapping...................................................................................................131
Good to Get to Know You..........................................................................................132
The PSA......................................................................................................................132
Triage..........................................................................................................................133
Doctors Are Allocated to Patients, Nurses to Cubicles..............................................136
Do Not Use Mapping to Talk about Solutions............................................................137
The Oxygen Cylinders.................................................................................................137
The Real Problem............................................................................................................138
Intervention.....................................................................................................................138
The National Health Service Modernization Agency..................................................139
Streaming........................................................................................................................140
The First Day..............................................................................................................141
ED Works...................................................................................................................141
Enhancing Team Work...............................................................................................143
Communication..........................................................................................................144
 Contents ◾ xi

Embedding and Sustaining..............................................................................................146

Evaluation........................................................................................................................146
Short and Long........................................................................................................... 151
Summary.........................................................................................................................152

21 The Care after Hours Program: Case Study..............................................................155

The Problem.................................................................................................................... 155
Authorization and Permission.....................................................................................156
Scoping............................................................................................................................157
Model of Care.............................................................................................................157
Diagnosis.........................................................................................................................158
Tracking......................................................................................................................159
Front-of-House and Back-of-House.............................................................................161
Four Major Work Streams...............................................................................................161
New Patient Work.......................................................................................................162
Care Progression.........................................................................................................162
Maintenance Work......................................................................................................163
Unstable Patient..........................................................................................................163
Distribution of Work Streams over 24 Hours..............................................................163
The Real Problem............................................................................................................164
Intervention.....................................................................................................................166
Do Today’s Work Today..............................................................................................166
Reducing Overburden and Handover..........................................................................167
Unstable Patient Work................................................................................................167
Problem and Scope of Work........................................................................................168
Real Problem...............................................................................................................169
Intervention.....................................................................................................................169
Maintenance Work......................................................................................................170
Shift Coordinator Identification..................................................................................171
Standardizing IV Equipment......................................................................................172
The Electronic Medical Task Board.............................................................................173
Evaluation of the CAH Program.....................................................................................174
Embedding and Sustaining..............................................................................................176
Continuity of Information...............................................................................................177

22 Visual Management: Case Study...............................................................................179

The Patient Journey Boards..............................................................................................179
Background: “The Man Goes to the Work”................................................................179
The Problem....................................................................................................................180
Scope...............................................................................................................................180
Tracking..........................................................................................................................181
The Real Problem............................................................................................................182
Intervention.....................................................................................................................183
Referrals......................................................................................................................184
Location, Privacy, and Confidentiality........................................................................185
Spread.........................................................................................................................187
Evaluation........................................................................................................................187
xii ◾ Contents

Evolving a New Visual Language.....................................................................................188

Discharge Traffic Lights and Blue Dots...........................................................................189
Diagnosis.........................................................................................................................189
Intervention.....................................................................................................................189
Evaluation........................................................................................................................192
Interdependency and Interoperability..............................................................................193
23 Redesigning Podiatry Care: Case Study....................................................................195
The Problem....................................................................................................................196
Evidence..........................................................................................................................196
Diagnosis.........................................................................................................................196
Big Picture Mapping...................................................................................................196
Tracking......................................................................................................................196
The Real Problem............................................................................................................197
Interventions....................................................................................................................197
Simplifying Structures................................................................................................198
Booking......................................................................................................................198
Evaluation .......................................................................................................................198
Summary.........................................................................................................................199
24 Process Redesign for Health Care Using Lean Thinking..........................................201
References..........................................................................................................................203
Index..................................................................................................................................205
Chapter 1

Introduction: An Accidental
Redesigner

I am an accidental redesigner. Yet, I have spent more than 10 years attempting to redesign the way
care is organized and delivered in hospitals and health services.
I am a psychiatrist and clinical epidemiologist by background. The Flinders Medical Centre
is a 500-bed teaching general hospital in Adelaide, South Australia. In 2000, I became its
Director of Clinical Governance. My job was to oversee safety and quality systems throughout
the hospital.
The main problem was apparent. The Emergency Department had become catastrophically
congested. Patients were being managed in far-from-optimal settings, and problems that started
in the Emergency Department were showing up all over the hospital.
The hospital was not facing an excess patient load, just the work the community had every
right to expect the hospital to be able to manage. A variety of efforts had been made to improve
things. None had provided lasting relief. Then, my colleague Melissa Lewis came across some-
thing called Process Mapping on the Internet. It seemed to involve bringing together the people
who worked in a unit and asking them what they did to move the patients through the unit.
We thought Process Mapping might help us understand what was going on. Although the senior
staff members who worked in the Emergency Department were confident that they had a pretty
good handle on how the department worked, they were willing to try anything to get the depart-
ment working, including Process Mapping.

Process Mapping
One Tuesday morning, about 20 staff from the Emergency Department, Melissa Lewis, and
I gathered in the Emergency Department seminar room. Every discipline group working in the
department was represented, from the Patient Service Assistants who did the cleaning, fetching,
and carrying, to the most senior Emergency Physicians.
Melissa and I decided to ask the participants to describe what they did, step by step, from the
moment a patient arrived at the glass doors at the entrance to the department until that patient left
the department and went home or was admitted to an in-patient unit.

1
2 ◾ Process Redesign for Health Care Using Lean Thinking

Over three long sessions, we mapped out the sequences of care the department provided. It was
a revelation. As soon as we started, it became clear just how confusing the care processes had
become. The Emergency Department staff were as surprised by this as we were.
Every patient who comes to a major Emergency Department in Australia sees a specialized
Triage nurse. The Triage nurse is stationed, literally and metaphorically, at the front door. She or
he makes a very brief clinical assessment of all the patients and allocates a Triage score to each
one. A Triage score is the Triage nurse’s assessment of how urgently the rest of the staff in the
department need to begin the work of providing definitive care: immediately, within 10 minutes,
within 30 minutes, within 60 minutes, or within 2 hours. Many of the problems in the Emergency
Department seemed to begin with the way Triage scores were being used. The Triage scores not
only described patients but were also used to place patients in queues. Whilst this might seem to
make sense, the case study in Chapter 20 makes it clear why this had become a problem.
As we presented our observations to various groups around the hospital, there was widespread
agreement that something needed to be done—but what?

The Modernization Agency

A small group of us, including Jane Bassham, at that time the senior nurse in the Emergency
Department, and Dr. Di King, the head of the Emergency Department, were able to spend a few
days in London as guests of an NHS organization, the Modernization Agency (since then dis-
banded). We visited Emergency Departments in busy hospitals that had been transformed from
war zones into acceptable places for staff and patients alike. Our Modernization Agency hosts,
who were very involved in supporting the improvements, gave us copies of the book, Lean Thinking
(Womack and Jones 2003), telling us that they had found it very useful. They gave us the book on
a rather secretive, need-to-know kind of basis. The secrecy surprised us.
Later on, we discovered that there was a concern that if the Modernization Agency talked
about learning from industry, it would be taken to mean that the NHS was going to be sold off
to private enterprise, which was not the impression the government of the day wanted to make.
Back in Australia, we were also able to spend a few days with Ben Gowland, then a senior
staff member of the Modernization Agency. Ben had played an important role in the changes we
observed. We kept asking him what we should do. He told us that we were clever people, and we
would be able to work things out for ourselves. While this did not feel very supportive, he was
right. Under the inspirational leadership of Dr. Di King, we used our experiences in London and
our reading of Lean Thinking to introduce some dramatic changes in the internal organization of
the Emergency Department (King et al. 2006). Overnight, those changes improved our capac-
ity to provide good, timely care. And over the next year, a hospital-wide dramatic decrease in the
number of patients seeking redress for serious failures in the safety and quality of care implied that
something was having an impact throughout the hospital.
Clearly, there was something to this Lean Thinking business (Ben-Tovim et al. 2007), even
though at that time it was not being used in other Australian hospitals and health services.
Ben also said that if we wanted to make a lasting difference, we needed to create a team, with
a formal structure and explicit governance, dedicated to improvement work. He said it was as
important to think about the team as it was to think about the changes we intended to make.
This was very good advice, without which we would not have given much thought to creating a
team and a governance structure. The hospital management listened to Ben and set up a small
team to “do Lean.” I was appointed its Director. Two full time, and one part-time, nurses and a
 Introduction: An Accidental Redesigner ◾ 3

psychologist completed the team. We established both the team (which included Melissa Lewis,
Jane Bassham, Denise Bennett, Margaret Martin part time, and later Jackie Sincock and Lauri
O’Brien) and a governance structure that brought together the senior hospital leaders. We decided
on a name—Redesigning Care—and got started.

Why Redesign?
Why redesign, not design or improve? It is because the hospital already existed, with skillful and
committed people already doing their best. We were not beginning with a clean slate. On the
contrary, we were trying to improve care processes already in place in an institution that did not
have the luxury of closing down until it got things sorted out.

Learning about Lean

Clearly, we needed to learn more about this Lean stuff. The team, plus some senior managers, went
on a local university course in Lean Manufacturing. Our fellow students came from a variety of
local industries. We learned as much from them as from the formal content of the course. Yes, the
contexts differed, but we were all grappling with the same kinds of problems.
Most importantly, during, and after the course, as we set about trying to redesign care across
the hospital, the team kept working together to try and make sense of what we were actually doing.
Then and later we were strongly supported by Julia Davidson, Michael Szwarcbord, and Susan
O’Neill in various management roles. Paul Hakendorf, Chris Horwood, and John Gray were
patient with us and helped us with the key tasks of data retrieval and analysis, as well as provided
general and, much needed, support.
Invaluable contributions to both theory and practice have been made by the hundreds of clini-
cal and nonclinical staff with whom we have worked, both at Flinders and across the country, and
by the people who worked part time in the Redesigning Care team for longer or shorter periods.
So many people have been important that it is almost invidious to mention specific individuals
or groups. But Peter Walsh from Lean Enterprise Australia has been a particular friend and sup-
port, as has the Lean community as a whole. Despite their many other responsibilities, Katherine
McGrath and Tony O’Connell have provided invaluable support and encouragement. The list
could go on but has to include the ever-patient Di Mackintosh and Kylie Thomas whose support
and assistance have been crucial.
The Process Redesign for Health Care using Lean Thinking method draws extensively, though
not exclusively, on Lean Thinking theory and practice. I begin with a discussion of the origins of
Lean Thinking and some of the issues involved in adapting it for Health Care. I then move on
to describe Process Redesign methodology in some detail. Brief case material is used to illustrate
the principles and the evolution of that methodology. There are then four extended case histories
in which I try to provide a more detailed picture of how Process Redesign for Health Care using
Lean Thinking (frequently abbreviated to Process Redesign or Process Redesign for Healthcare)
works in practice. Almost invariably, the most creative work was done by the staff on the ground.
They know the work and, without exception, have been anxious to improve the quality of care
they provide. The case studies are not intended to be templates for how to solve certain prob-
lems. They cannot be; Health Care problems need solutions that are relevant and specific to their
­context. The purpose of the case studies is to illustrate the Redesign Process and give a sense of
4 ◾ Process Redesign for Health Care Using Lean Thinking

how Redesign actually occurs. To make that possible, the extended case studies are based on the
materials produced at the time.
Health Care involves people at their most vulnerable and private moments. To minimize the
risk of identifying individuals, details that might identify specific participants, or institutional
issues of any sensitivity, have been altered or removed, and if diagrams or figures are presented that
are based on materials produced during Redesign programs, they have been altered and redrawn
so that anonymity is preserved. Facts or figures that might identify individuals or specific services
have also been altered to minimize the risk of inappropriate identifications. However, every effort
has been made to faithfully describe the spirit of the Process Redesign programs and not make
false claims for program outcomes. However, the case studies have been written up in a format
that clearly separates out various phases of the work involved. That was how the work progressed,
and where major deviations in the progression of work occurred, they have been discussed; how-
ever, case studies are by their nature somewhat simplified representations of a messier reality.
Writing up the case histories has only been possible because of the extensive documentation of
the work as it progressed. It is a tribute to the efforts Denise Bennett and the other team members
put into reporting to governance groups at each step on the way. Denise was a particular force for
good in this area, and much of the credit for the consistency of the documentation must go to her
leadership.
Throughout the text, when a personal contribution by a team member has been particularly
clear, I have tried to identify that person’s contribution to the development of theory or practice,
but again, whilst maintaining confidentiality and recognizing the importance of the team as a
whole.

A Decade Later
A decade after this work began, there is a growing community of Health Care redesigners using
Lean Thinking to redesign and improve Health Care processes, both in Australia and the rest of
the world. I am delighted with the role I and my colleagues have been able to play in this develop-
ment, and with the way the Australasian Lean Health Care Network, which the Flinders group
has been part of from the start, has supported that development in Australasia.
Process Redesign for Health Care is for anyone who is trying to improve how their hospital
or health service delivers care. I hope there is something in it both for the novice redesigner and
the more experienced practitioner curious to learn more. Redesign is never easy. It is hard work.
Things never go quite to plan. But it can be done. Process Redesign is a team effort. When faced
with the common experience of not quite knowing what you are doing or what to do next, as the
Flinders team always said, “have confidence in the method, and don’t miss a step.”
CONTEXT AND I
METHOD
Chapter 2

Craft, Flow, Mass

The term Lean Thinking first appeared in the book The Machine that Changed the World (Womack
et al. 1990). The book was a summary of a global research program into car-making around the
world. Lean Thinking was the term the authors used to sum up the distinctive production and
managerial methods they observed at the Toyota Motor Company.
To understand what excited Womack et al., it’s essential to know something about the evolu-
tion of methods for making large, complicated objects, such as boats or cars. It is possible to look
back in history to fourteenth century Venetian shipyard production or even earlier to the produc-
tion of terracotta warriors for the tomb of the first Emperor of Qin who died in 221 BCE, but the
important period to concentrate on is the end of the nineteenth century. That was when what was
commonly described as the British method of manufacturing gave way to the American method,
out of which emerged mass production as we know it today.
This short history (Lazonick 1981; Reinstaller 2007) is not simply included to make it clear
what Toyota was doing that was different. Modern Health Care makes use of every method of
production, from pre-industrial craft work to the most advanced manufacturing techniques.
Understanding the differences between the methods helps explain why they do not always fit eas-
ily together in the day-to-day work of Health Care.

British Manufacturing: The Extension of the Craft Work System

Britain was at the forefront of the industrial revolution, and the nineteenth century saw a
massive expansion in British manufacturing. However, many aspects of the organization of
emerging large-scale manufacturing firms stayed locked into pre-existing craft work structures.
Groups of workers with a craft inheritance, working in expanding manufacturing firms, gained
(or maintained) control over key components of the day-to-day operations of the large-scale
manufacturing companies. They retained control over the organization of work, including
hiring and firing workers (“no ticket, no start,” in the Australian vernacular).
Traditionally, craft work is paid as piece work: you get paid for what you produce. The craft
worker controls how he or she does the work and at what pace. By retaining control of the day-
to-day management of production, workgroups could determine the tempo of work. They could
retain control over rates of pay and influence the extent to which new technology leads to job losses.

7
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Title: The Mediaeval Stage, Volume 1 (of 2)

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 beginning of dublin Quem
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 THE
MEDIAEVAL STAGE

BY
E. K. CHAMBERS

VOLUME I

OXFORD UNIVERSITY PRESS

Oxford University Press, Amen House, London E.C.4
glasgow new york toronto melbourne wellington
bombay calcutta madras karachi lahore dacca
cape town salisbury nairobi ibadan accra
kuala lumpur hong kong

first edition 1903

reprinted lithographically in great britain
by lowe & brydone, printers, ltd., london
from sheets of the first edition
1925, 1948, 1954, 1963
To N. C.
 PREFACE
Some years ago I was thinking of a little book, which now may or
may not ever get itself finished, about Shakespeare and the
conditions, literary and dramatic, under which Shakespeare wrote.
My proper task would have begun with the middle of the sixteenth
century. But it seemed natural to put first some short account of the
origins of play-acting in England and of its development during the
Middle Ages. Unfortunately it soon became apparent that the basis
for such a narrative was wanting. The history of the mediaeval
theatre had never, from an English point of view, been written. The
initial chapter of Collier’s Annals of the Stage is even less adequate
than is usual with this slovenly and dishonest antiquary. It is with
some satisfaction that, in spite of the barrier set up by an incorrect
reference, I have resolved one dramatic representation elaborately
described by Collier into a soteltie or sweetmeat. More scholarly
writers, such as Dr. A. W. Ward, while dealing excellently with the
mediaeval drama as literature, have shown themselves but little
curious about the social and economic facts upon which the
mediaeval drama rested. Yet from a study of such facts, I am sure,
any literary history, which does not confine itself solely to the
analysis of genius, must make a start.
An attempt of my own to fill the gap has grown into these two
volumes, which have, I fear, been unduly swelled by the inclusion of
new interests as, from time to time, they took hold upon me; an
interest, for example, in the light-hearted and coloured life of those
poverelli of letters, the minstrel folk; a very deep interest in the track
across the ages of certain customs and symbols of rural gaiety which
bear with them the inheritance of a remote and ancestral
heathenism. I can only hope that this disproportionate treatment of
parts has not wholly destroyed the unity of purpose at which, after
all, I aimed. If I may venture to define for myself the formula of my
work, I would say that it endeavours to state and explain the pre-
existing conditions which, by the latter half of the sixteenth century,
made the great Shakespearean stage possible. The story is one of a
sudden dissolution and a slow upbuilding. I have arranged the
material in four Books. The First Book shows how the organization of
the Graeco-Roman theatre broke down before the onslaught of
Christianity and the indifference of barbarism, and how the actors
became wandering minstrels, merging with the gleemen of their
Teutonic conquerors, entertaining all classes of mediaeval society
with spectacula in which the dramatic element was of the slightest,
and in the end, after long endurance, coming to a practical
compromise with the hostility of the Church. In the Second Book I
pass to spectacula of another type, which also had to struggle
against ecclesiastical disfavour, and which also made their ultimate
peace with all but the most austere forms of the dominant religion.
These are the ludi of the village feasts, bearing witness, not only to
their origin in heathen ritual, but also, by their constant tendency to
break out into primitive forms of drama, to the deep-rooted mimetic
instinct of the folk. The Third Book is a study of the process by
which the Church itself, through the introduction of dramatic
elements into its liturgy, came to make its own appeal to this same
mimetic instinct; and of that by which, from such beginnings, grew
up the great popular religious drama of the miracle-plays, with its
offshoots in the moralities and the dramatic pageants. The Fourth
and final Book deals summarily with the transformation of the
mediaeval stage, on the literary side under the influence of
humanism, on the social and economic side by the emergence from
amongst the ruins of minstrelsy of a new class of professional
players, in whose hands the theatre was destined to recover a stable
organization upon lines which had been departed from since the
days of Tertullian.
I am very conscious of the manifold imperfections of these
volumes. They are the work, not of a professed student, but of one
who only plays at scholarship in the rare intervals of a busy
administrative life. They owe much to the long-suffering officials of
the British Museum and the London Library, and more recently to the
aid and encouragement of the Delegates of the Clarendon Press and
their accomplished staff. The literary side of the mediaeval drama,
about which much remains to be said, I have almost wholly
neglected. I shall not, I hope, be accused of attaching too much
importance in the first volume to the vague and uncertain results of
folk-lore research. One cannot be always giving expression to the
minuter shades of probability. But in any investigation the validity of
the inferences must be relative to the nature of the subject-matter;
and, whether I qualify it in words or not, I do not, of course, make a
statement about the intention, say, of primitive sacrifice, with the
same confidence which attaches to one about matters of historic
record. The burden of my notes and appendices sometimes appears
to me intolerable. My excuse is that I wanted to collect, once for all,
as many facts with as precise references as possible. These may,
perhaps, have a value independent of any conclusions which I have
founded upon them. And even now I do not suppose that I have
been either exhaustive or accurate. The remorseless ideal of the
historian’s duties laid down in the Introduction aux Études
Historiques of MM. Langlois and Seignobos floats before me like an
accusing spirit. I know how very far I am from having reached that
austere standard of scientific completeness. To begin with, I had not
the necessary training. Oxford, my most kindly nurse, maintained in
my day no École des Chartes, and I had to discover the rules of
method as I went along. But the greater difficulty has been the want
of leisure and the spacious life. Shades of Duke Humphrey’s library,
how often, as I jostled for my turn at the crowded catalogue-shelves
of the British Museum, have I not envied those whose lot it is to
tread your ample corridors and to bend over your yellowing folios!
Amongst such happy scholars, the canons of Clio may claim implicit
obedience. A silent company, they ‘class’ their documents and ‘try’
their sources from morn to eve, disturbed in the pleasant ways of
research only by the green flicker of leaves in the Exeter garden, or
by the statutory inconvenience of a terminal lecture.—
‘Tanagra! think not I forget!’
 E. K. C.
London, May, 1903.
 CONTENTS
Volume I
PAGE
Preface v
List of Authorities xiii
BOOK I. MINSTRELSY
CHAP.
I. The Fall of the Theatres 1
II. Mimus and Scôp 23
III. The Minstrel Life 42
IV. The Minstrel Repertory 70
BOOK II. FOLK DRAMA
V. The Religion of the Folk 89
VI. Village Festivals 116
VII. Festival Play 146
VIII. The May-Game 160
IX. The Sword-Dance 182
X. The Mummers’ Play 205
XI. The Beginning of Winter 228
XII. New Year Customs 249
XIII. The Feast of Fools 274
 XIV. The Feast of Fools (continued) 301
XV. The Boy Bishop 336
XVI. Guild Fools and Court Fools 372
XVII. Masks and Misrule 390
Volume II
BOOK III. RELIGIOUS DRAMA
XVIII. Liturgical Plays 1
XIX. Liturgical Plays (continued) 41
XX. The Secularization of the Plays 68
XXI. Guild Plays and Parish Plays 106
XXII. Guild Plays and Parish Plays (continued) 124
XXIII. Moralities, Puppet-Plays, and Pageants 149
BOOK IV. THE INTERLUDE
XXIV. Players of Interludes 179
XXV. Humanism and Mediaevalism 199
APPENDICES
A. The Tribunus Voluptatum 229
B. Tota Ioculatorum Scena 230
C. Court Minstrelsy in 1306 234
D. The Minstrel Hierarchy 238
E. Extracts from Account Books 240
I. Durham Priory 240
II. Maxstoke Priory 244
III. Thetford Priory 245
 IV. Winchester College 246
V. Magdalen College, Oxford 248
VI. Shrewsbury Corporation 250
VII. The Howards of Stoke-by-Nayland, Essex 255
VIII. The English Court 256
F. Minstrel Guilds 258
G. Thomas de Cabham 262
H. Princely Pleasures at Kenilworth 263
I. A Squire Minstrel 263
II. The Coventry Hock-Tuesday Show 264
I. The Indian Village Feast 266
J. Sword-Dances 270
I. Sweden (sixteenth century) 270
II. Shetland (eighteenth century) 271
K. The Lutterworth St. George Play 276
L. The Prose of the Ass 279
M. The Boy Bishop 282
I. The Sarum Office 282
II. The York Computus 287
N. Winter Prohibitions 290
O. The Regularis Concordia of St. Ethelwold 306
P. The Durham Sepulchrum 310
Q. The Sarum Sepulchrum 312
R. The Dublin Quem Quaeritis 315
 S. The Aurea Missa of Tournai 318
T. Subjects of the Cyclical Miracles 321
U. Interludium de Clerico et Puella 324
V. Terentius et Delusor 326
W. Representations of Mediaeval Plays 329
X. Texts of Mediaeval Plays and Interludes 407
I. Miracle-Plays 407
II. Popular Moralities 436
III. Tudor Makers of Interludes 443
IV. List of Early Tudor Interludes 453
SUBJECT INDEX 462
 LIST OF AUTHORITIES
[General Bibliographical Note. I mention here only a few works of
wide range, which may be taken as authorities throughout these two
volumes. Others, more limited in their scope, are named in the
preliminary notes to the sections of the book on whose subject-
matter they bear.—An admirable general history of the modern
drama is W. Creizenach’s still incomplete Geschichte des neueren
Dramas (Band i, Mittelalter und Frührenaissance, 1893; Bände ii, iii,
Renaissance und Reformation, 1901-3). R. Prölss, Geschichte des
neueren Dramas (1881-3), is slighter. The earlier work of J. L. Klein,
Geschichte des Dramas (13 vols. 1865-76), is diffuse, inconvenient,
and now partly obsolete. A valuable study is expected from J. M.
Manly in vol. iii of his Specimens of the Pre-Shakespearean Drama,
of which two volumes, containing selected texts, appeared in 1897.
C. Hastings, Le Théâtre français et anglais (1900, Eng. trans. 1901),
is a compilation of little merit.—Prof. Creizenach may be
supplemented for Germany by R. Froning, Das Drama des
Mittelalters (1891). For France there are the exhaustive and
excellent volumes of L. Petit de Julleville’s Histoire du Théâtre en
France au Moyen Âge (Les Mystères, 1880; Les Comédiens en
France au Moyen Âge, 1885; La Comédie et les Mœurs en France au
Moyen Âge, 1886; Répertoire du Théâtre comique au Moyen Âge,
1886). G. Bapst, Essai sur l’Histoire du Théâtre (1893), adds some
useful material on the history of the stage. For Italy A. d’ Ancona,
Origini del Teatro italiano (2nd ed., 1891), is also excellent.—The
best English book is A. W. Ward’s History of English Dramatic
Literature to the death of Queen Anne (2nd ed., 1899). J. P. Collier,
History of English Dramatic Poetry (new ed., 1879), is full of matter,
but, for various reasons, not wholly trustworthy. J. J. Jusserand, Le
Théâtre en Angleterre (2nd ed., 1881), J. A. Symonds, Shakespeare’s
Predecessors in the English Drama (1884), and G. M. Gayley,
Representative English Comedies (1903), are of value. Texts will be
found in Manly’s and Gayley’s books, and in A. W. Pollard, English
Miracle Plays, Moralities and Interludes (3rd ed., 1898); W. C. Hazlitt,
Dodsley’s Old Plays (15 vols. 1874-6); A. Brandl, Quellen des
weltlichen Dramas in England (1898). F. H. Stoddard, References for
Students of Miracle Plays and Mysteries (1887), and K. L. Bates and
L. B. Godfrey, English Drama; a Working Basis (1896), are rough
attempts at bibliographies.—In addition the drama of course finds
treatment in the general histories of literature. The best are: for
Germany, R. Kögel, Geschichte der deutschen Literatur bis zum
Ausgange des Mittelalters (1894-7, a fragment); K. Gödeke,
Grundriss zur Geschichte der deutschen Dichtung aus den Quellen
(2nd ed., 1884-1900); W. Scherer, Geschichte der deutschen
Litteratur (8th ed., 1899): for France, L. Petit de Julleville (editor),
Histoire de la Langue et de la Littérature françaises (1896-1900); G.
Paris, La Littérature française au Moyen Âge (2nd ed., 1890): for
Italy, A. Gaspary, Geschichte der italienischen Litteratur (1884-9,
Eng. transl. 1901): for England, T. Warton, History of English Poetry
(ed. W. C. Hazlitt, 1871); B. Ten Brink, History of English Literature
(Eng. trans. 1893-6); J. J. Jusserand, Literary History of the English
People (vol. i. 1895); W. J. Courthope, History of English Poetry
(vols. i, ii. 1895-7); G. Saintsbury, Short History of English Literature
(1898), and, especially for bibliography, G. Körting, Grundriss der
Geschichte der englischen Litteratur (3rd ed., 1899). The Periods of
European Literature, edited by Prof. Saintsbury, especially G. Gregory
Smith, The Transition Period (1900), and the two great Grundrisse,
H. Paul, Grundriss der germanischen Philologie (2nd ed., 1896-
1903), and G. Gröber, Grundriss der romanischen Philologie (1888-
1903), should also be consulted.—The beginnings of the mediaeval
drama are closely bound up with liturgy, and the nature of the
liturgical books referred to is explained by W. Maskell, A Dissertation
upon the Ancient Service-Books of the Church of England (in
Monumenta Ritualia Ecclesiae Anglicanae, 2nd ed., 1882, vol. iii); H.
B. Swete, Church Services and Service-Books before the Reformation
(1896); Procter-Frere, New History of the Book of Common Prayer
(1901). The beginnings of Catholic ritual are studied by L. Duchesne,
Origines du Culte chrétien (3rd ed., 1902, Eng. trans. 1903), and its
mediaeval forms described by D. Rock, The Church of our Fathers
(1849-53), and J. D. Chambers, Divine Worship in England in the
Thirteenth and Fourteenth Centuries (1877).
The following list of books is mainly intended to elucidate the
references in the footnotes, and has no claim to bibliographical
completeness or accuracy. I have included the titles of a few German
and French dissertations of which I have not been able to make
use.]

Aberdeen Records. Extracts from the Council Register of the

Burgh of Aberdeen. Edited by J. Stuart. 2 vols. 1844-8. [Spalding
Club, xii, xix.]
Acta SS. Acta Sanctorum quotquot toto orbe coluntur, quas
collegit I. Bollandus. Operam continuavit G. Henschenius [et alii],
1734-1894. [In progress.]
Ahn. English Mysteries and Miracle Plays. By Dr. Ahn. Trier, 1867.
[Not consulted.]
Alcuin. See Dümmler.
Allard. Julien l’Apostat. Par P. Allard. 3 vols. 1900-3.
Allen. The Evolution of the Idea of God: an Enquiry into the
Origins of Religion. By Grant Allen, 1897.
Alt. Theater und Kirche in ihrem gegenseitigen Verhältniss. Von
H. Alt, 1846.
Anal. Hymn. Analecta Hymnica Medii Aevi. Ediderunt C. Blume et
G. M. Dreves. 37 parts, 1886-1901. [In progress.]
Ancona. Origini del Teatro italiano. Per A. d’Ancona, 2nd ed. 2
vols. 1891.
 Ancona, Sacr. Rappr. Sacre Rappresentazioni dei secoli xiv, xv e
xvi, raccolte e illustrate per cura di A. d’Ancona, 1872.
Anglia. Anglia: Zeitschrift für englische Philologie. 24 vols. 1878-
1903. [In progress.]
Ann. Arch. Annales Archéologiques, dirigées par Didron aîné. 28
vols. 1844-81.
Antiquarian Repertory. The Antiquarian Repertory: A
Miscellaneous assemblage of Topography, History, Biography,
Customs and Manners. Compiled by F. Grose and T. Astle. 2nd ed. 4
vols. 1807.
Arbois de Jubainville, Civ. Celt. La Civilisation des Celtes et celle de
l’Épopée homérique. Par H. d’Arbois de Jubainville, 1899. [Vol. vi of
Cours de littérature celtique.]
Arbois de Jubainville, Cycl. Myth. Le Cycle mythologique irlandais
et la Mythologie celtique. Par H. d’Arbois de Jubainville, 1884. [Vol. ii
of same.]
Archaeologia. Archaeologia: or Miscellaneous Tracts relating to
Antiquity. Published by the Society of Antiquaries of London. 57 vols.
1770-1901. [In progress.]
Arnold. The Customs of London, otherwise Arnold’s Chronicle.
Edited by F. Douce, 1811.
Ashton. A Righte Merrie Christmasse!!! By J. Ashton, n. d.
Bahlmann, Ern. Die Erneuerer des antiken Dramas und ihre ersten
dramatischen Versuche: 1314-1478. Von P. Bahlmann, 1896.
Bahlmann, L. D. Die lateinischen Dramen von Wimpheling’s Stylpho
bis zur Mitte des sechzehnten Jahrhunderts: 1480-1550. Von P.
Bahlmann, 1893.
Bale. Scriptorum illustrium maioris Britanniae, quam nunc
Angliam et Scotiam vocant, Catalogus. Autore Ioanne Baleo
Sudouolgio Anglo. 2 vols. Basileae, Oporinus, 1557-9. [Enlarged
from the edition in one vol. of 1548.]
 Bale, Index. Index Britanniae Scriptorum quos ex variis
bibliothecis non parvo labore collegit Ioannes Baleus. Edited by R. L.
Poole and M. Bateson, 1902. [Anecdota Oxoniensia, Mediaeval and
Modern Series, ix, from a MS. compiled 1549-1557.]
Bapst. Essai sur l’Histoire du Théâtre. Par G. Bapst, 1893.
Barbazan-Méon. Fabliaux et Contes des Poètes françois des xi, xii,
xiii, xiv et xv siècles. Publiés par E. Barbazan. Nouvelle édition, par
M. Méon. 4 vols. 1808.
Barrett. Riding Skimmington and Riding the Stang. By C. R. B.
Barrett, 1895. [Journal of British Archaeological Association, N. S.
vol. i.]
Barthélemy. Rational ou Manuel des divins Offices de Guillaume
Durand, Évêque de Mende au treizième siècle. Traduit par M. C.
Barthélemy. 5 vols. 1854.
Bartsch. Altfranzösische Romanzen und Pastourellen. Par K.
Bartsch, 1870.
Bates. The English Religious Drama. By K. L. Bates, 1893.
Bates-Godfrey. English Drama: a Working Basis. By K. L. Bates
and L. B. Godfrey, 1896.
Bede, D. T. R. Venerabilis Bedae Opera quae Supersunt Omnia.
Edidit J. A. Giles. 12 vols. 1843-4. [The De Temporum Ratione forms
part of vol. vi.]
Bede, E. H. See Plummer.
Bédier. Les Fabliaux. Études de Littérature populaire et d’Histoire
littéraire du Moyen Âge. Par J. Bédier, 2nd ed. 1895.
Belethus. Rationale Divinorum Officiorum Auctore Joanne Beletho
Theologo Parisiensi, 1855. [In P. L. ccii.]
Bell. Ancient Poems, Ballads, and Songs of the Peasantry of
England. Edited by R. Bell, 1857.
 Bérenger-Féraud. Superstitions et Survivances étudiées au point de
vue de leur Origine et de leurs Transformations. Par L. J. B.
Bérenger-Féraud. 4 vols. 1896.
Bernhard. Recherches sur l’Histoire de la Corporation des
Ménétriers ou Joueurs d’Instruments de la Ville de Paris. Par B.
Bernhard. [Bibl. de l’École des Chartes, iii. 377, iv. 525, v. 254, 339.]
Bertrand. Nos Origines: iv. La Religion des Gaulois; Les Druides et
le Druidisme. Par A. Bertrand, 1897.
Bibl. des Chartes. Bibliothèque de l’École des Chartes. Revue
d’Érudition consacrée spécialement à l’étude du Moyen Âge. [I quote
the numbers of the annual volumes, without regard to the Séries.]
Bingham. The Works of Joseph Bingham. Edited by R. Bingham.
New ed. 10 vols.
Blomefield. An Essay towards a Topographical History of the
County of Norfolk. By F. Blomefield. 2nd ed. 11 vols. 1805-10.
Böhck. Die Anfänge des englischen Dramas. Von Dr. Böhck, 1890.
[Not consulted.]
Bolton. The Counting-Out Rhymes of Children. By H. C. Bolton,
1888.
Boretius. Capitularia Regum Francorum. Ediderunt A. Boretius et
V. Krause. 2 vols. 1883-7. [M. G. H. Leges, Sectio ii.]
Bourquelot. Office de la Fête des Fous. Publié par F. Bourquelot,
1858. [Bulletin de la Société archéologique de Sens, vol. vi. Not
consulted at first hand.]
Bower. The Elevation and Procession of the Ceri at Gubbio. By H.
M. Bower, 1897. [F. L. S.]
Brand. Observations on Popular Antiquities, chiefly illustrating the
Origin of our Vulgar Customs, Ceremonies, and Superstitions. By J.
Brand. Enlarged by Sir H. Ellis. 3 vols. 1841-2.
 Brand-Hazlitt. Observations on Popular Antiquities. By J. Brand.
Edited with additions by W. C. Hazlitt. 3 vols. 1870.
Brandl. Quellen des weltlichen Dramas in England vor
Shakespeare. Ein Ergänzungsband zu Dodsley’s Old English Plays.
Herausgegeben von A. Brandl, 1898. [Quellen und Forschungen,
lxxx.]
Brewer. Letters and Papers, Foreign and Domestic, of the Reign
of Henry VIII. Arranged and catalogued by J. S. Brewer [and
afterwards J. Gairdner and R. H. Brodie]. 18 vols. 1862-1902.
[Calendars of State Papers.]
Brooke. The History of Early English Literature: being the History
of English Poetry to the Accession of King Alfred. By S. A. Brooke. 2
vols. 1892.
Brooke, Eng. Lit. English Literature from the Beginning to the
Norman Conquest. By S. A. Brooke, 1898.
Brotanek. Die englischen Maskenspiele. Von R. Brotanek, 1902.
[Wiener Beiträge zur englischen Philologie, xv.]
Brown. Calendar of State Papers and Manuscripts relating to
English Affairs, in the Archives and Collections of Venice and in other
Libraries of North Italy. Edited by H. F. Brown and R. Brown. 10 vols.
1864-1900.
Brylinger. Comoediae et Tragoediae aliquot ex Novo et Vetere
Testamento desumptae. Basileae, Brylinger, 1540.
Burchardus. Burchardi Wormaciencis Ecclesiae Episcopi
Decretorum Libri xx, 1853. [In P. L. cxl.]
Burne-Jackson. Shropshire Folk-lore: A Sheaf of Gleanings. Edited
by C. S. Burne, from the collections of G. F. Jackson, 1883.
Burnet. A History of the Reformation of the Church of England. By
G. Burnet. Edited by N. Pocock. 7 vols. 1865.
Burton. Rushbearing. By A. Burton, 1891.
 Bury-Gibbon. See Gibbon.
Campbell. Materials for a History of the Reign of Henry VII, from
documents in the Public Record Office. By W. Campbell. 2 vols.
1873-7. [R. S. lx.]
Canel. Recherches historiques sur les Fous des Rois de France.
Par A. Canel, 1873.
Captain Cox. See Laneham.
Carmina Burana. See Schmeller.
Caspari. Eine Augustin fälschlich beilegte Homilia de Sacrilegiis.
Herausgegeben von C. P. Caspari, 1886. [Gesellschaft der
Wissenschaften zu Christiania.]
Cassiodorus. Cassiodori Senatoris Variae. Recensuit Theodorus
Mommsen, 1894. [M. G. H. Auctores Antiquissimi, vol. xii.]
Catholicon Anglicum. Catholicon Anglicum: an English-Latin
Wordbook (1483). Edited by S. J. Herrtage, 1881. [C. S. N. S. xxx.]
Cavendish. The Life of Cardinal Wolsey. By J. Cavendish. Edited by
S. W. Singer. 2 vols. 1825.
Chambers. Divine Worship in the Thirteenth and Fourteenth
Centuries, contrasted with the Nineteenth. By J. D. Chambers, 1877.
Champollion-Figeac. See Hilarius.
Chappell. Old English Popular Music. By W. Chappell. A new
edition by H. E. Wooldridge. 2 vols. 1893.
C. H. B. Corpus Scriptorum Historiae Byzantinae. Editio
emendatior, consilio B. G. Niebuhrii instituta, 1828-97.
Chérest. Nouvelles Recherches sur la Fête des Innocents et la
Fête des Fous. Par A. Chérest, 1853. [Bulletin de la Société des
Sciences de l’Yonne, vol. vii.]
Child. The English and Scottish Popular Ballads. Edited by F. J.
Child. 10 vols. 1882-98.
 Christmas Prince. See Higgs.
C. I. C. Corpus Iuris Civilis. Editio altera, 1877-95. [Vol. i contains
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