Wednesday, May 26, 2010

Is Lean persistent?

As you have seen in examples below, BIDMC is engaged in adopting the Lean philosophy to enhance our effectiveness in taking care of patients. An underlying premise of Lean is a respectful work environment for our staff, valuing each person and empowering him/her to call out problems and participate in improving things.

This approach raises a question, though. What leadership characteristics are appropriate to support the approach that characterizes a Lean company?

Yesterday, Gene Lindsey (CEO of Atrius Health) and I shared a podium in a session for human resource professionals, and he drew on the work of Robert Greenleaf to offer his view. Greenleaf set forth the concept of "servant leadership." Here's an excerpt:

"The servant-leader is servant first… It begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead. That person is sharply different from one who is leader first... The difference manifests itself in the care taken by the servant-first to make sure that other people’s highest priority needs are being served. The best test, and difficult to administer, is: Do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants?

Coincidentally, this kind of approach was recently reflected to a group of our senior leaders by Mike Hoseus, Executive Director of the Center for Quality People and Organizations. (Mike is the co-author of Toyota Culture.) He presented an inverted organizational pyramid. Instead of the usual pyramid showing the CEO atop, this one shows the CEO at the bottom, followed by the vice presidents, senior managers, and group leaders. At the very top are the suppliers, team members, and customers. Nonetheless, without the energy and commitment of the CEO to the Lean endeavor, it will fail.

An audience participant at yesterday's HR session skeptically raised the question of the sustainability of the Lean approach in a corporate setting. Citing previous management fads like re-engineering, six sigma, and the like, what assurance is there that the lessons of Lean will take hold and persist beyond the term of a given CEO? We answered that there is no concrete assurance. Each CEO employs his or her own management philosophy.

But I have a feeling that, properly implemented, Lean is remarkably subversive in this respect: Once you teach staff to be "wiser, freer, more autonomous," a successor CEO is going to find it pretty hard to undo those characteristics. Indeed, a Board of Directors would find itself compelled to search out candidates who have a similar underlying philosophy.

This is not to say that there is an inevitable persistence to the use of Lean in an organization. Like physical systems in which entropy takes over, consistently applied energy is necessary to maintain the process improvement system that we call Lean.


Jane Sherwin said...

Paul as an admirer of Lean for health care I appreciate your addressing it in the context of leadership as service and empowerment. Remarkable how a tool that started as a way to reduce manufacturing inefficiencies can be so closely tied to cultural change.

Medical Quack said...

I think finding balance is tough these days as there are so many more factors that appear that need attention than we had in days past.

In California, we have a battle that has erupted over "lean" here with a lawsuit filed by the City of Hope against there own doctors which could stand to set a precedence of how physicians and management work together in the future here and the doctors claim patient care will suffer. It's a long entangled mess of course, but long and short of it is money when it gets down the bottom of the barrel, like everything else.

The City of Hope also provides a very active research area with Cancer and of course is just about known nationwide for what they do. The medical group put out a press release which I posted a couple days ago stating their lack of faith in how contracts are being handled at the facility.

Anonymous said...

Skeptic must have previously worked at my hospital system. (:
From my failed experience, I believe the CEO must be consistently relentless at driving and cheerleading the transformation, from the bottom up, imbuing the upper layers of the pyramid with the tenacity to persist through the inevitable difficulties with achieving buy in and implementation.

This takes, above all else, absolute passion. The nanosecond that the staff perceives a weakening of the CEO's commitment, entropy sets in; because this is very hard work. Lip service, delegation of support, and passive attendance at meetings just simply do not cut it.

This is a huge commitment for a CEO and is why there are so few nationally known for it, such as Paul, Brent James, Gary Kaplan, and a few others. Only time will tell if their successes will survive their tenure; this will be an important piece of evidence.

nonlocal MD

Jimmy said...

Sounds like you're starting to understand what an undertaking a Lean transformation can be. Getting the staff engaged at the start, in my experience, is the easy part. Keeping the management team engaged throughout...not as easy. In my opinion, you're right, though, to focus on the mentality of leadership rather than the tools (observation, value stream maps, A3's, etc.) as you move forward. Anyone can learn the tools of Lean, but becoming a servant culture as you call it, is the more challenging and rewarding part. Good luck.

Jimmy Udall

Anonymous said...

Flattening of salary structure as a mark of return to financial sanity and recognition of common enterprise with all employees. This must be a cultural transformation across industries. A few gallant souls ain't gonna do it. This is not at all a knock on you or other CEOs; just a statement about the hideous imbalances that have grown over the last 50 years in most sectors.

The Chocolate Factory is always going to change hands. But the wise new CEO will understand that the Oompa-Loompas were there before him or her and will be there long after!

Mark Graban said...

I can't figure out what The Medical Quack's link and that lawsuit has to do with "Lean"...

Maureen said...

Just left Dr. Pattry Gabow, the CEO at Denver Health, who has been a leader in using lean to rid processes of waste, and she told me that DH has reached $50M of waste reduced over the last five years. I think she'd say it works with a persistant leadership focus and the great staff at the front line!

Er Ralston said...

Many years ago, Joseph Juran defined the "nondelegable" roles of upper managers. These roles apply to any type of improvement initiative, whether it is lean, six sigma or whatever. These roles still hold true today. When the leaders do their part, breakthrough improvements in performance can be achieved and sustained.

Mark Graban said...

That's great about Denver Health, but I'd hate for anyone to get the idea that lean is only about money or cost savings.

I'm sure that Denver Health has had positive results in other elements like safety, quality, patient access, and staff morale.

That's certainly the case at ThedaCare and other leading lean hospitals -- a balanced set of improvement measures, not just cost or ROI.

Lean isn't traditional cost cutting. Lean is quality improvement that leads to bottom line savings. There's actually a big difference even if that sounds like the same thing...

Anonymous said...


As I read more links about the City of Hope debacle, I believe Medical Quack is trying to say it's a poster child for how difficult close cooperation/integration between hospital administrations and physicians will be, going forward. Of course physicians must be an integral part of any Lean initiatives, as they are an indispensable part of the teams. If, however, they see this as imposed on them by administration, their buy-in will never be achieved and any PI efforts will fail.
This is why, as Paul has said in other forums, having at least one passionate physician champion along with the CEO is critical to bringing along the medical staff.

nonlocal MD

laura said...

Lean is an upside down approach to leadership for sure, at least that was its original design. The ways in which these ideas have been taken up in the US corporate (and healthcare) contexts have of course, led to certain cultured appropriations and misappropriations. It is about cultural change, more so than process or design change, and unless those central principles for flow, quality and respect for people are adhered to, we will end up with contract struggles, leadership frailty etc. I follow Mark in that I wish there was more talk of the intangible goods that come from such a shift such as morale, satisfaction, care, wellbeing, pride etc...