Saturday, July 07, 2012

You don't "do Lean"

If there were a form of medical malpractice lawsuit that I would like to encourage, it would be against those consulting firms that promise hospitals that they will teach them how to "do Lean."  I recently encountered a hospital in which a well known international consulting firm did it this way:  Assemble 25 top level managers for a week-long off-site seminar, teaching them all the Lean terminology and getting them ready to do Lean projects.  Then keep one or two of your consultants in residence for a few months to provide aid and comfort to the managers as they attempt to run rapid improvement events in areas of the hospital chosen by somebody as "high priority" areas needing cost savings.  Then leave behind your "trained" cadre of managers to carry on -- which they cannot or will not do.  Charge the hospital several hundred thousand dollars for this "service."  But not before you have given Lean a bad name and, worse, have caused it to be associated with layoffs (or redundancies, as they say in the UK.)

I'd like to explain all the things wrong with this, but I would just get upset.  Let me provide the simple explanation.  You don't "do Lean."  Lean is not a program.  It is a long-term philosophy of corporate leadership and organization that is based, above all, on respect shown to front-line staff.  There are two essential aspects, training front-line workers to be empowered and encouraged to call out problems on the "factory floor," and training managers to understand that their job is to serve those front-line workers by knowing what is going on on the front lines and responding in real time (when problems are fresh) to the call-outs.  Yes, there are all kinds of methods and tools and terminology, and as Virginia Mason Medical Center's Sarah Patterson notes, "Lean provides a common language for process improvement." She also reminded us, though, that it is a focus on process, not on the outcomes.  The idea is to "build key features into processes that are waste free, continuous flow."  To do this we need to "grow leaders-- to respect, develop, and challenge your people."

I hope that those of you who have been following my commentary about our Lean workshops at Ipswich Hospital NHS Trust will have seen an emphasis on these points.  You will have also seen that we employed on a pedagogical approach that relied heavily on going to gemba.  You cannot teach respect for front-line staff by sticking people in an off-site conference facility for a week.  You cannot teach people to notice the problems in work flows if they are not looking at the work flows.  You cannot teach the principles of incremental improvement and experimentation if you direct managers and staff to spend all their "Lean time" on time-consuming projects in "priority areas."

Jim Craig (seen here shadowing a person during the workshop) told me this story after we were done.  He was walking through a ward and heard a trainee grumbling about something.  He went up to her and said, in a friendly way, "I happen to overhear that you were upset about something.  Would you mind telling me what it was?"  The answer was that, many times per day, the resident would need to print out a form from the computer.  But the ward was a large ward, and the one printer was at the extreme end of the floor.  So, when she was seeing patients at one end of the floor, the resident would have to spend 5 minutes each time walking across the floor and back as she collected the form.  Jim said, "Would it help to have a printer at each end of the floor?"  "Oh, yes," was the reply.  Then and there, he called the IT department to arrange a printer to be delivered.  Result: A very grateful trainee, who will now have more time to be with patients rather than fetching papers.

The Lean aficionados out there are already fidgeting, for they have noticed other potential solutions to this problem.  And they are asking questions like, "What is the form itself, and does its production add value."  Those would be good things to explore.  The lesson, though, is that Jim was at gemba, heard the (unintentional) call-out, responded respectfully, and analyzed and solved the problem while it was fresh.  I give him an A+ for demonstrating what he learned at the workshop.  Well, let's make it an A- so he knows there is always the potential to improve!


Mark Graban said...

Great post, Paul.

I'm not defending the consultants, but there's a complex chicken/egg relationship between what those consultants are selling and what some leaders want.

If leaders are of the mindset that they want a "program" with an ROI focus (and known and perfectly quantifiable ROI, at that), then there are consultants there to provide that (and the consultants likely grew up in that same frame of mind... and then got introduced to Lean tools).

Once we've gotten through this wave of Lean expansion and popularity, many of those efforts (the programmatic "do lean" type) will fade away... self-satisfied executives will proclaim "lean didn't work" here.

But the hospitals who working on culture change and a less programmatic approach will continue their success and their improvement... and the hospitals that failed the first time might see the light that lean isn't just about programs and tools.

Manufacturing went through a few cycles and waves of lean adoption and decline before that broader "lean as a way of thinking" view took root... and it's still far from universal.

e-Patient Dave said...

Yes, yes, yes, yes, yes!

I don't know which sentence in this is my favorite, but it's probably this:

"You cannot teach respect for front-line staff by sticking people in an off-site conference facility for a week."

What expression would you recommend instead of "do lean'?

Paul Levy said...

It might be as simple as "be lean." What do you think?

Anonymous said...

"Live Lean." That's what you do, right?

Unfortunately your post gives me an excuse to point out why doctors often are skeptical about consultants hired by hospital administrators.......

nonlocal MD

@2DaysAMonth said...

Very well written. To me Lean is even simpler (and ultimately more challenging). It is asking your Customer what it is they Value, understanding what they mean, and then evaluating every single thing you do in that light. The hard part with this, as I have learned personally, is one realizes that better than 90% of what you do adds no Value to your customer. But if you can check your ego at the door and get past this soul-crushing realization, the opportunities for improving are limitless.

Marc Rouppe van der Voort said...

I try to encourage people in my hospital to study the lean principles / Toyota Way, reflect on their actions and learn. I tried not to call what they do 'lean', but they started to call it 'doing lean'. My biggest fear is that they stop thinking and reflecting and only use tools or aim for project results. So far so good, but it is a fragile journey and many stimuli to fall back on a classic approach.

Great post by the way

Mark Graban said...

I think my biggest fear is when people who are "doing Lean" starting asking for "the lean solution" that some other "lean hospital" already developed.

To my friend Marc's point, that's when people stop thinking and reflecting...

I often get emails asking if I have some pre-packaged "lean" solution from some other hospital. That draws a polite email back suggesting that the team and the people involved develop their own solution. They might think they are saving time by asking for somebody else's solution, but they are really (even if well intended) short-changing their own learning and improvement.

Paul Levy said...


Anonymous said...

I think the hunger for a 'lean solution' emanates from the fact that anyone in the field can walk into a hospital strange to them, starting talking to the staff and recognize all the same problems we encounter in our own hospital. It is difficult to accept that standardized solutions to what seems to be standard problems cannot just be inserted into the new environment. It is only now that I am realizing that the common problems are rooted in a common (broken) culture in health care. Peter Pronovost's book, although not about Lean, speaks loudly to this cultural root cause, which may be the Higgs boson of health care.

nonlocal MD

Marc Rouppe van der Voort said...

@nonlocal MD: any thoughts on the root causes of the 'common (broken) culture in health care'?

Anonymous said...

It's hard to answer your question in less than a novel, and I am sure that others here can do so better than I, but I think the toxic culture, unfortunately, begins inside physician training and practice. Paul quotes Dr. Brent James in a previous post, which, btw, is excellent (

"The term of art that is usually used to describe the present state – and which Don Berwick so eloquently explained (at least, at the level that an individual physician would experience it) – is “the craft of medicine.” It’s the idea that every physician (or nurse, or technician, or administrator, etc.) is a personal expert, relying primarily on their personal commitment to excellence. In a very real sense, every physician occupies his/her own universe, with its own reality, truths, physical constants."

This attitude is coupled with poorly systematized training ("see one, do one, teach one") and an atmosphere where human mistakes aren't tolerated. Then the nail in the coffin is the current situation whereby physicians practicing in a hospital are an autonomous force. Every hospital administrator I know, and I'm sure Paul would agree, talks about "getting the doctors to go along" as one of their primary obstacles to improvement - or conversely, the doctors want to improve and the administrators are only interested in financial performance.

The Higgs field was described as follows. Doesn't it seem analogous to the toxic culture permeating our entire industry?

".... the Higgs field can be present even in the vacuum, without any particles. As such, it provides a ubiquitous environment through which all elementary particles swim, and so must be an important part of any understanding of their properties."


Marc Rouppe van der Voort said...

@nonlocal MD: thanks, maybe that novel should be written :-)

I appreciate also the way Atul Gawande describes it, for example in this video:

Essentially the same line of thinking as you it seems.

What I'm looking for is: what is the strenght in the DNA of Medicine that we can build on as a new direction to develop health care

Anonymous said...

Marc, I think the strength in the DNA is that everyone in the profession starts out in it wanting to save lives and help people and stays that way, if it isn't beaten out of them by the brutal system. To return to Pronovost's book, he says;

"And once these doctors got it (the patient safety program he was trying to explain), they not only adopted the.....checklist, they embraced {the program} full-on. Doctors are, at the core, scientists. Once they get something, once they understand and believe the science, they are in."

The energy available, once harnessed to move in the right direction, will be mind-boggling. All that is lacking is leadership - to go along with the science, and to change the culture. I think in another generation, if not sooner, we will see these changes.


Anonymous said...

@nonlocal: so, would it be fair to say that 'all' we need to achieve is that doctors aim their energy to save lives and help people at contributing to the effectiveness of the complete care team instead of their individual effectiveness?

Perhaps a starting point should be then to make it visible what the difference is in safety and effectiveness of helping patients when doctors work in (real) teams instead of groups of individuals?

Anonymous said...

Hard data will trump 'visibility'. It is an axiom in medicine that things which seem intuitively obvious may not always be true. In addition, one must keep in mind that if the work occurs in teams, accountability must also fall to the team, not just the physician member of it.


Caitlin Dwyer, MD said...

I am a resident physician in a community hospital in a large urban environment. I, myself, am no expert in “lean,” but I have recently been doing extensive reading on the subject and have been involved in conversations with leaders in our residency organization (Committee of Interns and Residents) and am concerned about the way Lean Six Sigma is being implemented in my institution.

As you discuss, there has been an ‘expert’ in the field hired to teach the system to top level staff, who in turn are implementing new protocols throughout the hospital. I work in the ED, so as such, have a limited view on what is occurring in the rest of the hospital, but from what I view, the larger scale vision of lean is somehow being lost in translation. As your quote from Sarah Patterson suggests, ‘“The idea is to "build key features into processes that are waste free, continuous flow." To do this we need to "grow leaders-- to respect, develop, and challenge your people.”’ As I witness, my institution is attempting to implement the first half of this statement but have lost sight of the latter portion.

The message that is being portrayed is that Lean Six Sigma equals placing patients into ED beds faster (although there is not enough staffing) and eliminating clerical staff viewed as ‘wasteful.’ If any administrator were to ask the staff and physicians that work in the ED each day, they would hear both how important the clerical staff are to the work flow, and also how with increased staffing, how open we would be to immediate, no wait placement of patients into the fast track and urgent care areas of the ED. Simply, the idea that none of the day to day staff are being involved in these workflow decisions, in itself runs opposite the main ideal of ‘lean.’ There is no evidence “growing leaders” or getting to the gemba.

As a resident physician, it excites me to know that the institution I am part of is taking steps to learning ‘lean’ in order to improve the work flow of the hospital. However, it saddens me that the grander ideal is being lost and the staff have no idea what they are missing out on.

Mark Graban said...

I don't see how it would be "lean" to push patients into beds when there's no staffing... unless it's safer and better to be waiting in a bed instead of the waiting room. The Lean ideal would be to have a bed and proper staff available when needed.

To eliminate clerical staff as "wasteful" seems really silly if they contribute to the process. They might not be strictly "value adding" since they don't treat patients, but neither are the directors or the CEO. Are we getting rid of them in the name of lean??

You're right to point out that it's a problem if staff aren't being involved and if people aren't being developed.

A lot of what you describe is what I dubbed "L.A.M.E." (Lean As Mistakenly Executed) since much of it doesn't sound very lean at all.

Isam Osman said...

Hi Paul,
Since your visit the attendees of your Lean workshops have gone off and started to embrace the philosophy of small incremental improvement by listening to those on the 'shop floor 'calling out' problem.That small core of people are going to have lunch together every fortnight to share experiences and Lean successes.I know I have listened to my staff more receptively and applauded them for calling out.I don't always have immediate solutions for their problems but I try.Just today one of our newly formed centralised theatre booking team called out a problem.In the past under the pressures of a busy clinical and managerial practise i might of asked him to make a meeting to see me but after gemba I made the point of listening ,thanking him for raising the problem and was able to solve it for him.At the end his job was easier and our patients benefited.In the past I would have been more focused on my juxta-renal AAA on ICU day two post op.The problem in the UK has been that the Lean philosophy has been used as means to save money and rolled out to clinicians on that basis.Now I didn't go through all that surgical training to focus on cost savings and EBITDA's. If i had wanted that I would have done an MBA.However your visit has shown us that high quality patient care and cost efficiency are not necessarily mutually exclusive.Thanks for that

Anonymous said...

Great story!

I also think a very good lesson is demonstrated by the printer example. Too often, we have suggestions for improvement and are told "wait, XXX is coming and will solve all these problems" - in fact, we are in this cycle right now with SharePoint.

Here's the issue. We've been hearing that for almost 18 months, during which we've managed to get to a SharePoint test site. So in reality, the problem isn't solved, no one knows when or if it will be solved, or if the solution will be so outdated by the time it is fully implemented that it is even worth the effort.

You noted that Jim Craig didn't do what the "Lean aficionados" would have preferred. What he did do, however, was solve the problem, at the time, as it was identified to him. What that means, is that when he comes back around to talk about the form itself, at least a few people are more likely to recall the printer solution and think that he is actually listening. You don't get trust and respect, you earn it - and by his actions, that's exactly what he has done.

While moving to a discussion of the form might have been more "Lean", it would not have changed anything immediately, possibly not ever, and even if a redesign was started that resident - and every other footsore person on that floor - would still have had that long walk to the printer. Solve the little problems, build trust and respect for doing so, and you build community and engagement for tackling the big problems. You also show that big problems are almost always a collection of little problems...

Mark Graban said...

Paul - I'm working on a revised 3rd edition of "Lean Hospitals" and was revisiting the section on Toyota and long-term philosophy, which you mentioned here.

Long-term decision timeframes... there's a good reason that's Principle #1 of "The Toyota Way" and it's probably the Lean concept that's least likely to be adopted by an organization (it's, after all, easier to copy a Lean tool or two).

Do you have an example from your time as CEO of shifting toward longer-term thinking or what you did to try to encourage that in the organization, realizing that it's a difficult change?

Anonymous said...

A process of continuous Failure.

That is my current impression of Lean, tenderly guided by Simpler. Or should we call them "Harder"?
2 years in, our numbers are down, our employee turnover is high, and the overall unspoken rule is, "we are committed to the process".
PCMB boards posted but never used, managers running around from pareto charts, to weekly updates, to their center locations like chickens with their heads cut off.
Standard works written by the Lean team, read by no one, oh wait..... except for when they are being degraded and openly lambasted for having not done so.
Don't ask, don't tell phenomena, our internal Lean team doesn't see any value in doing regular pulse surveys on the staff with regards to their perception of the Lean process so far, yet proclaim themselves champion of listening to the staff and doing things to make their lives easier.
The worst of it is that our leaders have been brainwashed so thoroughly, that their every conversation is lined with a layer of frigid ice, daring someone to say something negative to their face about the process.
The real high moment was just after a Gemba walk, "Tim" Simpler Gemba Coach stated, "I would liquidate them all" due to running into many disengaged and dissatisfied employees.

Fun Times!!

Mark Graban said...


I'm sorry to hear about what you're describing. Intimidating and threatening staff has no place in the Lean movement.

Mark Graban said...

@anonymous -- please contact me via my blog -