Mark Graban, Quality Digest Interview (With Transcript)

Dirk Dusharme, Mike Richman, and I talked about:

Thanks to Quality Digest for interviewing me.

Here is a transcript:

Dirk Dusharme: That is the subject of this week’s article from Mark Graban, Lean is about quality, not just speed or efficiency. Mark is also the author of the Shingo award-winning book, Lean Hospitals, Improving Quality, Patient Safety, and Employee Engagement.We’re pleased to have Mark on our show today to talk about Lean and Six Sigma as well as some of the challenges of implementing Lean in a healthcare setting.

Hi, Mark. Welcome to the show.

Mark Graban: Hi, Dirk. Hi, Mike. Thanks for having me on.

Dirk: In your article, you talk about the misunderstanding many people have of Lean versus Six Sigma. In a nutshell, can you just explain the misconceptions?

Mark: That main misunderstanding is this, again, incorrect notion thatLean is somehow only about speed, only about efficiency, only about cost. Then people will tack on that Six Sigma is the only way to improve quality. I think this is just demonstrably false.If you look at the core of Lean and the Toyota Production System, there are two pillars, the idea of improving flow, just in time production. There’s also the idea of quality at the source. Lean actually has many different methods, managerial approaches that are really focused on improving quality.

Mike Richman: Mark, you’re getting into nuts and bolts right away rather than labels. As we always say, what’s in a name? Does it really matter, do you think, what we call a program as long as it works?

Mark: I think that’s not really the issue. If people are going to combine, and I think you can and you should, combine Lean and Six Sigma, I don’t care if you call it Lean Sigma, Six Sigma Plus, Operational Excellence, Process Improvement, PI, CI. That doesn’t matter.I think what does matter is when people say inaccurate things about Lean or TPS. What I’m talking about I think the way I react to that, the equivalent would be a Six Sigma Master Black Belt, I think, would be rightfully annoyed if somebody from a Lean background started saying things about DMAIC that were incorrect or misexplaining multiple regression analysis. To me, that’s the point, not the question of labels.

I would say Lean and Six Sigma are not synonyms. They are complementary practices. They can work together. Six Sigma certainly has different methods and practices to contribute, but I think it’s important to keep in mind, again, Lean is about both flow and quality. Those go very much hand in hand.

Dirk: Just to follow up on that a little bit, many consultants would say that there’s kind of a cultural imperative here, that the words that we choose do matter because it imparts something to the organization.Whether you choose to use Lean, whether you choose to use Six Sigma, what those things mean and the terms that you use. Do you think that’s a valid comment that there are cultural differences that are communicated through those words?

Mark: Sure, I would agree. Words do matter.Even though my book is called Lean Hospitals for a number of reasons including simplicity, I recommend, and I say this in the book, if I were at a hospital system, I wouldn’t necessarily go promoting to everybody that we have a “Lean” program.

I think terms like continuous improvement or performance excellence, or things like that that articulate a goal are something that people maybe are more likely going to get excited about.

The word lean has a lot of negative connotations to it. I even recently heard John Shook from the Lean Enterprise Institute lamenting on stage that if I had been there, part of that team that wrote The Machine That Changed the World, I would have argued for a different name other than Lean.

The word is out there. It’s not always helpful, and that puts us in a situation where we have to explain what is meant by that word. For example, lean is not an acronym for less employees are needed. There’s that perception. We do have to explain what the word means or maybe use words that are less threatening.

Dirk: Mark, let’s talk about that a little bit. This actually gets us into your book. You have released, I believe, the third edition of your Shingo award-winning book, Lean Hospitals, Improving Quality, Patient Safety, and Employee Engagement.I got to tell you my wife is a nurse. She saw the book sitting on the tabletop. She saw the title. She literally sighed, rolled her eyes, and said something like, “Great, lean hospitals. How to pile on more patients while decreasing staff?” Is that a typical response? If so, how do you deal with that perception?

Mark: I think we have to ask why do people react that way. They cross their arms and scowl. They’re hearing about the word. Like I said a minute ago, the word lean doesn’t always properly express the positive nature of what Lean and TPS really brings to people.I’ve seen people react that way to any new initiative brought to them by management. If we ask why, which I think is a good lean habit, why are people reacting that way, a lot of it has nothing to do with lean.

It has to do with an environment where there’s not a lot of trust of their leaders. People are cynical. They’re burnt out. They’re skeptical of all the different new initiatives that have been thrown at them.

I think leaders need to have that discussion and explain this is not about getting rid of people. It’s not about making you work harder. That’s the old approach to healthcare management.

Lean is about engaging people, asking them what gets in the way of them providing ideal patient care. What frustrates them? What are their ideas for improvement? We can’t just say lean is a good thing. We need to demonstrate that.

We can get some quick wins, solve some problems, get people involved. That turns the scowl into smiles. I think we need more smiles in healthcare.

We need to free up time so people can provide better quality care. If being able to see more patients is an end result of reducing waste and making work easier and preventing harm to our patients. Then people do see through practice that lean is a very positive thing for them and their patients.

Dirk: I’m glad you touched on management because one thing I was struck by is in your book, you have a chapter on preventing errors and harm. You give some examples of preventable errors that have led to the death or harm of patients. Some of these were in the news.It’s really sad, obviously, when you hear about the death of a child or something. It’s because of a preventable error that happened in the hospital. It’s sad for the family, but it’s also very often sad for the healthcare workers.

Sometimes, they’re made scapegoats and get prison time for really a problem in the system, a systemic error as opposed to a willful or egregious misconduct on their part. It’s a failure of the system.

Talk a little bit about scapegoating within the healthcare, what problems this actually causes and works against what we’re trying to accomplish.

Mark: That’s unfortunately one of the longstanding problems in the healthcare culture. That’s true not just here in the US. It’s true in other modern major countries around the world. The thing that frustrates me probably the most about healthcare is when we see the same problems, the same failure modes, the same patient harm being repeated over and over in different organizations.The old approach in healthcare, there’s a phrase for this. It’s described as “naming, blaming, and shaming.” That doesn’t solve problems. That doesn’t prevent future harm. It gets in the way of problem solving.

So that’s I think something that’s really important. I would say parallel between the lean approach and what Dr. Deming taught, trying to change that culture.

Dirk: Actually consistently, Deming comes up in all of these topics about…You can’t have a fearful environment whether it’s healthcare or anywhere else. What did you say, naming, blaming, and shaming?

Mark: That’s what we’re trying to get rid of, being more proactive, identifying risks, systemic problems, creating an environment where it’s safe for people to speak up and point out near misses. Here are things that could go wrong so that you can solve the problem in advance to prevent harm.That naming, blaming, shaming culture of fear means people hide and cover up problems. Again, that interferes with quality improvement and process improvement. So that’s what we’re trying to change with lean.

Dirk: Mark Graban, author of Lean Hospitals, thanks for joining us.

Mark: Thank you.

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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an book titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

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