Leadership Means Being Aware


The Courier News :: News :: Walter Reed ‘failed'

You may have read or seen reports about the poor conditions for injured soldiers at Walter Reed Hospital in DC. A good summary of the sad tale can be found here.

The article I've linked to looks at some of the management failings in the system.I'll call the military leaders “management” since that's the term we're familiar with in the manufacturing world, as I think there are general leadership lessons that can be learned from this case.

Flayed by lawmakers' criticism, Army leaders said Monday they accept responsibility for substandard conditions at the service's flagship Walter Reed Army Medical Center but also said they hadn't known about most of the problems.

Accepting responsibility is a good thing.Being unaware of bad conditions in your organization is miserable excuse.It's not an excuse, whether you are a plant manager who is “unaware” of unsafe working conditions or products your plant is shipping that do not meet customer quality requirements.Lean teaches us to “go see” (the concept of “genchi genbutsu).

In addition to going to see, we must create an organization that is free of fear, so that problems we do not see (or cannot see) are brought to our attention by those who can see.Deming taught us that we need to eliminate fear in our organizations in order to improve quality.Are your employees afraid that bringing an issue to your attention will get them yelled at or singled out as a “troublemaker?”This human dynamic is seen in manufacturing, healthcare (nurses are afraid to raise issues for fear of retaliation by powerful surgeons), and I would suppose the dynamic is true in military situations with poor leadership.

I assume many leaders are afraid of the lean “genchi genbutsu” concept because they are afraid of what they might see.Seeing problems means that you have an obligation to fix them.How sad that many leaders feel a compulsion to play ostrich and stick their heads in the sand.

“I'm afraid this is just the tip of the iceberg, that when we got out into the field we may find more of this,” said Rep. Tom Davis, R-Va., a member of the House Oversight and Government Reform subcommittee that held the session.

“My question is, where have you been?” Rep. John Tierney, D-Mass., chairman of the panel, asked Army Undersecretary Peter Geren, Army Chief of Staff Gen. Peter Schoomaker and Vice Chief Gen. Richard Cody.

The leaders had their heads in the sand.

VP Dick Cheney promised action and response:

“There will be no excuses, only action,” Cheney told a gathering of the Veterans of Foreign Wars. “And the federal bureaucracy will not slow that action down.”

Unfortunately, I hear different reports from a good college friend who is a physician at Walter Reed.In an email to friends, he wrote, in part:

“The adminstrative oversight review ordered into military medical centers has already in less than 5 days created an additional mountain of beauracratic paperwork, meetings, outside reviews, and productivity reports (think TPS report cover sheets) to be generated by us medical staff. This will further detract from time that could be better spent doing patient care.”

This is not good. When we go to the “gemba” (the actual place) and observe problems, we have to work on fixing the underlying root cause of the problem.We cannot add extra layers of inspection in place of preventing problems from occurring in the first place.Added bureaucracy is a wasteful approach to eliminating waste.

Lawmakers listened as several patients testified with stories of lax or poor treatment at Walter Reed. Staff Sgt. John Daniel Shannon, who lost his left eye and suffered traumatic brain injuries from a rifle wound, said that after he was discharged from Walter Reed, he was given a map of the grounds and eventually found his way to outpatient quarters by wandering around and asking for directions. Then, he says, he “sat in my room for a couple of weeks wondering when someone would contact” him about continuing treatment.

How sad that the leadership wasn't putting themselves in the shoes of their patients, their customers.How sad that traditional management approaches so often win out over lean thinking.Problems are hidden or ignored, and then when they arise, we claim we “didn't know” and add extra waste on top of the waste.We need to do better, for the sake of the soldiers and for the sake of the doctors and other health providers. This isn't a medical problem. This is a leadership problem.

What problems are hiding beneath the surface of YOUR organization?

Please check out my main blog page at www.leanblog.org


What do you think? Please scroll down (or click) to post a comment. Or please share the post with your thoughts on LinkedIn – and follow me or connect with me there.

Did you like this post? Make sure you don't miss a post or podcast — Subscribe to get notified about posts via email daily or weekly.

Check out my latest book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation:

Get New Posts Sent To You

Select list(s):
Previous articleAn Overview of Deming’s Work
Next articleCorrecting a GM Assembly Line Story – Did GM Cars Really Go To “Minor Repair” or “Major Repair?”
Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. No comments? Let me chime in.

    I agree with Mark’s assertion that the conditions at WR were the responsibility of leadership and lack of knowledge is no excuse. Consider the possibility, however, that the leaders in charge were no more or no less competent than the “average” leader.

    The recently fired GOs may have had such large spans of control and such limited time that they did not personally know anything about the current conditions. As Mark says, the key then is to create an organization that is “free of fear” in which people throughout the organization (1)care for the whole and (2)are empowered to make change. We can assume that these conditions do not normally exist in this environment and so the system is not conducive to success. With the average leader’s tenure being only a couple of years, no one person can really change things by him/herself.

    Add the fact that the facility is targeted for closure by 2011 (I think), and you have another factor that may have contributed to failure. It’s another version of the Army’s favorite game – throw the leader into the snakepit and tell him not to get bit!

    Replacing the leaders, unavoidable as it may seem, won’t materially improve the system. The real challenge is to address the underlying root causes as Mark suggests and engineer in the systemic changes that prevent this all from happening in the first place.

  2. Yes, WR is slated for closure, which is probably one reason for financial underinvestment in the facilities. The Army outsourced management to a company with a bad track record (they screwed up ice deliveries after Hurricane Katrina).

    I agree, dumping the leaders is a different form of excuse making. They were probably set up to fail. Everyone is part of a system, including those Army leaders.

    I read today that the oversight committee is going to make “gemba” visits to the other facilities around the country (my word, not theirs).


Please enter your comment!
Please enter your name here

This site uses Akismet to reduce spam. Learn how your comment data is processed.