L.A.M.E.: Not Involving Key Stakeholders


    Got this story during an email exchange, used with express permission:


    I saw my doctor yesterday and told him I was doing a lean publication, and he immediately started complaining about well-intended but impractical top-down measures being taken in the name of lean, there at [major university] Health System. Interesting.

    The example he gave me was a new form for requesting a test from the radiology lab. He pulled out both the old and new forms for me: the old form was short, with two spaces on it: one for the physician write in the name of the test he or she wants done, and a second space to write the reason for the test. The new form is physically much larger and ostensibly lists all the relevant tests; the physician just checks off the one needed. However, none of the choices include nuclear medicine-related tests, and there is no choice of “other,” where such a test could be written in. (I'm not familiar with the terminology.)

    When asked why those tests were not included, the response was that the form would be too complicated. So, from my doctor's point of view, a form that was simple at his end, and that allowed him to name whatever tests he needed, including the nuclear medicine tests, has been replaced with a form that is less flexible. Because, he opined, some small group at the main hospital decided that the new form would be an improvement. Obviously, this isn't how lean is supposed to work: my doc feels totally disconnected from the process of making improvements and feels imposed upon from above. The whole exchange between my doctor and I on this was probably under two minutes: the main topic was rotator cuff tendinitis.


    This is a shame. Lean improvements aren't something that should be imposed “top down.” We have to work to get input from those actually working in the system. Experts can't be expected to design perfect processes or Standard Work the first time through, without input from people. This is true if it's assembly workers, medical technologists, or physicians. The newly designed form should have been considered a “first draft” that should have then accepted input from the doctors. If the form needed an “other” category, that input should have been accepted, it seems reasonable enough. It seems like an important item was left out in the name of standardization and intended improvement.

    It's a shame that some hospitals are making the same mistakes that some factories made — having “Lean” improvements antagonize the value-added workers instead of being something that helps them do their jobs in an easier way. If Lean isn't helping people, it ‘s going to give Lean a bad name and it might just be Lean As Mistakenly Executed.

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    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. This may be an example of Standard Work in the sense of a ‘catch-all’ form not being the best solution. The old form sounds like it was able to deal with the variety of demand i.e. the same simple form can be used to request the full range of tests. By trying to standardise to a checklist you will inevitably have to miss some options and use our old friend the ‘other’ box.
      The risk of this approach is because different doctors know the same tests by different names they all end up picking the ‘other’ box, meaning interpretation at the lab is still required and making the time spent redesigning the form a waste.
      You need to strike a balance between standardising where that makes sense but also allowing the system to deal with variety in demand.

    2. Your doc feels disconnected. Does this mean that every employee should be involved in the improvement process for everything they touch?

      If there is 100 doctors in the system do all of them need to get involved in the new checklist form? Seems like waste to me.

    3. It’s probably not practical to involve all 100 in great detail, but it’s a good goal to at least let all of them have a chance to review a process that they’re going to work with. Missing an “other” category seems like something that just about any of the doctors would have caught and commented on. So, in this case, it seems more like ZERO doctors might have been talked to instead of 100. Maybe the people who pushed the new form out should have at least talked with a small group as a starting point.

      Saying it is “waste” to get input from people doesn’t sound very Lean to me. That sounds like the “I’m expert and can’t be bothered with getting input from people” approach.

    4. Even if the doc didn’t get input at first, it’s too bad he seems powerless to give feedback to a PDCA cycle or continuous improvement process. Does he know how to make a suggestion for improvement?

    5. I didn’t mean to imply that getting input was waste, rather how can you get input from everybody. If you asked 100 doctors what it should look like you will get many different answers.

      I guess the broader question is how do you get everyone’s input or involvement? Is that the goal?

      Or is it more about the idea that people don’t like change, or don’t like to be told what to do?

      Because remember doctors don’t have ego’s right?

    6. People don’t like to be told what to do, I’ll grant that. That’s why you need to get input.

      Again, I wasn’t involved in this situation with the doctor, but I don’t think the issue was something superficial. It sounded like there was a legitimate deficiency in the new form. People don’t like having something “improved” in a way that doesn’t meet their needs.

      Here’s what I would do to get involvement:

      1) Have a small group design the new form, including and MD and the lab
      2) Circulate the form draft to get feedback over the period of a week
      3) Pilot the new form but have a mechanism to get feedback from the users

      You can get input without having to have a large group meeting with all 100 MD’s in the room at the same time. I don’t think it’s that hard to get input from people.


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