How a Non-Lean Culture Can Harm Patients


Sometimes people ask me, “how does Lean apply in a hospital?” The critical issues in a hospital are more often about culture and environment (although using technical lean methods for improving processes and flow are important also).

Many hospitals, unfortunately, have “current state” cultures where people (particularly nurses or technologists) are afraid to speak up in the name of safety or quality. They are often afraid to speak up because they're intimidated by administrators or physicians or surgeons.

If somebody knows something unsafe has happened or is about to happen, they might keep quiet because:

  1. They are too busy to speak up
  2. They are too scared to speak up
  3. Speaking up didn't get anything fixed last time, it just brought them grief, so why bother

This reminds me of my time in the GM factory, circa 1995. There was nothing “lean” about that environment (until we got new leadership).

It's sad that hospitals are often this way. The employees deserve better and patients certainly deserve better.

The Lean approach and the Toyota Way philosophy are very different than this. People are supposed to speak up, to “stop the line” when there is a quality or safety concern. Thankfully some hospitals are working on improving this culture (like Virginia Mason and ThedaCare).

Tracing this back to Deming, employees are supposed to be able to have pride in their work. Not letting them speak up, knowing something bad might happen destroys that. It's also not very customer/patient focused. As Deming said, we have to eliminate fear from the workplace if we want quality, and that includes hospitals. Especially hospitals. It requires leadership. People preaching about “this is what a lean culture should be” won't be enough.

I'm curious to read more about the aviation concept of “Crew Resource Management” and how it is being applied in medicine. Many airline crashes were traced back to a root cause of subordinates not being willing to question or challenge the pilot who was “in command” and infallible. But guess what, pilots (and doctors) are human and therefore fallible. It seems intuitive that applying CRM methods and coaching could potentially help change hospital or O.R. cultures (if people are willing to admit there's a problem with the current culture). Physician, heal thyself, eh?.

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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. I think you’ve oversimplified why people don’t speak up in a hosptial. Like in every workplace there is a always people that intimidate others not to speak. My experience is far from that though. The stakes are very high and people talk every day at rounds, bedside, paging, etc….

    I think a major reason for not “speaking up” it that everyone has there own expertise and are licensed as independant professionals. Surgeons/doctors, nurses, pharmacy, radiology, etc.. the list goes on. It’s impossible to be expert in everything and you can’t just “stop the line” because it’s someone’s life. A friend once said “sometimes the wrong decision is better than no decision at all”. I think the root of not speaking up is the fear that it may cause more harm than good, not that you’re afraid of the backlash. I agree that most clinics and hospitals could lean down considerably and I agree that more respect is needed and helpful. But I think it’s insulting to say that people that are so dedicated wouldn’t speak up because they’re too busy, scared or apathetic. Most care much more than that.

  2. I respectfully disagree Ian, although I’m sure there is a good percentage of people that really care. But there are also others that fear for their jobs or found their opinions were not considered previously.

    The reference to “lean” in the post was also taken wrong. Lean manufacturing does not mean “lean down”. It means a relentless pursuit of the elimination of waste and the creation of the perfect value stream.

  3. Dr. Furst – I don’t think I’m oversimplifying or insulting anyone. I’m not just guessing or supposing… I’m reporting a real situation where those 3 conditions were reported by a nurse (and this isn’t the first hospital where I’ve heard this same sentiment).

    I agree with you that people care, I’m not doubting that. It’s exactly because they do care and they’re afraid to speak up — that’s what makes it sad.

    Is that universally true for every person and every hospital? Of course not, but it’s widespread enough to be a problem, it’s not just me saying that.

    As an MD, if people are intimidated by you and afraid to speak up, you’re probably the last to know.

  4. The headline says “How a Non-Lean Culture Can Harm Patients” (emphasis mine). The key word here is “culture.” As in every industry, the culture of the particular organization establishes the expectations of what is acceptable performance and behavior. Some cultures do not tolerate status quo, instead they strive for continuous improvement; while other cultures strive to maintain status quo. When I speak of a culture “striving” or “tolerating”, I’m really talking about the leadership of the organization, who creates the conditions in which the culture of the organization grows (or dies).

    In Healthcare, as in all other fields, some leaders foster continuous improvement by proactively seeking ways to improve the system, by asking the tough questions, by refusing to settle for “good enough.” The leaders in Healthcare who know how to do these things are the exception, rather than the rule. People like Quint Studer, who know how to make the culture change needed in a healthcare organization, are in demand as consultants and speakers. Why? Because they have a plan that works to change the culture for the better.

    Healthcare leaders in the US will have to learn about the “Lean Culture” to survive in the future. Why? Because insurance reimbursement rates are going to continue to follow Medicare reimbursement’s rates. Less money will be coming in. In order to be profitable and survive the tough economic times, organizations will have to become more efficient and effective, while simultaneously increasing their patients’ perception of care. In short: higher quality and efficiency.

    Healthcare is not a perfect industry: people make mistakes, patients’ conditions will worsen or die. But if we learn from Deming, The Toyota Way, Six Sigma and Lean, we know that we can certainly improve our processes, reduce errors and provide higher quality and customer satisfaction. Getting there won’t be easy for the Healthcare industry in America.

  5. Sorry Mark – I wasn’t trying to imply that you hadn’t observed this or that it doesn’t exist. I’m an Oral Surgeon in Canada and put people to sleep everyday. We have looked at the models from aviation and apply as many lessons as we can absorb and are strong believers in Lean thinking. Still, it’s a personal struggle to create an environment where staff will speak their minds in the face of patient safety. The history of surgeon intimidation in the OR is an especially strong one.

    What I was trying to say (not so eloquently) was that I don’t think that fear is the overriding reason for patient errors. You’re statement “…”current state” cultures where people (particularly nurses or technologists) are afraid to speak…” means, to me, that the prevailing culture is ruled by fear and intimidation and I don’t believe that’s true. Do I agree it exists? Of course. But when you’re faced with constant decisions, none of which is 100% right, which option do you choose? When you need to make many decisions very quickly at what point does constant “cross-checking” interfere and start to harm the patient? I agree that intimidation and the fear to speak is a factor, I just don’t believe it’s the only factor. On the other hand, according to that survey you posted I would be in the majority of surgeons that believe good teamwork exists whereas the nurses and technologists would say no.

    The link you provided to the application of CRM to Healthcare is great and we’ll put it to good use. It’s only through self-analysis like this that practices are going to evolve. Thanks for putting up the blog and sorry if I offended – just trying to add to the debate.



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