Lean is Not Sustainable, Except When It Is


What top-performing EDs do – Hospitals & Health Networks

I was really, Really, REALLY puzzled by the first line in this article, that read:

“Lean, Six Sigma and Toyota Production System applications have simply not proven sustainable in health care. While a number of stand-alone projects dot the case study landscape, only a few can point to strategic impact beyond 18 months.”

Strangely enough, this is written by Lean authors and Lean consultants.

That first sentence must be a typo or some bad editing, as the authors then go on the spell out six ways that sustainability can be increased.

I know, first hand, that Lean efforts are being sustained in many hospitals. Yes, sustainability is difficult and some hospital efforts fade away due to factors including a change in hospital or department leadership. Sometimes Lean dies because it was only focused on eliminating waste and it ignored the “respect for people” side of Lean.

What are you doing to help increase your hospital's chances of sustaining Lean? Are you thinking about this from the start?

When in the The Netherlands back in June, I asked a hospital CFO what his best accomplishment was in their Lean efforts. He answered, “Making sure Lean won't die when my future replacement takes over.”

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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. Seems like a flawed logic. The sites that approach TPS/Lean as a series of "stand-alone projects" by definition aren't aimed at sustainable strategic impact beyond 18 months. No small wonder that the impacts aren't present.

  2. Anon – good point. I've worked with clients where we had a "project" that was a defined period of work with the intent of it transitioning into a "management system" and "way of working every day" beyond the formal project period.

    Some clients hated the word "project" because you're right, that indicates an "end" and Lean is not something you "complete."

  3. For what it's worth, I recently took a government official to visit a hospital I had previously written about in "Lean as a learning system in hospital wards". The question was sustainability and as I had not been back to that hospital since 2004, this was quite an interesting test of concept.
    It turned out they still follow rigorously their patient incident rate, and do a systematic analysis (patient incidents were low enough to impress the Modernization Agency guy), and most of the tools they'd implemented are still up and being used. True they have not developed new tools, but that's a bit of a tall order.

    In terms of the lead article, all we ever did in that place was training in the form of two days every two months with the nursing manager team in the wards, where they learned "self-study" exercises they had to practice in the interim period to improve the performance of their wards. Four years later, they were still regularly conducting these exercises and improving or fixing processes.

    I have no idea whether lean is sustainable in healthcare in general, or whether this is an unusually smart and committed team, but it's quite rare to have the chance to go back after and see after such a long time span, so I thought it could be a point in case.


  4. One of my best clients is a hospital that started with Lean in their laboratory about 3 years ago. I have visited recently and they are:

    1) Still using the new "lean process"
    2) Still measuring performance daily (something that was new to them)
    3) Keeping up on (and expanding) use of their kanban system and other "lean tools"

    More importantly:

    4) They have expanded lean methods into other parts of the lab (on their own)

    5) They are making a more formal effort to get and implement employee ideas (following the David Mann method from "Creating a Lean Culture" and my book "Lean Hospitals"

    6) The director and her manager have learned that "lean is a new way of thinking" — they continue learning and experimenting and trying new things. They wouldn't go back (couldn't go back) to the old way.

    Are they "perfect"? No, but they have sustained and continued to improve and I'm very proud of them.

  5. From LEI:

    “Lean tools are important, but they can’t deliver sustainable results – and often can’t achieve any results . . .”

    In service organization can benefit from a change of thinking about the design and management of work. This just isn’t getting addressed in the US, all top-down, command and control style. This has to change first.

  6. Tripp, I agree with you strongly that command-and-control is bad. To say this is the “US” style is generally true, but not always. Thankfully, a number of U.S. healthcare organizations (including ThedaCare and others) are working on changing away from c-and-c to a true lean leadership model.

    You don’t change that management model overnight, though, do you?

    What bothers me is that you’re seemingly obsessed with dragging LEI into every discussion and making that organization the root of all evil in the lean world.

  7. Mark-

    I said this before. I attended LEI workshops that promoted tools. We walked through a tool-laced exercise. I even took the instructor to the airport. I questioned him about his teaching tools and that there was more to it than that. His response was that this is what fills the workshops.

    Somebody approved the curriculum and somebody promoted it. Lots of people left that day thinking they understood how to improve, they didn’t understand anything. I was disappointed and still am.

    I saw Deming’s teachings get hijacked this way with TQM and everyone knew the answer . . . they knew nothing.


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