LeanBlog Podcast #86 – David Sundahl, PhD, “Adaptive Design” and Lean in Healthcare


Episode #86 is a conversation with David Lawrence Sundahl, PhD, Managing Director of Rule 4 Consulting. They are a firm that works with healthcare providers to drive improvements using Lean and what they call “Adaptive Design” methodologies. Sundahl was a contemporary of Steven Spear at the Harvard Business School and also worked with Dr. John Kenagy, author of the book Designed to Adapt: Leading Healthcare in Challenging Times.

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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. Interesting gig and an important contribution. An understanding of the rules and capabilities that Spear teased out in his study of Toyota and other organizations gives a real boost to learning and teaching lean, and the rule of improvement is no exception. I have a beef with Rule 4 the way it appears in the HBR and on this podcast, though. I was really uncomfortable presenting Rule 4 to frontline employees until I changed the language from “at the lowest possible level of the organization” to “as close as possible to the front line”.

    We put some effort into drawing inverted pyramids to show leaders working for and supporting the next level of the organization and we talk about servant leadership. I think the language of our core lessons (among which I count the rules and capabilities) should reflect that understanding. Maybe it’s just “lean political correctness” gone mad, but I bend over backwards to avoid the language of traditional hierarchy. I’m not “over” anybody. I support the functional managers in the next layer closer to the front line.

    I use the four rules (and the four capabilities) in teaching all the time, hanging them on the wall in large fonts on 11 x 17 paper as points of reference, but until we made this change it didn’t feel quite right.


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