Lucian Leape Loathes Lean or “L.A.M.E.”?


Noted patient safety expert Dr. Lucian Leape spoke out recently about medical school culture being a root cause of poor quality (see my blog post “Is Medical Education a Systemic Root Cause of Poor Quality?“).

Now, he's criticizing Lean in the publication “Modern Healthcare,” as part of this article “Leape sees potential for change.” (free registration required)

It's not the core of the article, but it has me wondering if he's criticizing generally accepted Lean principles or what I call “L.A.M.E.” — Lean As Misguidedly Executed. L.A.M.E. includes stuff that people call “lean” but isn't a good representation of true Lean mindsets and practices.

Dr. Leape seems to be in a pretty negative mood — although he thinks the patient safety battle can be won, he says healthcare still has a long way to go:

Despite some successes, “I think it's safe to say the patient-safety movement also has been a great failure,” Leape said. “No one to my knowledge has implemented all 34 protocols from the National Quality Forum. Why not? Why isn't that priority No. 1 for all hospitals in America?”

That's a great question — why isn't safety and quality a top priority? The latest American College of Healthcare Executive survey of CEOs found that the percentage who said quality and safety were a “top concern” FELL from 43% to 32%. Keep in mind they are allowed to give MORE than one answer. The survey results:

So protocols aren't being implemented. Lean thinkers would say you should use proven protocols and standardized practices that improve patient care. And CEOs don't list quality/safety as a top concern. Lean thinkers would absolutely say that quality and safety are top concerns. They should be, especially in healthcare.

If you're a hospital CEO and it's really not a top concern, wouldn't it be smart to at least just SAY it is? How hard is that? A friend commented recently that it shows how far off the CEO's radar quality and safety can be. I guess they didn't get the Dr. Deming lesson that quality starts at the top (and with the board).

Now to Dr. Leape's comment on Lean

All that was quoted in the Modern Healthcare piece was this:

…while hospital executives have dithered around with concepts like Lean process improvement, which have “industrialized” the system without regard to care.

“Healthcare has become a production system,” he said. “We think more about nursing ratios than we do about nursing. … I don't think most of us think this is progress.”

Without regard to care? Where is Dr. Leape seeing Lean in practice? Is he speaking from experience or just about what he's heard (or supposes about Lean)?

Lean is all about patient care. Look at the examples like ThedaCare – they've reduced mortality and improved patient outcomes while reducing cost. I've been involved in Lean efforts where the goals (and results) are all about improving patient care — better lab turnaround times or freeing up nurse time for patient care comes to mind (like the NHS “Releasing Time to Care” program works toward).

I guess Dr. Leape hasn't visited or talked with the leaders at St. Elisabeth Hospital in The Netherlands who describe their Lean effort's goals as providing “loving care.

Terms like “industrializing” and “production system” are pretty empty — what exactly does he mean?

As for nursing ratios –   Lean thinkers wouldn't blindly apply benchmarked nursing ratios. We'd look at the process and patient demand/volume and determine the staffing levels and processes that provide the best patient care. So I'm not sure what he's referring to, maybe he was misquoted.

How much “L.A.M.E.” is out there?

So with all of the great examples of Lean improving patient care and creating a better work environment in healthcare, what is Dr. Leape talking about? Has he seen “fake lean” or Lean done badly?

Has he visited hospitals where Lean “experts” follow staff around with stopwatches without engaging the staff in process and quality improvement? Has he seen places that think Lean is only about efficiency, ignoring quality? Has he seen “lean” leaders who blame and punish people who make mistakes? Has he been around a hospital that only does week-long kaizen events with strict cost saving targets that don't try to manage differently? All of those things would be considered “L.A.M.E.”   – not real Lean that focuses on quality and the equally important pillars of continuous improvement and “respect for people.”

There are many out there who see something bad done in the name of Lean and they then make blanket statements about Lean always being bad. I hope Dr. Leape isn't one of them. I really wish I could sit down and talk to him about this. Maybe I'll pursue a podcast with him. I can even walk over to the Harvard Medical School to do it. I really do want to know more of his thoughts, more than a sound bite.

His National Patient Safety Foundation has given awards to Virginia Mason and their Lean efforts. He can't think it's all bad or that Lean is something to avoid. I hope it's just “L.A.M.E.” that Dr. Leape is against. If so, then we're on the same page. We're probably on the same page that executives are “dithering around” and not addressing core issues quickly enough.

Back to the question of “L.A.M.E.” – how much of that and “fake lean” do you think is out there? I'm always on the lookout for it, because stuff like that (Lean done badly or with the wrong mindset) gives Lean a bad name and makes it more difficult for those who are doing things right. I'm fearful of a backlash against Lean because of scattered L.A.M.E.-ness. Is L.A.M.E. becoming more widespread? I've heard some reports of it, but hoped it was isolated cases… what do you think?

John Toussaint is also going to blog about this soon on his ThedaCare Center for Healthcare Value blog, as I know he disagrees with Dr. Leapes assessment of Lean, from his own experience at ThedaCare.

Here is the actual blog post.

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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. The existence of fake Lean is widespread, as we all know. I don’t see any reason why Lean applied to healthcare should be different – meaning, why should healthcare be less prone to fake Lean than any other type of organization? If there is only scattered fake Lean in healthcare, then that would be a great improvement over what usually occurs. The problem, however, is that even scattered fake Lean can still do a lot of damage to Lean itself. Dr. Leape, while likely well-intentioned, is simply falling into the same trap that most people fall in to: they look for evidence to confirm their view that “industrialization” of a business or activity is bad and disregard empirical evidence that shows the successful application of Lean. Progressive management pioneers and practitioners have always had to deal with the problem of confirmation bias. Unfortunately, nobody has found a way to correct this problem quickly and easily. An endorsement of Lean by Hippocrates himself (note, a progressive physician) would not be sufficient to convince many physicians to learn and practice Lean management.

  2. Mark,

    I think an interview with Dr. Leape would go a long way to help educate healthcare professionals about what lean thinking really is. I wish you good luck with that and I look forward to the podcast.

    I know you are a fan of Dr. Deming and I am reminded of something he said on more than one occasion: “No one does you more harm than a hack”. He was referring to people to provide advice without knowledge. He would probably also describe the phenomenon of L.A.M.E as an example of “rule 4 of the funnel”, where he pointed out the hazards of “worker training worker”. In this instance, there are people who observe one or more aspects of lean thinking (usually a tool or technique without the theory behind it) and then teach and show someone else. They, in turn, teach others. And it’s “off to the milky way!”

    .-= Mike Stoecklein ´s last blog ..Fire the Bottom Ten Percent =-.

  3. The real failure lies within the medical profession itself. I used to work in aircraft heavy maintenance industry. Employees rarely had any education past high school and many performed complex operations exceeding what most physicians come across on a daily basis. During my 10 plus years there we never caused a failure resulting in a fatality or lost aircraft. Why? A culture of respect for process was in place. Everyone knew the success of organization, the potential loss of $100M aircraft, and hundreds of lives depended on respecting the process.

    Catastrophic failures are still perceived as inevitable in providing healthcare and part of the cost of doing business.

    If every sentinel event in a hospital was posted in the local newspaper and employees were provided with whistleblower protection things would change overnight.

  4. First of all, love the “L.A.M.E.” acronym. Unfortunately, I think L.A.M.E is on the rise as more and more people want to get on the Lean boat but are trying to take shortcuts and/or slap the Lean label on something else.

    Ran across a similar reference in Canada recently, as published in Le Devoir, a French-language paper in Quebec on March 24: “The Toyota method of using automobile assembly line techniques to improve health care efficiency is ‘catastrophic’ according to a sociologist at the University of Quebec who did a study of the workplace at the local area network in Ahuntsic and Montreal North. Professor Angelo Soares found four of 10 employees posted high levels of psychological stress, and over half felt a disconnect between their values and those of management.” The full article is actually about poor management and makes weak and misleading stretches to trying to run hospitals like assembly lines and seems to me it brings up Toyota in a move to tie into the recent bad press. Reads less like a valid study or news item and more like a political attack at the ministry that has been promoting Lean methods for years as part of addressing rising healthcare costs. Assuming that his intention was to bring the staff satisfaction issues to light, this is clearly another case of “L.A.M.E.” being the problem and not Lean or the Toyota System.

  5. Mark ,as I indicated on my blog today there are many failed or poor lean implementation attempts in healthcare. If organizations do not improve quality,lower cost,and improve staff moral all at the same time they are not doing it right(the implementation). It is easy for people not familiar with lean to to be pursuaded by one of these L.A.M.E. people. My guess is Dr. Leape was influenced by such a person.

  6. Lewis – hey, good to see you commenting here. Thanks for sharing the story about the professor. There’s certainly plenty of “L.A.M.E.” – for example, I heard the other day from somebody at a hospital where it’s all about draconian cost-cutting targets. And they don’t understand why the staff aren’t excited about Lean. Go figure.

    There’s L.A.M.E. and then there’s those who are biased against Lean and will frame anything they ever hear about in a “Lean sucks” approach, i.e. the “Labor Notes” blog that’s constantly ripping Lean. There’s a union agenda that they’re pushing above any measured analysis — “Lean is bad” suits their agenda. But we all know there are environments where the union is a partner in Lean, with management, and that it’s good for the company, customers, and employees alike.

    Likewise, I try to be cautious that I don’t have a mindless “Lean is always good” mindset. There’s a difference between the principles (which I think are unequivocally good) and the way people or organizations can implement them (which can be good or bad, or “L.A.M.E.”
    .-= Mark Graban ´s last blog ..What Makes You Want to Do Better? =-.


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