Guest Post: Lean Lessons from the Non Profit World


Mark's note: I consider myself very fortunate to have met Patrick Anderson during my journeys in the Lean world. Patrick is the executive director of Chugachmiut, a non-profit corporation to advance the overall economic, social and cultural development of the people of the Chugach Region of Alaska.

Patrick has previously been a Podcast guest, in Episodes #53 and #71 and he wrote a guest piece back in January about CEOs and kaizen. A long-time student of Dr. Deming's philosophy, I am happy to have Patrick share more of the Chugachmiut story, particularly their healthcare work. Patrick is also, coincidentally, the second lawyer of my guest blogging group. Now here's his post:

Lean Lessons from the Non Profit World

As a non-profit organization, Chugachmiut has been pioneering lean management in both rural healthcare delivery and numerous other non-profit activities. Please visit our website ( to see what we do for the seven Alaska Native Tribe we serve. My Lean in Alaska blog is linked through our website.   In addition, I spoke with Mark on a podcast in two parts where I explained come of our lean journey.

As a healthcare provider, I thought I would explain how we are using the tools of lean to try and implement a prevention and restoration to health strategic initiative. Our board of directors met on May 27-28, 2010 and adopted the strategy. The interesting part of the story is how the tools of lean informed us as we began to visualize what might be possible.

Chugachmiut has implemented what we call our “No Blame, No Shame” culture. Problems are treasures, defects are to be identified and fixed, and our employees serve as the engine of continuous improvement. We recognize that processes are the source of almost all defects encountered in the workplace. Our goal is to teach our employees how to recognize defects, stop, and fix them as close to the source as possible. Some of the tools we use are the 5 Whys, Root Cause Analysis, PDCA and the A-3.

Our greatest lean tool is, I believe, visualization, particularly the future state. The future state I have been talking to my employees about goes something like this: “I want to see happy, healthy tribal members, well educated and well trained, able to survive anywhere in the world, but wanting to live in our homeland.”

Believe it or not, we have found that the same tools apply when trying to look at why our patients develop chronic health conditions, and begin to rely heavily on medications to control their diseases. This is not a problem unique to Chugachmiut. The national health care debate fully recognizes that our country must get a handle on chronic disease if we are to avoid huge expenditures for health care in the future.

As I thought about what might be among the various causal factors for developing a chronic health condition, I realized that I was subconsciously using the 5 Whys to guide my thinking. Some chronic diseases have obesity as a causal factor. Obesity can be caused by overeating the wrong foods and failing to exercise. Overeating and failure to exercise can be caused by lots of reasons, but depression seems to be one source of overeating. How can we impact overeating behaviors on the part of our patients? How can be get them to exercise? Why? Why? Why?

As I talked to others about chronic disease and its root causes, one individual mentioned the research completed by Dr. Vincent Fellitti of Kaiser Permanente in California and Dr. Robert Anda of the Centers for Disease Control. The study is referred to as the Adverse Childhood Experiences Study, or ACES. ( Something in my mind revved on all 8 cylinders. Am I looking at the root cause of the risky behaviors we see in many of our patients who develop chronic disease? This question sent us on a research project to seek the answer to this question.

We believe the answer is yes. The influence of childhood trauma inflicted by one or more of the 10 adverse experiences studied seems to lead to a remarkable use of what we see as risky behaviors by patients to address their own issues. As their traumatized childhood brains encounter stresses of different kinds, their neurobiological development is affected. Tolerance to certain brain chemicals appear to lead to a need for increased production of those chemicals. Risky behaviors such as smoking, overeating, drug and alcohol abuse, violent behaviors and promiscuity seem to increase production of the tolerated chemicals. Eventually more and more are needed so the behaviors increase.

We presented our research to our board of directors and they have agreed with our approach. Now we need to design the experiences (PDSA) that we will try out in our restoration to health strategy. We are documenting the strategies using A-3s.

Our first challenge is to communicate with our patients   about the strategy and how it was developed. We are studying the theories of community readiness and motivational interviewing to help guide us in our communication efforts. Then we need to build support for the initiative, and want to invite the assistance of our patients in designing the programs we need to assist them in addressing the root cause of their chronic   conditions. Ultimately, we will need to deliver the programs. When we do, we will use the tools of lean management to try to deliver the most effective programs we can, and we will be ever mindful that our programs need to be guided by what is most effective for each patient.

When Chugachmiut started its lean journey, we had only hopes of maximizing our limited resources. That our lean culture provided a method for us to help visualize a future of good health and happiness is an incredible bonus. Having the tools of lean available to help us address what we believe is is root cause is a tremendous help.

Patrick M. Anderson
Executive Director
Chugachmiut, Inc.


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Mark Graban is an internationally-recognized consultant, author, and professional speaker who has worked in healthcare, manufacturing, and startups. His latest book is Measures of Success: React Less, Lead Better, Improve More. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. He also published the anthology Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also a Senior Advisor to the technology company KaiNexus.

  1. […] Guest Post at Today Mark Graban posted a guest blog I wrote for him when he was planning a long deserved vacation. In it I discuss how lean tools have guided my thinking about strategic issues such as the source of our increase in chronic health conditions. Take a look at: […]

  2. Ankit Patel says

    This is really interesting and I’m actually working with a non-Profit here in Nashville called Community Nashville that there mission is “to create a community that does not tolerate racism, bias, and bigotry.” Not an easy thing mind you but in the strategy session with the board members I asked the question how do we know if what we are doing is working? Surprisingly no one really knew so we had to go do some research and talk to some social psychologist on some good metrics and what will move those metrics.

    Defining the customer was also very interesting because you have don’t have just end customers. The customers would be who the charity serves but there are also the donors and the volunteers. I really enjoy working with non-profits because it’s different and has it own unique challenges.

    I’m curious as to how you got to the “No Blame No Shame” culture. What did you do to get the group to that point?

  3. […] to Health Root Cause Analysis As a guest blogger at Mark Graban’s, I spoke about how the tools of lean, particularly the 5 Whys and Root Cause Analysis, are guiding […]

  4. Mark Graban says

    I recently was introduced to “motivational interviewing,” as mentioned by Patrick in this post. I didn’t understand the context at the time, that it’s a formal methodology for helping those with addictions. It applies really well in the workplace, for those who are “addicted” to old management behaviors.

    My first post on this:

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