Notes from Dr. Brent James at the Shingo Prize, Part 2 – Comments on Lean
One of the more interesting things that Dr. James said was something he prefaced as saying it would be a criticism of Lean. Dr. James seems generally very supportive of Lean and TPS as a helpful force in healthcare, but he has reasonable criticisms — criticisms not of “lean” itself but of “lean as commonly practiced in this country.”
In Dr. James' view, Lean has three pillars:
- Flow & standardized work
- 100% participation
- Mass customization
James' criticism is when only the first pillar is emphasized. Focusing on flow with out staff engagement and flexibility does sound more like “L.A.M.E.” (Lean as Misguidedly Executed) than real Lean.
For what it's worth, I encouraged Dr. James to repeat that criticism as loudly and as often as he could, since it's not a criticism of true Lean, it's a criticism of how it's often practiced. “Fake lean” or “L.A.M.E.” helps nobody and it gets in the way (due to bad reputation) of those trying to do it the right way.
I'd actually create two different “3-legged stools.” One would have Lean healthcare focused on:
- Quality / Safety
- Flow / Access
- Cost (for patients/payers/providers)
With benefits going to a balance of:
- Healthcare Organizations
Whether using my constructs or Dr. James', I'm in full agreement that focusing only on flow or only on efficiency is not Lean. I've complained before when some people say that Lean is about flow and Six Sigma is about quality. No. The Toyota Production System has always been built on flow/just-in-time AND quality at the source. There's no denying that Lean is about both flow and quality. Or it should be, unless you misunderstand it or have been taught badly.
Dr. James is also correct to point out, basically, that we also need a balance between the two pillars of the Toyota Way — continuous improvement AND “respect for people,” as shown below.
Dr. James told a story of a major “Lean hospital” that had a number of doctors quit because they felt like “respect for people” was missing (my explanation of it). Dr. James told of doctors being followed around with stopwatches — that fell short of true 100% participation as he referred to it. The “efficiency experts” took away the doctors' chairs because they would be able to chart more efficiently without having to get up and down. This was done TO them. Argh.
Getting sidetracked again a bit from Dr. James' comments, there's a similar theme that I wrote about in a piece co-authored for the (I think) July/August Journal of Hospital Medicine. There were two pieces written by people at academic medical centers describing their “Lean” process and elements of it sounded exactly like what Dr. James was warning against – they were ignoring respect for people. The one hospital wrote about, guess what, following hospitalists with stopwatches and even timing or making note of how long they were in the bathroom. To that, I think, “Are you TRYING to make people mad???”
In the JHM piece, my co-author (from Northwestern Memorial Hospital) and I asked are you treating the hospitalists like “Subjects or Scientists“?? It's wrong to treat people like the subject in a science experiment, just following them and not engaging them in the process of identifying waste. That's very “Taylorist” to just follow with a clipboard. That situation seemed very low on the respect for people scale. You need to treat everyone like a scientist, allowing them to participate fully in the PDCA cycle related to their own work.
Dr. James, again with his roots working with Dr. Deming, talked also about how he has been through every possible improvement methodology that's been thrown at him, including
- Total Quality Management (TQM)
- Motorola-style Six Sigma (not meeting his 100% participation goal)
- Alcoa-style TPS (Toyota Production System)
- GE-style Six Sigma
- Now, a more Toyota-style Lean approach
As many complain about, Dr. James says that this new program mentality is often the fault of consultants repackaging things as something new to sell. In these different efforts, they:
Usually emphasized tools, and sometimes new tools, to roll out the new method.
The focus on tools is not a problem unique to Lean. Nor is it unique to try to “roll out” these methods in a very top-down command-and-control way (a way that usually does not show respect for people). Dr. James emphasized:
You can't manage doctors through command-and-control.
But, you really shouldn't manage anyone that way. Again, what Dr. James says he sees a lot of in “lean as commonly practiced today” is a bad Taylor-ist form, we can't take that approach (again, I'd call that L.A.M.E.)
Why do people, across industries, tend to fall into this Taylorist command-and-control approach? Dr. James said:
It's basic human nature… your God-like power to control others…
I've never heard it put that way…. it makes a lot of sense that people would be attracted by that sort of “power” over others. So when we ask why people won't give up that control to have a Lean culture, we're fighting human nature? You can, unfortunately, take any tools (Lean or Six Sigma) and throw them into a command-and-control culture. And you're likely to not get real sustainable results for the long-term. Dr. Stephen Covey has been saying the same things about how command-and-control is the wrong approach. Dr. Deming was teaching that decades ago, why aren't people listening??
I might have a Part 3, I still have some others notes where Dr. James was talking about Lean, standardized work, mass customization, and how to get doctors engaged in quality improvement.