How Many Hospitals Have Quit Lean Efforts?


I was asked a really good question today, a simple question that probably has a complex answer:

How many hospitals have gotten discouraged and quit their Lean efforts?

It's a simple question that doesn't have a simple answer. OK, maybe the answer is “17.” I don't know.

The question is a corollary to the question of   How many hospitals are implementing Lean?

Answering either question requires to start with “Well, it depends what you mean by…”

What do you mean by “implementing Lean?” To one hospital, they might mean they're dabbling with training people across many departments in just one tool. That's not a very robust or holistic approach. “Implementing Lean” might also mean that you are trying to transform the culture and management system through years of improvement efforts, education, leadership, and hard work (like ThedaCare, Group Health and others).

Looking at the quit side of the question – again, what do you mean by “Lean efforts?”

If a hospital was just dabbling with 5S or kanban systems in a department or two, they weren't like to see transformational change or huge quality improvements or cost savings. If they “quit” that, you could ask “did they ever get started?”

I guess these questions (the “how many”) are interesting to researchers who are looking at broader trends. But, tell me, for YOUR hospital, does it matter one bit what the answer to either question is? Are you starting or stopping Lean efforts because of a bandwagon effect or because you know or believe Lean works when you really go at it with dedication and the right perspective?

How would you answer the “how many” questions?

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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. There are also very different versions of quitting. More often than not, no proclamation is offered that says “we’re pulling the plug on lean.” Instead, leadership interest and support simply wanes, and stuff dies on the vine. There are probably still some people doing it, but that doesn’t mean the organization is really moving forward.

  2. Right, so we also have to say “it depends on what you mean by ‘quit'”!

    An organization might “pull the plug” by laying off lean facilitators, canceling a consulting contract, or other specific measures, or it might just wither on the vine…

  3. The driver of the “quitters” question begs this question:

    How many hospitals say they have a Lean program but have produced sub-par results?

    The reason for sub-par results are varied but without results “quitting” is only a matter of time.

  4. Sometimes declaring the end is healthier for an organization than allowing it to “wither on the vine” because it ends the pattern of people talking like they’re doing something when silently everyone recognizes the energy is gone (i.e. reinforcing loops of inauthenticity).

  5. I agree with your Amiel. The baggage that letting things continue unsupported creates can cause more problems in the future. If something isn’t going to be supported, I think the honesty to say so is important. I have seen a few organizations do this (but not many).

  6. At the senior executive level in many organizations, there appears to be less willingness to embrace ideas such as Lean and instead to rely on gross tools such as layoffs or expense cuts when the financial picture takes a turn for the worse. Short-term thinking is endemic in healthcare and is, I believe, one of the major reasons why the industry remains unable to nimbly respond to to the rapid changes that are afoot.

  7. There is only on approach I have come across so far that achieves the answer to three questions that confound most people and organisations who struggle to improve: they are 1) how to ensure that lean is adopted system-wide? 2) where to start? and 3) how to sustain the improvement? Without the answers to these questions pretty much all initiatives will fail. The approach in question is that used by Vanguard – a British systems thinking consulting firm run by John Seddon. If you haven’t heard of him, or if you know little about him I would suggest you look him up. It will be worth the effort. He has studied many improvement initiatives that have failed over the years in order to discover why, and has been remarkably successful in helping a range of organisations across both the private and public sectors to improve way beyond government targets and aspirations. Just in case this sounds like a sales pitch, can I point out that I have no vested interest in promoting his work other than conviction. I neither work for him, nor am I a client!

  8. The laboratory where I work is in the process of establishing Lean and I don’t know how long it will last because it will outlast me! I got out of Med Tech school in the mid 1980s and have worked in transfusion medicine ever since until taking this current part time job. I was hired to work in the blood bank and hematology departments. I was working on learning hematology when Lean happened. Having been in a military family I have moved and have worked in transfusion service, donor center, done some reference work, read, studied, reviewed and updated procedures, lived and breathed blood banking for my entire career. Now with lean, I am being asked to become a generalist, am sometimes asked to work in a position where I have yet to be trained, and made to feel that any warm body, including someone who doesn’t know what she is doing is good enough to do the job. I am a blood banker. I have spent a career of acquiring and honing as much specialized knowlege in transfusion medicine as I can but suddenly I find myself reduced to a button pushing robot on an assembly line. So, it’s back into the job market to look for a position where my knowlege and abilities will be respected and seen as an asset to the organization.

  9. Hi Robbie – I’m sorry to hear that. What you’re describing shouldn’t be the case with true Lean, especially if the staffing changes would do anything to jeopardize the safety and quality of the transfusion services area (which is a life-and-death matter, of course).

    A lean culture should be one where people are respected… it sounds more like what I might call L.A.M.E. than lean:

  10. Ah, DC, spoken like a true John Seddon “systems thinker” I suppose. Way to gloat. Why don’t you just focus on trying to educate people, as we’re doing in the lean community?

    I get really sick of the Seddon-istas constantly saying “if people implement lean wrong, that’s a failure of lean.” I’m sure you can appreciate (or you should) that lean is not just a bunch of tools, it’s a new way of thinking. And it’s often difficult to change that way of thinking from traditional management to lean.

    Same challenge would have to be true in the Seddon/Vanguard world. I’m glad you apparently have some secret sauce to get to this thinking change, but I have never seen evidence of that.

  11. DC – you REALLY have nothing better to do than be smug about some organization’s struggles or failures? Get a life, old chap.

  12. Oh dear, Mark and DC. I had no idea I was tapping into a source of personal irritation. And I am dissapointed at how condescending your reply was! I really do apologize if you think I was gloating, it certainly wasn’t my intention.
    My comments were truly an attempt to address the oft expressed frustration by lean practitioners in health related to their difficulties with knowing where to start, how to ensure system-wide spread of lean and how to avoid staff slipping back to old ways, something fairly common to discussion panels such as yours and many others. My suggestion to seek out Seddon’s writing and look at his results are the result of my personal research, which has nothing to do with some sort of cultish following. I do hope we can have a serious discussion, especially as I honestly believe that Seddon has a valuable contribution to make precisly about the issues you raise in your comments to me. Please don’t let us fall into the damaging, competetive trap so familiar to those of us who work in traditional management systems. Can we start again?

    • John, my comment was directed at “DC.” I’m sorry if my response came across as condescending, as that’s the tone normally taken by Seddon and the people who work with/for him (and his cultish followers).

      I didn’t mind your response at all. John Seddon has some excellent ideas, he’s right that command-and-control is not the way to go. But his recent harping on Lean being a “wicked disease” etc. is too much to take.

  13. OK. I do realize that John Seddon can be confrontational sometimes, but I am pleading for us not to chuck the baby out with the bath water! What I find really useful about his approach is what is usually missing from just about all the other lean endeavours I read about (observation, not criticism). Most hospitals attempt to begin to see their purpose from the patient’s perspective, but they don’t always devise a statement to that effect to act as a yardstick of whether they are keeping to their objective (not ‘vision and values’!). More importantly, I think that his adaptation of PDSA to CPD is key. To start by looking at an organisations’ key demand flows and their capability in meeting them, stops the temptation to start with a small projects – something which, in my experience, rarely helps to change management mind-sets and allows traditional managers to see lean as just another fashion. As we know, lean is mostly counter-intuitive to current belief. There are other aspects of his approach that matter, such as the discovery of failure demand, etc. What is important is that most of these methods do not stand on their own, but need to be seen as part of a whole, much like the chain of survival. I would love to discuss whether these issues have value in helping us to unravel some of our frustrations and questions along the way. And I do understand how difficult it can be as I have made little or no impact on my own command and control ambulance service. My outlook is being informed by what I have read for the past 10 years, and being involved in some projects that have had varying and, too often, minimal impact.

  14. John – Yes, Seddon can be confrontational and personally insulting. He has to live with that. But comments about “not throwing out the baby with the bathwater” should really be directed at him regarding Lean. Nobody is calling Systems Thinking or his brand of it “a wicked disease” as he says about Lean. Who needs to tone down the rhetoric, would you say?

  15. One thing I have learnt by living in a dysfunctional system is not to take things too personally – it is a blind alley. To me there is nothing more important than improving life and moving civilization on. Some of the most important ideas have come from those who others find objectionable. I’m reminded of someone who once criticised a leader of Greenpeace for smoking, which prompted the reply: “by all means come to me if you want to change the world, but don’t expect me to be a xxxxx saint at the same time!” As it happens, I don’t agree with you about John, however I hope we can keep on communicating. Much of what he says reflects his frustration with what he sees as other’s blind spot, but he can speak for himself. Perhaps you should be communicating with him? It worries me that you did not comment on any of the issues contained in my last submission. That would be really useful and is what I am really interested in. I really would like that.

  16. I’m not taking it personally, John. I’m defending a methodology that I know to be a good one – Lean. Do organizations often “fail” with Lean? Yes – is that the fault of the organization or of Lean? You say Lean is counterintuitive – exactly why it so often fails. The same would have to be true of the counterintuitive systems thinking of John Seddon, right?

    You disagree with what about John Seddon, that he shouldn’t tone down his rhetoric? He seems to love riling people up, so I shouldn’t give him the satisfaction, but just because some people find him objectionable doesn’t make him Socrates or something.

    The idea of looking at demand or even failure demand isn’t a unique discovery of John Seddon. This is something I’d consider a core part of the Lean approach – understand demand and takt time (oh wait, Seddon says that doesn’t apply to healthcare) and then understand defects in the process that lead to phone calls, rework, etc. (what he coins as “failure demand” and repeats incessantly).

    I don’t see the point in trying to communicate with John directly. I’d expect to get nothing but insults in return. I’ve tried having discussions with his man in the U.S. and he doesn’t listen or budge from his extreme position that “lean doesn’t work in services” (a position that is laughably untrue) so it isn’t worth my time to try to engage directly, frankly.

    Everything else you said makes sense, so I don’t know what else to say. It worries you that I didn’t respond? Why?

    There is much common ground between good Lean Thinking and Systems Thinking. It’s Seddon who is driving the unnecessary wedge… for what seems like selfish reasons, or that’s all we can surmise (Lean doesn’t work, hire me – that seems to be his mantra).

  17. Alright. I was hoping we could begin to discuss issues dispationately, but apparently that is not going to happen. You seem to have moved from your original statement that Seddon has some excellent ideas to a stream of vituperation and insult, on a par with what you complain about in him. By the way, I have seen no reference to failure demand (as he describes it) – or any other description of it in your book or others until long after John started talking about it. Moreover looking at key organisational demand flows and capability as a starting point is conspicuous by its absence in most lean writing I have come across. Which is why I thought it would be interesting for your contributors to look him up. I don’t know about the others, but I would still like to discuss the issues dispationately. Sadly, I am beginning to wonder if you can or if you are just intent on getting a sense of personal insult off your chest. Sorry to be so blunt – it is a reflection of my own disappointment.

  18. John – Sorry to disappoint you.

    You say “looking at key organisational demand flows and capability as a starting point”

    – That’s called value stream mapping and looking at customer demand. This is covered pretty well in the book “Making Hospitals Work” in a pretty direct way.

    – Failure demand = defects and rework. John has coined his own phrase here.

    This is all core lean thinking, I’d argue (dispassionately).

  19. My disappointment was with the direction the discussion was taking. I will answer your latest comments, but not now. I need to retire and do other things. Look forward to communicating again soon.

  20. What an interesting topic!

    I am not an expert, and I don’t suggest that I have any solutions. But I’d like to share a few thoughts.

    First, a minor point – to Mark’s observation about John Seddon: Lean doesn’t work, hire me – that seems to be his mantra. I’ve met very few consultants that don’t have this mantra. “Not getting results? You just had the wrong tool. We can help you with that.” Any it’s easy for management to fall for this line, since it implies an easy fix. Anyway, that’s been my experience. (But, of course, I’ve met some outstanding consultants, too.)

    To the topic being discussed – I’m really trying to wrap my head around how one would go about evaluating the general efficacy of an improvement system, program, tool, management framework, etc. Is it the success rate across various companies and industries? How does one measure success? How do you even evaluate whether the system, program, tool, etc., was applied correctly? I’m totally at a loss with this. Any criteria I come up with can easily be dismantled.

    For example, pick any failed improvement effort over the last few decades. You’ll always hear the practitioners and consultants claim it wasn’t implemented or applied correctly. Maybe that’s true, but does that matter? If it is too hard to get results with the system, is the fault in the system?

    If ISO 9000 or Six Sigma or Lean or TOC or Systems Thinking didn’t get the results we expected, what then? Try harder? Try a new system? Hire different consultants?

    How does a company know whether (1) the system is ineffective, (2) they’ve not applied it correctly, or (3) they just haven’t given it enough time?

    This is a challenging question to answer because of many different confounding factors, both internal and external to a corporation.

    Thoughts anyone?

  21. Walter – great questions, plenty for all of us to continue thinking about. Yes, there is plenty of that dynamic amongst lean consultants – whose approach (which “flavor of lean”) is best, etc.

    Seddon used to call his work lean service, now he seems to have gone out of his way to invent his own creation that’s different… but it seems not to be that wildly different. It’s a flavor of lean. So that’s an extra level of brazenness, perhaps, to create his own field or to co-opt the name “systems thinking” (which has roots tied to Dr. Deming, Peter Senge, and others).

    “How does a company know whether (1) the system is ineffective, (2) they’ve not applied it correctly, or (3) they just haven’t given it enough time?”

    Great questions. I’ll, again, put this out there: Some organizations and some leaders (and some consultants) are able to make Lean work (and it’s often a combination of those factors). Some organizations struggle mightily to change and understand Lean at a deep enough level to be successful…

    The variation in results can mean there’s a variation in how they went about Lean or even variation in what they did.

    My beef with the John Seddon crowd is the use of absolutes – “lean never works,” stuff like that. It’s a falsely overly absolute statement. So I’ll call them on that.

    Do I wish them ill or their clients ill? No, of course not. Anyone who brings quality improvement and a better workplace to people deserves praise. I wish they would just focus on that instead of their big focus on tearing down “lean” to their own benefit.

    If hospitals hear their “lean doesn’t work in healthcare (or services)” mantra and then the hospital doesn’t even try Lean, then one could argue John Seddon has done a great disservice to the hospital, their employees, and their patients. Lean CAN work and lean DOES work. That’s why I take offense when they say it does not. This stuff is far more important than the turf battle that the Seddon crowd started with their attacks on Lean.

  22. Much as I would like to continue taking part in this discussion, circumstances dictate otherwise for the time being. So I hope you will indulge me one final time so that I can summarize my thoughts on this topic.

    John Seddon is very worried (as am I and many others) about the number of lean initiatives that are failing around the world, including some very large organisations whose subsequent problems are receiving widespread adverse and seriously damaging publicity. The cause is pretty much always down to management’s – and their consultant’s – inability to change their mind-sets and their historical organisational cultures. Commonly managers fail to recognize that they need to transform themselves every bit as much as they expect their staff to change. There is a tendency to use inappropriate measures (such as arbitrary targets) and attempts made to incorporate lean tools into their autocratic, dysfunctional systems, much like the big auto companies did when they tried to ‘copy’ Toyota for decades without success.

    There is a real danger that lean will end up on the scrap heap of tried-and-found-to-be-wanting fads in the eyes of those that desperately need it most.

    Having studied these failing lean ventures, Seddon has come up with certain ideas and methods which he believes are best suited to addressing this problem.

    I would recommend that you read Seddon’s latest book (Systems Thinking in the Public Sector: The Failure of the Reform Regime..and a Manifesto For A Better Way) and look at the two websites he maintains. Much of the content is not healthcare related but don’t let that put you off: the subject matter is eminently transferable.

    Another option would be to read what a well respected writer on lean thinking, John Bicheno, has to say in his book “The Lean Toolbox for Service Systems” where he includes a clear summary of Seddon’s approach, giving an insight into how it differs from other lean practitioners in several important ways, and why it is worth learning about. The answers to many of the questions you ask, Walter, will – I believe – become clearer should you choose to follow the above suggestions.

    This is why I made my original entry to this blog: to inform participants about his work so that you could read about it and make up your own minds. Surely it makes sense to be as informed as possible about ideas related to what does, and what doesn’t work when trying to implement lean/systems thinking?

    In the spirit of Taiichi Ohno I shall now withdraw in order to let you all get on with your important learning. My only parting shot is to thank you for this opportunity and to convey to you all my best wishes in all your future endeavours.

  23. John M. – you seem like a reasonable fellow. Trust me, I share your concerns as you articulated so well. Part of my beef with Prof. Seddon is that he seems to take glee and joy in the failures of lean that he screams about in his newsletter and articles. That’s part of where we get off the rails. Thanks for reading and participating.

  24. On the original question of failure statistics: John Kotter (author of Managing Change) writes about his research on organizational change initiatives of all types and quotes a 30% success rate. Michael Hammer (co-founder of business reengineering) used to quote 10% unqualified success, an additional 20% qualified success, and 70% didn’t realize targeted results from reengineering efforts. I believe there are fundamental forces in organizations that make any sustained change problematic, including traditional mindsets, the disruption of change, competing demands for attention, strategic irrelevance, and traditional management processes.


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