Two Extreme Sides to Every Story in Politics *and* Lean??


This is going to seem like a political rant, but I promise this is mainly a post about Lean and healthcare, or at least it's about dysfunctional parallels in both settings.

It used to said that President Ronald Reagan and Speaker Tip O'Neill would actually go have a drink together at the end of the day, even though they were pretty much 180 degrees opposed politically.  Turns out it's a bit of political urban legend. Maybe that was just a mythical kinder, gentler time, as American politics has historically been bitter and nasty… like today.

As an experiment, do as I did the other day: watch Fox News for 60 minutes, then watch MSNBC for 60 minutes (especially in the evening opinion show times). You'd think there were two polar opposite Americas in existence from the vitriol from the right and the left. If you're on the right, watching MSNBC would make you think you were in “bizarro world,” where everything is opposite of your world. There's no middle ground, no compromise or “seeking first to understand” going on, it seems. Everyone is shouting past each other or just talking to those who already agree with them…

Look at the fight over the nomination (and now recess appointment) of Dr. Don Berwick to head Medicare/Medicaid (CMS). I'm not a fan of circumventing Congressional approval (when it's done by either party). Sadly, the extreme views come out about that procedural method (which is Constitutionally legal, but maybe bad form) and extreme views about Berwick himself. Dr. Berwick, who I support even with his comments about redistributing wealth, is painted by some, including Sarah Palin on Twitter, as a death-panel loving, socialized medicine obsessed, rationing monster. He seems to be no such thing. (Note: John Toussaint also supports Berwick).

Not to play the whole President George W. Bush “I saw President Putin's soul card”, but I've met Dr. Berwick briefly and he surely doesn't seem like Dr. Death Panel in his personality or based on his work at the IHI. Dr. Berwick is indeed pretty revered in the healthcare for his life-saving work and advocacy for quality and patient safety. Revered or radical? Two sides to that story, eh?

Dr. Berwick deeply understands that better quality and better processes in healthcare save lives AND it lowers cost. There's nothing the least bit evil about that. Dr. Berwick talks about making tough choices with our healthcare dollars    (“rationing with our eyes open” instead of today's form of rationing, but he also talks about eliminating waste from healthcare. (post continues below the ad)

Regardless of political sides, most people have a blind spot toward the idea that you can actually improve healthcare efficiency without resorting to more rationing or killing people early. People ASSUME, it seems, that because hospitals are naturally as efficient as can be because they're are full of smart people, with great technology, and new buildings. Lean thinkers know this isn't true. Bad processes defeat all the great people, technology, and buildings every day.

I heard Dr. Berwick's Institute for Healthcare Improvement called a “healthcare efficiency organization” on the news. I thought they were mainly a quality improvement organization. But, again, there's the catch — better quality leads to lower costs and it's hard for many to see that. The term “efficiency” was said with an ominous tone of voice, as if IHI's mission is to deny people care just to save money. Ridiculous.

I'm not in favor of “socialized medicine,” but I support Dr. Berwick for the CMS job. Actually, “socialized medicine” is  a term with such a vague and inconsistent definition around the world that it's a pretty meaningless statement to say I'm against it. I don't prefer a UK style system or a Canadian system, I'll put that much out there. But the U.S. system is far from perfect (as evidenced in this recent post from Jon Wetzel). So I don't fit easily into either political extreme… so who is representing me??

Extremes in Lean and Other Process Improvement Methodologies

Away from politics, we sometimes hear similar extremes about Lean, especially in healthcare. I'm squarely in the “pro-Lean healthcare” camp and there are some who run around saying “Lean doesn't work in healthcare.” Do I believe Lean *always* leads to good outcomes? No, of course not. The practices and principles of Lean are sound, but they're often very tough to implement since Lean goes against the culture of most organizations. I could run around with my fingers in my ears never wanting to hear about problems with Lean or what we call “LAME” here on the blog, but I don't. I would be an ideologue if I never admitted there were problems in Lean world (just as political ideologues would never admit their party is wrong).

Do the people who say “Lean NEVER works” really believe that extreme position? I'd hope not. They're probably just saying that to score points and to benefit their own methodology.

The Positive View of Lean

In a more specific case, let's look at Minnesota's Park Nicollet health system. They've been on the Lean journey for many years (and, conflict of interest disclosure, they're a member of the Healthcare Value Leaders Network that I work with). There have been many published accounts of how Lean has helped their organization and their patients.

Check out this great video (it's six minutes long, but worth it). Here's a 30-second ad version for the time-challenged. PN redesigned their cancer treatment in a VERY patient-centered way. They had patients involved in the design. Although the video doesn't talk about it, PN used a Lean 3P design process for this center (they presented about it at our recent Lean Healthcare Transformation Summit).

What a great story. There's the power of Lean to improve patient care and the patient experience. That's the best side of Lean, the “all is good” view — and I'm not criticizing PN for not telling “both sides of the story” in their video.

Patients are seeing an oncologist within 48 hours now (a “promise”) from PN. The UK NHS has a two week standard, by comparison. Park Nicollet patients are getting surgery within 10 days (compared to the UK NHS long-term “target” to get that wait down to ONE MONTH, the current goal being 18 WEEKS). In the new PN process, chemotherapy and testing and everything comes TO the patient, so the patient doesn't waste precious energy walking between campuses and departments. It's brilliant.

The Negative (and Distorted) View of Lean

Now, on the other extreme is the Minnesota Nurse's Union. I saw this video before my vacation, but I didn't want to get int the middle of a labor dispute that included  a 1-day strike – the dispute has recently been solved (I guess) with a new contract.

The nurses, unfortunately, put up this very misleading “anti-Lean” video on YouTube, with all of the subtlety of a typical political attack ad. It's their editing and spinning of a Park Nicollet produced pro-Lean video.

If you only saw this video, you'd think Lean was evil and something that should be banned. Does the nurses' union really believe that? I hope not, but again they're trying to score political points with their extreme argument. They're confounding the issue by slamming PN executives for their high pay (a separate discussion).

The Lean approach and philosophy clearly does NOT put profit over safety, as the video states. The nurses' union plays the Toyota card, exploiting their recent quality problems (a design and engineering issue, not a production issue) to slam Lean and TPS as being BAD for quality. Hogwash. It's just like a politician on either side of the aisle making cheap demagogic point that sounds good to an uninformed audience, but it sounds good.

One could argue, at the other extreme, that opposing Lean is  unconscionable because stopping a Lean program would likely prevent much needed quality and safety improvements. Again, neither extreme seems helpful.  There's no point in people calling the union evil, I'm certainly not doing that. They're to some extent well intended (I'll give them the benefit of the doubt that they care about patient safety, as do hospital execs), but they clearly have a “more nurses is better” agenda because that also means more union dues.

The major issue is that nurses say they need MORE nurses to ensure safety. The other view would be that we need to reduce waste and improve processes so we can provide better quality and safer care without hiring more nurses (we have major nurse shortages, by the way, a trend that will only continue). The one side argues that hospitals are not as safe as they would be with more nurses. That  might be true in the short-term (you'd have to look at real data and not generalize), giving current bad processes and waste in healthcare delivery. Lean often leads to productivity improvement, but sometimes data and patient needs lead to INCREASING staff in a Lean initiative (yes, I've seen that and recommended it at times). How many people do you need to get the work done the right way, in a way that's safe for everybody? That's the core question. Lean does not always stand for “Less Employees Are Needed.”

The Lean purists would say, for example, that inspection is bad, it's waste — we need to build in quality at the source. OK, but if your first step with Lean is moving the inspectors into other jobs, your customers are going to suffer if you haven't first fixed quality. So maybe in the short-term we *do* need more nurses to protect patients until we can improve the process – but I'm opposed to mandates in contracts or in state law (like California and others).

The union also twists the idea that you can see 50% more patients by taking waste out of the process (and the CEO even says “we're not trying to turn this into an assembly line”). The union implies that seeing 50% more patients mean you're working 50% harder. That doesn't seem possible when you have the view that healthcare MUST be already efficient (great people, great technology, great buildings).

People with Lean healthcare experience know that removing waste is good for patients, the staff, and the hospital. The hospital might make more profit (which the union seems to demonize), but as the CEO said, that profit is reinvested in patient care. The one point I agree with in the video that it's not the best use of funds to invest that profit in marble hallways and soaring atriums, but that's just me.

The original PN video also presents the idea of stopwatches being used to observe work – to identify “bumps in the road” and problems that interfere with care. But, the union twists that as being an inherently evil practice:

The stopwatches aren't there to make people work faster. If that's indeed happening (and I doubt it), then that's bad and it's  classic Taylorism and that's clearly L.A.M.E. Again, two extreme sides to this story.

The final distortion is shown here:

Sigh. I guess this nurses' union, like some other unions, will just never see Lean as a positive force. That's sad and closed-minded, just as it would be if a Republican would never listen to a Democrat or vice versa. I blogged last year about a nurses' union in Canada that was IN FAVOR of Lean, so there's some hope.

Actually, the final distortion in the video is the strikers with their kids holding signs, as if that validates them as the good side (sort of like using puppies or babies in commercials). As if the management side doesn't also have children. Good grief. Just like a political attack ad.

The nurses' union didn't get their mandated staff ratios in the new contract, by the way.

Where is the Reasonable Middle Ground?

Is Lean always bad? Are Democrats always wrong? Feel free to ask those questions in reverse. I'd say no, however you ask those questions. The extreme position is never correct (oops!). The extreme position is hardly ever correct. Either way, when extreme views keep people from even hearing each other, yet alone talking, I really worry about the State of the Union (and I don't mean the “state of the labor movement”).

Does this trend of polarization continue and spiral out of control, or what is the balance against that? Sorry for such a long post — your thoughts??

What do you think? Please scroll down (or click) to post a comment. Or please share the post with your thoughts on LinkedIn – and follow me or connect with me there.

Did you like this post? Make sure you don't miss a post or podcast — Subscribe to get notified about posts via email daily or weekly.

Check out my latest book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation:

Get New Posts Sent To You

Select list(s):
Previous articleGuest Post: Lean Starts at Home
Next articleMy Lean Message Board is No More
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. Unfortunately, there has been a consistent failure to respond to the 100+ year old arguments used by anti-process improvement people (e.g. “seeing 50% more patients mean you’re working 50% harder”). So, predictably, the problem remains with us, more or less in full-force. The arguments used against process improvement are well known, few in number, and are based on faulty reasoning, yet there is a persistent unwillingness by Lean community leaders to respond directly to these arguments. We will always have great difficulty moving forward until we accept the need to go backwards to address people’s legitimate concerns about process improvement. Also, by not understanding REAL Lean, stakeholders (unions, shareholders, etc.) miss grand opportunities to hold senior management accountable to superior leadership and creating organizations that are truly customer-first. This is another area of long-term neglect by Lean community leaders.

  2. I have been reading your blog for some time and this post is the first that has motivated me to comment. Having lost my mother to cancer in April and her sister, my aunt, just 3 days ago, I have way too much experience navigating our health care system.

    My mother was diagnosed with breast cancer on February 28. It had metastisized to many places including her brain. Not once did a doctor speak to us about the option of no treatment. It was ‘chemo right away’ and ‘radiation too’. I put my foot down when they wanted to do a brain biopsy. My mother lived for six weeks in pain and misery and died on April 8. She was in three different hospitals for a total of about three weeks. Her care cost over one hundred thousand dollars.

    My aunt, who was diagnosed with lung cancer last July, responded very well to chemo. Her cancer was caught much earlier and had not metastisized. Unfortunately the tumor was not operable and so could not be removed. I’ve learned that this is the best case for long-term survival. Otherwise it’s a fight to try to stay ahead of the cancer. It caught up with her in March when a scan showed the tumor, which had shrunk drastically in the fall, was growing again. She would have to re-start chemo. In mid-June she was feeling horribly after her monthly chemo treatment. She went into the hospital on June 18. On June 23 they told me that the cancer had metastisized and my aunt had at least 4 lesions in her brain, one 5cm (that’s big). The swelling in her brain had rendered her virtually unconscious at that point and she was no longer able to make decisions for herself. The brain surgeon came to see me. The 5cm lesion is operable he told me. Removing it would relieve some of the pressure on her brain. Well, ok, then what? Well, she’d have a few more weeks of life, maybe a month. Huh? What kind of quality of life? She may never regain consciousness, or she might.

    After much thought and prayer, we elected not to do the surgery but to make her as comfortable as possible for the remainder of her life. Well, apparently when you elect that, you can’t stay in the hospital anymore. Huh? She’s not conscious — she can’t go home! And her doctor didn’t think she should even be moved. But, according to Medicare rules, she was not sick enough to qualify for in-patient hospice. We could take her home and Medicare would pay for hospice in the home — with a caregiver for 35 hours a week. What about the other 100+ hours? Or we could put her in a nursing home where we’d be responsible for the room and board — Medicare doesn’t cover that. Of course, if we had Medicaid, it would be 100% covered. But my aunt who worked her entire life and paid her taxes diligently, didn’t qualify for Medicaid. And, of course, if we’d elected to do the brain surgery, Medicare would have happily paid for that and at least two more weeks in the hospital for her recovery. Is it only me who sees something really, really wrong with this?

    Our healthcare system has some serious problems and I don’t think they will be fixed easily. That being said, I am glad in both cases that we had a choice to treat or not treat. But should we have had that choice? Is that what is best for the patient? Is that what is best for the healthcare system? Miracles happen everyday… should we always try aggressive treatment, just in case? These are real moral questions that I’m sure we will struggle with for a very long time. In the meantime, patients and families must make these difficult decisions everyday.

  3. Mark & Bob,
    Timely topic considering my post for today. Dysfunction is rampant…choose your context.

    Bob – you’re right on regarding lean leader’s unwillingness to identify and respond to arguments.

    It’s Time to Stop and Fix Something!

  4. It seems that “I’m right & you are wrong” thinking and behavior is a type of waste. In addition to the 7 traditionally cited categories, I’ve seen “not tapping into human potential” listed as an 8th waste, but also “behavior” listed as an additional category.

    I’ve been reading Bob Emiliani’s book series on “Real Lean” and coincidently came across this passage in Volume 3 last night (Chapter 4 – Driving to the Bottom):
    “Instead of recognizing these realities and improving, we spend our time fighting over labels and calling each other names. Free market capitalists disparage progressives, liberals, socialists and vice versa, in a never-ending struggle that simply adds cost without creating any value. We cling to our bedrock ideas and make them part of our identity. Either-or choices are presented to us as the right way to think and align ourselves, forcing us to choose sides.”

    What are some possible countermeasures to this type of waste? Perhaps more dialogue (working for common ground) rather than discussion (trying to get our point across)?

  5. Maybe (???) the piece on the front page of today’s (7/11/10) business section of the Sunday NY Times will help. The headline hurts, but otherwise reported Julie Weed seemed to get it pretty much right on the mark.

    Getting quoted, a frightening and unpredictable process, didn’t even turn out too badly, Mark! Way to go!

    Once something is polarized in our current environment, though, I’m afraid that even consistent, documented successful performance may not matter. People see what they believe, not the other way around.

    • Andrew – thanks, yes, I’ll blog about that NYTimes piece this morning. link:

      Here is the link on my page if you want to comment on the Times article:

      I agree that I wish the headline didn’t just capture “efficiency” since those of us in manufacturing know that efficiency is hardly a given in all factories! I wish quality had also been mentioned in the headline, like it was in the article. Cost is such the focus in the healthcare debate right now, I wish the “cost and quality” relationship (better quality leading to lower cost) were in the headline, but oh well.

      It’s one of the better major media lean stories I’ve seen, though.

  6. The late psychologist Virginia Satir was fond of saying that “one choice is a trap, two choices are a dilemma, and three choices are a choice.” So polarizing gives no one a real choice, anyway.

    And, yes, unions love lean elsewhere. In Denmark, construction trade unions only want to work on lean construction jobs, because the provide predictable work and predictable workflow.

  7. Timely post for me. I work for people who it turns out hired me because they were told to hire a lean champion by their new owners, who supposedly support the lean transformation, but really just want a never-ending series of kaizen events that MUST have a direct and immediate impact on the magical BOTTOM LINE. No thought of building lean processes or systems, training and education programs, etc. It is a bad situation because not only is the union skeptical, most of the middle and senior managers give the lean process lip service at best. Many of them are afraid lean systems will mean they have to relearn how to do their jobs, most of which are technocratic and bureaucratic in nature, not leadership-oriented. I’m afraid there is a whole string of companies with this issue. I disagree with Bob Emiliani’s comments about lean leaders not wanting to address the critics. When a lean leader is in the situation I am in, where the “burden of proof” is constantly on me to show how lean systems will work at all, let alone better, the lean leader (me, at the least) becomes so disillusioned with the whole BS routine that they tend to stop defending lean all the time. Anyone can say anything about why lean will not work here, and they are never held accountable to prove it. Instead, I am held accountable to prove it will work and to prove their objections are wrong. That is a tough row to hoe and does not lead to good, sustainable improvements. I do not wonder at the attitude of the nurses’ union above. Lean was probably rollled out with poor education and poor explanation, the union was likely not involved in the transformation at the outset, the goals were probably not clearly defined or communicated, and there is likely some poor lean champion in the middle, told by senior hospital management who really don’t believe in the whole “lean transformation” philosophy, to show that it is the right way to go and prove the critics wrong. So, we have to stand our ground or find ground better suited for the battle and make our stand there.

  8. Thanks to e-Patient Dave for finding this:

    In Politics, Sometimes The Facts Don’t Matter

    “New research suggests that misinformed people rarely change their minds when presented with the facts — and often become even more attached to their beliefs. The finding raises questions about a key principle of a strong democracy: that a well-informed electorate is best.”

    Same seems to be true about Lean (say, the Minnesota Nurses Association…)

  9. Well I guess it’s a cultural issue, but it seems pretty biaised and one-sided when you use words such as socialized medicine. I cringe when I read such scarewords used about something that makes so much sense on a global point of view, and I thought a lean specialist – in health care world in addition – would recognize that ! For example no copayment on check up exams (including dental, women health, …) eliminates so much costs downstreams. (subsidized) low cost treatments avoids the “waste” (moral and economical) of people dying in ER. Centralized payments avoids the waste of so many accountants and recovery costs. And so on and so on.

    Waste and un-lean-ness are not only in care processes but also in the whole health industry processes !

  10. Matthieu – thanks for your comment. I was trying to make a similar point that saying “socialized medicine” (I put it in quotes) is a fairly meaningless term because it could mean 20 different things.

  11. Hi Mark,
    As I have shared with you before, working in both Canada and the United States I have seen my fair share of waste and inefficiencies. I can give you countless examples of patients in the US that I had on my caseload that were either denied access or has such limited access to services it would have made no difference. Insurance companies, my hands are tied! Very frustrating as a health care provider. There is a whole range of working middle class that have difficulty paying for what they need or are disallusioned that insurance will meet their need in their darkest hour. So yes socialized medicine in it’s vaguest term have longer waits and access issues too, but my view as a practioner in both systems is they all need help! No shortage of opportunities to use Lean is there? I appreciated KD’s story, that you for sharing!

  12. Hi Mark,

    I was unclear myself, I recognize you don’t embrace the “socialized medecine” meme but I just wanted to express some desire to see the Lean Healthcare community, like you, who is doing a great job on the “hospital shop floor” to tackle also the whole “health care value chain”.

    Is that better formulated ?

  13. Matthieu- I agree that we need to do more than take waste out of one portion of reactive sickness care. Some organizations, like Group Health in Washington, are looking at the whole healthcare value chain and doing some nice work across the interfaces of insurance, primary care, and the hospital care (often done through Virginia Mason).

    Many lean thinkers, ranging from Don Berwick to John Toussaint to Jim Womack look at the whole picture and ask a lot of “what if?” questions, but we need more action and more improvement across the big-picture system, not just hospital care, for example.

    Some leading lean hospitals say their long-term vision is that they aren’t necessary except for cases that are truly emergencies…

  14. I’ve come to visualize the real customer of healthcare as a successful healing experience. For me this is a more honest if abstract view of the end customer, and calls on everyone in healthcare to support a patient’s (or family’s, or couple’s, or community’s) healing. Is the provider supported in aiding the patient’s healing? Is the patient supported in preparing for a healing experience with the provider — whether a treatment, an operation, a splint, or the delivery of a baby? Do government and insurance plans support the healing experience? And, if not, time for some value-stream work and clearer processes supporting healing!


Please enter your comment!
Please enter your name here

This site uses Akismet to reduce spam. Learn how your comment data is processed.