3 Questions to Ask Before Starting with Lean


This is a companion post to yesterday's “3 Reasons the General Public Thinks Hospitals Can't Improve.” Lean zealots often take for granted that, not only does Lean work, but that people want to improve.

Before we dive into teaching people Lean tools and Lean management methods and Lean thinking, I think we should step back and ask some more fundamental questions.

These questions are:

  1. Do we need to improve?
  2. Do we think we can improve?
  3. Do we think Lean is a methodology that will help us improve?

Years ago, I would often default to starting with question #3, or at least starting with trying to convince healthcare staff, leaders, and physicians that Lean is the way to drive lasting, sustainable improvement.

But I learned other more fundamental questions or concerns would get in the way.

1. Do we need to improve??

Many organizations and the individuals within would often answer “no” to that question without thinking. I recently heard one hospital leader say “we were getting all of these awards, and I don't know why.” When hospitals rely on benchmarking comparisons and Top 100 lists, it's easy to think you're the best of the best when you're really the (I really feel awful typing this, but I've heard many Lean hospitals use it) “cream of the crap.” Being better than your competitors and benchmarks should be no consolation when you all have the same systemic waste in your systems and processes. Another healthcare leader I know called it “delusions of excellence” (again, I feel like a jerk typing that, but it's their words, not mine).

Now let's say you can get people past the “we need to improve” hurdle. You have to ask the next question:

2. Do we think we can improve?

Many organizations and the individuals within might recognize the need to reduce hospital acquired infections, but they might think it's a mission impossible. They might be cynical and discouraged after previous improvement programs that didn't make improvements or didn't make lasting change. People might see the gap but then think it's hopeless, the idea of closing the gap. If you didn't get hung up on Question #1, you might get tripped up on Question #2.   “Yes, we should try to get better, but anything we try won't work, so let's not try”   — that's a unfortunate mindset when you find it.

3. Do we think Lean is a methodology that will help us improve?

Now if your organization or leaders are arguing the finer points of Lean or Six Sigma or other methods, you might have already won the battle of Questions #1 and #2. Question #3 is pretty much what this blog is about, so I won't go making the case that Lean works and that, specifically, Lean works in healthcare. Or, I should say, it CAN work. Success with Lean is not guaranteed – as attitude and leadership are the most important factors, not your ability to learn Lean methods. As some say, Lean isn't that complicated, but it IS very different.

What do you think? Have you run into problems with Questions #1 and #2 with your organization or with your clients?

For those readers who aren't in healthcare, do you struggle with those questions in your organization?

How do you get the answers to #1 and #2 to be “yes”?

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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. Mark, I think this is a pretty compelling topic. I’m surprised you haven’t received any comments yet on this post–must be a slow day in the blogosphere. The more experience I gain, the more I see the importance of these questions. I agree that the first two definitely precede the third. I tend to phrase the second question differently than you do. I rarely encounter people or organizations who think they cannot improve (once they’ve answered ‘yes’ to the first question). I prefer to state the second question as, ‘what are your expectations for improvement?’ This implies an active, personal orientation toward improvement. It invites a conversation, not just a yes or no reaction. In addition, it is harder to consider this question in isolation of one’s self, it tugs the person to think about the organization and people around them. That is, improvement isn’t something that happens “out there” away from me, it includes me and involves me. This question also works well at all levels in an organization, from individual contributors to senior leaders, each of which has a distinct role in setting and meeting expectations for improvement.

    • Dale – you’re right. I don’t literally ask the questions in that exact form to individuals… the 3 questions were somewhat rhetorical for this discussion, but what you added makes sense.

  2. Great post, Mark, and 3 really excellent questions to start any business conversation, Lean or otherwise. To your Q#1, every colleague or client I know would admit they have something in their organization that needs improving – be it the success rate of commercializing R&D ideas, to addressing employee morale (Oh if Lean were the silver bullet for all these concerns!). The difference-makers I know are those who successfully resisted the organizational pressure to just do it and instead inspired their organizations with “let’s improve it”. They are part-realist and part-optimist who regularly get as excited about looking outside their organizaiton for inspiration as they do looking inside. And getting to “Yes” is enhanced with this outside perspective. They talk about it in meetings and look for good, relevant examples anywhere they can.

    For Q#2, I think the issue is more a function of the company’s own internal atmosphere. For leaders and employees who have been through 2, 3, sometimes 4 straight years of workforce reductions outsourcing and reorganizations, the “do you think we can improve” question is sometimes seen as just plain irrelevant. The energy that’s needed to get an organization rallied is often a daunting task for even the most confident leader. But I’ve seen glimmers of hope with these companies. One of the most reliable and fun paths to “yes” for Q#2 is digging within the organization and finding the successful examples that have occurred over the company’s history. Every company has these. But they’re often forgotten, or lost as people move on and the organizational memory fades. For large efforts, we’ve interviewed up to 50 people at a time within all levels and functions and uncovered some wonderful stories of pride, teamwork and yes, real measurable tangible improvement. By pulling out some of the methods and leadership principles buried within these examples we find that company leaders, middle managers and first line employees find a new sense of confidence and spirit for taking on an improvement effort. “Yes, we can improve”, becomes a little easier to declare. Lean’s ability to tie together first line associates and leaders helps strengthen the initiative. Communication – thoughtfully planned and delivered effectively by leaders and supervisors – is another link that helps bond the initiative and the organization together.


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