Follow Up Q&A from “On the Mend” Webinar


The Lean Enterprise Institute has posted the follow up text Q&A by John Toussaint MD and Roger Gerard PhD, co-authors of the book On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry. These were extra questions from their webinar, which is archived on this page (scroll down a bit from the top).

A few highlights and my comments:

It was clear that what  ThedaCare was] doing wasn't working. We scoured the country looking for manufacturing organizations with world class quality defined as 3.4 defects/million. We found it in a snow blower company 40 miles from ThedaCare. We went out on the shop floor and observed workers committed and trained in solving problems. We said to each other that this was what we were looking for in healthcare.

ThedaCare was struck by the CULTURE of a manufacturing company, that was their inspiration. It's the culture, mindset, and management system that is transferable and this is how Lean healthcare is not about copying factory tools.

They talk about providing service to doctors, as what I'd call an “internal customer” of important hospital support processes. This is far more constructive and effective than trying to force doctors to do new things:

The most important learning we had was to fix issues that the doctors had. Most of their biggest headaches had never been addressed so with the lean tools we fixed many headaches and by doing so started to prove to the docs that the lean method could help them.

By proving that Lean is a good thing, being helpful to the docs (and therefore to the patients), we can try to pique the curiosity of doctors so they might learn more about Lean, to internalize the concepts, and then maybe apply it to their own work. As Taiichi Ohno wrote, people must write their own standardized work. It can't be forced on them. We can inspire people to improve, as leaders.

More on learning from manufacturing leaders:

Q. As the leader of ThedaCare, how did you learn how to be a lean leader? Did you have a sensei guiding you?

A. I had several mentors but I wouldn't say I had a personal sensei. The mentors I chose were from manufacturing, had been CEOs, and had many years of experience in implementing lean. They all were willing to help at every step of the way, and I didn't pay any of them a dime. They were committed to fixing healthcare using lean.

Down in Texas, I'm starting to work to try to build some connections between local Lean industry leaders and some willing healthcare leaders… possibly with something in conjunction with the LEI Lean Transformation Summit in Dallas in March 2011. If you're interested in this, from the DFW area, contact me.

Some comments of theirs on standardized work:

Q. How is standardization maintained across the organization while allowing multiple lean process designs? Do you provide guidelines for lean improvement but allow different groups to create their own solutions?

A. Standard work is not etched in stone. It should change based on new learnings. If one unit has learned something new they change standard work. The challenge is how to spread the learnings quickly to other units and, as everyone knows who has implemented lean, spreading it is the hardest part.

From earlier discussions that ThedaCare has posted online, the idea of “yokoten” or spread doesn't mean just jamming a new best practice down the throat of other units. The 2nd unit learns from the 1st but then tries to improve the process, sharing learnings back to the 1st unit in a PDCA model – not just copying.

I'll also share is something I believe in very strongly, that “resistance to change” is often just an excuse from leaders:

Q. How do you specifically deal with people who are very resistant to change?

A.   Everyone is resistant to change. The question is, what is in it for people to change: is my work life going to be better; are the patients going to be safer; is the staff going to get more engaged? Until we train people on the fundamental components of lean we can't expect them to have a clue about it. Most “resistance” is actually our fault for not figuring out what are the benefits of change for people.

Or I'd add that a lot of resistance would be the fault of leaders for not engaging people in improving their own work. When we say “people hate change,” I believe strongly that it means “people hate to be told what to do.”

One great answer from Roger that I'll share on intrinsic motivation and tapping into that powerful force:

Q.  How did you motivate people to think and act lean?

A. As John and I stated in the  On the Mend , motivating people is not something that we accomplished directly in order to generate an engaged employee or physician. Rather we trusted that the professionals working for ThedaCare are already motivated to do the right thing for the patient and to do the right thing professionally. Our energies were focused on aligning that intrinsic motivation that our professionals already bring to their work, with the needs of the ThedaCare organization, to provide a very patient- focused, provider-focused, and friendly waste-free care delivery process. When you begin thinking about “motivating” other people, you are going down a trail that, over the long haul, can only be construed as  manipulation, and we are very sensitive to that in our culture. Rather, we would prefer to err on the side of assuming intrinsic motivation that already exists. Where we find that intrinsic motivation to do what is needed does not exist in a specific individual, it's possible that that individual is the wrong talent for our culture.

OK, I've cut as pasted enough… go read the whole Q&A at Feel free to add comments or questions here and I'll try to get John to participate possibly.

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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. I’m reminded in the last part on motivation that more often then not, management’s attempts to “motivate” are often likely to demotivate or have other undesired consequences, particularly in a service organization filled with professional staff.

    I also think we need to keep in mind the difference between “change” (e.g., a new process) and “transition” (e.g., new attitudes and beliefs that support and sustain the new process). As one of my MBA profs of long ago would say, “Change might be hard, but it is the transition that is a bitch”. Acting lean might be easy (with the proper supports in place) … but truly thinking lean is often very hard, especially when some people will need to let-go of their past ways of thinking.

    Ron K (PT Wonk)

    • I’m reminded, Ron, of Dr. Deming’s chart that showed how a person’s motivation can only go down. Management can only avoid demotivating people. Deming taught, as you said, that so many posters and incentive plans, designed to motivate, really end up having a demotivating effect because management doesn’t understand variation or psychology.

      Thanks for your comment.


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