Why Nurses Should Reject “LAME” and Demand Lean
There's a long-standing argument that I've been dragged into with a group that calls itself “new systems thinkers.” They loudly criticize Lean as being altogether awful (with the alternative, predictably, being their services). One of them wrote a blog post about why nurses should reject lean – you can likely find it via this Google search).
I agrees strongly that sometimes Lean is “done badly” — these are instances of what Bob Emiliani calls “fake lean” and what I've dubbed “L.A.M.E.” This anti-Lean crowd says the existence of anything that's done badly in a so-called “Lean implementation” proves that Lean itself is inherently bad. I think that's hogwash and this post will explain why.
I've written many times on this blog about instances of companies saying they are “doing Lean,” but it turns out they are doing any number of “L.A.M.E.” things including:
- Ignoring Toyota's “respect for people” principle
- Using Lean to drive layoffs or short-term cost cutting
- Not focusing on quality as a primary goal
- Not engaging front-line staff and managers
- Using Lean tools while ignoring the management system and culture
- Being top-down and coercive
L.A.M.E. things have happened in manufacturing companies, accounting firms, and sometimes hospitals. It's unfortunate when these things happen and it reflects badly on those leaders and organizations that are learning how to change their management system – those who are doing Lean the right way.
The real power of Lean is, of course, not the tools – instead it's the management system and culture, as described in great books like Creating a Lean Culture and Toyota Culture: The Heart and Soul of the Toyota Way. The mindsets, philosophies, and management methods in that book are transferable across different industries.
For example, Eric Ries talks about not blaming software developers and using PDCA improvement cycles in his “lean startup” movement. John Toussaint MD talks about the shift away from “naming, blaming, and shaming” as the old predominant culture in heathcare – and they are changing that culture at ThedaCare in Wisconsin (as told in On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry).
The traditional organization is often top-down, coercive, and fear-based. This is, sadly, often true in hospitals (or it's worse than it might be in a typical modern Western factory). When top-down organizations try to force Lean tools at people, we can't expect much good to occur. One could argue, with all of the great books and resources and consultants out there, that senior leaders need to be held accountable for not learning what Lean is really about (management system, philosophy, and culture change) or for not wanting to change.
So back to nursing — the best of the hospitals implementing Lean realize that it's about new ways of seeing work, being more customer (patient) focused, and engaging every employee in quality and process improvement.
Are there likely going to be L.A.M.E. cases where senior leaders continue to be top-down and coercive? Probably — not every leader wants to change (as John Toussaint and others have) and it's tempting to just throw new tools at people, expecting a quick fix that's not likely to happen. For Lean to work, leaders need to change so they can change the culture to something more constructive. Sometimes, that change takes time – people and organizations don't die overnight. Old habits die hard.
Some specific examples of what I'd consider to be “L.A.M.E.” in a hospital:
- Having dedicated process improvement people following nurses and doctors with stopwatches
- Giving medical professionals quotas for how fast they have to work, regardless of patient needs
- Getting rid of materials to have “just in time” inventory, but not having a properly working system that ensures supplies and meds are always available
- Telling medical professionals (or any staff) how to do their jobs (top-down standardized work)
- Laying off people after a Lean improvement effort
- Telling nurses how many pens they can keep at their desk (while patient care suffers)
Nurses should be opposed to all of that. I agree with the “new systems thinker” on that note. Nurses deserve a better workplace and they deserve to be respected and properly supported by doctors and administrators.
But the difference I draw from the Lean critics:
- They see L.A.M.E. and leap to the conclusion that Lean is inherently bad. They throw Lean under the bus and take the tone that these leaders are “idiots.”
- I see that Lean works well when leaders learn about and embrace the full management system. I work to try to educate healthcare leaders who are smart, but have a different viewpoint on management.
When it's really Lean, and not “L.A.M.E.”, nurses should be demanding more Lean. For example, the nurses union in New Brunswick Canada came out in strong support of Lean. That's because Lean was being done the right way – of course they wanted more of it.
Why would nurses WANT Lean? When organizations really embrace Lean:
- Nurses say, “Finally! Management is seeing the problems we face every day and we're going to work together on fixing things.” Instead of feeling neglected, they are being properly supported and involved in process improvement.
- The culture changes to fix routine “Every Day” problems – instead of jumping through hoops and constantly fighting the same fires, they get to focus more time on patient care.
- Lean helps support save care – proven documented examples include reduced patient falls, fewer infections, and fewer cases of V.A.P. — nurses want the best for their patients.
- With Lean, the space is designed and sized to match the processes for nursing care, instead of nurses being forced into spaces that don't have enough bed/equipment storage space, for example.
- They get to design their own standardized work and can improve it through daily huddles and kaizen boards.
- The nurses get to work as part of a team (such as ThedaCare's Collaborative Care model, where the RN helps direct doctors and pharmacists.
- Nurses work less overtime because they have more time during the day to do proper charting instead of batching it at the end of the day.
To those of you with nursing backgrounds, what would you add?
The culture and management system have been clearly defined in the Lean literature – the abundance of books from Jeff Liker, for example, and others. I humbly submit that my book tries to cover these same themes (and has been endorsed by Liker, David Mann, and others I consider experts on Lean management).