Regular readers might know that I'm working on a second book project, about “kaizen” (continuous improvement) in healthcare. Sign up to receive more info about the book, Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Improvements.
I have a lot of experience teaching kaizen methods and principles to healthcare leaders and staff, but I've been re-reading many of the classic texts – including Masaaki Imai's books Kaizen: The Key To Japan's Competitive Success and Gemba Kaizen: A Commonsense, Low-Cost Approach to Management. One question that's always interesting to talk about – and I'll be posing it to people at a former client of mine today… what are some of the barriers to “kaizen” – both before Lean was introduced and after starting down the Lean pathway.
What are your experiences? Please leave a comment on the post here – if you're from healthcare, please say so. You can enter your name as “Anonymous” if you like. Please contact me if you think you have stories (negative or positive) that you might want to have included in the book, or leave your name and email address with your comment. This will be the first in a series of posts about Kaizen, so there will be plenty of chances to tell your story. From reading Gemba Kaizen: A Commonsense, Low-Cost Approach to Management again, this time on my Kindle, and I shared some notes online (or at least I think you should be able to read the comments as I've made them “public”), quotes such as:
In this context, the word cost does not mean cost cutting, but cost management. Cost management oversees the processes of developing, producing, and selling products or services of good quality while striving to lower costs or hold them to target levels. Cost reduction in gemba should come as a result of various activities carried out by management. Unfortunately, many managers try to reduce costs only by cutting corners; typical actions include firing employees, restructuring, and beating up suppliers. Such cost cutting invariably disrupts the process of quality and ends in quality deterioration.
Ohno urged managers, too, to visit gemba. He would say, “Go to gemba every day. And when you go, don't wear out the soles of your shoes in vain. You should come back with at least one idea for kaizen.”
Hence the five golden rules of gemba management: 1. When a problem (abnormality) arises, go to gemba first. 2. Check the gembitsu (relevant objects). 3. Take temporary countermeasures on the spot. 4. Find the root cause. 5. Standardize to prevent recurrence.
and the funniest:
Jogging for health should be done in the gym, not in gemba! Ironically, some factories are equipped with gyms that have running tracks, but the workers spend more time jogging in gemba during working hours than in the gym during off hours.
One challenge he cites:
In Japan, the suggestion system is an integrated part of individual-oriented kaizen. The Japanese-style suggestion system emphasizes morale-boosting benefits and positive employee participation over the economic and financial incentives that are stressed in a Western-style system.”
What's your reaction to that statement? What are your challenges with instituting a “kaizen spirit” in your organization?
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Mark – Often, the zero-sum (win-lose) routines that have long existed in an organization is carried over into kaizen – whether in healthcare or any other type of organization – which creates substantial barriers. Also, kaizen is actually quite difficult for managers to understand beyond its surface-level meaning of “continuous improvement” – especially if they don’t participate in kaizen. Both large and small errors in management’s understanding of kaizen invariably lead to big problems which can quickly result in perfunctory improvement activities that yield little benefit to patients/customers, and, eventually, the death of continuous improvement in organizations.
I had a quick discussion with a healthcare leader this morning, one barrier he was raised was people being busy and not remembering to follow up on ideas. So it seems there are conceptual barriers (as Bob notes) and more tactical barriers, if you will – how do we keep track of ideas and how do we make time for follow up.
I was giving a presentation to some unnamed executives and asked, “Who here thinks our projects cost too much?” None raised any hands. “Who here thinks there’s a problem with our development schedules?” No hands, again. “Who here isn’t satisfied with the quality of life we give to our employees.” Again, no hands. “Who isn’t happy with the features we ship?” At that point, one of the executives turns to the others and says, “You better all raise your hands on this one.”
That’s my challenge.
@Andrew, it sounds like a combination of fear and groupthink gets in the way of kaizen?
Fear of change, fear of failure, fear that change will lead to failure. There’s certainty that the current system “works to a degree”; but, what will change bring?
And, group think primarily from the hierarchical system in place. It generates a lot of trickle-down thought (a manager’s idea influences the next manager in line and so forth).
Of course, that’s from games, not healthcare; but, I think we all have something to learn from one another :)
@ Mark, Andrew:
And yet another fear:
I regularly talk to colleagues who have great improvement suggestions, but keep them to themselves. Why, I ask them?
Well Martin, if I said it aloud, they’d make me responsible for this, and that would mean doing work for free in my spare time.
Mark, two related thoughts about the difficulty of Kaizen in healthcare.
1. Lack of a process focus – particularly nursing. Nursing leadership is focused on programs and front line staff are focused on tasks. Don’t underestimate the culture around either especially as you introduce new concepts that will be perceived by some as challenging the very essence of nursing. I know of a physician leader who recently took a number of staff to a high performing process intensive enivironment to observe tight process management. During the debrief the nurses were dumbfounded to describe even some of the most obvious process synchronization that was taking place. Even bigger challenges happen with nursing leaders who seem to have been taught that the solution to problems is another program rolled out through the nursing structure from on high.
2. The other related thought is that many (some? most?) leaders in healthcare acknowledge that while there are problems (medical errors, service break-downs, patient harm, avoidable readmissions, etc. etc.) all around them, still believe that they are doing a most excellent job. I have talked with folks that have first hand experience with the real deal Toyota senseis and they describe the experience a being fairly brutal. It has recently occurred to me that the likely reason for doing this in a “respectful” environment is the need to tear the student down in order to build them up. Without doing this many would not acknowledge their own failures. Take a group of healthcare leaders to a world class manufacturer and hopefully most would be humbled by the attention to achieving perfection that isn’t part of their own workplace. Unfortunately some will not be humbled and be dismissive of the relevance and will actually try to trivialize what they have just seen. These are the dangerous ones.
Mark, related to your comment about having ways to follow-up on and manage improvement ideas, I’ve found it difficult in clinical settings to use visual control boards and idea boards. Whether it’s the clinical leadership being worried about displaying internal information in locations where patients might see it, or something as mundane as not being able to place paper sticky notes on wall due to fireproofing requirements, this has been a challenge. It’s usually solvable with a little creativity and cooperation, but it can be somewhat challenging at times.
Also, many of the clinicians I’ve met are extremely action-oriented. This is great when there’s a need to put in place a “temporary countermeasure on the spot.” This can be challenging when trying to “find the root cause” and “standardize to prevent recurrence.” They are prone to jumping straight into identifying countermeasures, and don’t spend enough time trying to understand the problem at a deep level.
Another challenge of achieving kaizen in healthcare is the hesitancy of non-clinical staff to go to the gemba if it’s in a clinical area (especially an ER, ICU, trauma unit, etc.). Improvement initiatives often cross the boundaries from non-clinical to clinical, so if there is hesitancy to engage in a clinical gemba, kaizen can be challenging.
Here are a couple of general observations I have seen in healthcare:
1) I think people in a hospital frequently believe the problem lies in the upstream or in the downstream and therefore are powerless to make imrovements. Sometimes upstream and downstream relationships are dysfunctional. Both groups seem to blame each other and never work together to fix things. Also, some groups have a difficult time finding something in their own garden to weed before complaining about other’s.
2) There is no improvement capactiy time built in for daily small improvements. People already feel overburdened, so daily kaizen feels like just another task thrown on top of everything else.
2 things, but first, I am blown away by the comments in this discussion. The insights are superb and get to some of the very real issues at hand. Thank you all for sharing.
Cynical comment: we struggle with basic management skills across healthcare, why would the ability to manage continuous improvement be any better than so many other fundamental management behaviors? The history in healthcare is to promote good clinicians into management roles rather than treating management as a professional skill set. Those managers that were promoted/hired for their management skills, or those that have had good training and mentoring, are the unfortunate exception. The challenges with kaizen are a case study of the bigger problem.
Optimistic note: there are some demonstrating phenominal success in the face of all of these challenges. I know a Supervisor in the basement of a hospital that used to think his job was primarily to make sure people showed up and then put out fires as they appeared. However, once someone showed him some other options, he picked up and ran like no one expected. He now revels in the opportunities ahead, he has built time into his staffing schedule (funded by earlier process improvements) so that every employee has time to work on kaizen (plus the occassional dedicated project team), and in 4 years every time I have had the pleasure of dropping in for a visit, he and his staff have new improvements and stories. And it isn’t just him, his staff has the fever too – and they have a great example to show them how to do it.
From an anonymous correspondent (shared with permission):
In the spirit of making things visual, but not so public which could be a concern in healthcare versus a plant (my focus), yet without burdensome administration which nobody has time for, it is often helpful to create a simple spreadsheet of the ideas that come out of kaizen efforts, suggestion programs or the like. You can include a brief description of the concept, the date first suggested or proposed, what motivates it (better quality, better customer service, safety, time- or cost-saving, space saving, higher reliability, lower maintenance, whatever), any investment required to implement (in equipment, facilities, added space, etc.), any training needed and by and with whom and maybe how much time involved, priority based on expected result balanced with the other factors (a sort of cost benefit guess), expected time to implement, quantification of result if it can be estimated, any maybe who on the team will be the focus for leadership of implementation or further research or the like, and status of work on idea. You can add whatever other columns of comments, measures, milestones or whatever are appropriate to the particular setting.
One member of the team updates the spreadsheet with additions, deletions (maybe moved to a second spreadsheet so they are not lost on why idea was not pursued for future reference), and a change in status with maybe a color code indicating changes since the last issuance so they can be quickly seen (and where noting is happenening can also be seen). The same member can distribute and follow-up with team members on actions, from an information focus versus nagging. I like to have it updated at least bi-weekly and never longer than monthly, and the team can use in its meetings as a tool to spur actions, give help where needed, etc. It’s always helpful to have proposed improvements summarized somewhere (on paper or electronically in a shared file which is better) so they stay front and center and the team keeps focused on implementing them. Otherwise they get forgotten, a lot of time is spent re-hashing the idea all over again, and most importantly improvements don’t get implemented. The keeper of the spreadsheet is best if the biggest champion in the group re continuous improvement as well. Keep it simple, keep it timely, keep making things happen which always leads to more improvement as folks see results, get more motivated, etc.
While cumbersome rewards programs for suggestions are not very valuable, I have seen companies post names of contributors, numbers of accepted ideas submitted, and numbers of ideas implemented — a public recognition which is often better than a reward. I have seen others have periodic drawings of some token reward (restaurant gift certificate, sports tickets, etc.) with numbers of ideas submitted representing numbers of chances at winning. All seemed to keep focus on programs to have continuous improvement and resulted in more suggestions.
I definitely think it’s a key kaizen principle to celebrate each improvement. Posting ideas and completed improvements on the wall or in some format helps people feel good about the changes they have made, and that encourages more improvement.
I agree that recognition is often better than a reward. Financial rewards and bonuses for ideas can be problematic or create dysfunctions (such as people focusing on the reward instead of on improvement). Healthcare professionals have a great intrinsic motivation for improving patient care…
Barriers to Kaizen – effort, potential complexity and time to complete. U have habitually used what you might recognize as a ‘point kaizen’. As I work in the service industry at large I have found it much more easier to take one consumer or customer scenario, package it as a service request, and then inspect the ‘service request pathway’ or journey across the provider organization, or through the practice based response.
I have designed tabletops to help, and find that any and all staff members can contribute without training, and help document what happens and hat should happen.
Problem management methods are used to define the problems discovered and their impact upon stakeholders.
Then lean methods are then introduced and applied as utilities to create solutions and a final package – an opportunity for improvement’. A simple summary but. All of this is designed to be completed in a 2 or 4 hr session as a team, and a solution sized to implement in the next 30-day cycle.
Other reasons given in an email from a healthcare reader:
– Management’s short-term focus leads them to want any activity to have a documented ROI
– No manager can go ever over their labor budget without getting in trouble
The first dynamic leads to people looking for big projects, often called “innovation.” Innovation is important, but so is kaizen. Little small tiny improvements ultimately hit the bottom line, but you don’t (or can’t) take the time to calculate an ROI for every little improvement.
Small tiny improvements lead to improved morale also, as Imai points out, which has got to be good for innovation.
The second point about never going over your labor budget seems like classic short-term thinking. If I can’t invest a little time in improvement by maybe keeping people over 30 minutes to work in a problem that will save hours of time each week in perpetuity, then I’m sunk.
Regarding the comment submitted by email about ROI, I concur. I think this stems from managers doing their best to adhere to project management best practices. Problem is, kaizen activities are not synonymous with projects. Lots of differences, such as the ongoing nature of kaizen, and the “kata” aspect of kaizen. Unfortunately, many in healthcare equate kaizen to projects. My PI department was referred to yesterday by a clinician as the PM department, just as an anecdotal example.
The biggest barrier in my humble opinion is understanding that kaizen events do not equal kaizen. Kaizen is not only top down but also bottom up.
Yes, that’s one reason I’m writing the new book with Joe Swartz. Too many healthcare organizations think that kaizen equals “week-long events.” Agree that lean/kaizen is both top-down AND bottom-up, people working together.
Mark, me again with another barrier. Far and away most people do not place a high priority on learning after they’ve graduated. This is a premise supported by a lot of research done by Donald O. Clifton at U of Nebraska. So yes, change is hard by why is it so hard? Often change requires additional learning. In the lean journey at my own organization we have many that are struggling mightily not because they are not willing to change but because they want to be told precisely what to do and the lean leadership has been unable to tell them precisely what to do because we are still trying to figure it out. And their position is actually logical.
You mean you are going to take us on a lean journey which will deviate from the routines we currently know and you don’t know the details of even the next step after the next and… you want me to figure much of this out on my own?
Some consultants (very few that I know of) have figured this out and are trying to standardize the lean journey. This may or not be ideal but for most it is the practical thing to do.
There’s a real Catch-22 that you identified there. Lean can’t be just a standard cookbook approach (just as we can’t have “cookbook medicine”). It can be somewhat “standardized,” but there has to be thinking, PDCA, and “figuring this out.” Lean is all about learning – and if that point is true that people don’t want to learn, then we are sunk.
If leaders and organizations aren’t willing to do that, I’d argue that Lean won’t likely be successful.
I’ve found, though, that people do want to learn… I wouldn’t write people off that easily as somehow being uninteresting in continuing learning and education.
I’ll refer you to the research by Clifton. I agree most people are not adverse to learning and there is a continued expectation for continued learning, it is just not the strength or preference of many especially in a busy work environment with problems all around. Many prefer to simply be told what to do. I think you would agree that most would rather implement solutions (do) than do root cause analysis (learn).
We talk of learning by doing but often this is accomplished by doing many times. It is very difficult to set up these “many times” opportunities in organization transformations. Going back to the sensei model as I understand it, are not they repetitive to a high degree? Maybe that is the learning model? I think the related barrier then is that this type of repetitive learning is very off putting especially to the western executive.
I am sure Senge has said a lot on this. I’m going to have to go back a read his stuff within this context.
On the idea of people preferring to be told what to do. I think this is often a learned/conditioned response in the workplace (and often a behavior that’s learned in school, see Alfie Kohn, etc.).
I’m reading a great book right now called “Authentic Conversations” (which builds on Senge and another field of study called family systems theory) – the idea is that most workplace relationships are based on the parent/child model and that’s wholly wrong for a high-performing workplace. When the boss emphasizes that they are going to tell people what to do, it’s easy for employees to fall back into a position of “fine, tell me what to do” so when things fail, they blame the boss. So there’s no “kaizen spirit.”
It’s easier to get into that cycle than it is to break it. The Authentic Conversations authors say leaders need to be honest with people, “Start treating workers like adults”, and quit trying to be directive and/or trying to protect employees. I’ll blog more on this in a separate post.
The biggest barrier is the perceived lack of time. There is very little – if any – capacity to dedicate to process improvement. There also can be a lack of knowledge and skill among key senior leaders.
What I most often face is the contradiction of managers readily accepting their role is to put out fires – something that highlights that the process needs fixing – yet they are unwilling to implement a process change unless it can be shown that it will be 100% successful. The idea of iterative improvements is completely unacceptable to them.
From a staff perspective, early lean efforts can cut waste and free up time for process improvement. But too many leaders are stuck in the “send them home early” mindset when there is “extra time” instead of putting that time to productive improvement use.
To the other point, it’s a particularly difficult Catch-22 that managers won’t let you try something new unless there is 100% (or 110%) certainty that it will work 100% perfectly. Well nothing works that way and the current state sure ain’t perfect… but I’ve heard that a lot, that people aren’t willing to try a well thought out 90% solution that you would then PDCA. Certainly prevents any improvement from happening, that mindset.
I have found that the projects that I lead in hospitals often struggle to actually complete the projects because they can’t dedicate FTE time to the actual work. Leaderships sees the value of lean but they can’t define the value in order to justify have a surgical tech work on lean vs being in the OR suite for a case. They struggle with the cost justification of actually completing a 5S project even though it ultimately can equate in both tangible and intangible benefits. I have had so many excited team members who end up frustrated because they are not given the time to complete projects. My personal goal is to help to define the ROI of completing a lean project so that the cost justification doesn’t become a roadblock in the project.
Thanks for that leadership effort with your customers and clients, Suzi!
I’d also like to try to influence people that “ROI isn’t everything” but that is, as I’m sure you and the other readers know, can be a VERY tough sell.
[…] things, but “don’t sweat the small stuff.” As I blogged about recently (“What Are Barriers to “Kaizen” in Healthcare?“), Masaaki Imai wrote: In Japan, the suggestion system is an integrated part of […]
Mark, I can’t let this go as I have come across another barrier in healthcare that I think is worthy of discussion. Clearly there is a CEO or chief administrator at every hospital but for larger facilities out of necessity the CEO has turned the management reigns over the CFO, the CNO, the CMO, the COO and to an HR exec. Each of these execs think they have the solution to the organization’s problems. So unlike most manufacturing plants where the plant manager is clearly in charge and his or her captains understand their role as ancillary support to production, these healthcare execs are often competing for management control. In my own organization Lean is a threat to nursing, hr, operations, patient satisfaction and quality and is really only supported by the CFO because there has been a promise of reduced expenses. You could rightly say that the CEO mismanaged this from the start by not explicitly defining each of these key people’s roles. As many mistakes as Dr. Toussaint confessed to in On the Mend he clearly understood the need to get key players to explicitly sign on. Not an easy thing to do.
Interesting, Anonymous. Why do you think Lean is a “threat” to those leaders? Is it a “threat” because it invalidates their previous ideas that they had to fixing things? I know the reason for hospitals being broken is NOT a bunch of executives sitting around and doing nothing. They might be doing or talking about the wrong things. I’ve seen Lean be a threat to a Director who had been lobbying for a newly constructed department… the notion that Lean could have improved the process in his current space would have made him look bad in a way (looking wrong about the absolute need for new, bigger space).
What do you think the dynamic is?
I agree the CEO just delegating without still having unified leadership is likely to cause problems.
Great question and I had to think about the answers.
I think our organization really struggles with strategy deployment and it starts at the very top. Our senior leaders have a fairly large part of their comp at risk or incentivized. While part of the at-risk comp is for team performance (that for the most part is set at readily achievable measures with a couple of hard to get goals thrown in), there is a big piece that is individual goals. So what we have is a bunch of well comped execs thinking up ways to show how hard they are working. So they are very adverse to subordinating their efforts on something so difficult to describe as “Lean”. We went through a strategy deployment exercise a couple of years ago and it was a fiasco. In retrospect I think it was because after we got agreement on the high level goals some of the well comped execs suddenly realized that they personally were not all that relevant. So the CEO allowed two systems to go forward; one that promoted alignment and one that promoted individual achievement however irrelevant. We have been struggling ever since.
Strategy deployment then is a real test of how serious an organization is about lean.
Thanks for sharing your thoughtful example… it goes to show that kaizen can’t be just all of the front line staff all doing little things… it needs to be aligned across the organization. And I guess if you can’t get your senior leadership team aligned properly, it doesn’t bode well for the organization as a whole.
Agree with Anonymous’ comment which rings true both in my prior healthcare background and now outside healthcare.
In Australia much of the clinical management is autonomous – so in addition to the ‘general’ management streams competing for power, we see whole clinical departments whose interaction with the management – IT, finance, planning etc, is minimal below the top job. So getting engagement in process improvement won’t even succeed with ‘merely’ the Board, CEO, COO, Fin Director, Strategic Planning Mgr and so on onboard.
My own organisation is an amalgam of 10,000 product lines and each has its own tribe, world view, external stakeholders (tails wagging the dog in some cases) and again the management’s ability to set any single priority for this amalgam is strained.
I have certainly seen plenty of evidence of non-management eg “If at first you don’t succeed, destroy all evidence you ever tried”, “Shoot the messenger”, “Don’t do it better, people will ask why you didn’t do it better before” and so on. Much of preaching a message that better is possible is rejected by managers who feel this reflects poorly on their past efforts.
One idea as to an obstacle to kaizen is employees not feeling they will be compensated appropriately for their ideas. For example, perhaps an employee has an idea that will save the company five thousand dollars, but the incentive for sharing this idea will only gain the employee a bonus of five hundred. He or she will be much less likely to share their idea when knowing his or her idea is worth more and he or she will not personally reep the benefits.
[…] recently came across a blog posting about the challenge of sustaining lean initiatives in hospitals. There are many comments posted as […]
[…] It’s a chance to practice writing about ideas in small batches, getting feedback and input from readers (like this post). […]
Many great experiences referenced here. a key one I echo is that Kaizen too easily equals an event, which substitutes for the extremely hard work of instituting a culture. Mr. Ohno worked for ten years to implement Kanban in a single plant. This creates a picture for me of an executive not leading so much by heroically and very visibly “climbing the mountain” as much as persistently tunneling through it, moving the dirt out and making a way for those coming behind. Facilities I have been in do humanly think “the problem” is in the lab, or in admitting, or in triage, etc. All of us need to be helped to see that the problems we have are IN ME also. Once THAT is admitted, we can move on to implementation. IMO. Thanks.
Greg – sounds like you’re saying that one barrier to improvement is people wanting overnight results rather than working at things in a slow, systematic, sustainable way?
Spot on, Mark, but I would combine with many of the experiences of others commenting here; not only wanting overnight results, but also wanting to minimize the felt risk of exposure for something that doesn’t seem to work…yet.
I never closed the loop with all of the great commenters here… this is the table that Joe and I published in “Healthcare Kaizen.”