Be Careful When Going to the Gemba


This is always a tongue-in-cheek warning, but there are times when I warn hospital leaders that they have to be careful when going to the “gemba” (gemba being a Japanese word used in Lean to describe the place where the work is actually done – the front lines, such as the point of patient care).

Lean Thinkers might wonder “what is bad about going to the gemba?” Well, going to the gemba could be a bad idea and could make things worse if leaders exhibit the wrong kind of behaviors.

This old urban legend helps articulate that in a cheeky way:

Thanks to the site, a site that  debunks (or verifies) urban legends and myths, here is one version of a classic factory story (variations are told in different settings and this story could be adapted to healthcare):

[Braude, 1965]

The proprietor of a shop was once passing during the packing room and noticed a boy lounging towards a field and whistling cheerfully. Thinking of all his cash being wasted on this sort of exertions, the corporation requested gruffly, “How much do you get a week?”

“Ten dollars,” the boy spoke back.

“Here's your pay for the week,” stated the person. “Now get out!”

On his as far back as the administrative center, the shop proprietor bumped into the foreman and requested him, “When did we hire that boy, and who is responsible for hiring him?”

“We never hired him,” the foreman stated. “He was just delivering a package from another firm.”

The story is a silly one, but it illustrates one possible failure mode involved with going to the gemba – jumping to conclusions and making on-the-spot top-down decisions out of anger.

As Lean Enterprise Institute CEO John Shook wrote in his most recent e-letter, there are certain behaviors that must be exhibited when going to the gemba.

A lot of the ideas can be summarized in this sentence:

The words of Toyota Chairman Fujio Cho, “Go see, ask why, show respect” are now famous as basic lean principles.

In the urban legend, the shop owner went to the gemba, but he didn't stop to ask why. Arguably, he didn't show much respect by jumping to the conclusion that the boy he kicked out was lazy and shirking work.

As Shook explains, respect doesn't mean being nice all the time, it includes challenging people, but it includes making things better for workers:

Most of all, respect means doing what we can to make things better for workers, which starts by not making things worse. And we still find leaders doing more of their share of damage even as they try to help!

Which leads to the first rule of gemba walking: “Do no harm!”

The shop owner should have talked to the boy. Let's say it was an employee – asking “why?” about the idle employee might uncover a process problem, equipment breakdown, or delay. That's the problem to go after rather than blaming the person who is idle.

If leaders are going to behave in “old school” ways, it might actually be better to stay in your office and the conference rooms. Now the urban legend I shared is a really obvious portrayal, but what are some more subtle examples of the “wrong” sort of gemba behavior? What would make you want your CEO to go back to the office?

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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. Good example, Mark. We tell people to go to the gemba, but often we don’t tell them how, or what to look for, or what their presence in an area will do to the behavior of the people. How and why are important components to a gemba visit.

  2. Mark,
    I worked for a large cooperation years ago when my annual review came up. I worked on salary + commission and was in charge of the internet’s ROI and more, I worked 70-80 hours a week and had to deal with interns that were company executive nieces and nephews and not REMOTELY qualified for the job. Everything I did was pretty much online or by phone. When they brought me in the first thing he said was, “Jason, we need to talk about your desk, it’s really cluttered.”

    What the heck……. I agree…. for me it was the final straw and I put in a 4 weeks notice just a couple weeks ago.

    On a side note, I would love to exchange links with you on my “Medical Noise” blog. Let me know how you want the text to be listed and get back with me.

  3. Hi Mark

    I like the little tale you shared.

    As to the types of people who should avoid a Gemba here is a short list.

    1. Gods, it does matter if the god is an executive, or any professional they come with a total hatred of us mortals, when they come into any Gemba they always leave a path of destruction.

    2. Executive with narrow backgrounds going into any area in which they have never worked. An example a CEO whose background is finance going to a plant floor. Though the real question is why a board would have hired a finance CEO for a manufacturing firm is beyond any realistic explanation, these wrong background types are worse than blind and usually totally alienate everyone on the shop floor.

    3. Micro-managers types, they paralyze everyone around them and breed a culture of total dependence. They are also often members of the god group as well.

    4. Any I am the BOSS and you have to respect me types. Anyone that thinks respect is owed them lack the humility to listen and learn from others.

    5. The, I am irreplaceable types, it may surprise them, but in reality the easiest individual in a well run organization to replace is the CEO. The reality is that all daily activity is actually done by other people, and any good organization can keep to their planned direction with ease till a replacement is found.

    These five types of people should be banned from every workplace.

  4. Showing respect and thoughtfulness is a good idea in nearly any situation. That’s just a nice version on Wil Wheaton’s law.

    It is a little disheartening to think that the pointy haired boss is still relevant in a time when so much depends on working together. Go to the gemba, go often, talk to people and learn something.

  5. This is right on target. Now my question is….How do you put this information in the hands of one of the “Gods” as Mr. Drescher put it?

    I have a #2 and a #3 God at my place of business.

    Even worse than being that way is the fact that they do not realize the negative effect they have on people.

    How do you confront that issue?

    I have not had success with it so far.

    Two years trying!

    • Randy – hate to be cynical, but that sounds pretty hopeless. People have to want to change, and I’d bet that those folks think they are just great and don’t need to improve.

    • Randy

      It may not be totally helpless, since as you pointed out the #1 boss is not the God type. The solution lies in #1’s hands, they have to either force 2 and 3 to change or force them out. Does #1 know about the problems the other two are creating? Would #1 care if they knew about the problem?


  6. Mark,
    I know what you mean. Both of these people mean well, however it is very difficult to change that behavior when they are out of their element in the first place. But, we have to keep trying!

  7. What would happen if a company would eliminate performance reviews for two years? I recognize some believe these are a necessity but give it a chance. After all average workers are constantly asked to adapt to change. We all know how Deming felt about them. Too many just go cautiously from review to review trying not to make a mistake. Periodical Gemba walks could showcase the contributions teamwork and effectiveness of each individual and team. You can’t get to everyone but the culture will change as the true crème rises to the top. I believe this could spark creativity and teamwork. I haven’t fully developed this thought but I’ll throw it in the pool of ideals.

    • I’m with you, David. I know one Lean healthcare leader who said, privately, that he wished he could do away with the annual performance review system… but he’s not the CEO and he’s not going to take on that battle.


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