Len Berry on The Promise of Lean in Healthcare and Lessons from ThedaCare

Joining me for Episode #169 is Leonard L. Berry, PhD,  Distinguished Professor of Marketing in the  Mays Business School at Texas A&M University. We are talking about his article that he co-authored with John Toussaint, MD  Mayo Clinic Proceedings:  “The Promise of Lean in Health Care” (PDF)  – which I blogged about earlier.

In our conversation, Len shares insights from his time embedded at ThedaCare, one of the pioneers of Lean healthcare. He explains how Lean applies not just to manufacturing but to knowledge work and healthcare services, and why standardized work should be seen as a platform for creativity and continuous improvement rather than a constraint.

We also discuss the importance of leadership commitment and cultural transformation in sustaining Lean. Len reflects on the role of senior leaders in building trust, empowering frontline staff as problem solvers, and creating a culture of relentless improvement. His perspective as both an academic and an embedded researcher offers a unique lens on why Lean holds such promise for healthcare organizations.

Show notes and links:

• Mayo article
• His previous book Management Lessons from Mayo Clinic: Inside One of the World's Most Admired Service Organizations

This episode is produced in partnership with the  Healthcare Value Network.

For a link to this episode, refer people to www.leanblog.org/169.

For earlier episodes, visit the main Podcast page, which includes information on how to subscribe via RSS or via Apple Podcasts.

Transcript:

Mark Graban: Hi, this is Mark Graban. Welcome to episode 169 of the podcast for March 27, 2013. My guest today is Professor Len Berry. He's a Distinguished Professor of Marketing in the Mays Business School at Texas A&M University. And we're talking today about the article he co-authored with Dr. John Toussaint in the Mayo Clinic Proceedings. It was titled The Promise of Lean in Health Care.

In this podcast, Len talks about his time being embedded as a researcher at the ThedaCare Health System in Wisconsin and the lessons he learned about Lean and healthcare. For a link to the article and a link to his previous book, Management Lessons from Mayo Clinic, you can visit the show page for this episode at leanblog.org/169. This episode is produced in partnership with the Healthcare Value Network and you can learn more at the ThedaCare Center for Healthcare Value's website at createvalue.org. Thanks for listening, Len. Thanks for being a guest on the podcast today.

Len Berry: My pleasure, Mark. I'm looking forward to it.

Mark Graban: So it's going to be a real pleasure to talk about your article that you co-authored with John Toussaint. I was wondering if you could start by telling the listeners a little bit about your career and your work leading up to today.

Len Berry: Sure, Mark. I am a marketing professor. I'm in the Mays Business School at Texas A&M University and my area of specialty is the marketing of services and the quality of service. For most of my career, I focused on the commercial sector and doing my work in services marketing and service quality. About 12 years ago, I did a medical leave at Mayo Clinic and it was my first major research foray into healthcare and I got hooked on healthcare. I came back just absolutely fascinated with the opportunity we have to improve it, improve the service experience, improve efficiency, effectiveness of healthcare, reduce waste, all of that. And so for the past dozen years or so, I've been doing most of my work in healthcare service, healthcare service research. And that led me to my most recent big field research project which was in the state of Wisconsin and led to the article The Promise of Lean in Health Care that we're going to talk about today.

Mark Graban: Now that first experience you had at Mayo led to a book, if you could talk about that a little bit, right?

Len Berry: Yes, I wrote a book. It's actually a management book entitled, it's a co-authored book entitled Management Lessons from Mayo Clinic. It's a research-based analysis of how Mayo does what Mayo does to, for the last 150 years, have become and to have sustained a global reputation for excellence in healthcare. The book tells the story and articulates the management lessons from Mayo Clinic that apply really to any kind of industry, any kind of organization, not just healthcare organizations. It's been out a couple of years now. It's doing very well and it's been translated into many languages. My co-author, who was 14 years marketing director at Mayo Clinic, Kent Seltman, retired about the time the book came out. So he's been globetrotting around the world talking about the book while I toil away in my classroom at Texas A&M. Anyway, studying at Mayo was a powerful learning experience for me and it got me going in healthcare. So I'm very grateful to my association with Mayo Clinic.

Mark Graban: So we'll transition maybe from one of the world's biggest names in healthcare. Everybody knows the Mayo Clinic to ThedaCare, who's certainly become, I think, well-known to this listening audience for their 10 or 11 years of work applying lean management principles to the improvement in healthcare. But I think to a lot of people, Appleton, Wisconsin is maybe an obscure place. And ThedaCare doesn't have the name of a Mayo Clinic. So no disrespect to them for that, but I was wondering if you can talk about how it came to be that you were embedded there at ThedaCare to be able to spend time studying and researching what they're doing?

Len Berry: Yes. Well, how that happened, Mark, is I was looking for another big sabbatical-like field of research experience in healthcare since the Mayo study. I'd been to many other health institutions for briefer studies or briefer visits, but I was looking for a more in-depth experience. And I actually was in touch with the CEO of the Institute of Healthcare Improvement, who's a friend of mine, and was telling her about my plans for my sabbatical and gave her a list of famous health institutions I was thinking about studying and she said, “They're all great. I'll help you get into anyone you want to study at. But before you make the final decision, you ought to consider going to Wisconsin.” “I'm going to be there in the winter. You really want me to go to Wisconsin?” She said yes.

And then she described three institutions that she and the IHI organization are very familiar with in Wisconsin. High-performance institutions and ThedaCare was one of the three. So what I decided to do and what I did during the fall and winter of 2011, I spent four months in Wisconsin in the field studying. What I decided to do was to study all three. So I spent a month at ThedaCare in Appleton, but I also spent a month at a health system called Gunderson Health in La Crosse, Wisconsin. I spent a month in Green Bay studying at Bellin Health. And I went to Wisconsin because I was intrigued by how one state in relatively medium-sized or small communities, as opposed to Chicago or New York City or Cleveland or Baltimore, relatively small communities like Appleton, Wisconsin, had such high-performance healthcare. And I wanted to see if I could figure out what was going on in Wisconsin and if there were lessons from the three organizations, lessons that could be translated into a model that could then be shared with the rest of the country. Because everybody listening to this podcast, I think, would agree with me. We have a long way to go in terms of improving healthcare. So that's why I went to Wisconsin. And that's how I ended up at ThedaCare. And I spent a month embedded in ThedaCare in their hospitals, in their outpatient clinics, in their administrative offices, listening, interviewing, observing, going to meetings, watching what goes on. And now I'm in the process of writing up the research. The article we're here to talk about today about Lean is primarily from my work at ThedaCare.

Mark Graban: So the article, and I've shared it on the blog, the article from the Mayo Clinic Proceedings, and there'll be links available in the show notes on the webinar, the article does a very nice job of summarizing very succinctly and I think very clearly the principles and management behaviors. What were your key takeaways? Or maybe we can talk through those principles from the article. First off, how would you summarize at a real high level what you saw, what you learned before we get into those principles?

Len Berry: Sure. You know, Mark, my time at ThedaCare was a revelation for me. I'm a long-time experienced researcher and I've spent most of my career, as I mentioned at the outset, but in quality. But I really didn't know much about Lean other than what I had read or heard. And just the name Lean itself, which is not the best name for what it actually is, when well done, has connotations that don't facilitate true understanding of what it is. So I had to go to ThedaCare to really learn Lean and boy, I learned it because I was blessed to have the opportunity to study up close one of the finest practitioners of Lean in the country, perhaps the world. That's the ThedaCare organization.

One of the revelations for me was how well Lean applies to knowledge work. Because when you first think about Lean, if you don't know much about it, you think of it as a manufacturing philosophy. It comes from Toyota, comes from Japan, and that was my image.¹ And yet Lean is just as applicable, is just as powerful, it's just as relevant to knowledge work, to services, to performances, to the improvement of performances, not just to the improvement of manufactured goods. So that was an eye-opener for me. Another eye-opener for me is how Lean, when well done, when well practiced, well executed, how Lean unleashes creativity in an organization. It just unleashes the power of ideas embedded sometimes in the deep recesses of people's minds into the enterprise for testing, for trial, for application, for implementation. And I didn't expect that. When I did my report out with the ThedaCare management group at the end of my research there, I said something to them that I don't recall saying to any other management groups when I talked to them after studying them. And what I told them is I said, “You know, your organization is one of the most innovative organizations I've ever studied in my entire career.” And I wasn't expecting that when I went to ThedaCare. I was expecting a very efficient, cost-conscious, organization. I wasn't expecting such an innovative, bold enterprise. And that was a big surprise.

Mark Graban: And I think that's not an uncommon perception. I mean, I chuckle when you say Lean is perhaps not the best name for this. That's something we've discussed on here with a lot of guests and is kind of an interesting parlor game in the lean profession. Say, “Well, what word would you have given it if you were in the shoes of the researchers?” To have a word with more positive connotations, I think would certainly be helpful in terms of maybe getting people to even look at the approach. And I think the second misperception, like you said, is people think Lean would only be about efficiency or that somehow this idea of standardizing how we do things becomes stifling, kind of the opposite of innovation and creativity. So I wonder if you could touch on any of those points.

Len Berry: Yes. Well, maybe I'll touch on the last one. And that is the perception that standardization is stifling, because that is a common perception. But what I found, and we write about it in our paper, in fact, our last principle, we have six principles in the paper, as you know, and the last principle is, “Lean is flexible regimentation.” And that phrase actually came from a ThedaCare doctor who used that phrase. We quote that doctor. And what flexible regimentation means is it means that the opportunity for creativity is highest when you actually have standard work to study and to ask the question, “How can we do it better?” When you don't have standard work, when you don't have something to really focus on and study and measure, then creativity and improvement is much more difficult. So having the regimentation, in other words, the standardization, in order to encourage the flexibility, the creativity, the innovation, is something that isn't obvious until you really look closely and study it. But I think that's a really important part of the lean movement is the opportunity for improvement that comes from standardization.

Mark Graban: And did you find a lot of, I'm sure you spent a lot of time with physicians. Do you think that was a fairly commonly held belief amongst the different physicians you talk to? Because I think that's one group where some of these ideas are even kind of more… I don't know if controversial is not the right word, but where there's skepticism. “So how can this apply to what we do in terms of patient care?”

Len Berry: Yeah, you're right, Mark. There is a lot of skepticism. There's actually a phrase in medicine which is “evidence-based medicine,” and it's a phrase that causes some physicians, not all, but some, to recoil, to retreat, that creates a negative reaction in front of physicians. They want to do it their way. They have a lot of experience and they know what's best for their patients, and they don't want any kind of textbook solution to how to handle a particular medical condition. So there is a lot of pushback and resistance. And there's been quite a bit of literature in the medical journals on this topic. Now, of course, ThedaCare, they've been on this journey for so long now, seven, eight years, something like that, that much of the initial resistance has melted away. But you go to other medical organizations where lean hasn't really made a dent yet or hasn't been introduced yet, and you'll find, I'm sure, pockets of resistance to the concept of standard work in medicine or anything else. What motivated John Toussaint and I to write this article is we wanted to explain Lean and what it really meant to physicians, which is why we placed it in the medical journal. The Mayo Clinic Proceedings is one of the top medical journals, and it reaches about 130,000 physicians worldwide. And so we were purposeful in picking the outlet that we wanted to put this summary of the Lean principles in. We wanted to see if we could help move the needle in terms of physicians understanding what's inevitable in healthcare. And that's the continuing evolution of application of Lean.

Mark Graban: And it's great, like you said, to get that exposure to physicians. I think one of the other audiences for the article, and you write quite a bit about the role of senior leaders, and I think it's fair to say we're still trying to convince senior leaders in a lot of healthcare organizations that Lean principles are helpful, can be transformational, and that they have a very important role to play in making that happen, whether it's principle one in the article, creating an attitude or a culture of continuous improvement or these other factors. Can you talk about what you learned or what you saw about what senior leaders are doing at ThedaCare or other organizations where this is working well?

Len Berry: Yes. I was very impressed, Mark, at ThedaCare, with the commitment of the senior leadership to Lean, which requires a significant role change for a senior leader in organizations. Because if you're really going to do Lean well, then you have no choice but to trust your frontline staff, your frontline workers, to become chief problem-solvers, chief investigators, chief solution makers.² And your job then as a senior leader changes from the tradition of you being a problem-solver to supporting the field where the problems are addressed and resolved and solutions are developed.³ And as we point out in our article, that's perhaps the biggest challenge that many organizations face in truly and in an authentic and meaningful way implementing a lean philosophy. And that is the need for senior leaders to relinquish the command-and-control kind of leadership that many traditionally have followed and to develop the trust in the frontline staff. And we trust in them to be able to support their work, to enable their work, to invest in their work and to ask them to go forward in the problem-solving role. Some organizations just probably going to need a leadership change for the Lean movement to really take hold within them. Whereas others have leaders that simply need to learn about the potential and the promise of Lean and need a teacher, a sensei, and get started. It's a journey. It's not easy. There's nothing quick about it. It's cultural transformation. If you're going to understand Lean, the first thing one has to understand is this is a cultural transformation. We are going to change the way we do work in this company or at this organization or this hospital. And if we're not prepared to do that, we are not prepared to do Lean. And some organizations are ready and some are not, for that.

Mark Graban: So now, to the question and maybe to sort of wrap up the discussion, will others take on that challenge? The title of the article, I'm curious to hear how the title came about, is The Promise of Lean in Healthcare. It seems like at ThedaCare and like you said at Gunderson and other organizations, it's more than just a promise. But I guess at the larger level there's still maybe more promise organizations than there are ThedaCare organizations. What's your… I'm curious a little bit about the title and then what's your hope about that promise? Do you think it'll be a promise fulfilled in the future?

Len Berry: I'm cautiously optimistic, Mark, that there is enough momentum underway with Lean and healthcare today and there is enough interest about Lean and healthcare today that we are on the road, we are underway in the journey in the United States to start to apply Lean in a very meaningful way to the knowledge work we call healthcare. Now, having said that, I go back to my earlier statement and that is there still remains, and there will always be pockets of resistance, but there still remains a very large block of healthcare institutions in the country that have no interest in Lean whatsoever or they've heard about it, but they don't really know what it is. They could realize it and think it's just some kind of program or maybe they can have a seminar on Lean one day and do Lean. There are many organizations still in healthcare like that and it's going to be a slow process, but we are underway.

John Toussaint's organization that's affiliated with ThedaCare does a course, a two-day course. When I was at ThedaCare, I attended the course as part of my training and it's a wonderful course. It's oversubscribed. They do that course, I think, every other week. I've been to ThedaCare and I've gotten to do the two-day CEO site. Yeah, it's excellent. I mean it's a fabulous course. And it's oversubscribed. Every other week they have a contingent of people coming from all over the country and sometimes from other countries to take that course. And so there is growing interest in healthcare and there should be because healthcare needs to change and change dramatically. There's too much waste in healthcare.⁴ There's too much variability in healthcare. There's too many unnecessary applications and adverse patient outcomes in healthcare. There's too much cost in healthcare. Healthcare needs to change in a dramatic way. And I'm excited to, with my knowledge of healthcare that I've been honing over the last dozen years to have added to it my growing knowledge of Lean because of my time at ThedaCare and my time studying with the other ThedaCare leaders. And I'm really excited to have the background in Lean that I now have to see if I can help in some way, like writing articles or books or whatever might be coming next, help push this movement forward a little bit more.

Mark Graban: Well, I hope your article will help push the ball forward. I agree with you. There's so much opportunity, there's so much need. The human cost, the financial cost of waste and defects and problems in healthcare is so huge. I certainly admire all the great work that ThedaCare has done, John Toussaint and of course Dean Gruner, the current CEO and the other senior leaders who are not only doing such nice work in Appleton, but they're so kindly sharing what they're doing with others. It's really inspiring. And Len, I'm really happy that we were able to talk today and have you share your experiences and to be able to talk about the article. I hope everyone goes and reads it and checks out your book on the Mayo Clinic. Do you have any final thought that you might want to leave the listeners with about what you've learned in the course of this research?

Len Berry: Well, yes. First of all, Mark, let me thank you for your interest and for having me as a guest in your podcast. I really appreciate it and I appreciate your efforts to increase the awareness of the article because it is meant to help clarify what Lean really means. And there's because it's so prone to misunderstanding, starting with the word, as we discussed. But it's a much more complex, much bigger commitment, much greater investment than people realize when they first hear about Lean. And it's applicable to any organization, to any process, to any service. I mean, that's the magic of Lean is that whatever you do, whatever your profession, whatever your company or industry or organization, whatever your role in an organization, Lean applies to you, it can help you do your work better. I think the thought I would leave for your listeners is a quote. It's a quote we use in the article that I heard from consultant Joan Wellman. When I heard her speak, it was very powerful for me. It resonated with me. And let me leave that quote with you to end our interview. Here's what Joan said: “With Lean, you keep changing your definition of what good is.” And I found that at ThedaCare, they're just relentless in their journey to improvement. Relentless. As good as they are, they're one of the best health systems in the country. They're relentless in trying to get better every single day. And it was inspiring for me to be able to study there.

Mark Graban: Yeah, because that is a very special thing when you see that kind of culture in place. So, Len, thank you so much for taking time to talk today. Again, our guest has been Len Berry, Distinguished professor at Texas A&M University and the Mays Business School. Len, thanks for sharing your experiences with us here today.

Len Berry: You're very welcome. Thank you, Mark.

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