Too Many Patients Harmed, Too Few Leaders Committed to Real Change?


Stupid mistakeI recently received two emails that are worth sharing, in anonymous form here. One was from somebody I know who just quit a Lean role at a major academic medical center after a few years there, as he's looking to join an organization that has a “deeper commitment to profound change” (spoken like a reader of W. Edwards Deming's work).

The second email reads as follows (again, edited and anonymized):

I'm an industrial engineering graduate with a few years of experience in the field.   I've been following your blog, podcast, and tweets for a little over a year now.   Your content has helped me stay connected to the larger Lean community.   For example, I picked up The Essential Deming after seeing your post about the book.

I've had trouble drawing personally relevant useful ideas out of your stories on Lean in healthcare.   However, this past week, I spent a day in a hospital to support  my mother.

Upon reflecting upon the processes I was seeing, I was shocked.   This was a reputable teaching hospital and, in the nine hours we were there, I observed two errors that caused my mother physical pain, two that could have led to serious harm, and a good half-dozen clerical and  communication issues.

I was even more surprised when I heard staff members make comments that suggested that these were common errors.

Coming from a manufacturing environment, I've seen plenty of poor processes, but to see a system actively abuse the customer was heartbreaking.   This experience has caused me to start thinking of Lean as a sort of humanitarianism, rather than pragmatism.

As I watched the post-op nurse remove an IV and inadvertently put pressure on a botched IV needle in my mother's arm that she didn't know was there, I couldn't help but feel pity for the nurses who made the mistake.   They felt bad for harming the patient, not realizing that culpability was really with management for designing a bad system.

I've never considered a career in healthcare, but now that I've seen the need for good Lean thinking firsthand, I might have to reconsider.

Thank you for the opportunity to share my story.

As the I.E. writes, these are definitely not situations in which we should blame individuals. I appreciate that he recognizes that (he's clearly absorbing Dr. Deming's ideas).  I recommended that, if he's interested in helping improve healthcare, that he check out the Society for Health Systems (part of the Institute of Industrial Engineers) and their annual conference (where I will be presenting again in February — this time on Statistical Process Control as a way to manage better).

I haven't written about it because it affects me so personally, but my grandfather was in the hospital earlier this year and I heard similar reports from my dad and my aunt about the ongoing parade of mistakes and process problems (including a prescription error upon discharge that could have killed him, said the sharp-eyed retail pharmacist who questioned the medication and the dosage).

My grandfather is an incredibly kind and patient man, yet he was driven to comment, after a few days in a long-term care facility that, “it seems like they haven't done anything right so far.” This included being given the “new admission welcome packet” on Day 3 of his stay and numerous other errors that caused pain, discomfort, or annoyance.

There are so many problems in healthcare, we need “all hands on deck” to come help fix things. I just hope things can get fixed quickly enough. One thing that will help is not alienating and chasing away those who are trying to help, like the guy from the first email.

I recently gave a lecture at a hospital that had hired two engineers from Toyota. The engineers were very sharp and they seemed to be effectively making the transition into healthcare. But, two engineers, no matter how good they are and what their backgrounds are, can't save an organization of 5,000 people if the leaders aren't on board.

In the class I taught, there were about 20 nurses and front-line staff, including a few charge nurses. The higher-level managers who had been invited all had a reason to skip out and not attend – apparently, there was some fire to fight (isn't there always?) and their attendance was apparently not mandatory.

So, I had been asked to talk about “leading in a Lean culture” and I had to re-craft my talk to be more about “here's what it would be like to work in a Lean culture” – and I'm not sure the people in the audience will ever experience this. My talk was meant to helpful and inspiring, but it might have been discouraging and demoralizing. I talked about the need to look at systems and processes instead of blaming people… and they might very well get blamed for some error that's not their fault while they are “working on a Lean project.”

Why are we teaching front-line staff about Lean when their leaders are not participating in the learning? Share on X

It makes you wonder what the point is. Why are we teaching front-line staff about Lean when their leaders are not participating in the learning? At least the front-line staff might be able to parlay their Lean education and experience, as minimal as it might be, into a job in a different health system where leaders are on board with Lean thinking and Lean practice?

What do you think? Please scroll down (or click) to post a comment. Or please share the post with your thoughts on LinkedIn – and follow me or connect with me there.

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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. From a friend on Facebook:

    “Change has to come from the top down. In my current role, I’m a contractor. There was an employee engagement study done. The results were that in all areas except IT, the environment was authoritarian and discouraged innovation and creativity. IT is actively working to do even better. Other areas presented the results, and then proceeded to tell their people: “Now that we’ve got that out of the way, know that nothing is going to change.””

  2. An unrelated posting from a listserv… a process improvement person seeing waste and problems in his hospital stay:

    In a recent hospital stay, my hospital discharged me before they knew I was admitted so assuming all their other measurements were perfect, they discharged more people than they had!

    They also failed to give me lunch the one day I was there during lunch time because the only way the cafeteria knew to provide lunch was from information collected the day before. I wasn’t there the day before so couldn’t tell them. They had no reliable process to remember to ask patients admitted after the lunch poll what they wanted for lunch the next day, or to order something for them. Instead they had an ‘exception’ process which happened after I tackled the lunch lady who of course refused to give me any food because it was all accounted for. Since I had chased her down she also assumed I was healthy enough that I didn’t need any more energy and thus she could not perform the exception lunch procedure for me. In fact, she didn’t even know what that process was. I had to find out from the head nurse. All in all, while the medical part of my stay went well, the lunch part of it was a case study in stupid process design and bad measurement practices!

    Sometimes being a process improvement person is a curse. You observe this stuff all around you. Occasionally I like to point it out to the people where I observe it. Of course they seldom appreciate that so I usually do it only after I have nothing to lose. My lunch process investigation and feedback happened after I was already done with all medical procedures and cleared to leave so they could, theoretically do me no more harm. Don’t get me started about the fact that while they admitted me within 4 minutes, it took them 5.5 hours to process the discharge order!!

    BTW, lunch did arrive fairly quickly after I made the correct phone call and it was delicious! I can’t understand my 9 page bill so I’m sure that someplace in there is an extra few hundred dollars for delivering an emergency lunch to a guy who they thought wasn’t there.

  3. Mark – We are observing the same thing in the healthcare industry. There are always the great exceptions (and their great success stories). For the most part, healthcare is not adapting Lean and continuous improvement deep enough, fast enough, and permanent enough in their organizations. It’s more of a quick training exercise, a temporary “toes in the water” or “check the box” approach by a selected few. Most hospitals could add millions of dollars to their revenue lines if they committed to, and implemented these disciplined approaches to improvement for real. In a recent personal lab visit I asked about Lean and the technicians replied, “Oh yes, we did some training and finished Lean about two years ago.”

    • Thanks for your comment, Terry. Hospitals could not only add millions in revenue (additional revenue, faster cash cycle, etc.) but they can SAVE millions by reducing instances of preventable harm as well as having more efficient processes.

      Yeah, the “check the box” “we did that” mindset is really unfortunate. The same thing has happened in manufacturing, too.

  4. Waste in both physical form in the poor sourcing of equipment and basic items for the proper functioning of the care service let alone poor decision driven changes that not only waste but harm is a concept that is rife within care.

    Dinosaurs within upper echelons who are not only afraid of change but seem hell bent on preventing it in case they appear to break with the status quo or dare I say it stand out. Is a very big problem driving the institutional problems we face in health care today.

    I hope we do get to a point where lean ideas and sensible approaches win over but experience tells me the innovators are driven out before any real change can be allowed to take place.

  5. Sad, via twitter… hearing about a nurse who is “stuck in a ‘Lean to reduce head count 30%” environment’ and wants to break out.” She should run like mad and try to find a better health system to work for. It’s not really Lean if they primary goal is reducing head count by 30%…. and it won’t work anyway in terms of improving processes and quality.

  6. Leadership commitment is a factor that differentiates successful lean improvement efforts in healthcare. I have experience consulting and training with many healthcare organizations over the last 6 years, and where I have had leaders committed to providing the resources needed success rates are high. Where leadership commitment is low, success rates are low and participants begin to lose interest.

    The Affordable Care Act is going to dramatically increase the amount of care needed in clinical settings. Unless the level of errors is reduced and care becomes affordable through lean implementation, the US healthcare system is going to become even more problematic than it is today. Leadership has to pay attention or risk replacement.

  7. To be specific, Virginia Mason has a model than many could use to rally around. The face of their patient safety approach is a patient they killed through a system error.

    I just read in the book “Influencer” a story about how a manufacturing organization took leaders to the home of a disabled employee to see the catastrophic effects of a workplace injury on the lives of the employee and the family. I wonder if we routinely took hospital leaders to the homes of patients their systems have harmed that they would have a different emphasis and reducing patient harm.

    • Virginia Mason – their leadership and their “patient safety alert” system, in particular – are to be admired and emulated.

      That said, in the case of Mary McClinton (the patient who was killed by what I would consider a system error) led to an individual, Carl Dorsey, losing his license, etc.

      Article link

      Maybe an individual wouldn’t be thrown under the bus by the Virginia Mason of today? I hope not. I realize this is complicated by regulatory bodies and licensing agencies, but I think it’s a crying shame that Dorsey had his career ruined. He had tried speaking up about the risk of error and was told basically, “well, don’t make that mistake then.”

  8. It seems that the State Board gave the physician a pass on the tragic event while putting the blame on the tech. So now I am confused. I’ve worked in healthcare for several years and I honestly can’t telll you who iif anyone is ultimately responsible for the safety of a patient in an operating or procedure room. Clearly the State Board didn’t think the physician was. Does anyone know? If the whole team is responsible then isn’t that the same as no one being responsible?

  9. Amen Mark,

    Keep posting examples of healthcare process failures that happen routinely. It’s like the Sixth Sense. We can all see the “dead people” (waste), but most don’t have the gift and think everything is just fine. The only way to drive real change is to make sure the majority are not satisfied with the status quo. Then real change commence.

  10. I left the nursing field last July for many reasons. One is the lack of care for employees from the managers and higher executives. They want one person to do the work of two or three for the same rate of pay then do not understand why there is such a shortage. People do not want to work under those conditions , no matter that healthcare is their passion. Stop staffing by number and staff according to acuity.


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