Is it Lean’s Fault or the Old Management System’s?
It's easy for an organization to say they are “doing Lean” or they have “started a Lean transformation.” They might hire a consultant or put out a press release… or maybe there's an optimistic (but premature) news article about how the hospital or health system is going to turn around with Lean.
The problem is the culture doesn't change overnight. Leaders have years or decades of old habits (bad habits) that run counter to Lean thinking. They might be (might!) be trying to change, but people will still fall back into old habits, especially when under pressure.
I hear complaints (in recent cases) coming from different provinces in Canada that say things like:
- Lean is causing hospitals to be “de-skilled” by replacing nurses with aides
- Lean drives a focus on cost and cost cutting, including layoffs or being understaffed
- Lean is stressing out managers by asking them to do more and taking nothing off their plate
- Nurses hate Lean because they aren't being involved in changes
All of those comments get blamed on Lean. But, having studied and practiced Lean for 20 years, none of those complaints sound like Lean at all.
It sounds like what I call “L.A.M.E.” — Lean As Mistakenly Explained or Lean As Misguidedly Executed. If those things are really happening, it's not “Real Lean,” as Bob Emiliani calls it.
In all of the books I've read about Toyota… in all of the coaching I've received from former Toyota people (in both manufacturing and healthcare settings)… and my own books about Lean healthcare, nobody teaches that Lean should be used to drive layoffs. In fact, we strongly caution against it for many reasons… because layoffs are demoralizing and they're not usually the right long-term fix.
Read this hospital CEO's blog post on this topic. The old traditional management thinking is to cut costs by laying off staff. There's a lot of that going on, unfortunately, in healthcare these days.
Lean is the ALTERNATIVE to layoffs. Being cheap or understaffing or not working together with people… that's the OLD management thinking that's been taught and practiced for decades.
So, let's say an organization has started on their “Lean journey.” Old habits are hard to break.
What happens if a hospital hits a financial crisis (such as significantly lower Medicare and Medicaid reimbursements in the U.S.) just six months into this planned “Lean transformation?”
The Lean people (the consultant, the director of process improvement) might argue strongly against using layoffs and other short-term cost cutting. But, the senior leaders fall back on old habits and hire a non-Lean consultant who tells them how many people to fire (based on spreadsheets and benchmarks). The non-Lean consultants tell them to fire nurses and hire more aides because their “ratios” don't look good compared to the benchmarks.
Let's say they do all of this (and layoffs and deskilling) without actually studying the work or engaging the people.
Can we blame things like deskilling, stress, and layoffs on Lean?
NO! Those things were happening long before Lean.
On the topic of “de-skilling” — in a Lean approach, we talk about the “waste of human potential.” This includes the waste of not engaging people fully in improvement (such as through Kaizen). It also means that we shouldn't have people consistently working below their job level, education, and certification.
We'll study the work being done in a unit (including nurses, housekeepers, aides, unit secretaries), etc. to see who is doing what work — as part of a “standardized work” analysis. A key early step is to ask “who is doing what and who should be doing what?” If nurses are too busy (and they usually are), one thing we can do to free up time is to make sure aides are doing work that aides can do. This allows nurses to focus on the patients – it's compassionate to do so for many reasons, including better quality and patient safety.
We then have to make sure that the aides aren't overburdened, with too much work to do. We can remove unnecessary tasks from their plates (i.e., waste) or we can maybe actually hire more aides. The goal with Lean isn't headcount reduction — the primary goal is doing the right work the right way and making sure we have the right staffing to do so. That's Lean… and how it's different than spreadsheet-driven “de-skilling.”
Lean doesn't do anything good or bad… Lean is just a set of principles. But these principles, as powerful as they can be, are often misunderstood (reading one book or taking one class doesn't make you a Lean expert) or they are just ignored. We can't blame Lean or a lack of Lean… we can really only blame the senior leaders.
I know, you're thinking, “But you say blaming people is cruel and counterproductive. Didn't Dr. Deming teach that?”
Yes, but Deming also taught that quality starts in the boardroom (or in the government, if it's public healthcare) and Deming certainly held them accountable for their policies and decisions. It's fair to do the same today, I think, if leaders are making decisions based on traditional thinking that get in the way of Lean and quality.