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.”

Also see Paul Levy's post on this topic from a few years back.

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.

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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. To a great degree, the current generation of leaders is a lost cause. They are simply the product of their times: weak, “unimaginative thinkers” who see the solution to every problem as layoffs, closing plants or offices, and squeezing suppliers’ profit margins. Millenials don’t like this disrespectful way of doing business and are far more innovative and creative thinkers who I hope will do better than their predecessors. They seem better suited to understand “the criticisms of Lean” and take appropriate action “to eliminate them”. While one always hopes the “next generation will do better”, it could turn out to be a false hope.

  2. The problem with relying on old management approaches is compounded by by the absence of an ability to learn. I think it was Bob E in a prior reply identified that 90 (95?)% of adults are resistant to learning. This didn’t seem accurate until I scrutinized the actions of leaders around me. I rarely if ever saw a leader respond to new challenge by learning a new skill. Old management approaches are like a security blanket for many leaders. The extreme example I saw was the practice of holding people accountable till they got Lean (L.A.M.E. on steroids) all the while the leaders didn’t change behaviors. I have also seen this demonstrated by someone who grew up in a Lean organization. While this person had expert level skills to perform in the organization he grew up in, he totally floundered in trying to apply Lean in a different industry and organization.

  3. “But these principles, as powerful as they can be, are often misunderstood… or they are just ignored.”

    Or to the superhero fans out there, “With great Lean power comes great Lean responsibility.”

  4. Lots of interesting comments in this article from Saskatchewan.

    Much of it sounds like complaints against “L.A.M.E.” not “Real Lean.”

    I retired 10 years early because of the harassing management using the Lean Strategy. It was used to push out the older experienced workers, so managers could bluff the new workers. This strategy saves Lean money, as managers get their performance bonuses (10% per year).

    That doesn’t sound like it’s keeping with Lean principles.


    I have heard from staff in the Health department that they spent days cleaning, tossing and organizing their individual office space to meet the lean standard – crazy stuff like the number of pens in a space, frowned on number of personal items, and now get “surprise” assessments.

    I’ve complained before that stuff like this is more L.A.M.E. than Lean (Example)


    Doctor’s, cleaning staff, RN’s are paid a full days wages to attend the lean inservice to make paper airplanes. This concept may work for making cars but patients cannot be managed the same way. I found it to be a complete waste of time. Management has been brainwashed into accepting this program and are in endless meetings and not on the units where they need to be.


    That same friend also told us that due to ‘lean’ management many no longer have time for a lunch or coffee break during their shift but are required to spend time in a ‘huddle’ each day, for discussion purposes, but more often than not there is nothing to discuss and the time that could have been used for a personal break is wasted.

    Sadly, before Lean, too many nurses and staff DON’T get proper breaks, as they should. This stress and fatigue hurts patient care. If anything, waste reduction through Lean should HELP people take breaks. It shouldn’t replace breaks with huddles. That’s not Lean.

  5. Couldn’t agree with the sentiments Mark expresses here more. Just wrote a similar piece arguing that 95% of the action we are seeing in response to margin pressure is very much Old Management System and won’t create value, and urging CEOs to do just one exercise of “going and seeing” with a capable facilitator to begin to see the opportunity very differently.

    • Wise words in your article, Ken. Thanks for sharing. Everyone should go read it!

      A few highlights:

      Because job cuts destroy value from the minute they are executed, by profoundly harming morale and leading employees to hide process problems and inefficiencies, they hurt you – not help you – over the medium and long run.

      I know at least one hospital CEO who has come around to this thinking. The previous cycles of layoffs during tough times were followed by hiring because they didn’t know how to fix operational problems other than by throwing people at it. The CEO finally learned (PDSA!) that the old approach didn’t work. Lean is now their strategy.

      How do we get more CEOs to realize this?

      Get out and silently observe one of your key business processes end to end, through the patient’s and then the staff’s eyes. You will see that at least 50% of the total time, materials and effort invested by your team does not add value to the patient, yet the staff will likely be very stressed by process problems that they don’t have support to fix. Unlocking that 50% opportunity is your largest business opportunity, and it can only happen by focusing your leadership and support squarely behind your people to do it.

      Great stuff. Let’s all keep trying to spread the word and hope that CEOs don’t just keep falling back on “what they know.”

  6. A Canadian union is complaining about Lean.

    They claim:

    Lean programs considered “management by stress” and used to justify layoffs while increasing workloads of remaining staff

    The things the union complains about are exactly what you have in hospitals WITHOUT #lean (overburden, stress, layoffs). Hospitals are, sadly, really skilled at laying people off in the name of cost-cutting, which adds to the overburden and stress.

    Lean is just about the only alternative that gives you a fighting chance to reduce overburden and stress and to prevent layoffs.

    The union should really be fighting FOR Lean, unless they are happy playing politics.

  7. I’ve always been amazed that union leadership seems to never have bothered to understand Lean management, especially real vs. fake/lame. They could serve a role to hold managers accountable to practicing real Lean, which would result in better outcomes for everyone. Opportunity lost…

    • Union leaders sometimes support Lean until they get into a contract negotiation cycle… then they start bashing it.

      Union leaders are elected officials, therefore they are politicians.

      They will spin and tell half-truths and get people riled up like any politician. And it’s not always helpful.

      I’m currently having an exchange with a union president who refuses to even look at any medical journal articles that I’ve offered to send him that show how Lean helps in healthcare. He’s closed minded and has already made his mind up.

      He’s more interested in throwing insults at me and accusing me of being a greedy American.

      Sad. Old habits die hard!

  8. Another old habit that I’ve seen a lot of is the old management behavior of setting a target or quota and then, basically, beating people up until they hit the number (or, more likely, fudge the number).

    Lean is focused on working together to improve the process. We might set a goal that says an inpatient bed should be cleaned, turned, and prepped for a waiting patient in 30 minutes or less. This is often important because patients are waiting in sometimes miserable E.D. circumstances.

    But a goal (something that motivates us to work together on improvement) is not necessarily a quota and it shouldn’t be treated that way. Staff shouldn’t have the fear of God in them that they’ll be in trouble if a room turn takes more than 30 minutes. They shouldn’t be afraid. They shouldn’t fear punishment or blame.

    Punishment and blame are OLD habits, not Lean concepts.

    If a room turn takes 45 minutes, leaders should respond in a collaborative, helpful, problem solving mode.

    If that’s not happening, it’s not Lean.

    Yet, people will often complaint that “they’re forced to turn the room too fast, under 30 minutes, and it’s stressful” because of Lean. Ugh. What’s happening to them is not Lean. But it’s sadly too common.

  9. This is a Respect for People failing, both on leadership’s part and on our part as Lean coaches. Its difficult enough to teach and instill an true understanding of the other pillar, Continuous Improvement, but unless leaders are willing to absorb and demonstrate a true understanding of RFP and then consistently walk the talk, I will walk away from the organization. I’m tired of trying to push a rope up hill….

  10. I worked in a clinical laboratory of a hospital where a senior administrator started touting the benefits of LEAN. I had never heard of LEAN and I started researching. I became such a believer I took an 8 week Green Belt course and invested a lot of time educating myself on LEAN.

    I knew it would take time and given that this was not a facility wide LEAN initiative, it would have limited application but still I forged ahead. My department director had an authoritarian leadership style and I stressed that the management style required for LEAN was very different. To put it bluntly he was totally incapable of change. He would “lecture” staff that they would need to adapt to the coming changes. But he changed nothing.

    I suggested we start Huddles which he turned into “Nazi style stand up meetings”. He came to huddles with a sign-up sheet, agenda and a lot of finger wagging. I was sorry I ever made the suggestion. I tried to explain that huddles should be a positive start of the day.

    The senior administrator stood in front of the entire staff stating “this is not the flavor of the month – we are committed to LEAN”. Well that lasted for 4 months – she moved on to other flavors. In the end LEAN got a undeserved bad name. I made sure to explain that what we were doing was NOT LEAN. I ended up leaving the job disgusted and bitter. The sad part is that the staff members “got it”. Many were on board and enthusiastic. It was leadership that did not “get it” and dropped the ball.

    I learned my lesson but I still believe in LEAN but now understand that it absolutely must start at the top.

    • Rebecca – Thanks for sharing your story. I’m really sorry to hear about that. I wonder if the lab director or any of your senior leaders did ANYTHING to educate themselves about Lean. Did they get any education through a class? Did they read my “Lean Hospitals” book? Did they read the free chapter 1, even? Did they even read a good article from a lab journal about Lean management?

      Education doesn’t necessarily lead to changed mindsets. Sometimes a little bit of education is dangerous because leaders leap to the conclusion of “Oh, this Lean stuff is simple” then they go about bullying people into using tools, which is, of course, not the point.

      I hope you’ve been able to move on to another organization where they do “get it” and they’re willing to work on changing management mindsets.

      • The senior administrator had previously worked at a LEAN hospital (I forget which one). Two years prior the Emergency Department of the hospital had a consultant come and she and my director attended a week long education Kaizen event. I also did 3 1 hour presentations to staff that they also attended so they did have the background.

        The senior administrator has a tendency to micro manage and would get involved in various improvement projects only to move on to stamp out a fire somewhere else. It left people frustrated and the sentiment of “this wont last” was deeply entrenched. I dont think she saw her role in the ever growing lack of involvement amoung staff members.

        The senior admin also asked me to do a LEAN project for the pharmacy department. That was a disaster. She was all over the map with problems and it became clear very quickly there was a politcal war being waged between managers which prevented any process improvement.

        In the end I managed to get some processes improved but it was difficult because the senior admin would constantly shift the direction of the project. She would pop in on Kaizens and completely de rail the process. I tried to do some LEAN training but she kept telling me there was no time for it. I later found out she thought I spent too much time emphasizing LEAN terminology and not getting “people” to change their ways. She never told me about her concerns about LEAN speak. I am not sure how you do 5 S without explaining what 5S stands for??
        In addition to all of this I had no authority which also complicated matters.

  11. Management support cannot be a “one off” thing. They need to demonstrate on going support by walking the walk and visibly taking action to support the initiative. A third party (internal or external) consultant can help with this by staying close to the senior sponsor, meeting with them regularly and keeping them appraised of daily activities but this can’t substitute for being on the ground seeing what’s really going on. At the end of the day if the sponsor is not willing to make changes, do things differently and hold people accountable the effort will fail!


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