More on Lean in Saskatchewan
Since the healthcare improvement work I do is apolitical and non-partisan, I'm generally not one to butt into the political affairs of Canada or other countries. But, when I hear complaints about Lean or when it's being called a “scam” and a “cult” by some in Saskatchewan (read here), my ears perked up and I started talking with some folks up there. My goal isn't to blindly defend Lean, but to first understand, but also trying to clarify myths or misunderstandings where I can.
I've had some contentious discussions (a union president who arrogantly replied, “No, I'm good” when I offered to send links to medical journal articles about Lean), but also some lovely chats via Twitter and email. Yesterday, I had a long and interesting phone call with Murray Mandryk, a political columnist for the Regina Leader-Post. He apologized repeatedly (as polite Canadians do) for “dragging me into” this political fight of theirs. I told him that it was, if anything, my fault for diving in.
The start of the article:
So, your local village idiot (me) has stuck his nose into Saskatchewan “lean healthcare” and local politics. I'm glad the columnist referred to be as “down to earth” in a tweet, at least. It's probably arrogant of me to point that out.
I've only been to Saskatoon once, for about a week in 2006 when I was part of J&J and our Lean consulting group was at the University Hospital lab. My plane made a stop in Regina on the way (Saskatoon is not easy to get to, whether you're starting in Texas or Japan).
I don't know anything about their politics. I do understand a bit about how the Canadian health system is different. For one, each province (and I've visited all but a few) has a slightly different structure and setup for funding and the organization of hospitals, etc.
Canadians are quite proud of their system. Mandryk told me of his child's recent surgery and how the care won't bankrupt him (as it might in the U.S.) But, the facts are the data show that Canadians often wait longer for treatment (in the E.R. or waiting for surgery). That's one great reason to pursue Lean healthcare – to reduce those waiting times without spending a fortune and without hurting quality.
So, the discussion of Lean has nothing to do with whose coverage or payment system is best (those are political issues). The discussion isn't about whose system is safer, since the per capita patient harm rates are nearly identical in the U.S. and Canada (as I wrote about here).
I am encouraged that Saskatchewan has been trying to address quality and patient safety, as they recently launched a Patient Safety Alert system that allows staff, patients, families, etc. to “pull the andon cord” as we say in Lean.
In talking with Mandryk, I talked about the need for nurses to be able to speak up when they see a problem, such as a surgeon wanting to rush the start of a case (because they're behind schedule) and everything isn't properly set up. Mandryk asked why I'd want people to be able to do that. He expressed a respect for his child's surgeon, that they are one of the best and we should trust them. But, surgeons are human. Most healthcare errors occur due to bad systems, not bad people.
So, we talked for an hour or so and he wrote this column:
He asked how I should describe myself and I balked at the word “expert.” But, when you're interviewed by somebody, you lose control over how you are described (or how an editor describes you).
I'll comment on a few things:
“The $40-million question (in Saskatchewan) is: What is lean?” said Mark Graban, a consultant and author of three books on lean, in an interview from his office in San Antonio, Texas. “How do we go from here to there?”
What I really said was that it's easier to define and answer “What is lean?” than it is to determine “how to go from here to there.” Lean is Lean (and yeah, I probably would agree with 95% of what John Black, their consultant, would say and write) but there can be big differences in the consulting style and transformation strategy that will take you from here to there, towards being more Lean.
I've been re-reading John's book and most of it is spot on, such as emphasizing “bad systems, not bad people” and talking about how people are critically important and need to be engaged:
So, when I read even one complaint like this, I am concerned:
The nurse didn't feel empowered. Felt confused over goals, limited compassion care, issues w/ locating supplies. Lean is failing
That sounds like the opposite of Lean. It sounds like “Lean done badly” or perhaps L.A.M.E. What happens sometimes in a broad Lean transformation is that too many managers are trained too broadly, too quickly. They don't have coaches to help them oversee their work. If the nurses are confused or feel pressured or can't find supplies, something's not right. It could be that the old system just hasn't changed quickly enough, rather than it being “Lean is failing.” Lean doesn't fail or succeed. Lean is just a bunch of principles. People fail or succeed. Leaders fail or succeed.
Like I told Mandryk (and others), I'm the first to admit that Lean is not an easy silver bullet and that Lean is not guaranteed to work. Lean is hard. But, Lean works.
In the column, Mandryk did mistakenly refer to me as a “consultant” for GM in the 1995 timeframe. I was an employee. I was brand new to the working world and, while I was helping make improvements happen, I was mainly in a mode of learning about Lean. Employees there, before Lean, didn't feel empowered, were confused about goals, had limited opportunities to do quality work, and had issues with locating supplies. Lean helped with that. Lean didn't make any of that worse.
While a version of lean is being used in New York City's public health system with 35,000 employees, Graban said most lean initiatives are confined to smaller hospitals.
I meant to convey that Lean is exponentially more difficult as the size of the organization grows. It's not impossible in a large organization, it's just harder. The fact that we see more success stories from smaller hospitals is more due to the fact that it's faster to “transform” a smaller hospital like Virginia Mason or a group of smaller hospitals, like ThedaCare.
“I find the use of the word ‘sensei' to be pretentious,” Graban said, adding that some lean hospitals have dropped the use of Japanese terminology. “A lot of John Black's approach comes across as pretentious.”
That won't make me any friends with John Black and his team, but that's not my goal in life. Nor is my goal in life to engage in “consultant fights.” But, it's my honest opinion (as I've written about) that it's tacky or pretentious for Americans to use the word Sensei and especially so to hoist that label over one's own head.
I respect John Black and what he's done as an innovator in Lean healthcare. But, Lean is not “a cult,” so I'm allowed to disagree with him and his approach.
If you have a Japanese teacher helping you, it's reasonable to say “Thank you, sensei” as an honest show of respect. But, it's also bordering on pretentious (or let's just say it's a different style) to say you MUST visit Japan or that you MUST have Japanese teachers. There are many Canadians who can explain Lean well in plain English (or Americans). Black has also said some things in the press that come across as arrogant, (“My God, I wish I would have asked John Black to help me…“) where Lean leaders need to be humble. I like humility.
Mandryk ended the column with:
As Graban noted, health systems all over are filled with “smart people” and “sweet people who care a lot.” But their solution to their problems is always to hire “more, smart sweet people that care a lot.”
And that makes it even more difficult to impose lean – a model that may or may not be the right one.
I don't think Lean can be “imposed.” It needs to be embraced honestly by the people doing the work. If they're skeptical or don't understand, leaders need to lead. We all need to work together to make this a better health system – whether it's far-off Saskatchewan or our own back yard.
I sincerely wish for the success of everybody involved in Saskatchewan – the patients, the nurses and staff, the physicians, the managers, and the political leaders. If there is anything that's the least bit off track, I hope they will “Study” and “Adjust” in the spirit of the PDSA cycle. Nobody is perfect (gosh, especially me) and nobody's Lean journey goes smoothly. Black even warns in his book that it is difficult:
That might not be comforting, but it's honest.