Are There Any Hospitals That Should NOT Try Lean or Kaizen?
I was asked an interesting and thought-provoking question the other day:
“Are there any hospitals where you'd suggest not trying to adopt Lean or situations where it might be counterproductive or harmful?”
This question came from a PhD management professor who was, in my estimation from his comments, somebody who thought Lean was a bunch of overhyped hogwash. He kept citing studies that “prove that Lean doesn't work in healthcare.” Any time I talked about the reality I see and experience (admitting the risk of “confirmation bias”), he kept asking me for studies that proves that it works. He was asking the wrong question. I can prove that Lean “does” work or “can” work, but that's it.
I'd readily agree that Lean is not easy and that many organizations aren't capable of meaningful Lean adoption or transformation. Attempts at Lean don't always lead to measurable or sustainable success, but that's often due to the attempts being half hearted and superficial – a few tools or projects here or there – instead of a sincere attempt to change the culture and the management system. The idea that Lean often “doesn't work” doesn't mean that “Lean never works.”
So back to his question. Here's a scenario that I thought of in the discussion that would probably be harmful or counterproductive.
Let's say a hospital starts giving Lean training to employees. Maybe they are running a few Rapid Improvement Events. But, let's say the CEO and senior leaders aren't learning or participating. They think “that Lean stuff is common sense” and they think Lean is somehow about fixing the front-line employees.
In a likely scenario, if they have hired or brought in a capable trainer / consultant, they are going to be talking about aspects of Lean culture that make a huge difference. The consultant(s) might encourage employees to start pointing out problems, to speak up about quality and safety risks, and to try to shake up the status quo.
It's very likely that the CEO and senior team aren't on board with that. From the Lean training, a nurse is inspired and emboldened to point out a near miss or an error (it's likely, in an organization that has a very broken culture as a starting point that many employees would be too afraid to take a chance by speaking up).
If the CEO and executives react badly, in a “Non-Lean” way, such as blaming and punishing the individual instead of looking at the process and systems, there's career harm, financial harm, and psychological harm that might occur to that nurse. Trust is further eroded, staff get more cynical as stories spread about that nurse being blamed or punished or fired as a result of speaking up.
A scenario like that probably leaves the organization worse off than it was before. Is that Lean's fault?
If you don't have a minimal level of trust in the organization, can you (should you?) even try to do anything with Lean? If the executives aren't humble and engaged and willing to learn and participate, should you even try?
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The word you used is trust. When you have none, and moral is already in the toilet. Then incorporating a lean process can be difficult because people just see their jobs disappearing.
This is a great example of leadership support for improvement. Leadership doesn’t always need formalized training, but they definitely need to understand the right reasons for deploying Lean philosophies and to recognize that improvement ideas should not be viewed as threatening up or down the chain of command.
Quality begins in the boardroom. I think someone very notable said that.
That notable guy also said “Survival is optional. No one has to change.” So yeah, there are organizations that shouldn’t deploy Lean – those organizations that have no interest in long term survival.
It is not easy to say we can prove that lean is perfect for hospitals, but at least we can say it works. In my opinion the reason why it doesn’t work may result from three points. 1. Lean is considered as a bunch of improvement tools, so the improvement activities are fragmented and are nominal “Lean”. 2. Many lean practitioners within hospitals emulated the first three steps of lean principles, but often found it difficult to establish the equivalent organizational culture and mindset, causing unsustainability/failure of lean. 3. Variations in the scope of lean implementation affect the better understanding of lean in healthcare and make lean difficult to interpret as a general idea in hospitals. If the manager has a bias on lean because of these three points, how can we expect they have the trust on lean and on the employees as well and further how can we see the benefits lean brings about.
Great post Mark! I don’t think that there will ever be some double or triple blind trial scientific study that someone in academia would hold out as proof. It’s human nature to improve and to try something better. All one has to look to is from the Wright Brothers first powered flight to current commercial and experimental aircraft. The difference in the rate of improvement or no improvement at all is the “petri dish” or environment where the improvement is attempting to occur and it’s possible to end up in a poison dish were one is merely trying to survive instead of growing.
Great write-up Mark! I couldn’t agree more. Executive leadership is a key Lean philosophy. Lose the trust and engagement of staff, you might as well say bye-bye to Lean.
I think there are plenty of instances where a hospital shouldn’t try lean. It isn’t that they shouldn’t apply lean if they were willing to do what was needed to provide patients the service they deserve. But many organizations are more concerned about many other things than providing the best patient care.
Basically if the odds of a lean effort succeeding are fairly low (which would not be uncommon) I don’t think moving into lean would be wise. What to do if you wanted to get the hospital to improve patient care? Focus on using some tools well that will also build the capacity of the organization to be successful applying lean.
Lean is not just using some tools. But using some tools can build the capability of the organization to apply lean. For example, several tools when used help people to see process thinking in action. Applying them can get people to change their view of the situation. They can see with the right thinking and tools results can be improved.
This posts (and the links included in it) provide some guidance on building this capability in organizations http://management.curiouscatblog.net/2010/12/06/how-to-get-a-new-management-strategy-tool-or-concept-adopted/
Most management professors are career academics who have had no actual management experience in industry. Unless they have lived it and also specialize in Lean management as I have, they only know what they read. And probably more than half the peer-reviewed academic literature on Lean management is negative. So, the weight of evidence supports the conclusion made by the professor that Lean is bad. The professor is an example of someone who can claim to be an authority on the subject – which is good enough for most people – but who actually is completely lacking in authority.
There are plenty of hospitals that shouldn’t do real Lean.
Start with a behavioral based assessment of senior leadership. If these behaviors are don’t match with Lean leadership, then real Lean should be a non-starter. It doesn’t mean that these behaviors can’t be changed, it just means that the organization isn’t ready for the real deal. It’s also difficult to change some of the behaviors of senior leaders just by practicing Lean. If respect for others and humility isn’t there to start, then success isn’t likely to happen and can’t be coached in during an engagement. What are the other necessary behaviors? Profile the leaders of the organizations that are successful on their Lean journey. They’re out there and they’re accessible.
On the other hand, there are many hospitals that are making improvements without doing real Lean. I can point to some high-profile health systems that have done a bunch of internal or external driven value-stream projects that have generated substantial cost savings and others that have achieved improvement with just 5S, an idea board, and a morning huddle. Is this real Lean? Probably not. Should they stop doing this. No, but real learning or problem solving may not be taking place, improvement is just being done at a bunch of points in the organization, and the sustainability of improvements is questionable. But at least in the short term some of these organization’s is better off. But for others, these efforts just become part of the muddled agenda to do things better.
The other big qualifier is the organization’s readiness to Learn. Hospitals are much different that automobile assembly plants and hospitals are not all the same. For all the talk about Lean being a management system and not a collection of tools, 9 times out of 10 when a hospital leader talks about Lean they talk about tools or at best systems. So going back to the behavioral based assessment, the real question is: Does senior leadership have the ability, desire, commitment, and long-term resources to adapt Lean to their own organization?
This is spot on. Even in a chain of hospitals where LEAN is supposed to be the way they do business, the individual actions of the managers at each site can make or break the system. There are so many who are stuck in playing the name, blame & shame game, no matter how many lives we know self reporting saves. Like other commentators have said they may not be ready, but maybe they are just not able to adapt to the culture that is necessary to survive in this new health care delivery system. If the stakeholders could see value in LEAN then it maybe necessary for these top leaders to have those managers adopt the new culture or leave. Not everyone will make it in today’s American healthcare system, and there are many who should not if we are going to revolutionize an inefficient system.