Alternate title: “Lean is an Integrated System. Of Course Just Implementing Pieces Leads to Failure.”
Throughout the 10 years that I've been involved with Lean healthcare efforts, I've heard multiple stories of organizations that ended their formal Lean initiatives.
They do so, as I've been told, because they need to cut costs (so they end their Lean consulting contract or lay off people who had been in internal Lean roles). Or, they say, “we tried Lean and it didn't work here.” Or, there was a leadership change and the new leaders thought they had no use for Lean because they had been successful in past jobs without it.
One of the hospitals I highlighted in the first edition of Lean Hospitals doesn't appear in the second edition because Lean died (was intentionally killed) after a senior leadership change. Sharp-eyed readers of both editions might know which organization that is.
Some of these organizations were early adopters in that they started with Lean early on (circa 2004) and were among the first to stop their Lean initiatives (as early as 2006, if I remember these different stories correctly).
Although Lean isn't primarily about cost reduction, lower cost should be an end result. If an organization isn't getting results, such better quality and patient flow (perhaps leading to better financial performance if that's important to them), maybe they SHOULD kill their Lean initiative.
But, they should also reflect and ask why “Lean didn't work.”
It might be the same systemic reasons why TQM didn't stick or why Six Sigma wasn't effective in their organization.
I've said for a long time (as have many others) that a Lean transformation isn't easy. Meaningful and lasting culture change isn't easy.
It's easy to use a few scattered Lean tools or to initiate a project here and there. It's more difficult to adopt a new philosophy and to change the way we lead and manage. Oftentimes, it's especially difficult for executives to unlearn old habits and adopt new behaviors after decades of experience doing things the traditional way.
By the way, I'm guessing that organizations like ThedaCare and Virginia Mason Medical Center would never dream of ending their Lean transformation efforts because they are getting great results – improving quality and safety, lowering costs, improving patient flow, and creating more engaging workplaces. They'd also admit that, after 14 years, they are still not perfect and their improvement journey continues.
The best Lean health systems have made the most progress, I think, because they best understand what Toyota teaches — I'm paraphrasing here:
The Toyota Production System is an integrated system (therefore, Lean should be too). It's not just technical methods (like 5S or kanban systems), but also (and more importantly) a philosophy, a way of managing, a way of developing people, and an organizational culture.
Again, pay attention to how it's an “integrated system,” as Toyota people would say.
Organizations fail when they adopt just one part of the integrated system. New tools plus old mindsets leads to the same old results.
I was thinking the other day about other examples of “integrated systems.” A particular type of car or truck is an integrated system. As Dr. Atul Gawande (and others) have pointed out, you won't design the world's best car by benchmarking other automakers and choosing the best individual components, for example taking the best engine from one manufacturer, the best transmission from another, etc. You'd end up with a pile of parts that don't work.
A home theater system is an example of an integrated system.
Let's say you've visited the home of a friend with a great home theatre system, which, in their case, consists of a 70″ HDTV, a receiver and speakers, and an Apple TV device.
It might be tempting to discount their system, saying “Oh, I've been doing that for years,” when what you have at home is a 27″ Sony Trinitron tube TV from 1995 (I bought one of those).
But, after watching a movie, you walk away impressed. You want to improve your system at home, which includes an old DVD changer (which was impressive in its day) and the TV's built-in speakers.
You may say, “I liked my friend's Apple TV, so I'll implement that.” You buy an Apple TV (a new tool), but you decide to save money by NOT buying an HDMI cable (because you're still in a mindset, brought home from work, that focuses mainly on cost instead of on improving flow and quality). Plus, you thought the Apple Store employee was just being pushy in their attempt to sell you something else (they probably have quotas and incentives driving that, you think to yourself).
It's a good thing you saved money by not buying the cable, because the old Sony TV doesn't have an HDMI input anyway.
Not thinking about how to connect it (because you didn't understand your friend's system that well), you plug the Apple TV into the wall outlet… and nothing happens.
Would you say, “I tried Apple TV and it didn't work”? Would you write a journal article that somehow proves Apple TV is ineffective because your case study shows poor results?
(That happens in Lean healthcare, by the way — see this article). There is also a study that shows checklists don't work (or, more accurately, don't always work… due to similar issues of tools vs culture, I'm sure).
But, after a trip to another friend's house with a nice home theatre (including a ceiling mounted projector), you might hire a consultant to come in and tell you how to implement a home theatre system. You don't have time to learn more about home theaters, so you tell the consultant to fax over a written report that makes recommendations. The consultant recommends a number of new tools to implement, including a modern flat screen HDTV with, of course, an HDMI input.
You begrudgingly buy the TV, which upsets you because you're now spending more money on top of the fee to the consultant. The consultant recommends you buy a $100 gold-plated HDMI cable, which is actually a ridiculous expense when a cheap $5 cable works as well. But, you don't know any better (you didn't do any research and you expected the consultant to think for you).
Now, you at least have an Apple TV that can be connected to the new TV. You realize that the home theatre might not be perfect, but it should be better than before. You're on a “home theatre journey,” after all.
You hit the button on the Apple TV remote that powers it on.
You're disappointed to learn that you still can't watch anything on your Apple TV. You grumble about the consultant not being that good.
Why doesn't your new system work?
Because you don't have a wi-fi router in your home and there's not an Ethernet jack near the device to plug into.
You've now discovered another part of the integrated system that neither your friend nor your consultant told you about, because they just assumed you'd have wi-fi. It reminds me of the Dr. Deming expression that “a fish doesn't know it's in water.” An understanding of Deming's teachings is generally assumed within Toyota, so it goes unmentioned in many Lean books (although modern Toyota executives don't hide their continued admiration for him).
You might then say, “Home theatre isn't appropriate for my home. I've tried it a few times now and it just doesn't work. It's too difficult. I'll just continue watching cable TV, since that is the way we've always done it around here.”
Even if you had wi-fi, the sound coming out of that flat screen TV would have been disappointing compared to your friend's speakers (and even compared to your old Sony, which had the physical space required for larger speakers and better sound).
You implemented home theatre tools instead of implementing an integrated home theatre system. But you could say, “I was doing home theatre.”
Lean is not something you simply implement. It's not a set of tools that you buy and a Lean transformation doesn't magically happen because you hired a consultant.
You have to be willing to learn. To research. To spend some money when appropriate (without expecting to solve everything by throwing money at it). To directly participate instead of just delegating the effort to somebody else. You have to be willing to change. As they say, change starts by looking in the mirror… or maybe looking in the reflection in that new HDTV.