Is This The One Question That Determines If You’re Truly a Lean-Thinking Hospital?


Today's Post in <50 Words: The key question is “Let's say your census is lower and you have a few hours left in the shift… do you send your people home or engage them in something useful that invests in your future?” Truly Lean hospitals will engage staff in improvement instead of sending them home early.

I get asked a lot, “How do you know if a hospital is truly ‘Lean?'”

Nobody is ever perfect or “fully Lean,” but you could ask, “How do you know if somebody is on a legitimate Lean transformation journey?”

If you could only ask one question that would give you a pretty solid sense about whether they're on the right path or not, what would you ask? I'll give you the question I'd ask later in the post.

What If You're On a “Fake Lean” Path?

It's almost easier to answer the opposite question, you could maybe identify some characteristics that demonstrate that an organization doesn't yet “get it.”

For example, an organization that only uses Lean tools and hasn't yet changed the way they manage — they're not really Lean… yet (or never will be).

Also, an organization that thinks Kaizen is only a series of weeklong RIEs, RPIWs, or projects instead of also practicing daily continuous improvement — they're not really Lean… yet (or never will be).

This starts sounding like the Jeff Foxworthy “you might be a Redneck” jokes that are so easily to lampoon.

I recently adapted that style of jokes and created memes that illustrate my concept of L.A.M.E. (Lean As Misguidedly Executed)… I used Bob Emiliani‘s “Fake Lean” term because it flows better, I think.
3871056 (1)
Screen Shot 2016-01-18 at 12.41.45 PM

If you have another “… you might really be L.A.M.E.” or “you might be practicin' Fake Lean”  meme to submit, leave a comment or submit it as a Lean Meme.

But What About Flexing?

I was at a hospital last month where their Lean efforts, after two years, they said they had very little energy or progress related to Lean. I'm not sure if me giving a talk would help, but that was the intent.

Flexing that's actually funny
Flexing that's actually funny Flexing that's actually funny

A nursing director complained about how their Lean consultants brought in the practice of “flexing” — or sending nurses and staff home early when the patient census is low. This really had people demoralized and managers were frustrated about being hounded for being 0.06% over their labor budget.

These consultants (no longer being used by the hospital) come from a background of being hospital executives and it's unclear where they had any real Lean training or experience… so they seem to do pretty well selling what they're doing as cost cutting (which isn't really Lean, either).

I'll say it bluntly: Flexing is NOT a Lean practice. It's a common healthcare practice… but it's traditional cost cutting. It's not “Lean.”

Census is Low....

I've blogged about this before, back in 2009:

The Emperor's Sacred Cow's New Clothes – “Flexing” Hospital Staff

As I pointed out there, Toyota does NOT send employees home early to save money when production has stopped for some reason. They wouldn't do this if there was just two hours left in a shift. Heck, they don't lay off employees when a plant is down for WEEKS or MONTHS (see this blog post).

Hospitals think they are saving money and reducing costs by sending people home early. I bet the end result of “flexing” actually increases costs.

Does Toyota “waste money” by not sending people home? Of course not!

Flexing is NOT #Lean. Ask Toyota. They don't try to save money by sending folks home early. Share on X

What does Toyota or a Lean organization do?

Why would Toyota pay people to build Habitat for Humanity homes? Are they really that caring? Do they have that much money to throw around? They're investing in their people, in addition to helping the community and building up goodwill. Volunteer work is a great way for team members to get to know each other, which can improve workplace performance, and to develop and practice leadership skills.

If you're at a hospital, when you temporarily have “too many employees,” where does your mind go?

  • Let's send them home to save money and make today's productivity number look good
  • Let's keep paying them and invest in our future quality, productivity, and staff satisfaction

Paying hospital staff to work on improvement should have many positive results. I guess that's probably only true if you have a formal Kaizen methodology (otherwise, you might just be paying people to stand around and talk).

Cost savings isn't the primary goal of Kaizen, but I'd be willing to bet that paying staff to work on improvement would have a POSITIVE return on investment… not every single day, but over time. Improving safety and quality will reduce costs. Staff feeling more valued might lead to fewer people quitting out of frustration, which reduces your turnover and hiring costs.

There is so much potential that gets thrown away when hospitals reflexively send people home early. Share on X

So here's another new Foxworthy meme:

Screen Shot 2016-02-01 at 4.01.58 PM

Flexing staff is a classic example of short-term thinking versus Toyota's long-term thinking. Focusing on the long term is point #1 in the Toyota Way for a reason. Sending people home today saves you money in the short term and that's easy to measure. The benefits that come from paying them to do improvement work… that's more long-term and harder to measure.

But, being able to focus on the long term, respect your people, and engage them in improvement… that's the sign of a mature Lean organization.

So, if I had just ONE question to ask to see if a hospital is really an advanced Lean thinking organization or not, if they were on a Lean journey that would make me optimistic about their future, I'd ask:

“Let's say your census is lower and you have a few hours left in the shift… do you send your people home or engage them in something useful that invests in your future?”

I'm not sure how many hospitals pass that test today. Hopefully, more will in the future. Does yours?

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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. One question that I like to ask the folks at the top is:

    “What are you personally doing differently on a daily basis as a result of Lean?”

    Usually, the answer is nothing – or, a L.A.M.E. answer is given.

    Flexing an old practice used in manufactories 100 years ago. Amazing that it is still used today, and in hospitals of all places. Sad.

    • Great question, Bob. Too many “L.A.M.E.” or “Fake Lean” initiatives involve executives delegating Lean instead of participating… and, like you said, changing their own ways. John Toussaint is a great example of an executive who had the humility to admit his own leadership style was harmful and he worked to change his ways.

      Very sad, indeed, about “flexing,” especially since I’d guess the practice doesn’t really reduce costs over time.

  2. When I previewed this post on Twitter, here are some other questions shared by people:

  3. Other articles on “flexing” —

    ‘Go Home, Stay, Good Nurse’: Hospital Staffing Practices Suck the Life Out of Nurses

    I “get” tight budgets. I don’t get why it’s always the nurse staffing budget that’s cut to make up a budget shortfall. It’s especially irritating when one realizes that hundreds of thousands of dollars are spent on technologies that haven’t yet been shown to make a difference in outcomes—while the substantial evidence on the relationship between nurse staffing and patient outcomes continues to be ignored.

    AJN Report: The Other Side of Mandatory Overtime

    Some nurses refer to it as “health care’s dirty little secret,” and it goes by a variety of names: “flexing down,” “management requested time off,” “hospital convenience days,” or “staff adjustments.” But regardless of what it’s called, the outcome is the same. When the patient census decreases and the unit is then overstaffed, nurses’ scheduled shifts are routinely cancelled. They will not be paid unless they use vacation time to make up the lost wages and maintain their benefits. As a result, some nurses may be left without any vacation time.

    From discussion boards: “Low census/flex time

    This is currently a HUGE issue at the hospital I work. We have a low census at the beginning of the shift so someone is called off, and yes, this comes out of your PTO unles you sign the book that you dont want to be paid that day. By the middle of the shift we have 8 or 9 patients each, with no charge nurse because she was pulled to take patients. Then by the endof the shift we are back down to 4-5 patients because our original 3 are now being discharged after 4pm. Its’ been a nightmare. Last paycheck I was short 3 shifts due to being called off. It really has been brutal. If we are able to get someone to agree to be on “busy call” they get $2 an hour until they clock in/out. Danged if ya do, danged if ya don’t. One of the reasons I am changing departments

  4. As Keith Leitner from the University of Tennesee said today at the Society for Health Systems conference:

    “The best #Lean organizations in the world treat labor as a FIXED Cost. Treating labor as variable cost is dangerous.”


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