This Organization Chose Not to “Deploy Lean” Because a Leader Thought it is Not Customer Focused?


I posted an article on LinkedIn last week as a companion article and summary of my podcast with Dean Gruner, MD, the recently retired CEO of ThedaCare.

That article:

A Retired Hospital CEO Shares the Employee Feedback That was ‘A Bucket of Cold Water to the Face.'”

There have been over 125 comments so far… but one has me scratching my head.

It read:

“I looked at deploying Lean within our PNO, and ultimately decided against it, in part for two reasons:

  1. because Lean is about doing the same thing, albeit better and
  2. it is not as much customer/outwardly focused as we need in healthcare.”

Lean is not customer/outwardly focused? I hope this isn't a widespread perception or belief out there. I hope I'm overreacting to something that's not really a problem… but I wrote the post anyway.

I think PNO means “Provider Network Operations” in this context.

The person who posted the comment is a “President, Medical Group & SVP, Chief Strategy Officer” of an East Coast health system according to LinkedIn.

They don't list any Lean training in their profile. They don't have any color of “Lean Sigma Belt” certification. Maybe that's good since I'd hate to think their comment was something that came from training or education they received. Their comment comes from ignorance, I'd say.

Hear Mark read the post (subscribe to the podcast):

It makes me wonder how much research and learning they did while “looking at deploying Lean.”

Did they read any book about Lean, yet alone my book Lean Hospitals?

Even if they just read the free preview chapter, the word “customer” appears ELEVEN times.

As Dr. Beverly Rogers wrote in a blurb, in part:

Lean Hospitals is a foundational text for understanding the concepts and application of continuous process improvement in a healthcare environment, and provides practical guidance and concrete examples to eliminate waste and increase value to the customer.

As we say in the Lean methodology, value is defined by the customer.

More than 20 years ago at GM, I learned from our Toyota-trained plant manager that our focus was on improving quality for the customer, improving on-time delivery for the customer, and reducing cost for the customer.


In the first chapter, I wrote:

“Because every type of organization — including health systems — should be concerned with issues such as safety, cash flow, customer satisfaction, and quality…”

Yes, Lean is about the customer. The book The Toyota Way uses the word customer 248 times, including:

“Long-Term Philosophy. Toyota is serious about long-term thinking. The focus from the very top of the company is to add value to customers and society.”


“This is why TPS starts with the customer, by asking, “What value are we adding from the customer's perspective?”

Toyota works hard to understand customer needs in deep and meaningful ways. The Toyota Way has stories about engineers going out into the real world to see how customers use minivans and other vehicles in daily use. That message of “get out of the office” and understanding customer needs comes through loudly in The Lean Startup or any other good book about Lean.

Even Toyota's free website on the Toyota Production System makes this customer focus clear. The Lean Enterprise Institute's “What's Lean?” page makes this clear too.

Jamie Bonini, from Toyota and TSSC, points out that the Toyota philosophy starts with the customer (as I blogged about here):

  1. Customer first; provide customers with what they want, when they want it, and in the amount they want it
  2. People are the most valuable resource; Deeply respect, engage, and develop people
  3. Continuous improvement (kaizen); Engage everyone each and every day
  4. Shop floor (gemba) focus: Go to where the work is done to find and solve problems

Lean is not just about looking at the details of your work and how you do things. It starts with understanding and meeting (if not exceeding) customer needs.

Back to my book, I tell a story about a hospital lab working to better understand one of its “internal customers,” the emergency department:

“As another early step, the lab's leadership initiated discussions with internal customers and learned that particular tests were deemed crucial by the ED for the sake of prompt diagnosis and improved patient flow. They were sometimes surprised to learn that tests the lab thought not to be time-critical were, in fact, considered to be so by the ED. It became more important to the lab to improve the relationships with those who ordered tests and used test results — a key part of the customer- and patient-focused Lean approach. With this better customer understanding, success would be defined by their customers' needs rather than being defined within the lab and their assumptions.”

The E.D., of course, is focused on the end customer – the patient.

There's another example, again from laboratories:

“In another example of better understanding customer needs, the lab had been having difficulty meeting turnaround times for complete blood count (CBC) tests with what's called a “manual diff.” The lab was “killing ourselves” trying to improve turnaround time performance. The ED told the lab that the only urgent part of the result was the basic CBC, not the more time-consuming manual diff counts. As the ED explained, “We don't need that right away; we can wait on the manual,” so the lab focused their improvement energy on areas that would more directly benefit their customers. The full-time project team learned and used the analysis methods outlined in Chapter 4 to trace the flow of testing work from specimen collection through the reporting of test results. As in most hospital situations, the flow moved across multiple roles in many different departments. The team focused on improving the overall flow rather than looking merely to optimize their own departmental definition of success.”

Back to the uninformed LinkedIn comment, there are many reasons, I guess, for someone to not embrace Lean. “It's not customer focused” isn't one of those reasons.

The other part of the comment, about Lean being only about doing what you're doing better… I guess they also didn't get exposed to anything about “Lean Design” efforts where we sometimes radically redesign our spaces and workflows when building new facilities.

Or, they didn't learn about the idea of using Value Stream Mapping or Rapid Improvement Events as a structure for reinventing how work is done.

It's frustrating that a lot of material is out there about Lean, the Toyota Production System, and customer focus, but what can you do when some people choose not to learn?

What do you think? Please scroll down (or click) to post a comment. Or please share the post with your thoughts on LinkedIn – and follow me or connect with me there.

Did you like this post? Make sure you don't miss a post or podcast — Subscribe to get notified about posts via email daily or weekly.

Check out my latest book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation:

Get New Posts Sent To You

Select list(s):
Previous articleJoin me for a Change Management Workshop in Chicago on October 5
Next articlePodcast #288 – Dean Gruner, MD on ACOs and Healthcare Reform
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. Comments from LinkedIn:

    Andre DeMerchant
    Makes one marvel at how someone so bereft of the ability to understand their environment or research alternative pathways could even become ‘Chief Strategy Officer’ in the first place.

    Donald Scott, CLP
    That is…unfathomable. There is no theme more prominent in Lean than customer service. Is there anything more fundamental? Even “respect for humanity” is really a focus on a broadly defined “customer” outside of oneself. From my own emails, blog posts, articles, and tweets…just over the past couple weeks…

    “Everyone is in the customer-service department”
    “when everyone works for the customer, teamwork is a natural result”
    “alignment of employees to customer needs gives meaning to work”
    “teamwork development through relentless focus on the customer”
    “solve our problems to solve the customers problems”
    “Everyone works for the customer including the CEO”
    “let everyone in the company make “eye contact” with the customer”
    “I sometimes explain lean by pointing out that the customer is always right”
    “remove waste to let your people ‘see’ the customer”
    “value streams lead to customers”
    “the customer is the only source of revenue”
    “companies exist to solve problems for their customers”
    “don’t simply do your job, look how your work affects the customer”
    “don’t focus on your competition, focus on your customer”
    “if your customer doesn’t care about it, find a way not to do it”
    “Lean is a customer focused business strategy”

    …and that’s just from 30 seconds of reflection. I talk about the customer so much, I bore myself. Lean without a customer focus is like trying to…i don’t know…weld plywood.

  2. Perhaps the respondent was confused by the ubiquitous nature of the term “customer.” It is possible to focus so narrowly on “internal” customer needs that the ultimate recipient of the product or service, and how they define value, can be overlooked or undervalued.

    • Maybe – but any reading of Toyota would make it clear the end customer matters.

      I’d like to think the same would be true with my book, given the emphasis on patient safety and patient satisfaction… that’s the end customer.

    • Before we fall over ourselves about “the customer,” ponder this nugget from one of the best conferences I ever attended (in 1989):

      “STOP talking about ‘full customer satisfaction’ until your workforce knows its jobs!” (Standard work?)

      Puzzled? Read my article: “Isn’t It Time We Consider the Overlooked Problems?

      Also read the very sobering article by Heero Hacquebord about his back surgery…from 20 years ago! (link also embedded in article) When healthcare people brag to me about their quality results, I ask them to read about his experience and ask themselves, “Could this happen at my hospital today?” EVERY group sheepishly answers “Yes.” So what’s REALLY improved?

      Ironically, to get more customer focus, we need to STOP the expense and nonsense of the current customer satisfaction survey craze with its incisive questions such as, “Did the TV remote work?”

      By the way, my book Data Sanity is a great complement to Mark Graban’s ideas.

      • Thanks for commenting, Davis. I agree that your book is worth checking out, as are your QD articles. In fact, I have a blog post tomorrow where I’m including a link to your Part 1 “Data Sanity” articles where you address “bowling charts” and other methods that don’t work well. Thanks for that great content.

        Are you familiar with Dr. Deming’s notes from a hospital stay?? The same problems happen today, 30 years later.

        I blogged about it on the Deming Institute site.

        Customer focus is great… but it’s not everything that’s needed (insert pithy quotes from Henry Ford or Steve Jobs here).

        That said, I think a lot of the patient satisfaction questions are relatively superficial… and the way the analysis is done isn’t necessarily driving improvement in hospitals.

        Would I care about noise at night as a patient? Sure. But I care more about the hospital not giving me the wrong medication and not doing things that could really hurt or kill me.

  3. I’ll agree with Andre DeMerchant, but also go a step further: having worked with less nimble healthcare organizations, I’m no longer astonished when the “Chief Strategy Officer” knows nothing about…anything. Likely another person in the C suite is a member in the same fraternity (or sorority) or a cousin. Or maybe they attend the same golf club, yacht club or church as the CEO. I’m even more cynical when it comes to working with insurance carriers after thrilling a hiring manager at a carrier with a simple crosswalk that explained similarities and variances between programs that use quality measures. So don’t sweat it Mark; it sounds like you were trolled by someone with neither comprehension nor curiosity.

  4. Hi Mark

    I would say that the person used the apparent lack of customer focus as an excuse. He had to give some reason after all. Maybe I’m being too cynical but I wonder whether the real reason was that Lean Thinking demanded that he change the way he worked and he wasn’t prepared to do that. He wanted something that put demands on his workers without changing the way he managed.


Please enter your comment!
Please enter your name here

This site uses Akismet to reduce spam. Learn how your comment data is processed.