Mark Graban's leanblog.org - Lean Healthcare, Lean Hospitals, Healthcare Kaizen, Lean Thinking, Lean Manufacturing, Toyota Production System

Adventures in #Lean Healthcare Hiring, Part 2 Healthcare experience required... walking shoes not needed?

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I recently blogged about a healthcare improvement job posting that had me scratching my head when the interviewing process included an process improvement exercise that specified NOT talking to employees or patients.

Today, I'm blogging about another job posting that was sent to me by somebody I know at a children's hospital. Again, I don't want to name names, but this is a hospital I know well and have done some successful Lean work with.

But, even with that departmental success, the hospital has had, I think, four different directors or VPs of process improvement over the past decade. They've used Lean, Six Sigma, and every combination of those ideas. But, nothing (and nobody) seems to stick. And it seems executives are more delegating improvement and culture change than directly leading it.

I'm not sure if this job posting suggests a new, better direction, or just more of the same.

It's a “senior director of process improvement” role for the population health part of the organization (so it seems NOT to have the entire health system for its scope).

“The position will leverage prior health care industry experience in applied PDSA, Six Sigma and Lean concepts to develop and implement operation process improvement initiatives aimed at achieving outcomes of better care and better health at a substantially lower per-capita cost.”

The goals seem right… not just lower cost (since Lean is more than that), but also better care and better health.

No Outsiders!

Note that it says “prior health care industry experience.”

Yup, as it says later:

Process Improvement within the Health Care Industry, required.

PDSA Cycle within the Health Care Industry, preferred.

I think it's unfortunate when a health system limits their search to those who are already inside the healthcare club. So let's say an experienced Toyota leader decided to retire… the hospital wouldn't consider them? I can understand valuing healthcare experience, but filtering out outsiders before even having the chance to interview them is a wasted opportunity.

Does a healthcare process improvement person NEED to be an expert in healthcare? No, especially when that Lean leader knows how to work with others – the key stakeholders and the experts in doing the work. A skilled Lean facilitator teaches and coaches others on the improvement PROCESS rather than being the expert with the answers.

An experienced Lean person from another industry could collaborate in ways that are listed in the posting:

“They will work collaboratively with multiple internal and external provider and community groups, including healthcare providers, social service providers, business and industry leaders, governmental agencies and other community coalitions. This individual will effectively engage multiple stakeholders within the system, evaluate data from multiple sources, and keep children and their families' perspectives paramount in opportunities in process improvement.”

The right candidate, even an outsider to healthcare, would certainly be customer focused as a core mindset.

I've seen too many health systems, sadly, screen out really good candidates who had no healthcare experience. Does that mean EVERY outsider can navigate the healthcare environment? No, but that's what job interviews are supposed to be for… not resume screening.

Lean or Six Sigma or Whatever

The posting seems really confused about what methods they are looking for. Even after more than ten years of various process improvement projects and leaders, it seems they don't know what methodologies they support or expect to use. They REQUIRE “process improvement” experience in healthcare but also PREFER “PDSA cycle” experience in healthcare. That's confusing too.

Is Lean not PDSA at it's core? Toyota would say so (even if they use the term PDCA… it's the same idea).

As I quoted above, the posting asks for “PDSA, Six Sigma, and Lean.”

The posting also calls for:

Black Belt Six Sigma Certification, preferred.

Again, that would rule out an experienced Toyota person (or myself… and I don't think the person I know at the hospital sent me the posting because they wanted me to apply for it). I'm sort of technically certified as a a “Lean Black Belt” from my days at Honeywell, but it's not a Six Sigma certification.

I gave some feedback to the person who sent me the posting, suggesting that the Six Sigma preference might scare off some otherwise good candidates.

I asked what methodologies their leaders support and was told:

“I believe we are committed to a balanced approach whereby we have a portfolio of tools and use the one most appropriate to fit the situation.”

I replied:

My concern about viewing Lean, Six Sigma, etc. as “a portfolio of tools” is that approach often gives the appearance of progress (through improvement activity), but it doesn't seem to lead to much sustainable change.

Toyota would, of course, not portray Lean as a bunch of tools. Lean is not just “process improvement.” It's also a management system and a philosophy, as their people explain. When Lean is most successful and sustainable, it's part of a culture change that's LED (not delegated) by the CEO and other leaders.

The posting does reference the idea of “philosophy” and “practice” – but how much can a mid-level change agent influence the culture?

Proactively integrate the philosophy and practice of continuous quality improvement to meet desired goals and metrics across the system.

Where Does Culture Change Come From?

Much of the goals in the job posting make it seem like executives expect this single mid-level person to change the culture. This senior director appears to not have a team or any direct reports. An individual can run projects and get input from others, but can they really change the culture?

Some of the “specific knowledge, skills, and abilities” for the candidate and role include:

  • “Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.”
  • Interact with others in a way that gives them confidence in one's intentions and those of the organization.

If I were interviewing for this job, I'd ask how the executives I'd work for promote “openness and trust.” How much is that a part of the culture already? Do executives give employees confidence in their intentions?

  • Establish and commit to a long-term business direction

A long-term focus is classic Deming thinking. Taking the long-term approach is POINT #1 of The Toyota Way management philosophy. It's listed first for a reason. Many organizations copy Lean tools, but it seems not many try copying long-term focus.

I'd be curious to ask executives how THEY practice and promote long-term thinking.

  • Vividly communicate a compelling view of the future state in a way that helps others understand and feel how business outcomes will be different when the vision and values become a reality.

I'd also ask if executives do a good job of leading by example on that front.

  • Demonstrate a poised, credible, and confident demeanor that reassures others and commands respect; convey and image that is consistent with the organization's vision and values.

That one phrase would give me pause. What's the view and mindset of the executives in this health system. Do they “command respect” (thinking they are entitled to respect) or is respect something to be earned and given to you through others?

Sedentary?

Oh, and the job is listed as being “sedentary:”

Physical Demands

Sedentary – Exerting up to 10lbs. occasionally or negligible weights frequently; sitting most of the time.

Does the system expect this person to be in meetings most of the day, instead of being out at “the gemba,” actively working with people? I wouldn't expect to do a ton of lifting, but I'd expect to be standing and walking a lot… not sitting.

What Do You Think?

I wrote about this job posting on LinkedIn and got a lot of interesting responses.

Some comments included:

Bill Waddell

Only a fool would take the job. Zero chance of success.

Joshua Bittman

Command respect? Does this job come with a cattle prod?

Peter Gardner

Untenable position. Barbed wire canoe, up a mucky creek, without a paddle comes to mind

Mark Welch

Unfortunately the mentality shown in this job description is FAR more common than the Lean Leadership we all know SHOULD exist. This is one reason so many of us who love the Lean methodology/philosophy find ourselves as the first ones out the door when an employer's finances go south. I've talked with FAR more Lean professionals who find themselves going job to job – including myself- because the Leadership either doesn't get it or doesn't want to. Either they decide to leave or they're shown the door. Bottom line – we have to work and so we sometimes take these less than desirable jobs because we have to pay the bills.

Jason Consoli

I'm finding more and more job postings which are very similar, making the requirements of what is generally reserved for higher level employees for lower level employees. Unfortunately, they will find someone who isn't quite as qualified to do this job and they will meet their end game which is to pay someone at Director level rather than at senior executive level. They'll find some over zealous, over confident professional to take this on who will probably fail.

Michael Collins

This is a good one, thank you! It is interesting how organizations post positions that require candidates to meet expectations that are at least 1 level up, while the current workforce function 1 level down. The disconnect is so significant and the team becomes dysfunctional. Respect is earned, not commanded. The leader must possess emotional intelligence and executive presence, to say a few, in order to be respected.

Sabrina Butcher

The lean support role has an obligation to communicate and positively reinforce lean behaviors which requires us to not just “do all the lean work” but to ensure the culture understands and executes creating a lean culture that lives with the people on the floor. If something else is “commanded” it will fail as you know. I've left a lean role because of this expectation and continued unhealthy behavior of senior leadership. There was no other alternative. Although I really learned how to manage up with that experience and I'm so grateful for that. In this case, HR, who writes the job descriptions and senior leadership, who has a misunderstanding of a lean support role have an opportunity to align. I wonder if you could interview for this role and provide this helpful feedback for them?

I don't think I'd waste their time by interviewing for this, as it's very unlikely this is a job and role I'd want to take. I did offer, through my contact, to talk to the hiring manager (I don't know who that is or their role) to give free feedback and advice. That was about two weeks ago and I guess they aren't taking me up on that offer. I'd like to help because I respect the organization and their mission. They have a lot of great people (and patients) who would benefit from better processes and a better environment. I just don't think that role could really create that difference.

Carol Parkinson, SPHR, CCP

I find it interesting that healthcare leaders seem a little confused about leading. I would think the director level is operationalizing the leadership direction. Seems a bit backward.

There is a disconnect there about the organization's vision. Seems like that needs to be further developed before letting the process improvement leader loose to define and operationalize it.

Christine Zomorodian

I think that your initial assessment was right on the money. Senior leadership does not want to take responsibility for the culture. Things like HCAPS scores (the customer is always right) are strangling the professionals and creating new problems and roadblocks to an industry already in crisis. Whatever the metrics were intended to illuminate and solve, they are not getting the job done. The message is essentially confusing in healthcare; what is the mission? Profit, efficiency, appropriate and compassionate care? Regardless of philosophy, these goals are in constant conflict in reality. We will need real leadership to find the way forward.

Tony Benedict

Mark, after reading this, I feel your pain. My experience, especially in non-profit healthcare, is that senior executives either don't know how (more common) or aren't willing (least common) to do those things and believe it's best to delegate to “underlings” to execute. It's also part of the problem of accountability in healthcare. Senior Executives should breathe the value, exhibit the behaviors and hold those accountable to the same. That's hard, especially when boards don't hold executives accountable (non-profit). Probably much more to say on this topic. Just wanted to say to you, thanks for your bravery in your posting.

I hope that “bravery” is helpful to somebody. I know I'm being critical. But, I'm also frustrated that I've offered to help, as a member of the community, and apparently they don't need or want the help.

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Mark Graban is an internationally-recognized consultant, author, and speaker who has worked in healthcare, manufacturing, and startups. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent book is an anthology titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

17 Comments
  1. Lindsay says

    I’ve noticed most process improvement jobs require “Lean, LeanSixSigma” certifications, or Six Sigma Green or Black Belts as requirements for positions. Most also require experience in the industry the job is in or a degree in engineering. I believe people can come with a perfect resume, the right degree and certification and still not be able to do the job well. It takes passion and humility, along with knowledge and experience. Most jobs weed you out with a questionnaire to see if you fit these static requirements and then send an automated email to tell you you don’t “qualify”. I wish them the best of luck in finding their cookie cutter candidate.

    1. Mark Graban says

      The other response I got from the hospital was basically, “This person will help us sort out which method(s) we are going to use.”

      It seems like they have the mental model of the “process improvement toolbox,” which is a very incomplete view of Lean or the possibilities that come with improvement under any banner.

      If they’re emphasizing a Six Sigma Black Belt background (preferred), it seems they DO have a bias toward Six Sigma. That’s going to scare off many people with a great Lean background, as I tried telling them.

      You’re right, Lindsay, that temperament and attitudes matter. To me, that’s what the interviewing process is for.

      They’re unnecessarily narrowing the pool of ideal candidates by excluding outsiders and “preferring” a Black Belt.

  2. Mark Graban says

    LinkedIn Comment(s):

    Shrikant Kalegaonkar
    I share your frustration with job postings. I’ve been contemplating them a while, too. I’ve concluded that job postings are like the raw voice of the customer. They contain vague wants that often conflict with one another and don’t clearly communicate the real need.

    The job posting needs to be understood by the job seeker and translated into technical requirements. What does the org mean when it asks for lean, Six Sigma, PDSA? What is the real need? My guess is they’re want someone adept in the use of tools of these particular schools (e.g. lean: A3, Six Sigma: monetary impact, PDSA: ?) Why does the org prefer w/n industry experience? My guess is they’re not looking for facilitators/coaches/statisticians, but someone who’s going to do the actual subject matter work! In my case, med device/pharma orgs aren’t looking for Quality Engineers. They’re looking for Design/Manufacturing Engineers who are skilled in Quality. So subject matter expertise in the field is necessary.

    I’m not judging whether the org’s wants are right or wrong. I’m merely pointing out that we need to recast them into our language just as a design engineer translates customer requirements into engineering terms. Isn’t that part of our toolkit and mindset?

    1. Mark Graban says

      My reply to Shrikant:

      What I hear in the voice of the customer is: 1) We want to improve 2) We don’t know how 3) We think the culture and approach matters.

      I’ve had people encourage me to apply for the job as a way of giving feedback. I’m curious to see if I’d even reach the point of a phone interview.

      But, it seems VERY unlikely that I’d find this the right situation for me… so it seems respectful to not waste their time applying.

    2. Mark Graban says

      Also from LinkedIn:

      Nicolas Ruhmann
      This is almost ALL job postings for these types of roles. 1) They think their industry is special, and if you’re not from it – you can’t understand. 2) They want someone to “do” or “lead” CI, delegated….instead of someone to actually coach and mentor the executives on how they should be doing /leading.

  3. Mark Graban says

    Here’s a discussion that Dr. Greg Jacobson and I had on a similar topic – about finding a job in process improvement work.

    Greg, as an MD, think it’s “crazy” that a hospital would automatically rule out process improvement outsiders.

  4. Robert Kluttz says

    My own hypocrisy is not lost on me (since someone once gave me a chance to work in healthcare despite the fact that I had no prior healthcare experience), but I would be very hesitant to bring someone into the industry without solid prior exposure. I’ve worked in financial services, manfacturing/engineering, government, retail, etc, but I’ve found healthcare different in a lot of ways. Every industry has their nuances, but healthcare is especially complex everywhere from revenue cycle to consumer psychology to process flow.

    This is made even worse by the fact that many non-healthcare process improvement professionals THINK they understand healthcare due to their exposure as a consumer of healthcare services. If you’ve waited for six hours in an ED, its easy to leap to conclusions as to simplistic flow solutions. The beta risk associated with these assumptions would be dangerous enough in any other industry, but its especially pernicious in healthcare. If you approach patient flow with the same perspective as you would in any other industry, you’re going to kill someone. I don’t say that to by flippant. I say that because it’s really easy to “fix” processes in healthcare without having visibility to the severely (or even mildly) negative downstream consequences. Read through healthcare process improvement case studies, and it’s not hard to find potential clinical or rev cycle risks that weren’t contemplated, let alone mitigated.

    1. Mark Graban says

      Thanks for commenting, Robert. I think any good Lean practitioner wouldn’t THINK they know a process or system and they wouldn’t jump to simplistic or dogmatic solutions.

      I’d try to prevent this through a behavioral interviewing process… learning about the person’s motivations and approach, not just their skills and experience.

      Yes, healthcare is different in many ways. But I’m convinced that healthcare can be fixed just by the insiders… I think the ideal process improvement team is a mix of insiders and outsiders, clinical and non-clinical. This job posting that I’m writing about here seems to be a “lone wolf” position, which seems unlikely to work regardless of who they hire.

  5. BS says

    It’s easy to believe that wanting someone with healthcare experience is a direct response to prior experience with “Toyota trained” experts.

    I’ve had experience with one of those experts recommended it was ok to run out of a certain anesthesia medication to show where the weaknesses in the supply chain were.

    While healthcare has lots to learn from industry, it’s not unusual for a “Toyota trained” expert to come from a manufacturing plant where there is only one or two product families, a stable production schedule (always subject to change of course), and replacement workers can be trained in an afternoon. Not much about that type of experience translates well in healthcare.

    The other one is that of all the Toyota trained experts out there, very few have experience starting from ground zero.

    I am not saying all Toyota trained experts have limited capabilities. Buyer beware.

    1. Mark Graban says

      Thanks for the comment and story, BS.

      I’d never say “All former Toyota people would make an excellent healthcare hire” any more than I’d say “Never hire someone from outside healthcare.”

      The interviewing process is key. I’ve heard a story about a Toyota-trained person getting kicked out of a hospital for suggesting putting the operating room table on a slowly moving continuous flow line. Maybe they were being thought provoking. But, I understand why they’d get kicked out.

      Suggesting it’s OK for an important medication to run out is just as bad.

      When I worked for my last manufacturing company, a person was hired directly from Toyota. Supposedly, they had a meltdown and quit on the first day because they couldn’t handle our current condition starting point of waste and chaos.

      Knowing how Toyota runs and how to continuously improve Toyota is a VERY different skill set than knowing how to turnaround a bad operational setting. My GM experience, as frustrating as it was, was great experience in terms of having a BAD starting point.

      As always, buyer (or hirer) beware.

      Part of the problem, I think, is hospitals that don’t understand Lean trying to do a good job of choosing who to hire. The blind leading the blind? They should use a good recruiter. Or, again, I was trying to offer FREE advice as a member of the community… but they apparently feel it’s not needed.

  6. BS says

    All good points you make.

    Finding the right consultant or internal hire is difficult but perhaps not as important as a willingness for leaders to personally own the responsibility for learning how to move the org forward. I think that was the #1 message I got from your recent podcast with Dean Gruner.

  7. Mark Graban says

    I stumbled across this interesting Deming quote from “Out of the Crisis:”

    15. I should mention also the costly fallacy held by many people in management that a consultant must know all about a process in order to work on it. All evidence is exactly the contrary. Competent men in every position, from top management to the humblest worker, know all that there is to know about their work except how to improve it. Help toward improvement can come only from outside knowledge.

    1. BS says

      Awesome quote. I won’t disagree with Dr. Deming.

      Outside knowledge/learning from (the right) outsiders is necessary to a point. I’m guessing most never reach that point.

      1. Mark Graban says

        What do you mean by “reach that point?” I’d like to hear more…

        p.s. It doesn’t bother me if you disagree with Dr. Deming :-)

  8. Dewayne Whitener says

    Mark: Excellent article and you are correct in everything you say. I took a job as a “Performance Improvement Specialist” about seven years ago in a small (270 bed) hospital. My background was mainly in manufacturing, with my previous 13 years working in the Manufacturing Extension Partnership program through NIST. I was able to convince them to take a chance on me (pay cut). I feel I have done well, because I work well with all levels of the organization. I do spend a lot of time in the “Gemba,” working as the go between of the front line staff and support departments. There appears to be a major fixation in healthcare with Six Sigma certification (I am an ASQ-CQE, CMQ/OE and CQA, as well as CPHQ). We are preparing to hire a Director of Quality (part of their job will be managing me), but as you said, they want someone with Six Sigma certification, as well as an RN. Certifications are fine, but if you can’t work with people to get changes made, they are meaningless. Possibly the organization you talk about here is just getting their job requirements off another hospital’s website (the job descriptions all sound similar at that level – I certainly would not take the job). Thanks again for writing a great article.

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