Adventures in #Lean Healthcare Hiring, Part 1


I'm not looking for a traditional, full-time job, but a lot of job postings cross my path, as people are looking for referrals. A lot of what I see makes me shake my head, such as a job posting for “Lean” that requires a “Six Sigma Black Belt.” There's a lot of confusion.

Yes, part of our job, as experienced Lean practitioners, is to help the confused, but when they don't ask for help (or don't accept feedback), it gets frustrating.

Don't Talk to Them!

A reader of Lean Hospitals reached out me for some advice in their interviewing process for a health system on the west coast. I don't have the job posting (and can't find it on their website), but he was emailing me about something in the interviewing process that concerned him (and it struck me as very odd too).

I know what organization it is, but I'd rather not name names. I did a Google search using some phrases from what he sent me and that doesn't find any public document or page online. This health system's text is in italics. My comments will be non-italics and indented.

Interview Process:

You have been asked to do a preliminary assessment of a process in an area new to performance improvement.

You will have approximately two hours to observe the process and prepare for a report-out to the team.  The report-out will be to actual Quality Management staff portraying members of the process team.

  • One person will be the director
  • One person will be the manager
  • One person will be a front line staff person
  • Other individuals may be present but will be silent observers during the presentation

So we have role playing? I wonder if the ability to do effective role playing was part of their job description? Did they need to go through simulated role playing during their interviewing process?

You will have up to 40 minutes to facilitate your report-out with the team.  You will have no prep time in the room.

Consider including:

  • Introductions
  • Agenda for the report-out
  • A visual of the process
  • Assessment of current state
  • Teaching on an improvement concept that relates to the process
  • Issues and improvement opportunities you saw
  • Recommendations and next steps

At the start of the exercise, you will be escorted to a nearby area to begin your observations of the process.  Please avoid interacting with staff, customers, and patients while observing.

This really has me scratching my head.

For one, I'm uncomfortable with the model of a solo lone wolf “P.I person” assessing a process. What about respecting and involving the people who do the work?

In Lean Hospitals, Chapter 4 is about process observation. When I worked for ValuMetrix Services when it was part of J&J, consultants like me would often be sent in, alone, for a day or two, to try to do an initial assessment of a department or value stream.

More ideal is the consulting teaching staff members and managers how to observe and study their own processes, on more of a peer-to-peer basis. This is respectful AND more effective. For example, it's easier for me to teach and coach a nurse on process observation, allowing the nurse to then combine their domain expertise with Lean and basic industrial engineering methods. My role as coach was to be “fresh eyes” and maybe help challenge things they would take for granted as an insider.

During an assessment, I'd have to work alone because the organization had not yet made the commitment to the Lean improvement process, which in our work meant dedicating time for staff to study their process and to work on improvement (in projects like this one or this one). It wasn't ideal, but it was start.

But, you know what I did to help make sure I wasn't making a faulty assessment or jumping to conclusions about anything?

I talked to staff, customers, and patients!!!!!

Their input and perspective was CRITICAL. Now, there's a time and a place for this interaction. You have to be discrete and polite. You have to not get in the way of work. I wouldn't barge into an exam room and I wouldn't interrupt, say, a nurse who is doing medication administration (because interruptions increase errors).

I don't understand why a hiring exercise that's being used to evaluate a job candidate would specifically say DO NOT TALK TO PEOPLE.

I don't understand how that's a helpful application assessment exercise and I don't understand how that's a helpful method once the person is hired.

The work and the process to be observed in healthcare is not a repetitive assembly line cycle, with somebody doing the same work every 45 seconds. Even in that sort of manufacturing environment, wouldn't it be respectful to, at some point, talk to the employee to get their input or to ask them questions?

Any necessary supplies for your observations will be available, including:

  • paper
  • pens
  • clipboard
  • stopwatch
  • For your report-out, please use only the following, which will be provided: 
  • dry-erase board & markers
  • pen & paper  

The candidate said they were uncomfortable with the stopwatch. Yeah, I would be too. That sounds like old-school industrial engineering. That's perfect that they will also have a clipboard… that completes the “time study man” stereotype from back in the day.

What, no pocket protector???

Laptops, tablets, etc…  will not be permitted.

I'll be the stereotypical Lean person and ask, “Why? Why no devices?”

What's the “etc.” here? If I were having to time a process, you know what I'd use that would be more discrete and maybe less off putting than a stopwatch? My iPhone.

That said, timing a process has to be done respectfully. I'd make sure people in the area knew what I was observing and measuring – and why.

That means TALKING TO PEOPLE,  not sneaking around with a stopwatch.

After your report-out is complete, we will open up to the whole interview team to ask any questions about the exercise, and then transition to a traditional interview.

Time study isn't bad… but it should be done in a respectful way, as I blogged about here:

Time & Motion Studies Are Not “Discredited,” Just How They Are Used

Have you seen an organization use some sort of “process observation” scenario as part of the hiring process? What do you think about that, or process observation in general? Do you talk to people? What methods have you found to be most effective?

Coming Soon

I'll probably write another post for next week about a healthcare systems “senior process improvement director” role that also had me scratching my head for a dozen reasons or so… I'll expand upon this discussion that's taking place on my LinkedIn post from yesterday.

Here is Part 2:

Adventures in #Lean Healthcare Hiring, Part 2

Check it out…

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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. Mark, All points well taken. Your blog doesn’t mention exactly what position they were hiring to fill. Is there a possibility it was ill defined for them as well? If you feel you’re hiring a coach who’s also a take charge coordinator, Lean champion and Six Sigma Black belt, it could be the organizations’ understanding of their staff needs revision.

    • I can’t find the formal posting, JPesz, it was just described to me as an internal improvement consultant role. I don’t know much “Lean” was a focus, but my understanding was that it was a “Lean” role and that’s why they were interested in it.

      This organization DOES have a Lean program of sorts.

      Under “why lean?” in a presentation from a few years back, the slide says:

      “Lean is the way we will survive.”

      • Improved work efficiency (reduce waste)
      – More time for teaching, research, etc
      • ______’s Goal of Excellence in the Triple Aim
      – Outcomes for Individuals and Population
      – Patient Experience of Care
      – Reduce Total Cost of Care
      • Clinical excellence to command premium pricing
      • Create focus

      ““Lean” includes management systems and improvement
      methods that focus on optimizing quality and efficiency
      (referred to as value and waste reduction) – it is a
      distillation of the Toyota Production System.”

      But that stopwatch / clipboard approach is not very Lean or TPS.

  2. Hi Mark, Enjoyed your blog! As a physician, healthcare leader and student of Lean, I see the need to hire strong lean team members (or a lean team leader) as a major challenge for healthcare leaders who are well-intentioned but new to Lean . Many don’t know where to start, and there is a LOT of bad advice out there. In our team at Cleveland Clinic we have moved to hiring for the soft skills – heavily emphasizing respect for people and emotional intelligence , and also looking for critical thinking- as we feel the tools and “technical skills” are much easier to teach and develop. Perhaps a future blog on “How to start and build a strong Lean team: A guide for healthcare leaders” is in order? I think many of us would read such a piece with great interest.

    • Thanks as alway for your thoughts, Lisa.

      Yes, many in healthcare leadership are well intentioned but new. They’re able to learn… the question is, “are they willing?”

      I see too many organizations where executives are quick to say “Yeah, we understand Lean.” It could be the Dunning-Kruger effect.

      Or it’s just that bad formula of Ignorance + Arrogance + Unwillingness to Learn = Failure

      Hiring for soft skills and critical thinking is really important. It’s easy to teach “Lean tools,” but harder to teach the context in which those tools are best used. And a lot of that valuable experience in soft skills and working with others (working with people) is very transferrable across industries.

      Thanks for the idea for the post!

      • Thanks Mark! I like your equation: Ignorance + Arrogance + Unwillingness to Learn = Failure
        But – that’s a lot of components, with different causes and countermeasures.

        What if we just focus on the ignorance component? For those of us (healthcare leaders) who are not arrogant and are willing to learn … there is still risk of failure, or at least limited success (in pace and quality). There is not a lot of good guidance on how to start practicing Lean in your healthcare organization, including how to start/hire/build your Lean team. What guidance do you have for those of us who only have the ignorance gap?

        • Hi Lisa –

          Arrogance and Unwillingness to Learn might be the same thing, if not “co-morbidities” for an organization or a leader.

          There are many causes and countermeasures to the problem of failure or limited success.

          The ignorance gap can be addressed through “education” in different forms. But, I think the best learning comes from a “learn by doing… with a capable coach” mode… learning and results can go hand in hand that way?

          I see too many organizations focus on classroom education. Read a book. Take a test. I would call that just a good start…

          From what I’ve seen, an effective “Lean team” is very diverse in so many different ways, including a mix of insiders/outsiders to healthcare, a mix of clinical and non-clinical people, a mix of different types of clinicians, those with leadership experience and those who haven’t yet been ruined by that experience ;-)

          Hopefully that helps in some way… no easy answers.

          What do you think the biggest causes of failure or the risk of failure are?

  3. This method of “process observation” is not just misguided (a stranger walking around with a clipboard and a stopwatch all but guarantees you won’t see how the process actually works on a day to day basis – Hawthorne Effect & Observer Effect), but it also reinforces bad process management. The only conclusion that an observer in the ED should take away after spending a couple hours there is that they should observe the entire value stream before drawing any real conclusions. It may be a well-intentioned effort as part of the hiring process, but it’s going to lead to a bad hire. And that bad hire is going to make other bad hires as they fill out their team (and drive away actual good candidates).

    For an organization hiring for it’s first “improvement leader” role (or an organization that has only hired a few similar positions), PLEASE reach out to someone for help. Find an external set of eyes that can spend some time with your organization, talk to your leadership, review your strategy/data infrastructure, assess your competitive landscape, then craft a position description and recruiting strategy to find the right person. It is an incredibly important position and so easy to get wrong. Unless you work with these roles every day and have gone through a ton of hiring cycles, it’s almost impossible to distinguish between good candidates and bad candidates. Hiring the wrong person can set your growth back years, drive millions in lost opportunity cost, and worst of all, negatively impact patient care.

    • Hi Robert – this is not a case of an organization hiring their first Lean person. They’ve had a Lean approach for at least six years based on evidence I can find online.

      The scenario I posted on LinkedIn last week IS the case of hiring the “first” one. I’l blog about that soon, as I alluded to above. The problem is this will be about the 5th “first person” they’ve hired and churned through over the past decade.

      I agree with everything you said there in your comment.


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