Employee Complaints About Lean in Healthcare, Even at Some of the Best Organizations

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Last week, I blogged about some employee complaints related to rotating day and night shifts at the Toyota San Antonio plant. In that post, I mentioned that employees who post on Glassdoor.com and other sites might not be a representative sample of the full employee population.

With that in mind, what happens when we search the Glassdoor surveys of some well-known “Lean hospitals?”

I posted a few of these employee comments on LinkedIn the other day (a short post that has received over 50,000 views and prompted a lot of discussion).

Here is one of those employee comments about a health system that many would consider to be a long-time leader in “Lean healthcare:”

“Management needs to have a better understand of the work, because of [Health System's] Lean Culture changes are made on a continual basis by people not in the work and who don't understand who is all impacted by the change.”

As I said on LinkedIn, in a Lean culture, improvement is supposed to be done WITH people or BY people… it's NOT supposed to be done TO them. Improvement is supposed to be done WITH people or BY people... it's NOT supposed to be done TO them. #Lean Click To Tweet

Here another sad comment from another well-known Lean hospital:

“[Redacted] has gone too far in its attempt to cut costs. Many behind the scenes employees work in squalor and are treated like slaves. They are encouraged to skip lunch and breaks and are in constant fear of being fired. As a new employee, It only takes a few days to realize that you will be asked to commit hari kari if you make an honest mistake. That is the Japanese (LEAN) way.”

NO!

via GIPHY

The Lean way doesn't blame or punish individuals for an honest mistake. I don't understand how the leaders in these organizations misunderstand Lean… or maybe didn't bother to learn. If even one employee has this perception… I guess perception is the reality, as they say.

We need to do better.


Hear Mark read the post (Subscribe to Lean Blog Audio):


Another comment says:

“There is so much focus on lean and no focus on building better managers.”

That's sad to hear. Lean is supposed to focus on developing people, including managers. Lean is a different way of leading and managing, not just a set of tools or projects.

Are those comments representative of what most employees think? Of course not. But, if even a handful of employees have major (and understandable) issues with what they're experiencing with Lean, then that represents an opportunity for improvement. Do those organizations need to be more consistent with what Lean really is? Do they need to invest more in additional or more capable coaches for those leaders who are perhaps misunderstanding or misapplying Lean?

We're almost 20 years into the “Lean movement” in healthcare. But, there are still way too many organizations where Lean is limited to relatively trivial things, including straightening up the workplace or having daily huddles at the frontline. I'd say a majority of those organizations that are “implementing Lean” don't have executives who are actively learning about Lean, let alone teaching it or modeling the behaviors we'd want to see in an effective Lean culture. Click To Tweet

What health systems are these comments about? To harken back to a scene from the movie “Fight Club,” “a major one.”

Actually, it's “major ones.”

Here are some of the comments from LinkedIn about my post and those employee comments:

Please post a comment and join the discussion. Subscribe to get notified about posts daily or weekly.

Mark Graban is an internationally-recognized consultant, author, and professional 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 the anthology Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also a Senior Advisor to the technology company KaiNexus. His latest book has been released as an "in-progress" book, titled Measures of Success.

20 Comments
  1. Bob Emiliani says

    RE: “There is so much focus on lean and no focus on building better managers.” There is a perception that because one is a manager, there is little one needs to do to become a better manager. It is akin to the perception in higher education that because one has a Ph.D., there is little one needs to do to become a better teacher. Whether manager or teacher, the default assumption should be that one’s practice is poor and needs to be improved. Managers and teachers “operate” on people and therefore must devote themselves to improving their practice.

    1. Mark Graban says

      Agreed. Every professional should be practicing their craft, which means learning and having a capable coach.

      If an executive is too arrogant to have or need a coach, that’s a huge problem.

  2. BS says

    To Terence’s quote from above:

    John Shook – 2017

    What are the biggest challenges for the lean movement right now?
    JS: “First of all, the challenge that doesn’t go away: the human tendency of copying and pasting “best practices”. We have already fallen into the trap of blindly copying what Toyota does – and learned it leads nowhere – so we must remain vigilant to ensure it doesn’t happen again. Tools are not important; PDCA and learning are.”

    I wholeheartedly agree with JS. If you’re trying to copy Toyota in trying to be Lean you will do neither.

    1. Mark Graban says

      And trying to copy ThedaCare isn’t a good strategy either. And they’ve said as much. Don’t copy us… learn from us.

      I can’t tell you how many sad, unused “huddle boards” I see in different hospitals. They copied the ThedaCare bulletin board template precisely. I personally think their format is flawed and overly complicated in many ways. But the boards don’t get used.

      It’s about leadership and mindsets. Collecting “idea tickets” on a PICK chart is a waste of time if nothing is being implemented.

  3. Rick Bohan says

    “[Redacted] has gone too far in its attempt to cut costs.”

    I’ve repeated many times, in writing and discussions, that if an organization sees cost cutting as the primary goal of lean, the initiative WILL fail.

  4. Anonymous says

    Loved the blog today! I couldn’t agree more, I am tired of Lean being blamed/mis-used/solely for reducing costs and hitting executive incentive year end goals. I know some of these “long time leaders in Lean Healthcare” have had the following issues:

    Monetary incentives for senior executives to reduce costs via Lean, clouding their judgement on how to execute and apply lean

    Not allowing for a smooth process to increase resources when volumes increase significantly, b/c the yearly stated goal is to freeze or reduce FTE’s…

    Poor leaders (administrative & physician), making very poor business decisions, further worsening the economic climate and focus within their organizations

    Many in the administrative leadership ranks coming from finance, so they stay in their comfort zone and focus mainly on cost reduction..

    I think some health systems have so overly focused on cost reduction over the years, due to many needed reasons, but how much is too much if misapplied?

    Yes there is a ton of waste and we should always work on it, but our stated mission is taking care of patients, these executives that misuse and misunderstand lean due to cost cutting pressure, will be dissatisfied patients when they become patients in the health systems they led, and they are laying in their patient bed, waiting for a nurse to respond to their call light for more pain meds, etc.. Maybe it’s back to the monetary incentives, what if patient throughput and quality scores were incentivized equal to or over cost reduction?

    Losing sight of good leader/staff development

    Not working with physicians on their throughput and value stream, and TAT issues.

    I do agree some physicians want to be involved in improvement work, but for me, the jury is still out as to how many, for many reasons:
    Were physicians burned with a past lean effort so they have a bias on what they think all improvement work will be?
    Were the physicians properly trained in the principles that the managers were trained on?
    Were the physicians given time to work on improvement for the panel of patients they are ultimately responsible for?
    Also of need: lean training in med school and residency, health system from then lens that these are their patients, they MUST take an active interest in the delivery model and flow of their patients…

    Did the organization first try some things with a Champion/Model cell to highlight the benefits or just roll out it out quickly as a mandate?

    I do still think there is a % of docs (maybe small not sure), that maybe due to their personality traits and/or all things listed above, that just want to walk in and see their patients, and don’t have much desire to improve flow, unless of course it’s tied to their comp, and even then some want it done for them… “they went to school to treat patients” I think we need a dialogue with physicians that “treating patients”, also means being considerate of their flow issues, wait times, quality issues, etc..

    A smaller issue as I think this can be counter measured with good instruction and training on improvement, but I do still encounter this situation in many meetings with providers, I personally think physician engagement is the blue ocean opportunity in health care (that along with Med Record optimization & leader development J)

    My fear is there are still a lot of large health systems who’s stated goal or covert goal is to mainly cut costs via lean; and not to help create an overall better culture and better quality, safety, etc.. Some of them say the right things (“We want to improve quality, safety, costs, etc..”), but they really just mean they want to cut costs. If someone were in a health system where for years they were constantly told to cut costs, and reduce hours worked, regardless of volumes, than I think you see employees with the view points on Glassdoor that you cited. Yes there is a still a ton of waste in healthcare, but if that is the sole/over-riding focus, they are hampering the potential and true power of lean. I think so many are clouded on what the real end goal should be, and ultimately gets back to the chicken or the egg thing with good leadership or lean (when we need both), but we still try for good leaders, trained in lean doing the right things every day and engaging their staff in improvement work. Also of note, if this type of feedback can be gotten from the health systems that are “touted for lean”, what a troubling state of affairs for all health systems…

    Just my 2 cent’s :) and quick reaction.

  5. Giraud says

    Bonjour,
    effectivement moi je suis en France et chez nous je rencontre du personnel usé, désabusé. Quand on leur annonce “nous allons faire plus avec moins”, ils n’en peuvent plus.
    Le plus triste c’est que je rencontre beaucoup de personnes qui étaient pleines d’idées, de motivation et de passion mais, maintenant ils sont éteints.
    Alors, je garde espoir en me disant que si demain ils avaient la possibilité d’être bien aidé et guidé leur naturel referait surface.
    Mais il faudrait que les dirigeants et les financiers comprennent le Lean en profondeur, pour pouvoir le partager, et réalisent que les améliorations ne seront pas que financières mais, surtout humaines. Il faut accepter que l’amélioration continue c’est pour…toujours.
    La conseillère d’orientation à dit une phrase à mon fils :
    “c’est cette école et son fonctionnement qui ne te permettait pas d’exploiter pleinement ton potentiel et tes capacités ” elle lui expliquait pourquoi il n’avait pas reussi certaines choses dans son passé. Voila qui change des discours habituels et pourquoi il l’adore. Ce n’est pas un exemple de Lean mais d’une façon de tirer le meilleur de chacun car au lieux de dire, il faut faire mieux, elle lui explique qu’il faudra faire autrement. C’est Micheal Ballé qui disait il faut rester en mode apprentissage à vie (avec de plus jolies phrases) mais je pense sincèrement que le secret est effectivement là.
    Il reste encore tellement de monde qui n’a pas compris le vrai Lean qu’il y a encore beaucoup d’échanges à venir.

    1. Mark Graban says

      Google translation to English:

      Hello,

      actually I am in France and at home I meet staff worn, disillusioned. When we tell them “we will do more with less”, they can not take it anymore.

      The sad thing is that I meet many people who were full of ideas, motivation and passion but now they are extinct.

      So, I remain hopeful that if tomorrow they had the opportunity to be well helped and guided their natural would resurface.

      But leaders and financiers need to understand Lean in depth, to be able to share it, and realize that improvements will not only be financial but, above all, humane. We must accept that continuous improvement is for … always.

      The guidance counselor said a sentence to my son:

      “It is this school and its functioning that did not allow you to fully exploit your potential and your abilities” she explained to him why he had not achieved certain things in his past. That changes the usual speeches and why he loves it. This is not an example of Lean but a way to make the best of everyone because instead of saying, we must do better, she explains that it will be different. It’s Micheal Ballé who said you have to stay in learning mode for life (with nicer sentences) but I sincerely believe that the secret is indeed there.

      There are still so many people who do not understand the true Lean that there are still many exchanges to come.

      1. Mark Graban says

        I agree that when hospitals are understaffed, the last thing anybody wants to hear is “do more with less.”

        We often need to “do better with the RIGHT staffing levels.” Better quality, better safety. People are stretched thin. The cost cutters who set staffing levels based on spreadsheets and benchmarks aren’t in the gemba to see the chaos that’s created.

        A truly Lean organization would be reducing chaos and improving care, not slashing staffing budgets.

  6. Tom Gormley says

    I think saying “even one” or “even a handful” of employees with these views is a problem with how lean is being taught and used, is being too hard on ourselves. Adopting continuous improvement and lean principles as part of culture is a big change, and it’s reasonable to expect a portion of staff will be unable or choose not to accept it. I believe even in the best lean hospitals, they’ve had and will continue to have some number of employees who aren’t able to or choose not to change, but the best also adapt their hiring processes to sift those people out. John Toussaint wrote about this in “On the Mend”, reflecting on how quite a few staff including physicians left ThedaCare over the adoption of lean there. These people undoubtedly had and expressed negative, inappropriate staff views of lean. Their management team accepted that as reality, knowing that the results they were seeing were worth it. Sometimes, these negative views were even deserved … but in the book Toussaint says ThedaCare listened to employees, learned that “the problem was us” meaning senior management was in fact burning people out by not adopting lean in its own management style, and then changed to create their new “lean management system” to address that. So these views are a problem, but just not necessarily always caused by the implementation approach or leaders who don’t understand lean. I think a good root cause analysis of these comments would have to identify some employees who can’t or just prefer not to change, as one of the roots.

    1. Mark Graban says

      I think it’s valid stance to take that our ideal is not “even one” person upset and complaining online about Lean. And the solution isn’t to tell them to stop posting online :-)

      If an employee has valid concerns and criticisms of what Lean is at their organization (or their perception of it) and they aren’t able to have a discussion internally with their manager or others… and that leads them to vent online… then I think that IS a problem that leaders should reflect on, as Toussaint did.

      “These people undoubtedly had and expressed negative, inappropriate staff views of lean.”

      What’s an example of that? Does telling a person “your view is inappropriate” help? These comments are often made behind the backs of those who are being “negative” instead of engaging with them.

      If people are being “negative,” if we respect and value each individual, that negativity should be the starting point for a conversation about Lean. Too many leaders hear “negativity” and demand they “get on the bus” or something, which is only going to increase the negativity. And the cycle continues.

      I also don’t think blaming people for being resistant to change is very constructive. It doesn’t move the organization forward. The root cause isn’t the individual. If they’re being difficult, why? I’d more likely point to the culture of the organization as making them burned out or demoralized.

      I know you’re not calling these people “dead wood,” but it reminds me of the quote from Peter Scholtes:

      “Why do you hire dead wood? Or why do you hire live wood and kill it?”

      I’m reminded of the Jamie Bonini comment from Toyota: “If people are upset, it’s not really TPS.”

  7. Tom Gormley says

    Mark, I agree that it IS a problem, even one or a few staff holding these negative views, never mind expressing them. What I challenge is whether this is attributable to poor teaching, coaching, or leading of lean thinking, vs. just to the reality that a portion of staff won’t be able to make the change in their thinking.

    1. Mark Graban says

      Other than somebody who has some form of a psychological condition, have you really ever met somebody who can’t change?

      People try new things all the time. A person quits and leaves an organization in the fog of bad Lean and/or poor leadership demonstrates they aren’t “resistant to change” by changing jobs.

      Many times, the “resistant to change” label really means “resistant to my idea.”

      If some portion of staff can’t change their thinking, I’ll hold by my statement that it’s bad leadership. If management is hiring a bunch of people who are that inflexible, maybe they should rethink their hiring process. It’s a systemic problem, either way.

  8. Robert Kluttz says

    Dear Anonymous,

    I would guess that most hospital CFO’s know more about Lean than most Hospital lean practitioners know about healthcare revenue cycle. I would also guess that most doctors know more about process flow than most Hospital lean practitioners know about clinical pathways. I’d go even farther by guessing that if you took the HEDIS/HCAHPS/VBP/etc scores for the top 10 “lean hospitals” (however you want to define that), they wouldn’t look substantially different than a nationallly average hospital when we normalize for patient acuity and payor mix.

    If a hospital lean practitioner really wants their lean healthcare transformation to be impactful, then it helps to start with a little humility and acknowledge that there is far more that they DON’T know about health systems than they do know. I’ve learned way more from clinicians than they could ever learn from me. I’ve learned more about patient experience from administrators than they ever learned from me.

    I think too many lean practitioners are so focused on becoming senseis that they skip over the part about being students. That’s a bad enough trait in other industries. But in healthcare? It’s downright dangerous.

  9. Tom Gormley says

    Robert, that would be an interesting study of top 10 “lean” hospitals, whether their results show a significant difference from average. I don’t know of such a study, but I’ve read a study you might consider fairly parallel to ours in the lean world — Baldrige Award winners. I include links below to some of these studies which use company value (publicly traded stock) as a proxy for overall performance. Anyway, the study did show a significant difference in between the award group and their non-practicing peers as a group. I suggest it’s parallel because Baldrige like lean is a holistic systems look at improving organizational processes, culture, and performance.

    Results of 1990-1999 Baldrige Award Recipients 10-Year Common Stock Comparison
    Results of 1990-1999 Baldrige Site Visited Applicants 10-Year Common Stock Comparison
    Award Recipients Included in the Stock Study
    NIST 2000 Stock Study of Malcolm Baldrige National Quality Award Recipients

    Here is the main page for those studies. Here’s a snippet:

    Methodology:

    A hypothetical sum was invested in each of the 1990-1999, publicly-traded Baldrige Award recipient’s common stock, in the year they applied for the Award. The investment was tracked from the first business day of the month following the announcement of the Award recipients, (or the date when they began public trading, if it is later) through December 1, 2000. $1,000 was invested in each whole company, and for subsidiaries the sum invested was $1,000 multiplied by the percent of the whole company’s employee base the subunit represented at the time of its application. The same total dollar amount was invested in the Standard & Poor’s (S&P) 500 on the same day. The value of the original stock at the time of sale was determined and that dollar amount was reinvested in the new parent company. Adjusting for stock splits, the value on December 1, 2000 was calculated. The 24 publicly-traded Award recipients, as a group, outperformed the S&P 500 by approximately 4.2 to 1, achieving a 685.26% return compared to a 163.11% return for the S&P 500.

    I’m optimistic we’d find a significant advantage in performance results between our top 10 lean hospitals and everyone else.

    1. Mark Graban says

      Tom, I agree that Baldrige and Lean are both holistic systems (and there’s much evidence that shows Lean and Baldrige are very compatible, including in healthcare).

      I’m not sure how one would choose the “top 10” Lean or Baldrige organizations in an industry. The indicators we might have to determine that list might be lagging and inaccurate.

  10. Robert Kluttz says

    A quick check of a dozen or so Baldrige/Shingo-winning hospitals over the last decade shows a wide rage of corresponding clinical outcome measures. Serious Complication Rates as low as single digits (national percentile) to the mid-90’s. Readmission penalties and HAC’s show similar variation amongst the winners. HCAHPS scores are also a little all over the place.
    So I’m not sure if you could show any real correlation between Baldrige winners and Clinical Quality

  11. Tom Gormley says

    Robert, I looked a bit further and found a 2015 hospital specific study comparing 34 Baldrige with 153 non-Baldrige hospitals (in the same geo regions for apples to apples), showing a statistically significant difference in performance including HCAHPS scores of patient experience (in fact the article said that was the most significant difference vs. non-Baldrige hospitals in this study). This study is worth an extra look as it was published in a peer-reviewed journal giving it more weight than cursory comparisons we all typically have time for ourselves. Hard to dispute these results which are stronger even than I would have expected.

    Here’s a quick quote from the research, and the link is below that.

    “Hospitals that used the [Baldrige Health Care Criteria for Performance Excellence, abbreviated by the study authors as HCPE] had higher means and lower standard deviations [indicating a measurable positive patient experience] than the non-HCPE hospitals in all 10 measures.” The authors also report that the differences were statistically significant for nine of those 10 measures, showing that there is a definite positive impact on patient experience with use of the criteria.”

    https://www.nist.gov/news-events/news/2015/07/baldrige-helps-health-care-organizations-provide-superior-patient

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