What’s Going on with Lean at ThedaCare?
I've heard a lot of rumblings recently about what might be happening at ThedaCare, a health system in Wisconsin that's been considered one of the best examples of “Lean healthcare” anywhere in the world for more than a decade. It seems that there is an evolution occurring in their approach to Lean.
I've received a formal statement from ThedaCare public relations, which you can find in this post, so I will stick to the facts that they have given me and other information that's publicly available online.
My History with ThedaCare
I've never worked there (as an employee or as a consultant), but I've visited ThedaCare many times over the past nine years. I've been impressed with much of what I've seen at “the gemba” of various care delivery sites and departments, their “visual room,” and their famed “weekly report outs” of Rapid Improvement Events.
In 2010, I helped produce an instructional DVD about their “strategy deployment” approach and management system. I added new material to the third edition of my book Lean Hospitals based on what I had learned about their management system over time, supplemented with a site visit they hosted for me in 2015.
As a faculty member for Catalysis (formerly the ThedaCare Center for Healthcare Value), I have a lot of vested interests (if not conflicts of interest) in this story. It's probably in my best interests to focus only on the positive, but I've been doing my best to figure out the real reality.
What do we know about ThedaCare?
The new CEO has expressed an admiration for ThedaCare and their approach to Lean.
Fact: They have a new CEO, Dr. Imran Andrabi, who was hired from another health system in 2017 (release)
Fact: ThedaCare said the three finalists for the job were all outsiders (release)
Fact: By comparison, at least the last two ThedaCare CEOs (Dr. Toussaint and Dr. Gruner) had been internal promotions.
Fact: When hired, Dr. Andrabi expressed his long-standing admiration for ThedaCare's Lean journey (article)
What led you to ThedaCare?
“Back in 2007-2008, I was doing some work in lean (practices) at our institution in Toledo. As I was looking around with respect to other health systems that were doing that kind of work, I found ThedaCare.
At that time, ThedaCare was really front and center with respect to using the lean methodology within health care. I ended up sending a few teams of folks from Mercy to ThedaCare to learn what ThedaCare was doing and actually brought some of those learnings back to Mercy. “
The retired CEO talked about some challenges they've faced in the past few years.
Fact: Retired CEO Dr. Dean Gruner said, in my podcast with him after his retirement, that ThedaCare had run into problems with Lean in recent years:
“We believe that we, at a certain point, started to read too many of our own press clippings. We stopped studying what was really going on.”
When the former head of the ThedaCare Improvement System, John Poole, left the organization in 2015, Gruner started studying what was going on. Gruner said:
“[What employees] drew was a picture of an organization that had become very hierarchical and required approval from senior leaders to do things.
It had become an organization that was very dependent on facilitators to do improvement work, and an organization that had become much more inflexible and more rigid than we ever had imagined. All those things are exactly the opposite of what you intend to do with Lean.
We looked at ourselves and said, “How did this happen? We've been doing this for 12 years, we got everybody who comes here and tells us how great we are.”
One of the answers was we hadn't sat down and looked in the mirror really thoughtfully for several years. This had happened gradually. Maybe it's akin to the boiled frog metaphor. We didn't really think it through.”
Gruner also quoted Michael Hoseus, co-author of Toyota Culture as saying:
“The most common mistakes implementing Lean is thinking that Lean is a set of tools to be delegated to some Lean champions to implement, while leaders go around running the business as usual.”
“I would say we made some of the mistakes that they reference there. We developed a group of ThedaCare improvement system facilitators to do the improvement work throughout our organization.”
“I would say that Lean really sped our improvement journey for a bunch of years. Then, probably, for a couple years the feedback is it might have actually slowed our rate of improvement for a couple years because we were learning some difficult lessons.
Now that we think we've learned these lessons, we think we're back accelerating again, and stuff. That's why they call it learning and why they call it work. It's not like it's easy, or anybody would do it, right?”
Gruner ended the podcast by saying they had learned from their reflections and he was positive about the future.
What Comes Next?
At the very least, ThedaCare has decided to rely less on the “Lean facilitator” role.
Fact: The “lean facilitator” group at ThedaCare has been reduced in size in recent years from over 20 to just 7 people, which included a director of operational excellence. Those seven were all recently terminated by ThedaCare.
Questions: This seems to signal a change in approach. It's unclear what that future direction is. Does ThedaCare continue their Lean improvement approach and Lean management system without having a central group? Are they far enough along on their journey to not need a central group?
“The automaker last month created a single group, staffed with 200 employees, to manage the Toyota Production System, centralizing a function that was spread out through the organization.”
Questions: Does this mean “the end of Lean” at ThedaCare or is it just a shift in approach? Are Dr. Andrabi's actions that much different than what Dr. Gruner and his team would have done if he had not retired?
Asking ThedaCare Some Questions
I asked the public relations person at ThedaCare a number of questions via email. It seemed like the right thing to do, to get their reactions and statement instead of just speculating.
I asked her:
- Have ThedaCare lean facilitators been fired? If so, why?
- Is ThedaCare, under the new CEO, shifting away from a focus on Lean to another strategy for process improvement?
- What happens with the ThedaCare management system that has former executives have written about in recent years?
- Have 2017 margins or financial data been made publicly available yet?
Here is the response I got from ThedaCare:
“ThedaCare is committed to our mission of improving the health of the communities we serve by ensuring world-class outcomes and a strong future for our organization. We recently removed the centralized function specific to continuous improvement. As we go forward on our continuous improvement journey, we will be training team members, embedding best practices, and further empowering leaders to use rapid-cycle, results-oriented improvement and problem solving in our daily work.
ThedaCare is strong and will become stronger as we further enhance best-in-class access to expert, local care.”
So, ThedaCare confirmed the layoffs of the remaining Lean facilitators.
Notable in the statement are the things they did not say. The word “Lean” is not used once. The statement did not address the future of the management system… it spoke of training, team members, and problem solving.
It's unclear if ThedaCare's Lean management system, including the strategy deployment process or the daily management system (as documented in the book Beyond Heroes) remains in some form.
For what it's worth, I hope ThedaCare finds a path forward that provides the right care, the safest care, the most cost-effective care in a workplace that's engaging and stable for people.
I hope they can continue to be on the leading edge of Lean practice and that they find a way to continue improving their approach to improvement.