Lean Shouldn’t be a Reason for Nurses to Strike


Over the years, as a result of my advocacy for Lean in healthcare, I've been both:

  1. Attacked by labor leaders in the U.S. and Canada because I supposedly put “profits over patients”
  2. Labeled by someone at the Texas Hospital Association as “a labor union supporter” because of my criticism of a DFW-area hospital during the Ebola crisis.

I must be doing something right if I'm bothering people on both sides of the labor / management divide?

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Like many people who came into healthcare as a second career, I remain idealistic and I'm not worn down by healthcare. To me, patient safety and healthcare quality need to be the top priorities (and Lean can contribute positively to these goals in many ways). I know somebody who recently withdrew from a Lean hospital job possibility because he wanted to talk about safety and quality in the interviewing and he said the hiring managers only wanted to talk about cost.

I certainly get frustrated with hospitals whose daily activities don't seem to line up with the lip service about “patient safety is always our top priority.” I get frustrated when hospitals are staffed below their stated staffing plan, yet they don't turn away patients, thereby creating overburden for nurses, which harms patient care and puts everybody at risk.

A retired labor leader from the automotive industry (who reads this blog) sent me a link to this article:

#RedforMed: 1,800 Vermont Nurses Are On Strike Demanding Their Hospital Put Patients Over Profits

The article isn't from a newspaper; it's from a site that provides “independent and incisive coverage of the labor movement and the struggles of workers to obtain safe, healthy and just workplaces.”

Again, for the record, I'm all in favor of “safe, healthy, and just workplaces.” That's what Lean management aims to deliver.

But, far too often, business leaders (including some in healthcare) confuse Lean with traditional cost cutting. When their lens and priority has been cost cutting, it's natural (if not frustrating) that they'll view or frame Lean as a better way to do cost cutting.

In the Lean mindset, lower cost is the end result of doing everything else well. Improve safety, quality, and patient flow and you'll end up with better bottom-line results. Your cost might be higher to deliver better patient flow, but (in the American system) your revenue might be higher to make up for it. And, not to mention that safety and quality are moral imperatives. Healthcare likes to say, “We're not just cranking out widgets, this is life or death.” OK, then you need to act like that.

What stood out to me in the article about nurses going on a two-day strike in Vermont?

“In addition to low wages, the UVMMC employs lean production methods that put both nurses and patients at risk.”

How would “lean production methods” put nurses and patients at risk?

As I've written about in my books Lean Hospitals and Healthcare Kaizen, Lean is a solution to the existing problem of risk to nurses and patients. Before Lean (or without Lean), hospitals are workplaces with very high rates of employee injury and burnout. Lean helps address both of those issues. Before Lean (or without Lean), various estimates suggest that between 200,000 and 400,000 Americans die each year due to medical error. Lean can address that serious problem.

In a Lean workplace, staff aren't overburdened. A Lean workplace has the right number of staff in the right positions so we can take care of patients the right way. A Lean workplace is more ergonomically designed, to reduce injuries. Reducing waste through Lean (improving processes and systems) mean that nurses have more time for patients. When staff aren't short on time, preventable problems like bed sores, infections, and falls drop.

The problem is that any organization can label anything as “Lean” even if that's not really the right description to use.

Again, from the article:

“The union claims that the hospital has frequent shortages of support staff, including nurses' aides and orderlies.”

Being understaffed is NOT Lean. A Lean environment would have the right number of staff, including the right number of support staff so that nurses can focus on being nurses. This all ties into the Lean principle of “respect for people.”

Again, from the article:

“According to Tristin Adie, a nurse practitioner and member of the bargaining committee, nurses in the rehabilitation unit routinely do laundry for up to an hour a day, while nurses in the oncology unit are consistently tasked with billing and coding duties, and nurses across the board are forced to regularly clean rooms and accompany patients to far off places in the building.”

Those problems sound like they are caused by an understaffing of support staff. That's not Lean. That's just bad management.

“Adie says that such practices directly contribute to an unsafe working environment: nurses cannot adequately care for patients when they are forced to do the work of support staff in addition to their primary duties.”

I agree with what Adie says.

As I've written about before, a truly “Lean” management system would be the best thing that ever happened to nurses and patients.

Here is a blog post from 2009 that talks about a nurse's union supporting Lean:

In the case of this article from New Brunswick, the hospital in question gets it right:

“The goal is to deliver process improvements that allow provincial nurses to spend more time with patients and less on administration or wasted effort.”

That sounds like Lean to me.

But, here is another blog post from 2016 about a union being opposed to Lean:

Lean is a good thing. I can understand a union being opposed to bad management and practices that bring risk or harm to patients or staff. Unfortunately, too many people have had bad experiences, seeing or living through something that is labeled as “Lean” but doesn't really sound like Lean.

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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. Hospital administrators, like business leaders generally, understand budgets, not processes. They understand money, not waste, unevenness, and unreasonableness. Any method or tool they come across is re-purposed in support of traditional budget (cost) cutting. “Lean is a good thing.” Is it? After 30-plus years, Lean is still viewed negatively by workers. This outcome confirms that the original (and still dominant) go-to-market strategy for Lean — selling Lean to top executives (for wealth creation) — was too narrow a focus. For different reasons, both executives and workers misunderstand Lean, while professional staff typically possess a favorable understanding. For Lean to establish itself as a viable alternate system of management, executives, workers, and professional staff must all share a favorable understanding of Lean.

    • Based on my experience covering 100+ hospitals, clinics, ASC’s, etc, lean leaders have more to learn from healthcare leaders than healthcare leaders have to learn from lean leaders. Healthcare was doing Lean before Toyota was doing Lean. Healthcare was doing Lean before it was called lean.

      Making blanket statements like “healthcare executives generally understand budgets rather than processes” reflect a very real misguided arrogance shared by a too large segment of the lean community that actually ends up creating a barrier to fostering the improvement culture they assert to want to promote. Those same lean leaders that disparage leadership for not committing as they see necessary have blindly applied their lean expertise in areas where they have little understanding or visibility to the tangible negative consequences of their “improvements”. Healthcare leaders SHOULD be skeptical of Lean. Because most of the current lean activity in healthcare doesn’t actually improve outcomes or performance. That will change if we stop blaming leadership and start accepting accountability to learn clinical processes and healthcare revenue cycles. That will change when we stop assuming that lean approaches in manufacturing/financial service/retail/etc are automatically transferable to healthcare. Until then, we’re just alienating the very leaders that we’re dependent on to promote Lean in their organisations.

      • Robert – You say, “Healthcare was doing Lean before it was called lean.”

        Um, can you please elaborate on that?

        When I hear hospital leaders say, “We’ve been doing this a long time, we just don’t call it Lean,” it usually means they don’t understand Lean. They think that focusing on cost reduction or having tight staffing (I’d call it understaffing) is lean. Or they have some failed attempt at a suggestion box system and they think that’s Lean.

        If I alienate them by trying to correct this perception, then so be it. They probably weren’t lean or going down that path anyway.

        If hospitals “were doing Lean,” then we wouldn’t see so many staff members being burned out or as many patients being harmed and killed.

        • Ernest Codman was doing PDCA cycles on patients in the early 1900s. The Minimum Standards were published in 1919. Basically defined Leader Standard work. As far as Six Sigma goes, Lee Goldman used DMAIC to define his Chest Pain Protocol a decade before the term DMAIC was invented.

          Lots of examples of traditional lean tools being leveraged within healthcare long before it became fashionable.

          Physician burnout and medical errors are common to “lean” hospitals and non-“lean” hospitals. Either way, I’d guess that Atul Gawande has made more of an impact in that regard than Imai or Shingo.

          But I don’t have an issue with Lean. I have an issue with Lean practitioners who talk about Respect for People in one breath, then bash executive teams for not believing in the same approaches as they do in the next breath. I have an issue with far too many healthcare lean leaders who can’t articulate the end-to-end patient value stream even after years in the industry. I have an issue with going to healthcare conferences and seeing the same dozen or so suboptimization projects over and over again.

          Lean would be more predominant and impactful in healthcare if it’s practitioners would just actually embrace the values they outwardly promote. Learn things beyond the very narrow world of Lean. Because I can guarantee you that more hospital executives can explain kaizen than lean leaders can explain a CoN.

          I believe in lean. I’ve spent most of my career trying to imbed it in every organization I’ve worked in. But Lean practitioners who haven’t put in the time or the work to fundamentally understand healthcare, yet feel compelled to critique its leadership who have devoted their lives to helping patients and improving population health, are making it harder for all of us.

            • Not a broad brush. Just pointing out very specific behaviours based on very specific experiences. I just don’t think it gets us closer to where we need healthcare to be by blaming all it’s faults on everyone but ourselves. Let’s hold ourselves accountable. Let’s not greet every disagreement in strategic approach with assumptions of bad motives but rather an opportunity to understand different perspectives. Let’s direct a fraction of the scrutiny we’re placing on healthcare leadership towards our own skill gaps and developmental needs. We’re going to make a much larger impact on patient outcomes by doing that than by directing blame everywhere else

              • I feel like I’m doing the same – criticizing specific executive behaviors that I’ve seen out there.

                I’ve never said healthcare executives have “bad motives” — they just have different perspectives and priorities. They often have blind spots about process and culture that end up being really detrimental to their organizations and their patients.

                We can self-analyze and improve ourselves all we want, but I think the fact remains that some CEOs and some health systems are just not going to be open to Lean. That’s their choice. I can only wish them the best. But, I wouldn’t want to be a patient in a hospital that still has a “naming, blaming, and shaming” culture. That’s their right to perpetuate that culture, but I don’t have to like it.

                • “Naming, blaming, shaming” cultures exist it as many hospitals with lean programs as they do without them. Bad leadership is bad leadership. It’s not exclusive to healthcare or non-lean organizations. I’ve worked in them. I’m sure you have too.

                  But I’d just rather spend my time on the things I can influence and control; what I can learn, what my team can learn, and how we can collectively get our system to where it needs to be (whether that’s via Lean, RPA, BI/data infrastructure development, brand strategy, post- M&A integration, or any other approach that’s going to get the job done).

                  • But that’s exactly the problem with a “Lean program.” A “Lean program” is often delegated from top, without the participation of executives.

                    It’s not a Lean culture if “naming, blaming, and shaming” is the culture. If a CEO isn’t willing to lead that culture change, what’s the point of localized improvement efforts?

                    • That’s right, but who is that on? If, as a lean leader, I don’t understand change management, organizational strategy, etc, then I’m just going to see it as a leadership deficiency. But if I do develop competencies outside the traditional lean realm, then I realize that if the CEO doesn’t lead the cultural change, then that says more about my inabilIty to influence than it does about their issues. And if they don’t buy in to Lean, then I’m going to develop a different strategy to get to the same place. I’m not going to be stuck simply because Lean is the only thing I’ve learned. I’m just going to take ownership of it. I’m not going to let any perceived leadership challenges be a barrier to moving needles.

    • Mr. Kluttz – Generally, leaders — in healthcare or otherwise — fail to take interest in progressive systems of management. By preferring the status quo, they alienate themselves from Lean. So me and others point out that fact — but I also work diligently to figure out why that is the case. It’s not bashing leaders, as you suggest. It is merely thoughtful inquiry into the current state of affairs, which, after great study, reveals a far more complex and difficult situation than most people realize. In my work, it’s not blaming leadership; it’s understanding leadership.

      • “Generally, leaders — in healthcare or otherwise — fail to take interest in progressive systems of management. “
        That’s not representative of my experience. I can only think of a very small handful of executives I’ve worked with that weren’t willing to embrace any approach that would enable the execution of their strategic objectives (which were rarely predominantly budget-driven). But the approaches I recommended were never “only” lean (however you want to define it). Lean is only “progressive” if it enables execution of your defined strategy.

        I definitely agree with your premise that Lean professionals don’t understand CEOs. But consumer psychology advancements over the last decade have demonstrated that the end customer doesn’t actually want lower prices, short lead times, less wait, or even better quality. I bought a 20 go RCA Lyra almost 15 years ago that had more functionality, a lower price , and better quality than the video iPod available that year. JC Penney learned the hard way that competing on better service and everyday low prices was a market loser over Kohl’s. So not only do most Lean professionals not understand CEOs, they also don’t necessarily have a accurate depiction of the end customer needs as well. That’s why they should be reading Dan Ariely and the Heath brothers as much as they’re reading Deming and Liker.

        I don’t think the onus is on leadership to embrace lean. The onus is on us to know when it’s the right approach and be knowledgeable enough about alternatives when it’s not. That’s been the case in 95% of the executive interactions I’ve had.

        • Mr. Kluttz – If the onus is not on leaders to search for and embrace better management principles and practices (Lean), then they’re not leaders. Instead, they are stewards of the status quo. Hence, the need to convince them they need Lean, which nearly always results in acceptance of “continuous improvement” but not “respect for people” (meaning, perpetuation of the status quo).


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