Dr. W. Edwards Deming was explicit about where responsibility for hospital performance really sits: with the CEO. This post focuses on one overlooked conclusion from Deming's 1987 hospital notes–what they imply about executive leadership, system ownership, and why improvement efforts stall without visible CEO involvement.
Two years ago, I wrote an article for the Deming Institute about Dr. W. Edwards Deming's notes from his 1987 hospitalization.
— What Dr. Deming's 1987 Hospital Experience Still Teaches Us About Healthcare Today
As I wrote then:
The scenarios that Dr. Deming describes in the article could all happen today in a hospital, although he'd likely have a private room and slightly better food.
I had a chance to revisit Dr. Deming's notes and the ending jumped out at me. I didn't directly comment on it two years ago, but I will now.
As I shared on LinkedIn (which generated a lot of discussion and sharing):
The text reads (with my slight edits in italics):
What Deming Really Said About Hospital CEOs
“What is the moral of all this? What have we learned? One answer: the Chief Executive Officer of the hospital needs to learn something about supervision. Only the CEO can make the changes in procedure and responsibility that are required.
This wasn't a criticism of physicians or nurses–it was a clear statement that system design, authority, and accountability live at the executive level.
Talks between physicians and nurses, even with the Chief Nursing Officer, accomplish nothing. The same problems that I have noted will continue. A physician cannot change the system. A CNO cannot change the system. Meanwhile, who would know? Working harder will not solve the problem. The nurses couldn't work any harder.”
The CEO cannot delegate responsibility for the system. Responsibility doesn't mean the CEO fixes every little detail. The CEO is responsible for systems and policies, budgets and staffing, priorities and culture — the very factors that are the biggest drivers of an organization's results.
This is why Deming rejected the idea that quality could be delegated to departments, committees, or improvement offices.
As Darril Wilburn, formerly of Toyota, says:
“Leaders are responsible for providing a system in which people can be successful.”
That doesn't mean leaders have to do it all themselves. It means they need to lead.
A friend of mine works for a health system, and he's perpetually frustrated in the various jobs that he's had, because the organization's senior leaders never really support Lean. So, he changes jobs and finds the grass isn't greener anywhere else. He can make local improvements in the operating rooms, but he wants to really help change the system.
His current organization is demanding that “all managers” go to a day-long Lean Management 101 training course. That might be a good start, but I'm guessing the organization thinks the managers will “know” Lean after a day of training. They probably won't get the support and coaching that they'd need to really change their behaviors.
Notably, the CEO was excluded from the training. That absence sends a powerful signal–whether intended or not–about who is expected to change and who is not.
Why “Sponsoring” Lean Isn't the Same as Leading It
If the CEO is going to “sponsor” Lean training and then not go… is that CEO going to be leading by example? Probably not. The Lean training will probably be a waste of money and it might be a net demoralizer because the CEO and senior leaders likely won't be practicing what the Lean trainer is preaching.
Some CEOs take a good game… but that's it. More is needed.
Deming's message is uncomfortable but clear: without CEO leadership of the system, improvement efforts will remain local, fragile, and frustrating.
On the more positive side, CEOs like Vance Jackson and Gladys Bogoshi both seem like rare exceptions rather than the norm. They're LEADING their Lean transformation aspirations and efforts. They're involved. They're leading this.
What distinguishes these leaders isn't enthusiasm–it's direct participation, learning, and visible ownership of the system.
Listening to my podcasts with them (click on their names for the episodes) is probably more inspiring than hearing me moan about CEOs who aren't willing to learn and lead by example when it comes to Lean.
Great post. I’m a senior manager at the hospital chain I work for, and I’ve seen that same thing here. I feel like the clinics/departments I oversee are well maintained, but what else can we do if our CEO doesn’t show any interest in Lean or anything like that? Since I’m not the CEO, I’m not sure what else I can do. I try to implement everything I’ve learned from different courses and books, but do you have any other suggestions on what us managers can do? Always a great read. Thanks Mark.
Many CEOs “support” lean, meaning they talk about it, encourage others to use lean, but too often stop there. And the result is far from transformational. It’s also not enough for the CEO to attend the Lean Management course, although that helps. If a CEO participates and then learns through doing, and receiving coaching, and then shares that and exhorts others to follow him or her, now we’re getting somewhere. As John Toussaint and Roger Gerard wrote in On The Mend, when they used the word “we” in the book, they specifically meant themselves as direct participants in kaizen and rapid improvement events, in which they were coached along with others junior to them, by experienced lean practitioners. Without the modeling of this desired behavior from C-level leaders, the managers who attend the Lean Management training you mentioned above not only might not Get the coaching they need, many of them are likely to Decline offers of coaching or support and continue doing what they’ve always done. In my experience, that’s not unusual at all. Do our health system CEOs know this? Hear it but don’t believe it?
Mark, I wonder if you know US health system CEOs who are truly effectively supporting lean in their hospitals without going all the way to direct participation and coaching a la Toussaint and Gerard?