Joining me for Episode #340 of the podcast is Dr. Joy Furnival CEng MIET, an experienced senior NHS manager, improvement leader, and chartered engineer. I first crossed paths with Joy at a Lean healthcare event in England back in 2007. At the time, she was working for David Fillingham and the Bolton NHS Trust, which was an early adopter of Lean in the NHS.
Joy describes her early exposure to Lean in manufacturing, starting with Lego-based Just-in-Time simulations at university and later adapting principles for high-risk process industries like chemical plants. That experience shaped her ability to carry Lean thinking into healthcare, where direct application of tools isn't always possible but the underlying principles remain vital. She emphasizes how respect for people, psychological safety, and engaging staff in improvement are far more powerful than tool-focused approaches.
The conversation explores Joy's work at Bolton NHS Foundation Trust, where Lean played a key role in reducing patient length of stay and meeting national A&E standards. She also reflects on challenges–resistance, cultural barriers, and “fake Lean”–and why clinical leadership and staff engagement are essential for sustained results. Moving into her national role with NHS Improvement, Joy explains the Vital Signs Lean Improvement Practice and efforts to scale daily improvement practices across England's NHS workforce.
Mark and Joy also discuss her PhD research into healthcare regulation and improvement, which led her to reframe regulation as a potential enabler of improvement rather than a barrier. She outlines eight dimensions of improvement capability drawn from her research and highlights the balance between consistency and local adaptation in national Lean efforts.
This episode offers a unique view into Lean's application across industries, showing how principles can be adapted while maintaining a people-centered focus. Joy's reflections will resonate with anyone working to build sustainable improvement in complex systems.
I very much appreciate her perspectives as we talk about her roles in a few different hospitals and as a “national improvement advisor” for the NHS. I hope you'll enjoy the conversation as much as I did.
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Transcript
Announcer:
Welcome to the Lean Blog Podcast. Visit our website at www.lean-blog.org. Now, here's your host, Mark Graban.
Mark Graban:
Hi, this is Mark Graban. Welcome to episode 340 of the podcast. It is April 23rd, 2019. I'm talking today with Dr. Joy Furnival about Lean in the British NHS. My guest today, Dr. Joy Furnival, is an experienced senior NHS manager, improvement leader, and chartered engineer. I first crossed paths with Joy at a Lean healthcare event in England back in 2007. At the time, she was working for David Fillingham at the Bolton NHS Trust, where she was the director of Lean transformation efforts. They were an early adopter of Lean in the NHS.
In the episode today, we talk about how we are in some ways “Lean twins,” as we both started our careers as engineers in manufacturing. But our career paths then diverged when she joined the NHS while I've worked as an outside consultant. I really appreciate her perspectives as we talk here about her roles in a few different hospitals and her role as a national improvement advisor for the NHS. I hope you'll enjoy the conversation as much as I did. To learn more about Joy and some of the work she's been involved in, you can go to leanblog.org/340.
Joy, thank you for joining us today. It's great to have you as a guest on the podcast.
Joy Furnival:
Thank you very much. I'm very pleased to be here.
Mark Graban:
Well, I think we have a lot of interesting things to talk about today. If you can start off by please introducing yourself to the audience and tell a little bit about your career.
From Manufacturing to Healthcare
Joy Furnival:
Okay, so hello everybody. My name is Joy Furnival, and I work in the National Health Service in England for a national body that's part of NHS Improvement and NHS England. I work in a national role helping to support Lean implementation and Lean practice within healthcare. I've worked in the National Health Service for around 13 years now, and before that, I worked in industry as a manufacturing engineer for about 10 years, where I was also doing a lot of Lean-based practice.
Mark Graban:
You and I have shared backgrounds there. I started my career in manufacturing before getting into healthcare also about 13 years ago.
Joy Furnival:
That's right.
Mark Graban:
Can you talk a little bit about working as a manufacturing engineer and some of your recollections of how you learned about Lean?
Joy Furnival:
Sure. I did an engineering degree at a very traditional university. It so happened that the first year I was there, they decided to put this radical new final-year seminar in place that covered what were titled “Japanese Improvement Techniques” at the time. I did it in 1996; it was the year the book Lean Thinking was published, and that was part of the reading list. I can remember my very first seminar, we went in and we had to play a Just-in-Time game with Lego, and I was hooked. I devoured all the possible Lean-related books I could, whether they were written by Shigeo Shingo or others from Productivity Press.
Following that, I was a sponsored graduate engineer with a company called ICI, a large-scale chemical manufacturer in England at the time. That was my first experience of, “Well, how do you translate all these concepts that I've learned about Lean in automotive into the process industry?” You've got big, heavy continuous plants; it's high-risk, it's safety-critical, you can't just move things around, and you can't just stop the line–there might be a risk of an explosion. That learning was pretty important for when I jumped from manufacturing into healthcare because I'd learned a little bit about how you adapt the principles of Lean into a different context.
Mark Graban:
Principles like respect for people are, of course, critically important, not just the tools and tactics. Can you share maybe some of your thoughts on how your learning and understanding evolved?
Joy Furnival:
Sure, I totally agree. I feel like I've had a very similar story. Back in the mid-90s, we were learning Lean by learning tools. We'd learn Single-Minute Exchange of Die, we'd learn about Kanban, we'd learn about Just-in-Time, but we didn't really learn some of the people side of change. I think that principle about “the people who need to improve the work are the people that do the work,” I had to learn that very quickly because of the nature of the assignments I was given.
Of course, you get very frustrated as an engineer because you can sometimes see an answer way before everyone else can. But that learning around how you bring people with you and how everybody needs to talk through a problem becomes much more important than just the quick engineering fix. I think that grounding and doing that so early on was so critical for me in really understanding that Lean value of respect for people.
Adapting Principles to New Contexts
Mark Graban:
You talk about working in a process industry where people very well could have said, “This isn't an assembly line. We don't build cars.” We hear people in healthcare say that. You said there was a risk of an explosion if you stop the line.
Joy Furnival:
Right. That for me was one of the first things that I had to learn about how you adapt the principles. If you're working on a big ethylene cracker that might kill 30,000 people if it goes wrong, you're just not going to stop the line. You have to find alternative ways of doing that. If you think about the principle of “stop the line,” which is to force everybody to come and fix a problem because the cost of that lost production is so high, the principles there you can still apply, you just have to apply them in a different way when it's unsafe to stop the line. I think sometimes we forget you can be creative about the way you apply the principles. It isn't just, “That's how they do it in automotive, therefore every other industry must do it the exact same way.”
Mark Graban:
Very true. When I came into a pathology department in the NHS, some of the people there viewed Lean very negatively because previously there had been somebody who came in and told them how to rearrange their specimen processing area. That was not very well received, and I sort of had to recover from that. “Okay, we're going to do things differently here. We're going to engage you.”
Joy Furnival:
Yeah, that again sounds so familiar. There's a lot of, I suppose you might call it “fake Lean.” I think you've called it L.A.M.E. on some of your blogs. A lot of people may have experienced Lean practiced very badly. I think the one thing I've definitely learned as a 23-year Lean practitioner now is without the “respect for people” principle being part of your practice, you're not really practicing Lean.
Mark Graban:
Yeah. As long as we learn from our mistakes, that's better than repeating the same mistakes over and over again.
Joy Furnival:
I also wonder if there's just something about the developmental process. You learn a tool, you want to apply it, you accidentally then make other people do it without asking their opinion, and then you realize, “How does that work?” Maybe there is just something about people having to learn that themselves.
The Transition to the NHS
Mark Graban:
So let's talk a little bit more about how you came to work in healthcare.
Joy Furnival:
Yeah, it is quite an interesting story. The best man from our wedding, his wife worked for the NHS. We were talking at dinner one night, and I said I was looking for a new job. She said, “Why don't you work for the NHS?” I looked at her a little bit agog because I said, “Well, why would an engineer work at the NHS? You don't need engineers; you need doctors and nurses.” She directed me to a website that was trying to recruit people into the NHS who'd had different careers.
I was successful, I got through, and my first role in the NHS was at the Royal Liverpool and Broadgreen University Hospitals Trust. It was a really great job. I ended up in an improvement job that they created especially for me based on my CV, and I helped to set up some of the original improvement work they did in that hospital. I obviously used Lean as my method because that's the method I'd been taught.
Mark Graban:
What was that process of sort of getting in and discovering what to do?
Joy Furnival:
This is where I think the engineering training and the Lean training really kicked in because my immediate, subconscious habit was to just go and find out. I did a lot of walking the floor with people, visiting departments, hearing what improvement work they already had going, and trying to find out what would be helpful to them.
I would go and collect data myself. I'd just go and sit in a clinic and observe myself. Because if you were in a factory, that's just what you'd do. I probably spent six months doing that kind of work before I really felt like I had a bit of a view as to what needed to happen. But I would add that a hospital sometimes feels like it's 10 factories squished together. How do you involve people who only work nights or who only work on days on a weekend? There are a lot of challenges that I wasn't expecting. So I think that being willing to go, “I don't know,” made a big difference.
The other thing that really got me was terminology. I was looking for the equivalent of a daily production sheet, “How many patients were treated yesterday?” And everyone would look at me completely blankly. It probably took about two months before I realized that the language was just completely different. In the NHS, it's called “activity.” So there's an activity report, and it's on a daily “sitrep.” If I knew those words, I probably would have had that on the first day.
Mark Graban:
You said that sometimes it's not so much a lack of knowledge but a lack of confidence that gets in the way of improvement work. Could you say more about that?
Joy Furnival:
Yeah. So I think it's multifaceted. One, it's saying, “I've got an idea,” and being prepared to say that in front of peers. If you've already got a huge reputation for being a very clever medical professional, and then suddenly you go, “I don't know,” there's a risk that comes with that that might affect your status or your hierarchy. So people have to be comfortable saying, “I don't know something.”
The second thing is thinking about the wider cultural conditions. If people do say, “I think this doesn't work,” the reaction is not, “Well, that's your fault then.” Just thinking about how blame cultures can impact whether people are prepared to speak up.
And then there's something about the confidence bit. If you've been on a half-day course and you've learned 10 different improvement approaches, it might be a bit overwhelming. To then suddenly go back to your own department… it's quite hard, I think, to jump from a very simple process map into mapping a much more complex one. And I think sometimes just being there to encourage and to help people apply those tools in the real world is part of that “respect for people” thing.
Lean Transformation at Bolton NHS Foundation Trust
Mark Graban:
When I first came to England, it was for a Lean healthcare conference in 2008. One of the speakers there was David Fillingham from the Bolton NHS Foundation Trust. I was wondering if you could talk about some of your roles and experiences there.
Joy Furnival:
In many ways, for me, Bolton was a real career highlight. When I joined Bolton, I'd seen lots of noise about what was going on there with the Lean work. I remember reading a very early case study and thinking, “Oh, they're really trying to do Lean properly. I want to go and work there.” The irony being that I had been offered a job there in my original recruitment and then turned it down.
When I got there, they'd been about two years into their Lean journey. It was at that real transition point from just experimenting into, “Okay, we want to do this properly.” Bolton had worked with Simpler Consulting in a pro bono relationship as part of the IHI 100,000 Lives Campaign. So some of the very early work at Bolton was particularly related to mortality reduction connected to the trauma pathway.
The major value stream piece of work we did was really aimed at achieving the national Accident and Emergency four-hour standard. At the time, that was to achieve it for 98% of people who came to A&E. We also wanted to make it a much better patient experience. In that kind of “go and see” way, I had to be admitted to A&E only two months after I started because I have asthma. So I got to see for myself what it felt like to be a patient in that pathway on a night when it's very busy.
We did a lot of ward-based improvement work, what you'd call a “cell” in a Lean way. We developed our own way of doing that. That included putting in visual management on whiteboards. We experimented with how patients could be involved. The respiratory team decided instead of doing twice-weekly ward rounds, they were going to move to a model with daily ward rounds. That led to us being able to take off one and a half days of length of stay, and that flow improvement made such a difference that for the first time and only time, the Trust did achieve the 98% standard.
Mark Graban:
So hearing you talk about improvements in patient care and trying to create a better working environment allows us to demonstrate respect for people in some very tangible ways.
Joy Furnival:
Right. And I've obviously just given you the nice glossy story. I'm not saying it was very easy to do what we did. There were a lot of very difficult conversations, and I'm not saying we always got it right. But I think the thing that really made a difference was some of the clinical leadership that we had, people who were really going, “You know what, we're not putting up with it like this anymore.”
I think one of the things I've really noticed in healthcare is the leadership side of improvement really has much more of an impact than perhaps it did in manufacturing.
A National Role with NHS Improvement
Mark Graban:
So I want to talk also about the role that you played at more of a national level. If you could set the context organizationally, NHS Improvement, how that fits in.
Joy Furnival:
So NHS Improvement was one of the national regulators for healthcare in the UK. It had a remit for lots of things, including financial stability, national targets, as well as quality and improvement. As of today, we have formed, for want of a better phrase, a joint venture with NHS England, which is another national body that largely has a commissioning function. We're across the whole of England.
Mark Graban:
How much would you say, from your perspective, is there a standard, quote-unquote, “NHS approach” to Lean, or did you find variation across different hospitals and regions?
Joy Furnival:
I don't think there has been a consistent approach at all. It's more at an organizational level. You may have organizations that say, “Lean is the way that we do improvement here.” There's a lot of diversity in the improvement methods. Virginia Mason had quite an impact in the UK during the 2000s; they worked across the northeast of England developing the Northeast Transformation System. Western Sussex in the south of England has been working with KPMG and Catalysis, so kind of a ThedaCare/Providence way of doing improvement. There's a lot of diversity, and I guess that's part of our challenge now as improvement practitioners. We've tolerated a lot of variation in our own practice. Where's the sweet spot on having a lot of diversity versus having some consistency?
Mark Graban:
There's a need for balance. Somebody could take this really strict roadmap and say, “Look, this is the way it's done,” but if people say no and don't participate, you haven't gained anything.
Joy Furnival:
Yeah. And if it doesn't work in that context. You can't always implement things the way they're designed, so you need that local context. And the good thing about that is that's where your new innovation and new ways of improving come from. So you definitely need it. It's just having it in balance, I think.
Healthcare Regulation, Improvement, and Final Thoughts
Mark Graban:
One other thing I was hoping you'd tell us about. What is the Vital Signs Lean Improvement Practice?
Joy Furnival:
Okay, so that's the program I work in now. It's a national program working with seven sites across England to develop Lean improvement practice. My site is the Pennine Lancashire Integrated Care Partnership. This is a national program where sites can access enhanced support from the national teams to develop a Kaizen Promotion Office and develop Lean training within their organizations. I'm not doing it for them; it's about how I can help them skill up their own improvement practice.
Part of the intent behind this big program is how do we get the 1.5 million people who work in health and care in England to practice improvement every day? How do we move improvement from being a series of rapid improvement events into something everybody can do every day, and leaders own that improvement work? That's partly why we've really taken Toyota Kata on board in terms of how we might build that daily practice for improvement.
Mark Graban:
One other thing I wanted to ask you about is your PhD studies and the thesis that you did.
Joy Furnival:
So my thesis, which was funded by the Health Foundation, I did at Manchester Business School, and it was about healthcare regulation and improvement. I suppose when I started it, I had that kind of Deming perspective that gets oft-quoted, “Inspection is the enemy of improvement.” I probably thought, “Regulation bad, improvement good.” As I read more and got more into the evidence base, I realized that I was probably going to have to completely revise my viewpoint.
I discovered there are lots of reasons why there's regulation, not least the fact that some things need to be regulated at a system level that organizations can't impact. A classic example is air pollution. I also found out that regulation actually is improvement, which I found quite shocking. One of the main aims of regulation is actually improvement in the public interest.
So I looked at what regulators can do to not get in the way of improvers like me, if we've got shared aims. How would a regulator encourage improvement work without doing it to people? So I looked amongst the literature about different ways that you can measure improvement capability. I looked at EFQM models, the Baldrige Prize, and a lot of other research-based models. I synthesized those into eight dimensions of improvement capability. My research has really benefited my improvement practice now because I have that additional knowledge and different ways of framing some of what I do.
Mark Graban:
Well, I will put a link to the thesis document in the notes for the episode. Do you have any other final thoughts or a lesson that you'd like to leave for the listeners, Joy?
Joy Furnival:
So I suppose there's something I would say to healthcare staff, which is we do one of the most amazing jobs in the world. We get to help people every day make their lives better. And sometimes that's a bit overwhelming. But there's something about really drawing on that motivation that we have around how we can make it better, and in doing so, also make our own lives better because we've taken out waste, we've taken out frustration. And that actually frees up the time we've got to make improvement work. And I do genuinely believe everybody can be an improver, and I would just say to our healthcare staff, you can be too.
Mark Graban:
Well, thank you, Joy. It's great talking to you, and I really appreciate you joining us and having such a good conversation today. Thank you.
Joy Furnival:
Thank you.
Thanks for listening!
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