When Having a Process Improvement Idea Means You’re Weak?


I guess I'm wired for improvement. Or, it's just become a habit. Or, it's both.

I celebrate moments when I can identify an opportunity for improvement in my work. I tend to be pretty transparent about problems and even mistakes (like forgetting my socks).

The Toyota-ism of “No problems is a problem” resonates with me. Identifying a problem shouldn't bring blame and shame… it's the first step in improving the way work is done.

I'm fortunate that we've built a culture at KaiNexus where problems and opportunities are celebrated. It's safe for people to speak up and problems lead to improvement, not punishment.

Our book Healthcare Kaizen shares stories and examples from organizations that have built a strong and sustained culture of continuous improvement. I almost take it for granted that improvement is a positive thing.

But, I sometimes get reminders of the challenges that people face when working in an organization that is NOT a culture of continuous improvement.

Twice now, in recent weeks, I've heard a similar story from healthcare professionals (one American, one on another continent).

One of them, a nurse, is the type who also seems wired for improvement. She tries speaking up. She aims to be constructive in pointing out ways the work of patient care could be easier.

She gets told:

“Well, this is nursing.”

The implication is that she needs to toughen up and get better at dealing with the waste.

This mindset is really hard for me to wrap my head around. I think nursing should include the opportunity to improve the nursing work.

A small, real example:

A nurse notices that patients ask for ginger ale to drink when nauseous. There is no ginger ale on the unit, so the nurse has to go upstairs to a different unit to get ginger ale… or the patient's request doesn't get met if the nurse is too busy (“we don't have any, sorry”). The nurse points this out to the manager and suggests it would be nice to stock ginger ale on their unit.

A manager could say, “Suck it up… that's the job… go get the ginger ale even if that means walking. Nurses today want to have it so easy… good grief. And don't you dare say you're too busy to do it. It's part of your job!”

But, in a culture of continuous improvement, the manager thanks the nurse for pointing this out (without saying things like “why didn't you mention that before???”). The manager might contact dietary services to change what beverages are delivered to the unit, or they might teach staff how to contact dietary services as needed.

But, not every organization truly embraces continuous improvement.

It's sad to hear a healthcare professional have an idea that could be implemented right now, at little cost… only to be told:

“You have to understand, this is how healthcare works.”

But it doesn't have to work that way. The work could be easier… the culture could be better.

The implications of comments like these from managers include:

  • How dare you point out a problem? That's offensive.
  • You need to toughen up.
  • You should be more resilient.
  • I dealt with that waste when I was a nurse, so why can't you handle it?

It almost reminds me of the cycles of hazing that happen in organizations. “I survived this, so I'm going to make the next generation suffer through it too.”

This is all still very puzzling to me. Have you experienced similar situations? How can we help change this?

What do you think? Please scroll down (or click) to post a comment. Or please share the post with your thoughts on LinkedIn – and follow me or connect with me there.

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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. Hi Mark – “Hazing” is a wonderful way to express the problem. I have experienced the “blame and shame” for identifying problems in multiple contexts, past and present. Lean specifically, and improvement generally, is embedded in a larger system that is designed to maintain the status quo. The conundrum is that the leaders of organizations increasingly seek people with better problem-solving skills, but there are embedded routines and traditions that are very effective at undercutting problem-solving.

    • Bob, your comment about seeking out people with problem solving skills is spot on. In our trainings, we refer to this as “fire-fighting”. The theory is that people in healthcare (especially clinical folks) were originally trained to identify problems with patients (usually symptoms of disease or injury) and fix them as quickly as possible. Physicians are left to establish the root cause and deal with it. This talent of treating symptoms of a problem has easily transferred into the classic management style of a clinical leader.

  2. Thank you for shining a light on this issue. I have worked in healthcare for 15 years, as a bedside caregiver and now in performance improvement. I believe that the only way this problem can be solved is with an executive team who “gets it” and is committed to instilling these concepts into existing leadership and only hiring new people who already “get it” or are willing to learn it. In addition, the executive team must actively demonstrate the desired behaviors and hold those accountable who don’t.

    • Thanks for commenting, Abby. Yes, I agree that the CEO needs to lead by example, modeling behaviors and mindsets including humility, curiosity, a willingness to accept the real reality… not blaming people for speaking up, but encouraging them to continue to make things better.

  3. There is clearly a generational component here as well. Working in a flawed system for a lifetime, making due/do and perfecting work-arounds gets worn as a personal ‘can do’ badge, and change can be especially difficult for those who have had to work that way. Abby is correct in stating that those who don’t get it won’t get far with Lean initiatives. Unfortunately, it still feels like a version of shame and blame when those who have had to work in bad systems can’t find their way in a new one. Patience and understanding, as always, can go a long way.

  4. I was in a room for 10 days due to heart attack. I overheard nurses talking about “no time to enter patient info in the computer”. In talking with them, several tell me they walked 9 to 12 miles per shift! Thats half their time walking to get things, deliver things, etc. But no one knew how to do anything to fix it.

    By the time i was leaving I had a list of opportunities and discussed them with my Dr/nurse team who were shocked about my observations. Some were silly, such as a facilities guy that screwed the sharpes container to the wall in such a way it could not be opened to empty it.

    It was as if time has stood still 50 years regarding improvement, waste, teams, etc.


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