It’s Hard to Ask Leaders to Change the System in Which They’ve Risen and Excelled


The other day, I stumbled across an old article that I remember, as it was published in the Wall Street Journal in 2004. The WSJ normally has a paywall, but this article is old enough that it's free to the general public (or at least I think it is):

To Fix Health Care, Hospitals Take Tips From Factory Floor

Adopting Toyota Techniques Can Cut Costs, Wait Times; Ferreting Out an Infection

You might have better luck getting in if you first do a Google search for it, then click through. Or here is a PDF.

There's a lot to unpack and comment on from the article, including the mentions of ThedaCare and how their Lean journey is now past-tense, as I'm told.

A first thought is that I read this article when I was still working in my last manufacturing job, in Phoenix. I had an opportunity to visit (as a guest, not a patient) a hospital in Scottsdale that had two former Motorola employees there using Lean and Six Sigma to improve emergency department operations and flow. I forget if they were consultants or employees, the women I'm thinking of (I don't remember their names).

Anyway, that was really eye opening to me, as to the possibilities of helping improve healthcare. It was also eye opening in terms of the waste and the problems that I wouldn't have expected to see, not knowing healthcare at all at the time.

That visit and the WSJ article were both inspiring as I had the opportunity to move into healthcare in 2005.

More about that career transition:

So, the other day, I shared this article on LinkedIn (although it wasn't a Throwback Thursday or whatever):

I chose to share the introduction to the article that highlighted the great work of Dr. Rick Shannon. He was my guest on my podcast back in 2011 (and I believe I'll have an opportunity to interview him again soon).

One way hospitals and health systems are working to address the critically-important issue of patient harm is by using Lean-based (or Toyota-based) problem solving methods. But, before you can solve problems, people need to get better at seeing problems, seeing those problems as being solvable, and speaking up about those problems.

Leaders like Dr. Shannon are working to help create a culture where it's safe for clinicians and team members to speak up about waste, problems, errors, risks, near misses, and harm.

The WSJ article talks about andon cords a bit:

“In the factories of Toyota Motor Corp., any worker who spots a serious problem can pull a cord and stop the assembly line. Richard Shannon, chairman of medicine at Allegheny General Hospital, is applying the Toyota technique to an intensive-care unit here.”

To change the culture, leaders need to change. Dr. John Toussaint does such a great job of talking about that in this video clip:

To make it safe for people to speak up, one thing that leaders need to do is to stop blaming individuals for systemic problems. To help effectively solve problems, leaders need to stop throwing answers at people — learning to be more of a coach than the all-knowing expert on everything.

On LinkedIn, Steve Feltovich commented, in part:

“Systems thinking and good business fundamentals are never obsolete. Why do so few people at the top get this??”

In my attempt to be empathetic toward executives (and hopefully coming across more as empathetic instead of snarky or critical), I replied:

“People who rise to the top in the prevailing system of management tend not to want to tear down said system. I mean, they succeeded in the system, so that validates them, right?”

I intentionally used a phrase from W. Edwards Deming — “the prevailing system of management.” Steve is a big Deming proponent, so I knew he'd get the allusion.

My choice of “tear down” was maybe a bit too radical sounding. But replace that with “transform,” if you will.

John Toussaint is a relatively rare example of an executive (he was CEO of ThedaCare) who has been an effective leader of transformation. Dr. Gary Kaplan has done the same at Virginia Mason Medical Center, starting the Lean transformation as CEO and being very successful with it.

I've seen other very effective transformational leaders, like Dr. Eric Dickson, who came into the CEO role as an outsider.

The transformational plant manager I worked under at General Motors in 1996, Larry Spiegel, came in as an outsider to my plant. He was a career-long GM employee who, as he put it, had the benefit and good fortune of learning from Toyota at the famed NUMMI plant.

It can be easier for an outsider to come in and speak honestly about the current state — and the gap between the current reality and the ideal state. At GM, Larry laid out facts about how our engine plant's quality and productivity were really the bottom of the barrel in the global automotive industry — but it would get better!

What he said was factually correct, about the data, but the reality really stung and created a defensive reaction amongst many. I had only been there a year or so, so I didn't feel like I had created the problem. I had already been working, in small ways, to solve it, but it was really difficult to make much progress under the old fear-based, command-and-control, quantity-over-quality leadership style that preceded Larry.

Some leaders can change (like Toussaint and Kaplan) and others really struggle with it. Sometimes you need to change the leader and give somebody a fresh start.

I've seen, in healthcare, where an outsider executive can come in and say, “We're harming too many patients… our goal is zero… and we can make significant progress toward that goal this year by doing things differently.”

Hospital staff and leaders would understandably get defensive. It's a natural human reaction (as we learn about from the field of Motivational Interviewing). Other executives might cringe at hearing the real reality of the data.

Leaders at all levels might not like hearing, “You need to lead differently.” It's human nature to take things like that personally. If I hear things like that as an outside consultant, it doesn't sting the same way. I can always get better as a leader, but I'm not as deeply vested in the history of the organization as many of the hospital people are.

I remember one hospital Chief Operating Officer who was really struggling to change his behaviors after 35 years of healthcare leadership (and 20 years at the executive level).

Culture change takes time for an organization. It's not like flipping a light switch. The same is true of individual behavior change. It's. Not. Easy. That's true even when we agree with the change and we're highly motivated to make the change.

So, when we ask, “Why don't executives ‘get it' and change more readily?” I think the answer is, “It's really difficult, even if they want to change.”

But, some leaders don't want to change. Or, they don't see the need.

Why try to transform a system — a culture and a management approach — that, while perhaps a bit flawed, was a system that was smart enough to promote that person to the top (or to the C-level). That system validates them. That prevailing system said they were awesome and that their behaviors (or maybe just their results) were great.

Dr. Deming would say that we (people) created the “prevailing system of management” so, therefore, we can change it. We don't have to be prisoners to it. But, sometimes maybe prisoners get used to the life of being a prisoner…

It's really difficult to ask somebody to criticize a system that they've either built or been a part of for a long time.

So, as change agents, authors, Lean consultants, or whatever — it's really tempting to TELL people what they should do. Or what they need to do. And, you might be right… but that doesn't mean you'll be effective (another lesson from Motivational Interviewing).

How we lead and influence up in a way that doesn't cause defensiveness? I heard an ad while listening to a podcast about a diet and weight loss app, that basically said the app and approach…

“… doesn't tell you what to do… it helps you learn how to make better decisions” and it focuses on why the change is important to you.”

That also sounds like Motivational Interviewing. The ad said the app is “based in psychology” or something like that. The same is true with M.I.

Isn't that the right approach to change, whether we're looking at the details of the work with the frontline staff or if we're trying to coach executives on changing their behaviors, to becoming “Lean leaders”??

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. Seeing waste being eliminated in a process like healthcare compared to a production line is quite interesting. I’m curious as to how many hospitals and healthcare professionals use lean because it seems like it could really change the way hospitals operate for the better. It was also interesting to read about how leaders are hesitant to change processes for the better because they used that process to move up in the company. I think this idea that people are generally stubborn to change makes it important to surround yourself with people who are not afraid to speak up on how a process can improve. I think it is also important to continue to bring in new people to get a fresh look at the processes so they are not used to what is going on within the building.


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