I probably get asked some version of the following question, in person or via email, once a week or more:
“How many American hospitals are implementing Lean?”
Sometimes it's asked, as it was today, in terms of  “How many… are involved with Lean?”
It's really hard to answer that question… and, if I could, does it even matter?
I always answer the question with by saying either:
- What's your definition of “doing” (or “implementing” or “involved in”)?
- I don't know how many hospitals are…
What's the definition of “doing Lean” (as much as I dislike that phrase)? If it's a simple binary yes/no answer, does the hospital that experiments with 5S in one department get counted equally as an organization that's really embracing Lean as a culture and a management system? All of the “yes” answers wouldn't be as meaningful. So that's one reason why I don't even care to try to count. I know interest and participation with Lean is increasing over time, but I can't put a number to it, either.
Secondly, not every hospital out there reports what they are doing. Some organizations share freely and write books about what they're doing and hope to do… some keep their improvement work close to the vest. Could we could how many hospitals have an open job posting that mentions Lean? Maybe… that wouldn't be a perfect measure either.
I criticized ASQ a few years back for publishing a very unscientific survey… of just 77 hospitals (there are more than 5,000 in the U.S.). They said about 50% were implementing Lean… but without a consistent definition of what that meant.
According to the ASQ study, Â 53 percent of hospitals report some level (“minor,” “moderate” or “full”) of lean deployment…
Even if we DID have a good estimate of how many hospitals are “doing Lean,” what does that matter? It's been pretty well proven that Lean  can work in healthcare. Do we want more hospitals embracing Lean because it's popular or trendy? Are those organizations likely to be truly committed or successful?
How do you answer that question?
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I was told by a team representative this week that they cannot find another consulting organization doing what I’m doing. They also talked about trying to hit “industry standard” performance in some of their customer-facing processes.
My response to both statements is essentially “Who cares?” All that matters is what is right for your organization (hospital, factory, team, family), and if you find a solution to your problems that no one else is using but it makes a difference, does it matter if anyone else adopts it before or after you?
Thanks for the comment, Chad. It’s always hard being the first. It took a lot of guts for organizations like ThedaCare or Virginia Mason to be amongst those “going first” in lean healthcare. I can’t claim to be that innovative… by the time I got into healthcare, we already had examples like them (as well as the lean success stories of the J&J group I worked for). It was very helpful to have at least one example… so you’re right that “who cares?” is the right mindset if an organization is truly innovative… but having one vs 100 is different than having zero vs one.
I recorded a podcast earlier with Dan Florizone, the Deputy Minister of Health up in Saskatchewan. In this video, he talks about the need for organizations to measure themselves against the best instead of being just a bit above average. Who wants to just be “industry standard” when you can carve your own path? I guess that’s what was so great about Moneyball?
Mark,
Don’t you just love these questions. I often anaswer their question with another questions. Lots of hospitals say they are “DO-ing” lean, but how many are “BE-ing” lean? The list becomes much shorter.
Hope you are well.
Yeah, there’s a big difference between “doing Lean” (the CEO hiring an individual or retaining a consultant) versus “being Lean” and “thinking Lean” (the CEO actively participating in personal and organizational transformation – the way leaders like Dr. Gary Kaplan and Dr. John Toussaint have done).
Great post. How many of these hospitals that are “doing lean” have embedded stop the line authority for front line staff? How many of these hospitals live the philosophy enough to encourage colleagues to pull the cord and then provide resources and encouragement to rally around resolving the issue before more defects are produced? Without this basic foundational element in place its not possible to move from “doing lean” to “being lean”.
As Jamie Bonini, from Toyota, said a few weeks back at the Lean Healthcare Transformation Summit, the key is “exposing problems” and “solving problems.” Most organizations are still encouraging people to hide and cover problems… we fight the same fires every day. If somebody (like a nurse) did try to pull a proverbial andon cord, who comes running to help? Often, nobody.
Lean’s not that complicated… it’s just very different. I think I heard that pithy phrase from the author David Mann.
Exactly Jeff. Especially telling is when a staff member “stops the line” because of the actions (or inaction) of a high profile or high volume physician.
This rarely occurs, of course, because staff members are often given the tasking to “speak up” in the interest of patient safety, but aren’t told how to do it and when they do they’re hung out to dry.
To paraphrase Aristotle, “We are what we repeatedly do. [Lean], then, is not an act, but a habit.”
#DoingisBecoming
Steve – do you often get asked “how many hospitals are doing CRM/TeamStepps?” Similarly difficult to answer?
I’m rarely asked a question like that Mark. More often I hear, “Yeah, that’s pretty much how we do it.” “Pretty much”? Cool, I’m going to “pretty much” stop at red lights, stay in my lane, and avoid texting as I drive today.
What I also hear is something like, “Yeah, we did TeamSTEPPS,” or “We tried Lean.” I equate these statements to “going on a diet,” as opposed to changing one’s diet. The first is an intervention, the second a course change.
Saying “we did Lean” – whether than means tried and failed (maybe just trying a single tool) or that means “we’re done implementing it” (as in successful and somehow “done”) are both really frustrating things to hear, for different reasons.
Mark
Many healthcare organisations here in the UK NHS claim to have been ‘DO ing’ lean. The key driver being reducing ‘cost’ , expensive consultantcies are brought in costing £100’s of thousands and the hospital achives its 5% or 10% cost reduction for the year. Have they done Lean?
Of course not, as they face the same problem next year many of the improvements made are unsustained and so the process starts again… Great for many of the large consultancies not so great for the patient or tax payer here in the UK.
It also makes it harder for individuals like us to convince senior leaders that lean does work and that it is not a ‘Salami slicing’ cost reduction programme but long term cultural change.
The behaviors and facilitation must be from the top and cascaded throughout the organisation, getting an commitment at a senior level that it will take time possibly years to realise the full benefits is a hard sell in the current climate..
This is the biggest challenge we currently face in the UK and was very evident at the recent NHS commissioning conference 2 weeks ago, lots of talk about patients being first but then straight back to cost, lack of resources and funding…
Would ‘always learning lean’ be more accurate, palatable, and aligned?
I like saying we are “practicing Lean,” to borrow a term from medicine. I think that means always learning, always getting better, always challenging things…
Mark,
My response to this question is usually something along these lines. When I think about what lean and lean thinking really means, I think it’s about “transformation of management” (Deming’s term). Most people who have researched lean for all industries (like Bob Emiliani) cite very low percentages of “real lean” adoption (1-3%). I think this is about right for healthcare – 1% maximum.
So real lean understanding and adoption resides with a very small number of leaders and organizations. Most see this as a set of tools and something they can delegate to a department to cut costs and headcount.
I know a lot about 61 healthcare organizations that are members of the Healthcare Value Network in North America. Even among that group there is variation regarding what lean is and can be and the realization that it is fundamentally about “transformation of management”
Jeff Liker also said that very few in the automotive supplier world were really doing Lean (with the bar set very high… looking for cultural transformation).
Back in 2000, Liker was quoted as saying “50% of auto suppliers are talking lean, 2% are actually doing it.” How do you think those numbers have changed today?
(Liker answers that it was no different in 2006 when we talked.. “well, today, well over 90% are talking about it, and almost all who have talked about it have done something, like individual projects… the number that have deeply implemented the Toyota Production System… as a system… is probably under two percent…. what they’ve done is used individual tools.”)
So history repeats itself in healthcare?
History may be repeating itself with healthcare. Maybe. What percentage of leaders (healthcare or other) understand that the prevailing style of management that they were taught in school (and reinforced in organizations where they have worked) is simply wrong? We all went to the wrong school. What management is and needs to do is not taught in most schools of business. So organizations that really understand what needs to be done (the 1%) are engaged in rework when it comes to what is in our heads.
Healthcare has essentially been a craft industry with collections of various professions trying to care for people when they are sick or injured. They each learn their individual science either from a “master craftsman” or from a school that teaches a certain way of doing things (not all schools may be teaching the same thing). When they get to their job, the organization teaches them “the way we do things around here” (which is handed down from manager to manager – Deming would call it “rule 4 of the funnel”) Management of these healthcare organizations has historically been likened to the work of a mayor of a city – keeping all of the various factions relatively happy and working together. And management does not stay around long enough to create constancy of purpose or of a method.
There have been many attempts to try to “modernize” the management of healthcare, usually from the thinking that came from the Sloan school of management.
There have been several historical attempts to introduce and blend the “science of improvement” with the “science of medicine”. Usually, the craft mindset wins the day and the “Sloan method” (prevailing style of management) also wins the day because that’s what has been taught and is being taught in schools, conferences and by managers doing their best.
Great post, Mark!
I certainly agree with you that the popularity of a system does not determine it’s efficacy. But, popularity is reassuring; it makes people want to adopt the concept.
You said that Jeff Liker put the bar very high when he gave his numbers. Why not lower the bar a little, and give some credit to those implementing a tool or two–as long as they follow a bigger plan to a lean vision? in fact, some authors suggested to start with tools (5S, for example) and work your way towards a deeper understanding.
In the spirit of lowering the bar, my suggested answer to the question would be something like: ” Many are at different levels on the path to full implementation. Only one or two percent, however, have reached a mature stage.”
I hope it makes sense.
Yes, that makes great sense. Thanks for the comment, Sami.
Nobody gets to be a Lean culture overnight. I agree – you have to start somewhere. I think it’s OK if an organization is just getting started with a few practices or in a small part of the health system. Let’s say they are doing some waste reduction projects and 5S in a value stream or two. If that’s part of their “we eventually want to be a lean culture” roadmap then that’s fine (toward their lean vision)
The problem is when an organization, say, only does 5S and they have no aspirations to change the culture. Some aren’t trying to reach that “mature stage,” they are just cherry picking a tool or two.