Since the healthcare improvement work I do is apolitical and non-partisan, I'm generally not one to butt into the political affairs of Canada or other countries. But, when I hear complaints about Lean or when it's being called a “scam” and a “cult” by some in Saskatchewan (read here), my ears perked up and I started talking with some folks up there. My goal isn't to blindly defend Lean, but to first understand, but also trying to clarify myths or misunderstandings where I can.
I've had some contentious discussions (a union president who arrogantly replied, “No, I'm good” when I offered to send links to medical journal articles about Lean), but also some lovely chats via Twitter and email. Yesterday, I had a long and interesting phone call with Murray Mandryk, a political columnist for the Regina Leader-Post. He apologized repeatedly (as polite Canadians do) for “dragging me into” this political fight of theirs. I told him that it was, if anything, my fault for diving in.
The start of the article:
So, your local village idiot (me) has stuck his nose into Saskatchewan “lean healthcare” and local politics. I'm glad the columnist referred to be as “down to earth” in a tweet, at least. It's probably arrogant of me to point that out.
I've only been to Saskatoon once, for about a week in 2006 when I was part of J&J and our Lean consulting group was at the University Hospital lab. My plane made a stop in Regina on the way (Saskatoon is not easy to get to, whether you're starting in Texas or Japan).
I don't know anything about their politics. I do understand a bit about how the Canadian health system is different. For one, each province (and I've visited all but a few) has a slightly different structure and setup for funding and the organization of hospitals, etc.
Canadians are quite proud of their system. Mandryk told me of his child's recent surgery and how the care won't bankrupt him (as it might in the U.S.) But, the facts are the data show that Canadians often wait longer for treatment (in the E.R. or waiting for surgery). That's one great reason to pursue Lean healthcare – to reduce those waiting times without spending a fortune and without hurting quality.
So, the discussion of Lean has nothing to do with whose coverage or payment system is best (those are political issues). The discussion isn't about whose system is safer, since the per capita patient harm rates are nearly identical in the U.S. and Canada (as I wrote about here).
I am encouraged that Saskatchewan has been trying to address quality and patient safety, as they recently launched a Patient Safety Alert system that allows staff, patients, families, etc. to “pull the andon cord” as we say in Lean.
In talking with Mandryk, I talked about the need for nurses to be able to speak up when they see a problem, such as a surgeon wanting to rush the start of a case (because they're behind schedule) and everything isn't properly set up. Mandryk asked why I'd want people to be able to do that. He expressed a respect for his child's surgeon, that they are one of the best and we should trust them. But, surgeons are human. Most healthcare errors occur due to bad systems, not bad people.
So, we talked for an hour or so and he wrote this column:
Lean expert says change difficult
He asked how I should describe myself and I balked at the word “expert.” But, when you're interviewed by somebody, you lose control over how you are described (or how an editor describes you).
I'll comment on a few things:
“The $40-million question (in Saskatchewan) is: What is lean?” said Mark Graban, a consultant and author of three books on lean, in an interview from his office in San Antonio, Texas. “How do we go from here to there?”
What I really said was that it's easier to define and answer “What is lean?” than it is to determine “how to go from here to there.” Lean is Lean (and yeah, I probably would agree with 95% of what John Black, their consultant, would say and write) but there can be big differences in the consulting style and transformation strategy that will take you from here to there, towards being more Lean.
I've been re-reading John's book and most of it is spot on, such as emphasizing “bad systems, not bad people” and talking about how people are critically important and need to be engaged:
So, when I read even one complaint like this, I am concerned:
The nurse didn't feel empowered. Felt confused over goals, limited compassion care, issues w/ locating supplies. Lean is failing
That sounds like the opposite of Lean. It sounds like “Lean done badly” or perhaps L.A.M.E. What happens sometimes in a broad Lean transformation is that too many managers are trained too broadly, too quickly. They don't have coaches to help them oversee their work. If the nurses are confused or feel pressured or can't find supplies, something's not right. It could be that the old system just hasn't changed quickly enough, rather than it being “Lean is failing.” Lean doesn't fail or succeed. Lean is just a bunch of principles. People fail or succeed. Leaders fail or succeed.
Like I told Mandryk (and others), I'm the first to admit that Lean is not an easy silver bullet and that Lean is not guaranteed to work. Lean is hard. But, Lean works.
In the column, Mandryk did mistakenly refer to me as a “consultant” for GM in the 1995 timeframe. I was an employee. I was brand new to the working world and, while I was helping make improvements happen, I was mainly in a mode of learning about Lean. Employees there, before Lean, didn't feel empowered, were confused about goals, had limited opportunities to do quality work, and had issues with locating supplies. Lean helped with that. Lean didn't make any of that worse.
Mandryk wrote:
While a version of lean is being used in New York City's public health system with 35,000 employees, Graban said most lean initiatives are confined to smaller hospitals.
I meant to convey that Lean is exponentially more difficult as the size of the organization grows. It's not impossible in a large organization, it's just harder. The fact that we see more success stories from smaller hospitals is more due to the fact that it's faster to “transform” a smaller hospital like Virginia Mason or a group of smaller hospitals, like ThedaCare.
“I find the use of the word ‘sensei' to be pretentious,” Graban said, adding that some lean hospitals have dropped the use of Japanese terminology. “A lot of John Black's approach comes across as pretentious.”
That won't make me any friends with John Black and his team, but that's not my goal in life. Nor is my goal in life to engage in “consultant fights.” But, it's my honest opinion (as I've written about) that it's tacky or pretentious for Americans to use the word Sensei and especially so to hoist that label over one's own head.
I respect John Black and what he's done as an innovator in Lean healthcare. But, Lean is not “a cult,” so I'm allowed to disagree with him and his approach.
If you have a Japanese teacher helping you, it's reasonable to say “Thank you, sensei” as an honest show of respect. But, it's also bordering on pretentious (or let's just say it's a different style) to say you MUST visit Japan or that you MUST have Japanese teachers. There are many Canadians who can explain Lean well in plain English (or Americans). Black has also said some things in the press that come across as arrogant, (“My God, I wish I would have asked John Black to help me…“) where Lean leaders need to be humble. I like humility.
Mandryk ended the column with:
As Graban noted, health systems all over are filled with “smart people” and “sweet people who care a lot.” But their solution to their problems is always to hire “more, smart sweet people that care a lot.”
And that makes it even more difficult to impose lean – a model that may or may not be the right one.
I don't think Lean can be “imposed.” It needs to be embraced honestly by the people doing the work. If they're skeptical or don't understand, leaders need to lead. We all need to work together to make this a better health system – whether it's far-off Saskatchewan or our own back yard.
I sincerely wish for the success of everybody involved in Saskatchewan – the patients, the nurses and staff, the physicians, the managers, and the political leaders. If there is anything that's the least bit off track, I hope they will “Study” and “Adjust” in the spirit of the PDSA cycle. Nobody is perfect (gosh, especially me) and nobody's Lean journey goes smoothly. Black even warns in his book that it is difficult:
That might not be comforting, but it's honest.
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Mark,
This post is a helpful follow-up to your blog from yesterday. As I said, I was in Saskatchewan this past week and saw some really great things and witnessed some real leadership. It was (and is) the real deal. You and I both like to refer to the advice of Dr. Deming. I found something that might be helpful here on the topic of leadership (from Chapter 4 of The New Economics”):
To adopt the new philosophy and to not compromise, yet be a good listener in order to continuously learn is a real challenge. To lead with humility is not so easy. I look forward to visiting my friends in Saskatchewan in the near future and see how they are doing. I think they can teach us all a lesson about what leadership and transformation is all about.
Mike
Thanks, Mike. I try to follow that advice. I’m not always the best listener. I sometimes jump to conclusions. I try to set a good example.
A little better every day.
Thanks to a reader who “pulled the andon cord” (sorry for the jargon) and emailed me to tell me that I spelled Saskatchewan wrong in the post title. How embarrassing. You can see the misspelling in the URL.
“Saskatechewan” is probably some Lean Startup or entrepreneurship group in Saskatoon. Saska-tech-ewan.
Nobody called a “blog post title alert” until now.
The spelling mistake was an honest error, not a game I was playing.
But, it goes to show a few points maybe:
1) You can’t rely on human visual inspection to catch errors
2) Our eyes sometimes see what our brains expect to see, causing us to miss errors
3) Sometimes people don’t speak up to point out a problem for one reason or another.
What’s happening in Saskatchewan (and elsewhere) and your comments on the article written by Mandryk highlight a persistent problem: The great difficulty in clearly separating and effectively communicating the difference between Lean done wrong from Lean done right. Overall, people fall prey to the confirming evidence bias, and that based on past experience (anchoring trap), management’s intentions are “evil,” “zero-sum,” or “bad for me.” This makes it far easier for people to accept the possibility that Lean is bad. The proliferation of fake Lean/LAME does not help our case. And the few examples of REAL Lean make people think Lean is idiosyncratic and not likely to apply to their situation.
Given how many years we’ve been at it, I’d say we have not been very successful (failed?) at correcting the negative view of Lean in the general public. The rotten stench of fake Lean/LAME overpowers the refreshing fragrance of Real Lean.
Finally, people who dislike Lean often refer to this article, Lean Production by Will Johnson (Jacobin Magazine), to support their case https://www.jacobinmag.com/2012/09/lean-production-whats-really-hurting-public-education/. Please read my response here http://leanprofessor.com/blog/2013/12/19/lean-must-do-no-harm/. And please re-post my response wherever you see mention of the Jacobin magazine article. Thank you.
Thanks, Bob. I posted your article in the comments section of the Mandryk piece… in response to somebody who is most likely just “trolling” but also seems to have his mind made up that Lean is a tool for evil capitalists to better oppress the masses.
Hi Mark, I don’t understand US or Canadian Politics. I only know is that although we haven’t fully embraced a culture of process improvement in my Hospital in Mexico, the improvements we have made have been done thanks to the philosophy of Lean. I think the Process Improvement journey of each Institution is unique so we can’t critique something that has been proven its efficiency over and over in different industries and places. I hope the people unfamiliar to lean won’t be discourage by this comments, so they can discover that lean is a “suit” that has to be costumer made for each institution, it’s not a magic formula.
Hi Karina – that’s well said. It’s not a magic formula. Lean principles are clear. The philosophies of Toyota are well known. They’re just not very widely applied.
There’s no cookbook approach for how to “get Lean.” Learning to NOT look for one is often one of the first things to learn.
““Lean is failing.” Lean doesn’t fail or succeed. Lean is just a bunch of principles. People fail or succeed. Leaders fail or succeed.” I may have misunderstood this, but, shouldn’t it rather be “the application of Lean fails or succeeds” and not the people?
Fair point. By “people fail,” I don’t mean to be blaming individuals.
It’s more accurate, probably, to say “organizations fail or succeed.” But organizations are made up of people and led by people. Dr. Deming used to more directly blame senior leadership (since they have greater responsibility), but he was very understanding of front-line workers being a part of (victim of) a system. Leaders are part of a system, but senior leaders help create that system.
I’d rather speak in active voice (people fail or organizations fail) than the passive voice (the application of Lean fails or Lean has failed).
In my experience, to the extent that Lean empowers people on the floor to improve their processes and environments, it succeeds. However, wherever organizations treat their people with contempt, Lean faces political barriers and frequently fails. There may be actual corruption and law breaking (Enron) or questionable ethics (Wells Fargo maybe has a manual on cheating homeowners?) or just a lack of leadership competence (working with The Little People is too much work, boring or beneath the dignity of my office), but it’s still read as contempt by people on the floor.
When the people on the floor suspect that Leadership is using Lean as the latest fad out of contempt, they’ll be disengaged. When Leadership fears that Lean will expose wrong doing or incompetence, they’ll usually undermine it. (Do I need to mention HCA or GSK here?)
I’ve had some success in persuading disengaged workers that Lean can be a subversive tool to help them get the resources they need to do their jobs well. Once I whispered to an agitated physician at a presentation (who was complaining about ‘new quality requirements’) “You can use this project to get your patients what they need, because how else are you going to meet the requirements?” He replied “Oh, I hadn’t thought of that.” I heard a consultant who taught Lean at Boeing tell a similar story about explaining Lean to union-led teams, with similar results. (Yes, union members can be fierce supporters of Lean.)
I suspect that I’m not saying anything that everyone else has also experienced. I’ll bet that you’ve already helped leaders become engaged and watched them learn that working with people on the floor can be rewarding and meaningful. However it makes me wonder, if improvement programs don’t succeed without respecting people, why don’t we start there?
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