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A Total Shift in Mindset

by Ghassan Saleh
August 21, 2013

A Total Shift in Mindset

by Ghassan Saleh
August 21, 2013 | Comments (14)

I'm the lean engineer in MaineGeneral Medical Center in Augusta, Maine. For 17 years I've worked in public health research and healthcare, and for the last nine, I've worked as a lean specialist. I'm proud to say I've led 39 lean projects and been a part of 150 kaizen events, many of which have led to sustainable improvements.

Clearly, I am passionate about lean thinking and practice, but I also know it can be difficult. So I like to go back to the core concepts. Many people think of lean as a set of tools and try to use the tools where they don't necessarily apply. I always want to say, "If I gave you the same tools your mechanic uses, would you be able to fix your car the way he does?" Of course not. So if lean isn't a set of tools you can apply anywhere, what is it? How do we apply lean to healthcare?

In my experience, lean is a management philosophy, a methodology for process improvement including specific techniques and tools, a set of principles, and most importantly, a total shift in mindset. It's a way leaders can change the way they think about continuous improvement. It's a way for practitioners not to give up when things don't go as planned. And it's something we all must learn, whether we are senior leaders or frontline workers in the trenches. Lean is a reminder that 80% or more of any workflow and performance issues are actually system and process related problems, not people problems. It's a call to stop the blame game and start looking at processes and systems. It's a way of helping people come to work and ask themselves, "How can I make things better"? If we are thinking lean, problems aren't a bad thing; they are an opportunity for improvement.

Lean is difficult because it's different than what so most of us have been taught. How often do you hear the statement "think outside the box"? Lean tells us to move toward the box, not away from it, and to look at it. As lean thinkers, we break down the box into parts and steps using process mapping tools, identify value added and non-value added activities, calculate non-value added time, create flow, and implement a pull system, and then we seek perfection using PDCA.

So if you are new to lean and just getting started, here are a few things to keep in mind:

  1. Lean is a completely new way of thinking about continuous improvement, creativity, and innovation, NOT an add-on to your current way of thinking. If we consider lean as an add-on to other approaches (i.e. human relations, Taylor-ism) we end up with too many approaches. What we really want is for lean thinking to replace old, outdated models of management.
  2. It's not possible to replace old thinking with new (lean) thinking right away. There's always a transitional state between the old and the new. When we are at the tipping point between two, we need to keep doing what we are doing until we are sure that lean practices and principles are fully in place.

For example, in the case of communication: in an ideal lean environment, communication between one part of the organization and and another is hard-wired into the processes of the larger system (i.e. kanbans, andons, process dashboards, scorecards, etc.). Lean says that communication problems are the result of a poorly designed system, not the cause. A good system institutionalizes communication processes into the workflow. The idea is that we should never be waiting on someone to give us information. Good processes should handle all information needs, and visual management tools can be used to support all processes. But when lean is a new way of thinking and doing business, as it so often is the case, we need to address communication issues from multiple angles. We must communicate communicate communicate until we know that the information that needs to be shared is shared.

3) Lean is about trying something new, so don't be afraid to fail! The emphasis is on learning by doing. Most of us are good at brainstorming, but not so good at "try-storming". We must have the guts to try new ways of doing our jobs. As long we do PDCA, we have nothing to fear. Lean thinking requires both humility and confidence, and it's actually a framework to help us develop these qualities in ourselves and our team members.

What do you find most challenging about getting started with Lean?

The views expressed in this post do not necessarily represent the views or policies of The Lean Enterprise Institute.
Keywords:  getting started,  healthcare,  musings
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14 Comments | Post a Comment
Mark Graban August 21, 2013
1 Person AGREES with this comment

Thanks for the post. Agreed on Lean being a management system and a process improvement methodology more than a set of tools.

What are some of your reflections on why some kaizen events do not lead to sustainable results?

Reply »

Ghassan Saleh August 21, 2013

Thank you for reading the post. Your question is really an important one, and I don't want to share my reflections in a hurry, it has been a busy week for me. Hopefuly I will get back to your question early next week. By the way, I saw your presentation of the 8th annual North East Shingo Prize conference few days ago and I was realy impressed and inspired.  Thanks

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Glen B Alleman August 21, 2013

The notion that Lean is somehow hard is not reflected in practiice http://goo.gl/1TRa6

It has been a management philosophy for several decades in space and defense.

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Ghassan Saleh August 21, 2013


Thank you for reading the post and for sharing the Lockheed Martin report. It is really interesting.

I think what I meant (or what I should have expressed more explicitly) is that accepting lean as a management philosophy to replace the old approaches is hard (not lean itself). What happens quite often is that management systems, at least in healthcare, accept new approaches like lean and six sigma without the will to give up their old approaches. As such they end up with a huge management system that tries to manage everything. This reduces lean into a mere set of tools. Lean is about managing what counts and can be counted.  By the way I do believe that lean tools are very important but focusing on the tools only deprives the organizations from the full potential of the lean promise.

The resistance behind the will to not give up the old schools is partly because of the numerous training events that TQMers conducted in the 1980s, in fact some of the TQM teachings are still on the curriculum of some our MBA programs. The TQM call for a holistic quality improvement approach led the people to focus on output/outcome data (like throughput and production data) and neglecting the process data. As such they are happy with the know what and the know how without making a big progress towards the know why. As you can see we have a compounded problem. First is to have the gut to admit that TQM failed miserably, despite all the big bucks we invested in, second erase the teachings (or at least some) of TQM from the minds of our leaders and employees, and third start to teach them lean and apply it.

Having some organizations here in there with a successful implementation of lean philosophy doesn’t negate the fact that lean is “work in progress” in most of our organizations. Attending lean conferences for the last few years and looking at the titles of the breakout sessions give me the indicator that we are still talking about how to implement lean- at least in healthcare. We are not in a stage to talk about how to take lean into the next level yet.

By the way I googled your name and was really impressed with your project management experience, let me know what do you think? Thanks a lot.

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Visham August 22, 2013
Thanks for the interesting post Ghassan.

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Ghassan Saleh August 22, 2013
You welcome Visham! thanks for reading it.

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Joe August 25, 2013


Thank you for such an insightful post. I also enjoyed reading your post and I am impressed with your ability to take a complex subject and present it in such a simple formart. It is a rare quality.

Again, thanks.


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Ghassan Saleh August 25, 2013
Thank you Joe! 

I am glad you liked it. 

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Julia Dalphin August 26, 2013


This is a great post. The reminder that lean is a len through which one learns to see and think is vital I have found to its success. I get discouraged when I look at how some in management cannot understand that it is not just a set of tools that can be applied to our practice of healthcare. I wish there was a magic way to demonstrtae that you cannot combine "lean tools" with other tool and expect it to work.

If you have suggestions on how to get this idea cross, I would love to hear them.

Best, Julia

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Ghassan Saleh August 26, 2013


Thank you for your input. I don't think I have a clear cut answer to your important quesiton. But I always try to do a bit of education on lean thinking whenvever I have a chance. At the begining of each Kaizen or project meeting I do some ten minutes education. If it is a new project with new team participants, I do what I call "lean ground rules" , if it is process mapping session I talk about value stream mapping and the 8 type of wastes at the beginning of the session and so on.
I also write a monthly electronic newsletter "Lean It!" that we sent to all the employees in MaineGeneral. The newsletter has three sections. the 1st is educational lean article which is the longest section. The second is a sucess/improvement story that is usually authored by one of managers/ team leader to share their successes and how did they go about it. And finally the third sections, I call it "process design in action" when we update the organization on what is going on with the lean efforts: % of projects goals achieved, milestones achievement, improvement ideas and project data. I also hyperlink some relevant stuff like: project charters, grpahs, improvement plans, storyboards..etc.  I do put quite a bit of pictures in the newsletter too. Hope that is helpful.

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kevin kobett August 28, 2013
Can you share a success/improvement story?

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Ghassan Saleh August 28, 2013
Thanks for reading the post.
I am afraid I can't. Most of those success stories talk about organization-specific targets, data and info that might require an approval to be shared.

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Saad Alqahtani February 19, 2016


This is insightful Ghassan. Answering to your question, I think the most challenging thing about getting started with Lean is if you have to become the prototype in your area, public health for example. What's your say on the difference between using lean in healthcare delivery system and public health?  


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Ghassan Saleh March 07, 2016

Saad, Thank you for reading the post. Please read my other lean post "The Challenges of Lean in Public Health", it may answer part of your question.

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