Do we need more research to understand what works and what doesn’t when implementing lean healthcare?
Dear Gemba Coach,
There are controversies over whether Lean/TPS works in healthcare or not. Authorities in lean practice suggest conducting research that compares outcomes with lean and without. I feel like we are stuck proving wasteful activities are still valid when we run to research.
A system is just a system, as a tool is just a tool. Lean in itself doesn’t necessarily deliver the promised benefits, in healthcare or elsewhere: it depends how it is used. This is one reason why research is so hard to conduct – you can measure behaviors, but how can you measure attitude or intent? Worse, as Argyris and Schön suggested a long time ago, “espoused theory” (what people say they believe in) and “theory-in-use” (what they actually do) are not necessarily the same thing. Everyone has reasons for doing what they do, but not always full clarity on what these reasons are, which creates consistency issues, and great difficulties for their colleagues. Basically, measuring the ins and outs of lean programs to figure out what works and what doesn’t isn’t so easy, and, at this stage, we’re still collecting cases to draw the picture rather than quantify it.
Support or Engagement?
I’ve had a front-row view of about two dozen full lean programs over the past 20 years, five of them in hospitals. I have no general opinion, but self-reflection on my direct experience. Most people will agree, including academic researchers, that top management involvement is critical to the success of a lean effort – no debate there, but I now believe this is not enough. There is support and there is engagement. We’re looking at two fundamentally different leadership intents:
- Inspiring middle managers to improve their areas: Many senior leaders understand their roles in a lean program as motivating mid-level managers to follow the exercises and instructions of the lean experts/consultants and “improve” or, at the very least, manage their performances better.
- Discovering with their middle managers what improvement actually means: These leaders are far more involved in their business, not at a process/organization level, but at understanding the actual work and how to become more competitive by being better at how the job is done (which eventually involves capabilities and individual competences).
Although these might sound similar, we’re dealing here with radically different intents and – to a large extent, attitudes. In the first case, the leader assumes he doesn’t have to understand every aspect of the business as long as he runs the processes well and motivate or incentivizes managers correctly, performance should follow. This approach to performance is through an execution system to support the strategy, and lean, as they see it, is a key element of this execution system.
The second type of leader assumes that she can run well the parts of the business she understands inside out, but not the ones she doesn’t and is committed to learn more about all aspects of the organization. She will use lean as a learning system to discover what matters and what does not in every aspect of the business, what works and what does not, and what needs improving either on the surface at process level or, more deeply, through technological change.
The Best Nursing Director Ever
For instance, the best nursing director I have come across was obsessed (I mean it, obsessed) with reducing undesirable events for patients. She started by asking every ward manager to measure, by hand, all patient incidents in their wards, such as new infections, falls, complaints, etc. and would phone them up to gather the data herself, personally, once a week (eventually, her assistant took up the job). She then asked each ward manager to choose one banal practice, such as cleaning patients, and then to list all the steps and conduct one audit per week by personally looking first-hand at how the care was delivered against the checklist. As a result of these audits, the nursing teams in wards self-assessed many of their practices. They discovered both easy problems (preparing the care to avoid stopping in mid-care to look for something) and hard problems (hand washing and keeping hands sterile in the room, when one has to touch doorknobs, curtains, bed posts etc.).
Incidents went down quite visibly, but the key point is that the nursing director was not looking for better discipline or better processes – she was still thinking as a nurse. She wanted to understand which parts of which care were not done properly. She explored, and did not shy from hard problems. One such problem, for instance, was the interface between the wards and physiotherapy. Physiotherapists complained that patients came in without proper grooming, and nurses complained that physiotherapists had no notion of proper hygiene (hand washing, disinfecting tools of the trade, and so on.) and so patients caught infections in physio. The director set up various self-study groups with both nurses and physiotherapist until they learned to find some middle ground.
The problem with problem solving is that without a strong exploratory intent, without the will to find out what really happens it easily falls prey to “motivated thinking” where people orient the problem solving process to reach their pet theory or to score a “win” against their opponents. problem solving is powerful, certainly, but if it’s fueled by discovery, exploration, curiosity and not just passing the buck or scoring points on the indicators.
5 Traits of Successful Lean Leaders
With hindsight, there seems to be a common shape to the intent of lean leaders who succeed:
- Curiosity about the trade: Leaders who have never lost their interest about what their organization does and who’s first motivation remains discovering how to be more competitive not by fiddling with environmental parameters, but from within, by understanding better what impacts customers, what works and what needs to be improved – and constantly looking for smarter ideas and new solutions.
- Leadership in finding followers: The second trait of successful lean leaders is understanding that who’s in the bus matters. Because solutions are built with people, the reasoning and managerial attitudes of managers heavily influences outcomes. These leaders are very sensitive to how they compose their teams and how they work together, much like a sports coach would. They find deciding who to promote or recruit and on what basis (know-how? potential? fit to the culture?) their most important leadership decision.
- Creating common practices: Leaders then understand the value of creating common practices such as visual management, daily problem solving, team-based quality circles, suggestion follow up, and so on. The kanban system is a useful way to support these various practices, but they can also stand on their own as long as the leader sees the importance of supporting learning by common practices, not just execution.
- Seeking proprietary improvements: These leaders never tire of looking for the technical improvements that increase customer satisfaction, make employees’ jobs easier and reduce total costs. They see that the sum of these detailed, local improvements and innovations are what amounts to competitive pressure; competitors will have to seek similar outcomes but don’t have the learning curve to do so simply. The obsession with the product or service remains the core motivation of this kind of lean leadership.
- Understanding how to react to crises: Crises are a fact of life, particularly in healthcare, but too often, unfortunately, tactical decisions become policies (for lack of a better idea). Leaders focused on better understanding their service or product can take a longer look at how crises are settled and, more importantly, what conclusions should be drawn from the crisis in terms of process change, rather than jumping to conclusions with, regrettably, negative side-effects discovered a couple of years down the line, as is common in healthcare.
Research Is Important, But …
I fully believe more research should help us to better practice lean. The difficulty lies in understanding what we’re researching. A key issue is that a lean effort conducted in true kaizen spirit is hard to distinguish from a lean effort driven by a Taylorist determined to control in ever greater detail how people work. This will not appear in the slides and can only be seen on the Gemba at how freely people speak of their jobs, how committed they are to patients’ well-being, how smartly they solve problems, or with what initiative they come up with new ideas. In both cases, the leader will say the same things, but on the Gemba we’ll see radically different behaviors, reflecting the different leadership intents.
Research is very important, absolutely, but lean still hinges on learning to see at the Gemba and keeping an attitude of discovering with frontline managers what improvement means in their context rather than hiring experts to tell them how to improve.