5 Guiding Principles

The Lean Global Healthcare Initiative recently came out with a white paper titled “5 Guiding Principles to Transform Healthcare.” Its purpose is to accelerate the 10 years that it takes to “reshape management systems and leadership behaviors” given the “pressing issues facing the industry today: patient harm, aging population, squeezed budgets and an increase in chronic diseases.” No doubt that ten years is too long; patient harm, as well as employee harm and harm to other stakeholders (suppliers, owners, families, and communities) should be expeditiously ameliorated whether within the framework of Lean management or otherwise. Leaders have this responsibility whether they realize it or not. Lean is one of many methods to accelerate the timeline from the current state to the future state.

The purpose of this critique is to educate and inform, and to inject diversity into the conversation by offering counterviews of key elements of the white paper. My critique is organized according to the primary headings of the white paper:

Designing Our Initiative

Under the sub-heading The Findings To Date, it reads: “Here is what we consider to be the essence of what we have learned collectively, presented as five ‘guiding principles’ that you can start using today to achieve a faster and more sustainable lean turnaround.” Speed requires the removal of barriers, which, in a Lean turnaround, are almost wholly owned by the executive team. These barriers take the form of metrics, KPIs, policies, procedures, workplace and equipment layout, and so on. Sure, some improvements can be made despite these barriers; I know this from personal experience in my work in industry and academia. Yet, speedy progress in Lean transformation requires the engagement of the CEO and the entire executive team. If one does not gain the engagement of the CEO, then one usually does not have the engagement of the executive team, and consequently, a lack of engagement on down to the level of middle manager.

1. Don’t Wait for the CEO

This is advice that I have given to my students and others for decades because Lean requires extensive hands-on practice to gain proficiency. Waiting for the CEO to accept Lean results in the loss of valuable learning experiences, time, and needed improvement. It is like waiting for an invitation to perform at Carnegie Hall before one learns to play piano. Instead, you learn piano first, and then perhaps one day you will be invited to perform at Carnegie Hall.

Yet, in the white paper, a straw man argument is given for not waiting for the CEO: CEO turnover. This is cited as the primary reason for not waiting for the CEO, yet the end of the paragraph reads: “We  experienced CEO turnover in more than half of the eight case studies, which could be a factor of disruption of lean efforts” (bold added). This equivocation weakens the argument that CEO turnover is the primary reason for not waiting for the CEO. Based on our collective experience over the last 32 years, it is clear that CEO turnover is almost always disruptive to Lean efforts. Likewise for changes in hospital ownership, which (in the United States) have been common in recent decades in an attempt to diminish the market power of suppliers and payers.

Later in the white paper, it says: “Reflecting on our studies, we agreed that a supportive CEO is preferred; however, a neutral CEO can also work if physicians and other leaders are visibly engaged. What won’t work is a CEO who appears negative or actively blocks progress.” The CEO turnover straw man argument avoids the actual primary argument which is, as I have thoroughly documented, CEOs who avoid or actively block Lean — in my parlance, why CEOs resist or reject Lean management.

I realize that any person affiliated with the Lean brand is forbidden — perhaps reprimanded, penalized, or even ostracized — to cite my work, but ignoring it leaves its global Lean practitioners and customers poorly informed, ensconced in the status quo, and possibly exposed to professional or personal harm.

Given the white paper’s guidance that the CEO should be left behind, Lean transformation is not really possible except in rare cases where the CEO belatedly comes to accept Lean. Therefore, the title and contents of the white paper are misleading. A better title would be “5 Guiding Principles for Continuous Improvement in Healthcare.”

2. What is Your Next Move? And Why?

The next section contains the words: “Upon starting a transformation, you need to understand what’s important to your CEO, your Board and the organization as a whole.” We know from decades of experience that lower-level people have great difficulty in understanding what is important to the CEO and the board. What leaders say is important is often not what is actually most important to them. In other words, there is an enormous gap between what leaders think is important (their “privilege values”) and what followers think is important (leaders’ “instrumental values”). In my recent work, I have documented what leaders think is most important, and it is vastly different from what followers think is important.

Next, there is yet another call to do more of the same: “Examples that work generate interest.” Here we see the continued reliance of success stories as a means of generating executive interest in Lean. Yet we know from decades of empirical evidence that success stories are usually unconvincing to CEOs. Thus, the word “will” in the above quoted sentence is misleading. Success stories may influence some CEOs, but in most cases they do not. Lean people are remiss in their duties if they do not learn why that is.

Towards the end of this section it says: “People need to feel emotionally attached to the transformation: they need to co-create experiments and knowledge…” I agree. However, most CEOs, and especially those who resist or reject Lean management, are highly effective at emotionally detaching people from their work and from efforts to improve their work. Remember, in the absence of executive engagement in Lean, Classical management runs strongly and steadily in the background inducing workers valiantly trying to practice Lean to emotionally and intellectually detach from their work. This competition for attachment/detachment is heavily weighted in favor of Classical management.

3. Make it Your Problem

The first sentences read: “Previously, we talked about emotions, that if people feel emotionally attached to a problem, they would own it. Therefore, creating ownership is critical to the transformation.” I find this reasoning circular: emotions –> ownership therefore ownership –> emotions. While not an invalid argument, it is a confusing argument.

When one does their work, it is imperative that they not ignore problems in the work they do. If they do ignore problems, then that is concrete evidence they lack emotional investment in their work and do not own their work. Instead, they feel owned by their boss, their peers, the process, the system, etc., and believe it is a wiser choice for them to do their work as the process or system requires, or do as they are told. Classical management is extremely effective at habituating people to this normative order. Lean training can disrupt this normative order and generate emotional investment and ownership, though it can be ephemeral in the absence of effective Lean leadership.

4. The Right Knowledge for the Right People at the Right Time

This section begins with: “The speed of the transformation depends on our ability to develop the right capabilities quickly and effectively. But how to do it?” In this section, there is no explicit mention of kaizen, and the Lean brand has long downplayed its importance in transformation. That is odd given that the best and most rapid (<3 years) examples of Lean transformation in healthcare and elsewhere feature Toyota-style kaizen as the driving method behind learning and improvement. It is remarkable how the Lean brand remains largely indifferent to Toyota’s kaizen methods and the speed with which it helps people “develop the right capabilities quickly and effectively.” Yet, A3 reports are explicitly mentioned and apparently are judged to be more important than kaizen. That is just not true. What numbers are to arithmetic, kaizen is to Lean transformation. Kaizen is fundamental; it teaches people the basic way of thinking, how to understand work, and learn what improvement really means. Kaizen must be mastered before one can move on to other methods.

5. Cross-Pollination

This section begins with: “As lean thinkers, we believe that deep knowledge comes from practical experience. However, this is something that can’t be taught; it can only be learned.” To too great an extent, the Lean brand downplays the importance of learning by other means and from experts. This, unfortunately, is to the detriment of Lean practitioners, rapid progress, and to the goal of Lean transformation. Cross-pollination occurs by many more means than just sharing experiences within and between different departments. The whole Lean ecosystem of people and information in its myriad forms are sources to draw upon for cross-pollination.

Learning through the “sharing of inspirational stories” and “reflect on progress” are surely good things to do in an organization. A better thing to do is have people in different functional areas work together on a group of related problems and experience success via kaizen. The combination of participation in kaizen and beneficial results from kaizen produce a more substantial form of cross-pollination.

This section ends by saying ” It is critical that good examples and results are well documented for sharing.” What about the bad examples and bad results? These too are worth sharing and learning from. We always hear the phrase “you learn from your mistakes,” but the Lean brand prefers to ignore mistakes and instead demand a laser-like focus on success. That is plainly unrealistic and also to the detriment of Lean practitioners, rapid progress, and to the goal of Lean transformation.

Summary of Critique

The Lean Global Network is to be congratulated for producing a brief document describing guiding principles that some may find helpful. While it asserts an understanding of “…current knowledge regarding relevant success (and failure) forces…” I find that it lacks comprehensive understanding of the relevant published literature as well as the thinking, the facts, and the hands-on methods that illuminate the causes of transformation success and failure. Additionally, it oversells in its promise to “…help lean practitioners find smarter ways of building sustainable capability…” and “reduce the time and optimize the effort required to transform healthcare…” That is impossible to do without understanding why CEOs resist or reject Lean management, and the key role that Toyota-style kaizen methods play in both capability-building and the elusive search for sustainability in healthcare or any other organization.

I invite your comments or rebuttal.

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