“Being Lean” is rare among the many healthcare institutions that have tried “doing Lean.” There are many steps along the way from the initial introduction of Lean into an enterprise to the day when Lean becomes its operating system and the foundation of its new culture. I can guarantee you that if you go to any healthcare organization that has “become Lean” you will find an interesting story. I can easily remember how skeptical I was when Dr. Zeev Neuwirth first introduced me to Lean. I had been an enthusiast when TQM was introduced into our practice in the early nineties. The idea of fixing root cause problems made sense to me. Quality Councils made sense. I drank the koolaid and I was disappointed when the grand ideas went nowhere. As the organizational enthusiasm faded I tried to continue to practice the concepts of “quality in daily work life” that I had learned.
For the next dozen years we continued to establish goals for improved performance that were rarely met because the goals were not supported by any process or change in workflows that enabled their achievement. Good organizational intentions without effective supports can be frustrating. Realizing measurably positive changes by exhorting individuals to work harder leads to managerial frustration and frontline burnout and cynicism. I was polite and accepted the stack of papers that Zeev gave me to read and did introduce him to our CEO since I was the Chairman of the Board and did not want to undermine his enthusiasm even though he was not resuscitating mine.
Zeev had recently been hired as the Chief of Internal Medicine for our largest practice where I saw my primary care patients for a few hours each week. Our practice was not working well. We were a collection of doctors and nurses floundering individually together. In less than a year after Zeev began introducing Lean ideas onto our unit I was an enthusiastic supporter of the changes he was introducing, not because of my personal participation, that came later, but because the work he had done with the support staff using some rudimentary tools from the Lean tool bag had made my work life better.
My patients and I were passive beneficiaries of the good work of others. They had generated value for us by making the processes that controlled my work day more efficient. Zeev’s work impressed the CEO and he was named VP of Practice Improvement and Innovation. A year later after I became CEO, Zeev had done enough piloting of Lean through a grant from Blue Cross that other members of the senior management team enthusiastically agreed that we should embark on an organizational wide process of Lean transformation. In the interim we had visited Group Health and Virginia Mason in Seattle and ThedaCare in Wisconsin and were eager to follow their lead.
Simpler’s 12th Annual CEO Symposium was recently helded in Indianapolis. The theme was “turning strategy into action.” During the event I had the opportunity to review the Lean journey of Indiana University Health and to see how they had “become Lean.” On a gemba walk at the IU Health North Hospital I saw first hand how becoming Lean was enabling them to “turn strategy into action” across their huge delivery system.
As I walked around at the IU Health North Hospital and then listened to the IU Health leadership talk about their “journey,” memories of our Lean journey flooded my mind. They started their journey for reasons not much different than the ones that motivated us. Indiana University Health needed to lower their costs, improve their services, and revive their staff if they were going to succeed while realizing the external pressures of payment reform, demands for greater transparency, and a growing number of regulations and requirements associated with the demands of both public and private payers.
What I heard the medical professionals at IU Health North saying was reminiscent of what I had heard from the staff in every job in our practice, from building maintenance staff to medical specialists. They enjoyed making a difference. They enjoyed the opportunity to acquire the skills that enabled them to change the work they did in ways that added value for the patients they served. From executives to medical assistants, the staff talked about the joy that Lean had made possible because with a Lean culture they were able to do more for patients. Helping patients is why they went into healthcare.
In every organization that I have visited that has gone through a few years of implementing Lean there has been improvement in the measurements of employee and patient satisfaction as well as in the quality and business metrics. I can confidently say that Lean, “when done right,” can help any organization do today’s work more effectively than it did yesterday’s work. If any organization gives Lean a chance and has the initial help of an experienced consultant and the alignment of its board, senior management, middle management, and clinical leadership, the results will always be remarkable.
Doing today’s work better than you did yesterday’s work is necessary but hardly sufficient for tomorrow’s success. The challenges of tomorrow will surely be greater than today’s work. Being satisfied with the achievements of 2017 means that your practice or health system will be floundering in 2018 or 2020. Change is not something we usually chose. Change is what is forced on us by external realities and forces over which we have little if any ability to block or slow. “Doing Lean” improves you today. “Being Lean” and learning how to effectively use Lean to develop breakthrough strategies and then effectively deploy those strategies requires a cultural transformation to enable effective “strategy deployment.” My heart skipped a beat when I heard the nurse leader for transformation at IU Health North say that their goal was a “cultural” transformation that would enable them to fulfill their mission of better serving their community.
Every speaker at the conference referenced directly or indirectly the truth that healthcare professionals will engage in the deployment of strategies for improvement if they have effective Lean leaders who understand that their Lean role is to be seen frequently where the work is done and earnestly practice their role as effective coaches, mentors and teachers. When Lean fails, it is usually because senior leadership has retreated to its offices and endless meetings and tries to succeed by announcing difficult to achieve objectives described with numbers and opinions devoid of input from the people who do the work. Lean tools don’t work for long without the participation of senior managers.
If you go to reasonable Lean references like the website of the Lean Enterprise Institute and look for the “principles” of Lean you can read:
The five-step thought process for guiding the implementation of lean techniques is easy to remember, but not always easy to achieve:
- Specify value from the standpoint of the end customer by product family.
- Identify all the steps in the value stream for each product family, eliminating whenever possible those steps that do not create value.
- Make the value-creating steps occur in tight sequence so the product will flow smoothly toward the customer.
- As flow is introduced, let customers pull value from the next upstream activity.
- As value is specified, value streams are identified, wasted steps are removed, and flow and pull are introduced, begin the process again and continue it until a state of perfection is reached in which perfect value is created with no waste.
All of those words are true. It is a fifty thousand foot view of the process that they admit is not always easy to achieve. The LEI recipe above is missing the key ingredients, Lean leaders and a culture of trust. All the speakers that talked about turning “strategy into action” at the conference understood that for their organizations to be transformed they must first accept the transformation for themselves. The accomplishments of IU Health, like the famous accomplishments at ThedaCare, Virginia Mason, and Denver Health are testimony to what can be accomplished when the leadership invites their colleagues into a process of transformation that they are also experiencing.
Tomorrow’s work can be exciting. IU Health is proof that Lean can be used to shape an organization for tomorrow from many distributed pieces. The innovations that are rapidly being developed for tomorrow that are built with big data, augmented intelligence, and creative applications of telecommunications will be much more beneficial when they are woven into workflows and strategies with the benefits of Lean thinking and culture. Lean will enable the successful competitors in markets where multiple organizations seek the same patients through transparently lower prices and substantially better access, service and clinical quality. Being Lean is the greatest competitive competency a provider of healthcare can develop to insure that their mission will survive a future that seems harsher with each new executive order.