Lean gets started in different ways, but for it to survive and thrive and move from being used as a set of tools to being the core of a culture and operating system that is the source of sustained excellence, eventually the CEO and senior management must lead. One Lean consultant, Jamie Flinchbaugh, has said,
…recognize that few companies start a lean program with upper management support. Sometimes, but very rarely, lean originates and is lead by senior management. Slightly more often, someone in senior management gets the journey started, but does not maintain it. However, most common is the scenario where someone else in the organization needs to get them on board.
That was certainly the experience at Harvard Vanguard and Atrius Health. The Vanguard story is worth mentioning because you may find yourself in an organization that is “doing Lean” or “Lean like” activities and you may be wondering what you could try to do to move senior leadership and your board to becoming more effective Lean leaders.
In 2005 Harvard Vanguard hired Dr. Zeev Neuwirth to be the Chief of Internal Medicine at its largest and oldest site, the Kenmore Center. Kenmore is located at the edge of the Longwood Medical Area and is little more than the distance of a major league homerun down the street from the Red Sox at Fenway Park. When he arrived at Kenmore Zeev was confronted with an environment that was still recovering from the stresses that had been associated with the practice’s near death experience following the financial collapse of Harvard Pilgrim Health Care. In 2005 the spirits of the practice fell even further with the departure of our very popular CEO, Ken Paulus who most of us credited with having saved the practice.
My primary care practice and the central cardiology practice were located at Kenmore and I can attest to the dysfunctional environment that greeted Zeev. I can also easily remember the enthusiasm that he brought to his new assignment. One day he presented me with about ten inches of reprints outlining the wonders of Lean. I can remember thinking that he must be crazy if he thought that I would ever have time to read even one of the papers, but I did invite him to sit down and tell me about his ideas and Lean. I was already vaguely aware that he was doing something with the support staff that was making a difference. He talked continuously about respect and the wisdom of the people doing the work. His enthusiasm was attracting a diverse group of professionals and the other managers in the leadership team of Kenmore, as well as the support staff. People were getting excited about clinical improvement.
About this time our search for a new CEO was completed and when she arrived I told her about the benefits that I had experienced as the workflows in my unit were improving with Zeev’s work building teams and creating better “standard work” with his “spaghetti” diagrams and constant cheerleading. He had “started a fire”. The CEO was impressed with what Zeev was doing and created for him the position of VP of Clinical Improvement and Innovation.
Outside the organization there was some serendipity. About the time of Zeev’s promotion Massachusetts Blue Cross decided to invest many millions of dollars in grants to five organizations, four hospitals and Atrius. The program was called LEAD and the vision of Blue Cross was that each of the five organizations would create a pilot program of transformation to improve quality, safety, cost, and patient satisfaction. The money was given to Zeev as “seed” money for his new role. Zeev hired a “sensei” and targeted two of our sites as pilots.
Zeev met with some resistance, or at least skepticism, from other members of the senior management team who were not sure just what his role and responsibility was. His success was at the periphery of their interests and the LEAD work was in just a few of our many sites. When I became CEO a couple of years later I was impressed with what he had accomplished even without widespread buy-in from other members of the management team. Zeev’s story is documented in the second chapter of a little book by James Champy and Harry Greenspun, Reengineering Health Care: A Manifesto for Radically Rethinking Health Care. It took over three years of “doing Lean” or activities that looked like Lean before there was a consensus across senior management that we should begin the journey to “become Lean” almost a year after I became CEO.
My reason for telling the origin story of Lean at Harvard Vanguard/Atrius Health is that it is not a unique experience. Many organizations are introduced to Lean by the passionate initiative of a middle manager. Sometimes senior management thinks that naming a leader and providing a little budget before going on with business as usually is evidence of supporting Lean. That certainly was what Zeev experienced. Even when a senior leader or even the CEO or board chair declares that they are supportive of Lean, it is not enough. Nothing sustainable happens until senior management, the board, and the CEO see the need for their own transformation and adoption of a new culture and operating system. Everyone must understand that their “standard work” must change.
An effective Lean organization will have a vigorous conversation between the levels of management and with the frontline.That vital conversation requires involved leadership at every level and can never happen without the senior leadership team and the board being more than supportive. They must be involved, and their actions, understanding and commitment must be obvious to everyone in the organization. As discussed in a previous post, the relational contracts that are the foundation for a learning and improving organization will be heavily discounted and misunderstood without the obvious and authentic embrace of Lean by senior leaders and the board.
When Lean does enter an organization at a level below the senior management team its sponsors often find themselves forced to “speak truth to power.” That phrase reminds one of martyrs and patriots. Robert Kennedy gave a famous speech in Cape Town, South Africa in 1966 at an event called the Annual Day of Affirmation. The speech was meant to encourage those fighting apartheid. Mandela and many leaders were in jail having spoken truth to power. Kennedy used the moment to speak not only to those in the struggle against apartheid but also to speak to the folks back home. I may be misusing RFK’s advice to say that it applies to those seeking to grow and spread Lean in their workplace from a position deep in the organization, but I think not. Robert Kennedy told his South African audience:
It is from numberless diverse acts of courage and belief that human history is shaped. Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current that can sweep down the mightiest walls of oppression and resistance.
I put “how to influence senior management” into Google and hit enter. What I got was simple and straightforward advice.
If you want upper management support, then part of your job is to do whatever it takes to gain that support. One way you can do that is by applying lean to your own job and your own sphere of influence – whether that is just you, a team, a department or a process. You have to deliver results anyway, so why not use lean to do it? This will make things around you more effective, which then may influence upper management to support lean because of the results you achieve. Additionally, you will learn as part of the process, which is all the reason any of us should need.
In essence that is what Zeev did in a neat package. There is another great thought later in the article:
Many managers believe they are very supportive. They view themselves as 100 percent behind the lean efforts. The problem is that behind is still behind, but engaged typically means out in front. They might be very interested in what lean can do for them, but not really know what they should do about it.
I think there is wisdom in this statement. None of us can be objective in our self assessment. If you are in an organization where senior leadership, the CEO and the board may think they are supporting Lean but there is less certainty in their sincerity or commitment at your level in the organization, then there may be benefit in initiating a conversation that lets them know that you and your colleagues really need their leadership. That is speaking truth to power.
We tend to think only of Lean’s spread from manufacturing to healthcare, but it is moving through many industries. My search led to an interesting PDF of over 100 pages from McKinsey, the consulting firm, written for the financial services industry. The paper discusses managerial behavior in a way that you may find useful if you do chose to “speak truth to power” asking your management to get out ahead and lead. To be useful I lifted and compressed some of it for your consideration:
The perception that behavior is a “soft” topic leads managers to assume they can rely on their own instincts, an approach that seldom leads to sustainable long-term change. Instead, managers need to take the time to understand some of the factors that influence human behavior. In our experience, organizations that have achieved true behavioral change in the context of a lean transformation have incorporated six often-overlooked insights.
- People need to feel that change matters
- Change must be seen as fair
- Positive feedback and active learning help make change last
- Changing behavior means changing mindsets
- People won’t change unless their leaders do
- Personal involvement creates ownership and impact
It is a good list and I think that it offers actionable information and help to leaders at all levels of leadership in healthcare. Put it together with your own commitment and numberless diverse acts of courage and belief; and who knows, we may move closer to the day when we produce for our patients and communities
Care better than we have ever seen, health better than we have ever known, cost we can all afford, …for every person, every time.
