Lean at the Frontline: All Hands on Deck

Our own experiences here in the Henry Ford Production System have shown us that success in practicing Lean management goes beyond education and is predicated on how effectively leaders implement and execute new ways of working and ultimately change culture. As an aside, we were initially exposed to Lean through a grant from Pittsburgh Regional Health Initiative. I hope you enjoy this article by our friend Naida Grunden. -RZ

Lean at the Frontline: All Hands on Deck

By: Naida Grunden

(Adapted from her article in Frontiers of Health Services Management, 2009)

In 2001, the fledgling Pittsburgh Regional Health Initiative (PRHI), a nonprofit consortium of business and healthcare leaders in Southwestern Pennsylvania, began examining the region's healthcare system. Through PRHI, business leaders held out the possibility that the tenets of the Toyota Production System (TPS), or Lean, could improve efficiencies in hospitals.

At that time, the idea was a hard sell. A preponderance of hospital leaders still believed that improving quality would increase cost. They saw the goal of perfection as unrealistic. Many saw Lean as the latest in a series of top-down projects that would soon expire.

Pilot PRHI projects proved that: (1) improving quality reduces cost; (2) despite its industry genesis, Lean propels improvement in healthcare; and (3) without commitment from top management, efforts stall.

People first

A people-first philosophy undergirds Lean, and that tools are secondary to relationships. Liker (author of The Toyota Way and Toyota Culture) concludes that "organizational change must start with individual change. He believes coaching, self reflection, and learning by doing are needed at every level of the organization to achieve change"

American healthcare has traditionally been operated in a "top-down" or "command and control" fashion, with leaders giving directions that trickle down through managers to front-line staff, who are left to puzzle through implementation.

Graban speaks of the "incalculable waste when employees just show up, do their jobs (as told to, or as they have always done it), and go home." A facility that embraces Lean thinking views every employee as an asset. Their work furthers the organization's goals of providing (1) value for the customer and (2) prosperity for the hospital.

While leaders set the vision, priorities, processes, and measures, the real action occurs on the front-line of care, not in the C-suite. In such an environment, leaders move away from rigid command and control, away from "project by project" increments, and toward arming front-line workers with the tools they need to improve their work every day.

No longer "bosses," managers become mentors and coaches, helping bridge organizational boundaries to improve care and remove waste. Improvements are not immutable fixes, but experiments that can be revisited and adjusted as the work flow indicates.

Spear speaks of four capabilities of high-velocity organizations:

  • Designing work to capture existing knowledge and building in tests to reveal problems;
  • Swarming and solving problems to create new knowledge;
  • Sharing new knowledge at every level; and
  • Leading by developing the first three capabilities. Managing according to that fourth capability requires all hands on deck.

Finding the right tool for the job

Lean tools tend to be simple, designed for users throughout the organization, especially those on the front-line. Six Sigma tools are complex, requiring advanced statistical knowledge applied by higher-level employees.

Lean principles suggest that tools be only as complicated as they need to be to get the job done, by people closest to the work. Trying to implement Lean without a fundamental change in top-down philosophy has led some leaders to strip off Lean tools-a Kaizen event here, a 5S or kanban there.

Because Lean elements are integrated and interdependent, painted-on versions do not result in sustained improvement, and can demoralize staff who have become invested. Although, as Mann points out, tools do not make a program Lean, "Tools embody philosophy."

Introducing change in a hospital requires the commitment of top management (top down). When those leaders disseminate the knowledge to the front lines, and follow with coaching and support (bottom up), the real transformation can begin.

(Naida Grunden is the author of The Pittsburgh Way to Efficient Healthcare: Improving Patient Care Using Toyota Based Methods and an international speaker on the topic of Lean healthcare. She served as communications director for the Pittsburgh Regional Health Initiative (PRHI) from 2001-05.)