If you can't measure it, you can't fix it

In their 1999 Harvard Business Review paper, Decoding the DNA of the Toyota Production System, Bowen and Spear described 4 work rules of LEAN.

The 4th rule deals with how improvements are to be made. In this approach to work, problem solving is made by the workers to improve their own work, at the level where the work is done, guided by a teacher, using data, to move incrementally toward an ideal condition through continuous cycles of improvement. This scientific approach to problem solving and change is based on the Deming Cycle, or PDCA (Plan, Do, Check, Act).

Therefore, the 4th rule of LEAN work is founded in measurement that reveals to the manager and worker what isn't going right, or in other words, insight into work variation. Notably, the 4th rule also calls for employee engagement, the basis of the team approach to quality improvement.

How do the manager and the worker gain insight into the workplace variation that they own and they can change?

For a manager to ensure a system's consistency and reliability, it is vital to understand the level of variation (defects) in your operations on a daily basis in order to focus your efforts to bring work quality within predictable limits. This requires continually 'feeling the pulse of the machine' so to speak, from assessment of daily metrics. This is the manager's role in LEAN.

There are essentially 3 types of metrics of value that indicate variation in your operation and should be used as a basis of PDCA based 'scientifically' designed process improvements. What are your metrics?

  1. Defects that are handed to you by your 'supplier'
  2. In-process defects that you make
  3. Defects that you hand-off to your 'customer'

The definition of the terms 'customer' and 'supplier' used here, although borrowed from manufacturing, are translatable to our own complex processes along the path of workflow in healthcare. Who passes work to you ? (your supplier). This is who you rely upon for information, data, parts, tools, tasks, patients, etc. Who requests or gets work from you ? (your customer). Are they inside your section, division, or department (internal customer) or outside your sphere (external customer).

Use of daily metrics in feedback loops to guide quality initiatives that improve processes looks like this-


This systematic approach to work improvement is not new. In 1926 our own Henry Ford, reflecting on the extremely efficient auto manufacturing business he created, said-

"Our system of management is not a system at all; it consists of planning the methods of doing the work as well as the work." Henry Ford