The trouble with Lean

Are you Lean, becoming Lean, doing Lean or thinking Lean?

Almost the entire province of Saskatchewan has gone Lean.

On the surface Lean offers everything front line workers should want. It is a system that addresses work process and reduces waste. It looks at the appropriate use of tools, including us humans. It allows for continual process improvement with a focus on quality. It involves and values front line workers in process design. Some managers claim it even saves money that can be reallocated elsewhere.

So why is it we hate it so much?

Lean is a system of continuous process improvement that originated at Japan’s Toyota in the 1930s (sometimes misidentified as the Toyota Productions System – TPS), although founder Taiichi Ohno admits that he generously ripped off Henry Ford for many of his process ideas. Others say the origins go back thousands of years to Africa. The term Lean itself came from a 1988 article on Toyota’s management system by an MIT student.

While initially geared to assembly line manufacturing, Lean has expanded in recent years to include the service sector.

It’s everywhere, including health care, and yes there is even a Lean for Dummies book. You can even buy software to do nifty Lean process maps.

At a recent Insight Conference in Toronto some health care managers were more than happy to give case studies of how Lean improved quality service delivery at their hospitals. The case studies usually finished with a photo of a smiling “Kaizen” team. Kaizen’s are process committees.

While Lean is promoted as “transformative,” most examples were much more modest in nature. For some, it was hard to tell what the actual improvement was.

Rather than delivering major change, some were critical that relative to the labour expended, the results were less than impressive. Being labour intensive, many complain that it is difficult keeping Lean going over the long haul. Many hospitals may simply tick off the check mark – yup, we’ve been Leaned. Now back to work.

The Lean groupies insist that the process needs to be expanded up to scale to get the results they think can be gained, but the examples are elusive.

Working in health care is not for sissies these days. Ontario Hospitals are experiencing their first core funding freeze since the Harris era. Other sectors are not doing much better. Everyone is complaining about workload.

It is understandable in this environment that seconding a group of workers to take Lean training and work on a project to figure out where, for example, the lab equipment gets moved in order to save a few steps, can generate a fair amount of internal resentment.

The experts say the opposite of Lean is not fat. Implementing Lean in a hospital system that is operating on funding well below the national average still risks the perception that we are going from Lean to Anorexic.

The other common thread is that most health care environments really don’t have the culture or trust to make Lean possible.

It’s nice to see front line workers on committees, but are they really being listened to? In some cases, the Lean Kaizen team has simply by-passed those who have a front line perspective. Others have gone to the other extreme by bringing community members into the process. One doctor lamented that leaving out the support staff in his hospital was a big mistake. Choosing who goes on the team can be a choice fraught with peril.

Hospitals often blunder by leaving the union out of the process. Did anyone not think this would raise suspicion about motives?

One former CEO suggested to us that Lean was simply a way of co-opting our members into finding ways to eliminate their own jobs. More cunning Lean promoters will talk about quality improvement; the less savvy will focus on how much money they can save.

Let’s face it; all those chirpy Lean terms can be really annoying. One of our members was told recently that a Kaizen team leader had a green belt in Lean. The member replied she had a black belt in filing grievances.

Professions often invent complicated language as a way of distinguishing themselves. If nobody knows what you are talking about, you are probably really smart. Talking to an auto mechanic can make you feel like a complete idiot. Yet Lean uses the same kind of language blocks while at the same time expecting a culture of openness and buy-in from all.

Lean reminds us of the old joke, how many psychiatrists does it take to change a light bulb? The answer is one, but the light bulb has to really want to change. Executives and managers are like anyone else – they find change scary. Unlike everyone else, they have the power to make change or stop change. Hospitals and other health care providers are not democracies. For middle managers, having front line workers drive change can also be a little unempowering.

We note that there is intense pressure to adopt Lean even if the leadership doesn’t believe in it. It wouldn’t be the first time we heard a middle manager say, ‘ let’s just get through this until the next fad comes along.’ Anybody still remember Total Quality Management?

If you are one of those people who have a lot of ideas and oppose prevalent thinking, chances are your Lean team is going to shun you. Then you become an official naysayer and get to undermine the whole effort among your colleagues. The Toyota system puts much emphasis on respect for people. That’s a huge obstacle in many health care environments.

In a European study on psychosocial hazards at work, Lean production is actually listed among the top 10 stressors along with work intensification, outsourcing and poor work-life balance. That should stop anybody in their tracks who believes in evidence-based decision-making.

Henry Ford and Taiichi Ohno really didn’t design their systems for us. They designed them to make cars.

In a perfect world, with enlightened executives open to real process change, this might have a ghost of chance of working. Then again, it could also be a huge distraction at a time when we really do need to keep focused on the challenges ahead.

Have you been Leaned? Tell us your experience by commenting below.

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17 responses to “The trouble with Lean

  1. Thanks for the skinny on lean. Fat chance anyone doesn’t find this a good read. Laurie

  2. Interesting article. I am one of those “Saskatchewan lean believers”. One exception I am a patient,( not senior management or staff), who actually has been asked to participate in RPIW and P3 events. I think if this is working in Saskatchewan why knock it and perhaps try and dig a bit deeper into why it is working here. I am impressed I am included in decisions that regard my healthcare system that I rely on. I say its about time for this lean process. What has been done in the past didn’t work too well. With the focus in Saskatchewan also on Patient and Family Centred Care, I am thrilled that the voice of the patient is being listened to. One has to remember that Lean work takes time and results do happen. Have a little faith!!

  3. Pingback: The trouble with Lean | Canadian unionist blogger bashes Lean healthcare | Michel Baudin's Blog

  4. Lean N, Fallover

    Lack of control is a well known psychosocial hazard. Lean seeks to take all control of the production process away from workers right down to dictating where you will put your pencil and prohibiting work station individualization. Also many Lean implementations are an ergonomic disaster since the work becomes much more repetitive and the range of body motions reduced. The best ergonomic body position is the next one, the human body is not built to stay in the same position for extended periods of time, which is exactly what Lean processes try to do. Getting up to get something from across the room every now and then is a healthy natural break. Lean defines this as wasted movement which must be eliminated.

    • Lean is trying to eliminate, for example, all of the wasted motion that keeps nurses away from the bedside. The hours each shift spent searching for equipment and supplies lead to patients falling because they try to get up to go to the bathroom on their own and it leads to pressure ulcers – all because nurses and others are too busy dealing with the waste to attend to patient needs.

      Lean, even in a factory, is not trying to create motionless employees. In Toyota factories, workers are cross trained and rotate jobs much more frequently than they would at a non-Lean plant.

      But, maybe I’m just being “cunning” by pointing out these truths.

  5. I am sorry, but this article is entirely misleading. It conveys very little understanding of lean. Lean is not a kaizan event. It is not any one technique or any type of event. Lean is a culture that must be practiced from top to bottom in the organization. It only emerges over a period of time and everyone learns how to learn, how to practice the scientific method and study changes in their process as they experiment with improvements.

    I have no first hand knowledge of how lean is being implement in Saskatchewan, and it is entirely possible that it is being poorly implemented. That is not uncommon. I am working with other Canadian health care organizations in which it is being well implemented, with total support and engagement from executives to home support workers.

    Don’t confuse what lean is, versus how it may be implemented in on location.

  6. Lawrence — Nice to hear from the Lean industry. The article doesn’t even mention what hospitals are diverting in financial resources to Lean consultants and trainers. It’s interesting that part of the Lean culture is involvement from top to bottom, which would imply an open culture. Yet the first thing you have done is dismiss the criticism of people who have experienced Lean in their work environments. We have heard not only from front line workers, but from senior managers, who are referenced in this BLOG post. Dismissing concerns out of hand is what happens to our members too in the Lean process, which makes the process highly suspect. If it works so well, why is it that Lean has been identified as a major psychosocial hazard in the workplace?

  7. Do you have a link to that study?

    “Lean seeks to take all control of the production process away from workers right down to dictating where you will put your pencil and prohibiting work station individualization.”

    This is not true. This is what many traditional “command and control” managers do in the name of Lean, but this isn’t the Toyota approach. Lean is supposed to be a highly participative approach, where workers (regardless of their industry) DO have control over the arrangement of their workspaces, etc.

    Some organizations DO tell people where to put their pencils, but that’s not really Lean in spirit or principle.

  8. The study comes from the European Agency for Safety and Health at Work (2007) Expert Forecast on Emerging Pychosocial Risks Related to Occupational safety and Health (No. 5) Brussels, Belgium. How can you say what’s “true” given there is no “correct” outcome in Lean per se? If the outcome of a Kaizen event was to glue the pencils to the desks, then that would be the outcome, wouldn’t it?

  9. The goal (outcome?) of a Kaizen event should be to solve a meaningful problem. I’m not sure what problem “gluing pencils to a desk” really solves. What you describe sounds like a very badly done Kaizen event, in my opinion.

  10. Looking at that European OSHA report, they are suggesting that people in a “lean” organization have lower job security. I could show you data from a U.S. hospital I worked with where the anonymous employee survey data showed a huge INCREASE in job security and other job satisfaction factors — in part because the laboratory technologists and staff were engaged in improvement (they were finally being heard through the Lean process) and they were making great improvements to turnaround time and patient care. There was, by the way, ZERO involuntary job loss associated with this effort.

    Some people can do any number of nasty things, unfortunately, in the name of “Lean” but it’s not really Lean if it’s creating more fear and it’s not really Lean if it’s just about bullying people into doing what the managers want them to do.

    • Discouraged Employee

      We are in the process of going thru the Kazian Lean in our Saskatchewan Health Care System. Is part of the Kazian Lean to bully it’s Senior Employees? This seems to be what’s happening in every department to the point of staff being afraid to come to work. Why is it that this is even brought to Sask Health Care system for $39 million when the consultant John Black three times told us this system does not work on Publicly funded Health Care????? Something is seriously wrong with this entire process!

  11. I think you missed the point. Nobody is gluing pencils to desks. The point we were making is you can’t just take any stupid outcome and say it’s not Lean, when the process could lead to an infinite number of outcomes depending on who is involved.

  12. I think that the “infinite number of outcomes” is one of the beautiful results of a Lean environment. Where I work, we, the front line staff, are given the chance to “fix” any of the myriad problems with process that we come into contact with on a daily basis. Communication passes up from the grass roots of our system to the loftiest branches and back down again.

    Sometimes, the change dosen’t work, or even makes things worse, but as Edison said (and I am paraphrasing), “I didn’t fail, I learned 10,000 ways not to make a lightbulb.” If one exeriment dosen’t work, we go back to the drawing board and try again. When a plan does work, it is a beautiful thing. We have error proofed many of our processes creating a safer environment for our patients, made everything much more visual, and have cut down on accidents, near-misses, and medical errors.

    Though it may be a little more work focusing on quality improvement along with our normal responsibilities, we now work in an environment where my employer actually cares about improvements that we want to make, and more importantly, helps us to enact the change. Patients report that our staff has much more one on one time with them, our patient adequacy scores have risen dramatically as have our patient satisfaction survey scores. Though we were never a “bad” place to be, I couldn’t imagine going back to our pre-lean ways.

  13. Here is a collection of articles criticising Lean.

    Particular attention is paid to the industrialisation of services.

    http://www.thesystemsthinkingreview.com/index.php?pg=18&backto=1&utwkstoryid=300

  14. Always nice to see a person with not training or expertise in a subject matter wiegh in on how awful it is… The data proves otherwise of course. Can it be done wrong? Of course. However when it is done right – the employees are more in favour of this program than just about anything else. I suppose a union rep wouldn’t be doing their job unless they were trying to drive a wedge into anything that actually had their membership and the management team successfully working together without involving them.

  15. Well, John, certainly no shortage of either ego or anti-union animus in those comments. All the Lean apologists take this same elitist view, that if it doesn’t work it is the fault of the practitioners. Evidently there are a lot of faulty practitioners, no? Here’s another tip — try proofreading your comments before ranting about the lack of training or expertise… “a person with not training…”? “weigh in”

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