My hopes following the Virginia Mason Gemba Walk

A couple of weeks ago now, I watched on (slightly horrified and yet hopeful) as Jeremy Hunt MP and current Secretary of State for Health in England, went with a few other senior NHS and Health leaders to visit Virginia Mason in Seattle, USA. I have to commend him and his team for getting out there to the Gemba and seeing the actual processes, understand the work, ask questions, and learn for themselves.

Whilst I have visited many healthcare organisations trying to implement lean thinking, I haven’t had the privilege of visiting Virginia Mason. I have heard many times that it is one of the few healthcare organisations who have really understood the principles of lean and tried to apply them robustly, seriously, respectfully and successfully, with courage. Over the past ten years, it has delivered significant benefits for patients in safety, cost, delivery and experience, through their adoption of the Toyota Production System and adaption of it into the Virginia Mason Production System (VMPS).

This trip made a number of policy announcements and articulated new goals for the NHS to emulate the success of Virginia Mason on Patient Safety. Few can deny that the NHS still has significant improvements to make in this area. What I hope for from this trip however, is much more than some new patient safety goals, with centralised improvement resource supporting local champions able to support delivery and maybe a flurry of healthcare organisations trying out some lean tools that will deliver some safety improvements.

What I hope for, is that the learning from the Gemba walk will have generated deeper knowledge of lean healthcare and the level of self-discipline, humility and difficult decisions that it means for organisations, their stakeholders, their staff and its leadership (clinical and managerial), and what support and improvement capability might be needed. I also hope they took away that lean isn’t really tools and the elimination of waste, although at a surface level it can look like that, but a focus on making value flow for patients across care pathways in a way that is respectful of the patient, their families, their communities and of staff and focuses on delivering what matters to the patient, and importantly a way of thinking how everyone can contribute to make it better, every day.

Unfortunately, lean is often practiced as a set of tools, it is hard whilst people are learning about lean for this not to happen sometimes, I know I have fell into this trap myself on occasion. I’m sure many of you have heard of value stream mapping, 5S, 7Wastes, 7Flows, Ishikawa diagrams, Rapid Improvement Events (RIEs), or as Virginia Mason calls them Rapid Process Improvement Workshops (RPIWs) etc, these tools can and do deliver great improvements and there are great teams using many of their ideas across the country, for example in modules with the Institute’s fabulous Productive Series. But that is all they are, tools, and like any tool they need to be used and applied with care, skill, caution and thought. Unfortunately on many occasions I have seen these tools applied in isolation, without supporting infrastructure, out of context, or inappropriately for direct cost reduction at the expense of quality, usually by well meaning ‘experts’, some would say ‘toolheads’ and practice what others would describe as ‘fake lean’ or ‘L.A.M.E.’.

The hope I have, is that the entourage on the visit see past the fantastic visual management displays and tools and artefacts, used to highlight waste and non-conformance to standards and provide transparency and communication, and notice the subtle but significant thinking behind it, the supporting ‘system’ infrastructure, the focus on finding root causes of problems, making value flow with patients, creating inclusive behaviours that challenge and support improvement activity as routine whether as daily problem solving or RPIWs. New healthcare safety goals, are needed, but the ability to improve and keep improving locally every day for patients, needs more than measurement. It needs resilient and long-lasting leadership, constancy of purpose, time and space for teams working with patients to try out new things to make value flow, it needs to be able to get it wrong sometimes and learn from it without being labelled as ‘failing’ and it needs support and resources to build capability and skills locally, to not just deliver current goals but to keep moving the bar and delivering more than the ask. I hope on this Gemba walk the actual processes were really seen and understood and that there is a thirst for more learning about healthcare quality improvement.


  1. Did not Virginia Mason Institute badly fail an inspection by the USA Government ?and just a thought if the Virginia Mason “Lean Medicine”theories are based on the Toyota Car Co.Lean Production Methods did not Toyota have to recall 11.5 million cars last ?

    • Maybe they did, being lean doesn’t mean being perfect, it means listening to feedback and improving everyday. I’m guessing they took the regulatory feedback on the chin and got on with improving their services

    • Here is more detail about the failed inspection at Virginia Mason:

      As to Toyota — they are not perfect. Every automaker recalls vehicles. That doesn’t mean the vehicles were deadly. The sad reality is that defective healthcare kills more people than defective automobiles each year — by MANY orders of magnitude.

      The Toyota principles and approaches should be evaluated on their merits. In what world is it better to, for example, NOT engage everybody in improvement? On top of that, the Toyota leadership mindset is that “It’s the leader’s responsibility to create a work environment in which people can be successful.” As opposed to healthcare, which far too often sets people up to fail.

      I know which culture I’d rather work in. That’s why I’m passionate about trying to help healthcare leaders change their approach. But, if people don’t want to change, I can’t make them.

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