Have you ever had one of those moments when you realise in a conversation that the thing you thought you had been discussing animatedly with someone else using the same words and terminology suddenly reveals itself to be a conversation about two different things entirely, that just happen to use the same words. This is increasingly how I feel when hearing others use the word ‘lean’ when talking about improvement approaches, tools and methods in health and care, yet the concept, ideas and practices being discussed seem to me to be the antithesis of what ‘Lean’ thinking is all about. Our mental models are different. (Note the different capitalisations there for differentiation in this blog). The problem with this word ‘lean (Lean)’ is that it now means so many things to different people.
Examples at the moment include ‘we didn’t have enough PPE because we ‘leaned’ all the fat away’, and ‘we needed ‘just-in-case’ processes instead of ‘just-in-time’ ones (JIT)’ or that ‘lean is for simple, routine processes, like in manufacturing; not something with as much complexity and diversity as health and care’, which is just another way of saying ‘we don’t make cars’. The second phrase also inappropriately conflates JIT with the manufacturing trend of the 1990s onwards beloved by those ever wanting to reduce cost: offshoring, which really badly misses the point of what exemplary JIT looks like (see this for excellent explanation). The best example though, if you really want to set me off, is always ‘well it’s all about people in healthcare, that lean tool, it’s all about machines not people.’ Not only does this kind of phrase present Lean inaccurately as a tool, it also suggests that Lean isn’t about people, cause I presume that no-one has to design and operate any of those machines or service customers in manufacturing? And that sentence suggests to me also a belief that Lean doesn’t do ‘social’ or ‘relational’ change, only ‘technical’ change, never mind that Lean is ‘socio-technical’. Nothing really gets my goat more than this complete mis-understanding, mis-interpretation and possible mis-application of Lean thinking than this. (Yep, this is one of my triggers).
So what do I think Lean is then? (Your view might be different that’s ok, I’m not trying to have a row). So for me (and this is not exclusive or exhaustive):
1. Lean is a way of thinking, a mindset, a belief system that everything can always be improved no matter how good it already is; there is always a way to ensure better quality; whether you see that as safety, timeliness, equity, patient-centredness, effectiveness or efficiency. (As it is a mindset, in my mental model, it follows that it cannot be a tool, unless you consider mindsets to be a tool; it also follows that you can’t be ‘too lean’ cause what does that mean for a mindset? And that you can’t be ‘leaned’ as it isn’t a thing that will be finished at any point ever).
2. Lean rests on two essential values: a) Respect for people and society and b) Continuous improvement (eg through the removal of waste, or adding more value)
3. Lean thinking draws from the lessons learned by observing the Toyota Production System (TPS) but it is not the same as it. It is a management philosophy and system derived from TPS which through Toyota engineers such as Ohno and Shingo, drew from many quality pioneers and programmes including Juran, Deming, Shewhart, Feigenbaum and the ‘Training within Industry’ programme, as well as trips to Ford, Morris Motors and other facilities by Toyota Leaders.
4. Lean is not mean. Please read Prof. Bob Emiliani’s book on this if you want really meaty thought on this. My view is that if people have ‘cut to the bone’ and have branded that as lean, and cut jobs and generally speaking made things very difficult, that is not in keeping with Lean values, particularly Respect for People (see point 2). This type of ‘lean’: cost cutting has been described as ‘Lean in Name Only’. Others even more harshly call it ‘fake lean’. I’ve been generous and just not capitalised the first letter. Worse still many experienced Lean sensei now have stopped using the word ‘Lean’ and have distanced themselves as it has been so ubiquitously badly practiced.
5. Lean is in a way just a brand name for the mindset/approach, it has much in common (and some differences, else why have different brands) with many other improvement ‘brands’ including six sigma, lean sigma, IHI-QI, TQM and even action learning. Indeed much of action learning’s early thinking developed from the quality circles used in TQM at Toyota and elsewhere (Boshyk & Dilworth, 2010). See my improvement brands blog for more). When I learnt this stuff, tbh we didn’t really differentiate any of them, we learnt the principles and the different names, well they were all there to learn about in the round, as part of improvement practice. Who cares about the name as a pragmatic engineer would say, just think it through, what works? And yeah there are a load of tools associated with a Lean, like the 7 (or 8) wastes, or a run chart, but they are just as helpful with the other brands too, they are not exclusively ‘lean’ tools. The big ideas in Lean: nemawashi, genchi-genbutsu, hansei etc. are for me what make the big difference and what make Lean a mindset about learning rather than a toolkit for improvement. (I’m not explaining those concepts here, blog would be too long, wiki has good short explanations if you are not familiar).
6. As Lean, in my mental model, is a way of thinking, it needs practice and is suitable as a way of thinking for lots of different types of problems including complicated and complex ones. Some authors also argue its problem solving way of thinking is ideally suited for complex, and uncertain situations, helping to support rapid experimentation and learning everyday, and I agree with that, it mirrors my experience. It can also be argued that Lean was developed to support the resolution of complex problems and plan next steps, as a consensus taken by a team, together. (If I’m honest, I also find it quite disrespectful to many former colleagues working in very high risk, high variety, small lot/1piece flow diverse plants, that have been improved over and over to move away from mass manufacture when health care communities sometimes downplay manufacturing processes as simple and nowhere near as complex as healthcare).
7. Lean is designed to make processes run by humans fail. Yep that’s right. No, to improve them, you say? No, definitely to make them fail – in a controlled, safe way. To find out what happens if this process runs slower/faster? What happens if we reduce this stock level or this cycle time? What happens if we don’t do this task or workaround? Can we safely remove it? What happens if we introduce more variability here? What happens if we try to do this with 1 less person, (say if they have self-isolate from the plague)? What can we learn by doing these things … so that we can then improve, and build our resilience in learning these things? Sometimes I wonder if some only partially see the principles of Ohno’s ‘Rivers and Rocks’ meaning that they can see the rocks after the change but don’t ‘see’ the next step and conclude Lean doesn’t work, rather than see the bigger, second learning loop being enacted, i.e. the part where we learn to remove the rocks and see the waste they are hiding, not just get around them.
8. And finally, but most importantly, people, people, people. Lean is a mindset and a way of thinking, it isn’t possible to be Lean in any shape or form without the human factor and respect for people – people do the Lean thinking. People imagine new ways of being, making sense and solve problems together not processes. People make and enact decisions for new stock management systems that may or may not be appropriate for the use of JIT systems or MRP (materials requirements planning), and these decisions may lead to harm.
It is people who have to learn, and practice Lean thinking as a habit so that ‘Lean-as-imagined’ is much closer to the ‘Lean-as-done’. Fidelity and understanding matters for improvement practice. Improvement capability and associated performance won’t grow otherwise imho. Without better understanding, the common misconceptions, misunderstandings and misapplication of ‘lean and Lean’ will continue. None of that helps us to improve care for patients and service users, and to improve working lives and fulfilment for staff.
Ps. Addendum, I didn’t write it in this but on reflection, there should have been at least one more point… that is about who defines value in Lean. The customer defines value, or whatever name you want to use, the service user, the consumer, the resident, the patient. Lean is trying to continuously improve the safe, effective, resilient, reliable, high quality, timely (what ever other words you want to use to define quality) delivery experience of customer defined value to the customer. It follows then that value is not defined by others … including staff and stakeholders, including commissioners, regulators, contractors, professional bodies, trade unions etc. Very tough to enact authentically imho.