FEATURE – Is there such a thing as a lean plan? There is, but it's not an off-the-shelf solution that will appease your boss – and that's why traditional, bureaucratic organizations continue to exist.

Words: Michael Ballé, author, executive coach and co-founder of Institut Lean France; Eve Parier, Hospital Group Director, Assistance Publique – Hôpitaux de Paris; and Dan Jones, Chairman, Lean Enterprise Academy

_{"If you don't try something, no knowledge will visit you"}

_{- Lean CEO Art Byrne, quoting his sensei -}

How do you revitalize a 6,000-people hospital? To those CEOs who refuse to bury their heads in the sand and are determined to face the challenges of today's healthcare, it is clear that the current system of management has reached its limits.

On the one hand, medicine keeps harnessing technological advances to make further inroads into figuring out difficult cases and curing complex diseases. Yet, on the other hand, some of the basics of patient care are being lost due to bureaucratic friction, disaffected staff and legacy systems. Complexity costs are rising to a degree that every extra patient cured (sometimes of a very exotic illness) increases the systemic cost, at a time when politicians are under pressure to reduce social expenses and tempted to slash budgets and reform "the system" to make it more cost-effective (often achieving precisely the opposite).

The need to breathe new life into hospitals is becoming urgent as demographics shift towards aging populations with a sedentary lifestyle – with the explosive demand in healthcare that comes with it. The question is whether we decide to do it the traditional way or the lean way. The former entails administrative reform, lawmaking and large-scale, top-down projects, whereas the latter concretely helps each nursing and medical team to face and solve its own problems, orienting them all towards improving and accelerating patient care(so that the whole structure focuses on quality and working smoothly rather than getting bogged down in expensive, absurd and impossible solutions).

To an open-minded hospital CEO, lean is an attractive option. As a set of practices, it has been well established for years now and there are enough success stories (as well as instructive failures) to give the approach solid credibility – no matter how much some consultants try to muddy the water.

Still, lean can often feel like faith healing. True enough, the recipe for lean success hasn't changed in the 20 years since one of us (Dan) co-wrote Lean Thinking. In the book, we were taught to start from the top, find a sensei we can work with, and drive lean through the line by involving ward-level teams in discovering what improving care means at their level, and relentlessly look for value and improvement in its delivery. But even though this seems completely straightforward to the CEOs who have done it, those who haven't find themselves staring into an abyss of misunderstandings. To make matters worse, the leaders who have succeeded confirm that they had all gone through the same learning curve, which reinforces the perceived cultish-ness of lean, with "gurus" and initiation rituals.

Lean, however, is no cult – it's a method, with its own concrete learn-by-doing exercises and its own specific theory (the fabled Toyota Production System, which it would be more accurate to call Thinking People System). And this is part of the problem: like all methods, it needs to be learned.

Sadly, over the past two decades, an endless number of CEOs have tried to assimilate traditional "operational excellence" programs and rolled-out initiatives based on applying lean "tools" to every process (VSM, stand-up meetings, 5S, and so on) with little to show for it beyond the early low-hanging fruit results (and large fees to consultancies). Those who did succeed with lean, however, have sooner or later realized it is a different way of thinking about problems, not an organizational method. Learning lean thinking gets you to face your problems, frame them in a way all teams can understand and form solutions from the team's improvement efforts: as they learn, you learn.

FIGHTING BUREAUCRACY

As any other top leader, a hospital CEO is stuck between the hammer of its financiers, healthcare's upper-echelon administrators, and the anvil of powerful players, such as medical department heads, administrative directors or union representatives. The CEO keeps making trade-offs in terms of allocating resources and energy to such and such project, mostly to the detriment of other "burning" (according to the concerned stakeholder) issues. A critical part of the job is being able to explain clearly and convincingly how these trade-off decisions are made and why. Lean's try-and-see-what-we-discover approach clearly doesn't help in that respect.

Furthermore, a hospital is as large as a village – sometimes even a small town – and politics inevitably plays a big role in the running of the show. The hospital staff is used to process changes outlined by the top, with a supervisory committee and with a detailed action plan for each of the concerned departments and controlled execution. The idea that each team will practice kaizen and that, as a result, we will discover what our real issues are and somehow transform the entire system seems pretty naïve.

Worse, the lean notion that the system generally performs reasonably well (after all, the people who designed it mostly knew what they were talking about) but that our wrong-headed daily decisions and projects stop it from working is profoundly counter-intuitive (some find it insulting). Administrators generally share the belief that processes are broken and their job is to make them work somehow. The lean point of view that processes are OK to start with, and that the job is to discover the misguided assumptions and actions that make them fail, is a direct challenge to their very identity as "saviors" of a rotten system.

The fact is that, from a lean point of view, department heads are not short of weird beliefs about efficiency, such as getting a team to work 10 straight hours to up the OEE of operating theatres (and thus overburdening both doctors and nurses), or the logistics department delivering a week's worth of supplies at a time to wards to reduce their headcount (and filling the wards with stocks), or not fixing small material issues right away and waiting for refurbishment projects (and batching the fixing of problem, forcing wards to live with poor work environments), or even investing in more, newer high-tech equipment to make up for the poor usage of the existing machines. The list could go on forever.

The deeper issue here is that we can make two very different kinds of "correct decisions": the "make it work for the patient" decision, which is all about coordinating with other specialties to make sure that the flow of work to the patient runs without glitches and as fast and smoothly as possible, and the "make it work for the administration" decision, which makes sure each silo works as efficiently as possible, increases administrative control and optimizes line-by-line budgets.

As with any large (and bureaucratic) organization, the risk here is that institutional inertia will overcome the mission drive: in these cases, patients or customers tend to become alibis to do what we do, and, in extreme cases, hostages. Having said that, the latest brand of star CEOs (including Steve Jobs, Richard Branson or Jeff Bezos) preach a different lesson: give customer satisfaction your all, and the rest will follow – but this is still hard to hear for many. The upshot is that we don't have to redesign the blueprint of the entire hospital. We don't have to "transform" anything. We do have to go to the gemba systematically and teach people to conduct local kaizen efforts to identify the local leaders who want to make things work for patients (or customers) and not for the bureaucracy.

The bureaucratic dream is to create institutions that work people-free, where roles and rules are so clearly defined and thoroughly applied that who is in the job doesn't matter. The first lean insight, however, is that organizations are run by people: who's in the job does matter. Also, most people want to do what's right for the patient or the customer, but a few bureaucratic-minded leaders won't let them.

WHAT'S THE LEAN PLAN, THEN?

Once we've identified the few local leaders who take naturally to kaizen, the next step is to connect them. By creating a community of practice of kaizen-oriented leaders we also establish trust connections across silo barriers – these guys will naturally take to each other because they share the common purpose of doing what's right for the patient and adapting the organization accordingly – not the other way around.

Establishing these person-to-person trust links across functional barriers does a lot more than you'd think. It doesn't reinforce process efficiency in a bureaucratic way (most of the time, when managers "fix" a process, they just add a layer of bureaucratic control or overcapacity that hurts rather than helps), but it lays the foundations for the creation of a community devoted to making the process work for patients. And then you get lucky. As with playing tic-tac-toe – trying to align these circles or crosses – opportunities will arise naturally to align smart ideas and make things better.

Now it's time to do your job and get interested in those early successes, put them on a platform, explain to the rest of the organization that this is what you're looking for and promote or support the few local leaders who make good process,

to orient the rest of the organization to the common purpose of treating patients better without overburdening staff.

As a core community of lean thinking leaders comes together, the magic of lean kicks in: mindless bureaucratic decisions are contested, there are less stupid costly mistakes and screw-ups, "Situation Normal All Fouled Up" is no longer accepted and as a result quality of care goes up and costs go down.

No need to rethink or restructure the entire organization. Transformation will happen as you reach a critical mass of leaders who intend to work with each other to make the bureaucracy work for patients or customers and not for itself. And because processes are initially designed to work (when the bureaucracy intended to support these processes doesn't take over), the quality and flow of work will improve from the result of thousands of small local decisions all oriented towards the same purpose: better care of patients, greater support of front-line staff.

From a bureaucratic point of view, the main drawback of this lean approach is that you learn how to gather around you the best people to solve problems in innovative ways, but you can't tell beforehand what solutions they'll come up with. When your bureaucratic boss calls you in and says, "Don't just bring me problems, bring me solutions," you're stumped. You can't deliver a clever idea on striking PowerPoint slides to embellish the messy reality of life through simplistic rationales and seductive ideas.

So, is there a plan? Yes, there is. Here goes:

1. Go to the gemba everywhere to see concrete kaizen efforts;
2. Spot the leaders who "get it" and come up with great kaizen initiatives to improve the quality of care;
3. Connect them together in a community of practice;
4. Link them together through pull systems to tighten the interfaces;
5. Challenge and support them as they tackle wider cross-functional issues;
6. Create a critical mass of people who know what they're talking about and are keen to make things work for patients and staff;
7. Keep orienting towards improvement and focusing on learning.

The beauty of lean is that it requires no great organizational change ("lean" consultant-driven initiative that start by reorganizing are suspect, and stem more from traditional than lean thinking). The real change is in attitude.

You'll see things start shifting: when patient issues are mentioned more often (and more specifically, real persons rather than "the patient") in management discussions; when the obstacles encountered by ward teams are discussed more freely with less fear of "the messenger being shot" and lead to greater gemba observation; when initiatives from ward-level teams lead to changing proposals from department heads, who start to see themselves as supporters of the teams' efforts rather than enforcers of bureaucracy; when collaboration across functional silos happens more often and more spontaneously (without the need for institutional projects) as personal trust builds up; and when outcomes get as much air time as daily output decisions, and asking "why" repeatedly leads to deeper thinking.

The lean plan is both common sense and workable – but it does not deliver ready-made solutions to reassure the boss. This is why the bureaucratic approach keeps dominating large organizations: it pretends the chaotic, fast-moving, connected world we live in is static and manageable. It's stupid, but safe career-wise.

IN SUMMARY

Lean remains a leap of faith, but it is not as big a jump into the void as it may appear. Lean practice is by now well established, and although there are still many consultants selling tool-only programs, there are enough CEOs with real lean experience to get one's bearings. Furthermore, real lean doesn't start with any organizational change, restructuring, transformation or whatever program, so the real risk of going to the gemba and supporting teams' kaizen efforts is low. Finally, the vast majority of people working in hospitals are personally committed to better care for patients, even when the bureaucracy gets in the way. When you offer them a way to rethink how they work and improve, they'll surprise you – some will even discover new ideas no one has thought of yet.

Sure, the door to lean is narrow, but the room for improvement is immense. The key lies in trusting the good sense of the teams themselves and learning to practice lean thinking every day at the gemba. This is the real lean secret to making elephants dance.

_{THE AUTHORS}