Zarbo on Lean in Healthcare: June 2022

Wednesday's Words of Quality,

Lesson #13: How to Implement Lean

Now you know a lot now about continuous improvement, Lean principles, tools and supporting management systems. But, in the words of John Wooten, “ it’s what you learn after you know it all that counts.” Here I share some basics of implementation for your consideration from our own experiences.

The ultimate goal is to move beyond application of improvement tools and projects to establish a new approach to work that incorporates the mindset of continuous improvement as an essential part of everyone’s job. This is the transformation of culture to achieve Dr. Deming’s encouragement that “quality is everyone’s responsibility.” Transformation to a Lean enterprise, where continuous improvement thinking and actions are embedded from top to bottom throughout the organization requires adopting a new business philosophy, process and supporting management structures to guide human behaviors for consistency of execution.

To succeed, Dr. Deming also cautioned that “quality starts in the boardroom”, or at the top of the organization. However, you can most definitely adopt a continuous improvement culture and behaviors in your own span of authority that will not conflict with existing business models. After all, who would not accept improvement of business functions, outcomes and financials.

The hierarchy of adoption and effort to achieve are shown below, with achievement of cultural transformation and employee engagement in the process of improvement at the top.

The 3 elements of cultural transformation from Toyota’s quality system, inspired by Deming, are reflected here.

When implementing significant change, it is important to remember that most people express enthusiasm, until it’s their time to change. In Deming’s words, “an important obstacle to continuous process improvement is the supposition that improvement of quality and productivity is accomplished suddenly by affirmation of faith.” This is the hard work required of leaders and managers to effect behavioral change.

In his book, On What Leaders Really Do, John Kotter points out that the effort of implementing successful change “ is usually a time consuming and highly complex 8-step process, never a 1-2-3, hit and run affair.” And that “managers who opportunistically skip steps or proceed in the wrong order rarely achieve their aspiration.” The 8 steps to successful change implementation are:

Make sure you identify the why, the burning platform for change that creates a sense of urgency. Then be sure to assemble your best team, as this is a team sport, with new leader, manager and employee roles and relationships that we have described to you in the training. Go to the passionate, willing and ‘early adopter’ phenotypes of innovators and adapters to form that first team. Then start small, walk the foothills before mounting larger expeditions. Tackle and eliminate the small stuff, leave the big monuments alone for now until you and the team get good at this and can present positive results to the rest of the workforce, demonstrating that the new way of working with a quality focus is winning and worth the effort. Communicate what you are doing and why, teaching the workforce along the way. Make your accomplishments visible in PDCA A3 story board walls, daily management boards, whiteboards, posted key learnings, and engaged employee recognition walls. Plot your successes graphically for all to see the before and after. Take lots of pictures because you won’t remember the chaos you left behind.

Attend all meetings because if it isn’t important to you, it won’t be important to them. Your presence is key and your encouraging words and suggestions go a long way to bring the next group of early majority, then the late majority of adopters along.

Develop your team leaders to recognize key opportunities to-

Improve & develop a culture of efficient, safer work
Emphasize “system” determines performance
Recognize teamwork is the cure
Require & know your metrics in workplace
Redesign work to minimize variation
Use work rules, improvement tools
Make effective use of the management systems

In our own Lean cultural transformation, the original vision, mission and values from 2006 have never varied, reflecting our constancy of purpose for continuous improvement.

Our goal from business cultural transformation then is to leverage a new management system.

As a leader intent on cultivating the soil for continuous improvement, it is important to keep in mind this checklist to address in advance as these key aspects defined by leaders are core to success.

Our 18 year Lean journey to a unique culture of continuous improvement in medicine, our lessons, failures and successes can be found documented in the following publications.