Lean Transformation and Culture Change

The “Lean” approach to process improvement—derived from the Toyota Production System (TPS) developed by Taiichi Ohno and others in the 1950s, 60s and 70s—continues to establish a record of success with healthcare organizations. At Virginia Mason Medical Center (VMMC), for example, sustained improvements to service, outcomes, and cost have resulted from the Lean “transformation” Chairman and CEO Gary Kaplan, MD, initiated at VMMC in 2001. That story is told in Charles Kenney’s Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience (2011, CRC Press). Kenney’s book offers excellent background and detail about the history and implementation of Lean at VMMC. Written in an engaging style, this book is a surprising “page turner” read.

Last week I attended a three-hour presentation given by Lean guru George Koenigsaecker to Atrius Health, an alliance of community-based medical groups in Massachusetts. Koenigsaecker has led 11 corporations, including Jacobs Vehicle Equipment and Danaher, through Lean transformations and serves as an advisor and Board member for Simpler Healthcare and Simpler Consulting.

In his presentation, Koenigsaecker emphasized the role of leadership in implementing Lean, pointing out that Lean requires adults to learn new attitudes and behaviors—a far more sustained and challenging leadership effort than getting everyone on board with new technology and processes. Success with Lean takes time and involves culture change. That is always challenging, but traditional Lean teaching, beginning with Toyota, did not include leadership training of the sort that interests us today. TPS was taught and fostered through mentorship, without documented leadership principles.

Koenigsaecker reports that Taiichi Ohno did all of what we now call change management at Toyota singlehandedly. The lack of delegation and documentation created a blind spot in future training and, ultimately, an opportunity for Koenigsaecker:

What are the leadership issues in making this happen? What are the problems you run into? What kind of changes do you need to make in terms of leadership style, approach, and activities to be successful? That was missing from the education I got from my master sensei. Over the years, I began to realize, maybe I can make a contribution in that regard.

Koenigsaecker’s presentation to Atrius was rich and thought provoking; I look forward to reading his book, Leading the Lean Enterprise Transformation, which will be published in October.

Culture change and change management were not the only concepts in this presentation with obvious parallels to the patient safety movement, where we often refer to creating a “culture of patient safety” and dealing with change management. Describing that culture change, Koenigsaecker said that Lean can become a way of thinking, even a way of life. He offered the following progression of Lean learning, used in an organization (not healthcare-related) that has been working on Lean transformation for many years. The learning happens gradually through five phases, which can take at least 6 to 10 years to accomplish in an organization:

  • Lean survival of self. You do Lean because you’re told to. You don’t believe in it.
  • Lean survival of work. Lean is a nice box of tools. You only require your team to do Lean because you’re confident of a good result (because someone else did it before you). Not convinced Lean is the right way to run the organization.
  • Lean belonging. You do Lean because everyone else is doing it. Still don’t believe it’s the go-to way to run an organization. You’re going through the motions.
  • Lean recognition. Doing Lean to excel. Your belief is that Lean is the right thing to do is situational.
  • Lean walk-the-talk. (Some organizations refer to this as Lean Zealots or Warriors). Practicing Lean as a way of life. It starts to affect your thinking. You are teaching and contributing to the evolution of Lean. Lean is not negotiable; it’s who you are; it’s how you do what you do.

Koenigsaecker admitted that #5 is “a bit of an odd thing,” leading at times to intolerance for other ways of working. “It’s who you are; it’s how you do what you do” is a way of describing what we mean by “culture.” In fact, this 5-point list also describes patient safety culture change: from reluctant, narrow compliance, to learning to use tools, gaining a sense of belonging, beginning to excel and develop belief, to having it (Lean or patient safety) become non-negotiable, fully part of who you are. I’ve wondered in the past why Lean seems always to be referred to as a transformation, but now I’m beginning to understand that the pairing is more than a cliché, more than a verbal tic. Perhaps we should also be talking about patient safety transformation.