Welcome to the Book!

This book is a collaborative project that took shape over time, with different authors contributing chapters and essays about the early days of their Lean journeys. That includes people with experiences in Lean manufacturing, Lean healthcare, Lean Startups, and other settings.

As the editor, I wrote Chapters 1 and 2 as a way to inspire others to share their stories and their honest reflections about their own personal Lean journeys. As the subtitle says, this is all about “Learning How to Learn How to get Better, Better.” How have we learned about Lean through our own practice? Have we gotten better at how we help others get better? This is a book of those stories and reflections.

I asked people to contribute chapters that are first-person stories, with the emphasis on mistakes and honest reflections, not a chapter about how great they are with Lean.

This book evolved over the course of a year, with submissions being added to the electronic book through the LeanPub.com platform. Those who bought the book early received updates as chapters were added over time.

Now, as of February 2017, the book has been released as a Kindle eBook and a paperback book.

I’m really excited that this book now contains chapters by 16 authors from different industries (healthcare, manufacturing, services, government, and consulting) and from different countries (the U.S., England, Canada, and Scotland). Some contributors are published authors of books and some are sharing reflections for the first time in this form.

All author royalty proceeds are being donated to the Louise H. Batz Patient Safety Foundation, a Texas-based non-profit that does excellent work in educating patients and hospitals about patient safety improvement. Their publications, like the Batz Guide for Bedside Advocacy are really making a difference in the lives of patients and staff. Over $1000 has been donated, as of December 2016.

If you’d like to donate, please visit their website.

Thank you for reading! If you reflections you’d like to share, please email Mark@MarkGraban.com

Mark Graban

July 29, 2015 Updated February 11, 2017

Update April 18, 2017 — this book is also available in audio book form (at least the first half of the book is available now). Learn more or buy it at www.leanpub.com/practicinglean.

Update July 1, 2018 — this book has raised over $4,000 for the Batz Foundation!

Chapter One - Mark Graban

Originally written in 2015, edited December 2016

Note - Some of the Lean Blog posts referenced in this chapter are included in Chapter 19 of this book

Bio: Mark Graban is the author of the Shingo Research Award-winning book Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement (now in its third edition). Mark is also co-author, with Joe Swartz, of Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvements (also a Shingo Research Award recipient) and The Executive Guide to Healthcare Kaizen. His latest book is titled Measures of Success: React Less, Lead Better, Improve More

He is a board member for the Louise H. Batz Patient Safety Foundation, which is receiving all proceeds from this book.

He serves as a consultant to healthcare organizations through his company, Constancy, Inc. and is also the vice president of innovation and improvement services for the technology company KaiNexus. He has focused on healthcare improvement since 2005, after starting his career in industry at General Motors, Dell, and Honeywell.

Mark has a B.S. in Industrial Engineering from Northwestern University, an M.S. in Mechanical Engineering and an M.B.A. from the Massachusetts Institute of Technology’s Leaders for Global Operations Program. Mark and his wife live in Texas. He is also the founder of www.LeanBlog.org. You can find him on Twitter as @MarkGraban.

Identifying Problems is only the First Step in Improvement

It’s sometimes easy to find fault in what others are doing with “Lean.” Sometimes, we criticize because we don’t recognize what they describe as “Lean” in their organization. Maybe it’s natural for an experienced Lean thinker to identify problems, as we’re prone to want to fix things and coach people, even if we have to speak hard truths.

For example, we might see process improvement leaders (or trainers) who focus only on Lean tools (or just a particular Lean tool, such as 5S). Or, we might get frustrated when we see people just chartering a few projects or pushing pre-determined “solutions” on others, while not even working on changing their management system and culture.

If you dig deeper, you might find that their limited or ineffective approach to Lean is due to ignorance, a lack of experience, or a lack of proper coaching. Can you blame people for what they don’t know? You can’t blame somebody if they were taught the wrong things, but you should challenge somebody who doesn’t make the effort to educate themselves after declaring that Lean seems “simple” or just a matter of “common sense.”

It could be that you have good people who are trying but are working under leaders and executives who don’t support the idea of changing the culture (or they’re not aware of the need or the possibility). Or, the leaders and executives are the ones who don’t understand Lean (and sometimes, don’t even try).

We, too often, hear about executives who use Lean as a cost-cutting tool. They lay off employees, which destroys morale and hurts customer service, doing so while collecting big bonuses. It’s likely these senior leaders don’t share the same Lean values that we appreciate and they, quite possibly, never will. The idea of a transformative “Lean journey” might be a pipe dream, if the senior leaders see employees as a “bunch of warm bodies” who are just a cost on the P&L statement instead of viewing them as human beings to partner with and develop.

Or, we read (in major business publications like the Wall Street Journal, no less) about a company’s Lean office that has a self-proclaimed “5S cop” who does audits to make sure employees don’t hang sweaters on the back of chairs and don’t have any personal items on their desks. We read about another organization that bans “inactive bananas” from employees’ desks as if that does anything to improve the company’s performance.

Employees in these companies are understandably annoyed by clumsy attempts at 5S. Unfortunately, they come to hate the idea of Lean instead of seeing Lean as something that provides job security and allows them to feel pride and joy in their work. When Lean is just about putting tape outlines around staplers on individual desks, then Lean rightfully becomes a punch line. That makes things harder for the rest of us.

Inexperience and Ignorance or Incorrect Knowledge?

There’s inexperience, which we should probably be more tolerant of, and then there is flat-out ignorance or misinformation, which we should stand to correct. It’s tempting and easy to criticize a “Lean Six Sigma Master Black Belt” who has such little understanding of Lean that he would actually say, in a presentation on stage, that applying Lean to a quality problem would somehow “speed up your quality issue and make bad stuff faster.”

It’s unlikely that any of the people in these stories are stupid or evil. They just don’t know any better or they’ve been taught things that are untrue and harmful. We can criticize what was said – without personally attacking the individual. There’s no room in Lean for terms like “toolhead” or “concrete head,” if this is supposed to be all about “respect for people”.

It’s easy to find fault with beginners while forgetting one’s own early mistakes. I’ve been studying, practicing and teaching Lean for over 20 years in different settings. Whether you have 20 years of experience with Lean, ten years, or even five, you have experiences and life lessons that probably make you a better Lean practitioner than a beginner (or the willfully ignorant senior leader or “Lean Sigma” whatever belt who chooses to not even learn about real Lean).

Lean Means Always Learning

These years of experience hopefully make you a better Lean thinker than your own earlier self. That’s because learning and mastering Lean isn’t as simple as reading one book or taking one class. Heck, given some of the mistakes and misunderstandings that seem to be common out there, you’d wonder if some of these “Lean professionals” have even read a book or taken a class. Maybe they just read one. A little bit of knowledge can be a dangerous thing.

The best Lean practitioners are continually learning. We’re reading new books, re-reading old ones, attending webinars and conferences, listening to podcasts, and doing everything we can to better understand Lean and the Toyota Production System. We’re also learning by doing, putting knowledge and theory into practice as we work with staff and leaders, getting better at teaching and coaching, bettering ourselves and practicing our craft. We reflect on our successes, our failures and those times when things were just OK. We challenge ourselves to think better and act better, continually improving what we do, practicing what we preach.

If We Keep Practicing Lean, We’ll Get Good At It

Lean concepts might seem simple, but Lean is not an easy craft. Being an effective Lean leader, facilitator or practitioner requires more than books and classes – it requires people skills, judgment and wisdom and other things that can often only be developed over time.

It’s probably not realistic to expect people or organizations to be really good at Lean right away. It requires practice. Does a child (or an adult) sound good the first day they are playing a new instrument? Probably not!

I think that word – practice – is important. Attorneys get to “practice law.” Physicians are allowed to “practice medicine.” Think about that if you’re a lawyer’s first case or a surgeon’s first procedure. Try not to think of the sound of an awful, screechy violin being played by a new student.

There are many imperfect words that get used to describe a person or an organization that is utilizing Lean methods and mindsets:

• “Doing Lean” (which incorrectly implies it’s just action and not a different way of thinking)
• “Lean Thinking” (which implies action isn’t necessary)
• “Implementing Lean” (which mistakenly implies that you’ll be done at some point)
• “Getting Lean” (which also suggests there’s an endpoint or that it’s just about the results)
• “Leaning Out That Organization” (which sounds like something that’s done to the employees instead of done with them)

One of my earlier healthcare clients pretty much banned everybody from using the word “implementation.” I resisted that at the time, but I now see their point. That word bothers me more now than it did then. I’m progressing. I’m getting better… I hope.

I’m practicing.

We’re all practicing Lean.

If we keep practicing Lean, someday we’ll get good at it. Or, each day we’ll hopefully be better than the day before. Each year, we’ll be better than the year before.

In my own early days of learning and practicing Lean, I had a lot of misunderstandings and I made a lot of mistakes.

• I was taught a number of tools, so I tended to think about implementing tools.
• While I had mentors teaching me some of the mindsets, I didn’t have the opportunity to work in a true Lean culture… it was always in companies in transition toward Lean.
• I didn’t always involve front-line staff, as I was encouraged to come up with answers and solutions as an engineer.
• I was too focused, at times, on doing instead of teaching others.

During those various attempts, I had the best intentions. I was trying to improve quality and safety while creating a better workplace and aiming for long-term success for the companies I worked for and their customers. I was trying my best, but I sometimes failed others in the process.

I think we can reflect and admit mistakes without beating ourselves up. I know I’m not alone in lamenting past Lean mistakes. I’ve heard or read luminaries in the Lean world admit some of their own past mistakes. I admire their openness and honesty. That gives me the courage to write this chapter.

For example, at the 2015 Lean Healthcare Transformation Summit, Jim Womack made a parallel between healthcare and Lean. Womack, one of the most prominent people in the Lean world, told the audience, “You can treat a patient with drugs, but drugs don’t get at the root cause.” Womack admitted that he had, in the past, been a “drug pusher” for Lean tools. Womack now realizes that organizations need to think more systemically and change the way we manage instead of just doing more Kaizens and using more Lean tools.

In his outstanding book On the Mend, Dr. John Toussaint reflected on the early days of Lean at ThedaCare, when he was CEO. Today, ThedaCare has been practicing Lean for 13 years and is considered one of the world leaders in the use of Lean to improve patient care and reduce costs. However, in the early days, ThedaCare relied exclusively on weeklong Rapid Improvement Events. Toussaint wrote:

We were frustrated because the transformation seemed to be stalling or rolling backward in some areas. Sustaining the gain was a constant struggle and it did not seem to matter that our staff knew the lean tools and were pressing forward with RIEs (Rapid Improvement Events) and PDSAs.

Finally, some brave soul said to a senior executive, “How are we supposed to change when you keep managing the same way?”

To ThedaCare’s credit, they used the Plan-Do-Study-Adjust mindset to “study” how things were working. They “adjusted” by supplementing their RIEs with a process they call “continuous daily improvement.” More importantly, they also created a new management system that would help change the culture in a more meaningful way, as described in the book Beyond Heroes, by Kim Barnas.

Virginia Mason Medical Center, also considered a world leader in Lean healthcare, reported that, back in 2004, they had “backsliding” after 60% of their Rapid Process Improvement Workshops. This meant it was too “easy to slip back into old ways of doing things if there is a lack of accountability and follow-through.” They only sustained their new practices and results 40% of the time. But, by practicing Lean and getting better, Virginia Mason has improved its sustainment rates over time. By 2011, 90% of its projects showed sustained results after 90 days, but, still, only 50% held results for six or 12 months.

Jim Womack is, of course, one of the people who originally coined the term “Lean Production”. ThedaCare and Virginia Mason are great organizations. But, they’ve all gotten better with Lean over time. Nobody is perfect at the beginning, not even the world leaders in Lean. That’s an important point to keep in mind.

Is it Lame to Call Situations L.A.M.E.?

On my blog, I’ve been outspoken about criticizing incorrect or misguided things that have been said or done in the name of Lean or the Toyota Production System. My intent has been to educate people and to defend what I think Lean is all about. My criteria for “Real Lean” are the things that Toyota does and says or what respected Lean luminaries say, do and write. I run the risk of coming across as a know-it-all. I certainly don’t know everything. But, I know enough to know when something is factually correct instead of being merely a differing opinion.

A few years back, I went so far as to create a really awkward acronym, “L.A.M.E.”, which stands for either Lean As Mistakenly Explained or Lean As Misguidedly Executed. A union publication responded to one of my posts by saying the acronym, to them, stood for “Lean As Mostly Experienced.” Touché.

If a company is using Lean to layoff lots of people, many will criticize Lean, often quite publicly. They’re really criticizing the company’s actions, and probably rightfully so. We can explain that the company is not really keeping with Lean principles or practice… it’s L.A.M.E. instead. Or, if an organization is forcing employees to adopt a new “standardized work” method without involving them in the improvement process, that’s arguably L.A.M.E., as well. If a company is speeding up the work to the point that employees are getting hurt, that’s not very Lean. I think we have an obligation to those who came before us to call that out as L.A.M.E.

Along similar lines, Bob Emiliani, the author and professor, uses the term “Fake Lean” to distinguish bad practices done in the name of Lean from “Real Lean.” If an organization is just doing occasional Kaizen Events and isn’t engaging people in Kaizen as the practice of ongoing continuous improvement, that might rightfully be labeled as “Fake Lean.”

While it might be technically correct to label something as L.A.M.E. or “Fake Lean,” is it kind or nice to do so? Upon reflection, it probably is not. Is it necessary to speak out? Maybe. Is it respectful to call out bad practices? I’d argue it is respectful if we’re trying to help those who are being harmed or jeopardized by L.A.M.E.

Instead of just criticizing, is it better to take the patient tone of a coach or mentor? I like to think I’m a constructive mentor with people in person. I’ve never called a person or an idea stupid. But, I may have failed by shooting somebody a glance that might have suggested as such. We all have room for improvement.

By calling a scenario L.A.M.E., are we making the person involved in the story defensive, thereby possibly stifling their growth and development if they just retrench? What if the person who determined that employees shouldn’t put sweaters on their chairs because it looks bad is a conscientious – but inexperienced – Lean facilitator who is trying hard to learn and practice Lean? How patient should we be?

There are times I have probably been too harsh in my online writing. It’s easy to sit behind a keyboard and criticize. Maybe I should be more patient. Then again, perhaps some of the people behind these L.A.M.E. practices are choosing to be willfully ignorant of Lean principles. Does the criticism get through to them, or am I just preaching to the converted?

Let’s Reflect

My hope for this book is that we’ll celebrate the idea of practicing. I’m also hoping to inspire others to reflect upon being “bad” at Lean in our early days of practice and to get others to share their stories.

I’m hoping people will discuss questions such as:

• What did we misunderstand or not fully understand about Lean?
• What mistakes did we make?
• What do we wish we had done better?
• What lessons did we learn?

Sharing these missteps and reflections won’t necessarily help prevent others from making the same mistakes. And, I don’t think that’s the point. We learn from our own mistakes, and it’s probably necessary to go through that process. But, showing some humility and talking about our own mistakes might make others feel better about where they are at this point in their personal Lean journeys.

I’m certainly not perfect. I’ve made many mistakes, and I hope I’ve learned from them. I’m encouraging other contributors to this book to share their stories. My mistakes, from manufacturing and healthcare, are presented in Chapter 2. The chapters that follow will contain first-person accounts from others and their Lean journeys.