Tools for Leaders

A (Very) Short History of Lean in North America and 3 Things to Make Some (New) History

A (Very) Short History of Lean in North America and 3 Things to Make Some (New) History

In 1996, Jim Womack – arguably the father of “lean” in this country – wrote a book as a follow-up to his first book, The Machine That Changed the World. This then-new book, Lean Thinking was the book that would change the face of manufacturing for a long time. In a 1996 Harvard Business Review article Womack and Lean Thinking co-author, Dan Jones, give us five steps to start thinking lean:

1. Define value precisely from the perspective of the end customer regarding a specific product with specific capabilities offered at a specific price and time.

2. Identify the entire value stream for each product or product family and eliminate waste.

3. Make the remaining value-creating steps flow.

4. Design and provide what the customer wants only when the customer wants it.

5. Pursue perfection.

So, where would we look for the things that we need to do to eliminate waste and make value (everything but waste) flow? Well, because Womack’s system was presumably extracted from Toyota and other Japanese automotive manufacturers, one has to look at the source of Womack’s and other lean thinker’s inspiration, what he called the pioneer: Toyota.  Toyota taught its employees to look for the seven classic wastes. Taiichi Ohno, in his classic Toyota Production System, says this, “The preliminary step toward application of the Toyota production system is to identify wastes completely.” (Take care to analyze the English translation, especially the words preliminary, step, toward, application.)

In droves, we flocked to see what Toyota was doing. There we saw the artifacts: pull systems—Kanbans, a pull cord that triggered a light and a sound to get the attention of supervisors – andons, leveled work cells, and lots of visuals. Some wrote many books on lean “tools,” the things we could see when we looked at Toyota: teams solving problems using material and information flow diagrams (what Womack called a value stream map).

Many of us eagerly read the books and ran off to put those things into place. We installed pull cords. We established Kanban systems, and, through the wonders of modern technology, we added technology to them, producing “electronic Kanbans.” And what was the result? In some cases, the improvements were real, dramatic and sustained. Some companies—the ones with an existing Toyota-like culture— received those tools like seeds and nurtured them to produce much fruit. But, as with many vogue management theories, many companies applied the tools, enjoyed a quick burst of improvement, but quickly slipped back to the old way, disenchanted with the results.

Time went on and when “it” didn’t work, “it” was retooled, now including something called Kaizen Events, eerily reminiscent of the Deming-inspired Process Improvement Teams of the ‘80s when management theorists were imitating what they called “Japanese Management.”  This time, though, they combined the “blitzed” improvement with the lean tools, and the results were better, but only for a short time.  These events – often facilitated by consultants – followed the five-step pattern offered by Womack which had the appearance of – if not the substance of – Toyota’s team problem solving.

The failure was simple: you can only imitate what you can see, and you can’t see the whole system. You can observe the artifacts of an Andon system, but can you observe the heart of the team leader responding to the Andon system rapidly because he considers a problem a blessing?  Or, because he knows that the real reason the andon exists isn’t to stop the line, but to keep the line moving.  You can observe the process a team uses to solve a problem, but you can’t grasp the development of that team’s culture: the way they attack problems, the way they think about problems and the reasons driving both.

Just to be clear, I don’t credit Womack with the early failures.  He was clear: you have to focus on culture and on solving problems.   I believe that Womack and Jones and their closest colleagues knew that a management system – something to manage and apply this new way of thinking – was required.

I do blame a few other things with the fits and starts and repackaging of “lean”:

  • our need to see immediate results at the cost of building sustainable foundations
  • our “let’s hire a consultant” to do things to us or for us instead of hiring coaches to guide us to “do it ourselves.”
  • our insane idea that one size fits all and that a “best practice” is our hopeful plan for improvement

So, what’s a poor organization – bruised and calloused – to do?

Here are three things that you can do today to move forward:

  •  Go and watch a cornfield grow. I could elaborate on this idea, but it is best left to your imagination. Comments welcome.
  • Find a coach and ditch the consultant. Find the low-cost, do-it-yourself strategic partner, roll up your sleeves and follow the instructions (there are no shortcuts).
  • Stop thinking about other organizations’ best practices as your goose laying the golden egg. First, brush up on Aesop’s Fables; Google it. We’ve seen organizations “kill” the true wisdom – the “best idea” inside or behind a best practice – by trying to replicate the ‘best practice” accurately.  Think differently by asking: what’s the best idea behind this best practice and how can we adapt it to us?

A wise old Benedictine monk once said: (move) forward, always forward, everywhere forward. Shall we?

It’s the Process not the Person

It’s the Process not the Person

We Don’t Wake Up Scheming to Make Defects at Work (Most of Us)

My mentor, Rodger Lewis, drilled this one into my head from our first meeting.  While we love to blame people for outcomes, the truth is that the process is the culprit.  Most of us don’t wake up in the morning and think, “How can I cause a problem at work today?”  We don’t brush our teeth and ponder ways to create defects. In fact, most of us go to work thinking, maybe even hoping, that nothing goes wrong.  But, for some reason, we act like – therefore at least at that moment, we believe that – people are planning to do wrong at work.

We don’t wake up scheming evil at work.  Just our problem employees do.


I often find myself quoting another great friend and colleague, Dr. Rick Kunkle, a retired emergency medicine physician and healthcare executive.  Rick (“Doc”) Kunkle says, “The process is perfectly designed to give you precisely the result you are getting.”  When a defect surfaces, the process produces it.

Some will argue in favor of human error, to which I’d just reply, “Your process allowed the error.”

Med Error or Human Error: Process or Person?

I was working with a nursing manager a few years ago. She had 60 plus direct reports. As her organization hoisted lean on her without preparing her mind and heart, she saw it as a heavy burden. When problems surfaced on her team, she quickly ran herself ragged working offensively to contain them.  She was just doing what had been successful for her: firefighting.   When she couldn’t contain them all, she slipped back into her default defensive mode: blaming. First, she’d blame her leaders for forcing her to change, and then she’d blame her team.  One day, a serious medication error alerted the unit to the potential harm they were doing to their patients.  Instead of blaming people, she took a team with her to solve the problem. As she went from the point of recognition (the patient got the wrong med) to the point of cause (when the nurse was pouring the med), she realized that in the spirit of not harming anyone else, any one of her team could have made the same error.

Why?  Because the process allowed the error to be made.

Fatigue, distractions, confusing med names, similar patient names all create the potential for errors.

Waking up in the morning and devising evil plans to fail?  Not so much.

The distractions at the point of cause were many.  Their med dispensing unit had been located in the midst of their nursing station – the hub of all things on the unit – because power and internet cabling was readily available there.  They were thinking cost savings over safety.  It made sense to the nursing manager because so much of the nurse’s work away from the patients was done there at the hub.  They were putting productivity before safety.  When they observed nurses being interrupted endlessly whiling pouring meds, they knew they had put that step in the process, pouring critically controlled meds, in the wrong place.

As a new containment, the nurses would don fluorescent orange and yellow safety vests – the kind you’d see in a factory or on the highway – when they poured meds in the busy area.  It was a visual signal to not interrupt me when I’m pouring these meds.

Re-Thinking How We Think: it’s the process not the person

So, how does a wise leader correct his or her defensive thinking?

First, take every leadership thought captive to the principle: it’s not the person, it’s the process.  As much as your heart wants to believe that John Doe is an idiot or, worse, an evil person planning to make defects on purpose, let common sense prevail.  Sure, John Doe’s personality may make him hard to manage, but the process delivered precisely what it was designed to do.

Second, begin to practice error proofing.  There are four levels of error proofing: elimination, prevention, detection and loss control. Eventually, the nurse manager I mentioned was able to move the medication dispensing unit.  Her containment worked as a form of prevention, but by moving the dispenser to a quiet, non-traveled area, she eliminated distractions coming from the unit nursing station.  Yes, the nurse pouring a med still was responding to call signals and pager calls, but at least the manager had eliminated some of the distractions.  To her credit, the nurse manager rounded the pdCA cycle and began to work on solving the next med error distraction problem: group pages that didn’t require a nurse to stop pouring a med.

Lastly, lead your team into this new mindset.  It’s so easy to get caught up blaming someone else.  For some reason, we believe that we are better if we can compare ourselves to others failures.  Truth and transparency prove otherwise.  Remember how our nurse manager realized that anyone could have created the med error with the process as it was? Lead your team into humility by practicing humility as you lead them.

Rodger and Doc knew the principle and lived it: it IS the process NOT the person.  The sooner we believe that the sooner we find our way to sustainable gains and a safer place for our patients and our team.


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