LEAN GLOBAL

HEALTHCARE INITIATIVE

5 GUIDING PRINCIPLES
TO TRANSFORM
HEALTHCARE
WHITE PAPER
SPRING 2020

Flávio Battaglia, Director Lean Institute Brasil

Denise Bennett, RN, RM, MBA, Director Lean Enterprise Australia
Vyacheslav Boltrukevich, PhD, Graduate School of Business, Moscow
State University, Russia and Director Lean Enterprise Institute Russia
Oriol Cuatrecasas, PhD, Universitat Politècnica de Catalunya, Instituto
Lean Management, Spain
Cristina Fontcuberta, Eng. Healthcare Director, Instituto Lean

AUTHORS: Management, Spain

Alice Lee, Executive Director Lean Enterprise Institute, USA
Carlos Frederico Pinto, MD, MBA, Executive Director Instituto de
Oncologia do Vale, Senior Advisor Lean Institute Brasil
Roberto Priolo, Planet Lean Chief Editor, Lean Global Network
John Y. Shook, Chairman Lean Global Network, Senior Advisor Lean
Enterprise Institute, USA.
LEAN
IN HEALTHCARE
1 , then a graduate student at MIT who was working with

Jim Womack and Dan Jones on the International Motor Vehicle Program2 research that eventually led to the publica-
tion of The Machine that Changed the World3 . As more and more organizations and industries were exposed
to the potential of lean thinking, it became clear that its teachings applied not only to manufacturing. As we stepped

boosting the quality of care. Today, successful examples of lean in healthcare exist in all corners of the globe, with more
and more hospitals joining in every year. A recent survey from UC Berkeley involved more than a thousand hospitals,
of these, 2/3 were involved with lean implementation (and similar approaches like lean six-sigma or robust process
improvement) with several reported performance achievements like employee engagement, increased throughput in
the emergency department or reduced expenditures. A comparative analysis on quality measures (before/after lean)
also found reduced 30-day unplanned readmission rate; death rate for surgical patients with serious treatable condi-
tions (Z-score); and spending and operational margins4 .

Lean Global Network (LGN) supports dozens of lean transformations in healthcare. Five of the authors were directly
involved in some of the earliest lean healthcare transformations in their respective countries, as internal change agents
– at Beth Israel Deaconess Medical Center (USA), Flinders Medical Centre (Australia) and Instituto de Oncologia do
Vale (Brazil) – or acting as external supporters to pioneer organizations – at Instituto Lean Management (Spain) and
Lean Institute Brasil (Brazil).

LGN network Presence

1Krafcik, JF, 1988.

Program on Vehicle mobility Innovation (PVMI). https://mackinstitute.wharton.upenn.edu/events-and-programs/pvmi/, retrieved july

11th, 2018.
3Womack JP, Jones DT, Roos D. 1990.

4Shortell SM, et all. 2018.

1 © 2020 Lean Global Network, Inc All Rights Reserved

DESIGNING
OUR INITIATIVE
It can often take a healthcare organization a decade to develop and sustain the required capabilities for lean

organization and the ability to reshape management systems and leadership behavior.

We believe “ten years” is too long, especially if we consider the pressing issues facing the industry today: patient harm,
aging population, squeezed budgets and an increase in chronic diseases. And if we consider that just a very small
fraction of world’s hospitals is practicing lean and many are early in their lean journeys, the work ahead seems even
more challenging.

In September 2015, LGN started a lean healthcare working group (LHI – Lean Healthcare Initiative) to gather and
analyze data and build on the findings to identify critical “guiding principles” a healthcare organization should
consider to shorten the time it needs to develop the required capabilities to sustain the lean transformation.
The working group represents five LGN Institutes: USA, Brazil, Spain, Russia and Australia.

THE FIVE GUIDING

PRINCIPLES
1. DON’T WAIT FOR THE CEO

2. WHAT IS YOUR NEXT MOVE? AND WHY?

3. MAKE IT YOUR OWN PROBLEM

4. RIGHT KNOWLEDGE FOR THE RIGHT PEOPLE AT

THE RIGHT TIME

5. CROSS-POLLINATION

The exploratory sample includes eight organizations: [1] Beth Israel Deaconess Medical Center (USA), [2] Lynn
Community Health Center (USA) and [3] Stanford Children’s Health (USA), [4] Hospital São Camilo (Brazil)
and [5] Instituto de Oncologia do Vale (Brazil), [6] Consorci Sanitari del Garraf (Spain), [7] Bud’ Zdorov
(Russia) and [8] Flinders Medical Centre (Australia). Organizations vary from large teaching hospitals in the US
to a small practice in a developing country. There is also a mix of private practices and public organizations from
Europe and Australia.

2 © 2020 Lean Global Network, Inc All Rights Reserved

LTF was introduced in 2015 by
Lean Enterprise Institute (LEI) as
a heuristic framework to lean
transformation. It is a situational
approach to change, connecting the
key dimensions to transform and
sustain - the building blocks of the

action-oriented questions.

LTF .

Questions of the Lean Transformation Framework7

1.

2.
3.
4.

5.

THE STUDY WAS ORGANIZED IN FIVE STAGES:

6
1)
studies together at hospitals in the US, Spain and Brazil;
2)

3)
success (and failure) forces;
4) -
rent levels of the organizations;
5)
while aiming to shorten the time required to develop sustainable lean capability.

5https://www.lean.org/WhatsLean/TransformationFramework.cfm, retrieved July 13th, 2018.

6Gemba is the Japanese word for “the real place, the place where the work is executed”.

3 © 2020 Lean Global Network, Inc All Rights Reserved

 same questions apply whether working at the macro enterprise level or the level of individual responsibility
as you dive progressively deeper into each dimension. But, while the transformation model that has
emerged through years of experience is situational, the nature of the questions represents a clear point of
view: if an organization fails to address each question, and with a sense of how each relates to the others,
the transformation will struggle to sustain its momentum.” 7

Table: CHARACTERISTICS OF ORGANIZATIONS

IN THE STUDY

Organization Country Activity Size Lean experience

USA Teaching Hospital 673 beds

Beth Israel Deaconess Medical Center
8,000+ employees 14 years
Community Health 40,000 patients served/year
Lynn Community Health Center USA 4 years
Center 650 employees
361 beds
Stanford Children’s Health USA General Hospital 8 years
3,200+ employees
BRAZIL 760 beds (3 facilities)
Hospital São Camilo General Hospital 6 years
5,000+ employees
BRAZIL Outpatient 30,000 patients served/year
Instituto de Oncologia do Vale 8 years
Cancer Center 220+ employees
SPAIN 433 beds
Consorci Sanitari del Garraf General Hospital 8 years
2,500+ employees
RUSSIA 100,000 patients served/year
MedHolding Clinic Hospital 3 years
1,700+ employees
Flinders Medical Centre AUSTRALIA Teaching Hospital 593 beds
14 years
5,000+ employees

THE FINDINGS TO DATE

organization needs to develop sustainable lean capabilities is not acceptable.

healthcare organizations and lean practitioners should consider while trying to transform their work realities using
lean thinking and practice. Here is what we consider to be the essence of what we have learned collectively, presented

7Citation from: https://www.lean.org/WhatsLean/TransformationFramework.cfm, retrieved July 13th, 2018.

4 © 2020 Lean Global Network, Inc All Rights Reserved

 DON’T WAIT
FOR THE CEO 18%Annual turnover

Data from American College of Healthcare Executives
show that the level of annual turnover registered in 2017
is among the highest rates calculated over the last two
decades, around 18% 8 . Comparatively, healthcare CEO
turnover is six times higher than the insurance industry
and twice as high as retail9. So, we cannot depend on the
CEO to lead a transformation at all times. We
experienced CEO turnover in more than half of the eight
case studies, which could be a factor of disruption of lean
In our experience, involving key physicians or other
clinical leaders early is a key strategy as they hold
multiple roles and understand the work, hold strong
crucial to ensure that area managers play a leading
role in the lean transformation, as the changes
teams12
challenge of CEO turnover and distraction.

CEOs have organization-wide responsibilities. It may be
realized by studying the 8 initiatives mentioned above is
something that can be done without the direct involve-
ment of the most senior leader in the organization10.
levels of an organization (across a department, or in a
nursing team) and begin as the simplest of experiments 11.
In a large public hospital in Barcelona, the initial
push for lean came from the enthusiastic area mana-
gers of the Emergency Department (the head doctor
and nurse). After training and coaching they worked
with teams to run a number of pilot projects. A few
months later, the whole department was running
successfully under the lean system. Only at this point,
did the CEO realize what the ED had achieved. He
then encouraged other parts of the hospital to follow
their example.

physicians and other leaders are visibly engaged. What won’t work is a CEO who appears negative or actively blocks
progress. If the CEO is kept informed of progress and results, s/he is likely to become more supportive as

8American College ofHealthcare Executives, Hospital CEO Turnover Rate Remains Steady,
https://www.ache.org/pubs/Releases/2017/2017-Hospital-CEO-Turnover-Rate.cfm, retrieved July 13th, 2018.
9Challenger, Gray & Christmas Inc, 2018 February CEO Report: 113 CEO Exits, Highest January-February Since 2008,
http://www.challengergray.com/press/press-releases/2018-february-ceo-report-113-ceo-exits-highest-january-february-2008, retrieved
July 13th, 2018.
10Several other studies corroborate this approach. Holden (2010) did an extensive review oflean in emergency departments. Management
support and employee involvement were success factors, but senior leaders were not always involved.
11In another extensive review by Mazzocato and cols (2010), most cases published are initial and narrow applications, with limited
organizational reach.
12
element for the program success (Morrow, 2010).
5
 lean-trained practitioner/leader. In more than one instance, we discovered this to be the case - a supportive

spreading and deepening the transformation and thinks about what the next move should be. We call this role the
Chief Architect (CA)13. At the very beginning, when there is limited internal capability, the role of CA may be
covered by an external coach who will work to develop an internal CA, who in time will be able to guide the

their idea to try a lean approach – or might emerge from within the organization during the transformation.

In an ideal world, we don’t need a named CA, but at the beginning of a transformation an organization needs

much unless s/he challenges people to push the boundaries, come up with solutions to problems on their own, and
actively suggest improvements.

WHAT IS YOUR NEXT MOVE?

AND WHY?

At a clinic in the United States, the patient journey

simply understand what your next move should be, you
should always strive to address a pressing need14. front-line team focused on the question, “Why do

Upon starting a transformation, you need to understand

what’s important to your CEO, your Board and the applied possible solutions, informed by what they
organization as a whole. What problems appear to be had observed. After that, very few patients waited
most pressing? What safety concerns must the
organization address? What do patients care about? Once
needed to create a better patient experience and
everybody can row in the same direction. Examples that increased the number of patients that could be seen
work generate interest. With meaningful experiments, every day.
people will follow15
in the Surgery Department. I need to learn how to

If you don’t know where to start, we have found that

simply focusing on turning chaos into stability can go a
long way. Make the patient journey and the work visible

13

(Guimaraes 2012, Kane 2015, Woiceshyn 2017).

Continuous improvement attitude to be developed and required to succeed (Toussaint, 2013).
14

15

6 © 2020 Lean Global Network, Inc All Rights Reserved

 When we generate change through lean, we create new knowledge. A very important lesson we have learned over the

together. People need to feel emotionally attached to the transformation: they need to co-create experiments and
knowledge, rather than simply apply something that somebody else has developed.

elements of lean. It doesn’t matter if you start by trying to shift the culture in your organization (social) or by

MAKE IT YOUR PROBLEM

Previously, we talked about emotions, that if people feel
emotionally attached to a problem, they would own it.
transformation . When you get people to own problems,
you not only achieve organizational change, but also
personal transformations16.
In the same Barcelona hospital, the lean initiative in
the Emergency Department started to show good
results. At the same time, a consultant-led project in
the surgical department failed to involve the

asked themselves why one project succeeded and the

realized that the whole hospital should follow the

example of the ED in its approach to the transforma-
tion.

One of the American hospitals we mentioned above

transition responsibility to a front-line leader (this can
be anyone, from a nurse to a porter or a doctor).
Respect for people, one of the two pillars of the Toyota
Way17, means to wean people from dependence on the
improvement team. Let them take responsibility for
identifying and resolving problems and make them feel
safe enough that they ask for help when needed.
experienced something similar to the hospital in
support of external coaching, that she must gradually
step back while continuing to provide people with
structure and guidance, until they became fully
originally thought that her role was to be a part of
every improvement-related activity, whereas she now
understands that developing people is even more
important.

16Problem solving and local ownership is part of Toyota’s DNA (Spears, 1999).
17Liker JK. 2004.

7 © 2020 Lean Global Network, Inc All Rights Reserved

 set and practices. Sometimes we are the problem for stalled progress. Rather than requiring others to change, ask

the individual and team levels. It may also be helpful to seek an outside perspective to challenge and broaden your
18
.

transitioned from owning the problem-solving function to coaching the problem solvers.

THE RIGHT KNOWLEDGE

FOR THE RIGHT PEOPLE AT THE RIGHT TIME

In another hospital in Brazil, management hired a

how to do it? By providing the right people with the right
inputs at the right time. Healthcare people are very busy.
We must give people the right amount of knowledge they
need to solve their problems. Don’t overwhelm people by
bombarding them with knowledge they have no way of
using yet. Instead, wait until they need it. When you learn
something and apply it right away, you remember it.
group of professionals but failed to couple that with
regular coaching. Not only did this make the training
useless, but it also undermined the overall
transformation. Faced with a huge amount of
information that was too complex for front-line
workers and middle managers to grasp at that stage,
people got scared of what they were told lean was,
and no meaningful result was achieved.

Developing the capabilities, we need is striking a combination between mindset, practice in the gemba and tools.

competence at the same time, but the new approach to the work must be learned at the front line, where the work

Structured learning with a coach will help people build the habits and behaviors we need to have in our lean
organization. Make sure you are using the right teaching method, which may include traditional classroom training,
coaching by asking questions, and predominantly practice-based learning at the gemba19.

18 “Teach people to solve their own problems” (Ballé, 2014).

19

8 © 2020 Lean Global Network, Inc All Rights Reserved

As previously discussed, the early involvement of physi- In a number of hospitals that we have observed in
cians is a key strategy. Build relationships and trust Australia and the US, improvement is now
through deeply understanding their work and daily recognized as core competency – just as important
frustrations and then partner with them to improve their
development of rotation programs focusing
there is more. Unlike physicians, many senior leaders are
distanced from the work at the front. In our experience, clinical processes. We believe that building this
we have found that training leaders in the basics of lean capability in our next generation of doctors is vital.
and learning to see narrows this distance and builds
empathy and trust for the front line. Coupled with this,
learning and practicing A3 thinking will reduce propen-
sity to provide solutions to problems they don’t unders-
tand.
%

CROSS-POLLINATION

As lean thinkers, we believe that deep knowledge comes

from practical experience. However, this is something
that can’t be taught; it can only be learned. How can we
expose more and more people to direct experience and
leverage this to speed up the development of a Chief
model lines – one medical, one surgical. Over time,
nursing leaders recognized the need to spread the
approach adopted entailed bringing four additional
nursing teams to the model lines: they could choose
their improvements and tailor them to their own
environments. In some instances, the next generation
of improvements was subsequently adopted back in

approach was the breaking down of traditional

organizational silos.

20, between two

as part of your cross-pollination storytelling.

Within departments, cross-pollination supports peer-to-peer conversations to update others, share improvements

21 .

20
gained support using the cross-pollination concept (Morrow, 2010).
21
White Paper 2013, and O’Neill, 2011).
9 © 2020 Lean Global Network, Inc All Rights Reserved
 Across an organization, cross-pollination provides us
with a platform to learn what is going on and to share
inspirational success stories. Seeing others advance
applies pressure on teams, encouraging them to meet
their projects’ deadlines and to keep progressing in their
In Brazil, the clinic inspired organizations from
healthcare and other industries. A large insurance
company based in São Paulo sends a new group of
people on a visit to the clinic every month to capture
the knowledge and see how the lean transformation

“joint ventures of knowledge” between professionals from

another. Someone working in an ED who visits radiology
might not fully understand the work and how it connects
to her own reality, until she learns to see – often with the
help of her colleague – the underlying similarities
between the two processes
clinic relies on cross-pollination to develop its own
regularly visits a lean manufacturing plant located in
the same city. Seeing lean tools applied in a
safety alert system mentioned earlier was adopted in
the factory.

22. When people get out of

their
workplaces and comfort zones and see parallels with the work others are doing, they understand how universally
applicable lean ideas are. In Catalonia, for example, cross-pollination was the main driver behind the development,
over just a few years, of a vibrant lean healthcare community of 12-15 hospitals.

We believe this community-based model of cross-pollination is completely replicable: people move and talk, which
means that spreading the word is actually easier than one might think. It is critical that good examples and results
are well documented for sharing.

22 Mazzocato (2010) did an extensive review and proposed few mechanisms for how lean works in healthcare, collaborative approaches
and shared understanding are positive elements contributing to success

10 © 2020 Lean Global Network, Inc All Rights Reserved

SUMMARY

Our study has revealed a number of commonalities among lean transformations taking place in a variety of
healthcare organizations around the world. By grasping the history and current conditions of relevant lean

transformational characteristics, directly associated with lean capability development and sustainability across

knowledge regarding relevant success (and failure) forces; in action during a lean transformation initiative of a

practicing and thinking lean.

TIPS FOR
CHIEF ARCHITECTS
DON’T WAIT FOR THE CEO
-Clearly understand where the CEO stands and grow a relationship
-Report progress frequently to the CEO

WHAT IS YOUR NEXT MOVE? AND WHY?

-Align improvement to what is important to the organization

-Make the work and the process visible

-Lead by asking questions

MAKE IT YOUR OWN PROBLEM

-Problems are treasures
-Create space for problem solving

-Wean people dependence on the improvement team to create ownership and strengthen capability

RIGHT KNOWLEDGE FOR THE RIGHT PEOPLE AT THE RIGHT TIME

-Don’t create learning inventory – teach when relevant
-Communicate frequently and face-to-face

-Connect mindset to the practices and tools

CROSS-POLLINATION
-Learn through sharing
-Go and see what “good” looks like to guide improvement
-Fresh eyes are a great source of feedback on your progress

11 © 2020 Lean Global Network, Inc All Rights Reserved

REFERENCES
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 LEAN GLOBAL NETWORK
HEALTHCARE INITIATIVE

ABOUT LGN
LGN members are mission-driven individuals and organizations covering 32 countries taking responsibility for
advancing lean thinking and practice in order to make things better for our customers and society. As
members of the LGN community, we commit to work together to develop and strengthen our lean thinking capabili-
ties to create value for our customers and ensure the success of our institutes

LGN network Presence

13
 LEAN GLOBAL NETWORK

WHITE PAPER
SPRING 2020
© 2020 Lean Global Network, Inc All Rights Reserved