Modern Management Is ALL Wrong?!

Jim Womack argues in a brilliant essay entitled Modern Management vs. Lean Management (in his book Gemba Walks, 2011) that the biggest impediment to Lean Thinking is the prevailing modern management style, with which we are all familiar. This management system was pioneered by GM one hundred years ago, and has spread far and wide as modern organizations and management needs grew to massive proportions. It is firmly entrenched in healthcare, with the industry’s rigid hierarchies and myriad specializations, though there may be opportunity for change due to the industry’s somewhat unusual promotion policies.

Personally, I would not assign all the blame to GM, but would suggest that this command-and-control style has also spread and dominated due to fundamental issues of human nature. For one, there may be a self-selection element involved, in that those who would aspire to manage, and would beat out others for the role, may have certain personality traits that lend themselves to a more authoritarian style. Also, managers might gravitate toward that style as a tool for self-preservation, as an entitlement of promotion above peers, or simply because they have the power to do so. Many research studies have been done on what people are capable of once given a little power and authority. Its as though human nature has some latent authoritative tendencies that require deliberate design to keep suppressed. I guess history would overwhelming prove that point.

The fascinating and exciting thing is that Toyota turned all of this on its head after World War II, and has pioneered a much more effective management style that is opposite IN ALMOST EVERY WAY. Finally, since the 1990s, this system is getting the attention and study it deserves. Yet this fundamental issue remains: how to break the modern management style when everything (except the bottom line) supports it, including human nature, inertia, education and business schools, hiring policies, promotion policies, org structures, strategic plans, the “modern manager” stereotype, on and on.

Without further ado, the vast gulf between Modern Management and Lean Management (the source being Jim Womack’s thousands of studies and gemba walks at various organizations, and the collective learning of management experts, Toyota-specific and otherwise. Also, for reference, “gemba” is Japanese for “the real place,” the location of the actual work being done, the scene of the crime, etc.):

Authority vs. Responsibility

Modern managers seek authority to take action by referring to the organization chart.

Lean managers seek responsibility to address important issues by leading as if they have no authority.

Results vs. Process

Modern managers manage by results, to make their efforts look effective at the end of some reporting period (when the problems have already occurred).

Lean managers manage by process, by knowing at all times the condition of their process (which produces the results) so problems can be solved and improvements implemented before rather than after the fact.

Give Answers vs. Ask Questions

Modern managers give answers to their direct reports about the nature of the problem and its solution.

Lean managers pose questions to their problem owners about the nature of the problem and the best available countermeasures.

Plans vs. Experiments

Modern managers make grand plans…this leads to a focus on measuring compliance and determining who to blame when a plan fails.

Lean managers treat every plan as an experiment…this leads to a focus on discovering quickly how the plan is working and then rapidly devising and implementing countermeasures as the plan encounters problems.

Formal Education vs. Gemba Learning

Modern managers seek formal education to advance their careers.

Lean managers pursue gemba learning within their organization by participating in frequent [improvement projects] while being mentored by managers at the next higher level.

Staffs Improve Processes vs. Line Managers and Team Improve Processes

Modern line managers improve processes by outsourcing problems to staffs or consultants.

Lean line managers improve processes by directly leading improvement activities in dialogue with everyone touching the process, bringing in staff or consultants only as necessary on major technical issues.

Decisions Made Remotely With Data vs. Decisions Made On The Gemba With Facts

Modern managers make decisions remotely, analyzing data, usually in conference rooms far away from the gemba.

Lean managers make decisions on the gemba at the location of the problem, turning data into verified facts.

Standardization By Staffs vs. Standardization By Line Managers and Teams

Modern managers standardize processes by relying on staff experts. Or, more likely, they never make any serious effort to standardize the processes they are managing or their own management practice.

Lean managers standardize processes through hands-on engagement with all of the people touching the process.

Go Fast To Go Slow vs. Go Slow To Go Fast

Modern managers go fast to go slow, because problems are never fully understood and the quick countermeasures don’t (and can’t) address the real issue.

Lean managers go slow to go fast, by taking time at the outset to fully understand the process and its purpose, through dialogue with everyone involved including customers and suppliers, and by fully understanding the root cause of problems and the most promising countermeasures before taking action.

Vertical Focus vs. Horizontal Focus

Modern managers focus vertically on the organization, with all the functions and silos oriented toward the CEO at the top. This fits in perfectly with authority-based management.

Lean managers focus horizontally on the flow of value across the organization, from the initial concept for the product and the raw materials to the customer. This can only work by utilizing responsibility-based management where lean managers think horizontally to solve problems by dialoguing with many departments and functions over which they have (and can have) no authority.

Note that this last contrast is not just a matter of thinking. It must also be the way that managers act every day if value for the customer is going to be optimized by engaging all the people touching the process in steady improvement. It is the key to creatively fusing purpose, process, and people in a lean enterprise.

BOOK REVIEW: Healing Healthcare–A Leadership Journey

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5/5 stars.

Overview

An exceptional presentation of Lean Six Sigma principles applied to healthcare, told in an unusual but very effective format: a fictional story about the CEO of a typically mediocre medical center being coached to transform the entire organization by the CEO of a world-class Lean medical center.

As the CEO knows very little about Lean Six Sigma, the book starts out as a beginner’s guide to Lean Six Sigma, but builds in a clear and systematic way to become a comprehensive roadmap for transforming a large multi-hospital health system. It literally starts at the beginning of change management, with addressing the misconceptions and changing the mindset of one person at the organization (in this case, the CEO or course), to the first small steps to gain buy-in from a few others, all the way through to designing and managing a massive system-wide transformation.

No small feat in a brief 150 pages, but the author does a masterful job, bringing together his varied experiences as healthcare executive, consultant, professor, Black Belt, and psychologist. Aside from the idealistic CEO-first methodology and the rather stilted prose, this book is highly recommended for the easily digestible way it presents the merits of LSS for healthcare and walks the reader through the “Leaning” of a large health system. Now to get all healthcare CEOs, executives, and doctors to read it!

 Highlights

Several highlights include the “Quality Hierarchy” as modeled after Maslow’s hierarchy, “Healing Pathways” as Value Streams for healthcare, and the book’s overall structure as a health system transformation roadmap:

Quality Hierarchy

The publisher’s foreword praises the book for incorporating the many different aspects of quality into a seamless whole, rather than focusing on one or a few as “flavors of the month.” This is presented as a helpful Quality Hierarchy modeled after Maslow’s Hierarchy of Needs, which addresses human needs as layered from the most basic to the most advanced, with each building on the other:

Maslows-hierarchy-of-needs

The publisher’s Quality Hierarchy includes the following levels:

  • At the basic level is inspection and quality audits. It performs the important role of determining what is conforming and what is not.
  • The second level is total quality management. The organization builds on the basic level and engages all employees in improvement with the managers working on the system and employees giving insight because they are closer to what is really going on.
  • The third level is lean six sigma. This builds on the two lower levels by focusing on a company-wide improvement plan and ties each improvement project to that plan. It also adds statistical and lean tools that improve the effectiveness of the improvement effort.
  • The fourth level is creativity and innovation. This level corrects the number one weakness of the lower levels by supplying tools to generate new ideas at the beginning, intermediate, and advanced level. These tools are selected based on the level of difficulty of the problems and the level of sophistication of those on the team.
  • The fifth level is the transformation and organizational breakthrough level. This level ties together the goals of the organization with the goals of individual employees. It adds the best of organizational development and good change theory and practice.
  • The sixth level corresponds to Maslow’s self-actualization level. It looks to the purpose of the organization and looks to issues such as sustainability, spirituality, and improving the planet.
Healing Pathways

The valuable Healing Pathways tool can revolutionize patient care delivery. It addresses the common concern that the LSS methodology cannot apply to healthcare because patients are not “widgets” but rather especially vulnerable, needy people, the sick/impaired/dying, and because the goal is not merely efficient production but better health. Widgets do not “experience” the processes they flow through, as patients do, and thus an added perspective is needed. The true goal of all healthcare processes is (should be) better health for patients, and the Healing Pathways tool incorporates this goal into the patient-facing processes themselves. Poorly performing processes are proven to frustrate and inhibit healing, but even perfectly performing processes may not take healing into account. Processes can be analyzed, streamlined, and redesigned to heal.

Just as a value stream is analyzed for the Eight Wastes (which form the mnemonic DOWNTIME), Healing Pathways are patient-facing value streams additionally analyzed for the Eight Impediments to Healing (SICKNESS):

  • Stress & Anxiety – a common state of our patients created by the cause that brought them to us, uncertainty and fear about what may be wrong with them, and unfamiliarity with our setting
  • Inactivity & Waiting – Idle and unproductive time created when we cannot tend to our patients at a rate appropriate to their treatment
  • Coldness or Apathy – An aloofness or distancing from the patient by one or more caregivers
  • Knowledge Gap – The lack of information patients have about what is wrong with them, what is happening to them, and what is going to happen and when
  • Neglect – The absence of steady interaction and information sharing with the patient
  • Embarrassment – A negative patient experience caused by a lack of dignity in the treatment process
  • Submission & Helplessness – A state of learned helplessness exacerbated by information, power, and social status differentials
  • Statistic – Depersonalization of patients (e.g., “the chest pain in room five”)

Conversely, the Eight Enablers of Healing are the opposite of the Eight Impediments, and form core values of a world-class health system:

  • Calm & Comfort
  • Progress
  • Caring & Warmth
  • Abundant Communication & Understanding
  • Engagement
  • Dignity
  • Respect & Empowerment
  • Special

The book further describes how these are applied within the Lean methodology, which alone is worth the price of the book.

Health System Transformation Roadmap

The overall structure of the book forms a comprehensive “Health System Transformation Roadmap” (which will be discussed at length in an upcoming post).

The (Human) Heart of Process Improvement

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I previously worked in the nonprofit sector developing young adult leaders, and understanding the mysterious human heart and coaching to each unique case were keys to gaining trust, motivation, and commitment. After much learning in this way, I had opportunity to lead a large and lengthy organization redesign. While the more technical operational activities of analyses, planning, and process improvements played to my strengths and eventually led me to Lean Six Sigma, I can never forget how essential were those delicate aspects of the heart. As we were working with volunteers in a culture almost entirely responsibility-based rather than authority-based, people had to be treated as partners and take full ownership to participate, or else they would tend to drop away. In this case, we were able to gain buy-in and hand over ownership, and those hearts caused the changes while, at the same time, the changes further fueled the hearts. With this background, my later discovery of Lean Six Sigma was a revelation. This is the essence of Lean Six Sigma methodologies, a two-sided nature of process improvement and personal empowerment. This duality must remain at the forefront of the work, because it is easy to over-focus on the process improvement tools and goals and underemphasize the human element.

This duality became readily apparent in a Black Belt project I led as an external consultant in which a number of interconnected processes were embedded within ONE person (she managed them from beginning to end with little documentation). It is one thing to get different perspectives and ideas for improvement from a process owner and numerous process operators; it is another task entirely to delve into the process steps and intricacies when they are hidden within one person who is not keen on such exposure. The fact that she was “suspect” (according to management) in the first place indicates a culture of blame, which may have been at the root of her standoffishness. Fortunately, I was able to reassure her, even vindicate her through the data, and she remained very helpful throughout the project. Rather than “elbow past her” in an authoritative way, granting her attention and respect went a long way to forming a partnership to work together towards a mutually acceptable goal.

Which brings me to a brilliant portion from John Shook’s Managing to Learn (2010), a highly recommended book on empowerment through A3 management:

“It took Sanderson [the senior manager] many years to accept that many of the so-called “problem people” in his plant were of his own doing. Occasionally there truly was a bad egg, but most issues for which he and others previously had wanted to point an accusatory finger–safety, quality, delays, waste in all forms–ultimately could be traced back to underperforming processes that were owned by management.

Sanderson knew that awakening Porter [his leadership protege] and others to this perspective was crucial in his quest to develop leaders in the plant. It isn’t only a matter of getting better results, but of putting people in positions to succeed and improve their own work based on well-designed, standardized processes.

Ironically, prior to Porter sharing the latest addition to his A3, Sanderson had pulled out a piece of crumpled paper with this quote [from Toyota Chairman Fujio Cho, 1997]: “We want to not only show respect to our people, the same way we want to show respect to everyone we meet in life, we also want to respect their humanity, what it is that makes us human, which is our ability to think and feel–we have to respect that humanity in the way we design the work, so that the work enables their very human characteristics to flourish.”

The foundation for this mindset is developing a no-blame culture in which problems are brought into the light of day and not hidden for fear of retribution or embarrassment. This was key to the culture within [the organization] of people looking at problems impersonally. Importantly, however, a culture of “no blame” did not mean a culture of accepting problems that repeat without investigation nor one that would tolerate excuses: no blame requires no excuses.” (pp. 52-54)

And Mark Dean addresses this “simple but powerful act of empowerment” in the introduction to Healing Healthcare (2012), an excellent Lean Healthcare primer for senior managers who are unfamiliar with the Lean mindset:

“Lean fosters not only process improvement but, equally important, cultural transformation.

Lean focuses on improving the flow of patients through the system while also enhancing their care. It achieves these ends by empowering team members to objectively evaluate and improve their work processes. This simple but powerful act of empowerment has the added benefit of stimulating a cultural transformation from the bottom up. Thus, Lean and cultural transformation are two sides of the same coin. The act of empowering team members to improve their processes enables both the cultural transformation and process improvement.I learned a lot along the way. I am a much stronger and wiser leader for the struggle. [Some points of learning]:

  • Leadership is the key. What leaders should do is empower their people to improve processes to acheive excellent organizational performance.
  • It’s about the people and the process — together they provide patient care. It is truly through well-developed and empowered people that the best processes in support of patient care are developed and implemented.
  • Management owns the system, and is responsible for ensuring that the system works for the people; not against them. It is management’s job to eliminate barriers to success, allowing our people to be the best and most effective they can be.” (pp. x-xi)

Costlier Care is Worse Care?

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McAllen, Texas, one of the most expensive healthcare markets in the country, costs Medicare per-person double the national average and 125% of the average local SALARY. Dr. Atul Gawande delves into this cost conundrum in an enlightening article.

Cheesecake Factory and Healthcare: Lessons in Quality, Cost, & Innovation

A must-read for his straightforward yet profound observations, Dr. Atul Gawande’s article studies Cheesecake Factory’s keys to success and how they can be brought to American healthcare.