10 Key Lean Mindsets for Factories, Hospitals, Startups, and More

It's been more than 25 years since the term "Lean Production" was coined, although the Toyota Production System is much older than that. Hospitals and health systems have been using Lean as an improvement methodology and management system for more than ten years. It's also been about five years since the "Lean Startup" methodology was codified by Eric Ries.

What makes Lean applicable in so many different settings (including banks, law firms, government offices, and non profits)? It's not necessarily the specific tools - it's the thinking, the mindsets, and philosophies of Lean. Now, Lean isn't all about thinking. The actions taken and methods used are the result of the underlying thought processes and beliefs. Many organizations have been tripped up by thinking, unfortunately, that Lean is just about some tools or tactics that you implement.

I learned these mindsets during the first decade of my career in manufacturing. In the second decade of my career, I've seen how powerful these ideas are in healthcare. And, I'd propose they would be helpful to any "Lean Startup" in their early stages or as they grow into a larger company.

These are by no means the only 10 mindsets that matter, but here are some that seem most relevant to me, listed below in no particular order. I think the Toyota notion of "Respect for People" is deeply embedded in all of this.  I'd love to hear your thoughts or your explanation of additional Lean mindsets in the comments.

1) Lean is Obsessively Customer Focused

Lean thinkers realize that value is defined by the customer. What problems do we solve for our customers? Toyota had a chief engineer drive minivans across North America to better understand the needs of customers here (which illustrates a related concept of "go and see" or "genchi genbutsu"). Lean health systems redesign cancer treatment so everything and everybody comes to the patient, rather than making a fatigued patient walk from building to building. Lean Startups excel at understanding customer needs and value through the "customer development" approach. If you're not sure where to start in your Lean journey, start with something that makes life better for your customers.

2) Silos. Are. Bad.

As organizations grow, silos are created for functional areas - it happens in manufacturing companies, health systems, and larger software companies. It's unusual for a single isolated function or department to deliver value to a customer. Lean teaches us how to break down silos through our use of methods like Value Stream Mapping. But, if we don't have the mindset of breaking down barriers to collaboration, which includes looking at budgets and incentives, the mapping might just be a waste of time.

3) Don't Expect Technology Silver Bullets

Most industries are prone to the "silver bullet" trap, where leaders think that software, automation, or technology will provide an easy solution to our problems. This usually turns out to be untrue, whether it's ERP for a manufacturer, EMR/EHR for a hospital, or CRM for a sales and marketing team (hopefully those aren't two silos). The Lean mindset is to make sure we don't automate bad process or ignore our workflows. As Toyota says, in “The Toyota Way“:

“Use only reliable, thoroughly tested technology that serves your people and processes.”

Dr. Bob Wachter's recent book The Digital Doctor includes a cautionary tale about how technology solves some problems, but hides or causes others. I think the headline of this excerpt unfairly blames the technology - it's also a human factors and psychology challenge.

4) Problems are Treasure, Not to be Hidden

Most organizations use overt fear and subtle intimidation to get people to hide and cover up problems. I saw that at General Motors and it happens all the time in hospitals, where errors and near misses are chronically underreported. GM is still trying to change their culture to get employees to speak up about problems (although I think the problem was more a lack of listening). A Lean organization thanks people for speaking up and focuses efforts on identifying the root cause (see point #6) and preventing future occurrences. As they also say at Toyota, "No problems is a problem."

5) Lean Ends “Command and Control”

Command and control structures, where the boss gives orders and expects you to not contribute ideas, are outdated - yet so many organizations cling to this approach. Lean is a far more collaborative and participative approach where leaders still set direction, goals, and strategy, but the rest of the organization contributes ideas, helps prioritize improvements, and even pushes back on what used to be top-down direction through a process called "catchball." Layering a few Lean tools onto a command and control culture is not really Lean at all or forcing people to embrace Lean methods in a command and control way misses the point completely.

6) Stop Jumping to Solutions

People love jumping to solutions. Sometimes, they even jump to Lean as a solution for their company, hospital, or startup. Lean thinkers first ask, "What problem are we trying to solve?" We use root cause analysis, which includes not just the "5 Whys" approach that's talked about so much in the Lean Startup movement, but we often first use methods like "fishbone diagrams" to brainstorm and analyze different causes before diving deeper with the whys. In the "Plan Do Study Adjust" cycle of problem solving, Lean thinkers tend to spend at least half of their time on problem definition and analysis. Pro tip: Five is not a magic number... your problem solving might require just three whys or maybe six.

7) Go to Gemba

Lean thinkers realize that problems are rarely solved in offices or conference rooms. "Gemba" is a Japanese word that means the actual place or where the work is done. It's a good habit for leaders to "go and see" - walking or traveling to where a problem is being seen, in the factory, a nursing unit, or a software customer site. "Go and see" is followed by "ask why" and "show respect" as key mindsets. Lean leaders don't go to the gemba to jump to solutions, reinforce silos, or blame employees (see point #10). Lean Startups should already be doing a good job of "getting out of the building" to go and see and better understand their customer needs and a day in the life of their customers. 

8) Stop Accepting "Necessary" Tradeoffs

Many industries have a mantra (or joke) about tradeoffs between cost, quality, and time. We see this in construction, software, and healthcare. When I was a young engineer at GM, I asked our Toyota-trained plant manager which we needed to focus on first, quality or cost? He said, "Both." When we improve processes and value streams with Lean methods, cost and quality both improve. But, many get held back by thinking that's not even possible, hence the need for changing the mindset - challenge people instead of assuming those tradeoffs are necessary.

9) Stop Jumping Through Hoops

If people generally love jumping to solutions or barking orders, they often also, in a way, love jumping through hoops. Some people find pride in constantly fighting fires, even if they're fighting the same fires every day. Or, people get numb to the waste and problems in their work, so they don't think to improve it. Lean thinkers realize that we should all collaborate in making work easier, which means we can spend more time focusing on customers or patients. 

10) Don’t Blame

One other deeply engrained human habit we have is blaming others or individuals for problems. It's basically in our DNA. The habit pops up in workplaces all the time -- the developer gets blamed for the bad code that crashed the website or the nurse gets blamed for giving the patient the wrong medication. We'll never be able get to the root cause of problems if we get sidetracked with "naming, blaming, and shaming" as they call it in healthcare. As Dr. W. Edwards Deming taught, something like 94% of defects and problems are caused by the system. Maybe it's confirmation bias, but that seems very true in my experiences.

What do you think? Has your organization embraced some or all of these mindsets? What else would you add to this list?

Mark Graban (@MarkGraban) is a consultant, author, and speaker in the “Lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen. He is also the VP of customer success for the technology company KaiNexus and he's a board member for the Louise M. Batz Patient Safety Foundation. Mark blogs at www.LeanBlog.org.