Toyota situation is no reason to abandon Lean, say experts

System works; Toyota 'took eye off the ball,' QI expert says

For years now the name Toyota has been synonymous with quality — not only to the car-buying public, but to a growing number of health care professionals. Lean methodology has been at the heart of numerous QI success stories, standing as the gold standard for performance improvement and efficiency.

Small wonder, then, that the recent spate of recalls at Toyota has raised questions among some as to whether the problem lies in the company's methodology itself. But at a recent program broadcast on WIHI, the Institute for Healthcare Improvement's new online radio station, called "Success at the Right Speed: Learning from Toyota," a group of quality experts responded to that suggestion with a resounding "no."

"Our leadership came together quickly to understand what we thought about what we were hearing, reading, and what we needed to say," said Gary Kaplan, MD, chairman and CEO, Virginia Mason Health System in Seattle. "We separate the Toyota production system from the motor company. The company is the organization that has been at it the longest and has taken it as far as it can come, but many successful companies employ these principles around the world and are still successful; we made that distinction clear."

In addition, he continued, his leadership team pointed out that this was a "wonderful learning opportunity." Lean, he explained, entails the concept of "Fail forward fast." It's better to go for it and test whether something works rather than letting the failure of fear take hold and doing nothing or taking a lot of time to make a change; it's from mistakes that we can learn, the concept holds. "Without risk, you can't have success," he noted. "This is a great opportunity to learn from the missteps of someone other than ourselves. We've begun to explore what we could learn about this — about how you can take your eye off the ball, expand too fast, and what in the Toyota culture allowed this to happen." In fact, he emphasized, "They strayed from the core principals of Lean that have so heightened the vigilance here at Virginia Mason."

"It's been interesting to go back and look at things," added John Toussaint, founder and President of the ThedaCare Center for Healthcare Value, Appleton, WI, and now CEO Emeritus and CEO of the Thedacare Center for Value. "We do Hoisin planning [a Toyota tool that involves taking strategy from the senior management team throughout the organization so that everyone understands the core priorities and strategies]," he notes. "We use that thinking as a way to deploy strategies. There's been a lot of talk around growth, and looking at how Toyota basically outgrew itself." A number of experts who have studied the situation, he pointed out, said that Toyota could not keep up with growth in terms of quality. "There were not enough people who understood the system as they opened up plants all over North America and the world; the speculation is that this growth was too fast," he asserted.

At ThedaCare, he added, the delivery of value to the customer is more important than growth. "We're all rethinking things, and questioning what the core components of how they got off track were," he noted. "But you have to separate the system from Toyota strategy. Many people believe the strategy is what created these defects."

Patrice L. Spath, of Brown-Spath & Associates, Forest Grove, OR, who was not one of the panelists, agrees. "One conclusion that could be drawn from the quality problems at Toyota is that the Lean methodology needs to be significantly modified; but the lesson to be learned, however, is not that Lean techniques don't work," she says. "Consider this: For all of our quality improvement efforts, which has a greater influence on outcomes — the process changes or the culture of the host organization? In my experience any improvement effort — Lean, Six Sigma, rapid system improvement, root-cause analysis — will stumble or eventually fail if organizational factors are inhospitable."

First, and foremost, she notes, health care leaders must differentiate between Lean principles and the techniques used to design more efficient processes. "Much has been written about how to reduce waste by using Lean techniques," she observes. "Thus, the concept of Lean has come to refer to something that improvement teams use when redesigning processes. However, a Lean organization is not just focused on eliminating waste at the front lines of patient care. Leaders in a Lean organization are also personally involved in advancing the principles."

Lean organizations, she asserts, are committed to continuous improvement. "This is evident in a number of practices and procedures, such as formation of rapid-cycle improvement teams and simulation-based training that exposes physicians and staff to new problems or unusual situations," she says. "Heightened awareness of quality problems and ongoing training are crucial components of Lean principles."

Avoiding Toyota's mistakes

What should hospital quality leaders be doing to ensure their facility does not repeat Toyota's mistakes? "They've got to keep their eye on the fundamentals," said Steven J. Spear, senior lecturer, Massachusetts Institute of Technology Sloan School of Management, Cambridge, MA, and a senior fellow at IHI. "I think that's what it was for Toyota. It went from being a crummy car company to being the best in world. They did so because they had mastered a set of skills most other organizations do not have. What they had developed and mastered was how to design systems and operate and improve them when they broke along the way; a science for taking local discoveries and broadly applying them, and having leadership involved in that."

He agreed with Toussaint that while Toyota took advantage of marvelous growth opportunities, "They probably inadvertently overtaxed their internal capacity to develop people. People joined the company, but they were not grounded in these skills."

If you run a health care organization, he continued, it's clearly important that your staff have great clinical skills. "But, in addition, if you really want to achieve breakthrough quality access and affordability, these [Lean] fundamentals are absolutely essential — and they need constant cultivation," he emphasized.

"I think Toyota has set the direction for all of us on the Lean journey; all of us have watched them, and tried to emulate them," added Toussaint. "There's a lot to be learned from this latest snafu; Mr. Toyoda, in a Wall Street Journal article, apologized to the world for getting off track and said they needed to go back to basics; that they had lost their way in terms of focusing on continued improvement and respect for people. It proves the Lean journey is a challenge for all of us — even Toyota — to stay focused, and disciplined."

For health care, he continued, one of the major points of focus should be the collapse of time. "What we try to do is take the waste out of our systems, and as we do, wait times go down, times for STEMI go down, and we're able to provide more timely care," said Toussaint. "The other key thing is that every process must be looked at in terms of whether it is adding value to the patient or not. We try to take non-value-added steps out of patient care; as we do, we reduce errors. There are fewer handoffs, and fewer opportunities for error; this drives lower costs to the patient."

Get out on the 'Gemba'

"One of the key principals of Lean management is to be visible on the Gemba — to go and see for yourself," noted Kaplan. (As the original Lean principals were designed for the plant environment, this basically meant walking the plant floor.) "Toyota expanded beyond the ability to train people and keep processes within the line-of-sight Gemba, to be on the Gemba and respond to workers' concerns. This ran against their own philosophy and principals."

Toussaint added that potentially bad situations will not be caught early "if we are not out on the Gemba." He said that at ThedaCare, "The CEOs and senior executives were there once a week or more often than that." The place of work, he explained, "is where value is created for patients and where you can deeply understand that."

If leadership does not focus on the Gemba, he continued, "We can get excited about a 'new shiny object' and lose focus on what's most important — what problems our staff face, how to remove barriers, how to assure defects are identified and processes are continually improved. You need to be at the bedside to try and understand how to improve process."

Just what are those "shiny objects"? "How many things do we report to the government?" Toussaint posed. "How many other things are overburdening the staff? When I was CEO, I decided that we had seen the enemy and the enemy was us — me — because we kept adding more to their plates. When I started to go to the Gemba and understood that the only thing that matters is what happens at the bedside, I understood it comes down to picking out what is really distracting. We need to stop overburdening our staff and managers and focus on what adds value to the patient."

The way you know if there is proper focus, he continued, is to look at the management team and see where they spend their time. "If they are in their office and at meetings and less on the front line trying to identify defects and solve problems, that's the thing I look at as the first sign of unraveling," he shared.

Spath agrees. To create a hospitable environment that nurtures quality, she says, "It starts with leaders having a better understanding of what is actually happening on the front lines of patient care. Systems and processes must be measured and analyzed with both quantitative and qualitative information. Quantitative data are necessary for policy development, and qualitative data are necessary to know what patients and frontline workers actually experience."

There also must be a climate of open communication among all staff, she continues. "A practice that can promote open communication is reporting of near-misses — situations in which mistakes are caught and corrected before patient harm occurs," Spath explains. "Reports of near-miss events reveal operational trouble spots requiring further investigation. Regular discussion of near-miss events heightens everyone's sensitivity to operations and reinforces the benefit of pointing out quality problems."

Finally, says Spath, "People at all levels in the organization must be encouraged to question the way things are done and question decisions made by others. Frequent interactions between leaders and frontline staff should be encouraged. In some hospitals, senior leaders and middle managers regularly visit different clinical areas to learn about the patient safety concerns of frontline staff and gather their opinions on how risks can be reduced. These interactions reinforce the importance of keeping everyone's eye on the 'safety' ball."

A 'more planful' approach

"Going to the Gemba can be valuable, but we've also created a program here of required executive and leader rounding that is more planful," added Kaplan. "Everyone rounds at least weekly — and many do it more often — with questions that must be asked of both staff and patients. In addition, we use centralized deployment so rounding is not just in their areas of responsibility." This approach, he explained, brings "outside eyes" into the process. "If you're acclimated to an area, you often can't see defects and waste," he explained.

In addition, said Kaplan, data are critically important to look for early trends. "If Toyota had picked up on signals earlier, it may have been able to prevent this from getting as big as it has," he offered.

"People do get distracted by shiny objects," added Spear. "Fundamentally, the way to achieve exceptional performance is to generate and sustain high-speed, broad-based improvement and innovation. You never hit it right on the first try; you have to 'discover' your way to perfection."

That "way," he continued, involves the cultivation of how to design something that captures the best knowledge to date, seeing problems in design when they arise, and if they arise, determining how to solve them. "It's a disciplined process of diagnosis to treatment — getting to the root cause," he noted. "When you have discovered something locally, you share it systemically," he added.

The other key element, he continued, is "the rigor with which leaders are in engaged on the Gemba. Are more people with more rigor doing all of this in a rigorous fashion? If you see that, you can have pretty good confidence you are sustaining."

Kaplan agreed. "You have to remember that in order to really have sustainable change of the magnitude required in health care, you need a deep commitment of senior leaders; I can't emphasize that enough," he said. "The same is true of quality improvement in general — you can have a whole cadre of committed middle management, but all too often but they're up against the inattention of senior leaders."

The bottom line, Spear added, is that health care quality professionals should not lose faith in the Lean methodology. "In the first pass it had tremendous lessons for health care," he asserted. "Toyota took a huge variety of specialties and disciplines and iterated them into a harmonious, well-coordinated system. When people outside of Toyota started to practice Lean, you had tremendous improvement in the late '80s and early '90s." But not all health care facilities, he emphasized, have reaped those benefits yet. "Today, many health care facilities and systems are still in an organizational form like they were in the '80s — stovepipe silos by specialty without good systems to mesh into service lines to deliver great quality," he noted.

Kaplan, for one, is a keen believer in the benefits of Lean, and his system was an early health care adopter. "We decided to take the plunge, and said if you wanted to be a senior leader you had to join us on a two-week trip to Japan," he recalls. A total of 32 people went on the trip, "and came home totally transformed." Said Kaplan: "We saw the opportunity to bring Lean to our patients and our organization, and came to believe the only way to do it was jump into it with both feet. We said, 'This will be our management system: the Virginia Mason Production System.'" They focused on training all 5,000 of their staff in the language, methods, and tools of Lean, with more than 100 certified leaders, who continue to lead workshops every year.

Fortunately for facilities who are now looking to adapt Lean methodology, a trip to Japan is hardly necessary, added Kaplan. "Most facilities that have had success have not been; for us it represented a 'see-feel' we felt we needed." Today, he said, there are lots of other ways to learn Lean methodology. "Manufacturing companies use Lean in most communities across the country," he noted, indicating that many would be pleased to permit a site visit. "And there are now many consulting companies, the Lean Enterprise Institute, IHI, and the Virginia Mason Institute."