John Toussaint’s Monthly Reflections – Why Do We Practice Lean Thinking?

I have had to answer many people during my career why I should espouse this management philosophy that is so hard to learn. The reason is simple; it saves lives. This has never been more clearly demonstrated than the work we witnessed in Westrand and Johannesburg, South Africa. The results CEOs Gladys Bogoshi and Grey Dube achieved are stunning. Maternal mortality dropping 100% in the labor wand at Leratong Hospital. NICU infection rates dropped over 90%, meaning 72 babies were saved year over year from 2017 to 2018. This is in addition to many more lifesaving accomplishments. If you’d like to read more about this click here.
If it works in South Africa, it can work anywhere. Why? South Africa spends 8.2 % of its GDP (the US spends 18.5%) on healthcare, but only 4% on public healthcare. The public system covers some 50 million black South Africans while the other 4.2% of GDP is spent on private healthcare. The majority of the 8 million white South Africans have access to private insurance, private practice physicians and private for-profit hospitals. Most public hospitals are overcrowded, underfunded, and have difficulty serving the needs of the poor black populations. The result are long wait times to see physicians, huge lines to receive medicine, and in some cases very high hospital infection rates that often lead to death.
Mr. Dube was tired of problems landing on his desk that he thought others could be solving. He had been in healthcare for 47 years but was burning out. As CEO of the 850-bed Leratong Public Hospital in Johannesburg he had to do something differently or he was going to quit. He was asked by the Member of Executive Council (MEC) in Gauteng in 2016 whether he would like to join the tour of a hospital practicing lean thinking. He had been recently introduced to the method by a professor from Cape Town University, Norman Faull, who headed up Lean Institute Africa. He jumped at the chance to come to Wisconsin to visit Kim Barnas and me because he was curious to see a different way of managing healthcare. Ms. Bogoshi, CEO of Charlotte Maxeke Johannesburg Hospital, one of the largest academic medical center in Johannesburg, was also struggling with problems. There were throughput issues in the AIDs clinic and soaring infections in the NICU. Staffing was thin and people were over-worked. She was also looking for a different way to address the seemingly endless list of problems landing on her desk at her 1200-bed public hospital. She was excited to come to Wisconsin.
Both were forever impacted by their visit. They saw a lean management system in action and quickly understood how this could impact their operations in South Africa. Kim and I agreed to work with Norman Faull and the two CEOs virtually. Unbeknownst to us the virtual coaching we would do would be a precursor to how we would end up doing all of our work during the pandemic.
We outlined a 13-month Shingo principles-based executive coaching process, which was designed for each of them to apply the learning of a new principle monthly and then practice a behavior related to that principle in their daily work. At the end of the month, they would report back what they were learning and ask us questions. Using a series of video learning materials and chapters in our books they persevered and almost immediately began seeing results.
Both commented that the secret sauce was changing their own behavior. Mr. Dube and Ms. Bogoshi are excellent students. Culture is about behaviors and they took to heart our first teaching session regarding leadership behaviors. There are five behavioral traits important to building a culture of continuous improvement. Willingness to change is at the top. We observe whether an executive is willing to change if he/she is practicing the process of self-reflection. Is there a time in the day or week when the executive steps back to deeply understand how their behavior is impacting the staff? Some questions that can help guide this reflection are; what did I do this week that unleashed the creativity of my team or what did I do this week that shut them down? A second trait is humble leadership. This trait is practiced when leaders go to the gemba, whether this is in the emergency room, surgical suite, or anywhere else value is create for patients. Leaders carefully observe the work and ask open-ended questions to understand how the work is performed to understand the barriers staff face. The third trait is curiosity. This is practiced by listening carefully to staff. This must be done in an empathetic way to deeply understand what they are trying to tell you. Executives should never propose ideas until they have listened carefully and understand the current state of the existing work. The fourth trait is perseverance. This is manifested by anointing a “buddy,” someone you trust to give you direct feedback about your behavior. Both CEOs used a buddy every week. The buddy watched whether they were leading in a way that supported and celebrated the work of staff or conversely turned their brains off. Finally, the remaining trait is self-discipline. This is practiced by creating leader standard work, which is focused on creating better customer value. An example would be making sure you have gemba visits on your calendar each week.
Ms. Bogoshi and Mr. Dube found leader standard work to be the biggest challenge. Going to the gemba became the mantra and they did that two or three times a week. They shared their behavioral trait radar chart with their subordinates, and they created an expectation that all managers would focus on the same behaviors. They coached their subordinates on these behaviors and had them review the same video homework we had given them. Ms. Bogoshi said she viewed one of the videos nearly 20 times.
The change in the leaders’ behavior led to soaring staff engagement. Most of the ideas that resulted in dramatically lower infection rates and reductions in mortality were proposed and implemented by frontline staff. In one case, a housekeeper became the teacher of the appropriate handwashing technique in the NICU. The doctors learned from a housekeeper. That would not have happened before lean.
I am sure you have your own remarkable story about how lean thinking has changed your life and the lives of others. Share it with me at [email protected]

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