Lean at the front line: all hands on deck.

AUTHORS DAVID MANN AND KURT STUENKEL and Taunya Faulkner offer encouraging views of their hospitals' journeys toward improving quality, safety, and efficiency while reducing costs. Their articles represent a breathtaking shift in the philosophy of healthcare improvement over the past decade, and point the way to future action. In 200I, the fledgling Pittsburgh Regional Health Initiative (PRHI), a nonprofit consortium of business and healthcare leaders in Southwestern Pennsylvania, began examining the region's healthcare system. Through PRHI, business leaders held out the possibility that the tenets of the Toyota Production System (TPS), or Lean, could improve efficiencies in hospitals. At that time, the idea was a hard sell. A preponderance of hospital leaders still believed that improving quality would increase cost. They saw the goal of perfection as unrealistic. Many saw Lean as the latest in a series of top-down projects that would soon expire. Pilot PRHI projects proved that: (i) improving quality reduces cost; (2) despite its industry genesis, Lean propels improvement in healthcare; and (3) without commitment from top management, efforts stall (Grunden 2008). Mann and Stuenkel and Faulkner demonstrate a deep understanding of safety and its relationship to cost and satisfaction, and a commitment to making continuous improvement part of hospital culture. Theirs is becoming the prevailing attitude. PEOPLE FIRST Mann understands that a people-first philosophy undergirds Lean, and that tools are secondary to relationships. Lean expert Jeffrey Liker concludes that "organizational change must start with individual change. He believes coaching, self reflection, and learning by doing are needed at every level of the organization to achieve change" (Falbo n.d.). American healthcare has traditionally been oper- ated in a "top-down" or "command and control" fashion, with leaders giving directions that trickle down through managers to frontline staff, who are left to puzzle through implementation. Graban (2008) speaks of the "incalculable waste when employees just show up, do their jobs (as told to, or as they have always done it), and go home." A facility that embraces Lean thinking views every employee as an asset. Their work furthers the organization's goals of providing (1) value for the customer and (2) prosperity for the hospital (Graban 2008). While leaders set the vision, priorities, processes, and measures, the real action occurs on the front line of care, not in the C-suite. In such an environment, leaders move away from rigid command and control, away from "project by project" increments, and toward arming frontline workers with the tools they need to improve their work every day (Thompson, Wolf, and Spear 2003). No longer "bosses," managers become mentors and coaches, helping bridge organizational boundaries to improve care and remove waste. Improvements are not immutable fixes, but experiments that can be revisited and adjusted as the work flow indicates. Spear (2009) speaks of four capabilities of high-velocity organizations: (1) designing work to capture existing knowledge and building in tests to reveal problems; (2) swarming and solving problems to create new knowledge; (3) sharing new knowledge at every level; and (4) leading by developing the first three capabilities. Managing according to that fourth capability requires all hands on deck. Mann and Stuenkel and Faulkner provide blueprints for engaging managers, which, while important, may not be sufficient to achieve organizational transformation. The real work begins when the new process knowledge is disseminated throughout the organization, and when frontline workers, under the guidance of a coach, begin to call the shots on what to improve. Convis (1999) says, "People are an organization's most important asset, and... the focus of a successful company must always be on the shop floor. Many executives fail to place proper emphasis on these critical areas. …