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The Missing Link: Lean Leadership

B Y D AVID M ANN

Su m m a r y • People often equate “Lean” with the tools that are used to cre-
ate efficiencies and standardize processes. However, implementing tools rep-
resents at most 20 percent of the effort in Lean transformations. The other 80
percent of the effort is expended on changing leaders’ practices and behaviors,
and ultimately their mindset. Senior management has an essential role in
establishing conditions that enable that 80 percent of the effort to succeed.
Their involvement includes establishing governance arrangements that cross
divisional boundaries, supporting a thorough, long-term vision of the organi-
zation’s value-producing processes, and holding everyone accountable for
meeting Lean commitments. This is accomplished through regular, direct
involvement. When upper management sets the example, durable Lean suc-
cess and an increasingly Lean leadership mindset follow.

F E A T U R E

David Mann, PhD, an organizational psychologist, retired as the manager of

Lean management and organization development after 21 years at Steelcase in
Grand Rapids, MI. He is a consultant on Lean issues to healthcare and other
industries.

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Introduction process-focused measures alongside

There is a missing link in Lean. This conventional measures of results;
missing link is the set of leadership 5. Creating conditions in which a sustain-
behaviors and structures that make up a able Lean culture of continuous
Lean management system. improvement can develop.
Lean management bridges Lean management bridges
a critical divide: the gap a critical divide: the gap For an enterprise-wide Lean initiative
between Lean tools and between Lean tools and to succeed, leaders at three organizational
Lean thinking. Systematic levels must play complementary roles.
Lean thinking.
Lean management sepa- Figure 1 shows a schematic of these three
rates Lean initiatives that start well but fal- levels, areas of primary contribution, and
ter from those that sustain initial gains tasks. Note the overlap between adjacent
and deliver further improvement. levels. This overlap reinforces continuity
Senior leaders play a central role in of support for new practices throughout
Lean management. Their contributions the organization, e.g., disciplined adher-
are essential in: ence, attention to process performance at
intersections, and gemba walking (which
1. Developing and implementing struc- takes managers to the front lines to look
tures and processes that anticipate and for improvement opportunities). This con-
respond to the difficulties of a Lean ini- tinuity maintains the internal integrity of
tiative that crosses internal boundaries; Lean tool implementations and the Lean
2. Transforming commitments to change management system.
into actual change, supporting and sus- Most of the literature on Lean conver-
taining new behaviors and practices; sions has focused on implementing the
3. Increasing the odds that process Lean tools (to create flow, establish pull,
improvements survive the transition support just-in-time production, etc.) in
from project mode to ongoing process; manufacturing (Womack and Jones
4. Establishing and maintaining new, 1996; Rother and Shook 1998; Dennis

Figure 1. Organizational Roles and Contributions to Sustain

a Lean Initiative
Leadership Roles in Sustaining Lean

Organization Primary Secondary

Level Contribution Tasks Contribution Tasks

Strategic: Senior Governance; Steer- Support for a cross- Measurement; Adher- Monitor intersection
(CEO, Sr. VP) ing and oversight boundary perspective ence to post-project measures; Gemba walks
processes
Programmatic: Accountability Meet project commit- Disciplined adherence; Collaborate in process
Function (VPs, ments; Manage inter- Commitments to management; Gemba
Directors) section performance processes post-project walks
Tactical: Depart- Tactical Lean Disciplined adherence; Associate engage- Teach, practice root
ment (Managers, Mgment System Gemba walks ment; Continuous cause problem solving
Supervisors) improvement

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2002). Some of the literature has implementations often blame the initia-
explored Lean tools in healthcare, office tive’s collapse on a failure to adhere to the
settings, or product development Lean design at lower levels. This failure in
processes (Graban 2008; Keyte and turn is often caused by changed, weak, or
Locher 2004; Swank 2003); or focused absent support by senior leadership—
on leadership rather than tools (Mann CEOs and their direct report senior VPs.
2005; Spear 2004). Critiques of the tools- All three levels called out in Figure 1 are
only focus note that even brilliant use of important, and closely related.
tools without changes in culture rarely
produces lasting change, or even lasting Lean Principles and Value
improvement. But, what does culture Streams
mean in the context of Lean conversions? Womack and Jones (1996) identified sev-
eral Lean principles. Their first is that
Culture, Reinforcement, and value is defined from the perspective of
Persistence the customer. The second is that value
For purposes of this discussion, culture streams need to be identified. Value
is simply the sum of how those in an stream is another way to refer to a
organization would describe “the way we process; often, and especially in health-
do things here.” These customary ways care, processes include multiple steps.
of operating often directly contradict Moreover, in complex organizations, most
stated rules and policies. Behavior—i.e., value producing processes cross many
the customary way of doing things—both departmental and functional boundaries.
creates and reflects actual culture regard- Many units in an organization play value-
less of the official definitions of what is added (and frequently non–value-added)
to be done, or how. Behavioral science roles in the value streams.
shows that reinforced behaviors persist, For example, the following depart-

F E A T U R E
which helps explain how cultures ments are parts of a surgery value stream:
develop. In an organization, the most admitting, scheduling, medicine, radiology,
important source of reinforcement is laboratory, surgery, operating room man-
leadership. “The way we do things…” in agement, pharmacy, nutrition services,
other words, reflects leaders’ reinforce- nursing, patient transport, housekeeping,
ments, conscious or not. finance, billing, social work, purchasing,
Successful sustained Lean conver- and compliance and audit units. There are
sions often involve changes in culture. So many multi-step cross-functional processes
it follows that success in Lean implies a on the administrative side as well. Consider
change in what leaders reinforce—a those involving customer service, registra-
change in leadership behaviors and prac- tion, billing, medical records, third-party
tices. The failure of most Lean initiatives payers, IT, clinical quality, and others. For
can be pinned on a failure to change lead- purposes of our discussion, Lean improve-
ership practices (Mann 2005). ment projects focus on improving the per-
As Figure 1 suggests, effective Lean formance of the value-producing process,
1
leadership comes from the top as well as the value stream, as a whole.
from lower in the organization. Post- If customary ways or habits are one
mortem discussions of unsuccessful Lean complicating factor in Lean transforma-

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tions, organizational boundaries are a Some tools-only approaches to Lean

second. In a word, this is the problem of focus on productivity or service quality in
turf. Womack and Jones’ third principle of individual departments, creating islands of
Lean calls for finding and eliminating the improvement. However, improving value
interruptions—such as turf battles—that from the customer’s perspective nearly
impede the flow of value. always involves collaboration across bound-
Organizational boundaries often cre- aries, even when improvement might
ate flow interrupters in the value streams appear from a distance to be the result of
of complex organizations. For example, change in a single department. For exam-
Radiology resists moving available equip- ple, reducing central line infections, which
ment into the Emergency Department appears to be a single point focused effort,
(ED) even though it would speed ED in fact is the result of information and pro-
patients’ diagnosis, treat- cedure changes across several organiza-
Wise executives leading ment, and discharge. Such tional units—admissions, residency
Lean initiatives recognize a move would hurt Radiol- supervision, intensive care, pharmacy,
that people in functional ogy’s productivity and over- nursing, and phlebotomy (Spear 2005).
head numbers—they would
organizations naturally
have to staff and maintain CEOs and Senior VPS: System-
resist cross-functional assets beyond their bound- Level Intervention for Lean
initiatives. aries. So, Radiology’s focus Governance
on internal measures of Wise executives leading Lean initiatives
productivity and efficiency compromises recognize that people in functional orga-
customer value—the patients’ desire for nizations naturally resist cross-func-
speedy treatment and release. tional initiatives. This is often worse in

Figure 2. System-Level Support for a Value Stream Perspective

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multi-specialty, multi-stakeholder organi- internal perspective. The LSO group also

zations such as healthcare institutions requires leaders to support planned
and universities. In a functional organi- improvements, even when that requires
zation, horizontal processes—value changing processes or priorities in their
2
streams—do not appear on the organiza- areas of responsibility.
tion chart. No one is responsible for The second element of the executive
managing a value stream. Value streams governance process occurs at the project
have no independent budget or level. It consists of a project resource and
resources. And measures of value stream accountability (PR&A) panel made up of
performance rarely appear among those leaders of the functions or departments in
considered important; in fact, measures the value stream targeted for improve-
rarely exist for horizontal processes. ment. It is an informal group, a steering
Lean governance responds to the team for the project rather than an ele-
dilemma of a process approach within a ment on the org chart or an item in any-
functional organization without changing one’s job description. The leader of the
the formal structure. These arrangements PR&A panel, the value stream sponsor, is
are represented in Figure 2. A senior exec- usually the leader of the function or
utive governance process is the first step. department that encompasses the largest
The second is an accountability and excep- portion of the value stream or whose area
tion management structure. The executive is most critical for the customer in the
governance process should create recogni- value stream’s performance. As value
tion of and commitment to a sense of stream sponsor, the panel leader is
common purpose across boundaries. The responsible to the Lean executive gover-
commitment to a shared view of customer nance body, the LSO, for setting appropri-
value carried across organization bound- ately bold objectives (e.g., 50 percent
aries is required for an effective approach reductions in cycle time, errors, and

F E A T U R E
to value stream improvement projects. rework) for the project, and for executing
Later, this commitment sustains and the plan to achieve them.
extends the project’s gains. The LSO oversees the value stream
The executive governance process Lean projects. The organization’s Lean ini-
has two elements. The first is an execu- tiative leader serves as secretary and
tive Lean steering and oversight (LSO) agenda manager for the LSO, and he or
group made up of the CEO and his or she tracks progress of all the projects.
her senior vice president direct reports. When a project stalls, the Lean leader
The LSO group calls for, sanctions, and invites the project’s value stream sponsor
supports Lean value stream improve- to brief the LSO on the project’s status.
ment projects. These steps mandate a These updates usually result in action
“virtual process organization” for the to overcome the project’s obstacles, which
entire Lean value stream improvement might include, among other factors,
project. The LSO group insists that VPs, unmet commitments by a unit repre-
directors, and department managers con- sented on the PR&A panel, unavailable
sider the entire organization when evalu- resources, or conflicting priorities. PR&A
ating proposed changes to the value panel members report directly to LSO
stream, rather than taking a parochial members, or individuals one level below

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the LSO. So, LSO members can remove stream sponsor is for LSO support in
obstacles or encourage more vigorous removing obstacles. Accountability in the
support for projects, by their direct inter- formal authority structure is normal. But
vention or through the Lean leader. accountability also flows horizontally
among the PR&A panel members, which
Vertical and Horizontal is unusual in functional structures.
Accountability for LSO group members make clear
Improvement within their units and during project
The relationship between the two ele- updates that commitments to Lean pro-
ments of executive governance—the LSO jects are to be met. If achievement of the
group and the PR&A panel—implies an project’s objectives requires compromise
expectation for accountabil- and collaboration with other departments
If achievement of the ity between the LSO and in the value stream, so be it.
project’s objectives PR&A, an expectation made
requires compromise and explicit when process spon- VPs and Directors: Meeting
sors are invited to brief the Commitments to Projects
collaboration with other 3
LSO. and Intersection Measures
departments in the value The expectation of the As seen in Figure 3, measures of process
stream, so be it. executive governance performance for most value streams are
process is for the subordi- straightforward and scalable. A value
nate functional VPs and directors to stream’s process measurement set typically
meet the commitments they have made consists of safety, quality, delivery, and cost.
to Lean value stream improvement pro- Safety covers workplace accidents
ject teams. The expectation of the value and injuries. The quality measure

Figure 3. Value Stream Process Performance Measures

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includes defects, errors, rework, first- three levels of leadership in a successful

time quality, and customer satisfaction. Lean initiative.
Delivery (or throughput velocity) refers to
total cycle time, or the total end-to-end Department Managers:
time from beginning to end of the Tactical Lean Execution
process (sometimes known as total lead Lean applications, the Lean “tools,” are the
time). Cost is measured by labor hours focus of most discussions about Lean. The
(also known as process time, or touch tools are typically seen where the task-level
time) and externally purchased services work gets done, at the department level.
and materials. Some examples include: color-coded
All of these measures apply to the patient garb indentifying those at risk of
process in its entirety, as end-of-process falling; visual indicators in an ED signify-
measures. And, each of them applies just ing ready for X-ray; regular routes for
as appropriately to a function’s or depart- replenishing consumable supplies in
ment’s performance at the point where patient rooms; standard procedures for
the process intersects the function. Value handling incoming hard copy charts and a
stream improvements can almost always takt pace (a pace that matches production
also be described in terms of discrete to demand) for scanning them into elec-
improvements in safety, quality, delivery tronic medical records; and standard pro-
or cost within departments, or at between- cedures in sterile processing with
department handoffs. one-procedure-ahead tray delivery to the
This translates into concrete measures OR.
of collaboration and commitments. PR&A These are a few of many applications
panels meet at 30-day intervals to review of Lean tools. As noted earlier, although
their project team’s progress. These “inter- these tools may on the surface appear to
section” measures put the value stream be single point, within-department

F E A T U R E
sponsor’s job of working with peer PR&A process improvements, many involve two,
panel members on project governance on three, or multiple organizational units.
a more straightforward and objective foot- Rapid improvement activities, or kaizens,
ing; intersection measures meet their within individual departments are impor-
goals or not. And, it puts the LSO’s tant for the experiential learning central to
assessment of project status on an objec- developing a broad base of Lean thinking
tive footing, along with corrective action in an organization. But kaizens tied
members might direct in their own orga- together as the implementation plan of an
nizations. end-to-end process are far more potent in
So, responsibility for accountability changing organizational, as opposed to
overlaps the boundary between senior departmental, performance.
and subordinate executive leadership lev- This tactical level of Lean is where
els (in Figure 1, between levels 1 and 2); emphasis on disciplined execution is
accountability is a task and responsibility clearest, the primary Lean responsibility
at each of these two levels. This is also the of departmental management. The fre-
case between level 2 executives and quently updated performance tracking
department managers (see Figure 1). In charts, focus on root cause analysis and
fact, disciplined execution permeates all problem solving, value stream mapping,

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and kazien projects are all based on adherence to process. It has three core
adherence to standardized methods. elements: visual controls, consisting of
This approach is in keeping with the sci- frequently updated process performance
entific method, i.e., systematically vary charts; standard accountability processes;
the independent variable (the planned and standard work for leaders (“leader
change to the standardized procedure) rounds”). Among other things, leader
and observe the variation in the depen- standard work ensures execution of stan-
dent variable (the process outcome to be dardized processes. Leader standard work
improved). If improved outcomes are also ensures performance-tracking data
observed as predicted (safer, fewer are well and faithfully recorded, and then,
defects, faster, or less costly) verify the in accountability processes, converted
causal relationship, and then institute into assignments for problem solving and
the changed procedure. corrective action. Finally, leader standard
Lean is a high-maintenance For departmental man- work ensures consistent execution of the
approach.... agers, supervisors and resulting improved process. Figure 4
Most of us prefer to do team leaders, this approach shows this closed loop process. (For a full
is called a Lean manage- discussion of the Lean management sys-
things as we always
ment system (LMS). It is a tem, see Mann 2005).
have....It is what set of leadership practices, Leader standard work is developed
humans do. tools, and behaviors that with intentional partial redundancy
creates a closed loop sys- upward through the chain of command. In
tem for focusing on process and driving a Lean design, value adding task-level per-
process improvement. This system is, in sonnel spend virtually 100 percent of their
effect, a behavioral recipe for disciplined time following task-level standardized pro-

Figure 4. Lean Management as a Closed-Loop System Focused on

Process to Drive Improvement

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cedures. Some examples are: Following the tered and interruptions to expected rou-
defined process when consumables in a tines noted?) of at least one of the leaders
specific location reach the reorder point; between the task level and the executive.
observing defined times and routes for This built-in redundancy reflects the
picking up lab specimens; ED providers importance of standard methods as the
adapting to agreed protocols for patient foundation of Lean execution, as well as
prep; OR managers following the intent, the basis for Lean as an improvement
not just going through the motions of pre- system. If the independent variables are
surgery checklists; patient care assistants being held constant, outcomes should be
following prep-for-X-ray procedures; or predictable, and when not, sources of
unit clerical staff following standards for variation are more readily diagnosed and
preparing hard copy chart documents for eliminated.
scanning. Team leaders spend most of
their time —70 to 80 percent—making CEO to Department Manager:
sure defined procedures in their areas, Lean in Every Leader’s Role
such as the above examples, are being fol- Expect Lean applications to require a sur-
lowed. The rest of their time is available for prisingly high level of attention. Lean is a
troubleshooting and work on improve- high-maintenance approach. Though this
ments. Supervisors spend roughly half may seem paradoxical, it is true for two
their day on standard work, including veri- reasons. The first is that most of us prefer
fying execution of one procedure or prac- to do things as we always have. Without
tice in each team leader’s area per day, and an ongoing and consistently reinforced
reviewing the team leaders’ standard work set of behaviors that replace our habits,
documents. The department manager’s we revert. It is what humans do.
standard work might account for 25 per- Second, Lean applications require
cent of the day, and includes spot checks of attention because they are designed that

F E A T U R E
a procedure or practice per day per supervi- way. Specifically, Lean processes are
sor, as well as reviewing supervisors’ stan- designed to be, well…Lean. That means
dard work documents. consuming the least material and time;
Directors and above also have stan- the least space, inventory, and equipment;
dard work, but more in the form of a and overall the fewest resources possi-
checklist to use when they are in their ble—and maintaining this level requires
groups’ work areas. The expected fre- attention. Moreover, Lean processes are
quency and duration of tasks in execu- designed to be sensitive to abnormalities
tives’ standard work is quite a bit less such as defective inputs, scrambled tim-
than for department managers and ing and sequence, and other variances
below, perhaps only an hour a week. The from specified operating conditions. Has
executive checklist should nevertheless sterile processing returned to batching
include verifying procedures and prac- rather than procedure-by-procedure
tices at the task level—where the value- preparation, one per OR at a time? Are
adding work takes place—are being labeling procedures being followed for
faithfully executed, and asking to see the lab specimens when nurses are busy? Are
standard work document (is it current? is procedure carts left where last used
it being followed? are problems encoun- rather than returned to the designated

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location? Are they restocked with some pursues Lean, the more opportunities for
but not all of the regularly used consum- improvement it sees. When members of
ables? Is the ED stat lab getting speci- a Lean organization say, “We still have a
mens a patient at a time, or batched by long way to go,” it is not false modesty. It
corridor or wing? is the result of constantly improving Lean
Lean processes are designed to high- acuity, the ability to see more clearly the
light problems. In a Lean thinking mind- next opportunities.
set, problems are valuable nuggets of
information to be mined for clues to the Lean as Improvement: What
best places to make improvement. By con- to Expect
trast, in a conventional mindset, problems Lean is more than a cost reduction sys-
are obstacles to be worked around, buried, tem. Instead, at its essence, Lean is an
and forgotten, even if they improvement system. Lean designs serve
The longer an organization constantly recur. Lean both as operational processes and as
pursues Lean, the more processes are precise and hypotheses. The hypothesis is that the
opportunities for delicately balanced, but effi- current design is the best way we know at
cient and predictable. Con- present to perform these steps or proce-
improvement it sees.
ventional processes may dures. The implication is that associates
not be efficient or predictable, but they are and leaders are observing, recording data
robust with respect to variation, and with on process performance, and participating
enough time, resources, and heroics can in learning. This is preparation for the
be “muscled through.” next improvement—an application of
Lean is often mischaracterized as Deming’s iterative plan-do-check-act
being all about cost reduction. In fact, it (PDCA) cycle, in which experience with
is quite different from any conventional an implemented plan (plan-do) produces
method for lowering costs. Lean most feedback that suggests refinements
definitely reduces costs, but as an ancil- (check-act), which are designed and
lary benefit. Consider the fifth of Wom- implemented (plan-do), leading to further
ack and Jones’ five principles of Lean: experience, feedback, and improvement.
strive for perfection. In context, this Do not expect a Lean process conver-
means continuing to iterate your way sion to be a set-it-and-forget-it proposition.
through the first four principles (identify The regressive pull of old habits and con-
customer value, find the value streams flicting priorities and practices elsewhere in
that produce it, eliminate impediments to the organization, and the deliberate sensi-
let value flow, and arrange for customers’ tivity to faults designed into Lean processes,
ability to pull value when and how they make a Lean conversion a high-touch enter-
want it) until you have achieved perfec- prise. Lean designs require attention to the
tion: delivering value with zero faults, their root causes, and root cause cor-
4
non–value-adding activity. For scale, the rective action. Otherwise, temporary
best value streams in repetitive manufac- patches morph into permanent fixtures, the
turing industries operate at only a 10:90 design degrades, and practices revert to the
ratio of value-added time to non–value- way we’ve always done things.
added time; many operate at a shocking However, if the Lean design is accom-
1:99 or below. The longer an organization panied by a Lean management mindset,

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you will come to view the current process is known as gemba walking. Gemba trans-
as an experiment. It will be an improve- lates as the “real place,” where the action
ment, but also a way to discover further of interest happens—where the value-
improvements. Shigeo Shingo, an impor- adding work occurs. Executives should
tant early participant in the development expect to spend 45 to 60 minutes every
of Lean thinking at Toyota, noted that the week or two gemba walking with a Lean
best approach is to seek out problems teacher, or sensei, for six months to a year.
where none are thought to exist so as to Thereafter, they should regularly gemba
identify opportunities for further improve- walk on their own. Gemba walks are cru-
ment (Shingo 1985). So, in the fifth Lean cial to maintaining the disciplined adher-
principle—strive for perfection—the ence to Lean process designs, part of the
emphasis falls on “strive,” as in “don’t Lean support role permeating all leader-
cease working on improvement.” ship positions. Gemba walks form the
connective tissue that maintains the gains
Gemba Walking: A Teaching- from Lean and the muscle that drives fur-
Learning Model for Leaders ther improvement.
at All Levels Executives should read about Lean
Given that Lean is an intentionally high tools and principles, and attend a Lean
maintenance approach, and that Lean event annually. But the principal Lean
management sustains it, it should not be education for executives comes via struc-
surprising that a standard approach exists tured gemba walking with a sensei-coach
for leaders to monitor Lean management (see Mann 2005, Ch. 6).
practices. The practice follows a three-part
rule: 1. Go to the place. 2. Look at the Summary: A Lean Mindset for
process. 3. Talk with the people. This Lifetime Lean Leaders
process has two benefits. When senior Lean is more than just a kit of tools to

F E A T U R E
executives go to the work area, carefully improve flow and quality. It is a business
observe the work as actually done, and philosophy, and to be effective over the
inquire about the process, they reinforce long run, discipline is essential. Every
Lean management practices, which sus- leader must spend some of his or her
tain and extend the gains from Lean con- time focusing on the adherence to the
versions. This benefits the Lean initiative. Lean process, and noting the improve-
A second benefit comes when the ment opportunities such focus reveals.
senior leader goes to the work area, accom- Discipline is the essential element in sus-
panied by a Lean coach and prepared with tained Lean performance.
diagnostic questions to guide his or her Most Lean conversions fail to deliver
observations, questions, and conversations the promised benefits or hold initial
with those in the area. This benefits the gains. These disappointments result
executive by engaging him or her in active from the mistaken belief that Lean is a
and challenging experiential learning cost reduction system, and once imple-
about Lean principles and the issues that mented, brings permanent improve-
arise when implementing them. ment. This is simply not true. Lean
The practice of regularly going to the conversions require a consistent Lean
Lean workplace to see the actual practices management approach.

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Sustained Lean success requires a 3. An effective practice limits duration of implemen-

change in mindset and behavior among tation plans to 90 days at a time, with successive
leadership, and then gradually throughout 90-day segments as called for. Ninety days is
the organization. Lean success occurs when long enough for substantive improvement, yet
short enough to maintain a sense of pace and
senior leaders put appropriate structures
urgency. Within the 90-day segments, weekly
and processes in place and get personally reviews internal to the project team, and monthly
involved in sustaining the Lean conversions, reviews with the PR&A panel, reinforce pacing
learning Lean, and develop- and surface interrupters and obstacles early
Lean provides the ing other Lean thinking lead- enough to respond, recover, and maintain pace.
4. Although note that Lean thinkers are not insensi-
templates and practices ers throughout the tive to the need for temporary patches or coun-
enterprise. Lean manage-
that enable leaders to termeasures to keep the process meeting its
ment is surprisingly different commitments.
learn, and then look for, from conventional leadership
ask about, and reinforce practices. It emphasizes visi- References
the leadership behaviors bly observable discipline and Dennis, P. 2002. Lean Production Simplified: A
accountability. Unlike other Plain Language Guide to the World’s Most Power-
that sustain the gains. approaches to improvement, ful Production System. New York: Productivity
these cannot be delegated. Lean provides Press
Graban, M. 2008. Lean Hospitals: Improving Qual-
the templates and practices that enable lead-
ity, Patient Safety, and Employee Satisfaction. New
ers to learn, and then look for, ask about, York: Productivity Press
and reinforce the leadership behaviors that Keyte, B. and D. Locher. 2004. The Complete Lean
sustain the gains. Enterprise: Value Stream Mapping for Administra-
When senior leaders establish the sys- tive and Office Processes. New York: Productivity
Press
tem-level elements of Lean management,
Mann, D. 2005. Creating a Lean Culture: Tools to
engage consistently in the Lean initiative, Sustain Lean Conversions. New York: Productiv-
and adopt it as an important element in ity Press
their organization’s strategy and approach, Rother, M. and J. Shook. 1998. Learning to See:
benefits will accrue from a progressively Value Stream Mapping to Create Value and Elimi-
Leaner leadership mindset. Eventually a nate Muda. Brookline, MA: Lean Enterprise
Institute
Lean culture will grow from this consis-
Shingo, S. 1985. A Revolution in Manufacturing:
tent effort, and striving for perfection will The SMED System. Stamford, CT: Productivity
become “the way we do things here.” Press
Spear, S. 2004. “Learning to Lead at Toyota.” Har-
Notes vard Business Review 82 (May): 78-86.
1. Some Lean initiatives are more narrowly Spear, S. 2005. “Fixing Health Care from the
focused, concentrating on improvements Inside, Today.” Harvard Business Review 83 (Sep-
within individual departments. While this tember): 78-91.
approach can yield benefits, it is prone to pro- Swank, C. 2003. “Lean Service Machine.” Harvard
ducing isolated islands of improvement that Business Review 81 (October): 123-129.
have little cumulative effect on the customer’s Womack, J. and Jones, D. 1996. Lean Thinking:
perception of value produced by the end-to-end Banish Waste and Create Wealth in Your Corpora-
value stream. tion. New York: Free Press
2. In this way, senior executive sponsored Lean pro-
jects can act as vehicles for strategy deployment
as well as for process improvement.

26 • frontier s of h ea lt h s e r v i c e s m a n a ge m e n t 2 6 : 1