My Dad used to buy Rovers until one blew up…

My Dad always used to buy Rovers – then one at only 18 months old blew up on holiday. Stranded with family, reliability suddenly took center stage. Ever since then every car has been a Toyota or Honda. As a result Rover went bust (well a contributing factor at least!).

UK Car manufacturer reliability index (2012)

1. Daihatsu
2. Honda
3. Suzuki
4. Toyota
5. Chevrolet
6. Hyundai
7. Lexus
8. Ford
9. Mazda
10. Skoda

+ 29 others!


It’s no surprise that 6/10 top brands are Japanese – but what’s the secret?

A few months ago Eiji Toyoda died after 60 years in service at the helm of Toyota. Things were not always great. The CEO went home humbled after trying to get a Toyota over the Rockies in a US PR stunt  Toyoda was the guy who turned this mediocre car company that manufactured just 2000 crumby cars a year in 1950 into a global powerhouse.

So what happened?

The first step was they acknowledged who and where they were in the quality stakes then looked outside the box for assistance and help. Enter Edward Deming, sent by the US to assist post war Japan. The improvement scientist taught a new leadership and systems approach in Japan that involved 1) empowered front line staff, 2) a systems approach, 3) live statistical variance analysis and most importantly 4) continuous incremental improvement (termed kaizen by the Japanese). His methods meshed perfectly with the Japanese tireless effort to eliminate waste and a lean society. The highest medal for manufacturing in Japan is indeed the Deming award while Toyoda developed the Toyota Production System.

How do we define a perfect process? For Toyota its one where every step is:

  • Valuable
  • Capable
  • Available
  • Adequate
  • Flexible
  • Linked by continuous flow

The main focus of all this is to eliminate waste (or muda) in its widest sense:

  • Overproduction
  • Waiting
  • Transporting
  • Processing time
  • Excess inventory
  • Excess motion
  • Correction of defects

At this point it’s important to note that one cannot simply apply the ideas of lean manufacturing to get the results. Leadership create the culture on which to build the learning system. Staff then use the tools effectively as part of a standardized process.


So what does a lean culture look like? Maybe reflect on where your organisation is at.

‘Traditional Culture’

‘Lean Culture’

Functions in silos Integrated interdisciplinary teams
Managers direct Managers enable
Benchmarking justifies ‘just as good’ Seek ultimate performance, absence of waste
Blame people Root cause analysis & system diagnostics
Rewards individuals Rewards groups
Supplier is enemy Supplier is ally
Guard information Share information
Volume lowers cost Removing waste lowers cost
Internal focus Customer focus
Expert driven Process driven

Here’s a few examples of how it plays out on the production line:

  1. Quality at Source: A worker sees something that has the potential of going wrong. One pull and the whole production line slows, another and it stops and a senior technician is there is 30 seconds
  2. Pull systems ensure the correct inventory is drawn to the line, ‘just in time’
  3. Middle managers on the line – no offices remote.
  4. Worker empowerment: Workers provide 1.5 million suggestions a year – over 90% are tested practically
  5. Suppliers are seen as integral part of the system, involved in the system diagnostics and trained alongside
  6. Reduced set up times as new kit is prepared in parallel and process improved to slot into the flow

toyota-production line

Now the first observation everyone makes is that patients are not cars and so it really doesn’t apply. (before that they said this system could only work in Japan, only on cars and all kinds of other rubbish). Healthcare is incredibly complex and involves all kinds of processes, flow, equipment, knowledge, timing to produce the desired effects. (Hey cars are pretty complex too, with on average 30,000 parts). Categories of ‘waste’ are certainly present wherever there is a process and thus the principles apply, but the specifics need translation.

For instance, imagine the above were translated into healthcare:

nhs staff

  1. Everyone including the HCA or cleaner is comfortable enough to interject and call a time out regarding a patient safety concern
  2. Key assessments, equipment, investigations and treatments are facilitated by triggers drawing patients through the system / restock is automated ensuring key equipment is always in place.
  3. Middle managers are in amongst the work for the majority of the time and execs do the rounds, engaging with staff and patients.
  4. There are no work-arounds or putting up with inconvenience as staff suggestions are actively encouraged and systematically incorporated into the improvement machine
  5. Different departments, even sectors train each other at the fringe of their interactions, all having an appreciation of one another’s flow and challenges
  6. Patients don’t wait for staff to set up for procedures, they enter the room and it’s a seamless flow of progress

virginia mason

These are just some of the aspects of ‘lean care’ at Virginia Mason, a small healthcare system with 5000 employees in Seattle. Back in 1990s it too was a mediocre outfit, losing money and quality was poor. They too humbly accepted the data and looked outside of themselves for solutions. The clinical leaders visited the heart of Toyota, observing the shop floor, culture and processes. A Toyota manager who visited the hospital to assist was shocked to see so may rooms with no apparent function. “Those are waiting rooms” they said. “Are you not ashamed” he asked?

Using the LEAN principles of Toyota, Virginia Mason produced startling results after just 2 years with no layoffs:

–          Nursing time with patients 30% > 90%

–          Productivity:  Free up 150 WTE – reinvestment in increasing capacity and capability

–          Inventory down $1.3m

–          $7m saved in cancelled building projects not required

–          Waiting times down 44%

–          Floor space down 41%


The translation to healthcare was the Virginia Mason Production System. So how does it work day to day, month to month?


–          Every Tuesday all projects are presented to the executive and clinical directors (on average 20 projects at one time)

–          Execs do regular floor rounds with staff and patients

–          Mandatory training with regular site visits for all execs (including to Toyota)

Staff training:

–          40 full time improvement experts support and guide the workforce ‘masters level’

–          400 clinicians trained to ‘experts’

–          All staff receive basic training

Process change

–          3P Production preparation process: 5 day event bringing dedicated and diverse stakeholders to design a new plant, unit or product

–          Rapid process Improvement Workshops:

4 weeks of system diagnostics by the lean team e.g. value stream mapping, spaghetti diagrams

5 days when about 5 key personnel offline who don vests and engage on the front line to apply multiple PDSAs. Report out at end of week and 4 weeks to translate the concepts.

–          Everyday lean idea system: Formal method to capture staff ideas

It may seem quite overwhelming to try and achieve what another health system has managed over now 10 years of development. However, we can all start thinking – what are the processes around me? Where is the waste and key areas to focus? How can I work with my colleagues to plant the seed of a leaner system?


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