The Missing Link - David Mann Lean Consulting

IntroductionThere is a missing link in Lean. Thismissing link is the set of leadershipbehaviors and structures that make up aLean management system.Lean management bridges Lean management bridgesa critical divide: the gap a critical divide: the gapbetween Lean tools and between Lean tools andLean thinking. SystematicLean thinking.Lean management separatesLean initiatives that start well but falterfrom those that sustain initial gainsand deliver further improvement.Senior leaders play a central role inLean management. Their contributionsare essential in:1. Developing and implementing structuresand processes that anticipate andrespond to the difficulties of a Lean initiativethat crosses internal boundaries;2. Transforming commitments to changeinto actual change, supporting and sustainingnew behaviors and practices;3. Increasing the odds that processimprovements survive the transitionfrom project mode to ongoing process;4. Establishing and maintaining new,process-focused measures alongsideconventional measures of results;5. Creating conditions in which a sustainableLean culture of continuousimprovement can develop.For an enterprise-wide Lean initiativeto succeed, leaders at three organizationallevels must play complementary roles.Figure 1 shows a schematic of these threelevels, areas of primary contribution, andtasks. Note the overlap between adjacentlevels. This overlap reinforces continuityof support for new practices throughoutthe organization, e.g., disciplined adherence,attention to process performance atintersections, and gemba walking (whichtakes managers to the front lines to lookfor improvement opportunities). This continuitymaintains the internal integrity ofLean tool implementations and the Leanmanagement system.Most of the literature on Lean conversionshas focused on implementing theLean tools (to create flow, establish pull,support just-in-time production, etc.) inmanufacturing (Womack and Jones1996; Rother and Shook 1998; DennisFigure 1. Organizational Roles and Contributions to Sustaina Lean InitiativeLeadership Roles in Sustaining LeanOrganizationLevelPrimaryContributionTasksSecondaryContributionTasksStrategic: Senior(CEO, Sr. VP)Governance; Steeringand oversightSupport for a crossboundaryperspectiveMeasurement; Adherenceto post-projectprocessesMonitor intersectionmeasures; Gemba walksProgrammatic:Function (VPs,Directors)AccountabilityMeet project commitments;Manage intersectionperformanceDisciplined adherence;Commitments toprocesses post-projectCollaborate in processmanagement; GembawalksTactical: Department(Managers,Supervisors)Tactical LeanMgment SystemDisciplined adherence;Gemba walksAssociate engagement;ContinuousimprovementTeach, practice rootcause problem solving16 • frontier s of health services management 26:1

2002). Some of the literature hasexplored Lean tools in healthcare, officesettings, or product developmentprocesses (Graban 2008; Keyte andLocher 2004; Swank 2003); or focusedon leadership rather than tools (Mann2005; Spear 2004). Critiques of the toolsonlyfocus note that even brilliant use oftools without changes in culture rarelyproduces lasting change, or even lastingimprovement. But, what does culturemean in the context of Lean conversions?Culture, Reinforcement, andPersistenceFor purposes of this discussion, cultureis simply the sum of how those in anorganization would describe “the way wedo things here.” These customary waysof operating often directly contradictstated rules and policies. Behavior—i.e.,the customary way of doing things—bothcreates and reflects actual culture regardlessof the official definitions of what isto be done, or how. Behavioral scienceshows that reinforced behaviors persist,which helps explain how culturesdevelop. In an organization, the mostimportant source of reinforcement isleadership. “The way we do things…” inother words, reflects leaders’ reinforcements,conscious or not.Successful sustained Lean conversionsoften involve changes in culture. Soit follows that success in Lean implies achange in what leaders reinforce—achange in leadership behaviors and practices.The failure of most Lean initiativescan be pinned on a failure to change leadershippractices (Mann 2005).As Figure 1 suggests, effective Leanleadership comes from the top as well asfrom lower in the organization. Postmortemdiscussions of unsuccessful Leanimplementations often blame the initiative’scollapse on a failure to adhere to theLean design at lower levels. This failure inturn is often caused by changed, weak, orabsent support by senior leadership—CEOs and their direct report senior VPs.All three levels called out in Figure 1 areimportant, and closely related.Lean Principles and ValueStreamsWomack and Jones (1996) identified severalLean principles. Their first is thatvalue is defined from the perspective ofthe customer. The second is that valuestreams need to be identified. Valuestream is another way to refer to aprocess; often, and especially in healthcare,processes include multiple steps.Moreover, in complex organizations, mostvalue producing processes cross manydepartmental and functional boundaries.Many units in an organization play valueadded(and frequently non–value-added)roles in the value streams.For example, the following departmentsare parts of a surgery value stream:admitting, scheduling, medicine, radiology,laboratory, surgery, operating room management,pharmacy, nutrition services,nursing, patient transport, housekeeping,finance, billing, social work, purchasing,and compliance and audit units. There aremany multi-step cross-functional processeson the administrative side as well. Considerthose involving customer service, registration,billing, medical records, third-partypayers, IT, clinical quality, and others. Forpurposes of our discussion, Lean improvementprojects focus on improving the performanceof the value-producing process,the value stream, as a whole. 1If customary ways or habits are onecomplicating factor in Lean transforma-F E A T U R EDavid Mann • 17

tions, organizational boundaries are asecond. In a word, this is the problem ofturf. Womack and Jones’ third principle ofLean calls for finding and eliminating theinterruptions—such as turf battles—thatimpede the flow of value.Organizational boundaries often createflow interrupters in the value streamsof complex organizations. For example,Radiology resists moving available equipmentinto the Emergency Department(ED) even though it would speed EDpatients’ diagnosis, treatment,and discharge. SuchWise executives leadingLean initiatives recognize a move would hurt Radiology’sproductivity and over-that people in functionalhead numbers—they wouldorganizations naturallyhave to staff and maintainresist cross-functional assets beyond their boundaries.So, Radiology’s focusinitiatives.on internal measures ofproductivity and efficiency compromisescustomer value—the patients’ desire forspeedy treatment and release.Some tools-only approaches to Leanfocus on productivity or service quality inindividual departments, creating islands ofimprovement. However, improving valuefrom the customer’s perspective nearlyalways involves collaboration across boundaries,even when improvement mightappear from a distance to be the result ofchange in a single department. For example,reducing central line infections, whichappears to be a single point focused effort,in fact is the result of information and procedurechanges across several organizationalunits—admissions, residencysupervision, intensive care, pharmacy,nursing, and phlebotomy (Spear 2005).CEOs and Senior VPS: System-Level Intervention for LeanGovernanceWise executives leading Lean initiativesrecognize that people in functional organizationsnaturally resist cross-functionalinitiatives. This is often worse inFigure 2. System-Level Support for a Value Stream Perspective18 • frontier s of health services management 26:1

multi-specialty, multi-stakeholder organizationssuch as healthcare institutionsand universities. In a functional organization,horizontal processes—valuestreams—do not appear on the organizationchart. No one is responsible formanaging a value stream. Value streamshave no independent budget orresources. And measures of value streamperformance rarely appear among thoseconsidered important; in fact, measuresrarely exist for horizontal processes.Lean governance responds to thedilemma of a process approach within afunctional organization without changingthe formal structure. These arrangementsare represented in Figure 2. A senior executivegovernance process is the first step.The second is an accountability and exceptionmanagement structure. The executivegovernance process should create recognitionof and commitment to a sense ofcommon purpose across boundaries. Thecommitment to a shared view of customervalue carried across organization boundariesis required for an effective approachto value stream improvement projects.Later, this commitment sustains andextends the project’s gains.The executive governance processhas two elements. The first is an executiveLean steering and oversight (LSO)group made up of the CEO and his orher senior vice president direct reports.The LSO group calls for, sanctions, andsupports Lean value stream improvementprojects. These steps mandate a“virtual process organization” for theentire Lean value stream improvementproject. The LSO group insists that VPs,directors, and department managers considerthe entire organization when evaluatingproposed changes to the valuestream, rather than taking a parochialinternal perspective. The LSO group alsorequires leaders to support plannedimprovements, even when that requireschanging processes or priorities in theirareas of responsibility. 2The second element of the executivegovernance process occurs at the projectlevel. It consists of a project resource andaccountability (PR&A) panel made up ofleaders of the functions or departments inthe value stream targeted for improvement.It is an informal group, a steeringteam for the project rather than an elementon the org chart or an item in anyone’sjob description. The leader of thePR&A panel, the value stream sponsor, isusually the leader of the function ordepartment that encompasses the largestportion of the value stream or whose areais most critical for the customer in thevalue stream’s performance. As valuestream sponsor, the panel leader isresponsible to the Lean executive governancebody, the LSO, for setting appropriatelybold objectives (e.g., 50 percentreductions in cycle time, errors, andrework) for the project, and for executingthe plan to achieve them.The LSO oversees the value streamLean projects. The organization’s Lean initiativeleader serves as secretary andagenda manager for the LSO, and he orshe tracks progress of all the projects.When a project stalls, the Lean leaderinvites the project’s value stream sponsorto brief the LSO on the project’s status.These updates usually result in actionto overcome the project’s obstacles, whichmight include, among other factors,unmet commitments by a unit representedon the PR&A panel, unavailableresources, or conflicting priorities. PR&Apanel members report directly to LSOmembers, or individuals one level belowF E A T U R EDavid Mann • 19

the LSO. So, LSO members can removeobstacles or encourage more vigoroussupport for projects, by their direct interventionor through the Lean leader.Vertical and HorizontalAccountability forImprovementThe relationship between the two elementsof executive governance—the LSOgroup and the PR&A panel—implies anexpectation for accountabilitybetween the LSO andIf achievement of theproject’s objectives PR&A, an expectation maderequires compromise and explicit when process sponsorsare invited to brief thecollaboration with otherLSO. 3departments in the value The expectation of thestream, so be it. executive governanceprocess is for the subordinatefunctional VPs and directors tomeet the commitments they have madeto Lean value stream improvement projectteams. The expectation of the valuestream sponsor is for LSO support inremoving obstacles. Accountability in theformal authority structure is normal. Butaccountability also flows horizontallyamong the PR&A panel members, whichis unusual in functional structures.LSO group members make clearwithin their units and during projectupdates that commitments to Lean projectsare to be met. If achievement of theproject’s objectives requires compromiseand collaboration with other departmentsin the value stream, so be it.VPs and Directors: MeetingCommitments to Projectsand Intersection MeasuresAs seen in Figure 3, measures of processperformance for most value streams arestraightforward and scalable. A valuestream’s process measurement set typicallyconsists of safety, quality, delivery, and cost.Safety covers workplace accidentsand injuries. The quality measureFigure 3. Value Stream Process Performance Measures20 • frontier s of health services management 26:1

includes defects, errors, rework, firsttimequality, and customer satisfaction.Delivery (or throughput velocity) refers tototal cycle time, or the total end-to-endtime from beginning to end of theprocess (sometimes known as total leadtime). Cost is measured by labor hours(also known as process time, or touchtime) and externally purchased servicesand materials.All of these measures apply to theprocess in its entirety, as end-of-processmeasures. And, each of them applies justas appropriately to a function’s or department’sperformance at the point wherethe process intersects the function. Valuestream improvements can almost alwaysalso be described in terms of discreteimprovements in safety, quality, deliveryor cost within departments, or at betweendepartmenthandoffs.This translates into concrete measuresof collaboration and commitments. PR&Apanels meet at 30-day intervals to reviewtheir project team’s progress. These “intersection”measures put the value streamsponsor’s job of working with peer PR&Apanel members on project governance ona more straightforward and objective footing;intersection measures meet theirgoals or not. And, it puts the LSO’sassessment of project status on an objectivefooting, along with corrective actionmembers might direct in their own organizations.So, responsibility for accountabilityoverlaps the boundary between seniorand subordinate executive leadership levels(in Figure 1, between levels 1 and 2);accountability is a task and responsibilityat each of these two levels. This is also thecase between level 2 executives anddepartment managers (see Figure 1). Infact, disciplined execution permeates allthree levels of leadership in a successfulLean initiative.Department Managers:Tactical Lean ExecutionLean applications, the Lean “tools,” are thefocus of most discussions about Lean. Thetools are typically seen where the task-levelwork gets done, at the department level.Some examples include: color-codedpatient garb indentifying those at risk offalling; visual indicators in an ED signifyingready for X-ray; regular routes forreplenishing consumable supplies inpatient rooms; standard procedures forhandling incoming hard copy charts and atakt pace (a pace that matches productionto demand) for scanning them into electronicmedical records; and standard proceduresin sterile processing withone-procedure-ahead tray delivery to theOR.These are a few of many applicationsof Lean tools. As noted earlier, althoughthese tools may on the surface appear tobe single point, within-departmentprocess improvements, many involve two,three, or multiple organizational units.Rapid improvement activities, or kaizens,within individual departments are importantfor the experiential learning central todeveloping a broad base of Lean thinkingin an organization. But kaizens tiedtogether as the implementation plan of anend-to-end process are far more potent inchanging organizational, as opposed todepartmental, performance.This tactical level of Lean is whereemphasis on disciplined execution isclearest, the primary Lean responsibilityof departmental management. The frequentlyupdated performance trackingcharts, focus on root cause analysis andproblem solving, value stream mapping,F E A T U R EDavid Mann • 21

and kazien projects are all based onadherence to standardized methods.This approach is in keeping with the scientificmethod, i.e., systematically varythe independent variable (the plannedchange to the standardized procedure)and observe the variation in the dependentvariable (the process outcome to beimproved). If improved outcomes areobserved as predicted (safer, fewerdefects, faster, or less costly) verify thecausal relationship, and then institutethe changed procedure.Lean is a high-maintenance For departmental managers,supervisors andapproach....Most of us prefer to do team leaders, this approachis called a Lean managementsystem (LMS). It is athings as we alwayshave....It is what set of leadership practices,humans do. tools, and behaviors thatcreates a closed loop systemfor focusing on process and drivingprocess improvement. This system is, ineffect, a behavioral recipe for disciplinedadherence to process. It has three coreelements: visual controls, consisting offrequently updated process performancecharts; standard accountability processes;and standard work for leaders (“leaderrounds”). Among other things, leaderstandard work ensures execution of standardizedprocesses. Leader standard workalso ensures performance-tracking dataare well and faithfully recorded, and then,in accountability processes, convertedinto assignments for problem solving andcorrective action. Finally, leader standardwork ensures consistent execution of theresulting improved process. Figure 4shows this closed loop process. (For a fulldiscussion of the Lean management system,see Mann 2005).Leader standard work is developedwith intentional partial redundancyupward through the chain of command. Ina Lean design, value adding task-level personnelspend virtually 100 percent of theirtime following task-level standardized pro-Figure 4. Lean Management as a Closed-Loop System Focused onProcess to Drive Improvement22 • frontier s of health services management 26:1

cedures. Some examples are: Following thedefined process when consumables in aspecific location reach the reorder point;observing defined times and routes forpicking up lab specimens; ED providersadapting to agreed protocols for patientprep; OR managers following the intent,not just going through the motions of presurgerychecklists; patient care assistantsfollowing prep-for-X-ray procedures; orunit clerical staff following standards forpreparing hard copy chart documents forscanning. Team leaders spend most oftheir time —70 to 80 percent—makingsure defined procedures in their areas,such as the above examples, are being followed.The rest of their time is available fortroubleshooting and work on improvements.Supervisors spend roughly halftheir day on standard work, including verifyingexecution of one procedure or practicein each team leader’s area per day, andreviewing the team leaders’ standard workdocuments. The department manager’sstandard work might account for 25 percentof the day, and includes spot checks ofa procedure or practice per day per supervisor,as well as reviewing supervisors’ standardwork documents.Directors and above also have standardwork, but more in the form of achecklist to use when they are in theirgroups’ work areas. The expected frequencyand duration of tasks in executives’standard work is quite a bit lessthan for department managers andbelow, perhaps only an hour a week. Theexecutive checklist should neverthelessinclude verifying procedures and practicesat the task level—where the valueaddingwork takes place—are beingfaithfully executed, and asking to see thestandard work document (is it current? isit being followed? are problems encounteredand interruptions to expected routinesnoted?) of at least one of the leadersbetween the task level and the executive.This built-in redundancy reflects theimportance of standard methods as thefoundation of Lean execution, as well asthe basis for Lean as an improvementsystem. If the independent variables arebeing held constant, outcomes should bepredictable, and when not, sources ofvariation are more readily diagnosed andeliminated.CEO to Department Manager:Lean in Every Leader’s RoleExpect Lean applications to require a surprisinglyhigh level of attention. Lean is ahigh-maintenance approach. Though thismay seem paradoxical, it is true for tworeasons. The first is that most of us preferto do things as we always have. Withoutan ongoing and consistently reinforcedset of behaviors that replace our habits,we revert. It is what humans do.Second, Lean applications requireattention because they are designed thatway. Specifically, Lean processes aredesigned to be, well…Lean. That meansconsuming the least material and time;the least space, inventory, and equipment;and overall the fewest resources possible—andmaintaining this level requiresattention. Moreover, Lean processes aredesigned to be sensitive to abnormalitiessuch as defective inputs, scrambled timingand sequence, and other variancesfrom specified operating conditions. Hassterile processing returned to batchingrather than procedure-by-procedurepreparation, one per OR at a time? Arelabeling procedures being followed forlab specimens when nurses are busy? Areprocedure carts left where last usedrather than returned to the designatedF E A T U R EDavid Mann • 23

location? Are they restocked with somebut not all of the regularly used consumables?Is the ED stat lab getting specimensa patient at a time, or batched bycorridor or wing?Lean processes are designed to highlightproblems. In a Lean thinking mindset,problems are valuable nuggets ofinformation to be mined for clues to thebest places to make improvement. By contrast,in a conventional mindset, problemsare obstacles to be worked around, buried,and forgotten, even if theyThe longer an organization constantly recur. Leanpursues Lean, the more processes are precise andopportunities for delicately balanced, but efficientand predictable. Conventionalprocesses mayimprovement it sees.not be efficient or predictable, but they arerobust with respect to variation, and withenough time, resources, and heroics canbe “muscled through.”Lean is often mischaracterized asbeing all about cost reduction. In fact, itis quite different from any conventionalmethod for lowering costs. Lean mostdefinitely reduces costs, but as an ancillarybenefit. Consider the fifth of Womackand Jones’ five principles of Lean:strive for perfection. In context, thismeans continuing to iterate your waythrough the first four principles (identifycustomer value, find the value streamsthat produce it, eliminate impediments tolet value flow, and arrange for customers’ability to pull value when and how theywant it) until you have achieved perfection:delivering value with zeronon–value-adding activity. For scale, thebest value streams in repetitive manufacturingindustries operate at only a 10:90ratio of value-added time to non–valueaddedtime; many operate at a shocking1:99 or below. The longer an organizationpursues Lean, the more opportunities forimprovement it sees. When members ofa Lean organization say, “We still have along way to go,” it is not false modesty. Itis the result of constantly improving Leanacuity, the ability to see more clearly thenext opportunities.Lean as Improvement: Whatto ExpectLean is more than a cost reduction system.Instead, at its essence, Lean is animprovement system. Lean designs serveboth as operational processes and ashypotheses. The hypothesis is that thecurrent design is the best way we know atpresent to perform these steps or procedures.The implication is that associatesand leaders are observing, recording dataon process performance, and participatingin learning. This is preparation for thenext improvement—an application ofDeming’s iterative plan-do-check-act(PDCA) cycle, in which experience withan implemented plan (plan-do) producesfeedback that suggests refinements(check-act), which are designed andimplemented (plan-do), leading to furtherexperience, feedback, and improvement.Do not expect a Lean process conversionto be a set-it-and-forget-it proposition.The regressive pull of old habits and conflictingpriorities and practices elsewhere inthe organization, and the deliberate sensitivityto faults designed into Lean processes,make a Lean conversion a high-touch enterprise.Lean designs require attention to thefaults, their root causes, and root cause correctiveaction. 4 Otherwise, temporarypatches morph into permanent fixtures, thedesign degrades, and practices revert to theway we’ve always done things.However, if the Lean design is accompaniedby a Lean management mindset,24 • frontier s of health services management 26:1

you will come to view the current processas an experiment. It will be an improvement,but also a way to discover furtherimprovements. Shigeo Shingo, an importantearly participant in the developmentof Lean thinking at Toyota, noted that thebest approach is to seek out problemswhere none are thought to exist so as toidentify opportunities for further improvement(Shingo 1985). So, in the fifth Leanprinciple—strive for perfection—theemphasis falls on “strive,” as in “don’tcease working on improvement.”Gemba Walking: A Teaching-Learning Model for Leadersat All LevelsGiven that Lean is an intentionally highmaintenance approach, and that Leanmanagement sustains it, it should not besurprising that a standard approach existsfor leaders to monitor Lean managementpractices. The practice follows a three-partrule: 1. Go to the place. 2. Look at theprocess. 3. Talk with the people. Thisprocess has two benefits. When seniorexecutives go to the work area, carefullyobserve the work as actually done, andinquire about the process, they reinforceLean management practices, which sustainand extend the gains from Lean conversions.This benefits the Lean initiative.A second benefit comes when thesenior leader goes to the work area, accompaniedby a Lean coach and prepared withdiagnostic questions to guide his or herobservations, questions, and conversationswith those in the area. This benefits theexecutive by engaging him or her in activeand challenging experiential learningabout Lean principles and the issues thatarise when implementing them.The practice of regularly going to theLean workplace to see the actual practicesis known as gemba walking. Gemba translatesas the “real place,” where the actionof interest happens—where the valueaddingwork occurs. Executives shouldexpect to spend 45 to 60 minutes everyweek or two gemba walking with a Leanteacher, or sensei, for six months to a year.Thereafter, they should regularly gembawalk on their own. Gemba walks are crucialto maintaining the disciplined adherenceto Lean process designs, part of theLean support role permeating all leadershippositions. Gemba walks form theconnective tissue that maintains the gainsfrom Lean and the muscle that drives furtherimprovement.Executives should read about Leantools and principles, and attend a Leanevent annually. But the principal Leaneducation for executives comes via structuredgemba walking with a sensei-coach(see Mann 2005, Ch. 6).Summary: A Lean Mindset forLifetime Lean LeadersLean is more than just a kit of tools toimprove flow and quality. It is a businessphilosophy, and to be effective over thelong run, discipline is essential. Everyleader must spend some of his or hertime focusing on the adherence to theLean process, and noting the improvementopportunities such focus reveals.Discipline is the essential element in sustainedLean performance.Most Lean conversions fail to deliverthe promised benefits or hold initialgains. These disappointments resultfrom the mistaken belief that Lean is acost reduction system, and once implemented,brings permanent improvement.This is simply not true. Leanconversions require a consistent Leanmanagement approach.F E A T U R EDavid Mann • 25

Lean provides thetemplates and practicesthat enable leaders tolearn, and then look for,ask about, and reinforcethe leadership behaviorsthat sustain the gains.Sustained Lean success requires achange in mindset and behavior amongleadership, and then gradually throughoutthe organization. Lean success occurs whensenior leaders put appropriate structuresand processes in place and get personallyinvolved in sustaining the Lean conversions,learning Lean, and developingother Lean thinking leadersthroughout theenterprise. Lean managementis surprisingly differentfrom conventional leadershippractices. It emphasizes visiblyobservable discipline andaccountability. Unlike otherapproaches to improvement,these cannot be delegated. Lean providesthe templates and practices that enable leadersto learn, and then look for, ask about,and reinforce the leadership behaviors thatsustain the gains.When senior leaders establish the system-levelelements of Lean management,engage consistently in the Lean initiative,and adopt it as an important element intheir organization’s strategy and approach,benefits will accrue from a progressivelyLeaner leadership mindset. Eventually aLean culture will grow from this consistenteffort, and striving for perfection willbecome “the way we do things here.”Notes1. Some Lean initiatives are more narrowlyfocused, concentrating on improvementswithin individual departments. While thisapproach can yield benefits, it is prone to producingisolated islands of improvement thathave little cumulative effect on the customer’sperception of value produced by the end-to-endvalue stream.2. In this way, senior executive sponsored Lean projectscan act as vehicles for strategy deploymentas well as for process improvement.3. An effective practice limits duration of implementationplans to 90 days at a time, with successive90-day segments as called for. Ninety days islong enough for substantive improvement, yetshort enough to maintain a sense of pace andurgency. Within the 90-day segments, weeklyreviews internal to the project team, and monthlyreviews with the PR&A panel, reinforce pacingand surface interrupters and obstacles earlyenough to respond, recover, and maintain pace.4. Although note that Lean thinkers are not insensitiveto the need for temporary patches or countermeasuresto keep the process meeting itscommitments.ReferencesDennis, P. 2002. Lean Production Simplified: APlain Language Guide to the World’s Most PowerfulProduction System. New York: ProductivityPressGraban, M. 2008. Lean Hospitals: Improving Quality,Patient Safety, and Employee Satisfaction. NewYork: Productivity PressKeyte, B. and D. Locher. 2004. The Complete LeanEnterprise: Value Stream Mapping for Administrativeand Office Processes. New York: ProductivityPressMann, D. 2005. Creating a Lean Culture: Tools toSustain Lean Conversions. New York: ProductivityPressRother, M. and J. Shook. 1998. Learning to See:Value Stream Mapping to Create Value and EliminateMuda. Brookline, MA: Lean EnterpriseInstituteShingo, S. 1985. A Revolution in Manufacturing:The SMED System. Stamford, CT: ProductivityPressSpear, S. 2004. “Learning to Lead at Toyota.” HarvardBusiness Review 82 (May): 78-86.Spear, S. 2005. “Fixing Health Care from theInside, Today.” Harvard Business Review 83 (September):78-91.Swank, C. 2003. “Lean Service Machine.” HarvardBusiness Review 81 (October): 123-129.Womack, J. and Jones, D. 1996. Lean Thinking:Banish Waste and Create Wealth in Your Corporation.New York: Free Press26 • frontier s of health services management 26:1