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Mark Graban

Health Care

Lean Is About Quality, Not Just Speed or Efficiency… in Factories or in Hospitals

There’s a lot of misinformation about lean and Six Sigma

Published: Wednesday, July 20, 2016 - 14:18

Given all of the problems that exist in our American healthcare system, it’s encouraging that most healthcare organizations are endorsing or practicing some form of process improvement or operational excellence strategy. Under the banner of different labels and using different combinations of methods, some organizations are preventing errors and improving care, while reducing waiting times, lowering cost, and improving the workplace environment.

Others are, sadly, confused or ineffective in their approach. What matters is improvement (or the lack thereof), not “turf battles” for using different methodologies. One cause of confusion and ineffectiveness is that experts are teaching concepts that are just flatly incorrect.

Unfortunately, there are far too many people who are writing and speaking about how, supposedly, “Lean is for speed and Six Sigma is for quality.” Sure, Six Sigma has a lot to contribute toward quality—that is, if it hasn’t been bastardized into just another corporate cost-cutting program.

One consultant lamented in a video posted on YouTube that people often get “confused” about the differences between lean, Six Sigma, and the Theory of Constraints (I’d add these are three methods that can all work well together). The consultant said: “Go ahead and apply lean to the process; you’re gonna speed up your quality issue, and you’re gonna make bad stuff faster.” Yes, he actually said that. He wasn’t making a joke. He was dead serious—and dead wrong.

It seems this consultant views lean as a “tool” to “use” instead of also viewing lean as a philosophy with fundamental principles on which management systems and even organizational cultures are built upon, as Toyota would explain. I can’t imagine why lean-thinking leaders would want to “make bad stuff faster.” That’s hogwash. In lean organizations, people are empowered to stop the line when they see problems; they error-proof processes instead of telling people to be careful. Lean leaders engage everybody in quality improvement (even using basic statistical methods when appropriate).

It’s factually incorrect to say, “Lean is just about efficiency.” It’s not just a differing opinion. I won’t just agree to disagree on that point. Up is not down.

One author has a book about lean and Six Sigma for healthcare. There are a lot of good things in that book, including warnings against overcomplicating process improvement efforts with complex Six Sigma methods when they’re not necessary. But, he makes the same error by quite directly saying Six Sigma is the only way to improve quality.

He writes about the “seven types of waste” and explains: “Lean will help you to reduce or eliminate [wastes] 1 through 6. Six Sigma will help you to reduce number 7 [defects].”

Again, this is factually incorrect. Toyota doesn’t use formal Six Sigma methods in their factories (and they don’t certify “belts”), yet they do a lot to reduce defects using Toyota Production System methods that would be described as “lean” elsewhere.

Why do people say lean is just about speed and that Six Sigma is needed for quality improvement? Look no further than the book by Michael George, Lean Six Sigma (The McGraw-Hill Companies, 2002). It’s perhaps the seminal book on the combination of lean and Six Sigma, and the cover says, “Combining Six Sigma Quality with Lean Speed.” I think we can judge the book by its cover, or at least its subtitle.

I’ve always tried to remember that you can’t blame people for what they haven’t been taught, such as people in healthcare not being taught about operations management, let alone lean. You also can’t blame people for having been taught the wrong things. You can blame the teacher, but who was their teacher?

Of course organization leaders want to improve quality. So, when they’re taught this false “lean sigma” dichotomy, they say, “Of course, we want to learn Six Sigma then. Learning two things is better than one.” That could be true, except when the “lean sigma” curriculum is basically full-blown Six Sigma with watered down lean (consisting of 5S and value-stream mapping). Lean sigma is usually not a 50/50 mix of lean and Six Sigma; it's more like 90-percent Six Sigma. That’s fine, but it should be called “Six Sigma.”

Many hospitals went down the “lean sigma” route and their directors decided that Six Sigma was overkill for many of the problems that hospitals face. They trained and certified too many employees as Six Sigma belts, and then didn't let them do enough projects (which is arguably an organizational culture problem, not a Six Sigma problem). Many of these organizations scrapped their Six Sigma efforts to focus on lean.

Two of the leading health systems working in the lean realm, ThedaCare and Virginia Mason Medical Center, often get labeled incorrectly as “lean Sigma.” That’s not true, since neither hospital has ever used Six Sigma formally, nor do they have “belts.” Does it matter how they are labeled? I think so, since falsely labeling them “lean Sigma” encourages people to look into “lean Sigma” (with its often superficial lean methods) instead of the true depth of the lean approach.

Would Virginia Mason and ThedaCare have better quality if they also smartly incorporated Six Sigma? Probably. I wonder if the hospitals that first went down the Six Sigma route would have made more progress by first focusing on lean methods to solve pressing quality and productivity problems.

Or, it’s possible that the organizations that failed with Six Sigma might have just as likely failed with lean due to the same root cause of executives not learning lean or changing their approach to management. These same organizations might have also failed previously with total quality management. (See the 1994 book Why TQM Fails by Mark Graham Brown if you want to see history repeating itself.)

My point isn’t to bash Six Sigma. But I will criticize those who muddy the waters and confuse people who are trying to learn by spreading mistruths about lean or not telling the full and complete story about the Toyota Production System.

Today, despite practicing some sort of operational excellence strategy, productivity and quality are pretty abysmal at most hospitals (and this is a global problem). We need to improve in both dimensions at the same time. Lean provides a path to do so, if the right kind of leadership is in place. That leadership is lacking in many hospitals, even if they have a “lean program.”

Don’t miss Mark Graban as a guest on Quality Digest Live, Friday, July 22, 2016, at 2 p.m. Eastern/11 a.m. Pacific.


About The Author

Mark Graban’s picture

Mark Graban

Mark Graban is an author, educator, podcaster, and speaker in lean and continuous improvement strategies through his company Constancy Inc. He is a senior advisor to the technology company KaiNexus, the founder of LeanBlog.org, and the author of Lean Hospitals, Healthcare Kaizen (with Joseph E. Swartz), both recipients of the Shingo Publication Award. Mark’s most recent books are Measures of Success and The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation.



At Maytag Corp. (which registered the term LeanSigma®), we taught that lean is about reducing waste and six sigma is about reducing variation.  Waste and variation are both enemies of quality and efficiency.


Lean also helps focus on reducing variation, through approaches like standardized work, 5S, etc. Maybe the word "variation" gets used more in the Six Sigma side of things... but I'd agree both Lean and Six Sigma should help address both quality AND efficiency. That's the point of my piece, reminding people that Lean focuses on both.

But, I'd add there's also a subtle distinction between "efficiency" and "flow." Lean focuses on improving flow - preventing delays, improving the end to end flow. "Efficiency" is basically a measure of outputs divided by inputs. They're related... the Lean idea would be improving flow and quality leads to better efficiency, which is different than the old approach to "cost cutting" that puts efficiency first (and often reduces inputs without giving mind to outputs).

Lean Sigma is hogwash

Great article!

Not to bash either Lean or Six Sigma but the two are not synonymous or interchangable.  

I do agree that Lean and Six Sigma complement each other when executed properly.  (both Lean and Six Sigma are victims of  people who don't really understand them)

*I* explain - and practice - the difference as:  Lean is for 'people' processes and Six Sigma is for 'physics' processes.  Lean can't fix science and six sigma can only address science based waste/defects.

One slight disagreement:  Toyota does use 'six sigma'.  Oh they don't use the DMAIC phase gate overly/quasi statistical statistical powerpoint multi-colored belt six sigma.  but they do use statistical quality engineering practices to design their products and solve their physics problems. And given some of their recent physics problems they *might* benefit from either a refresher or some additional training and practice of some of the more effective of these tools and methods (reflection and continuous improvement is at the heart of lean after all).  Strong, effective quality tools existed long before Motorola named it 'six sigma' and gave it some marketing pizazz; just as the Toyota Production System existed long before it was named 'just in time' and later renamed 'lean'...

Toyota, Six Sigma, and their factories

Hi - thanks for your comments. I think we're actually in agreement.

Toyota Financial Services does use formal Six Sigma along with TPS. But, the factories are quite specific they don't use formal Six Sigma. They use statistical methods (the 7 basic QC tools from TQM), but they don't train belts or use DMAIC or other methods. Of course, they have engineers and specialists with deep statistical knowledge and skills, but that was true of every automaker 20 years ago when I worked for Ford and for GM.

So, I agree "strong, effective quality tools"are not the same thing as Six Sigma. Six Sigma, to me, is a formal methodology... different colored belts, use of DMAIC as a framework, etc. Like you said, these statistical methods existed long before Six Sigma. For example, I learned how to do DOE and multiple regression analysis as an engineer and it had nothing to do with "Six Sigma" as practiced in the last 20 years.

I'll be on QDL this Friday

I look forward to the comments and discussion from the community. I'll be the guest on this week's episode of "Quality Digest Live" by the way.



Interview Video

Here's the QDL interview recording: