1.19.2016

The Second Edition of “The Complete Lean Enterprise: Value Stream Mapping for Office and Services” -- Why Is It Needed?

It has been 10 years since the publication of the award-winning, best-selling book called The Complete Lean Enterprise: Value Stream Mapping for Office and Services. This book brought value stream mapping and Lean thinking out of the factory and into office and service environments in all industries. The authors, Beau Keyte and Drew Locher, have just published a second edition of this book, and I recently asked them: “Why is a second edition of this book needed?” Here is Drew Locher's complete response:

During this time, my co-author, Beau Keyte, and I have continued to deeply learn about the application of this powerful methodology in our work with a wide variety of organizations and industries, including financial institutions, healthcare, hospitality, the “back office” in manufacturers, and engineering firms. Beyond the “mechanics” of the use of the tool, we have come to better appreciate the “social” benefits of the approach to any organization. The second edition represents our collective experiences over during those 10 years and captures many key lessons.

The collaboration that the methodology ignites between departments and functions (that have traditionally not worked effectively together) is nothing short of stunning in most cases. Through the process, they learn from each other, develop a common vision going forward, and form a true team that is critical to the successful implementation of the "future state" that provides breakthrough results for their organization. In addition, we learned many other success factors. For example, it is not solely the objective to implement the tools and techniques envisioned in the future state that fundamentally change the way work is processed and flows -- a new way to manage the value stream is needed. Only then will sustainable change occur and continuous improvement be practiced beyond the first future state – the true objective of Lean Thinking.

The new content includes an entire chapter dedicated to the “management process,” and “learning your way to the future state.” In addition, during the past 10 years, we have observed many individuals and organizations practice their own use of the methodology, often with mixed results. Most commonly, we have seen current state maps without proper future state designs. Value stream mapping should result in radical improvement resulting in significant improvement in key metrics; greater than 50% reduction in lead time, up to 90% improvement in information or service quality, and the like. Very often, however, the projected results are modest and represent incremental improvement. Other times the future state is nothing more than the current state with up to 100 ideas for improvement noted. Long “to-do” lists are created and responsibilities and dates assigned. This represents a “waste war" or a ”drive-by kaizen” approach rather than the thoughtful redesign of the value stream based on the key principles of Lean that will achieve the aforementioned breakthrough results.

We have honed our messaging and teaching with regard to future state design in the second edition. The future state questions have been revised and applied to a new case study so the reader will find them easier to put into actual practice.

We feel that even seasoned practitioners will benefit from the second edition if they are open to honing their skills in the powerful value stream mapping methodology. And for those who are new to the subject, here is the opportunity to learn the current thinking from the original leaders on the application of value stream mapping and Lean to office and services. 

What do readers of this book think? Do you feel the second edition of this book is a welcome addition to the Lean literature currently available?

12.16.2015

The Lean IT Transformation -- Is There a Roadmap?

During the past few years, many books have been published addressing the advantages of deploying Lean continuous improvement in IT operations. In addition, there are many books on DevOps, Agile software development, Lean project management, Lean startup, continuous deployment, and IT Service Management. In fact, in 2010 Productivity Press published Lean IT: Enabling and Sustaining Your Lean Transformation (authored by Steven Bell and Mike Orzen), which has been called the most comprehensive and definitive resource on Lean IT.

Recently, Mike released a new book with coauthor, Tom Paider titled The Lean IT Field Guide: A Roadmap for Your Transformation, and I had the chance to sit down with the authors and ask them why they wrote this book and why it is different from the myriad of books recently released on Lean IT and related topics. Here are the highlights from that conversation:

What inspired you to write this book?

The first book, Lean IT, was well received by the Lean and IT community, but many of the people we spoke with consistently said the same thing: “Great book, but how do we do it?” The first book thoroughly explores the “what” of Lean IT by providing definitions, examples, models, and case studies. We have always been uneasy with the idea of prescribing the “how” of Lean IT because I learned it through many years of trial and discovery. Our coaches and sensei always emphasized the need to experience one’s own discoveries and made it rather painful by not providing a roadmap. They used open-ended questions to develop our thinking, but it was up to us to figure to the direction we were going to take. Similar to the approach used in the first book, these teachers explained the goal and targets and helped us to envision a future-state, but they did not tell us how to get there. They seemed to intentionally avoid providing us with a roadmap, so we would discover our own way. We had to find our path forward through an endless series of experiments, reflection, and more experiments until the route ahead began to come into focus.

Is it possible to provide a roadmap to Lean transformation without being prescriptive and creating a implementation?

That is the very question we struggled with before committing to write this book! On the one hand, we had received many requests to share the “how to” mechanics of Lean IT transformation. In the final analysis, we realized we could share the key elements of building a Lean management system that effectively drives transformation without violating the necessary learning and discovery that is required to develop and engage people to become Lean practitioners. In a Lean transformation, particularly in IT, the actual steps and adjustments we will need to take will become apparent as we progress -- they cannot be known at the outset. We were very careful to stress the need for personal experimentation -- trial and discovery, using PDCA and refection -– to position the reader to successfully launch and deliver on a Lean transformation without approaching it like an implementation. An implementation presupposes that we know all the steps needed to reach the goal.

A Lean transformation can take years of hard work, in your opinion what is the hardest step in the journey?

In our experience, by far the hardest step is the first one – actually beginning your first set of routine team-based lean activities. In the book, we call the the first step "day zero" and provide details of the elements and preparations required of leaders, managers, and associates to success launch the transformation effort. During the years, we have found that sequence is just as important as content. What we mean by that is: you can do all the right things, but if they are done out of sequence, the impact and lasting effects just don’t take place. The sequences we share are based on years of trial, error, discovery, and success!

Are any readers currently involved in a Lean initiative focusing on aligning the IT function? If so, what were your biggest obstacles?

11.17.2015

Can Design of Experiments (DOE) Be Simplified?

Mark J. Anderson and Patrick J. Whitcomb just published the the third edition of their innovative book, DOE Simplified: Practical Tools for Effective Experimentation, and I had the chance to speak with Mark about its content. I asked him: "Nothing could be simpler than the traditional scientific method so why abandon this old-school approach for experimentation?" Here is Mark's complete answer:

It is true that that the scientific methods we all learned in school could not be any easier -- simply hold everything in your system constant other than changing only one factor at a time (OFAT). For example, It works very well for demonstrating scientific principles in a chemistry class. For the following two reasons, however, the OFAT method falls flat for real-world experiments:

1. It cannot detect interactions of factors (e.g., the combination of time and temperature burning the food you cook in your kitchen).
2. It is very inefficient.

I explain why in this very brief two-part primer -- Trimming the FAT out of Experimental Methods and No-FAT Multifactor Design of Experiments.

Now that you understand why OFAT must be abandoned, you are ready to take the next step (i.e., mastering the multifactor test methods of design of experiments -- DOE -- by reading our book). We start you off easy with several chapters with some basic statistics and simple comparative experiments. Then in Chapters 3 through 5, we explain how to use the primary tool for DOE: two-level factorials. These designs are excellent for screening many factors to identify the vital few. They often reveal interactions that would never be found through OFAT methods. Furthermore, two-level factorials are incredibly efficient, producing maximum information with a minimum of runs. Most important, these designs often produce breakthrough improvements in product quality and process efficiency.

Continuing on from there, the book fills in all the gaps remaining for getting an effective grasp on the powerful tools for multifactor testing. We cap it all off with a new chapter written especially for 3rd Edition -- It reveals a middle way, called “split plot,” between OFAT and DOE when experimenters are confronted with factors that are very hard to change.

By the way, this new edition vaults the book into a format amenable to electronic users as it's available in many eBook formats. Now, web-connected experimenters around the globe can read DOE Simplified. Furthermore, mainly from the hard work of my colleagues at Stat-Ease, we accomplished a re-launch of the “Launch Pad” -- a series of interactive web-based lectures that cover the first several chapters of the book. The Launch Pad e-learning class provides momentum that propels readers through the DOE Simplified text. Contact workshops@statease.com for more information about the Launch Pad. 

Have any readers here used the new edition of DOE Simplified: Practical Tools for Effective Experimentation? Has it been helpful? Do you agree with Mark Anderson's points? 

10.26.2015

So Why Did Pascal Dennis Update a Classic Book?


I spoke with Pascal Dennis this past week and had the chance to ask him a few questions about the recent publication of his new book Lean Production Simplified, Third Edition: A Plain-Language Guide to the World's Most Powerful Production System.The two previous editions of this book have been very successful with Lean practitioners at all levels within organizations, and these books have proven to be the best introductory texts to Lean methodology on the market. Here are a few of the questions I asked him and his answers follow.



What motivated you to originally write the book Lean Production Simplified?
I wrote the first edition of Lean Production Simplified hoping to share what I’d learned at Toyota. It had been my blind luck to work with patient senseis. I felt that if I could explain things simply, then perhaps I had gained a certain level of understanding. During the past 20 years, I’ve been the sensei helping companies apply the Toyota system or Lean. My practice has taken me far from the Toyota shop floor – into hospitals, power plants, container terminals, and research laboratories.  I’m certain that I learn as much as I teach. And the more I learn, the more I think of Socrates -- "The more I know, the more I realize I don’t know."


Why did you write the 3rd edition? 
We must learn the Toyota system – and not just in manufacturing.  Hospitals, banks, universities, software developers, government agencies and other service providers are also hungry for Lean thinking and methods. Customers will no longer accept substandard safety, quality, delivery, or cost performance. 


Who composes the audience for this book?

Leaders and learners at all levels in manufacturing and in the ‘undiscovered countries’ – healthcare, financial services, the process industries, software development, construction, universities and the public service.


What’s different about the 3rd edition?

I’ve added many more examples from outside the factory (e.g. design, engineering, administration, etc.) and from the industry sectors I previously mentioned. I’ve also included study questions at the end of each chapter.  My hope is that this third edition will be a working book, and that I’ll continue to find in the gemba, filled with highlights and notes in the margin. My study of aikido had prepared me for the Toyota “way.” I understood that it was a "do" or path, and that the Toyota shop floor was a dojo -- a place where you practiced a profound art or worked on your technique and on yourself.  Indeed, before stepping on to the shop floor, I felt like bowing -- a sign of respect for my team, organization, and the art of management. I still feel that way.  

What are your thoughts on Pascal's book Lean Production Simplified? Did it help you understand the objectives of a Lean initiative and enhance a successful journey?

9.17.2015

Painting the Factory Green with Lean Thinking

Last month, a book titled The Green Factory: Creating Lean and Sustainable Manufacturing authored by Andrea Pampanelli, Neil Trivedi, and Pauline Found was published. This book proposes a new model, the Lean and Green Business Model (L&GBM), where the environmental aspect of sustainability is integrated with Lean thinking to create a way of thinking that contributes to and balances the three sustainability dimensions of people, profit, and planet. 

I spoke with Andrea Pampanelli about the book and asked her: "How does combining your Lean business model with a green initiative actually result in environmental benefits and higher profits?" Here is his answer: 

We know that walls, or organizational structure, cannot stop the flow of ideas but it does not mean that they are able to flow through quickly and easily. Lean and green thinking are rooted in differently, have different meanings, and occupy different spaces inside the business world. The environmental benefits and cost savings discussed in the book come from the integration of both by taking the powerful Lean culture already implemented in one organization and using it, not merely for eliminating the seven classic wastes (transportation, inventory, motion, waiting, over-processing, over-production, and defects) but in this case, for increasing the performance of the manufacturing mass and energy flows -- the important supporting flows for production. These two different ways of thinking will meet during the crucial Kaizen events and Lean thinking will dramatically increase environmental benefits and profits. 

What are your thoughts in regarding to combining Lean and green initiatives? Do you have experience
deploying Lean and Green in a manner that resulted in environmental and cost benefits?

8.17.2015

Lean Drives Innovation at Goodyear

I often hear the fear from right-brained functions, staff, and executives that Lean kills creativity. In the watershed book titled Lean-Driven Innovation: Powering Product Development at The Goodyear Tire & Rubber Company, author Norbert Majerus proves it doesn’t need to be that way. Norbert’s book describes how Lean expanded innovation capabilities and capacity at Goodyear, and, more important, led to competitive advantages and powerful business results. I asked Norbert, an engineer by trade and Goodyear’s Lean champion, “What are the keys to Goodyear’s success with Lean research and development (R&D), and are they replicable by others in innovation?” Here is his response:

An important first step within Goodyear R&D was that we didn’t view Lean as a way to reduce product development costs. That may sound counter-intuitive to those in manufacturing, where major savings can be gained from Lean and the removal of production wastes, but it doesn’t work that way in R&D. Unlike manufacturing, R&D is a small direct cost to the business and there is only so much to gain from cost-cutting — but R&D casts an enormous shadow over the products and activities of a company. Design decisions can affect the product’s performance (price), cost, manufacturability, complexity, and even distribution. Design processes also assure that the right product is available at the right time. We chose to focus Lean on how R&D designs product, the powerful ways it can increase value for customers, and its impact on the profitability of the value streams. Leveraging that shadow with lean thinking has a return that is an order of magnitude greater than direct cost savings in R&D.

We also recognized that Lean could enhance many of Goodyear’s already existing R&D strengths — knowledge management, advanced computer modeling, people engagement, matrix organizational structure etc. We weren’t looking to apply a whole cloth version of Toyota’s Lean or a Lean template promoted by another company or consultant, but a Lean that could work within Goodyear. That sounds simple, but it required a fundamental commitment that every Lean innovation transformation requires: that is, we took the time and effort to learn, understand, and validate Lean principles that would work in our organization.

When I was selected to get Goodyear’s Lean R&D effort underway, I had little knowledge of Lean. I read everything I could get my hands on and attended Lean conferences and seminars. It was all fairly confusing. Eventually I started to see the science that underpins Lean, which, as an engineer, convinced me of Lean’s potential in product development. (Too often I see individuals trying to apply Lean tools without understanding the principles of how and why it really works.) I began to teach these Lean principles to our R&D experts. I coached and encouraged them to leverage the principles, and they made the changes we needed to be more competitive. We changed our innovation culture from the inside out, and even developed some new Lean principles along the way — Lean R&D principles are the backbone of  Lean-Driven Innovation.

We repeatedly applied these principles and tools to continuously improve safety and quality (already industry-leading at Goodyear), service (e.g., on-time delivery), and efficiency (e.g., innovation cycle time). As R&D improved its ability to serve the business, it also freed resources for more knowledge development (innovation capability) and more product development projects (innovation capacity). And all of this was done without additional investment in R&D.

Many other things contributed to our Lean R&D initiative and business success, particularly the unwavering support of our Lean initiative by Goodyear leadership, which grew as we showed how the results affected the bottom line. It wasn’t an easy journey, with many challenges — and challengers — met along the way. I write about both the good and the bad moments in Lean-Driven Innovation. In doing so, I hope I can help others avoid some of the problems we encountered and overcome their own Lean R&D challenges as they arise.

Norbert has written a powerful and engaging story about Lean innovation within Goodyear, and their journey and outcomes will surprise you. Clearly, Lean innovation thrives at Goodyear. Let me know what you think of Norbert’s Lean R&D principles, especially if you are in product development and striving to create, sustain, or enhance innovation capability in your organization.

7.16.2015

Ideas Transformed the Culture at Baylor Scott & White Health

Last month, an important book titled The Power of Ideas to Transform Healthcare: Engaging Staff by Building Daily Lean Management Systems, authored by Steve Hoeft and Bob Pryor, MD, was published. It details Baylor Scott & White Health’s journey from just one-of-many to one-of-the-best idea generating, staff engaging, Lean Management System building healthcare organizations in the world. I had the chance to speak with Steve about his book, and one of the main questions I asked was: "Why haven’t more healthcare organizations seen successes from choosing Lean as a methodology to transform and improve their culture?" Here is his complete response: 

Let’s start with an even more basic question. If you are a healthcare leader at any level, ask yourself, “Do we have good employees working in our organizations? And, do we think they have ideas for improvement?” If so, how many ideas have your staff brought forward and implemented this week? How about this month? Does anyone even ask them? And, if they did, have leaders helped build quick-feedback systems so they can Check if their ideas worked (Plan, Do, Check, Act)? Next, ask yourself the only Lean question – “Why?” 

From those questions, Dr. Bob Pryor, then CEO of Scott & White Health (before merging as equals with Baylor Health Care System in 2013) and I accelerated our previous project-based continuous improvement journey by teaching all leaders to build systems for daily improvements.

 At last count, we see over 2,000 ideas implemented every week! When we just did improvement “projects,” we didn’t see that many ideas tried out in a year! Our culture is changing. We are building a culture of continuous safety, quality, morale, service, finance, respect, and... everything improvement! You asked a good question. Now that a dozen or more healthcare systems have seen sustainable successes applying the Toyota Production System (TPS) aka Lean principles in healthcare, why haven’t more organizations seen successes?

There are many reasons, but we would say the main reason is still denial. Throughout the history of healthcare, leaders were able to use heuristic rules that reinforced their thinking, which was, “What has worked in the past, will work again now.” Coin in, gumball out. But, as healthcare environments change even faster, what worked in the past will not work in the future. Think of how quickly healthcare finance and reimbursements have already “reformed.” The need to change may not appear bigger (yet) than the pain of changing for some. For many, it will be too late. 

Another important reason is that we have relied way too much on low-level, leader-absent improvement projects by small teams. Maybe consultants have added to this myopic focus because projects are easy chunks to schedule and “sell.” But, consultants leave, improvement teams disband, and the changes often slide right back to where they started. 

There is a better way! And, it can engage more staff, while aligning them around common North Star goals. At Baylor Scott & White Health, we still do great continuous improvement training and projects. But, we also use hoshin kanri to align all staff’s North Star goals (CEO Joel Allison’s Vision 2020), and build Lean Management Systems to bring forward their full brainpower daily and close the gaps! 

Our leaders teach all employees that they wear two hats. They are to do their jobs well (follow their standard work), and they are to improve their jobs every day (make it easier, get rid of waste). We also promise to give them the tools to do this, and that their leaders will help build systems to allow them to try out their ideas. Something changes inside a staff member when they bring forward an idea in a pre-shift huddle, their team tries it out, they see that it worked, and then a leader thanks them. It changes in a very positive way when they see a meaningful measure move toward their goal and get recognized. The staff member goes home that night, gathers his or her family around, and says: “Kids, if I wasn’t working at Baylor Scott & White, that place would be going to heck in a hand basket. I am helping achieve all our goals with my ideas. You should have seen how happy the team was today when my idea worked! I knew it would. I think I’ll bring up another idea next week.” 

Organizations often ask for ideas from staff on teams but few have done so to the extent and with as much success as we have thus far. In the book, Bob and I share our experiences building a wide culture of continuous improvement over the past eight years at Scott & White, now Baylor Scott & White -- including our successes and failures. We weren’t smarter than other health systems. Maybe we were just more desperate, given the challenges we wrote about. 

Our new book offers insight on how to engage staff and garner ideas through projects, goal alignment and creative use of huddles. It also presents ways that your good staff members can try out their ideas without spending time away from their work. It works.

What do you think of Steve's thoughts on the power of ideas to transform healthcare? I'd particularity like to see comments from healthcare leaders and practitioners who are currently on a Lean or continuous improvement journey.

6.15.2015

Lean, Value Stream Mapping, and Process Industries

I spoke with Peter L. King this past week about his new book, Value Stream Mapping for the Process Industries: Creating a Roadmap for Lean Transformation. This book is Peter's the third book on how Lean concepts apply to process operations, so I asked him: "What fuels this interest?" Here is his complete reply:

Actually, it’s much more of a passion than an interest -- a passion created during my 18 years applying Lean concepts to DuPont’s operations. I found it very frustrating that none of the available literature nor any of the courses I took could put Lean in a context that was appropriate to the kinds of processes I was working on, such as synthetic rubber extrusion, sheet goods manufacture, household and automotive paints, bulk chemicals, food and beverages, and carpet manufacture. These processes were quite different from the discrete processes, such as bolting sheet metal together to make refrigerators or automobiles, discussed in the then current books. I wanted to share my experiences with others in similar process industries to help them climb the Lean learning curve much faster than I did.

Value Stream Mapping (VSM), the subject of the latest book, is a very good example. While the format presented in Learning To See is very appropriate to both parts assembly and process operations, it must be expanded and adapted to completely describe the wastes and flow barriers found in process operations. Because the number of material types tends to expand significantly as material moves through a process operation, the VSM must clearly illustrate this diverging product flow. Traditional Lean deals with takt (customer demand) as a time factor, whereas in processes it is much more effective as a rate factor. While the assumption is often that takt is constant throughout the operation, in process manufacturing, however, it often must increase as you move back through the process to accommodate yield losses. And, the fact that key pieces of equipment are often shared across several product families presents a challenge on how to balance the need to clearly and simply illustrate flow with the need to be thorough and complete; bad choices in this area can understate utilization and hide bottlenecks. These are just a few of the issues I faced in creating effective VSMs for DuPont’s processes which are all described in the book.

A well-constructed VSM can be the blueprint that a Lean architect uses to guide a complete Lean transformation, as the examples in the book demonstrate. 

Do you have experience applying value stream mapping to the process industries? What have been the challenges?

5.19.2015

What is the Key to Lean's Long-Term Success?

I recently had the opportunity to speak with both Bill Baker and Ken Rolfes about their new book, Lean for the Long Term: Sustainment is a Myth, Transformation is Reality. During our conversation, I asked them: "Why did you write this book? What was unique about your experiences?" Here are their complete separate responses:

William (Bill) Baker: When Ken and I began this book, we found we had been in different industries during the past 40 years, but we had witnessed similar transformations that had started strong with management commitment, but when the low-hanging fruit had been harvested and/or a new executive was hired, the transformation was derailed and lost its momentum. It seemed many times lean was viewed as a “project” executed by a manufacturing manager or continuous improvement leader, but it did not have full-time support by upper management. So we researched organizations that have been on the Lean transformation journey for 30 to35 years to discover their approach to share in Lean for the Long Term: Sustainment is a Myth, Transformation is Reality.

Ken Rolfes: Having been an early adopter of the Toyota Production System methodologies we call "Lean," I have had the opportunity to benefit from Lean strategies in multiple industries and companies. I have seen businesses transform with Lean and then lose it. We wanted to understand why so many Lean initiatives start off strong, plateau, and then recede as well as how can that be prevented. What we found is the Lean transformations that fail to last were not transformations after all. They were high-energy attempts to rally the organization to action, and when the energy is spent, so goes the transformation effort. A Lean transformation is, in reality, a different management system. Lean for the Long Term challenges our organization and management system models.

Business transformation is currently on most CEOs' agenda, and General Electric (GE) is only one example. GE’s announcement in April that it plans to sell off most of its big finance unit, GE Capital, represents one of a number of moves in the transformation of the company under the CEO Jeffrey Immelt. Mr. Immelt described it as a lengthy and often humbling corporate journey recognizing that GE’s real strength lies in industrial engineering rather than financial engineering.

A few years ago, when he was speaking at Stanford Business School about following Jack Welsh after his tenure at GE, he stated “The trick, if you follow someone famous, is that you’ve got to drive change every day without ever pretending anything was ever wrong,” This is the premise of the Lean management system described in Lean for the Long Term. Most are familiar that core idea of Lean is to maximize customer value, but many lean practitioners are hung up in their current business model and structured organizations that are compartmentalized, departmentalized and driven by MBO (management by objective) goals.

The structure and isolation from the customer will not work in the unprecedented trends in sheer number, speed, and intensity of today’s business transformation activity. The need for business transformation may be caused by external changes in the market such as an organization’s products or services being out of date, changing income streams, new regulations, and/or competition becoming more intense. Organizations need the flexibly and responsiveness required to drive business model transformation which a Lean management system is designed to deliver.

To accomplish this, management must change the focus from optimizing separate technologies, assets, and vertical departments to optimizing the flow of products and services through entire value streams that flow horizontally across technologies, assets, and departments to customers. The Lean management system described in Lean for the Long Term describes that system and gives examples how it applies in every business and every process and the line of sight management process required from the front-line operations to the board of directors. The application of the principles described in our book can make any business more effective and profitable. At the end, this can benefit all of us – owners, managers, employees, and communities. 

So many companies have experienced the Lean initiative "plateau" -- the beginning of the initiative is strong but it soon loses direction and energy. In your experience, what is the cause of this situation? Do you agree with Bill and Ken's perspectives?

4.14.2015

The Need for "Safety Culture" in Radiation Oncology

I recently had the opportunity to speak with both Lawrence Marks and Lukasz Mazur, who are the authors of a very important new book titled Engineering Patient Safety in Radiation Oncology: University of North Carolina’s Pursuit for High Reliability and Value Creation. During our conversation, I asked them: "Why did you write this book? What was unique about your experiences?" Here are their complete separate responses:

Lawrence Marks: I studied engineering before medical school. I have always been struck by the differences between engineering and medicine; particularly in the way that the workplace in organized, how work in done, and how each address safety concerns. In the engineering setting, it is often acknowledged that people’s actions, and hence safety, are impacted by things such as leadership, workplace/workflow design, and the organization’s safety culture. This lesson has not been widely learned within medicine. As medicine in general, and radiation oncology in particular, have become more complex, it is becoming increasingly important to consider these “upstream” factors.

For the most part, radiation therapy is very safe. Nevertheless, there are recognized risks. Further, the interactive complexity of modern practice makes it challenging predict where problems will occur. Presently, much of the emphasis on making radiation therapy safer is in the realm of technical solutions: medical physics, computer software, etc. These initiatives are necessary and will certainly help to address the safety issues. This approach alone, however, will not bring us to the level of reliability we strive to achieve.

We can and should do better, and the way to do that is to apply lessons from engineering/industry. We must consider the leadership/administrative component, the workplace and workflow component, as well as the people component, to minimize errors. We must use Lean improvement principles to motivate and enable all colleagues to be actively involved in assessing and improving their own systems -- This will increase safety mindfulness and help to create a “safety culture.” It is only through this multipronged approach that we can become the highly reliable organization that our patients deserve. And this is the focus of this book. We provide an honest and heart-felt summary of our journey in applying this approach in our radiation oncology clinic. We hope that readers will become motivated to apply similar strategies in their own clinics. While we did this work in the context of radiation oncology, the lessons described are applicable in any area of medicine.

Lukasz Mazur: Most quality and safety improvement programs in healthcare delivery industry are currently structured to: transform leaders into effective change agents, design efficient and ‘waste-free’ workplaces, and develop people into creative problem solvers. This is perhaps one of the key reasons why continuous quality improvement (CQI) programs based on Lean or Six-Sigma philosophies become so popular and are now being implemented throughout the healthcare delivery landscape. Despite many positive reports in the academic literature, books, and press, however, it is still difficult to determine whether the transformation of colleagues to innovative problem solvers has indeed occurred in the healthcare organizations utilizing CQI programs. One of the reasons for this shortcoming is lack of valid and detailed implementation – the basis for transformation to safety mindfulness. 

This book’s purpose is to fill this shortcoming and provide ample examples of our hard work at transforming our leaders, enhancing our workplaces, and supporting people in their journey towards safety mindfulness. We have an important message to send—that the patient safety and quality concerns within radiation therapy (RT) field are not merely a technical issue, but rather a more global cultural issue grounded in attitude and behaviors. We emphasize a need for leaders to create and nurture a culture that promotes a transformation from quick fixing, conforming, and expediting behaviors to enhancing and initiating behaviors. Leaders must acknowledge that they are responsible for modeling and developing these desired improvement behaviors in colleagues by developing infrastructures that promote these values and, as needed, use their authority to enforce these values as well. 

The broad application of the principles described in our book to healthcare can make healthcare delivery more efficient and safer. At the end, this can benefit all of us – providers, patients, and families. 

What are your thoughts on the application of lessons learned from Lean initiatives in engineering and industry to radiation oncology clinics?