Lean Blog

Guest Post: My Transition to Health Care

2009-11-06T04:00:00.001-05:00

By Dale Hershfield:

I am fortunate to have recently transitioned into health care from outside the sector. As someone with lean and performance improvement expertise, I recognized opportunities in health care for both professional and personal growth. I’ve taken a small measure of the industry through my job search networking and initial on-the-job experience and here are a few first impressions.

Structurally, the organization of lean, quality and performance improvement resources within a hospital is similar to other industries—an arrangement that connotes the value and emphasis placed on these roles.

Perhaps 80% of the performance improvement job openings I found required the successful candidate to be a registered nurse (RN). There were very few positions specifically devoted to lean—judging by job titles, at least. The primary focus for improvement centers appears to be on clinical quality (thus the prerequisite for an RN). In larger hospitals and systems, I found two separate departments:, one for clinical quality improvement and another for “operations” improvement. The operations improvement group more frequently welcomes professionals without a clinical background. I learned that this is the group most likely to apply lean principles given that they focus more on business process related improvements (in both clinical and non-clinical parts of the hospital).

The structure and the areas of emphasis echo the majority of manufacturing companies I know: improvement is a part of the mix but it does not define the core of how they operate as a business. Yes, I am familiar with a refreshing, though small, number of hospitals that have embraced lean (or Baldrige) as a central tenet of who they are and how they operate. However, the balance of organizations (in my sample, at least) appear to view lean and six sigma in a supporting role. I suspect that the rate of improvement in results in health care organizations, like their counterparts in manufacturing, matches the level of resources, focus and commitment for improvement.

While I can’t claim a scientific sampling, the proportion of energetic and committed-to-improvement organizations within healthcare seems about the same as the ratio outside of health care. Yet, I think the balance will shift over time and that a greater proportion of healthcare organizations will embrace lean. Many organizations that have not yet begun an improvement journey, or who are at a very early stage, will be motivated to become lean leaders in order to keep pace with the changing landscape of health care.

I admit to one culture shock experience so far: peer review. I learned the rudiments of peer review during a couple of sessions at a conference I attended recently. Here is a process, as I understand it:, that peer review is invoked when there is suspicion that the level of care provided by a physician has not met an appropriate standard, e.g. a wrong site surgery. All right, I can understand that. Here’s the piece that is dissonant for a lean thinker: for most of the 60 years of its existence, peer review has never been connected to clinical process improvement. A perpetual Check, with no Plan, Do or Act. Peer review occurs only after-the-fact, and it looks backward in time. The outcome of peer review is binary, yes or no, did the care provided meet the standard?. Review outcomes, historically, were not connected with process improvement, preventive action or best practice development and sharing.

The implications of an adverse peer review action for a physician can be significant. In turn, what kind of culture has this approach shaped, where the physician is the central actor in the provision of care yet he or she is conditioned by a react-after-it-happens method instead of a continuous improvement mentality? What kind of cultural and mindset impediments will there be for a lean transformation where a focus on process improvement is fundamental for success?

Notably, the sun is rising on a new approach for peer review based on revised guidelines recently issued by The Joint Commission. Some conference attendees reported that, in fact, they have conjoined their peer review and performance improvement approaches into a single framework. (Check on Focused Professional Practice Evaluation and Ongoing Professional Practice Evaluation.)

With that note of optimism—I always like to carry a little sunshine in my pocket—I look forward to more joyful discoveries on my journey.

Dale Hershfield is a lean professional with 18 years of performance improvement experience in manufacturing, process and service industries.

For more resources on making a career transition to healthcare, visit www.movetohealthcare.com.

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The Purpose of Kaizen Events

2009-11-05T03:47:00.003-05:00

I recently ran into David Meier, co-author of the outstanding books The Toyota Way Fieldbook and Toyota Talent. Look for a guest post from him here on the blog soon.

He was talking about kaizen events and he made a few interesting points from his time at Toyota:

1) He was only involved in a handful of formal kaizen events in 10 years at Toyota, saying they did kaizen every day, not based on events.

2) He said the purpose of a kaizen event, when they were done, was for management to LEARN about kaizen. I had never heard that from anyone before, that's a really interesting proposition. I've also heard before that kaizen is primarily about developing people (the short-term improvement is secondary).

Interesting stuff, don't you think?

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Guest Post: Emergency Blood Product Release: Using the “6-3” to Work Smarter

2009-11-04T04:00:00.002-05:00

Many thanks to the staff of Barnes-Jewish Hospital for providing this for publication. You might also be interested in my podcast with Dr. David Jaques from the same hospital.

By: Rebekah Johnson, BS, David Jaques, MD, and Colleen Becker, MSN, RN, CCRN

A large Midwestern hospital with a Level I Trauma Center and a surgical volume of 35,000 cases per year addressed the urgent need to provide a standardized process for the emergent release of blood products to patients with acute hemorrhagic blood loss. Any difficulty in obtaining critical blood products for emergency massive transfusion situations can lead to a patient’s death. We used Lean-based tools and methodologies to move from event pre-work to solution implementation in eight weeks.

The traditional Lean Rapid Improvement Event (RIE) takes place over the course of five days and requires a full-time commitment, roughly 35 hours, from all team members. Considering the urgent need for a resolution of this problem and the need to have critical stakeholders present through all steps of the solution process, we chose to use an innovative “6-3” event to alleviate scheduling concerns for team members and to more rapidly address the crucial issue of emergent blood product release.

The “6-3” event, a unique concept created by our organization, uses the fundamentals of the Lean RIE in a refined event structure. A “6-3” is chartered using the standard RIE format, but focuses on a narrower scope. The event consists of one 6-hour and one 3-hour workday, with several days between for follow-up items. The flexible schedule of the “6-3” event for this project allowed all critical stakeholders to serve as full-time team members and provide the requisite approvals to move forward with solutions immediately.

The project team consisted of administration, process owners and end users from the operating rooms, the blood bank, the emergency department, anesthesiology, and trauma services. Target deliverables included the development of standard definitions and standard work, to be combined in a complete Massive Transfusion Protocol as an organizational policy.

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LeanBlog Podcast #78 - Sorrel King, Improving Patient Safety

2009-11-03T14:00:00.002-05:00

Episode #78 brings a very special guest, Sorrel King, to talk about systems, communication, and patient safety. Sorrel's 18-month old daughter, Josie, was the victim of a series of preventable medical errors at a world-renowned hospital, passing away in the hospital's ICU. Sorrel channeled her grief and energy into the Josie King Foundation, which works to educate healthcare providers, patients, and families about the patient safety and systems improvement. From their website:

The Josie King Foundation’s mission is to prevent others from dying or being harmed by medical errors. By uniting healthcare providers and consumers, and funding innovative safety programs, we hope to create a culture of patient safety, together.

Sorrel is also the author of the recently released book, Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safe. I think much of what she talks about will resonate with Lean thinkers, as well as anyone with an interest in safer healthcare.

For earlier episodes, visit the main Podcast page, which includes information on how to subscribe via RSS or via Apple iTunes.

You can use the player (use the VCR-type controls) below to listen to a "streaming" version of the podcast (or click here for the streaming audio and RSS subscription). The streaming link is faster for one-time listening (hardly any delay to start listening). Or you can use the download link to put it on your iPod or other MP3 player.

MP3 File Right-Click to "Save As"

Enhanced AAC File

If you have feedback on the podcast, or any questions for me or my guests, you can email me at leanpodcast@gmail.com or you can call and leave a voicemail by calling the "Lean Line" at (817) 776-LEAN (817-776-5326) or contact me via Skype id "mgraban". Please give your location and your first name. Any comments (email or voicemail) might be used in follow ups to the podcast.

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Leanies of the World, Unite!

2009-11-03T04:00:00.001-05:00

Will the Real Lean Production Please Stand Up? | Labor Notes

Yesterday, I blogged about how a nurses' union in Canada was supporting the province's lean healthcare activities for improving patient care.

Going back a few weeks, I blogged about a union website's criticism of what they described as "Lean" in some hotels. I put "Lean" in quotes because much of what the union wrote about sounded more like "L.A.M.E." (Lean As Misguidedly Executed, as I coined it a few years back)., not real Lean.

There's nothing, unfortunately, stopping any company or organization from practicing what Jim Womack has called "stupid meanness" in the name of what they call "Lean." Managers could say they are implementing "systems thinking" while doing bad things that would make that crowd squirm and cringe. Bad management is bad management.

True "Lean," based on the Toyota Production System, starts with the customer and includes the ideal of "respect for people" (meaning their employees, among others). If hotels use Lean as a mindless "speed up" program where employees are pressured to work faster, or if more people are getting hurt, or if employees aren't included in the process, that's L.A.M.E.

So in the light of that original union criticism, I tried to defend Lean to try to help clarify that not all Lean efforts are equal. Just because some people do bad things in the name of Lean, that doesn't mean Lean should be discounted completely as a methodology.

The union wrote back with a second post, linked at the top of this post and also here. They made fun of our use of the term "lean community" but, hey, the union folks call each other "brothers and sisters," so there's no monopoly on curious sounding terms. My point isn't to get into a tit-for-tat with the union... so back to the topic at hand.

The union writer, Chris Kutalik, gives our "community" some credit for being "high-minded" in defending what's really Lean vs. L.A.M.E. It's fair to say that many (or most) of us reading my blog on a regular basis do show respect for people and don't want people getting hurt.

Kutalik says that Lean, ideally, is about eliminating waste. He forgets (or doesn't know) the "respect for people" principle. Does Toyota live up to that ideal perfectly? No, they are human. But at least Toyota sets the bar high, unlike a lot of companies who practice the "to hell with people" principle.

He writes:

"In theory, a more efficiently-organized workplace would be a safer, happier workplace."

Yes, that's absolutely true when Real Lean is being practiced. It's not just "theory."

They trot out a study or two that supposedly proves (extrapolating) that all Lean efforts make workers miserable and hurt people. That's not true, their criticism is overgeneralizing by far. I have helped teach Lean methods and thinking to professional staff members and managers in many hospitals where morale improved dramatically (in measurable ways, based on survey data). Lean done right creates a happier, more engaged, fulfilled workforce. L.A.M.E. creates frustration and cynicism (so does bad management under any label).

Even if we disagree on the extent of how common place "L.A.M.E." is, I'll give them credit for coining a new "L.A.M.E." acronym: "Lean As Mainly Experienced." I'm going to add that to my repertoire.

"[Lean] has frequently meant fewer workers doing more work in jobs they control less and less."

Real Lean is about giving MORE control to people doing the real work. Lean leaders give up their old command-and-control mindsets and allow people to practice "kaizen," making their work easier and better serving customer needs.

We're on common ground with Chris. I appreciate people also standing up to criticize L.A.M.E. when we see it - taking control away from people is certainly L.A.M.E.

I think we need to do more, to unite and speak up to defend the ideals of what Lean is supposed to represent. When other groups unfairly criticize Lean as being "just a bunch of tools," we need to speak up and remind people that Lean is a philosophy and management system. When consultants promise "fast Lean" or simple prescriptions that can be blindly followed, we need to speak up and say, "No, Lean is hard, and it requires you to think, not copy."

A friend suggested we need a support group to deal with this sort of unfair, overly broad criticism. Maybe this blog is that support group. If you see articles representing "L.A.M.E." of any form, share them with me. As the union suggests, the "Real Lean Production" does indeed need to stand up... and speak up. I've registered the domain "LAMEnotLean.com" -- what should we do with as a "community"?

Thanks to Labor Notes and Kutalik for spurring us to action.

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Nurses Union Supports Lean

2009-11-02T04:00:00.001-05:00

telegraphjournal.com - Lean process, big results

More on this topic of unions and Lean tomorrow, but I wanted to share this story from Canada.

The New Brunswick provincial health system is going to start working with the Lean methodology. This earlier article says the pilot will start at one facility in the near future. Starting with the problem statement:

The provincial government must find ways to manage health care on a sustainable basis. It also must address persistent complaints about waiting times and concerns about hospital working conditions.

Lean is a great way to address both patient needs *and* employee concerns. More satisfied employees lead to happier customers in any service business, especially in healthcare.

I'm not crazy about how the article refers to it as an "efficiency" program, as that ignores the dual quality component of the Lean approach. Better quality and efficiency go hand in hand with Lean.

The one major goal, as with other efforts involving nursing is to use efficiency improvement to create more time for patient care activities. Talk about win-win: better outcomes for patients and more rewarding work for the nurses.

The goal is to deliver process improvements that allow provincial nurses to spend more time with patients and less on administration or wasted effort.

It's also "win" for the hospital because they can get more patient contact time (and better outcomes) in a way other than hiring more nurses (nurses who often aren't available due to shortages in the field). Just to be clear -- "process improvement" does not mean cracking the whip and making people work faster. It's about eliminating wasteful motion, effort, and paperwork.

Proof that it's "win/win/win" is that the nurses' union endorses the effort:

The New Brunswick Nurses Union is supportive of the pilot project because Lean process has been used successfully in other health care systems, from the United Kingdom to Saskatchewan. Provided administrators and employees engage in the process with an open mind, it is a time-tested way of finding and eliminating inefficiencies.

The emphasis there is mine... provided administrators (especially) go about it the right way (involving staff and not forcing changes top-down) then Lean certainly can work.

As always, the article's reader comments provide a range of reactions, including this one:

"Processes are not the key to efficiency. Efficiency is due to good management. Bad management are always proposing changes to the system to hide their incompetence. You can bet your last dollar that this so-called lean system will not work in our health care system. The self-interest group whithin our health care system will not let their priviledges be reduced which is where the waste is."

Hmmm, interesting viewpoint. Wonder what drives their cynicism? Previous "program of the month" fatigue? There's another commenter who says that you obviously have to add people to fix the problem. That's very common pre-Lean thinking... just give me more money, more people, and more space and everything fixes itself, eh?

The earlier article has an even more negative comment about Lean, including this gem:

The company I used to work for went with the Toyota model - and ended up screwing up so many departments (trying to fit round pegs into square holes )that we lost at least 30% of our customers & a good portion of really good people who did their own jobs really well during the implementation.

Sounds like a case of "L.A.M.E." that that reader was describing?

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Toyota article from 1997 - the "Soul" of TPS that's hard to copy

2009-10-30T04:00:00.000-04:00

How Toyota Defies Gravity

In doing some research for an upcoming presentation, I found this FORTUNE article from 1997. I was looking for a reference to Toyota letting its competitors (yes, Ford, GM, and Chrysler) tour its factories.

Why would they do this? Because what you can see with your eyes (tools and artifacts of Lean) is NOT the important stuff, the "secret sauce" if you will:

Two days a month, more than 50 automotive executives and engineers travel to a sprawling manufacturing complex in Georgetown, Ky., to learn how Toyota makes cars. The tours, which include an intensive question-and-answer session, last five hours and are booked months in advance. Although the visitors all work for competing automakers, Toyota charges them no money and places nothing off limits. Lately Ford and Chrysler technicians have been regular visitors to one of the two assembly lines, while General Motors personnel have demonstrated a particular interest in the powertrain operations.
Toyota's showing the opposition how it makes cars is a bit like Coke's giving Pepsi a peek at its secret syrup formula. The Toyota Production System on display at Georgetown applies not just to manufacturing but also to almost everything Toyota does, from product development to supplier relations and distribution. But Toyota officials don't mind. Deep down, they know that the TPS techniques that visitors see on their tours--the kanban cards, andon cords, and quality circles--represent the surface of TPS but not its soul. Toyota isn't worried about giving away any important secrets on a plant tour.

The same idea holds true for hospitals looking to apply TPS and Lean. The key is not copying tools, like 5S, but rather copying the general principles and management philosophies.

Even in 1997, Lean was "old hat" to many, yesterday's news. What the latest and greatest fad to jump on?? Will we reach that point with Lean in healthcare?

From the article:

Anyone want to read more about Japanese management techniques? I thought not. Last year's management fads are about as appetizing as yesterday's sushi, and ideas such as just-in-time inventory and continuous improvement feel shopworn, to say the least.

Continuous improvement is "shopworn?" In 1997? That's the problem -- the small improvements, the discipline to practice kaizen each and every day... that's boring... the basic blocking and tackling of making sure checklists are used and truly followed each and every day... also boring? It shouldn't be. Or at least it shouldn't be ignored because it's "boring" to those who are only interested in the exotic cases or the next great technological leap.

I visited a hospital recently where they were excited about the latest innovation in the use of their expensive surgical robot. That's great innovation -- but is that sort of innovation enough? The hospital leaders also talked about how they had "no standardized work for anything" generally around the hospital.

They were realizing that the basic blocking and tackling is important. Fancy technology can save lives, but so can processes, standardized work, and disciplined daily management. Maybe healthcare can focus in both areas - technological innovation AND process innovation?

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Womack & Jones at the Gemba: "Spread" and Innovation

2009-10-29T14:00:00.002-04:00

Womack and Jones video on spread - Blog - ThedaCare Center for Healthcare Value

From John Toussaint's blog, this video starts with a question about (I'm paraphrasing) how do you balance continuous innovation (in how "Lean" works in a hospital) with the desire to spread what already works? Are there organizations to study to learn about this? That's John running the FlipVideo camera and commenting, also, from behind the camera.

The video of the response:

Jim says, basically, that you're always going to be innovating and if the next area thinks they can just copy, then they're missing the point. Being "cookie cutter" and "spraying this a molecule deep" will certainly fail, Jim says.

Dan asks if you're expecting the next units to be 100% ready when they start or 85% ready with additional experimentation? What's the proper pace of spreading the implementation throughout ThedaCare or any organization?

What do you think of their answer? How would *you* answer that question?

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Reducing Interruptions - And Improving Patient Safety

2009-10-29T04:00:00.001-04:00

by Dan Markovitz

Long-time readers of this blog (and my own) know that I focus on bringing lean techniques to individual work habits. One topic I often cover is how interruptions -- from email, phone calls, colleagues -- creates inefficiency and waste for office workers. I suspect that readers sometimes think that this is a pretty minor issue -- that "real lean" addresses more significant things, like defective parts coming out of a grinding shop.

Now comes a report from the University of California at San Francisco that interruptions aren't just minor annoyances that make people a little less efficient. They cost money and lives.

A study involving nine San Francisco Bay Area hospitals focused on improving accuracy in administering drugs - with particular emphasis on reducing interruptions that often lead to mistakes - resulted in a nearly 88 percent drop in errors over 36 months at those hospitals.

"Medication errors make up the largest slice of the medical error pie," said Julie Kliger, director of UCSF's Integrated Nurse Leadership Program, which developed the medication errors program. "Improving these numbers is a huge benefit to patient safety and, secondarily, it reduces costs."

Lest you think this is just a minor issue, the Institute of Medicine estimates that errors in administering medication cause about 400,000 preventable injuries in hospitals and about $3.5 billion in extra medical costs each year.

What's most exciting about the study is the way they reduced those errors. In true lean fashion, front line workers -- nurses -- figured out ways to improve the current state without spending money. No fancy jargon, no value stream maps -- just common sense and a desire to fix a problem.

Striving to reduce interruptions that lead to mistakes, teams of nurses at the different hospitals came up with a variety of methods - often surprisingly low tech - to alert others they were administering medications. The strategies included everything from wearing brightly colored vests or sashes to establishing "quiet zones" or making announcements at key points in the day when medications are being administered.

At San Francisco General, for example, nurses found they were constantly being interrupted in the medication room because their colleagues could see them through the windows. So they covered the windows.

The solutions "have to be low tech because we, as staff nurses, don't have the money or ability to make high-tech changes," said Celeste Arbis, a registered nurse in the medical-surgical unit there. "Something as simple as changing the process just a little bit can make a big difference."

Much of the program's success came from allowing the nurses on the floor to develop their own countermeasures. Kaiser nurses used fluorescent sashes to signal they were in the middle of giving a patient medications and conducting necessary safety checks. But

at St. Rose Hospital in Hayward, for example, nurses in the maternity wards found the sashes too flimsy and opted instead to use bright green vests. In the large medical-surgical units, nurses rejected the vests and sashes in favor of carrying yellow folders. In the hospital's intensive care unit, nurses put a border on the floor around the electronic medication dispensing machine along with an overhead sign.

Mark has been preaching for awhile now about the false dichotomy presented in the media between better health care and lower costs. This is just another example of the waste that is both easy and inexpensive to eliminate, and would improve quality AND lower costs.

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Quote from Seth Godin on the Scientific Method

2009-10-28T04:00:00.000-04:00

This was in Inc. magazine, a quote from a favorite of mine, Seth Godin (click on the graphic for a larger, easier to read view):

The scientific method is the basis of PDCA (Plan-Do-Check-Act), also known as the Deming Cycle (or the Shewhart Cycle). It's also known as PDCA (Plan-Do-Study-Act). It's also been re-named IDEA (Investigate, Design, Experiment, Adjust) by the design group IDEO... but I digress.

What do you think of the quote? If Lean and TPS is all about a scientific approach to problem solving, how much do you see that actually practiced in your own organization?

When you put a change in place, do you have a hypothesis about what you expect to happen? Do you disprove (or prove) the hypothesis based on observation and data?

PDCA / PDSA is intuitive to most people in healthcare... they were taught the approach (and they've often heard of Deming), but is it really practiced? Do you have a "culture of testing and inquiry," regardless of your industry? Is that something you aspire to?

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Ten (Mostly) Common Misconceptions About Toyota & Lean

2009-10-27T04:00:00.000-04:00

Ten Common Misconceptions About Toyota | Quality Digest

I found this interesting column from Quality Digest, by Stewart Anderson, a guy who says he has first hand experience with Toyota people and suppliers. The website bio page requires registration to view, which is a ridiculous request of QD, I believe. So out of principle, I'm not registering just for that. There is a short "about the author" at the bottom of the article that doesn't really distinguish his background (such as, did he really work for Toyota or not?).

It's generally a good piece, an attempt to knock down some of the misperceptions about Lean. That's important work, helping people understand what's really Lean and what's L.A.M.E. I don't agree with all of it... I'll outline my comments below.

Anderson highlights a theme that I heard expressed by Mike Hoseus and David Meier last week -- that TPS is ultimately about the thought process:

Toyota’s basic pattern for improving a process is based on a simple three-part model:
Understanding the current condition.
Developing and defining a target condition.
Understanding and tackling problems which need to be overcome to move from the current condition to the target condition.

That's far more important than individual tools, like 5S and kanban.

Misconception #2: Toyota operates a just-in-time system.

He is right in mentioning that "one piece flow" is an ideal state not always reached by Toyota. With the NUMMI plant in California, Toyota had to significantly vary its supply chain operations from the methods used in Japan. Getting parts via rail from the midwest is very different than getting parts via truck in a small country. "Zero inventories" isn't the end-all-be-all goal, nor is it achieved by Toyota. Anderson basically restates the same point as Misconception #6 ("Toyota uses one-piece flow in all processes"), so this is probably just 9 Misconceptions, not 10.

Misconception #5: Toyota’s shop floor is linked to and controlled by a powerful IT system.

I think Anderson is wrong in the sense that the misconception about Toyota is often quite the opposite. I think the common misconception is that Toyota is a bunch of Luddites who do everything with paper and pencil. Toyota DOES use technology -- but only the right technology that serves their people and processes (as written about by Jeff Liker and others -- see Principle 8). Anderson is right in saying:

Toyota uses IT systems with discretion to support its operations, primarily using such systems in the areas of supplier interface and control, and outbound distribution logistics.

That middle ground normally is reached from a starting point of misconceiving that Toyota uses almost no IT. I don't know anybody who has ever thought Toyota goes overboard with technology. I wonder where Anderson got this impression?

My nitpicking aside, take a look at his list - some real misconceptions are there, and he knocks them down.

As he mentioned in Anderson's intro, I really love the whole "Toyota _________" series, along with Spear's book, and I'm just starting Toyota Kata from Mike Rother.

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"McDreamy" Fights the Blame Game on "Grey's Anatomy"

2009-10-26T04:00:00.005-04:00

Grey's Anatomy : I Saw What I Saw

I'm not normally a Grey's Anatomy watcher (yeah, right, some of you might say... but I'm not). My wife watches the show every week. I paid close attention to this past weekend's Tivo showing because my MIT friend Aaron tipped me off that this episode dealt with issues of blame...

I'll try to summarize the story in my layman's terms (both as a non-doctor and a non-Grey's watcher). You can watch the whole episode online (for a few weeks, anyway) and I'm posting a clip below.

A young MD was examining a woman in the E.D., a burn victim from a hotel fire, a mass casualty event. To say it was hectic in the E.D. would be an understatement.

She was about to look down the patient's throat with a scope and was distracted (a patient was wheeled by with axe in his chest - yikes!!). She turned back and said "you look great." The patient ended up dying after respiratory distress and multiple organ failure... the investigation was a series of individual interviews that seemed like a witch hunt. In the very first scene of the show, the chief foreshadowed at the start of the investigation that he was looking for "who" was responsible.

The investigation panel fired the MD when they realized she hadn't looked down the patient's throat.

This scene toward the end is an exchange between the Chief of Surgery and Dr. Shepard (aka "McDreamy" -- not my nickname for him).

Dr. Shepard says "It's not the doctor... they're all good doctors."

The Chief said he "needed to know WHO finally was responsible... at least I was able to do that."

Drew a big sigh from McDreamy.

"Maybe it's not one doctor... maybe it's too many doctors who don't know each other and who don't trust each other. When I got to that room, it was chaos. Because that's the system now -- chaos. That's the system that's been in place since this merger, your system. I'm saying you should look again at who's responsible."

Dr. Deming (not a medical doctor) would be proud. Who is responsible for the system? Top leadership Why fire an individual for a mistake that could have happened to any of them in those conditions?

Dr. Yang makes this exact same point, that it was a systemic error -- "our patients didn't die, that's why we didn't get caught." The process was bad for all, but the only one who got punished was the one with the bad result pinned on them.

To those of you working in situations like this, how realistic was the portrayal on the show? It leads to a great discussion topic -- would you have fired the physician? What would you do instead of focus on fixing the system and preventing a similar error in the future?

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Lean & Collaborative Care at ThedaCare

2009-10-24T09:59:00.002-04:00

Six Best Practice Elements of ThedaCare's Collaborative Care Model

Here's an article from Becker's Hospital Review about the six best practices of Lean-based Collaborative Care at Thedacare. This is the same model that was featured a few months back on Fox News, you can see some video interviews with ThedaCare staff here.

The collaborative model has been widely successful in improving the quality of patient care and making that care more efficient, according to Kathryn Correia, senior vice president of ThedaCare and president of Appleton Medical Center and ThedaClark Medical Center in Neenah, WI.

ThedaCare has reduced costs by 25% under the Collaborative Care model, while also reducing:

length of stay by 25 percent and various error margins to nearly zero and significantly increasing patient satisfaction scores.

Correa highlights that the key to this innovation and process redesign is staff involvement at all levels. Collaboration among physician, nurse, and pharmacist roles is increased and waste and non-value added activity is reduced.

The six elements of Collaborative Care, according to the article, are (with my comment following)

Collaborative rounding upon admission: rounding as a team to reduce delays and minimize handoff errors
Evidence-based plans of care: standardized work for treatment of the patient
Nurse as manager of care: Nurse as process owner, making suggestions to the MD (a huge culture shift)
Tollgates: Ensure consistent, documented care, with the ability to stop the line if there is a problem or delay
Electronic Medical Record: EMRs that provide notifications to nurses (a form of process error proofing)
Purposeful design of physical space: Reducing walking to create more value-added time for patient care -- 80% of supplies are kept in patient rooms.

The article suggests that more hospitals will be adopting this model. With the desperate need to reduce healthcare costs (and improve quality), my question is "When?"

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UPS: Disrespect for People?

2009-10-23T04:00:00.003-04:00

by Dan Markovitz

I took this picture of a UPS truck recently in NYC. (The orange signs say "SAFETY.") At first I thought, "Great! UPS management cares about safety for its drivers. Terrific!"

But then I looked at the signs a bit longer and wondered just what exactly they're supposed to mean. Is it an exhortation to the drivers to be safe when they're on deliveries -- in other words, this is just a reminder? Or is it directed to drivers of nearby cars, warning them to be careful when passing the UPS truck? Or is it both?

Mark has written often about the prevalence of signs encouraging hand washing in hospitals, and about the very low level of adherence to this policy. As he points out, signs and admonishment just don't work, which has led to discussions about "error-proofing" hand washing.

It would be far better for UPS to provide traffic cones or some other control device to create a safe zone next to the truck. The cones would ensure that the driver has room to operate, rather than simply hoping that people will read -- and respond -- to a simple slogan like "Safety."

And, in fact, UPS does provide each truck with two cones. So why aren't they out there? I went to the gemba to find out. (In other words, I talked to a few drivers.)

It turns out that drivers love the cones. They were introduced a couple of years ago, after a UPS driver had his leg crushed against the back of the truck by a car and needed to have it reattached surgically. But they've run into two problems. First, some people steal the cones. Second, cars (in NYC, at least) don't give the cones a wide-enough berth: they run over them and drag them away.

Getting UPS headquarters to replace the cones is a long, slow, bureaucratic process filled with numerous forms and delays. It's a constant source of frustration for drivers. But since they're paid to make deliveries, they do they best they can with the orange "SAFETY" signs -- even if it's not as safe as it could be. So much for respect for people.

It seems to me that UPS has a fantastic "kaizen" opportunity here. They can either streamline the cone replacement process, or employ their thousands of drivers to figure out a solution to the root cause of the problem. Surely someone can come up with a way to keep the cones from disappearing -- and to keep the drivers safe.

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Lean Healthcare Intro Workshop Dec 2-3 @ LEI

2009-10-22T14:00:00.001-04:00

Key Concepts of Lean in Healthcare

Blatant self-promotion time: I will be teaching this workshop for the second time (after the Philly debut last month) in Cambridge at the LEI office December 2 and 3. Here is a video where I talk about the course. We need to shoot a version with better lighting (and maybe a better spokesman!) ... but here goes.

I'd love to see you at the class. We had a few Lean Blog readers at the last session. We had a nice mix of physicians, nurses, hospital managers and leaders, and some from outside of healthcare who were looking to learn more to help their transition into the industry. I'd anticipate a similar mix for the Cambridge workshop.

This will also be offered many times in different cities in 2010.

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Mike Hoseus Webinar on Toyota Culture

2009-10-22T04:00:00.004-04:00

Industry Week Webinar - To Register

Technical note: I've been having some problems where "leanblog.org" gives a "404 not found" error, but "www.leanblog.org" works just fine. I am working on getting this resolved permanently. Thanks for your patience if this has affected you.

The other day, I watched the online archive of a webinar given by Mike Hoseus, co-author of Toyota Culture: The Heart and Soul of the Toyota Way.

You can use the link at the top of this post to listen the free audio archive (with registration) and even download the slides in PDF form. The message that he sent is applicable to any industry.

One story that intrigued me was Hosus talking about how, when he was an early employee at Toyota's Georgetown Kentucky plant, he was sent to Japan to work on the assembly line for 30 days. Before he could be a team leader (the first level of supervision at Toyota, with 4 to 5 direct associates reporting to him), he had to work the line.

Why? "To build empathy" for those doing the work. How great is that?

Compare that to the old GM approach (still in place when I started in 1995) of taking a freshly-graduated engineer and making them the supervisor over a process they didn't understand, supervising people they might have trouble relating to. That was a formula for disaster.

Now looking at healthcare, it's much more common for charge nurses, supervisors, or team leaders to be promoted up from the rank and file. Most of the managers (even executives) have done the work of the people they manage. A VP of nursing tends to be a nurse. I do know one extremely effective laboratory director who came in from a nursing background -- she was effective, but had a lot of work to do to build trust and respect from the staff.

So, in the cases where managers are promoted up -- that natural empathy should be there. But why do healthcare leaders often fall into the same types of manager and supervisor behavior that I saw at GM, a non-Lean environment?? Why do managers plead for people to be careful, to work harder, to suck it up and not complain... they should feel empathy, but I guess the greater management system that they're now a part of sends the same message... keep your head down, don't make waves.

That's why the cultural transformation effort required for Lean seems so similar to me comparing manufacturing to healthcare. It's all about how you lead. It's all about having empathy and being a servant leader, not being "the boss." Having empathy doesn't mean being a pushover - it means being able to put yourself back in the shoes of the people doing the work.

What do you see in your organization, in terms of supervisors or managers -- do you have to build empathy? Do you have to help them not lose their sense of empathy once they become part of management?

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Management Improvement Carnival #79

2009-10-21T04:00:00.003-04:00

Again, I'm very happy to host the Carnival for John Hunter and his Curious Cat blog. My job here is to share some noteworthy and thought provoking posts from the past month. I hope you'll discover a new blog or two (or new idea) in the process. My Carnival selections run the gamut from manufacturing to healthcare to other industries, but I hope it will help you see the common themes of Lean and the Toyota Production System.

Put Down That Tool (Jamie Flinchbaugh): "Use the simplest tool possible. When you start to use tools that are more complicated than they need to be, we add unnecessary waste and bureaucracy to the process of improvement."
Kaizen Corner -- for lack of a battery (Paul Levy, Running a Hospital): "The idea is to keep asking why (the 5 why’s) until they discover the root cause, which is defined as that level of understanding that will permit development of a countermeasure that will prevent the problem from occurring again."
Words of Taiichi Ohno Sensei: Kaizen by Inspiration is Not Kaizen (Jon Miller, Gemba Panta Rei): "Taiichi Ohno explains that the type of kaizen that you do when the survival of your company depends on doing kaizen is the most important kaizen."
We Will Solve Your Problems, But Let Us Solve Some Of Our Own (Lee Fried, Daily Kaizen): "This contract is based on the premise that if management provides the resources and capabilities to allow frontline teams to solve problems that are important to them and help out when the problems need to be escalated these same teams will be far more willing to solve problems that are important to management."
Problems Hidden Out in the Open (Mark Rosenthal, The Lean Thinker): "It isn’t enough to ask the team member to call for help. You have to expect it, encourage it and require it."
Kaizen - FastCap Style (Ron Pereira, Lean Six Sigma Academy): "If you’d like to see kaizen in action, and I do mean real kaizen, you need to set aside around 23 minutes to watch this video of the FastCap team improving the way some items are packaged."
Never try to change something (Marc Rouppe van der Voort, Lean Thinking in Healthcare: "A burning platform gives momentum for change, but usually the baby is thrown out with the bathwater by also disqualifying what is good."
How NUMMI Changed Its Culture (John Shook, Lean.org): "What I learned was most powerful at NUMMI was to start with the behaviors, with what we do."
Why is Asking "Why?" So Important? (Tracey Richardson, Toyota Gal Blog): "So what happens if we keep asking WHY? How do we know when to STOP?"
Boeing Pulls Another Rube Goldberg (Kevin Meyer, Evolving Excellence): "Of course had they not gone down the outsourcing path they could have just walked next door to see how component assembly was going."
A Natural Match (Deborah Dolezal, Lean Healthcare Grand Rounds): "As a healthcare worker and an implementer of lean, I am often struck by the similarity of the human body and the lean methodologies."
The Lean Manager Book Review (Mike Wroblewski, Got Boondoggle?): "In the case of The Lean Manager, it is hands down the best business novel on lean transformation that has been written yet and I thoroughly enjoyed reading it."

Please submit your favorite management posts to the carnival. Read the previous management carnivals on his site or my previous carnivals by clicking the "Carnival" tag at the bottom of this post.

FTC conflict of interest disclosure: I work for the Lean Enterprise Institute, publisher of John Shook's Management Column and the book "The Lean Manager." Further disclosure, that link to the left earns me a commission from Amazon. Happy, FTC?

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Wachter is Right: Patient Safety is Not the Patient's Job

2009-10-20T13:00:00.001-04:00

Wachter's World : Can Patients Help Ensure Their Own Safety? More Importantly, Why Should They Have To?

The whole subject of asking patients and families to participate in safeguarding their own safety is something I've written about before and the idea makes me cringe. Do airlines ask me to double check that the pilot has set the flaps properly? No. Where do hospitals get the idea they can ask patients to confirm that caregivers have washed their hands or that they are bringing the right meds?

Is it probably in your interest to double check, to inspect their work? Yes, because healthcare has not proven that it can operate as reliably as patient safety or the U.S. nuclear navy (as highlighted so well in Steve Spear's book Chasing the Rabbit.

Double checking the hospital's work should be considered, at best, a short-term countermeasure -- a workaround. It shouldn't be considered the ultimate quality improvement solution.

Dr. Bob Wachter writes about this on his outstanding blog. He's not opposed to patients and families being involved -- he's just skeptical that it really helps. Where is the data? Do hyper-involved patients cause more problems than the avoid?

Read his whole post, but Wachter sums up his thoughts this way:

Patients encountering the healthcare system lack this trust [as exists with airlines], which make relaxation and passivity seem maladaptive, even suicidal. So I completely understand why patients and families would want to do whatever they can to improve their odds of emerging unscathed. I’m just not sure how well the resulting tactics work or how to apply them most effectively. Clearly, this is a testable hypothesis, and it should, in fact, be tested.
In the meantime, while we should support the efforts of patients and families to participate in their own safety when feasible, our primary focus should be on making such hyper-vigilance unnecessary. This one is our bad, not theirs.

Well said.

The patient hyper vigilance should be considered, at best, a short-term countermeasure until better systems can be put in place to protect patients and provide perfect patient care.

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LeanBlog Podcast #77 - Bob Emiliani, Principles of Mass and Flow Production

2009-10-20T04:00:00.006-04:00

A returning guest (episodes #30, #38, and #48), Bob Emiliani is again featured in episode #77 of the LeanBlog Podcast. Bob is the President of The Center for Lean Business Management, LLC. He is a leading authority on Lean management, who since 1995 has focused his efforts on de-mystifying the "black art" of Lean leadership through a number of efforts, including his acclaimed "Real Lean" series of books.

Today, we talk about his most recent work - the re-publication (with additional material and commentary from Bob) of a book by Frank Woollard called Principles of Mass and Flow Production. You can read more about the book here on Bob's web site.

For earlier episodes, visit the main Podcast page, which includes information on how to subscribe via RSS or via Apple iTunes.

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Hotels Give "Lean" a Bad Name??

2009-10-19T04:00:00.003-04:00

Housekeepers' Giant “Hope Quilt” Puts Hotel Job Injuries in Spotlight | Labor Notes

Articles like this are incredibly frustrating to see. It makes me think of a variation of the famous Bon Jovi song that would go something like "You Give Lean a Bad Name." As Jamie pointed out in the comments, this is totally "L.A.M.E."

One problem the Lean community has is that there's no ownership of the word "lean." Companies and people can do whatever they want under the self-proclaimed banner of "lean." Many of the practices or mentalities described as "lean" have absolutely nothing to do with the Toyota Production System and true "Lean" (I capitalize it when I mean the formal system based on Toyota, Dr. Deming, Training Within Industry, and other methods).

So this piece about hotels (rabble rousing to get hotel workers to join unions) either:

Intentionally misrepresents what is going on with "lean" or
Sadly represents how hotels are really operating under a so-called "lean" umbrella.

The part that jumped out at me:

LEAN CLEANING

Lean production—including speedup, understaffing, “just-in-time” production, and the resulting jump in workplace injury rates—hasn’t been limited to auto assembly lines or meatpacking. A Wachovia Capital Markets report says hotels employed an average of 71 workers per 100 rooms in 1988. Two decades later, 53 workers are handling the same workload. Speedup has created a tussle over the number of rooms cleaned per shift.

There's nothing Lean about workers getting hurt. Blindly speeding up work (ala the "I Love Lucy" candy factory) is not Lean at all. Cutting staffing levels to the point where work can't get done properly represents everything bad about traditional approaches to management and cost cutting. How people get off calling that "Lean" is beyond me.

The staffing data, in and of itself, isn't necessarily the sign of a problem. Going from 71 workers to 53 per 100 rooms might be OK if there was a reduction in "waste." I doubt it, but it's possible. True process improvement (true "Lean") would eliminate wasted motion and give the housekeepers better tools to be able to do their job quickly. They might eliminate some "overprocessing" by not changing the sheets every night during a 5-night guest stay.

Improvements like that would allow housekeepers to clean more rooms per day, without hurting quality or hurting the workers. Determining the number of housekeepers required should be based on standardized work (real data about how long it takes to do work) and real observation of the process. Staffing levels shouldn't be based on spreadsheets or benchmarking data.

One other complaint from workers:

Heavy covers, pillows, mattresses, and linen carts weighing up to 80 pounds add to the chance of injury, housekeepers say. “It's like pushing a bull,” said Eunice Zapata de Juarez, a union supporter who spent months on light duty after being injured on the job.

This sounds like a real problem that should be addressed. Can carts be redesigned? Can they be made smaller? Can linens and materials be moved in smaller batches to reduce the load and the weight?

Just pressuring the housekeepers to work faster or "be careful" to not get hurt in a bad system -- that's not Lean at all. How do we spread the word in the hotel industry?

Here's a case study from our friend Jamie Flinchbaugh about real Lean methods at Marriott.

[Lean] worked well, since this was in line with the values of J.W. Marriott himself -- take care of the associates and they will take care of the guests.
For example, in assessing what was needed, she saw that the room cleaning process could use more support and structure. To accomplish this, a member of the cleaning staff was appointed as Team Leader. This person has many roles - getting parallel processes such as laundry started earlier instead of having to wait until everything was collected, performing room inspections to ensure quality and coaching staff on key job skills. But, perhaps the most important role is being that key go-to resource. After restructuring this process, it became standard protocol that when one of the cleaning crew enters a room and recognizes that the standard 50-minute cleaning time will be exceeded, the Team Leader is called in for backup. This ensures that every room will be done on time without adversely affecting the rest of the cleaning schedule.

Small changes like this have made cleaning more efficient and effective and, most importantly for the guests, cleaning is now more predictable and reliable. And, despite appointing one of the existing crew to the new Team Leader role, the hotel hasn't had to increase any paid-hours because of the efficiencies that were gained.

That's why I've often used quotes from Mr. Marriott in lean training -- it's all about supporting the associates doing the work, they will take better care of the guests.

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Pittsburgh Area Hospital Transforms its E.D. with Lean

2009-10-18T04:00:00.001-04:00

Toyota model transforms St. Clair Hospital ER - Manufacturing principles meet medical care

Here's a nice overview of a Pittsburgh area hospital's Lean efforts in the emergency department. What were their results?

The average wait to get into the emergency department fell to just four minutes from 49 minutes; seeing a doctor after patient arrival shrunk to 28 minutes from 76 minutes, and patient satisfaction rose to the 99th percentile from the 60th percentile, according to Joan Massella, administrative vice president and chief nursing officer.

The hospital is eliminating waste, focusing on the patient, and applying technology to support their processes. It also sounds like the hospital has strong executive sponsorship and support for Lean:

Among the champions of the Toyota-inspired changes at St. Clair is Dr. G. Alan Yeasted, senior vice president and chief medical officer. Standardization of equipment, training and procedures has helped the hospital all but eliminate infections that are picked up with the insertion of central lines in intensive care unit patients — they haven’t had a central line infection in two years, he said.

“The acceptance by the emergency room staff was phenomenal,” he said. “These aren’t medical breakthroughs — it’s attention to detail.”

Steve Spear often talks about this last point -- how healthcare has focused so much on technical and clinical achievement. St. Clair seems to understand that you need technical innovation AND process innovation. Discipline. Attention to detail. Basic blocking and tackling. The basics can help save lives.

It's great to see improvements like those at St. Clair.

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Like Lean: Solving Health Care Problems By Design

2009-10-16T04:00:00.000-04:00

Solving Health Care Problems By Design : NPR

Thanks to Andrew B. for passing this along - audio and web text from NPR with some concepts that might sound a lot like Lean.

In an interview with the CEO of the design firm IDEO, Tim Brown, he tells the story of using visual management concepts in an emergency room:

So one very simple idea - this was one of many ideas that got implemented - was each of the various people, the health care people in the emergency room: the doctors, the nurses, the charge nurses, the porters, we designed these very simple kind of uniforms for them to wear so that it was really clear who was who. And it even said it on big graphics on their uniforms, so that you weren't asking a nurse the question you might be asking a doctor or you weren't asking a porter a question you might ask a doctor.

What really makes it sound "like Lean" is the engagement of the people doing the work.

Well, this is where the participation of the people themselves that are going to change in the design of the new approach was key. And we see this all the time, don't we, in larger organizations, that when something's designed on the outside and then pushed into the organization, there's often a lot of resistance. But when you involve the people themselves, then they already own the new solution, and it's so much easier then to get the change to happen.

That's exactly the approach I've tried to take with Lean in hospitals. This took me some time through my career to learn. When you're a young engineer, you're taught (or expected) to have answers. Lean is really about teaching others to improve their own work. So when I was consulting in hospitals, I would teach Lean concepts to the front line staff (like nurses or pharmacy techs) and let THEM figure out solutions. They own the solutions, they can sell the ideas and countermeasures to their colleagues. It's so much easier to make the change happen, like Tim Brown says.

Tim Brown is the author of the book Change by Design: How Design Thinking Transforms Organizations and Inspires Innovation.

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Lean Methods for Aerospace and Healthcare in Ontario

2009-10-15T03:00:00.000-04:00

Article - How Toyota builds cars

Here's an article from Canada about how Toyota (an automaker) manages to be influential to Bombardier (maker of planes) and St. Joseph's Hospital in Hamilton, Ontario (a fixer of people).

The article, I think, somewhat overplays the value of metrics. Don't get me wrong, performance measures are important in manufacturing or healthcare -- if they are timely, frequently taken, relevant to the employees, and are used for performance improvement, not punishment.

This is how it works: Posted outside of each department in each facility is a newspaper-sized piece of paper showing the performance rank of each department on a daily basis using five key metrics: safety, cost, quality, productivity and employee relations. These pieces of paper serve at once as an incentive for improvement and an easy way to identify and address issues on a day-today basis, Mr. Robert said.

Every morning the plant manager walks through the factory and collects the data off these sheets, and any problems that have arisen in the previous day's work are discussed during a fast-paced 30-minute meeting held at 10 a.m. with the department heads. Any issues are addressed collectively here.

None of that is bad, but it's not the full essence of Lean.

St. Joseph's Lean journey, as many in healthcare, began with heavy influence from a manufacturer, in this case Toyota.

St. Joe's partnership with Toyota came together somewhat serendipitously after a family member of the head of Toyota Motor Manufacturing Canada, Ray Tanguay, became a patient at the hospital. In the hours Mr. Tanguay subsequently spent at the hospital, he started to notice ways the automaker's methodology might be able to help with the hectic flow of traffic through St. Joe's.

The next day, Mr. Tanguay called Dr. Smith and encouraged him to come visit the automaker's operations and to see if they could work together -- a service Toyota has offered free of charge through its charitable arm.

What are the results in their Emergency Department?

Since the new system was implemented, St. Joe's wait times have fallen on average by a couple of hours per patient, Dr. Smith said. Roughly 90% of St. Joe's patients now have a wait time of less than four hours, as opposed only 50% before, he added.

Less waiting - and I'll bet better care at a lower cost. These tend to go hand in hand with Lean.

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Change from Inside or Outside of the System

2009-10-14T12:00:00.000-04:00

Last week, I tweeted a quote that's supposedly from Dr. W. Edwards Deming. I can only find one other online reference... does this sound like something Deming would have said?

"Knowledge required to change the existing system to a better system must come from outside the existing system."

A few folks on Twitter seemed to challenge that assertion (hard to tell tone in 140 characters, sometimes).

I think you need a balance of INSIDE and OUTSIDE.

A team of all insiders might be stuck in the old way of thinking, just seeing variations of how things have always been done. I think of Dr. Sami Bahri, the Lean Dentist... he used to go to dental conferences and training sessions and he said he just got the same variations of the same practices that didn't work well.

He needed some outside influences -- his reading of Shingo and Ohno brought a Toyota perspective that's served him well (as he describes in his book Follow the Learner: The Role of a Leader in Creating a Lean Culture.

Dr. Bahri combined outside influences and ideas (from the automotive industry and engineering) with his inside knowledge of dentistry.

When I've worked with hospitals, the improvements we made were a combination of outside and inside ideas. We couldn't have done anything with ONLY my outside perspectives... we needed both perspectives. It's much easier to teach smart and motivated nurses the Lean concepts... it's not rocket science, they take to it very quickly. But, left on their own, they wouldn't have come up with Lean on their own.

Is that what Dr. Deming was (allegedly) trying to say? What are your experiences?

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LeanBlog Podcast #76 - Dr. David Jaques, Lean in Surgical Services

2009-10-14T02:00:00.000-04:00

Episode #76 is a discussion with Dr. David Jaques, VP of Surgical Services at Barnes-Jewish Hospital in St. Louis, MO.

Dr. Jaques is a skilled surgical oncologist and surgery department administrator. He came to Barnes-Jewish after serving as vice chairman of the department of surgery and director of graduate education at Memorial Sloan-Kettering Cancer Center in New York. He received his medical degree at the University of Michigan, Ann Arbor, which was followed by a distinguished career in the U.S. Army Medical Corps. He served as a combat surgeon in the Persian Gulf War and was later chief of surgery at Walter Reed Army Medical Center as an oncologist. He served as the senior medical officer during Operation Desert Shield/Desert Storm. Honors during Dr. Jaques' time in the U.S. Army Medical Corps include the Legion of Merit, the Bronze Star Medal, and the Army Commendation Medal.

In this podcast, Dr. Jaques talks about how he has led Lean efforts that involve physicians in a unique "6/3" format that helps solve tightly-scoped problems without the need to have surgeons and clinicians for a full 4-day kaizen event. We discuss how he got started with Lean, improvements that were made in the "Mass Transfusion Protocol," and their broader Lean and physician engagement efforts. Really fascinating and innovative stuff. I hope you'll take a listen.

"A 6/3 event is a two-day event developed at Barnes-Jewish (six hours the first day, three the second) in which the scope of the project is very narrow or specific and the problem clearly defined. The team is prepared to determine the solution during the six hours and has at least one day in between the two work days to try and verify their solution. The last three hours is spent analyzing and finalizing the outcome of their solution."

For earlier episodes, visit the main Podcast page, which includes information on how to subscribe via RSS or via Apple iTunes.

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Exec from Seattle Children's on Lean Healthcare in the Washington Post

2009-10-13T04:00:00.003-04:00

Patrick Hagan: Waste Not, Want Not: The Key to Reducing Costs - washingtonpost.com

Here is an outstanding piece from the President & Chief Operating Officer of Seattle Children's Hospital, Pat Hagan. Coincidentally, I just recorded a podcast today with Joan Wellman, a Lean healthcare consultant who helped get them going on their journey.

I had a chance to visit Seattle Children's earlier this summer and I was very impressed with what I saw and heard. This is the real deal, one of the top Lean hospitals in the U.S., if not the world. It's great that one of their leaders would help spread the word about healthcare process improvement during all of this debate about insurance reform.

The results that Hagan cites from Seattle Children's are impressive, including:

"Patient days on ventilators have been safely reduced by 26 percent" (which reduces risks of infection)
Saving $2.5 million on supplies in the first year alone
"Reduced cardiac surgical site infections and hospital-acquired blood stream infection rates by 50 percent in just three years"
"Seattle Children's has reduced direct per-patient costs by 3.7 percent"

In his piece, Hagan references Toyota and a number of Lean management methods, including:

Standardized work
Error proofing
Visual management

He perfectly sums up the idea that Lean concepts are easy to understand, but hard to instill into an organization:

These results came from standardizing the way dressings are changed, central lines are managed and medication is administered. Simple, straightforward and very hard work.

The management side -- the discipline and attention that's required, the leadership that's involved... that's much tougher than just putting tools in place. Seattle Children's has been working at this for more than ten years -- very impressive.

As always, the reader comments (now closed) are interesting. There's the usual mix of praise for ThedaCare (from one reader who is a patient there), political shouting, a comment that people shouldn't be treated like car bumpers, and a final question asking how Hagan could claim 95% of healthcare activity is waste but they only reduced 3.7% of cost.

I think there's a difference between "activity" and "cost"
A good deal of the "waste" is required in the current system and can't be eliminated
I think 95% is a very high estimate. That's the only thing I could take issue with in the piece. Dr. Don Berwick from IHI says 30 to 40% of what we do in healthcare is waste. I've heard others say 30 to 50%. 95% of the time in some processes (as percent of cycle time, length of stay, or turnaround time) is waste, but not necessarily 95% of the hospital's labor activity (including management and overhead).

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Q&A with Adam Zak on Lean Leadership

2009-10-12T11:47:00.003-04:00

BioTechnology Supply Chain Conference – interview with speaker Adam Zak | LeanConnections

I'm reposting parts of this with permission of Adam Zak, a regular contributor to the blog over the years. You can read the full Q&A on his blog, Lean Connections.

Devendra Mishra, Executive Director of the Bio Supply Management Alliance, which organizes the - Rx FOR A LEAN & HEALTHY BIOTECH SUPPLY CHAIN conference, recently posed some questions to Adam and that Q&A is here:

MISHRA: What does Lean manufacturing mean to you in the context of executive performance in organizations, both manufacturing and service?

ZAK: Lean came into being as the concept called J-I-T (just-in-time) back in the 1980s. In North America we started referring to it as Lean Manufacturing in about 1990, and today it's more accurately known as Lean Management, having moved way beyond those production-focused origins. Lean spread readily from its automotive beginnings and is now firmly rooted in a broad cross-section of industries. Today we find Lean performance improvement initiatives in everything from banking and financial services, to U.S. military and state and local government operations, and even the fast-food business and dentistry.

Lean's greatest impact on executive performance in both manufacturing and service sectors is very clear to me. Lean helps management and associates at all levels in the organization uncover and identify the problems, from your customer's point of view, that need to be solved in your business. This is its real strategic value. As you become faster and more adaptable in meeting customer requirements at ever higher levels of quality, you build customer satisfaction. And that translates into top-line advantage - organic growth - and bottom-line success - profitability - with the added benefit of enhanced employee engagement at all levels within your company. And aren't these major factors in how we define and measure successful executive performance?

MISHRA: How do you assess the desired skills and capabilities of executives in the areas of lean manufacturing and service?

ZAK: Back in the day when every company simply wanted to recruit someone who had worked for or been trained by Toyota or their kieretsu companies, it didn't take all that much effort to make an assessment. But most North American and European companies learned pretty quickly that they were not a Toyota, and what they really needed was to identify Lean leaders who could adapt their experience to the existing company culture and environment. Today my work is traditional in that I look for traits which are considered consistent with strong executive leadership. But what really super-charges my evaluations of candidates is another layer of filters I employ for these additional critical skill sets: change management, empowerment and respect for people (a key pillar of the Toyota Management System), collaboration, passion for continuous improvement, process focus, and drive towards outcome-based activity.

How, you ask? Ah, that's the secret sauce! But I can tell you that we use a proprietary methodology called pdcaSearch™ which I created based on Dr. Deming's principles of Plan-Do-Check-Act (P-D-C-A). This is also a key tool in Lean transformation, and we've used that tool for the foundation of our executive search process.

MISHRA: How would you describe the current landscape of application of Edwards Deming's QA Principles and Toyota's Lean Manufacturing?

ZAK: It has not yet lived up to its potential, so we still have quite a way to go. And I believe that there are three key factors underlying this deficit.

The first is that many companies have been led somewhat astray and gotten bogged down by all the great tools which Deming and the Toyota Production System provide for us. But Lean is not about the tools. It is about using the appropriate tools within the context of a systemic, top-down transformation effort within the organization. Lean needs to become "how we do things around here" and not just a lot of periodic shop floor level activity led by "Kaizen Kowboys" whenever the mood strikes us. Only under such circumstances can Lean become so deeply ingrained in our corporate culture that it will withstand changes in markets, products, technology, competitors and yes, even changes within our own management ranks.

Secondly, a different perspective. To a disappointing degree, we sometimes see even formerly strong Lean-thinking companies begin to slide backwards. They lose the ability to build on past progress and to sustain improved outcomes and financial gains. Partially this is directly related to the "Kaizen Kowboy" mentality just mentioned. But often it's just really a case of no one minding the store. The solution here, I believe goes right back to Deming's P-D-C-A cycle. Our Lean leaders and champions must periodically and regularly go back to the basics and audit, if you will, the activities and processes in every value stream within the organization, clearly report on these, and have the responsible individuals and teams take action towards desired outcomes. In other words, we need to build in a process for continuously improving our continuous improvement methods. This will further strengthen the walls of the Lean fortress.

And thirdly, by limiting ourselves to seeing only what goes on within the "four walls" of our enterprise, we're missing what is possibly the greatest potential pay-off from thinking Lean: the tremendous hidden and untapped operational and financial kinetic energy which lies across our integrated supply chain. If we can use Lean to dramatically improve the operations of our outsource partners and eliminate the weaknesses inherent in non-Lean supply and distribution channels, just imagine the collective impact we could make on people-planet-profits. Sorry, I didn't mean to get into a Green/Sustainability discussion. But maybe we'll have some time a bit later.

MISHRA: Has the Jack Welch pool of executives been a source for your executive placements?

ZAK: Surprisingly perhaps, not as many as you might expect. Under Jack Welch, Six Sigma was the primary GE religion. Some of GE's business units, notably Aerospace and Medical Systems, had begun experimenting with Lean based on the model of GE "workouts" which were in some ways similar to Kaizen events. Within the last few years, Lean has become widespread as the continuous improvement umbrella across GE's business units, and the combination of Lean and Six Sigma at all level is proving to be a powerful influence on operations. We expect to be seeing more and more executive candidates coming out of General Electric.

MISHRA: What have you found to be the educational background and on the job experience you select for executive placements?

ZAK: I've found that our clients' search requirements vary so considerably that it's difficult to offer a compact and precise answer to your question. However, there are some patterns which I discuss in a special report that I'm just putting the finishing touches on titled (tentatively) Supply Chain Executive, Generation 3.0. This report will be available as a PDF download at http://MySupplyChainExecutive.com within a few days after the conclusion of the 2009 Biotech Supply Chain Academy conference on October 19 and 20.

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RN Doesn't Follow Standardized Work, Exposes Patients to Risk of Disease

2009-10-10T19:34:00.004-04:00

Broward General nurse possibly exposed patients to risk - South Florida - MiamiHerald.com

A number of you (thanks!) sent me this article from CNN about a Fort Lauderdale nurse who resigned -- and may face criminal charges -- for reusing disposable IV bags and chemical stress test supplies, thereby exposing patients to risk of hepatitis or HIV.

Terrible.

She was turned in by a co-worker who saw her violating the standard process:

Hospital managers learned of the problem when someone reported seeing the nurse using the same saline bag and tubing more than once when giving intravenous fluids to patients undergoing chemical cardiac stress tests.

The good thing is that somebody noticed that she wasn't following the standardized work, although it wasn't a direct supervisor or manager. The nurse certainly needs to be held accountable, but what about managers? Can managers be held responsible for what seems like an individual violation of rules? Back to the Wachter discussion from last week, what's the balance between a systems view ("no blame") versus accountability?

It's unclear if this was a one-time problem or if it was this was the individual nurse's standard practice:

The hospital did not offer an explanation on how an employee could have continued a dangerous practice for five years without being noticed or admonished.

It's unclear how there would be proof of this -- is it really a 5-year track record of continued risk and bad practice? It's prudent to assume the worst and test every patient who was under her care.

Assuming it WAS going on that way, every day, for five years -- why didn't managers notice? Managers and hospital leaders can't hound employees every single minute, nor should they.

Rather than just pressing charges against the nurse, Qui Lan, I'd also ask these questions:

What was the training process when she was new to the hospital? Yes, she was a qualified nurse, but was there training done about how that hospital does chemical stress tests?
Were the correct supplies easy to get and always properly stocked?
Did the nurse (and other nurses) have enough time to do their work properly?
Did managers or supervisors ever verify that she (and other nurses) were following proper procedures?
Was this just a single nurse who was cutting corners, or was this a wider problem?
What other corrective action has been taken, other than accepting the nurse's resignation?

The hospital CEO said:

"This is an individual's unacceptable practice that once discovered was immediately corrected," said James Thaw, CEO of Broward General Medical Center, in a written statement.

Let's certainly hope it was just one individual.

Lan's attorney says:

"Ms. Qui Lan has been a registered nurse for over 37 years providing excellent medical care to all of her patients. She has an excellent reputation in the medical community due to her professionalism and ethical manner. We are confident that once the facts surrounding this incident are revealed, Ms. Qui Lan will continue to be seen in the same light."

Is this just "create some doubt" lawyer talk, is there more of a systemic problem behind this story? It will be interesting to follow this and see what comes out.

If you're a leader at another hospital, do you read this and then take steps to verify that the same thing isn't happening with one of your nurses, as hard as it might be to believe that it could happen where you are?

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"No Blame" Doesn't Mean "No Accountability"

2009-10-09T02:05:00.003-04:00

Wachter's World : Physician Accountability for Violation of Safety Rules: The Time For Excuses Has Passed

I think Bob Wachter has it completely right in his blog post. He also makes the same point in his book Understanding Patient Safety.

While Dr. Deming taught (and patient safety experts like Wachter have emphasized) that most problems are due to the system, that doesn't mean it's ALWAYS the system.

There's a difference between a nurse or physician being part of a systemic multiple-failure medication error and someone intentionally choosing to not follow a process. Now, if someone chose to not follow a process because they didn't have time, management has a responsibility to help improve the system so that people DO have time. But "no blame" can't be taken to an extreme where personal accountability isn't part of the picture.

Wachter's piece starts:

In this week’s New England Journal, Peter Pronovost and I make the case for striking a new balance between “no blame” and accountability. Come on folks, it’s time.
At most hospitals, hand hygiene rates hover between 30-70%, and it’s a near-miracle when they top 80%. When I ask people how they’re working to improve their rates, the invariable answer is “we’re trying to fix the system.”
Now, don’t get me wrong. I believe that our focus on dysfunctional systems is responsible for much of our progress in safety and quality over the past decade. We now understand that most errors are committed by good, well-intentioned caregivers, and that shaming, suing, or shooting them can’t fix the fallibility of the human condition.
But not washing hands? When I hear, “It’s a systems problem,” my BS detector goes a little bit haywire, particularly after I walk around the hospital and see alcohol gel dispensers every 2 feet and glossy photos of smiling clinical leaders cleaning their hands at every turn. I think all of us realize that in 2009, failure to clean hands is no longer primarily a systems problem. It’s an accountability problem.

Click on the link up top to read the rest. What do you think? Where do you strike the balance between "no blame" (systems view) and personal accountability?

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Lean at Windsor's Hotel-Dieu Grace Hospital

2009-10-08T02:04:00.006-04:00

Here is a video from Hotel-Dieu Grace Hospital (HDGH) in Windsor, Ontario Canada about their Lean effort, the video is part of their main Lean page.

The video starts with John Shook talking about the real definition of "Lean" (it's not "Lean and Mean"), along with David Verble, who also used to work for Toyota. Others from the hospital, including Lean leaders and an Emergency Room physician also set the stage for a discussion of their Lean value stream mapping and project in the department.

The whole video is a great overview of the purpose and ideas behind Lean. Might be something you can share with your team.

Hotel-Dieu Grace is a member of the Healthcare Value Leaders Network.

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No Rx for Lean

2009-10-07T04:00:00.000-04:00

by Jamie Flinchbaugh, Lean Learning Center

I recently have had the opportunity to review a wide range of sites and companies and provide feedback on their lean journey. One of the things that really surprised me was how many of them were still trying to follow a prescription for lean. I heard things such as "the book says to do this but it doesn't work for us, what should we do?"

Simple, drop it or change it.

Too many lean thinkers (I use the term loosely because to me, they aren't thinking) try to take a prescription or recipe and apply it across all sites within a company universally, or across multiple companies. There are many people to "blame" for this (sorry, hate to even use the word) from authors to consultants to new hires into companies. Here's an author that we've come across that in my opinion is part of the problem. His statement includes:

I reduced applying lean to almost a prescription that you can follow with detailed steps that have been proven, time and time again. I have a number of case studies in the book where the prescription is laid out and you just have to implement it.

That's a prescription for one thing: failure. We hope that you don't follow the same approach. Every organization is different. You have different cultures, resources, skills, business needs, restrictions, and hopefully a vision of your own ideal state that you would like to achieve.

Understand your current state, have a vision of where you would like to go, and chart your own course of action. This is a lot more work, and that's probably why some people avoid it. But it's working on the hard that separates from the good lean efforts from those that fail. Take ownership. Only you can lead your organization, don't try to rely on a prescription.

You can also find my at jamieflinchbaugh.com or on Twitter

5S the Coffee Pots

2009-10-06T13:00:00.001-04:00

It's time for some coffee talk other than Starbucks... afternoon coffee break here.

In Philadelphia last week during our LEI workshops (have you seen our new web design?), I was there three days, teaching my workshop for two and attending one other day.

Day One, the Regular coffee was to the left and Decaf was to the right. Each was clearly labeled, no big deal.

Day Two, the hotel staff set up things in reverse, Decaf was to the left (ugh this was a blurry iPhone pic):

Why not standardize the location? Is it that hard? What if a decaf drinker wasn't paying attention and took coffee from the same location as Day One? This could cause health problems (or drowsiness, depending on the direction of the error by the coffee drinker). Maybe I should have moved them rather than just taking a picture...

Now the signs were correct each day. But, would you blame the coffee drinker for "not being careful" and not reading the signs? Or is this a systemic error? Thoughts?

On Day Three, the coffee was back to the original Day One configuration, of course.

If you come take my Key Concepts of Lean in Healthcare course at the LEI office in December, our single cup (small batch!) coffee maker is always in the same location...

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Innovation Is as Innovation Does?

2009-10-06T04:00:00.001-04:00

Dispatches from the Frontier: Innovation as Outcome

This story also seems like it couldn't be true, from the Harga-Blog:

I once asked a class full of senior executives whether they wanted innovation. They all said yes. When I then asked whether they wanted their direct reports to spend time developing and experimenting with new ways of doing their work, they all said no. They wanted innovation-as-outcome but not not the process.

Does your organization, regardless of what the top leaders say, reward people for coloring in between the lines?

More than rewarding "experimentation" (which is necessary for "kaizen" or continuous improvement), does your organization manage to not punish "failure?"

I've heard an expression about Toyota:

Toyota is successful because they have a high tolerance for failure.

OK, insert your own Toyota floor mat recall joke here about "failure." That's not the type of failure that the expression is referring to.

What they mean is people following the PDCA (Plan-Do-Check-Act) cycle. If you have a well-thought out plan, a hypothesis of how a change should help, you have to have an honest organization that allows you to 1) measure the results from the change and 2) be willing to say "no, that change wasn't really an improvement."

Too many organizations say they want "experimentation" but then people, because of fear, do everything they can to rationalize or justify the experiment as a success, no matter what.

We need honesty, not just random acts of experimentation.

Does your organization manage to encourage, or at least not completely kill, experimentation and true kaizen?

p.s. Remember our recent discussion on the merits of Lean certification? Jeff Hajek is running a short survey on his blog and we'll report results here.

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LeanBlog Podcast #75 - Peter Ward, Lean Education Academic Network

2009-10-05T04:00:00.001-04:00

Our guest today for Episode #75 is Peter T. Ward, a professor at Ohio State University’s Fisher College Business and Chair of the Department of Management Sciences.

Professor Ward is a leading expert in lean management and is president of the Lean Education Academic Network. His research has been published in a number of journals, including Decision Sciences, Journal of Operations Management and Production and Operations Management. He is research director for the Center for Operational Excellence, associate editor of the Journal of Operations Management and Decisions Sciences. Among other distinctions, he serves as a judge for Industry Week’s Best Plants program.

In this podcast, we talk about efforts to standardize and improve formal education about lean in universities and other academic settings.

For earlier episodes, visit the main Podcast page, which includes information on how to subscribe via RSS or via Apple iTunes.

MP3 File Right-Click to "Save As"

Enhanced AAC File

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Leadership Lessons from Larry Kellner

2009-10-04T04:00:00.000-04:00

Corner Office - Bad News or Good, Continental’s Chief Wants to Know - Question - NYTimes.com

This interview with Larry Keller, CEO of Continental Airlines, had elements of "Like Lean" -- ideas that are similar to Toyota Production System or Lean approaches. Sometimes it's just coincidence or common sense (like here) or the people involved are just downplaying Toyota connections.

Kellner seems to have learned early on that it's important to go to the "gemba" (where the work is being done) and to listen to the people doing the work:

When I was a kid, he was a manager in a Campbell’s Soup plant and had several hundred people working for him. When I watched him at work, he never really seemed to tell people what to do. He always seemed to figure out how to get them to want to do it. He always spent a lot of time figuring out who his best people were, and he spent a lot of time figuring out what it was they wanted to do, and then it all seemed to work flawlessly. So it comes back to getting the right people, and getting them doing the right thing, and getting them the right training.

Leaders are supposed to develop people, not have all of the answers. I applaud Kellner for sharing that philosophy.

Kellner seems to subscribe to the famous "no problems is a problem" philosophy:

It’s a leadership structure that says, “Look, I don’t care how bad the situation is — the sooner you catch it, the better.” But if you’ve known about it for months and have been hoping against hope that all your other contingencies would solve the problem and you’ve burned up all our opportunities to solve it, I’m going to be a whole lot more unhappy.

Sounds "like Lean," eh?

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I Guess These Couples Should Worry - We Need Lean, not More Regulation

2009-10-03T11:35:00.002-04:00

Embryo mix-up worries couples | detnews.com | The Detroit News

I've seen a lot of news stories about couples who suffer through errors caused by in-vitro fertization labs. A Toledo woman recently gave birth to a baby that was actually from another married couple -- laboratory mixup and preventable error. Stories often talk about how IVF clinic staff members failed to follow basic processes. This is not a problem of a technology that's not ready for prime time -- these seem to be basic fundamental operations issues.

When I was in the UK this year, there were major news stories about the rash of such errors. A new report said there were 182 errors or near misses in 52,000 cases in the UK. That's nowhere near Six Sigma quality levels, yet alone being error-proofed perfection.

When mistakes like this hit the media, the reaction of many is to say "well, we must need more regulation."

"...errors are rare in reproductive technologies, which help thousands of couples become parents, and more regulation won't eliminate all mistakes.
"We aren't a bunch of cowboys running around the West making our own rules," said Ronald Strickler, a reproductive endocrinologist with Henry Ford Health System. "We've been given license to look largely after ourselves. You can write all the regulations you want but you can't deal with human greed or human stupidity."

By "stupidity," I hope Dr. Stricker doesn't mean the individuals who make these errors. I hope he means the leaders that aren't ensuring that processes are error proofed. That's stupidity. If you're not managing the process every day to make sure standardized work is being followed (instead of just reacting and blaming someone when there's a bad result), that's stupidity.

At a presentation yesterday, I recounted cases (like Darrie Eason's, from two years ago) where individuals were blamed AFTER the fact, when management should have known that short cuts were being taken habitually. If your employees are cutting corners, that's YOUR responsibility to make sure that isn't happening.

I'll give the UK community for taking a constructive approach:

"We wanted to build trust, to assure centres that our aim was to learn and to promote higher standards, not to punish human error.

"But we now have a solid foundation on which we can continue to build a culture of learning and improvement throughout the sector.

Learning and improvement -- not punishment. But let's speed up the learning!

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5S and Kanban at BIDMC = Happiness

2009-10-02T04:00:00.000-04:00

Running a hospital: MICUs go Lean: Result = Happiness

In lieu of a blog post today, I'm leaving you with a recent post on Paul Levy's "Running a Hospital" blog about Beth Israel Deaconess Hospital. You can see pictures and video showing the before and after of some 5S and kanban work done in some patient units.

Happy employees lead to happy patients (and well cared for patients). Freeing up time for patient care, by eliminating waste -- that's one of the best things you can do.

Forgive my own blog laziness -- busy week. Had a successful first run of my LEI "Key Concepts of Lean in Healthcare" workshop, spoke to a Wharton MBA operations strategy class this afternoon, and Friday I'm giving a talk at a hospital quality awards event in San Juan Puerto Rico. 20 hours in Puerto Rico... sounds like a good book title, eh?

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A "Step Backward" in Patient Safety?

2009-10-01T04:00:00.002-04:00

Joint Commission Changes Requirement for Patient ID during Blood Draws | Dark Daily

Thanks to my friend Robert Michel and the Dark Daily for bringing this story and issue to my attention. Definitely check out his web site if you work in the laboratory and pathology fields.

Keep reading here if you're interested in patient safety... that should be all of you, I suppose.

When drawing blood (collecting a specimen) from a patient, it's very important to make sure that there are no errors in matching the patient to the specimen that is sent to the lab. Erroneous laboratory results can delay the proper patient care or lead to incorrect medical decisions being made for a patient.

Laboratories and those who draw blood (nurses or phlebotomists -- the specialists who collect blood) take many precautions and need to follow consistent standardized work to prevent errors or specimen mismatches.

For example, to avoid labeling errors, it is important to label specimens (by hand or, better yet, with printed labels and bar codes) IMMEDIATELY after blood is collected. If you batch up the labeling, you introduce the risk of mixing up patient specimens.

It's also important to confirm the identity of the patient you are drawing, to make sure the labels you are about to put on the tube indeed match the patient.

In the case of patients with the same name, hospitals are supposed to use TWO identifiers (name and date of birth or a unique identifier number). These dual identifiers are often found on the patient's wristband.

But what if the wristband is on the WRONG patient? Up to 16% of wristbands have erroneous information (link). You might be verifying TWO pieces of equally incorrect information on that wristband. That's why a "best practice" has been to verbally ask the patient to state their name (of course, not all patients have the capability to do this). I've seen phlebotomists do this many many times. It makes sense.

It was shocking to me to see that the Joint Commission has removed the rule requiring this precaution. Phlebotomy and laboratory experts are questioning this change, advising that hospitals continue to follow the higher level of standards still advocated by those groups -- continue asking the patients to identify themselves verbally.

When The Joint Commission recently changed the patient identification requirement for drawing a blood sample, one national phlebotomy leader considered it a step backward in patient safety.

“Per a revised policy issued by The Joint Commission, it is no longer required for the phlebotomist or person drawing the blood to actively involve patients by, for example, asking them to state their name,” commented Dennis Ernst, MT(ASCP), the long-serving Director of the Center for Phlebotomy Education. He’s one of the leading observers of phlebotomy trends and he’s concerned about what this means to patient safety.
“Having a patient state their name before a blood collection is a very important step in patient identification,” declared Ernst. “The Joint Commission now finds it acceptable for the phlebotomist to use the identification bracelet alone, which we all know can end up on the wrong patient. That’s disturbing to me because it’s taking a chance with a patient’s life. I think any time you dilute the requirements for patient identification, you create a possible scenario that is not favorable to anyone seeking healthcare.”

Read the Dark Daily piece for more comments. I agree with Ernst. Why would you remove this simple, yet important verification?

The Joint Commission informed him that their clients feel that it is “burdensome and unnecessary” to ask a patient to confirm his or her name.

Burdensome? What?? It takes all of a few seconds. Unnecessary?? Unnecessary if you're arrogant and think that your organization couldn't possibly put the wrong wristband on the wrong patient.

The Joint Commission explains:

"...it was determined that the EP was rendered not surveyable or enforceable through the accreditation process. This is the reason behind the deletion. We continue to support active patient involvement in the identification process as a best practice and will encourage organizations to use such an approach when it is reasonable to do so."

So they are encouraging it, but not requiring it?? The rule was not enforceable, so they removed it? Seems like that sends a mixed message.

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Video about Lean Startups

2009-09-30T04:00:00.000-04:00

Gov 2.0 Summit 09: Eric Ries, "Lean Startups: Doing More with Less"

I was tipped off a while back to the work Eric Ries is doing around Lean concepts in startups (here is his blog).

Eric says that it's not the original idea of a company matters, but how they adapt and evolve. This reminds of Steve Spear's theme in Chasing the Rabbit that they key is how quickly an organization goes through rapid PDCA cycles, since nobody ever designs a perfect system. I guess nobody ever initially designs the perfect startup? It's all about how quickly you evolve. It seems Eric and Steve agree on this.

He calls this moment of adaptation "the pivot." He says, "Within every bad idea is a kernal of truth." Isn't this true even with employee ideas inside a non-startup company? It's often thrown around that Toyota implements 90%+ of employee ideas... but not necessarily implemented in the initially suggested form. The "bad idea" is not thrown away, rather it is the starting point for discussion and inquiry... this leads to "something" being implemented.

Here is his video:

He sums it up in an interesting way: Lean Startups = More experiments per dollar. Eric says Lean is not about cheap, it's about faster and it's about learning. It's about getting more out of our dollars and more out of "our precious human capital." Sounds Lean to me.

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Upcoming Podcast: Sorrel King

2009-09-29T13:00:00.000-04:00

If you're a regular Lean Blog reader, you might know that I've conducted a few fundraisers for the Josie King Foundation in the past. I'm very glad to support this important organization that works to improve the systemic problems that lead to patient harm.

If you don't the tragic story of Sorrel's daughter, Josie, you can read it here.

Sorrel has written a book that was released earlier this month: Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safe. She has agreed to do a podcast interview with me, I think it will be next week for future release.

If you have any questions, you can post them here under "Comments."

You can see her appearance on NBC's Today Show here:

Visit msnbc.com for Breaking News, World News, and News about the Economy

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Defects in Air Travel -- At Least I Got There Safely

2009-09-29T04:00:00.001-04:00

Ah, what a day yesterday. You'd think getting from Boston to Philadelphia would be easy. I'm here, teaching my "Key Concepts of Lean in Healthcare" workshop for the first time for LEI.

I got to Logan a little before 1 PM for my 2:30 PM flight. I got a call from the airline (part of which used to have the nickname "America Worst") that the flight was canceled. At 1 PM, the ticket agent puts me on the 1:30 flight. "Do I have time to make that?" So, off I went.

First defect in the process was the TSA video that was playing. That video must be FOUR years old, because it clearly showed and explained that passengers should put their beverages (showing a Coke bottle and a bottle of Juice) into their carry-on bags for screening and x-ray.

HELLO?? Liquid explosives threat, circa 2006 anyone?

Of course, the TSA agents were confiscating a lot of drinks at the x-ray station. BAG CHECK. Slowing things down for us. No, it wasn't my drink, but the infrequent flyers could understandably be confused by the conflicting rules.

So I run to the gate, near B6... they were in final boarding, I hand the agent my boarding pass, she tears it, and I go down to the tarmac, gate check my suitcase, and get on the regional jet.

Hmmmm, my ticket says 17F and there are only 11 rows on this plane. I ask the flight attendant about this and he says, "Oh, this flight is very empty, just sit anywhere." I guess it didn't seem strange that I got assigned a non-existent seat.

About 2 minutes later, the intercom pages "Robert Graban" (no, my dad wasn't on the plane, but my middle name is now on the boarding pass, thanks to new TSA rules). They must mean me.

Turns out I had boarded the wrong gate (off by one) and this was a plane to Rochester, NY. So much for the error proofing at the gate (the bar code scanner, not being used, apparently) or checking as you board the plane (as they often do).

I'm standing on the tarmac and, of course, the gate check bags had already been loaded.

"What's your bag look like?"

"Um, a black suitcase. It has my name on it, the American AAdvantage tag."

They pull a bag off that, at a distance, looked like mine. They wheel it over. Argh, not my bag. They had already close up the plane.

"Try the one with MY NAME on it," I had to shout over the engine noise.

Now, the Rochester people are getting delayed, and I figure I'm going to miss that 1:30 to Philly.

They finally find my bag, and off I go back into the terminal. The 1:30 flight is now delayed for three hours due to Philly weather.

At least US Airways and their staff didn't treat me too rudely or do much to blame me for the error. That's the first time I've boarded the wrong plane. I'll blame the process!

And like I said, at least I got to Philly safe and sound. That's what really matters. No defect there.

Back to regular Lean Blog posts tomorrow. No more defect-plagued travelogue entries... actually, check back later today at 1 PM when I'll have an announcement about a future Lean Blog Podcast about patient safety...

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Muda (Waste) Driven By Government Protectionism

2009-09-28T04:00:00.002-04:00

To Outfox the Chicken Tax, Ford Strips Its Own Vans - WSJ.com

If people and organizations are good at anything, it's gaming a system or finding workarounds.

From a recent WSJ article comes a tale of how Ford works around import tariffs:

Several times a month, Transit Connect vans from a Ford Motor Co. factory in Turkey roll off a ship here shiny and new, rear side windows gleaming, back seats firmly bolted to the floor.
Their first stop in America is a low-slung, brick warehouse where those same windows, never squeegeed at a gas station, and seats, never touched by human backsides, are promptly ripped out.

Muda muda muda. Adding features just so the van can technically be categorized differently, features that will never be used by the customer, just to avoid taxes.

What happens to this material?

The fabric is shredded, the steel parts are broken down, and everything is sent off along with the glass to be recycled.

It least Ford can claim this as a "Green" initiative? What a waste. The article details some of the wasted motion (muda) that does nothing to benefit the customer.

The tax is supposed to protect U.S. truck production, but Ford can import these vehicles (whatever you call them) from Turkey by jumping through hoops:

The company's wiggle room comes from the process of defining a delivery van. Customs officials check a bunch of features to determine whether a vehicle's primary purpose might be to move people instead. Since cargo doesn't need seats with seat belts or to look out the window, those items are on the list. So Ford ships all its Transit Connects with both, calls them "wagons" instead of "commercial vans." Installing and removing unneeded seats and windows costs the company hundreds of dollars per van, but the import tax falls dramatically, to 2.5 percent, saving thousands.

Where there's a will to avoid a tax, there's a way!

This detail made me laugh, that Ford basically could have REALLY recycled the seats, re-using the same seats over and over:

Rob Stevens, chief engineer for Ford's commercial vehicles, says the auto maker decided against shipping the seats back to Turkey for use in the next wave of vans for the U.S.

"We thought going through the recycling process was best," he said. "The steel is valuable."

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Lean Healthcare Conference in Italy

2009-09-27T14:00:00.000-04:00

Lean Forums - Lean Healthcare in Italy

I wish I was attending, but I was asked to pass along this info about a Lean Healthcare conference that's being held in Genova in December.

The link above goes to the Lean Enterprise Institute forum page that also has the PDF describing the event.

It might be a long shot that anyone else reading this will attend, but it speaks to how Lean is spreading throughout the healthcare world!

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Sunday Catchup and Update: Certificates and Certifications

2009-09-27T04:00:00.001-04:00

Not to rehash the whole discussion, but I wanted to point out Tuesday's blog post about lean certifications... and the fascinating string of comments that dragged on all week. Over 40 reader comments, I'm pretty sure that's a record. The topic sure struck a nerve.

If you're not normally a comments reader, I'd encourage you to check it out. Click on the link and scroll down below my post and the question I posed. A lean thinking friend said the comments area was some of the best stuff he's read about Lean anywhere in a long time.

Among the discussion points:

Are all certifications created equally?
What's the difference between "certificate" and "certification"?
What's the proper role in using certifications to screen job applicants?
What's the role of certifications outside of the U.S.?

As a follow up, I'm going to do a podcast with somebody from the AME/SME/Shingo certification committee so they can give an extended view of their perspective on this.

Any particular questions you would want me to ask in that Podcast? Post them here in comments. If you have comments about the original topic, please add them to my post from Tuesday.

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Spotted: "Kaizen Corp." Van in Boston

2009-09-26T04:00:00.001-04:00

I saw this van in Boston the other day. I can't find a listing in the Yellow Pages for who they are or what they do, but I like the name of the company.

Do they really practice continuous improvement, I wonder?

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Silver Bullets and Easy Answers -- Always Appealing

2009-09-25T04:00:00.000-04:00

While in Boston, I'm getting the chance to sit in on some sessions of an MIT Seminar in Healthcare Systems Innovation.

Today, the session that focused a lot of Lean as a means to improve quality and cost. Lean is the focus of a few class sessions, including guest lectures from MIT's Deborah Nightingale and Steve Spear. It's great that Lean is being given such attention.

The professor made a great point that no single solution, Lean or otherwise is a silver bullet. Complex systems require complex solutions. He's right. I agree that Lean is not the ONLY systemic change that's required in healthcare.

He brought up an interesting point -- one reason that any organization struggles to "become Lean" is that they are often just copying Toyota too literally instead of thinking for themselves. Even Toyota does "un-Toyota-like" things when it makes sense -- like adding buffers in the middle of a long assembly line so one andon-related stoppage does not stop the entire line.

The real key to TPS seems to be developing problem solvers -- as some hospitals are aiming for, a culture of everybody solving problems and improving every day.

Will you get that by copying? Probably not.

The professor then placed blame on consultants for selling a cookbook-like Gospel According to Toyota. Easy answers and rules to blindly follow.

I spoke up and asked, "Doesn't the client take some responsibility for WANTING easy answers, silver bullets, and 90 day paths to 'being Lean' without wanting to think?"

We agreed that the consultant (a good one) has an obligation to inform the client that they can't get Lean in 90 days, that there are no easy answers. But some consultants are happy to sell cookbooks and easy answers.

It's a chicken and egg problem -- who is to blame? The consultant, or the client, or both? What is your experience with this, from either side of the equation?

p.s. Maybe this is a trick question, since this blog tries to be a "no blame culture"???

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Au Bon Pain is not French for "Stop the Line"

2009-09-24T04:00:00.000-04:00

I had an interesting encounter at the Kendall Square Au Bon Pain yesterday morning. Not a bad customer experience, but something I noticed in the checkout process that might be worth discussing.

I had a bagel sandwich (wasbai salmon on multi-grain bagel) and brought the sandwich, with the order ticket, to the register.

The cashier started to ring it up and apparently made an error -- she rang it up as a bagel, plain bagel. The cost for that is about $1.06 where the bagel sandwich must be about $4.

She sort of muttered and said, "Oh, I don't want to do a void out, so here you go." To set context, it wasn't really THAT crowded where an angry mob would have formed (there were multiple register stations feeding from a single queue).

Here was a classic opportunity, in a Toyota or Lean sense, for her to "pull the andon cord." She had a problem -- misrang customer order. It was EASIER, apparently, for her to just give me the sandwich, losing $3 in company revenue.

If the tradeoff was "$3 isn't worth it, let's keep the customers moving," then maybe that's an OK decision. But is that decision approved as "standardized work?" Does she have the judgment to make that decision?

Or, was the whole thing a workaround?? I'm sure voiding the order requires a manager override (a theft-prevention measure, I'm sure) and that either takes too much time or it gets them a reprimand for making the error?

Wouldn't it be the case, if Toyota ran this, that she would have a "help" button (an andon cord of sorts), where the team leader would be there immediately to resolve the problem right then and without any bad attitude? Then, maybe they would do some training or root cause problem solving to reduce her error rate in ringing up orders? Or maybe there's a problem with the register?

I'm sure the reaction at Au Bon Pain was to just move on and never think about that transaction again. Typical of most organizations?

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Interviewed for articles in "Becker's Hospital Review"

2009-09-23T04:00:00.001-04:00

I was recently interviewed by a reporter at Becker's Hospital Review and these are the articles, linked below, written for a hospital and operating room audience.

5 Key Principles for Hospitals From Toyota's Lean Production System

This first article came out fine, I think, although I'd take issue with Point #3 that you must "embrace technology" - a focus on technology isn't strictly a Lean approach. That didn't come from me.

Technology's not bad, but it's not always necessary. Toyota Way principle #8 says:

Use only reliable, thoroughly tested technology that serves your people and processes.

You can use technology and be Lean. You don't have to use technology to be Lean. Technology "can" reduce the need for labor, but I've seen many cases where it does not reduce labor because the technology was bad or wasn't integrated well into processes and the way work was done. You can eliminate the labor involved in manual inventory counts with a paper kanban system -- technology might help,but it's not a core part of the Lean approach. I've seen hospitals with amazing bar code-driven Lean inventory control, but such technology can actually hamper you if it's not in line with your people or your processes.

I've seen many labs with automation technology that actually slowed the process and required just as much labor. Same is sometimes true in pharmacies. Nurses are often slowed terribly by poorly designed bar code scanners (for medication) or electronic medical record systems that don't match their workflow.

This second article was driven more directly from my discussion with the reporter:

3 Best Practices for Implementing Lean Processes at Your Hospital With the Author of Lean Hospitals

Any comments? Leave them here, as there's no comment function on their web page.

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What's the Buzz on Lean Certifications?

2009-09-22T13:00:00.000-04:00

Question for the readers... what's the latest thinking out there about certifications for Lean?

I'm biased against certification, I'll lay that out there. I've never been enamored with the Six Sigma "belt" approach, nor do I think certification tends to be an indicator of much other than your ability to get certified.

Maybe I'm too cynical about that. Too many of us in the Lean world were brought up in a pre-Certification era, if you will. I learned on the job, from some great mentors. Do I really have to go back and get certified when I have a track record?

One of those mentors of mine from my GM days is looking to switch companies. Yes, a great Lean guy at GM -- he was hired in from the Toyota supply based and he's done great work in GM. I was surprised (and somewhat appalled) that he emailed me asking about certification.

Any company who looks at his resume and talks to him and STILL wants certification... that's probably a company for him to stay away from. A company like that doesn't get Lean, I'd say.

The organization I work for, the Lean Enterprise Institute, has never gotten involved in certification and I think the position is that LEI will never do that.

There is a predominant lean certification model that has evolved - from the SME, AME, and Shingo Prize organizations.

I'll open it up to reader comments... what are your thoughts on certification (as a job seeker or as an employer)? Do you have experience with any particular certification model that you can recommend to others?

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Q&A #4 - Michael Balle, What's the big deal about A3?

2009-09-22T04:00:00.005-04:00

I recently invited questions for Michael Balle, the author of the Shingo Prize winning book The Gold Mine: A Novel of Lean Turnaround. He has a new book (published by LEI, my employer), recently published, called "The Lean Manager."

Here is the fourth Q&A. If you have a question for Michael, click here for more info on how to submit them. If you have a question in response to this post, please the comments feature. For previous Q&A, click the "Balle" link at the bottom of the post. Michael also has a new blog at the LEI website.

Q: A3 thinking seems like the latest buzzword in the lean world. It's just a single 11x17 paper, what's the magic in that?

Answer from Michael Balle:

It’s kind of puzzling why some tools become fashionable at some time or not. A3s have been around a long time, and certainly, this is one of the lean tools which are not TPS specific – many Japanese companies have been using them over time, and I remember seeing A3s from Japanese automakers and suppliers as far back as fifteen years ago. I have no clue why suddenly it’s become such a buzzword, other than it is a critical lean tool in a very specific way. Most TPS tools are all about the front line worker, the team leader – because we’re collectively not very good at this lean stuff, this is a point easy to miss, and indeed, I’ve stood corrected and humbled many times on the gemba showing off to the sensei something we’ve done only to be asked: “what’s the mission of the operator with this ___ tool (fill in the blank)?” Over the years, I’ve learned the hard way that tool ownership must pass from lean officers to operations managers, to supervisors, to team leaders and finally to team members themselves.

On the other hand, TPS has very few tools for middle-managers such as supervisors and beyond, and indeed, many of these people feel rightly ignored of by-passed by the lean initiatives – which creates difficult problems of involvement and teamwork when you go beyond the obvious stuff on the shop floor, and one of the reasons companies have trouble breaking out of tool kaizens (5S, SMED, Flow and layout, etc.) and into system and budget level results. There is no “magic” that I know of in the A3 other than it fills in a critical gap as it addresses middle-management and knowledge development for critical staff at that level.

Everyone has a different path of discovery of the lean tools and I can only describe how I ended up relying on A3s in hospitals about a decade ago. In that respect I recommend Cindy Jimmerson’s book A3 Problem Solving for Healthcare: A Practical Method for Eliminating Waste. Here’s how we got to using A3s :

Like on the factory shop floor, the hardest barrier to lean in hospital wards was to get ward managers to accept that 1) all was not well in their ward, and 2) they could do something about it – they mostly had accepted they were only a cog in the machine and solutions always belonged to some other staff service. In socio terms this is called learned helplessness: good people are convinced they can’t do anything about the mess they’re in, which, in the end, either makes them angry or depressed – and neither is good for them or for the patients (try being stuck in a hospital bed with an angry, depressed, or both nurse of doctor). So, working with the Nursing Directors of a number of hospitals we decided to try to address this first.

At the time, in the mid-nineties, no one had heard of “lean” in healthcare and we were very careful not to mention automotive OEMs and Toyota, for reasons you’ll easily understand. What we did was walk around – we’d walk with the nursing director in every ward in about twenty minutes with the ward manager and highlight obvious problems such as:

Trolleys, beds, bins in the corridors (safety hazard)
Basic cleaning (check out those corners and those skirting boards)
Unmarked bio waste disposal bins (Yuck!)
Out-of-date drugs and materials (check those fridges – find the food as well)
Trolleys stored with all the bits and pieces still on when stored away (have they been sterilized?)
Clean/dirty circuit for laundry, blouses, etc.

Nothing earth shattering, just very visible stuff.

The good point about this is that the nursing manager didn’t like it, but they couldn’t disagree they had a problem; They would then argue they couldn’t do anything about it: how can we take the laundry bags out of the corridor? We don’t have enough storage room and what we’ve got is full of diapers!”

“Look,” we told them. “let’s pick one of those issues. Then you’ll gather your team, explain why it’s a problem, and work with them to find a local solution to this.” You’ve got zero budget, so don’t come and ask for money or help from support structures – you’ll get neither. Think of something.

It sounds harsh, but in many, many cases we had astonishing immediate results. What also appeared is that some ward managers were much better than others at getting their teams to think creatively and pragmatically to solve small problems. Some just went through the motions with very indifferent results, and a few people invented a weird solution that totally defeated the purpose, but that’s humans for you.

In any case, once this got started and established, the next step was to get each ward manager to start measuring very simply adverse events for patients and staff and to review this weekly with their teams, and monthly with the Nursing Director.

By having both activities running in parallel, many basic issues got solved but the more advanced ward managers got, by themselves into actual care problems – problems of things they did to patients, and then the issue became incredibly complex for an number of reasons, including the pre-existing quality assurance initiatives and the whole issue of “protocols.” On the one hand there was no issue of ignoring centrally devised protocols, on the other, these were not well known at staff level, and sometimes difficult to apply locally (this is a difficult and entire other debate, central, I believe, to lean in the wards).

What we then decided to do is have the nursing team come up with a checklist of how they actually performed the care act – based on their practice not on the protocol – and then observe a minimum of twenty patients being cared for (the ward manager would do the observations with the checklist in hand). They would then do two things:

Measure what was done and what was not (did we wash hands every time?)
How did the checklist differ from the protocol

These two questions largely clarified the problem, and it then struck me that this was close enough to the two first boxes of the A3s I had seen in the auto industry: “what is the problem?” And “Grasp the situation.”

The deeper problem we were facing at the time with the Nursing Directors is that we had low confidence in the ward managers ability to come up with the correct solutions to the problems. On the one hand, we realized that the concrete problems they faced WERE DIFFICULT, and actually we couldn’t think any top of the head sensible solution in their local situation (terminal cancer patients in a XIXth century building with a splendid view on the Fort-de-France bay in the West Indies – how do you keep the wind and dust out?), second, protocols were far too generic to solve the problem in concrete terms, and most importantly, we didn’t trust the ward managers to come up with acceptable solutions, quality-wise (yeah, so, this is the real world, right?)

Which is about when we started using the A3 (okay: A4s), as a communication tool between the ward manager’s proposals and the Nursing Director. Before implementing anything, the ward manager had to detail her understanding of the problem and the solution she wanted to apply. After the first initial cycles, we even managed to get the best ward managers to propose two or three different solution to the problem.

In this manner, we tackled all sorts of previously intractable problems, such as:

Reinfection on bandaging wounds
Cannula maintenance in tracheotomy
Bedsore development in bed bound patients
Dealing with families in emergency wards

And so on.

So where’s the magic of the A3. Not the size of the paper, certainly (A3 was the largest piece of paper that could be faxed, back in the day – now, with e-mail, size don’t matter much in excel, although it does in PowerPoint or Word). The magic is in the back-and-forth between the middle-manager and the senior manager, and then other specialists, such as, for instance, getting the opinion of the hospital’s hygiene expert and other experts.

So here’s the thing: A3 is an incredible powerful tool IF the work is being done at the gemba. A3 without “zone control” will, in most likelihood, lead you astray. In the same way, A3 as a “problem-solving” methodology, done by people in isolation, will get you to paint yourself in a corner. The key point is that we don’t know what we don’t know. First we have to face what we don’t know, and this happens by Go and See on the gemba and asking why? Why? Why?, second we have to realize many things can be solved without A3s, just by getting the team to chew on the issue, try things and reflect. Finally, when the twin practices of accepting the Gemba as the greatest teacher, and standardizing work through kaizen have been accepted by the teams themselves, A3 is a great way to develop the ward managers in tackling more complex technical problems. On the other hand, I would urge practitioners to be wary of A3s before having done the foundation work at Go and See, Standardized Work and Kaizen levels with the teams. You’ll get to solutions all right, but you won’t have a handle on the check mechanism of the PDCA – so we have no idea whether we’re getting into the right kind of solution.

Sorry to be a curmudgeon, but I know of no magic in lean. It’s all about the two main tools: your legs and your eyes, and a lot of hard work. The power of A3s is in the giving management a tool to develop middle managers and include them in creating a lean culture. But it’s hard work, and more hard work. On the other hand, you should see the pride and motivation of ward managers and their teams when they’ve managed to reduce reinfections on specific bandage techniques by half. Or when they succeed in caring for patients after tracheotomy so that the cannula does not clog up so badly. No one has ever accused me of being soft, but I’ve rarely felt so moved in a working situation. Even with the jaundiced view of doing lean every day on the shop floor (everybody says “no” all the time – when they say “yes” it’s a good day), seeing improvement of care at the patient is the greatest payoff I can thing of. In industry, you get to a point where kaizen becomes fun (yes, yes, you do), but in the wards, solving A3 problems with ward managers and their teams can be, indeed, pure magic.

Michael is the co-author of The Lean Manager and The Gold Mine, and can be contacted at:http://michaelballe.org.

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