Lean Blog

LeanBlog Podcast #70 - Tamra Kaplan, Long Beach Memorial Medical Center

2009-07-09T00:00:00.001-04:00

Episode #70 is an interview with Tamra Kaplan, the COO of Long Beach Memorial Medical Center. We talk about the lean transformation work being done in the hospital and Ms. Kaplan's experience in leading this effort. For an earlier blog post about her promotion to COO and Lean at LBMMC, click here.

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.

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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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Medical Errors in Hospitals Still Occur at Alarming Rate

2009-07-08T05:00:00.003-04:00

It has been over 10 years since the publication of the Institute of Medicine's study on preventable medical errors: To Err Is Human: Building a Safer Health System. So how are we doing? Are there still nearly 100,000 patients dying in the U.S. each year due to preventable errors? I haven't heard anyone claim that this problem is solved yet.

FOXNews.com - Study: Medical Errors in Hospitals Still Occur at Alarming Rate - Longevity | Prevention | Aging

The first story, above, indicates errors are still a major problem:
While patient safety in US hospitals is improving, "medical mistakes still occur at an alarming rate," according to the sixth annual HealthGrades study of patient safety in American hospitals, released today.

Between 2005 and 2007, medical errors cost Medicare over $6.9 billion and were responsible for more than 92,000 potentially preventable in-hospital deaths among Medicare beneficiaries, report Dr. Rick May and others at HealthGrades, a healthcare ratings organization in Golden, Colorado.

Keep in mind these are just Medicare patients. What percentage of all patients are on Medicare? I don't have that number handy... would really be interested to extrapolate 30,000+ Medicare patient deaths to the whole patient population.

Some more numbers:

More than 913,000 total "patient safety events" occurred, representing 2.3 percent of the nearly 38 million Medicare hospital admissions.Patients who suffered one of these mistakes had a one-in-ten chance of dying, the report indicates.

Multiplying those out, that's a 0.23% chance of dying because of a "potentially preventable" error. Or 2.3 out of 1000. Yikes.

The AHRQ says there are about 29 million hospitals admissions each year in the U.S. At 0.23%, that would be a total of 66,700 deaths per year.

Are these incidents random events? It seems not -- it behooves us, as patients, to find out which hospitals have better quality. You can do so at the HealthGrades website, but alas they sell the detailed reports (and no need for disclosure here, I don't take a cut for referring you to them). It seems difficult to, as a patient, draw valid conclusions from the data they show, but maybe that's the subject of another post (or for another blogger).

The investigators observed that, on average, Medicare patients treated at award-winning hospitals were 43 percent less likely to experience a medical error compared with those at bottom-ranking hospitals. "This finding of better performance was consistent across all 12 patient safety indicators studied," the authors write.

At least things aren't consistently bad. So what are the "award winning" hospitals doing differently? It's got to be a matter of PROCESS, not people. I can't imagine the award-winning hospitals are hiring people who are smarter or more careful.

Errors with the highest occurrence rates were "failure to rescue," defined as death among surgical inpatients with serious treatable complications; bed sores; postoperative respiratory failure; and serious postoperative infections.

There are some problems inherent in extrapolating the Medicare numbers, since those patients are older and, presumably, more likely to get bed sores. But still, this is a serious problem.

This related article also caught my attention:

Nearly 90 major medical mistakes logged at Utah hospitals in 2008 - Salt Lake Tribune

This number was only the events that caused death or serious harm in Utah, not all errors.

Despite a years-long effort to cut down on one type of medical mistake - surgical errors - they remain Utah's top problem. There were 45 surgical errors last year, such as performing the wrong surgery on the wrong body part. One example: A gastrointestinal tube that was guided into a lung instead of the stomach.

"We're struggling," said Iona Thraen, who reviews the mistakes as director of patient safety for the state health department.

Why are they struggling? It's not just Utah... why do the experts (I'm not pointing at myself as the expert) say many or most of these are preventable?

The standard practice is for hospital staff to manually count the sponges before and after surgery to ensure they are removed and confirm the removal with an X-ray, said Thraen. When reviewing the cases when sponges were left inside patients, the staff members are usually certain they counted and re-counted the material, she noted.

OK, you might wonder -- how hard is it to have some standardized work that says you count and even re-count? Does the phrase "usually certain" set off red flags?

Counting -- this is a form of visual inspection, done by a person --- it's going to be prone to error. We're human. We make mistakes.

But do we have to make as many? The sidebar at the bottom of the article highlights a situation that might not be unique or rare:

During a routine inspection of McKay-Dee Hospital in Ogden last year, state health department surveyors cited the facility for compromising patient safety because surgical staff didn't count instruments before and after surgery. They did count sponges and needles.
Inspectors were told that staff only counted instruments during open-heart surgery and that surgeons were "reluctant to allow staff to perform instrument counts" because "it added more time to the surgical procedure," according to the inspection report obtained by The Salt Lake Tribune.

Whoa. So when things like this are happening, as fancy RFID technology the only solution? The most cost effective solution?

How do you win the cultural battle that patient safety, not speed, comes first? Can you eliminate waste and take time out of the procedure rather than eliminating this step that impacts patient safety?

Seems like this, and many other medical mistakes, are cultural and social problems more than they are technical problems.

So I'll leave it on that. The LEI's John Shook has a blog post about looking beyond the technical for root causes of problems that fall in the social realm. Seems to fit here.

Comments?

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Lean Guy Drove a Prius For Two Years And...

2009-07-07T05:00:00.000-04:00

... I wasn't impressed in the least. In my previous role as a consultant, I was given a company vehicle to use, even though it was basically for commuting to a local client, the airport, and occasional personal use.

I had the Prius just over two years and put about 12,000 miles on it. The driving experience was OK (it was peppy enough, I suppose) and it did get 41 MPG. But, aside from being ugly (which is a matter of taste), I was left with some pretty poor impressions of Toyota quality.

This is hard to stomach to a "Lean guy" who preaches the gospel that the Toyota Production System leads to better quality.

My impression was that, to keep the total price of the Prius low (since price is driven by the market, as Toyota teaches), they had to "get cheap" with components that we're part of the expensive hybrid drive system. Toyota couldn't just add cost (hybrid drive) and then try to pass that cost along in "cost plus" pricing. Toyota customers wouldn't buy the Prius at a significantly higher price (or at least not enough, Toyota must have figured).

The interior just felt cheap... the components, materials, and construction.

I wore a hold in the carpeted floor mat and I don't have particularly pointy heels... I drive with my heel in the same position, rotating my foot over to the accelerator. I have a Saab with 40,000 miles and the carpeted floor mat is just fine. The Toyota mat is pictured below:

OK, but a floor mat could be replaced easily (and probably under warranty). The driver's seat cloth was pretty worn and cruddy looking, if that is conveyed in the picture:

Fumbling with a GPS unit that I was unsticking from the windshield, it fell and, in my fumbling, I struck the clock on the dashboard. It wasn't that hard of a hit, but it must have been in just the right spot to knock the clock into the dash. On it's own, I'd say that was just an unlucky blow, but it got me thinking that maybe Toyota had used cheap fasteners or clips to hold the clock in place.

Has anyone else had a similar experience with the the Prius? For many people, the Prius might be their first Toyota. This is supposed to represent Toyota quality? The company that brought us Lexus?

Maybe people are so happy to drive a hybrid car and feel so good about that, so the customers/drivers are willing to forgive and overlook other flaws and cheapness? Is Toyota giving the market the quality they desire at their price they are willing to pay?

I wouldn't spend my own money on a Prius after my experience. What do you think?

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Great Op-Ed from Paul O'Neill on REALLY Improving Healthcare

2009-07-06T13:00:00.000-04:00

Op-Ed Contributor - Health Care’s Infectious Losses - NYTimes.com

FINALLY, a major contribution to the discussion about how we need to improve the quality of care delivery. That's how we are truly going to bring costs down - by improving delivery, not just paying people less for the same old waste (and a bit of value).

O'Neill asks (click through to the NY Times to read the whole thing):

HEALTH care reform seems to be on the way, whether we want it or not. So I have been asking questions about the various proposals. Here is a sampling.
•
Which of the reform proposals will eliminate the millions of infections acquired at hospitals every year?
•
Which of the proposals will eliminate the annual toll of 300 million medication errors?
•
Which of the proposals will eliminate pneumonia caused by ventilators?
•
Which of the proposals will eliminate falls that injure hospital patients?
•
Which of the proposals will capture even a fraction of the roughly $1 trillion of annual “waste” that is associated with the kinds of process failures that these questions imply?
So far, the answer to each question is “none.”

Amen to that. This should be a non-partisan issue, the need to improve the delivery of care. These same problems exist in the U.S., Canada, and the UK, so it's not a matter of which payer system is best. In the UK, they discuss MRSA and c-diff rates in the news all the time and you never hear about it here. We *know* how to fix these problems, as O'Neill writes in the Times. The solutions just aren't spread widely enough yet? Why not? We could go through a hearty "5 whys" analysis on that one...

We can debate all we want the issues of how to provide access -- the sad reality is we'll be providing MORE access to an unsafe healthcare system.

I don't mean to be alarmist. It's not guaranteed you'll be harmed in a hospital. But the odds are far worse than they need to be. More on this coming later this week, a blog post I had already written about medical errors and why it's a cultural issue, not a technical one.

Great job, Paul O'Neill, getting this into the Times. I hope it's heard and given its due attention.

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Do Ideas Go "Poof" at Starbucks?

2009-07-06T05:07:00.001-04:00

By Mark Graban:

I'm always fascinated by Starbucks. For one, I'm a regular customer and Starbucks has a reputation for hiring pretty educated people as baristas given their health benefits and all. So it seems like a huge opportunity to engage those employees in each and every Starbucks location (how many???) in kaizen, sharing those improvements across locations.

Ordering a drink for my wife and myself, I handed by "Gold Card" to the woman running the register. She ran the card. Then a few seconds later says, "Oops, I need to swipe it again for payment." Some, but not all Gold Cards are used as stored value cards, some are just used for the discount and people pay cash or credit. There was a "defect" in the process (she almost forgot to take my money and it required more effort on her part).

She says to me, unprompted, "You should only have to swipe the card once. It would be nice if the computer could determine, on that single swipe if it's stored value and, if it is, just take the money off."

Now that's not a Norman Bodek "Quick and Easy Kaizen" style idea... in his approach, the idea should be something the employee can take action on, such as moving where the lids for cups are stored to reduce walking.

But the employee has a valid idea -- it's an idea that has to flow up. It's similar to a scenario where a nurse has an idea about the Electronic Medical Record system that would make her job easier. She can't fix it, but there needs to be an avenue for the idea to be heard.

I asked the barista, "That sounds like a good idea you have. So what happens to the idea? Does it just go poof into the air?"

I was checking to see if she would find it worth the time to tell her shift leader or store manager.

She smiled and said, "I dunno. There's probably a good tech reason why they can't do that, but they haven't told us."

So if she *did* go to her store manager with that idea, the least she should deserve would be an answer back explaining why it wasn't possible (of course it *is* possible -- it's just software) or why it's not possible right now. Or, is that a P.O.S. (Point of Sale) register feature that they *plan* on implementing at some point. She can't be the only one who has made that suggestion.

It would be a shame if the idea just went "poof." I wonder how often she makes that same mistake. Do we blame her or the system? Is there a better process that they can put in place for the existing P.O.S. to make it harder to forget to swipe the Gold Card twice? Would that be a good short term fix?

Stay tuned, later this week I will blog about a very detailed article from the WSJ about two weeks ago that outlined some operational improvement efforts at Starbucks.

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Independence Day Holiday

2009-07-03T10:17:00.002-04:00

Hi - I'll most likely not post over the weekend, but will prepare an interesting week's worth of blog posts for the week ahead. It's "Independence Day" tomorrow in the U.S. I prefer that term over the more popular (and somewhat meaningless "4th of July.")

A day to be thankful for liberty and to think about those who do not have it.

I'd invite you to check out the blog archives or explore areas in the blog you might not have seen before - podcasts, video podcasts, use the search box in the upper right or bottom of the page or visit the other blogs on my blogroll.

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I Sometimes Sort of Hate My Book's Title, I Think

2009-07-02T05:00:00.000-04:00

First off... I made a mistake yesterday, a defect in my blogging process, if you will. I normally attempt to practice "heijunka" on the blog, leveling out posts so one is published each morning at 5 am and, if there's a second, at 2 pm.

Yesterday, I accidentally posted two posts at 5 am. So, if you're used to the cadence of one per morning, go back to yesterday and see, there were two posts in the AM. Now onto today... tomorrow is a holiday (observation of Independence Day), so it will be slow over the weekend here...

Another interesting discussion that came up during my trip to The Netherlands... my book's title: Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction

I'd have to admit, the phrase "Lean Hospital" is a tough description to live up to. The term "lean" originally referred to the performance gap between auto plants run under the Toyota/lean system and those run the traditional way. To be "lean" meant that your plant was significantly better in many regards - not 5% better but 50% better: quality, labor productivity, etc.

Are there hospitals that are uniformly 50% better than the standard benchmark? Probably not... yet. Maybe some are getting there, but it will still take time. To be a "Lean Hospital," does that mean half the infection rates, half the preventable mortality rates, twice the nursing labor productivity, etc.? Is that possible?

We have to be careful that "Lean" doesn't mean "perfect." Lean is not a destination, a point we reach where we get a flag to fly out in front of the hospital. If Lean meant perfect, then nobody is lean, including Toyota, since everybody has waste.

Ultimately, "Lean Hospitals" was meant to be a snappy short title. A more accurate title might have been:

"Hospitals That Are Using The Lean Methodology in a Significant Way."

More accurate, but probably not a better title.

Then, there's the discussion about the subtitle. Where does long-term financial performance enter into the picture? Is this not important? Toyota says the goal of TPS is long-term corporate vitality, as they put it. Long-term vitality is important for a hospital... have to not lose tons of money, have to keep the doors open.

So maybe a better subtitle is:

"Achieving Long-Term Hospital Financial Vitality through Continuously Improving Quality, Patient Safety, and Employee Satisfaction, Amongst Other Important Goals."

Nah, it's probably better the way it is... what would you call it?

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Podcast Technical Update

2009-07-01T14:00:00.000-04:00

Just an administrative update on some technical glitches I've had with the podcasts that are now resolved.

If you listen to the audio podcasts via the original feed (MP3 format), there's been no problem.

If you had subscribed to the AAC format feed (via RSS or iTunes), the feed had stopped updating after Episode #66. The last three episodes weren't getting out in that feed... but that's now fixed.

Root cause - Apple changed the MobileMe service addresses from "mac.com" to "me.com" and I ddn't update the feed? Why didn't I update the feed address? I didn't know... why not? What's the root cause of this?

Links to subscribe in iTunes ---> via MP3 and AAC. If you use iTunes or an iPod, the AAC feed is probably better (smaller file size).

The Video Podcast series is now also on iTunes for easy viewing, downloading, and subscribing. Click here for the link to iTunes.

For those who don't or can't watch video podcasts, all video episodes will also be published in audio only format... which creates a little waste for those of you who subscribe to all of them.

I just (Monday) recorded an audio interview with the COO of Long Beach Memorial Medical Center, Tamra Kaplan. Any other ideas for future episodes?

Any other podcast ideas or feedback?

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How Does Your Team React to a New Person?

2009-07-01T05:00:00.001-04:00

I 've mentioned here, I think, that I was in The Netherlands earlier in June for almost a week. I was invited to speak at an annual symposium for hospitals around the country that was put on by St. Elisabeth Hospital (regular readers of the blog).

I'm very thankful to them for hosting me, not just the symposium, but the great discussions and gemba time in different parts of the facility. It was very thought provoking and I have many items I'd like to blog about - either what they are doing (which I'll blog about with their permission) or general thoughts that were inspired by the discussions.

One discussion that I thought was really interesting:

Let's say you have a new person on your team -- a new employee right out of school, somebody who has transferred into the department or unit, or somebody from another organization.

This new person asks a question about the process or makes a suggestion about doing things a different way....

How does your team or individuals react?

Thank you, tell me more...
We've always done it that way...

Which response is more likely? Which response is going to lead to more organizational success? Which approach is going to lead to more input from the new employee?

The answers probably seem obvious... so the real question is how do we get people to be open minded to ideas, questions, and suggestions and not just shut people out with the "we've always done it that way" response?

Is it a good gauge of a "lean culture" that more people (or all people) would respond the first way, not the second?

Have you been successful in shifting the culture and the primary response from #2 to #1? If so, how did you do it? If not, what gets in the way?

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Bad News not Flowing Either Direction at GM?

2009-07-01T05:00:00.000-04:00

Last week, I blogged about an episode where bad news wasn't flowing up in Boeing (or, it's part of a pattern).

In my Sunday morning reading, I ran across two articles that reminded me of the situations where fear (and other dynamics) lead to communication failures.

The Truth About Cars blog had a months-old story called: Inside GM: Mystery of Crap Interiors Solved.

In the post, our friend Robert Farago told the following believable story from a GM insider:

Agent X reveals one of the main reasons GM’s interiors failed to match the competition: the executives didn’t know there was a problem. Still don’t. Here’s why . . .

As you probably know, ever since GM was founded, its execs have either been driven by a chauffeur or provided with carefully prepared and maintained examples of the company’s most expensive vehicles....

Our agent says that all the vehicles the execs drove were “ringers.” More specifically, the engineers would tweak the test vehicles to remove any hint of imperfection. “They use a rolling radius machine to choose the best tires, fix the headliner, tighten panel and interior gaps, remove shakes and rattles, repair bodywork—everything and anything.”

Did the execs know this? “Nope. And nobody was going to tell them . . . As far as they knew, the cars were exactly as they would be coming off the line. That’s why Bob Lutz thinks GM’s products are world-class. The ones he’s driven are.”

I asked Agent X if the GM execs would ever drive the cars again. Did he know if Wagoner or Lutz dropped in at a dealership to test drive a random sample off the lot? He found the idea amusing.

When you are not practicing "genchi genbutsu" (go and see) as Toyota leaders do, this sort of thing happens. I bet if Wagonner or Lutz went to a dealer, it was a well-planned dog-and-pony show where, again, the reality wasn't being presented to them.

When I worked at GM (mid 9o's), we put on many planned dog-and-pony shows for execs. If I remember right, the highest exec we had was an up-and-comer, Tom Stephens, who now recently took over for Bob Lutz. When execs were visiting, everything got magically cleaned up. Inventory was hidden, things were cleaned, defective parts were stashed behind construction curtains... these execs were "at the gemba" (not a term we used then), but they weren't seeing anything close to reality.

And I still hear reports from friends in the manufacturing world about how this happens. The same thing happens in hospitals when they know the inspectors are coming from one oversight body or another... things get "fixed", but it's temporary... the visitors never see the reality of the hospital. So it's no wonder hospitals get acccreditation and then often have some embarrassing quality mishap right afterward.

Why were the GM people afraid to let Lutz and the execs see reality? Why were they fearful in my plant? Why are they fearful in hospitals? Why aren't things "made better" instead of being "made to LOOK better"? Pretty common organizational dynamics once again.

Go to the TTAC site and read the comments, especially this informative comment here. “Potemkin Village".... having my old history course memories drudged up now, this is very common behavior, the urge to make things look good (it's often easier then true improvement).

The second story is from the Sunday NY Times Magazine (G.M., Detroit and the Fall of the Black Middle Class).

It's a very long story and it's not all relevant to this discussion. I found this interesting because I grew up in the Detroit suburbs and when I worked at GM, I worked with many African-American UAW members who were part of the generation that had moved up from Alabama and the Deep South.

One story jumped out at me, regarding communication:

Just a day before, the line was stopped early for a plantwide meeting on the factory floor. A G.M. executive had recently spent a day touring the plant to determine its future, and the guys wanted to know if any decisions had been made. Would they be bringing back any of the laid-off workers? Were there going to be more layoffs? Was the plant going to close?
The plant manager did his best to reassure everybody but offered no definitive answers. By the time most of the plant’s employees got home, however, local news outlets were reporting that General Motors would be shutting down all of its factories for as many as 10 weeks this summer.

Now was this a case of bad news not flowing DOWN in the organization? We'll never know the answer to this, but I could see a few scenarios being possible:

The plant manager hadn't been told and honestly didn't know
The plant manager knew and was told not to say anything
The plant manager knew and CHOSE to say nothing
The news media were wrong about the closures for ALL

Either way, you'd have to think that people did NOT enjoy hearing about this in the TV news. The sequence of events didn't do much to foster trust, and I found the lack of trust was a huge dysfunction within my GM plant.

There are a few random details in the story that are lean related:

The article talks about nepotism that had developed. Basically, Marvin Powell, as a young UAW worker, got his job because his dad worked there. Hiring came only through referral, rather than choosing the best person for the job. The screening was a one page "referral sheet" and application.

Powell submitted his referral sheet, and after a few simple tests — math, reading comprehension, manual dexterity — followed by a team-building exercise, a formal interview and a physical, he started working at Pontiac Assembly.

Compare this to the hiring scrutiny at Toyota. For 2,000 jobs, they had 63,000 applicants to go through. I'm not saying Marvin is a bad guy or a bad worker... but Toyota has a much more stringent and deliberative process of hiring and training (you can read more about that in the books Toyota Talent: Developing Your People the Toyota Way or Toyota Culture: The Heart and Soul of the Toyota Way -- disclosure: the links are affiliate ads).

GM did have a week-long orientation and training process for Marvin, as mentioned in the article. But, again, that sounds much less intensive than the Toyota training and orientation process.

Anyway, the NY Times article is probably interesting general reading for those from Michigan or those in (or formerly in) the auto industry.

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A Breakthrough in Training -- Call it "Near-TWI"

2009-06-30T05:00:00.003-04:00

I'm very pleased to present a guest post from Arizona about the successful use of Lean concepts and, more specifically, the "Training Within Industry" methodology. You may recognize Dr. Pete as a regular commenter here on the blog. We've spoken a number of times by phone about the lab's work and I invited Dr. Pete and Chuy to document some of their collaborative work here on my Lean Blog. If you have questions, post a comment and I know Dr. Pete will be glad to interact with you.

A Breakthrough in Training -- Call it "Near-TWI"

By: Jesus “Chuy” Ellin, HT PA & Peter P Patterson, MD MBA

The histopathology laboratory at our hospital recently had a breakthrough in the lean journey we began in 2007. The monthly defect rate in the order entry process has fallen precipitously from 33.5% to 2.5% over the past five months, after we initiated comprehensive new employee training.

The order entry person in our laboratory is responsible for logging in patient samples and setting them up for processing and subsequent slide production. The position had chewed up six people in three years -- no one seemed to last more than a few months. The high rate of mistakes in order entry necessitated a great deal of rework and delay. This was a constant source of friction between the histology laboratory and transcriptionists in the office. Our conventional management wisdom was that we just could not seem to find good people. We did also notice that criticizing the mistakes and exacting various forms of employee discipline did not improve the defect rate. Sound familiar?

When the order entry incumbent resigned without notice in November 2008, our management team began to seriously investigate the real sources of the high defect rate. A major insight was the realization that initial training of new employees was completely inadequate. Furthermore, many of the important aspects of the job were either undocumented or inadequately documented making effective training difficult.

We began two efforts simultaneously -- one was complete documentation of the correct procedures and steps; the other was initiating a way to engage the laboratory staff such that they became active players in the improvement efforts. Our motto became "everyone has a part to play".

After documenting all the important steps in the order entry process, the new person hired in was carefully trained one-on-one by the supervisor over a period of weeks. The new hire was trained in a way that did not overwhelm her with new knowledge and yet no detail of the job breakdown was left out. Here, insights and detailed job knowledge provided by the staff helped shape the training content and sequence.

At the same time, the lab staff was asked to share their concerns, insights and recommendations for needed changes. One of the first results here was a list of tasks that needed to be completed every day, and an additional list that needed to be completed with a regular periodicity – say weekly. New visibility was given to uniform expectations regarding complete work around each task on the list. As the improvement process became much more interactive, the staff naturally had ownership of the updated lists.

In the first month after the new person was hired and trained the new way, the defect rate fell 72%. The next month it fell 17%. The defect rate has fallen by similar amounts each subsequent month, now five months running. As the defect rate falls to low levels, we have begun exploring the ideas behind a “zero-defect” program.

In researching the problem prior to the new hire, we tapped into the rich vein of TWI in Healthcare. Since we made the connection, we have opened a large body of knowledge which now informs the evolution of our work. We have refined our training efforts along the lines of the Job Breakdown Sheet (JBS) and Job Instruction (JI). New employee training was conducted in the four step TWI sequence: prepare the person, present the job, let the worker try it and follow-up frequently. We are realizing that the instructor has a defined job sequence just like the employee.

As our thinking and methods have developed over time, we see that we are evolving our own unique approach rather than simply trying to implement someone else’s way. As we currently see it, the two pillars of our improvement system are: 1. Engage and develop your people. 2. Get continuously better at what you do. Over the course of multiple PDCA cycles, we have validated the principle that a well-trained workforce is the foundation for standardized work and kaizen.

Jesus “Chuy” Ellin, HT PA
Peter P Patterson, MD MBA

[Potential conflict of interest disclosure - the firm I used to work for, ValuMetrix Services, provided some initial consulting to their organization, although I was not directly involved in that consulting work.]

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"Do" Lean or "Be" Lean in IT?

2009-06-29T20:21:00.001-04:00

Lean & IT « IT Business Alignment (IT2B)

Oops... I accidentally hit "publish" instead of "save as draft." For a Lean guy, I don't have error proofed, apparently. So that was released as my shortest blog post ever.

The author of the linked post, Glenn Whitfield, makes some excellent general points about Lean for any setting:

Toyota does not have a ‘Lean initiative.’ Toyota does not ‘do’ Lean, they ‘are’ Lean. It’s just the way they do business. Implementing the tools of Lean will get you results, and will help move you toward becoming a Lean organization, but Lean is bigger than the tools.

So, as IT organizations move to embrace Lean thinking, the question becomes, “Are you going to ‘do’, Lean, or are you going to ‘BE’ Lean?”

Great questions for factories, or hospitals....

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Breaking: GM Dumps NUMMI Partnership with Toyota

2009-06-29T17:57:00.003-04:00

After 25 years, GM ditches NUMMI tie-up with Toyota

In the news this afternoon:

PRESS RELEASE:

2009-06-29

GM Media Statement Regarding GM's Ownership Stake in NUMMI

Attributable to Troy Clarke, president, GM North America

"As part of its long-term viability plan, General Motors has decided that its ownership stake in the New United Motor Manufacturing Incorporated (NUMMI) joint venture with Toyotawill not be a part of the 'New GM'. After extensive analysis, GM and Toyota could not reach an agreement on a future product plan that made sense for all parties. Accordingly,NUMMI will end production of vehicles for GM in August, and there are no future GM vehicles planned for the joint venture at this time.Given that, GM believes it is in the best interest of the 'New GM' and its stakeholders that we placeour ownership interest in NUMMI in 'Old GM'. We have enjoyed a very positive and beneficial partnership with Toyota for the past 25 years, and we remain open to future opportunities of mutual interest."

Click the "NUMMI" link at the bottom of the post for more/old stories about NUMMI, including my tour there in 2005.

NUMMI was such a wasted opportunity. My plant manager (the second one) during my time at GM's Livonia Engine was one of the first GM managers to rotate through NUMMI. He got it, what an incredible leader he was.

When I was there touring, we got some time with GM managers who were rotating through at the time. The guys there in 2005 were more interested in bad-mouthing Toyota to our group of MIT alumni than anything else (we got insights NOT in the public tour). Sad. Their apparent arrogance led them to highlight how Toyota wasn't as perfect as everyone thought and that GM was a lot better in many regards.

For context, this 1989 NY Times article is interesting to revisit:

No Utopia, but to Workers It's a Job

Thoughts?

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Book Review: "Kaizen Express"

2009-06-29T05:00:00.002-04:00

I have always learned a lot from John Shook. As I've blogged about before, I've seen John present about TPS and management (leadership, really) a few times and probably learn more "insights per hour" than anyone else in the Lean world, as he has a way of communication concepts and methods in a way that's easy to relate to and share with others.

His most recent book, co-authored with Toshiko Narusawa, published by the Lean Enterprise Institute, is "Kaizen Express: Fundamentals for Your Lean Journey." It is also available from Amazon.com, if you prefer.

In an era where many think we've "moved beyond tools," we often talk about management and culture -- high level goals. But tools and fundamentals should not be forgotten. Kaizen Express is a "back to basics" primer on the Toyota Production System. Since John was one of the first Americans to work for Toyota in Japan, this book is pretty closely "straight from the source" as much as any recent publication.

Personally, I loved the book. I've been reading books about Lean since 1995 when I started my own journeys in implementation. This book is a nice compilation of lean basics that you might find in the books from Ohno and Shingo. There are gems scattered throughout, some ideas you might have already known, plus a few ideas that were new to me or stated in a new way.

Who is this Book Best Suited For?

Do I recommend this book for you? Well, it depends. If you're like myself -- experienced with Lean, an engineer, a bit of a "Lean Geek" then this will find a welcome place on your bookshelf as a reference and you'll enjoy reading it. The Japanese style cartoons are nice visuals that will remind you of Toyota publications.

If you're implementing Lean in a factory, then this will provide a ready reference. There are many details about topics like Kanban, Heijunka, and "Zone Control" that will prove useful. There are many templates, forms, and examples that the authors encourage you to use (including blank templates in the back of the book). There are also training slides in the back of the book that you are encouraged to use in your workplace (or adapt).

Some downsides of the book -- it is probably best suited for a manufacturing environment, given the examples and scenarios that are given. While the general history and management points are very transferrable (more on this later in the review), the book might be a bit off-putting to those in services or healthcare settings. Now, if you're like Dr. Sami Bahri, you might enjoy reading this in an open-minded sense of wanting to read the basics so you can figure out for yourself "does this idea apply... and how?" This is the process that Dr. Bahri went through, reading the original Ohno and Shingo texts, asking how to apply the ideas to dentistry. Not everybody has that patience, so I would only give this book to someone in healthcare if they thought like our friend "the Lean Dentist."

Additionally, the book is a translation from a Japanese text. The Japanese and English are presented side-by-side in the text and the diagrams/pictures. This was done, the authors explain, to have one global edition of the book, since English is such a common business language. To some, the Japanese will only feed into the "well we're different, TPS is only for Japanese companies" mindset that unfortunately appears in some organizations. So make sure your organization is open minded to seeing so much Japanese.

For these reasons, this proabably isn't an "introduction to Lean" book for most readers. I think the book, as great as it is, is best suited for experienced professionals and those who have already been learning about Lean and have been implementing it. That's not a criticism of the book, but I'm trying to give some guidance around how it might best be used.

Highlights of the Book:

Like I said, there are many gems in this outstanding book.

Page 14 has a great discussion about a primary benefit of kaizen being growth and new opportunties for employees.

"But surely nobody will be willing to support kaizen if it results in a loss of employment."

The authors give practical suggestions beyond just not laying people off. They emphasize having a training development approach and planning so employees can get new experiences or move into management. One of my favorite examples with Lean in a hospital was seeing an experienced employee finally WANT to become a manager (because the culture was changing) and because his time had been freed up through Lean and kaizen.

"... the purpose of kaizen is to make processes better and to develop people's abilities, not to simply reduce the number of operators."

Now that's a great universal point and this book makes it well.

Page 23 has a great illustration and description of "fake flow" versus "pure flow." In fake flow, we've just rearranged the machines, but we still have batches and uneven production. In pure flow, we've taken steps to ensure true single piece flow. Or, as the book rightfully points out, single piece OR "small consistent batches." Single piece flow isn't an absolute, it's an ideal.

Page 25 has a nice discussion about "Why a U-shape" for a production cell?

In the discussion of Heijunka (level loaded), on page 45, there's a nice discussion of how uneven workloads can cause:

"..strain, which corrodes safety and morale."

So again, the methods are brought back to people and employees, not just the benefit to the company or customers.

I love the description and discussion of Standardized Work in the book:

See, standardized work is NOT about telling people what to do or shutting your brain off at the door. This section should be great ammunition in discussions about whether you can or should standardize things in healthcare or other settings.

Section 5 on "The Lean Journey" has a discussion of Toyota history and what is called "Genryo" or "genryo management." This refers to Toyota's need to be successful in the face of limited resources, to be frugal and creative. That's a similar motivation as we have in healthcare today -- not just throwing money at problems, but being successful in trying economic circumstances.

One challenging idea for healthcare readers: part of genryo management involves what we could call capital linearity and labor linearity. Instead of building one huge factory (or hospital) that opens all at once, can we scale up the factory over time by adding chunks of capacity? Ironically, I've read recently about how Honda is better at that, lately, than Toyota. By labor linearity, we want processes where we can add and remove people as customer volumes change. Hospitals often gain this by "sending people home early." Does this method, which hurts people's paychecks, show "respect for people?" Can we find other ways of using people's time for kaizen if they have no patient work to do?

So that ties into the final part of the book on kaizen and employee engagement. This is the most transferrable chapter of the whole book. I'd wholeheartedly recommend this chapter to those in healthcare. It talks about why employee involvement is "critical" in general and for implementing lean.

"A lean conversion may be started as a top-down process in many companies. However, nobody can realize it by him/herself and any new system cannot run well only by orders from above."

The book describes Toyota's respect for people and belief in people by highlighting that most everybody can contribute to kaizen. The authors emphasize the need for classroom training AND practical "learn by doing." They also point out that the classic 5-day kaizen workshop isn't always the best format for all learning for all problems.

There's also a very nice back-and-forth discussion on page 102 about engaging employees and asking questions when they don't agree with changes. If they want to change back from the U-shaped cell, how do you respond? Hint -- it's not a matter of crushing the revolution, instead you need to work with people and listen.

The final section is beautifully labeled as "Respecting People Is Always The Basis of Your Kaizen (How do we change from "command" to "committment"?).

Final thoughts -- great book, very welcome addition to the lean literature. Great insights, but also very practical in a "how to" sense with the forms, templates, and training slides (like the one below) that are made available for use.

Other Reviews:

Conflict of interest disclosure: I work for the publisher of this book, the Lean Enterprise Institute, but played no role in its development. The amazon.com link is an "affiliate" link for which I earn a royalty.

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Clear and Relevant Metrics

2009-06-28T05:00:00.000-04:00

By Matt Wrye:

I have been implementing lean over the last 10 years at five different companies. Only during the last eight years and three companies was I truly learning about and implementing lean (and not just the tools). During that time, I have become very passionate about metrics.

Are they correct? Do they drive the right behaviors? Are they being looked at and used?

Not until recently did I spend some time reflecting on metric characteristics in areas that were using them successfully to drive improvement. Metrics must be both clear and relevant. It sounds so simple and easy but I have seen so many failures in not doing this.

First of all, the metrics need to be relevant to the employees that are targeted to use them. I have learned to ask the employees in an area I visit if the metric displayed mean anything to them. A vast majority of the time, the answer is ‘no’. It used to be shocking at first, but unfortunately now it isn’t. This creates busy work for people maintaining the metric and adds waste to the system. More importantly, it shows underlying disconnect between the people creating the metric (supplier) and the people using the metric (customer). If the levels of management have a disconnect with the metrics, it is pretty safe to assume there are many more disconnects with in that supplier-customer relationship.

It isn’t only important that the metric is relevant to the people using it, it must also be clear. It must be clearly understood, clearly connected to cascading up goals, and the goal must be clearly stated. Too often, I see examples of metrics that are very unclear to the user. An example might be having front line hourly employees using standard cost metrics. It is very unclear what the front line employee can do to affect the standard costing. This leads them to not drive improvement.

Another metric that I find very unclear is OEE (Overall Equipment Effectiveness). This is one that is used by many companies to drive improvement. I find it very unclear. It is a product of three factors: yield, uptime, and machine efficiency.

OEE = Yield x Uptime x Machine Efficiency

So, if OEE changes which one caused it to change? Or worse yet, what if OEE stayed flat but it was because uptime increase and yield decreased? Would anyone know? The equipment is still performing the same according to the OEE. In order to understand what is happening, you have to break apart the metric into the three components, so why add the over processing? Please, I have seen OEE misused so many times, but that is for another discussion.

When I have seen clear and relevant come together, I have seen greater improvements and greater buy-in.

One great example was an area manager where I work. When asked if the current metric (packages completed) meant anything to the employees they said ‘no’ and ‘they don’t pay any attention to it’. His uptime on a line was 2.6 hours / shift. He wanted to get more packages per shift but that metric didn’t mean anything to the employees but uptime did. The area manager connected number of packages completed in hours of uptime in order to make it relevant to the employees on the floor. Then he took away all other metrics in the cell and asked them to hit 5.0 hrs of uptime per shift (he also gave them some problem solving help).

Within the first week the cell was hitting hours of uptime per shift. Three months later he had to increase the goal to 6 hours per shift. The area manager has been able to reduce the number of cells needed by 50% and eliminate the need for temporary employees in his area. When an employee is asked what is their goal they clearly state, “Six hours of uptime per shift.” The connection between uptime and all the other management goals is clear as everything else has moved in the proper direction, cost, delivery, OEE, etc…..

So whenever you are looking at metrics, make sure they are clear and relevant and I will bet that once that connection is made you will be very successful.

Matt Wrye graduated from Purdue in '99 with a BSIE. After implementing Lean in various industries, Matt now works for Hallmark cards as part of the central lean implementation team working to build lean systems and process excellence throughout the company.

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The Power of Explaining Why - A Funny Example

2009-06-27T05:00:00.005-04:00

This sign and picture might be a bit rude, so I saved this for a Saturday.

To me, a very powerful and often unknown principle of the Toyota Production System and Lean is the idea that managers must "explain why" to employees if they give a directive order. I saw this when I visited the NUMMI plant and wrote about how they treated employees like adults by explaining why certain defective parts shouldn't be used rather than just barking orders or relying on formal positional authority.

I've found this to be a very powerful method to use in hospitals -- going out of your way and making the extra effort to explain "why?" to employees or even patients and families.

When I was able to visit a hospital in The Netherlands a few weeks back, I was able to spend some time touring Amsterdam with my hosts.

I spotted this sign on a door in an area where there's a lot of partying and late night drinking, apparently (you can tell I was there during daylight hours). It's on a door at the street level, larger picture to follow below:

Larger version of the sign, and it reads:

I wonder if that's more effective than a sgn that simply says, "Don't piss here."???

And... walking to work the other day, from Boston into Cambridge, I saw this gem of a "why?" sign:

Isn't that more effective? By saying "this drains into the River" and having the picture of the fish (who wants to harm fish?), I bet there's far less dumping than if it just said "DO NOT DUMP!!!"

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Bad News Not Flowing Up at Boeing?

2009-06-25T17:00:00.000-04:00

Tomorrow's blog post today... not that anyone will be reading anything non-Michael Jackson related. RIP. A modern tidbit... I learned about the news via a friend's Facebook status update. The new, new media, I suppose.

Communications Woes Show at Boeing - WSJ.com:

Non-aviation folks (and healthcare readers)... stick with me, this isn't strictly a post about making airplanes.

Isn't it a fairly common dysfunction of organizations that bad news doesn't flow up? This happens in manufacturing... an old boss at unnamed company (not GM) once typified this by saying (bragging really) that "my job is make my boss look good." That "goal" certainly wasn't accomplished by sharing any bad news. I was sickened. I wanted to focus on making things better, not just creating the fake impression of better. Bad news never flowed up.

In other organizations (and this was a GM dynamic) bad news didn't flow upward. Why? Mainly fear. Fear of being yelled at. Fear of being embarrassed in front of others and ridiculed. That fear led to team leaders faking the hourly production numbers (the shift total was correct, but the hourly numbers were smoothed out to eliminate the peaks and valleys... the valleys got you yelled at).

Last week, Boeing announced at the huge annual Paris Air Show that the test flight of the troubled 787 was on track.

"...Boeing had said at the Paris Air Show just days ago that the plane was ready to fly."

I'm not an aviation expert, but I know the annual air show (in France or the U.K.) is THE wheeling and dealing show of the year. Many planes are sold here, right?

Then, Boeing announced after the show that the test flight will be delayed.

So what gives?

I often have a bit of a philosophical debate with my wife when a company screws up -- are they dishonest or are they incompetent? Sometimes you can't tell. We have a little debate about which is worse -- competent but dishonest (at least they're competent) or honest and incompetent?

You might think the Boeing executives were lying in Paris. But they'd have to be smarter than that, to think that the lie would eventually catch up to them.

I don't think Boeing's executives (or GM's) are stupid.

Did they HONESTLY think the test flight was on time?

"'During the last two years...some investors described optimistic statements by management as misleading,' wrote Doug Harned, aerospace analyst at Bernstein Research, in a note to investors Tuesday. 'On the contrary, we saw the answers as honest, which is the heart of the problem. Management appears to have been operating without adequate visibility into the details of program performance in the 787 organization and at suppliers.'"

Honest, but a clueless sort of honest. Why did the information not get to the Boeing execs? They must be pretty embarrassed (they didn't comment for yesterday's WSJ story).

The above quote blames the suppliers, in a way. Blame -- there's another dysfunction of broken organizations. Is it really the suppliers' fault? Do you "blame" those who chose the suppliers? Those who manage the suppliers? Does it matter?

This article assigns blame internally in Boeing:

The structural flaw that has grounded Boeing's 787 Dreamliner originates with Boeing's engineering and will likely add months of delay to the new jet program, an executive with key partner Mitsubishi Heavy Industries said Wednesday.

Trying to piece this together... it's probably not too much of a stretch to assume that people in Boeing KNEW that there were problems or likely delays.

Oh, the WSJ reports that people in Boeing DID know... in May, when the Air Show was in June. D'oh!

This week, however, Boeing said its engineers and senior executives alike had known since May of the structural problem that will keep the jet grounded, possibly for months.

Why did this news not get to Boeing execs? At what point in the communication chain did things break down? Who was afraid to share the bad news?

The same type of dysfunction exists in hospitals... bad news not filtering up to VPs or the CEO. Do you have examples to share (anonymously) about bad news not flowing up? What caused that? Was it fear, as Dr. Deming would have said??

There's a story in my book, Lean Hospitals, about how the CEO in a leading lean hospital was helping create an environment where people could be honest without fear of retribution. A nurse told him bad news -- that she wasn't entering information about medication errors into the computer system because it took too long. He thanked her for telling him this and worked to get the problem fixed as a "servant leader."

I guess Boeing doesn't have that type of culture? Or am I wrong?

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LeanBlog Video Podcast #5 - Dr. Sami Bahri, D.D.S.

2009-06-25T05:00:00.003-04:00

This is an interview with Dr. Sami Bahri, D.D.S., a dentist from Jacksonville, Florida. He is a pioneer in using Lean methods in the management of his dental practice. The book documents his learning journey for himself and his office staff as they learned how to apply Lean in a very non-traditional setting.

His book, Follow the Learner, is available from the Lean Enterprise Institute. You can also watch an archived webinar that he presented (archive here), along with some text Q&A follow ups that were recently posted.

There is also an audio podcast version of this discussion available as episode #69 at www.leanpodcast.org. For audio podcast episodes, please visit www.leanpodcast.org. For video podcasts, visit www.leanvideopodcast.org.

You can also go to YouTube to watch (the full series can be found there.)

Video (YouTube Link):

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.

Click here to access and subscribe via the iTunes Store Podcast Directory (that RSS feed is: http://feeds2.feedburner.com/LeanBlog_VideoPodcas t)

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LeanBlog Podcast #69 - Dr. Sami Bahri, D.D.S., "Follow the Learner"

2009-06-25T04:59:00.006-04:00

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"

AAC File

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Toyota Leaders Get a Lecture From a Toyoda

2009-06-24T05:00:00.000-04:00

Toyota Names Akio Toyoda President, Apologizes to Shareholders for Losses

This was rumored for a while, but Toyota has formally named Akio Toyoda as the next President. Yes, "Toyoda" with a "d" -- that's the family name. Back when Toyota starting making automobiles, the company name was changed from Toyoda to Toyota. Two reasons I've heard for that - one had to do with the number of strokes in the kanji character for Toyota being a lucky number and second that it was easier and quicker to write than Toyoda.

Toyota officially confirmed 53-year-old Akio Toyoda as company president today. The grandson of company founder Kiichiro Toyoda takes over for outgoing president
Katsuaki Watanabe, who will stay on as vice chairman.

It will be interesting to see how Toyota's strategy or direction changes with new leadership. I assume they won't "pull a Wiremold" and ditch Lean methods... seriously, that's a risk in many organizations (including hospitals) where a leadership change might put Lean efforts in jeopardy. The difference, at Toyota, is that "Lean" is really the Toyota Production System, which is really just the way Toyota does things (embedded pretty deeply in their DNA).

Toyoda Asks How Many Times Toyota Errs Emulating GM Failures - Bloomberg.com

This second article caught my eye yesterday, as a Toyoda family patriach lectured the company leaders for their recent business struggles.

The son of the man who started them in the auto business was upset.

“How many times have you made a mistake?” Shoichiro [Toyoda] grilled [former President] Watanabe, who sat silently among stunned audience members, according to a person familiar with the meeting.

Shoichiro scolded the president for being so anxious to boost sales and profits that he’d let Toyota emulate now bankrupt General Motors Corp. and Chrysler LLC. Toyota had become addicted to big, expensive cars and trucks and had forgotten the customers’ need to save money, Shoichiro said, according to the person’s account.

Shoichiro wasn’t just lashing out at Watanabe. He was railing against the threat to everything his family had struggled to create.

There are quotes in the article from everyone under the sun, including friends from the LEI:

“Toyota has been addicted to U.S. profits these last five years,” says John Shook, a University of Michigan management instructor and former Toyota engineer. “They’ve been slow everywhere else, particularly in China, where the growth is. Hyundai could be the big winner.”

And:

“I don’t think anybody sees Akio as a highly original kind of guy, but he’s really earnest,” says James Womack, chairman of the Lean Enterprise Institute in Cambridge, Massachusetts, which trains companies on the automaker’s methods for cutting production costs. “He’s been in the Toyota system all his life. He doesn’t know anything else but to go back to the basics.”

Toyota gets criticized in the article for overexpanding and charging too much for their newer vehicles.

The article, in a more positive light, illustrates the way Toyota is investing in its people during the production and sales downturn rather than just laying off staff.

Dozens of Toyota workers, wearing green or orange vests that signify they’re on temporary assignment, inspect unfinished trucks. These same workers cleaned parks and enjoyed yoga and Pilates on company time when a 15.6 percent sales drop forced Toyota to shut the plant for three months starting in August and then cut a second shift.

Ray Tanguay, executive vice president for manufacturing in North America, sees a silver lining in the downtime. The company is using its kaizen process to build vehicles with fewer workers, aiming for more profit when sales pick up.

“We have to go back to our core values,” he says. “This might well make us stronger.”

Kaizen-sparked improvements are taking root in San Antonio. Production manager Dan Antis says employees studied everything from workplace diversity to how to hold a screwdriver.

When you’re chasing volume, you don’t have time to teach people,” Antis says. “The kaizen we’re capable of doing after the shutdown is endless.”

What do you think about paying employees to do Yoga? My understanding was that they were taking the time for training on production skills and the Toyota Production System? Paying people for Yoga starts to sound like the infamous Jobs Bank from the Detroit Three, don't you think?

There is, however, a nice example in the story about real employee creativity and kaizen:

Standing near the assembly line’s end, team leader William Steubing says he wanted a better way to handle a 20-pound plastic box that carries parts alongside unfinished trucks.

Initially, Steubing’s team attached the box to metal frames holding the trucks. As the Tundras moved along the line, workers reached into the box for headlights and other parts. When they emptied the box, they’d lift it off the carrier and carry it back for refilling.

During the shutdown, workers designed a conveyor to do that job. Now, as a truck moves forward, the conveyor tilts up a corner of the empty box and snaps it off the carrier. The box falls onto the conveyor and rolls back for refilling. The change saves 11 seconds of walking per truck.

Steubing and his co-workers also got training in welding and metal cutting. Then they recycled old conveyors, spending $2,000 compared with $90,000 that Toyota engineers had planned for a motorized conveyor.

I'd say it's better to be spending time on Kaizen instead of yoga... interesting times for Toyota.

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Virginia Mason's CEO on Health Reform

2009-06-23T14:00:00.000-04:00

Dr. Gary Kaplan, the CEO of Virginia Mason Medical Center is now part of an effort called "Health CEOS for Health Reform". He posted a video on YouTube talking about health reform, framing some of it in a "lean" or Toyota Production System perspective.

For more on the "Virginia Mason Production System," click here for a quick overview.

Key points:

Need to stop complaining and take action
The path to better quality and safety is the same as the path to reduced cost
Our system is so full of waste (non-value-added activities), need to systematically reduce and eliminate that waste
Policy makers should think big and get honest about what's possible
Improvement is not coming from a technological arms race

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Saving the Most L.A.M.E Day Ever

2009-06-23T05:00:00.000-04:00

By Andy Wagner:

This summer, I am supervising three interns. The first week one of them asked what "lean six sigma" was about. She had heard about it, and that our company was into it, but didn't really know much about it. Would she get a chance to learn about it this summer?

What an opportunity! Young impressionable minds, ready to learn from a true believer. The challenge is to teach my love of real lean thinking without corrupting them with corporate cynicism and the negativism so pervasive where I work. A previous co-op had described our department as a "train wreck". What impression will we make here? Two of the three engineers are mechanical engineers, and not likely to stay in manufacturing. How will this experience shape their careers and their thoughts on what it is that we do on the economic front line?

My company is well known for it's Six Sigma program, but several years ago it changed the name to Lean Six Sigma because our Six Sigma projects weren't satisfying our customer's needs and they weren't lasting when the black belt sponsors moved on to their next assignment. There is some serious lean work going on in parts of the business, but for the most part lean refers to inventory reduction . It's so far from what I believe lean is that I have a trouble calling it lean, and most people are so negative about the word, that I have trouble calling what I try to do lean.

This week, I experienced the most L.A.M.E. day of my career. I won't go into all the details, but after the interns spent a few hours making us seem leaner than we really are, one of them asked me if we shouldn't be working to make the place look like that all the time.

The heavens opened, the clouds parted. A beam of light came down upon us. I think there were lean angels singing, but I don't remember exactly. "Yes! Exactly!" said I.

We spoke about lean and what it was, that there were many tools and that I could teach them, but that most importantly, lean was a way of solving problems and eliminating waste. We spoke about how it applied to anything from home loans to hospitals.

"I had an idea for the project I've been working on, can I try it?" he asked.

"Yes, of course. You have a goal, you can do anything that you think will work, and if it doesn't try something else."

So here I go, turning another L.A.M.E. day into something special. Wish me luck!

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More Online Criticism of Lean Healthcare

2009-06-22T05:00:00.001-04:00

Park Nicollet CEO to retire

In the new story about CEO David Wessner's retirement, one of the listed accomplishments is their use of Lean methods:

Wessner, the first non-physician CEO at Park Nicollet, also brought Japanese-style lean manufacturing techniques to health care, adopting productivity principles later adopted by a number of other health care organizations. He declined to quantify how much the strategy saved Park Nicollet, saying only it has reaped more than what was invested into it. "It's not a short-term initiative," he said.

It could be that the retirement is tied to recent financial difficulties and layoffs, events that led to some criticism of Lean (as discussed on my blog here).

As often happens with these stories, the newspaper's reader comments section brings out some vitriol from people who might be staff members (or just from the community).

The link to view all comments is here. Part of me hates to give these comments a wider audience, but I think we can try to respond constructively as a Lean community both here and maybe on the newspaper website.

One comment reads:

The idiots who run PN think treating sick people is like making cars - thus the kaizen system - total quality management for medicine - has been implemented. PN has spent millions - to no effect - on this huge boondoggle. Thus PN has implemented a "production" model on doctors, treating patients like cars on an assembly line. Note to PN management: Treating patients is almost NOTHING like making cars. Do cars live and breath, have thoughts and consciousness? No? Then why treat patients like cars? Because the process of medical care has been turned over to MBA morons who don't understand that everything is not a "business."

You're right, working with patients *is* very different than building cars. I'm sure everyone at PN realizes that. You have to look at what Lean is -- it's not a system for "building cars", it's a management and quality improvement system.

So people might say they don't want to be like Toyota. What's wrong with:

Investigating the root causes of problems (looking for systems and processes instead of blaming individuals) and preventing those problems from occurring again?
Making the workplace run more smoothly by eliminating waste, improving processes, and
changing the physical layout of the space?
Making sure that quality is improved (improvements that always lead to productivity improvements as well)
Listening to employees and staff and getting them involved in the improvement process (instead of being told to "check their brains at the door.")

When you rant and rave and say "this isn't about building cars", that misses the point. The four bullet points above can and DO apply to a factory or a hospital.

When Lean is done properly, the hospital employees should be DEMANDING more Lean instead of calling people idiots. So I wonder what the root cause of this person calling PN management "idiots" is? Lack of education about Lean? Are the managers not really living and practicing Lean as a daily mindset? Are the employees not being involved? Or it's probably a side effect of the layoffs and the anxiety created there?

Another interesting reader comment defends Lean but still points a finger of accusation against Park Nicollet:

Kaizen is not an improvement process with limited application to the automobile industry. Those who make such comments only demonstrate their lack of knowledge on the matter and thus demonstrate they are incompetent to comment. PNC is guilty of misguided application of Lean principals and kaizen techniques. My team successfully applies both in the construction industry daily. I watch PNC "fumble the ball" daily in the dysfunction generated in my spouse's workplace.

I have no first hand working experience with Park Nicollet -- in what way are their Lean efforts misguided, I wonder? Is it the focus on "how many pencils we have at the nursing station" as the previous blog post highlighted? Are they running a lot of "kaizen events" without the proper follow up and proper focus on the management system? If so, that's a common dysfunction in the Lean world, the over-reliance on event-driven Lean.

Another reader comment further explained and defended Lean (highlighting is mine).

The Kaizen efforts do NOT treat patient's like cars. The make the work that staff does more efficient so that more time can be spent treating the patient. Without Kaizen at Park Nicollet, nurses would still be WASTING several minutes per hour walking back and forth to poorly placed printers, float receptionists would still be fumbling to find basic paperwork every time they sit down at a new desk, business office staff would be spending/wasting many valuable minutes an hour on hold with insurance companies. Everyone always thinks that because Kaizen was developed by a car company that it can't be applied across the board. MANY MANY MANY companies use it.

The point about printers being in the wrong location rings true because I see it everywhere. One reader asked why you need a million-dollar consultant to figure that out? The answer to that is very complex -- why do people not see systemic waste (maybe someone suboptimized IS/IT costs by having fewer printers)? Or, if they see the waste, why are people powerless to make changes? Or why do they feel powerless? That's the important question, ultimately -- why is there waste and why are things not fixed, not "why are the printers set up badly?"

While I cringe at reading criticism of Lean online, it doesn't do anything to shake my belief (a belief that comes from experience and evidence) in Lean working in healthcare. Does that mean "Lean" always succceeds? Well, no, because people and organizations are imperfect. Changing to a Lean culture is very difficult. I hope these are just bumps in the road for Park Nicollet, a starting point for a better Lean program in the future.

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Another Bad Design Example

2009-06-21T11:39:00.002-04:00

Badly designed pepsi machine, the graphics look like buttons ... on Twitpic

Let's go with a light thought and topic for a Sunday, considering there are sad examples of medical malfeasance and poor management oversight in the news today.

Following up on my blog post from last week about hotel room lighting controls that were so confusing, they required directions, I found this picture in my recent archives. It's a hotel Pepsi machine (from the U.S.) where the front of the machine has these huge rectangular pictures of the products.

Apparently, the big pictures looked like buttons (they did to me). So they added a "Choose Here -->" sign, taking away from the aesthetic appeal of the machine.

I think it's a great lesson in visual controls and design... what's obvious to you as designer is not necessarily going to be obvious to the user. Don't blame the user... I wonder if this flaw or weakness in the design was discovered early in the design process (and they just decided to run with it) or if it was discovered AFTER the machine was out in the market?

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Learn to Play Before Picking Up a Sax

2009-06-20T05:00:00.000-04:00

by Jamie Flinchbaugh, co-author, The Hitchhiker's Guide to Lean

A3 thinking, A3 problem solving, A3 report writing - whatever you might call it is growing popular in the same way that value stream mapping did many years ago. But just like value stream mapping, just using the tool solves nothing. You still need to get the right thinking in place to make any of the tools, methods or skills effective.

This month's Leading Lean column for ASSEMBLY Magazine begins a series of column on the proper use of A3. You can find it here. My favorite line, just for the fun of it, is "it won’t magically turn you into a lean thinker any more than picking up a paintbrush or a sax will magically turn you into another Rembrandt or John Coltrane." In the following months I will cover more specific aspects of the methodology.

Like any tool, I encourage you to think about why you are using it before you just start using it.

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Lean at Long Beach Memorial Medical Center

2009-06-19T13:00:00.000-04:00

Tamra Kaplan Named COO of Long Beach Memorial Medical Center - Yahoo! Finance

There aren't too many details in this story, but Lean *has* led to some good results at Long Beach Memorial Medical Center in CA... benefits to the hospital and a promotion for the former head of the Lean program to Chief Operating Officer. Congrats.

Most recently, Kaplan served as Executive Director of the MC*21 (MemorialCare for the 21st Century) Management System, a system-wide initiative to take patient care to the next level by implementing new technologies and methods, such as electronic medical records, across all medical centers.
In this position, Kaplan facilitated master planning through the MC*21 Management System Oversight Committee, oversaw the development and integration of all system-wide MC*21 Management System activities, and led the daily operations of the Resource Office, including Lean Fellow development. Kaplan incorporated the principles of the Toyota Production System (LEAN), a management philosophy that emphasizes creating a sense of purpose to transform business and cultures. Under Kaplan’s leadership, the pilot year of MC*21 resulted in an estimated $2.1 million annualized return, and fiscal year 2009 will yield a three-year return of $15.3 million.

Their goals -- not just saving money, as Kaplan says:

“I look forward to applying my knowledge of hospital operations to Long Beach Memorial, as I work with the leadership team and the rest of the staff to uphold our standard of enhancing patient safety, service and satisfaction.”

Glad to see another Lean success story.

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LeanBlog Podcast #68 - Ben Harrison, Lean from CEO Perspective

2009-06-19T05:00:00.000-04:00

Podcast #68 is a discussion with Benjamin G. Harrison, President & CEO of Kaysun, a privately-held manufacturer that, for over 60 years, has designed and manufactured complex, high-tolerance plastic injection molded products and assemblies. In his role as CEO, Ben is the champion for Kaysun's lean strategy and efforts and we discuss his support for lean in this episode. Kaysun was just named Lean Initiative and Plastics Supplier of the Year by Rockwell Collins, so congratulations to them for that award.

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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AAC File

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Article about Lean Hospitals in my Local Paper

2009-06-18T17:18:00.000-04:00

Doctors praise consultant’s book | News for Keller, Texas | The Keller Citizen

This story isn't important enough to be a main blog post for the morning, but I'll slip it in here. A reporter did a very nice job about learning about Lean to write this article about my book and the Shingo Prize.

The first story, as printed in my local paper in suburban Dallas, is embarrassingly about me, although it mentions some great work done by the team at Children's Medical Center in Dallas.

The reporter wrote a longer version of the article which is more about lean healthcare, in general. She's hoping to get it published in a larger venue. Unlike some reporters who get the facts wrong on lean, Sarah really spent a lot of time with me to understand the issues and the promise of lean. She even went to a "gemba" at a local hospital to see things first hand, which I appreciate.

So anyway, I thought I'd share the piece with my friends here on the blog.

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Right Words, Right Time @ the Hospital

2009-06-18T05:00:00.001-04:00

Lean Leap to Health Care #11 (click for Part #10)
by Scott McDuffee

"Have a nice day."

When my daughters were younger, they would cheerfully wave at everyone as we drove around with the top down on my Jeep Wrangler. It didn't take long for them to notice a pattern - some people smiled and waved back while others ignored them or frowned. After a while, this turned into sort of a game where the girls classified those they tried to engage at a friendliness level of either "sweet" or "sour".

At the hospital, greeting around a hundred people a day with a smile, I receive similar sweet and sour responses. As I sit at the information desk penning this post between "good morning"s and "how are you?"s, I wonder if I am saying the right things. If I ask - How are you doing? it may trigger some angst based on the trauma they or a loved one is experiencing. If I respond in turn that I am DOING GREAT! It could also be perceived as insensitive.

I may be over-analyzing this (I've been accused of this behavior more than once.) because most greetings are little more than formalities and if someone stops to ponder the question - How am I really doing? - it is rare. I guess in this volunteer role, it may be most important that I smile and be quick to offer help and support.

Although my contact is part of the total patient experience, what about the words chosen and shared with patients in direct care? As the surgical waiting area liaison, which is my second volunteer role, I hear a large variety of good-byes at discharge. Everything from Have a Nice Day (which seems sweet) to just Okay, Bye (which seems a bit sour). A few are discharged with some final instructions, words of encouragement, empathetic questions, and a suggestion to call if there are any questions.

When I asked about the variety, a hospital employee shrugged and responded with, "No two people do things the same way around here." But there should be right words at the right time, I thought - not necessarily cloned comments but at least some standardization.

One of the many major differences between my previous enterprise endeavors and hospitals is - the customer is right there. Feedback is ready for the asking. Also knowing the customer total experience must have more to it than just sweet and sour, there must be best practices from those willing to see the patient's perspective. I looked again to the book Hardwiring Excellence, remembering a section called Key Words at Key Times.

"In building a culture on service and operational excellence, it is critical to let the patient, staff, and physician know why we do things. They want to know what is going on. They want us to connect the dots. We do this by using Key Words at Key Times.
For example, if you have curtains between beds and you walk into the room and pull the curtains closed without saying anything, what's the patient going to think about that? Anything he wants to:
He might think you're rude.

He might think you are trying to hide something.
Every day, thousands of curtains get moved. How many times is there an explanation to go along with this action? Here's what we recommend. When you close the curtains, say:
"Mrs. Medley, we want to make sure you have privacy here at our hospital. Let me close these curtains for you."
A patient will often associate closed curtains with a hospital that cares. That's an example of Key Words at Key Times. However, you can also test key words with patients by asking permission, "Ms. Medley, would you like me to close the curtains?" (Note: Using key words also give patients an opportunity to respond and share their preferences and needs with you. If you offer to close a door for privacy for instance, one patient may express gratitude while another may say he feels lonely when he hears friendly voices in the hallway.)"

Relevant to this, I must confess my one phobia. Needles. You may recall in Hospital Badge the delays during the process (or lack of process) to become a hospital volunteer. Despite the pain of waiting, the experience with the nurse was exceptional. She spoke calmly; shared what was happening and why. Shared honestly I would experience a small pinch sensation for a short time. I was so relaxed by her demeanor, her empathy, and her reassurance; it was done before I knew it. I said out loud, "Are we done already?"

I thanked her profusely for an experience which is normally traumatic for me.

Quint Studer, in Hardwiring Excellence describes an A-I-D-E-T framework to remember the right things to say at the right times - as the nurse illustrated for me.

"A stands for "Acknowledge the patient." You may want to acknowledge them by their last name if possible.
I is for "Introduce." Introduce yourself, your skill set, your professional certification, and your training: "Hello, Mr. Clark. My name is Jackie and I'm a medical technologist. I will be taking your X-ray today. I have been a medical technologist for 10 years. In fact, I've done this procedure hundreds of times and I go back for additional training each year. I also have certification from the American Registry of Radiologic Technologists."
D is for "Duration." Describe the test: how long it's going to take; how long they're going to be there; and how long they'll have to wait on the results.
E stands for "Explanation." Explain the tests, the pain involved (be very honest), and what happens next. Explain you are going to be looking at their wristband and why. Connect key words with patient safety and excellent care.
T stands for "Thank you." "Thank you for choosing our hospital."

Sweet is only a part of it. Using this type of framework for standardizing the right words at the right times at the hospital can make all the difference. Patients may not remember the specific procedures of their care but they definitely will remember the caring of their care.

Scott McDuffee is an experienced Lean professional who is currently searching for a new career opportunity. He is based in Mansfield, TX.

More resources @ the lean community @ Move to Healthcare - http://www.movetohealthcare.ning.com

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It Might Be Bad Design If Instructions Are Required...

2009-06-17T05:00:00.000-04:00

... or if it's too easy to make mistakes.

One of my favorite books of all time is Donald Norman's The Design of Everyday Things. Not strictly a Lean book... even if you're not a product designer, the book teaches great lessons about how controls should be intuitive and visual. I guess the one lesson is to "not blame" the user and, as Lean people, we should focus on the design of the system, not the individual (often easier said than done, I'll admit).

When I was in the Netherlands (more substantive blogging to come on this) last week, my one hotel had some pretty confusing light switches and I can't blame a language barrier. One of Donald Norman's rules of thumb is that any controls that require instructions are too complicated...

The light switch inside the door was like this:

The button labels just barely map to the buttons themselves. And on the headboard was worse:

The button with the picture of the bed was the "go to sleep and turn off all lights" button, it turned out. Very confusing.

Sure enough, there was a full page sheet of laminated instructions on the desk for operating the lights:

Many pieces of equipment in factories (or hospitals) have confusing controls. Maybe our organizations should be more demanding and NOT buy equipment that's not designed to be intuitive.

A book I'm in the middle of right now (and will review) is Why We Make Mistakes: How We Look Without Seeing, Forget Things in Seconds, and Are All Pretty Sure We Are Way Above Average. In the book, one example of systemic error and unintuitive controls comes from the hospital world. The field of anesthesiology got much safer when, among other improvements, hospitals started standardizing the equipment.

From the book:

For a long time, there were two major makes of the machines that delivered the anesthesia—essentially Ford and GM, if you want to think of it that way. The models were similar except for one key difference: on the Ford, the valve controlling the anesthesia turned clockwise; on the GM, it turned counterclockwise. Sometimes, anesthesiologists became confused about which model they were working on. They turned the valve the wrong way. The cure was to standardize the machines, so that they all turned the same way.

The field had to move away from blame... they had to look for systemic improvement, as the anesthesiologists:

...began using checklists so they wouldn’t forget to do important things. They also engaged in some attitude adjustment. They began discouraging the idea of doctor as know-it-all, and encouraged nurses and others to speak up if they saw someone—especially the anesthesiologist—do something wrong. In error-speak, this is known as “flattening the authority gradient,” and it has been shown to be an effective way to reduce errors. In all, these changes required that anesthesiologists acknowledge their own limitations and then do what few of us have the chance to do: they began redesigning their work environments to fit those limitations....

...results have been profound. Over the past two decades, patient deaths due to anesthesia have declined more than forty-fold, to one death per 200,000 to 300,000 cases from one for every 5,000 cases. Their malpractice premiums have also declined—while those of other types of physicians have continued to rise.

Anyway, not a strictly "lean" topic, I guess, but interesting to me...

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Alan Mulally's Mind Map Doesn't Include Lean?

2009-06-16T05:00:00.001-04:00

Can Alan Mulally save Ford? - May. 11, 2009

Interesting story last month about Ford and CEO Alan Mulally. He's a Toyota admirer and Lean devotee' from his time at Boeing. FORTUNE magazine was allowed to share a diagram that Mulally drew up before the interviews. Click on it for a larger view (I couldn't find it online, so I scanned it)... interesting that Lean/Ford Production System isn't there in the company strategy.

The piece by Alex Taylor III is very interesting -- he might be the best auto industry writer around.

I've heard a similar story about Mulally being new to the Ford culture and having to create a climate of openness -- a "no problems is a problem" culture as the Toyota expression goes:

Mulally instituted color coding for reports: green for good, yellow for caution, red for problems. Managers coded their operations green at the first couple of meetings to show how well they were doing, but Mulally called them on it. "You guys, you know we lost a few billion dollars last year," he told the group. "Is there anything that's not going well?" After that the process loosened up. Americas boss Mark Fields went first. He admitted that the Ford Edge, due to arrive at dealers, had some technical problems with the rear lift gate and wasn't ready for the start of production. "The whole place was deathly silent," says Mulally. "Then I clapped, and I said, 'Mark, I really appreciate that clear visibility.' And the next week the entire set of charts were all rainbows."

Mulally appreciated the honesty, rather than wanting Fields to hide the truth. Seems like a good start.

The one thing that rubs me about wrong is the "me me me" orientation that Mulally seemed to have in preparation for the interview. He prepared a one-page guide, for the writer's benefit, to his own leadership style and characteristics? Mulally's here to save the company? (this all comes out in the FORTUNE piece).

Does that seem a bit self-absorbed to be a truly effective leader?

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Reminders: Upcoming Lean Healthcare Events

2009-06-15T18:59:00.002-04:00

A reminder about two upcoming events for the Lean Healthcare community:

MIT Professional Education - Short Programs: MIT will be holding three short courses on campus this July focused on various lean concepts geared towards busy professionals (Lean Academy® Course, Lean Engineering Seminar, Lean Healthcare Academy). To learn more visit them on the web at http://shortprograms.mit.edu/lean. The Lean Healthcare Academy is July 16-18 and can be found at this link. I will be giving a talk on Saturday the 18th.

-------------------

Lean Enterprise Academy Events; Lean Healthcare Transformation Summit 2009

I'm fortunate that I'll be attending this July 10th summit in London, run by Dan Jones and the UK-based Lean Enterprise Academy. If you're attending, be sure to let me know so we can meet up.

Presenters include John Toussaint, of ThedaCare, David Fillingham, CEO of the Bolton NHS Hospital, and a number of healthcare practitioners from the UK and their National Health Service.

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Medical Mistake in In-Vitro Fertilization: Blaming Process vs. People

2009-06-15T05:00:00.003-04:00

IVF baby given to wrong woman - as couple's last embryo was aborted | Mail Online

This was front-page news in one of the UK papers that I read coming back from The Netherlands on Sunday. Coincidentally, I briefly saw an in-vitro fertilization lab in The Netherlands last week (look for upcoming blog posts about lean healthcare in that country). Part of our discussion was around process error proofing and the need to avoid giving the wrong embryo to the wrong couple.

So, the timing was interesting to see that this exact type of error occurred in England. A couple's last embryo had been given to the wrong couple, ruining their chances at a sibling to their only child (born years ago after their initial IVF efforts).

Early in the article, my Lean eyes started "seeing" (imagining) the opportunity for Lean thinking in a process like this (emphasis mine):

The error was made by an overworked trainee doctor who failed to carry out strict checks that require all fertility procedures to be witnessed and verified.

Uh oh, I know what happens when people are "overworked" -- they are under time pressure and they end up often cutting corners... and this is when errors occur. Whose fault is it that the doctor was overworked? Pointing out that they are a "trainee" -- whose responsibility is it to make sure people are being trained properly? The "Training Within Industry" methodology points out that it is the instructor's responsibility and I'll add that Dr. Deming would have said that top leadership is ultimately responsible for all of the above questions.

Whose responsibility is it to make sure standardized work is being followed? Again, that's management's job. Especially with a trainee involved, shouldn't management be paying closer attention.... especially if they are overworked? This seems like a disaster waiting to happen... and the waiting is over.

I wonder how long these conditions were in place before an error actually occurred (or was actually detected)?

This scenario should emphasize the importance of focusing on PROCESS and not just waiting for a bad RESULT.

The story describes an investigation by an oversight group:

An urgent HFEA investigation into the incident found that vital safety checks were not being carried out at the clinic and that overworked staff were being placed under too much pressure to clear a backlog of cases.

And:

But there are now fresh questions over the HFEA’s effectiveness as a watchdog as it had previously been told of two other ‘near-misses’ at the clinic - also understood to involve failures in ensuring procedures were properly witnessed by other staff - just months before the latest incident.

So this had been going on for sometime. I'd expect it's rare to be burned by the one and only time somebody didn't follow procedures. You could question the role of the watchdog, but we should also question the role of local management. I guess you need a watchdog because they weren't managing the process and quality effectively...

A few more details emerged if you read the story, including:

The embryo was also taken from an incubator that was carrying embryos for other patients, which goes against good-practice guidelines because of the possibility of making an error.

The process was very reliant on having a second person making double checks, which didn't happen in this case. But, the inspection and double checks would be less necessary if you had an environment where people couldn't disregard the standard process of not keeping embryos from multiple patients in the same location.

So we had someone not following the standard process and management wasn't detecting that process problem. They were relying on inspections that didn't happen. That should also illustrate the problem with relying on double checks. If double checks are good, wouldn't triple checks or quadruple checks be better? Maybe not, even if they actually occurred.. (oops, the triple checks were also skipped, or they would be if they were that pressed for time).

It is understood that staff at the clinic - based in the University Hospital of Wales, Cardiff - had been under enormous pressure because of an increased workload as the clinic accepted a higher volume of cases.

It sounds like they accepted more workload and didn't properly analyze staffing levels? If work is very manual, adding work volume means you would likely have to add staff (very generally speaking).

The one and only somewhat bright spot is that the organization is not necessarily blaming or punishing the "trainee" (who probably already feels bad enough):

The clinic has not named the trainee and will not confirm whether she is still working for the clinic or whether disciplinary action was taken.
It is understood that the clinic has a ‘no-blame’ policy and that the HFEA highlighted systemic failings rather than individual human error for the mistake.

It certainly sounds systemic to me. Will the clinic learn? Will leaders be held responsible? If it's the "system's" fault, the people responsible for the design and management of the system should be held accountable, right?

However, the HFEA has decided the clinic has made improvements. IVF Wales will not face any disciplinary action or restrictions on its licence.

I'd be curious to hear what those "improvements" are...

Click here for related posts and errors on pathology mixups... similar thinking and scenarios. This is a general healthcare problem, not just for IVF labs.

As always, the reader comments are interesting, including:

"It is understood that the clinic has a 'no-blame' policy" that's the problem with the Public Sector right there. if no one is to blame for msitakes then who cares if they are made or not?

"No-blame", as practiced by many hospitals, probably just doesn't sound right to the general public. Maybe we need a different term like "system blame" because what they're really not blaming is the individual. To the commenter, I'd ask if blaming and even punishing the trainee (and doing nothing else) would really help anything?

Another commenter gets it half correct:

What has worried me is the sentence "...the clinic has a 'no-blame' policy". The staff; medical, managerial and administrative will never learn from their mistakes if there is an attitude of "mistakes happen" throughout the clinic. The managers are to blame for not employing sufficient staff, and the traineee is to blame for not following the safeguard procedures. Admit that and they are halfway to ensuring that the same mistake will not recur.

Funny that all of these comments about mistakes have a spelling error or two. Yes, the managers are to blame if they didn't have enough staff, but management also has a role in making sure people follow procedures and standardized work.

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Cost Crisis for the NHS? Quality Improvement Can Help?

2009-06-13T04:00:00.001-04:00

Britain's health service "facing funding crisis" | Reuters:

Watching the BBC morning news the other day, I took an interest in the discussion of the cash crunch with the National Health Service and their "free" (free at the point of care) healthcare in England:

"The Confederation said funding shortages could lead to 'across the board cuts', longer patient waiting lists, falling standards, and staff and patient dissatisfaction.

It added a cap on the budget for new drugs may have to be considered, and suggested looking at a 'total resource ceiling' for the National Institute for Health and Clinical Excellence, which assesses the cost-effectiveness of new treatments.

'With little or no cash increase from 2011/12 the NHS has to prepare itself for real terms reductions in what it can afford to do,' NHS Confederation Chief Executive Steve Barnett said in a statement accompanying the report."

Very sad... typical thinking of "do less" as a way to save money.

The BBC "Breakfast" program had the new NHS chief on for an interview. The host asked basically, "So, you're going to have to fire people and deny drugs to people to save money?"

The NHS head said (I'm paraphrasing) that, no, QUALITY improvement and their continued efforts in those areas were the best way to reduce costs.

Pollyanna or a pipe dream?

The NHS is actively using Lean methods. We know, with Lean, that better quality and lower cost go hand in hand. We know there is way too much waste (and extra cost) in the delivery of healthcare... he didn't mention "Lean" or the programs like "Releasing Time to Care", but his message was still a good one. But do you think it's a realistic message for the UK? For the US?

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F.S. Production System

2009-06-12T05:00:00.001-04:00

By Scott McDuffee:

The recent discussion of beignets at the Cafe Du Monde and breakfast sandwiches at Starbucks helped inspire the following. In concert with recent suggestions for using common language to get across lean principles in palatable ways, here is an analogy which may be useful for some audiences - The Fruit Salad Production System!

Let's say our finished goods consist of make-to-order fruit salads. We would need to keep inventory and processes stream-lined so grapes wouldn't wilt, bananas wouldn't brown, and pineapples would be crisp.

If this were the case, how might we manage the supplier partnerships and proximity? What would inventory turn-over look like assuming we wanted everything to be fresh, not frozen? How might we think about vertical integration v. outsourcing of grape de-stemming? How might our inventory be delivered, moved, or stored as to not let it age or bruise through excess handling?

How would the customers’ feedback and what they value become a part of everyone's focus and driving philosophy? What would the process be for ensuring the taste is just how our customers like it - not just by tasting the final fruit salad result but for each ingredient before and during processing and combining? How might we optimize our product offering to please the customer?

How would we adjust to changing demand from holiday peaks and the picnic season - because overproduction would be an immediate disaster due to spoiling? How could we smooth out both mix and volume to reduce variation for both our internal processes and reduce chaotic surges on our grape, banana, pineapple, and jello suppliers? Could we truly have a system where if the mixing station had a delay, the upstream pulling and chopping processes would halt?

What would be the process for proactively keeping blades sharp and mixers operating with zero down-time? How could mistakes and near misses be embraced to drive Safety corrective actions? How would we make it really difficult to have a Safety incident at the workstation?

How could everyone from the janitor to the president have the understanding their job is not only to run-the-biz but also to improve-the-biz? How could we ensure the leaders AND operators will follow standardized yet continually improving methods? How could we create a disciplined system where people are held accountable by processes so they don’t need the boss to be the bad guy or gal? How could we get support functions to truly support by observing the process, talking to the people, and routinely getting excited about problems?

How could we instantly be able to see if the process was healthy? How could we rapidly escalate process issues and respond quickly to embrace problems before they reach the next step and to solve them while the pain and information is still fresh? How could the right metrics and visual controls be real-time linked to the processes to inspire constant improvements and problem solving? How would leaders respond if someone brought up a problem?

What type of processes might be in place to help banana cutters and jello stirrers share the best way to do things and engage in thinking about the whole system - as if from the perspective of the banana - with ideas valued and implemented? How could successes be shared through the organization so the Flintstones know what the Jetsons are doing?

How could customers see us as being very easy to do business with through the simplicity of ordering and specifying? How could we make it easy for customers to pay us for fruit salads speeding up the time between when the customer has a need to when we get paid? How would we ensure our customers are so excited about our product they would sell to others for us? How could we partner so well with our customers they help us define our next offering?

How could we be the exemplary fruit salad producer in the world being benchmarked by other industries wanting to use FSPS (Fruit Salad Production System)?

What questions are still missing for the FSPS?

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Lean Lab Story

2009-06-11T05:00:00.001-04:00

AHRQ Innovations Exchange | Hospital Laboratory Redesigns Space, Standardizes Staff Roles and Collection/Processing Systems, Leading to Enhanced Efficiency and Productivity

Short post today as I am having Internet problems during a visit to learn about lean healthcare efforts in the Netherlands. More about that soon.

For now, check out the linked case study from a hospital lab published by the AHRQ. There are many nice case studies if you search the site.

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Lean Leap to Healthcare: Hospital Sabbatical

2009-06-10T05:00:00.012-04:00

Lean Leap to Health Care #10 (click for Part #9)

by Scott McDuffee

In my first Leap to Health Care blog, I mentioned using a two-pronged industry approach of Health Care and Defense - patch 'em up and blow 'em up. In Networking with Buffalo and Doctors, I mentioned blasting e-mails in response to job alerts.

It is said, only 15% of jobs are found via this explicit avenue. Most landings come from networking, connections, and seeking - a "rifle approach" vs. the "shot gun approach" of the published job market.

But given a sample size of two - my job search associate Steve and me, it looks like we are defying the odds. Steve found a job via Internet job postings which he started this week. He will be relocating his young (as in easier to move than than my teenagers) once his house sells. But for now, he will commute the two hours and stay in a furnished apartment.

Despite my two industry approach, it appears a third option is opening for me (via an Internet job board like Steve) in the manufacturing of building materials. It seems the most interest I am getting is for a role is the third down on the totem pole of 1) Health Care Lean, 2) Manufacturing Lean, and 3) Manufacturing Manager.

This is a dilemma. Since I had a career shake up, I have really been focusing on reinventing myself and trying to find an ideal fit. The trick they say is to make your vocation a vacation by finding your "natural" making you jazzed up to go to work each day. The more I learn, I am convinced continuous improvement in Health Care will be my legacy. My personal mission statement simplified has been to help people do things better. I am already moving toward a mission to help people do things better to help other people .

But what if my interview tomorrow (with 8 people in 2 states) goes well? I have every indication it will. My background, energy, accomplishments, and leadership will take any manufacturer to a better place. I am confident of this - which will certainly come across in an interview. I just hope hope I can do some verbal ju jitsu if they ask my about my ideal job.

During this multi-step interview process, I have already been given an indication my qualifications would set me up for 2 or 3 positions up the chain of command. This company has only begun any kind of improvement and employee involvement so it could be challenging and exciting.

Although I believe Health Care is my "natural" or my calling, decision-makers have not seen it as my natural often because I lack a clinical background. I just heard it again this week. Through linkedin.com - a professional networking tool we should all be utilizing (employed or not), my associate Mike introduced me to the Director of HR at a major Health Care system I have been targeting. The positions I am interested in had lean and process improvement in their titles. One was a director level and the other was a specialist.

The HR Director's first question to Mike was, "Does Scott have any clinical experience?" When Mike said no, the Director said, "No thanks." He went on to explain there were plenty of people out there with both clinical and lean backgrounds.

Really? I thought. Are there really an abundance of people which have built grass-roots lean efforts, engaged the executive team as champions, driven dramatic technical as well as cultural change, and sustained the gains as a leader of the operations through visual controls, leader standard work, daily accountability, and discipline? Have they worked through strategic planning and budget processes to ensure continuous improvement and lean become the organizing philosophy of the enterprise?

Are there a lot of people who have led hundreds of formal improvement events as well as engaged organic employee improvements - running into obstacles and adjusting approaches to connect to cultures and sub-cultures with multiple businesses and functions? Are there a lot of people who have experienced the challenge and reward of influencing lean nay-sayers to become lean evangelists? For the benefit of Health Care, I hope the HR Director is right.

The manager of volunteering is on standby for my potential hospital sabbatical. It would be sad to turn in my hospital badge (after waiting so long for it). Despite fighting boredom at times, volunteering earned me what I was looking for - information and an affirmation Health Care is right for me. I would also miss seeing Grown Folks in Slippers and Pajamas (Crocs and Scrubs) especially after coming from an environment of steel toes and safety glasses.

After my rude awakening this spring, I am not so naive to think I will spend the next 20 years at my next company. The world has changed in the past two decades. It may be helpful, if I do land in manufacturing, to think of it as a bridge job. Don't get me wrong, I only know one way to work which is to put my heart, head, and hands into what I am doing. But, I don't want to have all my eggs in one basket ever again.

If I refocus on manufacturing, my blogging would probably go on sabbatical too at least in this form. I will continue to network, research, and participate in leading the kaizens which I have starting to get requests to do - mostly on the east coast.

But wait, I just received an e-mail from a hospital administrator which I have been networking with from a premier hospital in Dallas. I had offered to do a guest gemba for his staff who is studying Creating a Lean Culture. Additionally, I offered to be a thought partner to help brainstorm and strategize for disseminating lean beyond the model built in one part of the hospital.

The e-mail says he would like to set up time for us to meet with a prominent VP with a continuous improvement and lean mindset. Hmm, they are expanding their lean efforts. It would be an amazing place to work.

Coach Mike's hospital also called wanting me to interview with the director of the training and development department next week.

Maybe there is still hope for me in Health Care after all.

"Scott McDuffee is an experienced Lean professional who is currently searching for a new career opportunity. He is based in Mansfield, TX.

More resources @ the lean community @ Move to Healthcare - http://www.movetohealthcare.ning.com

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Formal Announcement of LEI/ThedaCare Lean Healthcare Network

2009-06-09T15:13:00.002-04:00

Thought I'd share this here on the blog even though many of you might have gotten an email from Helen Zak at the LEI about this:

Dear Mark,

No doubt you've heard and read a lot about the debate in Washington D.C. over healthcare reform.

Like me, you're probably concerned about the lack of discussion about how to take waste out of healthcare delivery by applying lean principles before any of the proposed solutions are enacted.

So, the Lean Enterprise Institute and the ThedaCare Center for Healthcare Value have formed a nonprofit partnership to make sure lean thinking is part of healthcare's future.

More importantly, we will bring together leaders from business, healthcare, and government, not to just talk --- but to do -- to take out waste from processes that actually deliver healthcare. (More about this in the very near future.)

For now, I thought I should introduce the partnership to you by sharing our statement of values, which you can download here or read below this letter.

I also want to introduce -- to those who don't already know him -- Mark Graban. Mark writes the popular Lean Blog and has years of experience implementing lean principles in healthcare. He also is the author of Lean Hospitals which recently won a Shingo Research Prize. Mark has just joined LEI as a Senior Fellow to help us expand our healthcare offerings.

To learn more about the partnership and how you can get involved, visit our web site at www.HealthcareValueLeaders.org

And please feel free to forward this message to colleagues and leaders in business and healthcare who should know about this new partnership and the resources we are developing to give healthcare a boost up in making its lean leap.

Sincerely,
Helen

Helen Zak
Chief Operating Officer
Lean Enterprise Institute, Inc

The Lean Enterprise Institute (LEI) and the ThedaCare Center for Healthcare Value have nearly 20 years combined experience in leading the development and implementation of lean thinking. We have now formed a partnership to fundamentally improve healthcare delivery by systematically identifying and eliminating waste while engaging all employees and physicians in efforts that improve quality, cost, safety, and morale.

We are partnering because we believe proposed solutions to the country’s healthcare problems, such as electronic health records and expanded insurance coverage, miss the underlying problem -- healthcare's systemic waste and errors, which drive down quality and drive up costs, producing:

100,000 unnecessary patient deaths annually
15,000,000 unnecessary patient injuries annually
100,000,000 hospital medication errors annually
Escalating costs that now stand at 16.2% of GDP, 50% higher than the next highest country

We believe the solution is the application of lean thinking to all of the processes delivering care in hospital rooms, clinics, operating rooms, pharmacies, emergency rooms, and outpatient centers. Unless we eliminate the waste and errors, proposed reforms will only be different ways to pay for and perpetuate a broken system.

What We Will Do
We will engage healthcare professionals in learning how to cut costs while improving quality by implementing lean thinking:

Educate healthcare professionals in lean thinking
Sponsor an annual conference for networking and sharing best practices and results
Provide resources through our web site at www.HealthcareValueLeaders.org
Facilitate a learning network of committed healthcare organizations

The principles and tools of lean thinking, applied successfully for decades by manufacturers, dramatically improved quality, cost, safety, morale, and delivery by systematically identifying and eliminating waste. Manufacturers that have diligently and thoroughly applied lean thinking have reaped steady productivity gains with falling defects while improving the customer and employee experiences.

Compared to traditional mass producers, lean organizations typically require half the human effort, manufacturing space, and capital investment to produce a given amount of products, half the engineering hours to develop a new product in half the time, while making a wider variety of products profitably at lower volumes with many fewer defects.

We ask you to imagine the results that similar improvements could bring in healthcare.

Already, the adaptation of lean methods in healthcare by pioneers such as ThedaCare, a four-hospital system in Appleton, WI, has proven to be remarkably successful and sustainable. ThedaCare began its continuous improvement journey in 2003 based on the Toyota Production System, the original lean system. Since 2006 ThedaCare has saved more than $27 million from productivity improvements, permitting it to treat more patients without laying off any of its 5,500 employees.

Together, our partnership creates a unique and powerful team that is well-positioned to leverage the latest lean knowledge. LEI brings 12 years of expertise in developing resources for companies on their lean journeys, while the Center brings six years of specific healthcare experience in creating a cultural transformation around lean thinking.

About the ThedaCare Center for Healthcare Value
Created in 2008 by ThedaCare President/CEO Emeritus John Toussaint, MD, the ThedaCare Center for Healthcare Value is working to close the gap between value creation and marketplace reward. Its goal is to create a healthcare marketplace that rewards providers for delivering value measured in terms of optimized quality and cost for patients. The Center targets these issues by documenting innovative processes that reduce waste by transforming healthcare's current culture into one focused on continuous improvement. Dr. Toussaint served as president and chief executive officer of ThedaCare, Inc. from March 2000 until April 2008, and launched ThedaCare's lean transformation in 2003. For more information, visit the Center at http://www.createhealthcarevalue.com/

About the Lean Enterprise Institute
The Lean Enterprise Institute, Inc., was founded in 1997 as a nonprofit research, education, publishing, and conferencing company with a mission to advance lean thinking around the world. We teach courses, hold management seminars, write and publish books and workbooks, and organize public and private conferences. We use the surplus revenues from these activities to conduct research projects and to support other lean initiatives such as the Lean Education Academic Network and the Lean Global Network. LEI's contribution to the healthcare partnership is being led by Chief Operating Officer Helen Zak. For more information visit LEI at http://www.lean.org.

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Doofus and Leanie Cartoon #3

2009-06-09T05:00:00.000-04:00

Here's the 3rd in the "Doofus and Leanie" series, obviously inspired by recent discussions about the failures of "just in time" inventory strategies.

Cartoons can be accessed via www.doofusandleanie.com, which forwards to its own blog with its own RSS feed if you want to follow them specifically. As always, click for a larger view.

Text by Mark Graban, Artwork by Ed Butler:
HELL BOUND www.hellboundcomics.com
ILLUSTRATION ww.edbutlerillustration.wordpress.com

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Virginia Mason and Lean Healthcare on the CBS Evening News

2009-06-08T14:00:00.003-04:00

A Carmaker As A Model For A Hospital? - CBS News

Short blog post here, just to get this out there... Virginia Mason and their use of Lean and TPS was featured on the CBS Evening News on Saturday. This is huge, I think, for the lean healthcare movement to have positive mention in a major news venue, video below:

The piece seemed to paint Lean in a very positive light, exploring some of the mindset and solutions after succinctly summing up the problem:

"This is one of the reasons health care has become unaffordable in the United States is that we are wasting time and we're wasting valuable medical assets," said Dr. Robert Mecklenburg.

The debate about fixing healthcare can't only be about who pays for what and how to pay people less. We need to reduce the true waste and cost in providing care, not just play financial games or get to the point where people are denied care that's truly needed (but part of the problem is deciding who decides what's "needed" or not).

The CEO, Gary Kaplan, summed it up:

"Kaplan takes staff to Toyota's factories in Japan every year and practices what the car maker preaches. Just as the automaker's executives spend part of each day on the factory floor, Kaplan tours the hospital daily looking for problems and solutions. Everyone is encouraged to look for changes to make work more efficient. Nurses developed ways to spend most of their time with patients instead of at the nursing station. "

It's an interesting point for debate: do people really need to be dragged to Japan, at this point, to really see and understand lean? That's a big expense.

But look at how Kaplan visits "the gemba" (as we say in the Lean world) to see problems first hand and to get EVERYONE engaged in finding solutions. Freeing up more time for patient care is good for everyone, as well. The video, if you watched, points out that VMMC has saved $11 Million, a point not in the web text, for some reason. Keep in mind, this isn't just cost savings... quality and care has improved, as well, here and at so many other "lean hospitals."

I'll probably review more of the reader comments on the CBS site, I encourage you to check them out. It's interesting to see the range of reactions ranging from "way to go!" to a somewhat misguided "why would you listen to a company (Toyota) that lost $8 Billion last year?"

So, here, be sure to comment not just on the piece and the CBS video, but on the CBS reader comments as well.

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Book Review - The Myth of Multitasking

2009-06-08T05:00:00.000-04:00

The Myth of Multitasking - Dave Crenshaw

I am long overdue on a review of this book, which I feel bad about because I really enjoyed it. Maybe I didn't get to it because I was too busy multitasking...

First off, this is written as a business novel. Lately, I have been really weary about business novels. For one, I'm not a novel reader and, since The Goal, the only business novels I've liked and gotten through are SHORT ones, including All I Need to Know About Manufacturing I Learned in Joe's Garage: World Class Manufacturing Made Simple and The Ice Cream Maker: An Inspiring Tale About Making Quality The Key Ingredient in Everything You Do
(my review here).

This book, written by business coach Dave Crenshaw, tackles the idea of "multitasking" -- that we can do two things at once. If you think about multitasking from a Lean perspective, you might think about the practices of Standardized Work. In a factory, standardized work assumes a person can really only do one thing at a time. At most, you might reach for a part with your left hand while simultaneously reaching for a tool with your right. But, this is a relatively simple task that, in a repetitive manufacturing environment, can be done without thinking and through a lot of muscle memory.

In professional settings, we often trick ourselves into thinking we can multitask. While on conference calls, people play Minesweeper or surf the web. This works, except for when you realize you haven't been listening or someone calls on you and you can't answer -- it's embarrassing. Nurses and other medical professionals are often the queens (and kings) of multitasking, or so they think. Can we really do TWO things at once? Can a medical secretary really be entering data into the computer while taking a phone call?

The NY Times recently had an essay, written by a doctor, who wrote that she stuck herself with a needle from a Hep C patient because she took her glove off and reached for her pager (which was going off for the sixth time for non-urgent reasons) and hit the needle she was holding with her right hand. Justify the need to have the pager or to reach for it in the middle of patient care, the multi-tasking put the doctor's health and life in jeopardy.

Back to the book... this book, through it's story, does a good job of dispelling The Myth of Multitasking. Crenshaw makes a good case that, at best, we rapidly switch back and forth between two tasks at a time, losing attention and mental capabilities each time we switch.

In the story, the productivity coach works with a busy executive - she is convinced that she multitasks effectively, but the coach helps show her a better way. Many issues are addressed, including:

Interruptions by colleagues during the day while you're working on something
Electronic distractions, such as email, mobile devices, instant messaging, etc.
Difficulty focusing on the task at hand or others who are speaking to you
Juggling work and home at the same time

Crenshaw also addresses the "myth" that women are better multitaskers than men, sharing data that goes beyond the illustrative stories.

In the book, he shares coping mechanisms and better ways -- not just highlighting the problems caused by multitasking, but also sharing what you should do.

The story is a quick, interesting read and isn't too contrived, although it's obvious the author places himself in the role of consultant. The executive character pushes back on the consultant's advice, although, as these fables and stories tend to go, she of course magically sees the light at the end of the day.

It will be thought provoking for engineers, managers, medical professionals, and any other professionals who feel "forced" into multitasking (or even those who choose to multitask, thinking they are helping their personal productivity or effectiveness).

Outside of the book, do you see multitasking as a problem for yourself or others you work with? Do you have any strategies you use to avoid or prevent multitasking? One classic one is to turn OFF the Outlook new email notification, only checking and responding to emails at certain times. Another strategy I've seen is a "do not disturb" sign on a cubicle, asking co-workers to come back if it's not urgent because the person needs to focus and concentrate on a task.

Share your thoughts in the comments - if you've read the book and want to share an opinion or if you want to share thoughts on multi-tasking.

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LIFE Magazine August 1980 - Healthcare Costs

2009-06-05T05:00:00.001-04:00

Yesterday, I shared some old auto industry images and clips from the August 1980 LIFE magazine. More striking to me was an ad from Aetna health insurance, pictured below, the full ad and then some detailed clips below (click any for larger view):

Surprise, surprise, in 1980, people thought healthcare costs were too high. The ad expresses shock that the U.S. was spending 9% of GDP on healthcare and we need to find ways to reduce that. Well, here we are in 2009 and healthcare is 15.2% of our GDP. Ah, so past solutions didn't work... or did we save "Trillions" because we'd be at 18% of GDP without the previous fixes? Ah, things like that can never be proven...

So healthcare costs had doubled in five years, and radical changes were proposed (sound familiar?).

This last part sounds familiar -- coordinating care, preventing duplication... all sounds fine in theory, I suppose. Can anyone shed some history on the HSAs and why they worked or didn't work?

This last clip talks about over-investment in equipment and facilities... idle and open beds isn't really the problem today, is it?

I'm certainly not the expert on big-picture issues like this... but sharing the old clips to hopefully get some input from those who know more about the history and issues on this level.

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LIFE Magazine August 1980 - Auto Manufacturing

2009-06-04T14:00:00.000-04:00

I ended up having the chance to flip through a LIFE magazine from August 1980 and, given that was also a major recessionary period, it wasn't huge surprise to see articles about joblessness and the decline of the auto industry in Indiana and the Midwest. Come back tomorrow for some "things remain the same" illustrations that magazine about the state of healthcare.

You can click on any of these for a larger view that should be readable.

Although that recession was of the more normal cyclical variety, it was clear there were problems ahead in the U.S. auto industry that weren't being addressed. One of those threats was, of course, Toyota and their high MPG vehicles:

The Corolla was getting 41 MPG highway, which is just about what my company car Prius was getting. It's a bit of an aside, but I drove a Prius for two years in my previous job and I was NOT impressed -- that will be addressed in a future blog post.

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First 90 Days as Hospital Lean Director - What To Do?

2009-06-04T05:00:00.003-04:00

Lean Leap to Health Care #9 (click for Part #8)

by Scott McDuffee

“I’m not sure if I have ever learned anything with my mouth open. But, I know I learn a lot with my eyes, ears, and mind open.”

Sitting in front of Buffalo wings at my second office with my co-conspirator and accountability partner Steve, we skipped our normal job search strategy session in lieu of a first 90 days plan for the job he landed.

His request got me thinking: how would I structure my first 90 days as a lean champion in Health Care? First, it would be valuable to reflect on the journey in manufacturing then look to books like Lean Hospitals and Going Lean: Busting Barriers to Patient Flow.

There was a whole punch list of topics we engaged along the journey which could be useful for my first 90 days in Health Care. I would want to know more about the financials, measures, accountability, org structure, culture, patient /physician/staff survey trends, information systems, media perceptions, and competitors/benchmarking. I could easily focus on 5S, spaghetti diagrams, materials replenishment, quick change-over, first-pass-yield, scheduling, and many other tools.

"Dig where the gold is…unless you just need some exercise.” - John M. Capozzi

Along our manufacturing lean journey, this quote often helped funnel our approach toward the concepts of Rother and Shook's Learning to See. The answer to our “Where do we start?” question echoing sage advice about Value Stream Mapping from one of my early and long term mentors mentioned previously, David Mann.

David emphasized starting closest to the customer, understanding value and pace of demand. Then, working upstream always keeping the customer in mind. Flow where-ever you can, pull when you can’t, never push.

David also reminded us to use a pencil and "go see". We often referred to this as “putting the cook in the kitchen”. Don’t sit in a conference room. Instead, go observe the actual versus someone “intellectualizing” about the work or remembering how much wait time / inventory is between operations. Go get a snap shot of the current state. Go measure. Go count. Observe at Gemba.

Although this process led us to successful initial focus on relatively repeatable processes with a probability for success, then working from final assembly all the way back upstream through the supply chain. This may or may not be the right 90 day focus for a hospital.

So, I looked to Lean Hospitals by Mark Graban for advice. Chapter 11 is called "Getting Started with Lean," which seemed like a good place to pull some notes of concepts that resonated with me from a 90 day plan standpoint.

It makes sense to focus on one value stream or area instead of spreading resources and focus too thin. Also, Mark advises against approaching lean with a focus on a certain tool, instead focus on important problems determined by asking the questions:

What is a patient safety problem or risk to solve?
What are the most pressing complaints from patients?
What major issues do physicians or other employees bring to your attention?
What departments have been struggling with employee shortages?
Who is proposing an expansion or renovation of their space?

Also insightful for my 90 day planning, according to Mark Graban’s survey of 50 hospitals, lean initiatives were started with the following motivations (allowing for multiple responses). David Letterman-esque, The Top Ten Reasons for Lean Hospital Initiatives Are…

20% Emergency Department Waiting Time
30% Need for Growth
34% Patient Safety (proactive)
38% Labor Costs
38% Employee Satisfaction
42% Overall Cost Pressures
44% Culture Change
50% Labor Shortages
50% Patient Satisfaction, and the number one motivation for hospital lean initiatives,
56% Quality and Rework

Yet another alternative from Lean Hospitals to determine where to start is sharing a lean overview with the staff then base your decision on someone who volunteers or really wants to engage lean principles in their area. Essentially, look for the “pull signal”. It is wise to build on strategic successes. It is un-wise to train en masse and expect results to just happen.

Yet a third way to determine where to start, according Mark, is to perform assessments. Common tools include Value Stream Mapping as well as observations and employee insights. Many hospitals start in areas which are more “production like” such as laboratories and pharmacies. Ultimately, where to start is a situational “It Depends”. Culture should be taken into account - specifically the appetite for change.

Mark emphasized one should never implement change without a plan to sustain. Leader Standard Work and 30, 60, 90 day metrics {Plan, Do, CHECK, Act (or Adjust)} should accompany the many forms of kaizen (good change). The importance of change management cannot be over emphasized. As much as 90% of the challenge of lean implementation is related to people and their acceptance of change.

My 90 day plan is coming together. “It Depends” and “It Depends on People” aggregates a lot of wisdom with the principles shared in Lean Hospitals to pave the way.

"Going Lean: Busting Barriers to Patient Flow" from the American College of Healthcare Executives (ACHE Management Series) was another reference. Although the title says "Lean," much of the text seems to be Theory of Constraints methodology. There are some great points to help guide my first 90 days here as well. I scribbled down more notes from the text as reference for my 90 day plan.

We need to understand how efficiency at a point (batching / point velocity) must be overcome to maximize patient flow (minimize patient time through the system). In "Going Lean," Smith, Barry, and Brubaker, use the example of one large elevator in comparison to an escalator to drive their points home with something to which most can relate.

Echoing this message, “The Lean Management Method moves healthcare from its traditional task orientation to provide better patient service, better patient care, and better utilization of assets.”

If patients, payers, and providers are in favor of moving the patient more briskly and smoothly through the system, why isn’t it happening already? The key can be cooperation with physicians and with administrators.

According to Nobel Laureate Herbert Snow, three determinants are necessary to drive changes to culture and behaviors. For strong change management processes, determine:

“1) how to get the important problems to the top of the management agenda, 2) how to represent the issues in a way that others can understand them, and 3) how to represent the issues in a way that facilitates solutions.”

When I read this, value stream mapping again came to mind as well as the practical language emphasis received from insights from the comments on this blog – speak in the tongue of the natives. Good affirmations but what is the real “take away” for me for my 90 day plan?

Here is something. Hospitals today often do well at optimizing a department or a stand-alone process but they need to become strong at optimizing the whole from the patient perspective. This does not mean to just “work harder”. Instead, it means measuring success differently – and thinking differently. Okay, I get this. Makes sense.

Then, I had an Aha! Moment while reading a Going Lean segment called, “That’s the Governor on the Stretcher.” I hadn’t connected the dots before now but I had a similar epiphany on my first kaikaku of the conference chair line in manufacturing.

After trying (and failing) to implement lean by sharing the vision and the principles in a professorial style, I walked out on the floor in the fall of 2000 to ask the working leader Chris, “Assuming a national sports team wanted one chair built as fast as possible with their team color specified along with perfect functionality and aesthetics; how fast could you build it and what would be the progressive steps to build it – ASSUMING A MILLION DOLLAR ORDER WOULD BE PLACED BASED ON YOUR RESULTS?”

Chris told me, “No problem, we could do step A, then B, then C, then D, then E – moving immediately from one step to the other without interruption; we would have to leap frog all this inventory (waiting) but each station would be ready and able. We would need to have quality assurances at each operation and not wait until inspection. This line would produce a conference chair in a half hour.” Most importantly, Chris said, "I know we can do it."

Up until this time, because of all the waiting, racking, hand-offs, queuing on conveyors, and stacks of parts, it took over 2 days just in assembly to complete and took 20 days total from warehouse picking to finished goods to complete a conference chair.

That afternoon, Chris and I with three people from the line, reduced the footprint of the line by 75%, got rid of the in-process inventory racks, and started the next morning assembling chairs in less than 30 minutes - with improved quality! Sure, we stubbed our toes almost immediately realizing the line was unbalanced but we were experimenting, learning, and never going back. It was liberating.

So, when I read about “…the Governor on the Stretcher”, I knew I had seen the equivalent of Chris’ million dollar chair. It is best to quote Going Lean directly for a few paragraphs.

“The ambulance arrives. The trauma team is ready. Blood samples are drawn and sent by courier to the lab, where technicians are standing by. The trauma team’s leader orders an x-ray, so the patient is rolled directly to the x-ray department, where technicians and a radiologist are standing by.
Exploratory surgery is ordered; surgeons, anesthesiologists, and surgical nurses are standing by. A surgical theater is cleared and prepped. Post-op space is freed up, the intensive care unit is standing by. Meanwhile, the admissions department is told to retrofit insurance formalities as the case unfolds. A skilled nursing home, a rehabilitation hospital, and a home nursing service are put on notice to stand by for later information and be ready to accept the patient.
All utterances of the patient’s attending physician are transmitted in real time to the medical transcription service, to transcribe on the fly and to return for signature. The same goes for nurses’ care plans and reports. Discharge orders are prepared in advance, including take-home instructions for medicine, therapy, and follow-up care. An ambulance is ordered to stand by for the earliest possible discharge of this precious patient.
Oops! It Isn’t the Governor After All!”

From this provoking example, the difference between how the governor and the average citizen is treated is not the quality of care, it is the time it takes overall flowing (or not flowing) through the Health Care Delivery System.

If I really want to dig where the gold is, I had better observe and shadow patients’ total experience through the current system - picturing them in the future as a governor in a million dollar chair.

"Scott McDuffee is an experienced Lean professional who is currently searching for a new career opportunity. He is based in Mansfield, TX.

More resources @ the lean community @ Move to Healthcare - http://www.movetohealthcare.ning.com

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Pathology Mistakes (Again) on Oprah and in the News

2009-06-03T06:00:00.002-04:00

After watching and blogging about the first half of Oprah's medical errors show that featured the story of Dennis Quaid's kids, I finally got into the second half.

The first story is that of Molly (left), a woman who was told, after a mastectomy, that she indeed did NOT have breast cancer. Eight days after the operation, the doctor informed her that her anatomic pathology slides had been mixed up in the lab, leading to an incorrect diagnosis and many unnecessary tests (and the stress from thinking she had cancer). This happened at a medical facility that "was known for cancer care" per Molly.

Mixing up slides is what occurred in the case of Darrie Eason, a case that I blogged about here. I have spent time in pathology labs and there is no inherent reason why two patients' slides should be mislabeled or mixed up - it's a matter of bad processes, or at least processes that are not error proofed the way they should be.

The headline on Oprah's page says "Shocking" medical mistakes (and the picture is an audience member who was clearly shocked). If errors like this had never occurred before, but might be shocking... but errors like this occur frequently enough that every pathology lab should be aware of the risks and should be putting process controls in place to prevent slides from being mixed up.

Processes and work need to be designed so that "batching" cannot occur. When slides are labeled in batches or tissue is worked on in batches (of multiple patients), there are risks of mix-ups occuring. Managers need to make sure employees don't cut corners by batching (introducing the risk of mix-ups) and top leadership of a hospital lab or private pathology lab need to make sure managers aren't implicitly or explicity emphasizing productivity and speed over quality.

Molly was relieved, but asked, "what about the lady whose slide was switched with me?" This type of error impacts two patients -- the other woman had her cancer diagnosis (and treatment) delayed.

Oprah asked how the hospital discovered the error after the fact. After the surgery, they found no signs of cancer in her breast or her lymph nodes. It turned out that the lymph node slides had been switched. Now, before surgery, the doctors found breast cancer cells in Molly, but could not find a tumor (confirmed by multiple diagnostic tests, including CT and MRI). They were convinced Molly had a rare form of breast cancer where cells are found in the body, but there's no tumor. When this "rare" cancer occurs, why not go and do another biopsy and re-test before rushing into surgery?

Oprah emphasized the dynamic where patients tend not to question doctors because "they're smart people, they went to school for this." The pathology errors (the physcial switching of the slide) is an operations error that has little to do with medical training. It's the type of error that Toyota would probably be great at error proofing (not putting the wrong radio inside a certain car). Now maybe the medical training could play a role in the decisions being made (not re-testing for this supposedly "rare" disease, but the doctors and pathologists wouldn't even be in that position if not for the operational error). Dr. Oz rightfully says the doctors "work hard, but they are humans."

That's why we need good processes and error proofing - we are human, we are not perfect.

Dr. Oz recommends asking for second opinions, asking for pathology reports and part of the specimen. This, unfortunately, adds cost and contributes to higher healthcare costs. So I'd prefer error proofing -- this is how you can improve quality without increasing costs. Doing the same work twice gets quality but INCREASES costs.

Dr. Oz asks, "how could you switch the slides??" with a bit of incredulity.

Molly gives the answer I expected and already wrote about: the tech was working on two patients and cases at a time and my name got put on the slides of a lady who did have breast cancer.

To the pathology labs -- no more batching, please!!!

In a related story, it seems like the same thing may have happened to another patient... a MAN. Yes, that's right, a 28 year old man who was told, mistakenly, that he had breast cancer and underwent surgery.

Man suing hospital for unneeded mastectomy - UPI.com

Cruelest cut of all: 28-year-old man gets mastectomy, then finds out he didn't have breast cancer

I saw him interviewed on TV, but there are very few details of his case online (probably because lawsuits are in the works.

As he relayed on TV, Scott Aprile was told "good news, you don't have cancer." AFTER the surgery. So he is suing and claims that the hospital "attacked" him, that the charges are inflammatory. Of course the charges are inflammatory. What do you bet that his slides were also mixed up because of this misguided "efficiency," this batching???

I'll try to follow up on his case.

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My Daily Workaround: Deleting Commercial Emails

2009-06-02T06:00:00.002-04:00

I had an epiphany the other day. It was one of those moments where I was pretty ashamed and was ready to turn in my Lean credentials.

I spent too much time each day deleting the same emails from companies that I don't read.

Delete. Delete. Delete. I cringe to think about adding the time spent deleting emails from the Yahoo account that I've had and used as my primary email for 12 years. I'm not talking about "spam" (or unsolicited) emails -- I'm talking about the emails that come from news sources or companies I've done business with and not unchecked the "please contact me" box with.

golf.com (I don't even golf, how did this start getting into my inbox?)
realsimple magazine (how did I get on this list??)
gourmet magazine (I love food and cooking, but I never open these)

I was embarrassed because I was practicing classic "workaround" behaviors, as seen in many workplaces and industries (including healthcare, where it's a major barrier to quality improvement, the willingness of employees to continually work around the same problems every day).

An example of a healthcare workaround:

There aren't enough blood pressure meters/cuffs in the nursing unit
Nurses run around searching for meters
Nurses sometimes hide them or claim them as "theirs", preventing others from doing their patient care work in a timely way
Working around the problem (not enough meters) does nothing to prevent step 1 from occurring the next day

Instead of spending all of that time every day, the Lean mindset leads the nurses to solve the root cause of the problem. Why are there only three meter/cuff sets when they are supposed to have seven? Where did they all go? Find them and bring them back to the unit.

But, finding and bringing them back is another sort of workaround if the nurses don't stop and ask "why did they disappear in the first place?" We have to investigate and find out if other units don't have enough equipment (leading them to "borrow" from another unit). Maybe the hospital, as a whole, has a shortage and we have to buy a few more.

The ultimate non-workaround solution would replace every day searching with the implementation of a PROCESS and a SYSTEM that makes sure the needed equipment stays where it's used and needed.

Considering this is what I preach and what I help others practice, I decided "enough." For a week, instead of just deleting the emails (which *is* faster and expedient, after all), I would invest the time in clicking on the "click here to unsubscribe" links that you find in these emails.

Some sites make it easy -- one click and you're unsubscribed. Some less scrupulous sites make it difficult, requiring more clicks or making the process confusing (maybe intentionally so).

One site had the default box checked saying "I do want to receive...", so if you hit "submit" you are basically saying "Yes, keep sending these to me" which is ludicrous considering I only got to that web page because I had clicked unsubscribe for a reason...

My assumption is that this one-time investment of "unsubscribe me" time will pay off day after day, week after week. My inbox will be less cluttered and I'll waste less time deleting emails I don't read.

Of course, the San Jose Mercury News' "Good Morning Silicon Valley" daily email newsletter (which I read voraciously in 1999 and 2000) STILL keeps coming even though I have unsubscribed a few times. I guess that's a different kind of unscrupulous... a different form of waste.

p.s. If you don't like getting my email newsletters, unsubscribing should just require one click and should be effective... let me know if Constant Contact is dropping the ball on this, but they are supposed to be good and ethical.

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Criticism of Lean at Park Nicollet Hospital

2009-06-01T06:00:00.000-04:00

Hard times curtail Park Nicollet's ambition

Minnesota's Park Nicollet health system is often held up as one of the leading "lean healthcare" examples in the U.S. As I mentioned in my book, Lean Hospitals, they claimed $7.5 million in savings from lean improvement events in 2004, reinvesting the savings back into patient care.

The linked article talks about current financial problems, including layoffs of of 7% of their workforce. Initial questions that might come up might include:

Were these layoffs because of Lean?
Why didn't a Lean strategy help prevent the layoffs?
Would things have been worse without Lean?

I have no idea - those are legitimate and honest questions and I claim no inside knowledge. There are people asking "Why didn't Lean save Toyota" from a financial loss. The world isn't that simple. Lean isn't a cure all or silver bullet, for a manufacturer or a hospital.

Some details do emerge from the Park Nicollet news story.

Park Nicollet Health Services is the Twin Cities' smallest hospital and clinic group.

But its ambitions were big.

During health care's boom years over the past decade, Park Nicollet invested heavily to compete with its far-bigger rivals, Allina and Fairview. It sent executives to Japan to learn Toyota's "Lean" production process, adopting productivity techniques that would later spread to the rest of health care. It installed not one but two electronic medical record systems, one after the other, and borrowed millions to build new specialty centers.

Then the recession hit, and hospital groups big and small saw their rosy business projections fall apart.

The article details how their small market share (about 6%) may give them structural disadvantages against two competitors who each have >20% share.

The CEO is given credit for being a strong proponent of Lean:

He also applied business ideas and technology to health care. Among them was the Toyota "Lean" method, which studies work processes to reduce waste and raise quality. Devotees say anything can be "Leaned" -- from improving the flow of instruments in operating rooms to assigning pillows to each hospital room so a nurse doesn't have to walk down the hallway to fetch one.

Yes, anything CAN be leaned, but part of the question comes back to "are you 'leaning' the right things?" Freeing up nursing time is, I agree, one of the most important things you can do in a hospital -- for the benefit of patient care and the hospital itself.

Some complaints emerged:

Staff friction

The succession of changes wore down staff. Some believed they had become incidental to the work of caring for patients. "People are kind of tired of management fads," said Kent Searl, a nurse in the intensive care unit who joined Methodist Hospital in 1992. "We were offering suggestions and getting pushback on safe staffing, yet being told to reduce the number of pens and pencils."

I can see where this would be frustrating. If you're not addressing the core issues for the hospital, for patients, and staff - say, you're dabbling around the edges with a kanban system for pens at the nurse's station - people might see Lean as a distraction or a bit of foolishness.

If you're focusing on the right things, the important things, staff members won't feel this way.

That said, if staff members are always saying "we need more staff, we need more staff" and that is just an old habit (as opposed to being supported by data), then hospital administrators might be right in not approving the increases - and it might be true that current staffing levels are not "unsafe" (safety can be a staff excuse for forcing staff increases... if management says no, you accuse them of not caring about safety).

Either way, when conflicts like this come up, communication and leadership are key. Even if it is the right decision to NOT increase staff, you have to communicate "why" and gain buy-in with the staff. Otherwise they might be resentful and morale can/will suffer.

I hope things are going well with Lean at Park Nicollet. The news article, in keeping with the "things are going badly" theme of the article, may have just focused on the negative aspects of Lean. Are they still saving $7.5 million a year or more through their Lean events?? Maybe not, but maybe that just went unsaid in the article.

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Getting Started with Lean in Nursing

2009-05-30T05:00:00.000-04:00

By Dean Bliss:

One of the big challenges we have as Lean people is to get beyond presentations, classes, and posters, and get to the real work done by the real workers.

At our hospital system, we’re learning a technique from a group called Rule 4 Consulting that is an intriguing approach to the problem. The technique involves using the “rules in use” that were defined by Steven Spear in the 1999 HBR article “Decoding the DNA of the Toyota Production System” and applying them in a systematic way to directly to a workplace – in our case, an inpatient care unit.

The rules in use can be found summarized here via google books.

One of the key features is lots and lots (and lots) of direct observation, which results in a few things.

One, the observers develop the skills to “see” and to quantify what they are seeing (learning to see what we call "waste" in lean -- we talk about learning to see with different eyes.). Two, the staff gets comfortable with the observation process. Three, the staff starts to be able to “see” problems in their work, which they previously either didn’t notice, or simply worked around. And four, the staff begins to identify suggestions for how the work can be done better – in other words, problem solving at the front line.

A simple example: When the food trays come to the floor, they frequently don’t have salt and pepper, since they must be ordered by the patient. The nurses have to run to the supply area to retrieve the condiments – on one day, there were 3 requests within a one hour timeframe. Each time the nurse made a trip to the supply area, which took time away from her other duties. When we first discovered this, their reaction was “yeah, we have to do this once in awhile – no big deal”. Now they see running to get salt and pepper as a workaround to the problem. We did an A3, and talked to patients, nurses, and the dining service people, and started to get to the root cause. Nothing has been solved yet, but the recognition is there from the nurses that there is a problem that can be solved.

We’re only about four weeks into the process, so we have a long way to go, but I see this as a possible way to get to the core of improvement work – problem-solvers at the staff level. And I think this process has the potential to take us to places we haven’t been before in terms of improvement.

I can’t wait to see how things progress. It’s exciting stuff. I’d be happy to follow up in a few weeks as we progress.

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NPR Does a Great Job of Covering Toyota

2009-05-29T05:00:00.000-04:00

Following The Toyota Way, For Better Or Worse : NPR (listen or read)

I'll hand it to NPR, they generally do a much better job understanding and covering Toyota than the Wall Street Journal, NY Times, or Reuters.

Tuesday, there was a piece that explored The Toyota Way and Toyota's management system, much more accurately than the other media.

The piece wasn't a total Toyota love-fest, thankfully, a good balanced report.

In contrast to GM and Chrysler, the Japanese carmaker has not yet laid off any full-time staff and has not sought government assistance. Efficiency and thrift have so far been the company's saving virtues, although some critics believe that Toyota has taken these qualities a bit too far.

How do you take those qualities too far? If they are so thrifty, why did Toyota overexpand?

While lifetime employment has always been a key Toyota policy, it has had to cut around 9,000 temporary workers in recent months.

It starts to sound like a real technicality that Toyota never lays anyone off when they have that many temps?

NPR goes back to the Toyota loom-making days and the introduction of error proofing:

To really understand the Toyota Way, it helps to look at the company's origins. Before Toyota started making cars in the 1930s, it built automatic looms for the silk industry centered in the city of Nagoya.
One of the company's innovations was a loom that would stop immediately if a single thread broke. Tokyo-based Toyota spokesman Paul Nolasco explains that if a Toyota worker discovers a defect in a car, he is now required to stop the whole assembly line by pulling a string hanging overhead.
"The idea is to stop the problem at the source," he says. "In the case of producing vehicles, as soon as you stop the production there, you don't have to go tracking back to find out where something went wrong."

There is some honest criticism from a Japanese Toyota employee, who says:

But Ishida says that Toyota should have used its cash reserves to save temporary workers' jobs. He says that there's a fine line between thrift and stinginess, especially on some assembly lines, where workers race to assemble a car in less than 60 seconds.
"It's great that you can assemble a car in one minute and eliminate waste," he says. "For the company, it's an economically efficient way of making cars. But I understand Europeans get breaks. We, too, should have this humane touch in our system. You should at least have a second to wipe the sweat off your brow."

Sounds like Ishida doesn't agree that the "respect for people" principle of Toyota is always followed?

A Toyota assembly line designer thinks that the company, for the most part, does a good job in this regard:

How tough the assembly line is depends in part on its creator. Shigenobu Matsubara has helped design assembly lines from Japan to Georgetown, Ky., which has the biggest in the United States. He says he has always designed the lines with the workers' welfare in mind.\

How tough the assembly line is depends in part on its creator. Shigenobu Matsubara has helped design assembly lines from Japan to Georgetown, Ky., which has the biggest in the United States. He says he has always designed the lines with the workers' welfare in mind.
"The workers liked me for this," he says. "But there are other ways of applying the Toyota Way. Some Toyota designers and engineers treat the workers as disposable, just like a machine. They give them big burdens and try to extract the maximum from them."

Is it surprising that there's so much variation here? You'd think that Toyota would have a standardized way of designing assembly lines so that it wasn't so dependent on WHO the designer was...

The topic of standardized work and work methods did come up:

Toyota's corporate culture is surely one of Japan's strongest, and Ishida says he's never felt comfortable with what he considers the company's overbearing paternalism. He says that Toyota basically asks employees to leave Japan's constitution outside the company's fences.
Toyota "educates the workers a way that's quite special, even insane," says retired Toyota worker Shunichi Sakae. "I've always been impressed by the fact that workers talk about it like it's a normal thing, but it's not," he continues. "For example, when walking down the corridor from one office to another, you're supposed to turn at right angles. You're not allowed to cut corners."

Does anyone know the story behind turning at right angles? Is this for safety? Having standardized methods is the core of any Lean environment... at what point does it become overbearing or paternalistic? That's a judgment call.

I'm no constitutional law expert, but it seems that your company asking you (or even forcing you) to work a certain way isn't a violation of the First Amendment in the U.S. Hospitals shouldn't allow nurses to choose to NOT gown up properly when entering an isolation room. If and when the process is not followed, it's not a matter of "free expression" it's a matter of people "cutting corners" in the figurative sense, not the above literal sense.

Toyota, Honda Manage Global Economic Downturn : NPR (listen)

Today had a piece that talked about the struggles of both Toyota and Honda, with a comparison that Honda has been much more conservative about growth and that maybe Toyota got sidetracked by wanting to become the largest automaker?

Again, bravo to NPR for their Toyota and lean coverage.

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Jim Collins on Leadership - "Like Lean"?

2009-05-28T06:00:00.003-04:00

How the Mighty Fall: A Primer on the Warning Signs - BusinessWeek

Jim Collins, of Good to Great fame, has a new book out called How The Mighty Fall: And Why Some Companies Never Give In. Excerpts were printed in a recent BusinessWeek (a magazine that's printed weekly, unlike IndustryWeek, but I digress).

Collins raises some interesting points about how a company's success can breed arrogance or complacency or all sorts of other dysfunctions that can lead to a downfall. One of the difficulties, Collins points out, is that the seeds of the destruction are already planted long before the problem (the fall) is widely recognized or admitted to. A company might have success, although the foundation is crumbling, right up until the point when things fall off a cliff.

Check out the link to the full BW article at the top of the post in case I didn't summarize or paraphrase him accurately.

I didn't see an online link to this table, so I scanned it from the magazine. Click on it for a larger view.

I have a bit of an ongoing series called "Like Lean" where different ideas or practices remind me of Lean and the Toyota Production System even if they aren't called out as Lean. Sometimes, good ideas just germinate in different ways or they just seem like common sense. I think the table above is an example.

If you labeled the left column "Traditional Mass Producers" or "Sloan-ist Management" and the right column "Lean/Toyota Management", it would still be pretty accurate, I think.

Some right column items that seem particularly "lean":

Leaders never criticize those who expose harsh realities
Data, logic, and solid arguments used
Socratic style of leaders asking questions
Argue and debate to find the best solution
"Autopsies without blame" when problems occur
Accepting full responsibility and learning from mistakes

Some of these could also be good "Goofus and Gallant" or "Doofus and Leanie" captions, don't ya think?

Does your organization exhibit more of the left column (on the way down) or right column (on the way up) behaviors??

Interesting other tidbit about Collins from this NY Times article -- he time studies himself and how he allocates his time:

And in a corner of the white board at the end of his long conference room, Mr. Collins keeps this short list:

Creative 53%

Teaching 28%

Other 19%

That, he explains, is a running tally of how he’s spending his time, and whether he’s sticking to a big goal he set for himself years ago: to spend 50 percent of his workdays on creative pursuits like research and writing books, 30 percent on teaching-related activities, and 20 percent on all the other things he has to do.

These aren’t ballpark guesstimates. Mr. Collins, who is 51, keeps a stopwatch with three separate timers in his pocket at all times, stopping and starting them as he switches activities. Then he regularly logs the times into a spreadsheet.

Interesting, I've never heard of anyone doing that...

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