This article appeared back in March… March of 2013… as in this year: “Windsor Chrysler workers reduce waste to be world class.” I mean, good for them, but they are just now getting to this (even if the effort started in 2009 or so)… in the auto industry? Many hospitals were applying Lean thinking before then. Was that Chrysler plant expecting Toyota to just go away? I worked at a GM plant from 1995 to 1997 and the writing on the wall was clear that Lean / Toyota Production System was the winning formula.

Thankfully, they have gotten results in the areas you’d expect:

By eliminating waste, Windsor Assembly has achieved cost savings of $232 million since the inception of WCM [world class manufacturing], said Dan Omahen, plant manager. Workplace injuries have been reduced by 81 per cent, he added.

On the quality front, the number of minivans requiring warranty repairs has decreased by 69 per cent.

At least Chrysler / Fiat realizes it’s about people:

At the heart of WCM is employee engagement, said Omahen. Since the implementation of WCM, employees have contributed 97,778 ideas for improvements and 77 per cent were implemented.

“There’s several important pillars here, but the most important one we realize is the people.” Omahen said as he motioned towards a wall of the front office that displays the most outstanding cost-saving ideas by employees. “We want people to take ownership when it comes to driving change.”

Omahen has adopted the language of WCM, referring to employees’ ideas as kaizens — the Japanese word for  improvement. One kaizen, for example, came from an engineer whose project saved more than $59,000, he said.

In fact, more than 80 per cent of [plant manager] Omahen’s time now is spent on the factory floor talking to employees.

That’s the leadership style I saw from the second GM plant manager I worked under (he was one of the first GM at the NUMMI joint venture plant with Toyota). Being at the “gemba” (the workplace) and working together on improvement, not just dictating answers to people.

From the Chrysler article:

“Before WCM, we were dictated to,” said Mark Dana, an hourly worker who leads a team of about 10 employees in the plant’s tire assembly area. “Now workers have a say, and as a team, we work to solve problems together.”

That’s the Lean / TPS leadership style. Congrats to Chrysler for finally getting on board…

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.

My co-author Joe Swartz and I are happy to announce that our book Healthcare Kaizen was named a recipient of the prestigious Shingo Professional Publication and Research Award. The award will be formally presented to the co-authors in early 2014 at the Shingo Prize annual conference. A formal release will be coming out in a few weeks, but we were told we could share this news.

Joe and I are honored by this designation and we thank our mentors and teachers, including Norman Bodek and Masaaki Imai, both of whom contributed “front matter” to be included in our book. Thank you, thank you to them.We also thank all of those whose Kaizen improvement work has inspired us – including the amazing people at Franciscan St. Francis Health System, Joe’s organization, as well as all of the healthcare professionals Mark has worked with at numerous organizations who were willing to share their improvement work. We share this honor with all of them and hope their work continues to inspire others to improve healthcare.

Thanks again to the Shingo Prize Organization for once again honoring my work, after my first book Lean Hospitals also received this recognition in 2009.

Buy the book via Amazon.com or our publisher Productivity Press. Speaking of Productivity Press, thanks go to our acquisition editor, Kris Mednansky, and the team there.

This Award is named in honor of Dr. Shigeo Shingo, credited as one of the creators of the Toyota Production System. It’s also an honor to included with such an illustrious list of previous Research Award winners.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.

MP3 File (run time 28:17)

My guest for podcast #175 is Mike Taubitz of the firm Sustainable Lean and FDR Safety. Mike is a retired GM employee (including a stint as Global Safety Director) and we met at the Michigan Lean Consortium conference in 2011. We quickly discovered our shared interest in Dr. Deming, Lean, and, most importantly, safety improvement.

I hope you enjoy our chat about his background and lessons from his career, the integration of Lean practices and safety improvement, lessons from Paul O’Neill and other great topics. Like my dad, Mike is a graduate of the then General Motors Institute (now Kettering University).

Some key quotes:

• “It’s not just what you do, but why.”
• 5S is not just neat, clean, and organized – it’s about team identifying waste and developing standards
• We are “a nation of solution seekers” instead of working on “foundational thinking.”

For a link to this episode, refer people to www.leanblog.org/175.

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) at the top of the post 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.

A new way to listen to free streaming episodes of the podcast: Download the free Stitcher app and use promo code LEANBLOG for a chance to win $100.

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.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.

My friend Chad Walters has contributed guest posts to my blog (and has been a podcast guest) and I’m happy to return the favor with a guest post on his site: “Guest Post: A Clown Post About Bryce Harper and Warnings.”

Since his “Lean Blitz” blog is sports themed, I wrote a post about warning tracks (and how players like Bryce Harper, pictured below, often ignore them), the general ineffectiveness of warning signs in different workplaces (including healthcare), and how mistake proofing and better processes need to be the way we ensure safety and quality. Check out the post. Hope you enjoy it and that it’s a bit thought provoking.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.

Hosted by Steve Hoeft, author of the book Stories from My Sensei: Two Decades of Lessons Learned Implementing Toyota-Style Systems, I had a chance to visit Scott & White Hospital in Temple, Texas. With his permission (but without editorial review), I am sharing some stories from my visit to their excellent health system (which is in the process of merging with the larger Baylor Health system in the Dallas / Fort Worth area).

Baylor is one of the largest health care providers in North Texas with about $4 billion in annual revenue. Scott & White, with a national reputation for quality care and efficiency, is dominant in Central Texas. (link)

Huddle Room

The visit started with a stop in their “huddle room” where the senior leadership team, including the hospital CEO and the system CEO, Dr. Bob Pryor, have their daily stand up meeting. It’s a room similar to the “visual room” at ThedaCare that’s full of strategy deployment objectives and actions. Dr. Pryor is expected to be the system COO at the merged Baylor/S&W system. 15 senior leaders packed themselves int he room, as part of a cascading series of huddles that go all the way down to the front line staff for rapid communication up and down the chain in both directions.

One wall of the room has “leader standard work” posted for many executives, including the CEO. Each posted document lists items that are done daily, weekly, monthly, or quarterly. This is a new initiative, so not every leader had their SW document posted yet.

The second wall is their Hoshin Planning board (another term for strategy deployment)… the “Scott & White Alignment Tool” (or SWAT), to gain alignment in the organization around their goals (in five categories) and HOW the goals will be accomplished. The system CEO was personally reviewing progress against these goals.

The third wall was their “SQDCM” metrics board, showing performance in the typical Lean areas of Safety, Quality, Delivery, Cost, and Morale. These goals are aligned at each level of the organization (as we also see at ThedaCare, see their DVD on this process: Thinking Lean at ThedaCare: Strategy Deployment).

The fourth wall is a white board that has in-progress “A3s” and other working initiatives.

Walls 2 and 4 (I just realized I didn’t describe them in order):

The leadership team models a problem solving behavior of four questions:

1. What’s the target?
2. How are you doing versus the goal?
3. What are your ideas or action plan?
4. How can I help?

As the leadership team review metrics, common questions were “are we working that action plan?” and “do we understand why?” As one bit of progress was discussed, Dr. Pryor said “I’d like to go see that” (and I’m betting that he did). As another issue was discussed, Dr. Pryor emphasized the classic “no problems is a problem” mindset of Lean.

Dr. Pryor ended the huddle by asking, and it seemed very sincere, “Any suggestions for me? How can I do things better?”

Lean Management Systems

Lean is by no means new to Scott & White, but their Lean Management System effort started about a year ago after visiting the Toyota Georgetown plant in Kentucky.

The LMS includes four levels of “accountability meetings”:

1. Front-line staff
2. Supervisors, managers directors (ideas that Level 1 can’t address get escalated)
3. Directors / VP / Chief Nurse Executive
4. Senior leadership team

It also includes leader standard work (as seen in the executive meeting), visual controls, and daily accountability – combining for a process focus for the organization.

Huddles

Team huddles are used to work issues that can be worked on quickly, measuring the impact of changes. For example, a team might work on:

• Reducing the number of call lights per day (by more effective hourly rounding on patients)
• Noise at night
• Pain management for patients

A team worked on an issue related to labor and delivery, measuring patient wait times DAILY and huddling to talk about reasons for delay and capturing suggestions for improvement.

The CNE said this whole management process was a “life changing experience for me as a leader” and “I wouldn’t go back to the old ways.”

They emphasized that the improvement process “has to be easy” and they had been “making it too hard” before. The teams charted data by hand now, for example. The process was “challenging for the first few months, but one success happened” it took off. I have seen this with the Kaizen process in other organizations. Once people see that it works, you no longer have to push. The improvement process and the things being measured “has to be meaningful to them” (the staff).

Dr. Pryor said, “For 115 years, we didn’t do this… we didn’t ask what’s meaningful and we didn’t ask for their ideas.”

Summary

I saw many great Lean management practices at Scott & White. The years of Lean leadership provided by Marji Henry have been supplemented with the addition of Steve Hoeft (formerly of the University of Michigan and Altarum Institute). They have hired people away from Toyota and have a lot of internal coaches and talent.

Many teams presented projects and huddle board work that they had done. It’s great to see educated and passionate healthcare professionals have a methodology for reaching their goals for improving patient care.

More impressively, the senior leaders, from Dr. Pryor on down, are VERY committed to the Lean management system, including modeling these behaviors themselves. It’s easy to find a place to see Lean tools and tactics — it’s much harder to find a place where you can wee Lean management being practiced every day.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.

Dr. W. Edwards Deming‘s last book was The New Economics for Industry, Government, Education. In Chapter 5, Deming writes, “Transformation in any organization will take place under a leader. It will not be spontaneous.” A leader “possesses knowledge, personality, and persuasive power.”

How does a leader accomplish transformation?

1. The leader has a theory and “understands why the transformation would bring to his organization and to all the people that is organization deals with.”
2. The leader “feels compelled to accomplish the transformation as an obligation to himself and to [the] organization.”
3. The leader is practical, with “a plan, step by step, and can explain it in simple terms.”

Deming writes about the balance between head and heart, that the “head is not enough.”

The first point about understanding WHY is familiar to those who have read the Toyota Production System literature.  Taiichi Ohno wrote that we must “Start from need,” which sounds like understanding the reason why change is needed. Shigeo Shingo wrote that “We have to grasp not only the Know-How but also ‘Know Why’”, if we want to master the Toyota Production System (TPS).”

I like how Deming emphasizes the understanding of benefits to ALL the “organization deals with.” This would include customers, employees, suppliers, the community – a similarly broad focus that Toyota takes in describing their “respect for people” principle.

In Chapter 6, Deming writes about the “role of a manager of people” in an organizational transformation effort. Forgive the gender-specific nouns… this is verbatim from Deming’s book.

A manager understands and conveys to his people the meaning of a system. He explains the aim of the system. He teaches his people to understand how the work of the group supports these aims.
He helps his people to see themselves as components in a system, to work in cooperation with preceding stages and with following stages through optimization of the efforts of all stages toward achievement of the aim.
A manager of people understands that people are different from each other. He tries to create for everybody interest and challenge, and joy in work. He tries to optimize the family background, education, skills, hopes, and abilities of everyone.This is not ranking people. It is, instead, recognition of differences between people, and an attempt to put everybody in position for development.
He is an unceasing learner. He encourages his people to study. He provides, when possible and feasible, seminars and courses for advancement of learning. He encourages continued education in college or university for people that are so inclined.
He is coach and counsel, not a judge.
He understands a stable system. He understands the interaction between people and the circumstances they work in. He understands that the performance of anyone that can learn a skill will come to a stable state – upon which further lessons will not bring improvement of performance. A manager of people knows that in this stable state it is distracting to tell the worker about a mistake.
He has three sources of power:
1. Authority of office
2. Knowledge
3. Personality and persuasive power; tact
   A successful manager of people develops Nos. 2 and 3; he does not rely on No. 1. He has nevertheless obligation to use No. 1, as this source of power enables him to change process – equipment, materials, methods – to bring improvement, such as to reduce variation in output. He in authority, but lacking knowledge or personality (No. 2 or 3) must depend on his formal power (No. 1). He unconsciously fills a void in his qualifications by making it clear to everybody that he is in a position of authority. His will be done.
He will study results with the aim to improve his performance as a manager of people.
He will try to discover who if anybody is outside the system, in need of special help. This can be accomplished with simple calculations, if there be individual figures on production or on failures. Special help might be only simple rearrangement of work. It might be more complicated. He in need of special help is not in the bottom 5 percent of the distribution of others; he is clean outside that distribution.
He creates trust. He creates an environment that encourages freedom and innovation.
He does not expect perfection.
He listens and learns without passing judgment on him that he listens to.
He will hold an informal, unhurried conversation with every one of his people at least once a year, not for judgment, merely to listen. The purpose would be development of understanding of his people, their aims, hopes and fears. The meeting will be spontaneous, not planned ahead.
He understands the benefits of cooperation and the losses from competition between people and between groups.

Point #7 reminds me of the Toyota expressed, shared by Gary Convis, John Shook, and others that states “lead as if you have no authority.”  This doesn’t mean completely giving away your authority… it means not relying on that formal authority.

Point #5 has also been taught to me as “be a coach, not a cop.”

Point #3 emphasizes the idea that people are not robots. We are complex individuals and effective leaders and managers realize that.

Point #4 reminds me of my friend Sami Bahri, DSS – author of the book Follow the Learner: The Role of a Leader in Creating a Lean Culture. It’s better to be a “learn it all” than a “know it all.”

Lots of great stuff here in Dr. Deming’s work.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.

This video was uploaded to YouTube in the middle of 2012, but I just got tipped off to it. It’s an 11-minute video from Nemours, a children’s health care system.

Watching this video that provides an overview of their improvement approach might be a nice way to end the week:

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.

Occasionally, I have transcripts made from podcasts – and here is the transcript from Podcast #164 with Rachelle Schultz, CEO of Winona Health.

Last year, Rachelle was also part of the CEO panel at the Lean Healthcare Transformation Summit. I’ll be at this year’s Summit, June 5-6 in Orlando, and I hope to see you there. I’ll be moderating a panel with three CEOs: Henry Hawthorne from Columbus Regional Healthcare System (Whiteville, NC), Alan Aviles from New York City Health and Hospitals Corporation, and Don Shilton from St. Mary’s General Hospital (Ontario, Canada).

Mark Graban: Hi. Welcome to episode 164 of the podcast for February 1, 2013. This is Mark Graban. My guest today for this episode is Rachelle Schultz. She is the CEO of Winona Health in Minnesota. Rachelle was part of the CEO panel that I moderated at last year’s Lean Healthcare Transformation Summit, and her comments on leading a health system’s Lean transformation were very well received, so happy to have her on the podcast today. In this discussion, she says, in part, “Everything I do has to drive Lean.” We’re going to talk about how her system is using Lean in these difficult and challenging times and what the impact has been on quality, patient satisfaction, financial measures, and other things.

This episode is produced in partnership with the Healthcare Value Network. For links about the network, about the Transformation Summit in June, you can go to leanblog.org/164.

Rachelle, thanks so much for being part of the podcast today.

Rachelle Schultz: I’m pleased to be talking with you today, Mark.

Mark: Thanks. I was wondering if you can start off by introducing yourself and a little bit about Winona Health.

Rachelle: Sure. My name is Rachelle Schultz, and I’m the CEO at Winona Health. We’re located in southeast Minnesota, right on the Mississippi River. Winona Health ‑‑ we would define ourselves as a primary‑care organization, birth through end‑of‑life. We have a hospital. We have ambulatory clinics, senior services, which includes our long‑term care, assisted living, home care, hospice. We provide surgical and specialty care, of course emergency departments, and urgent‑care services. We’re a full spectrum, across the primary‑care continuum. Our community is about a 30,000 population. About 30, 40 miles either side of us, we have our tertiary referral centers, one in Rochester, and then over in La Crosse as well, there’s two over there. We’re one of the fading types of organizations in that we are still today an independent hospital system or health‑care system in a rural community. It’s something we hold on to a lot as part of who we are and how we can serve our community, but it is something that seems to be being challenged a lot by our current environment.

Mark: You’re independent but a fairly integrated system, it sounds like.

Rachelle: We are integrated with the services that we have, across the continuum. Part of our system, the clinics, the hospital, the senior services and so forth ‑‑ all the physicians are employed here, for example ‑‑ as a community health system, we’re really integrated that way. We still, as a community system, are independent of those large health‑care systems, if you will.

Mark: Transitioning, we’re going to talk a little bit about the current health‑care environment, with health reform and the pressures that health care is under. Curious to hear how you’re using Lean to help improve your operations, improve carrier providing, coping with that challenging environment. Are there other particular opportunities being integrated at the hospital, primary care? How does that all work together?

Rachelle: From my perspective, we started our Lean journey really formally about four years ago, and we dabbled in a few things a couple of years before that. We really started this work intensely four years ago. From my perspective, it was really around the key strategy that goes to our long‑term survival. I felt as though, as we really learned more about this, if we operated using these principles, if we really understood this, we could really weather many of the things coming our direction. Today I still believe that. I actually probably believe that more strongly even now as opposed to then. I think that there are so many things coming down the pike that are yet to be defined. Our imperative is really around making sure we’re very efficient around our systems and practices and doing it, actually, going forward, from a patient perspective as opposed to the regulatory environment, or are often designed around providers, for example.

It flipped a lot of that for us. We really have to look at the true continuum on how a patient moves through a clinic to a hospital stage to going home and how then they’re managed in the home. Actually, I think a lot of the dialog nationally is around that kind of a model. I think that’s the direction we’re working in. Lean is the context, I guess, in which we are defining how that work needs to happen, how those systems or processes need to be redesigned. I think it lends itself pretty critically to our long‑term viability and sustainability as an organization.

Mark: For a lot of organizations out there ‑‑ you used the word “survival” ‑‑ do you think it may really come down to that for community hospitals in other parts of the country that aren’t being as aggressive with process improvement and other methodologies like Lean?

Rachelle: I do. I think that many organizations, smaller institutions, like ours, for example, you see a lot of mergers and acquisitions, lots of them coming together thinking bigger is better, and if we do that, somehow we’re buffering ourselves from what might be coming down the pike. I think, fundamentally, what we’re missing as an industry is the need to go back and really do this redesign work and really understand what the principles are around that and really tackle what have been very difficult issues. Whether they’re internal political issues or medical‑staff issues or whatever they are, I think, if we stay focused on what we need to do to help patients be well and be healthy and solve disease problems and things like that, if we really design our systems along that, I think we can make a lot of progress. I think there still remains a lot of reticence to do that. I see that in our organization on any given day. It’s a resistance to change. This has worked for us. At a time, it did work for us, but it doesn’t work for us anymore. I think we’re needing to embrace the need to make those kinds of changes, which really impact everything we do and how we think about just about everything we do.

I don’t think we’ve gotten over that hump. I think it’s more, a lot of the advocacy, if you will, that’s out there is really more about protecting what we have than changing to meet what the future demands are.

Mark: You bring up a good point. You’re right, there’s a lot of consolidation and merger and acquisition. A lot of times people think bigger is better. Sometimes bigger just leads to bigger. If we can focus on the better, through process improvement, improved care, it’ll be interesting to see how that plays out. Sounds like you plan on staying independent and going the “better is better” route, not the “bigger is better” route.

Rachelle: Exactly. I think that’s a fallacy that so many have. I do think that for smaller institutions, there’s a sense of “We don’t have the resources, and so we can’t do this,” and so then they join up. I mean, it’s just the logical steps. We join up then with a larger organization, and they’ll make the changes or they’ll help us or they’ll give us the resources. I go back to ground zero, which is, they don’t have those same capabilities to make these changes. Nothing changed, other than you became part of a bigger system, but the problems still remain, and you still have to make those changes. I guess I fundamentally feel that it’s like the principles of empowering your staff and getting things to the lowest level of where the work is done. By trying to delegate it up, it’s moving it the wrong direction, and I think we still have to solve our own problems. That’s the beauty of ‑‑ I think what I like about our independence and our community health system is our Lean work has made everything so transparent. We see the brokenness of the system every day. There are thousands of problems to work on. Our challenge is to pick the right ones that move us in the right direction.

Mark: Looking at the context of all of the Lean improvement work that’s been going on, how do you, as the CEO, gauge or measure the impact of that Lean work on the long‑term strength of the organization? How do you look at that and evaluate that?

Rachelle: There are a couple things. One is just our results. When we look at it at a macro level, it’s our quality results, our satisfaction results, our financial results. Those are all in the right direction, or we’ve achieved pretty high levels there, and we need to sustain that and continue to look at how we improve some things. More things are always coming down the pike in those buckets, and so we have to always back that into different processes and systems. Probably a broader way that I look at that is, what is the engagement level that I have across the organization of the staff and the physicians towards this work? We’re fairly ‑‑ to use the term Lean ‑‑ Lean, managerially, so there’s very few levels between me, for example, and all the staff.

How we utilize our people, which is our biggest resource here, and leverage that is critical to the success of Lean. Health care is still a people‑dominant type of industry. There is electronics system and all of that, and we leverage those and we need to use them, but how we use it and leverage our people. When I look at engagement and thinking, “I’ve got 1,200 employees here,” if I have 1,200 employees, even 1,000 employees, moving the right direction, and in the same direction, that’s a lot more powerful than having them scramble all around doing different kinds of things.

That, for me, is a measure of just the consistency and then looking at our strategies getting implemented the right way, how much and how much time it takes for that, and then are we actually hitting our targets as far as that goes. It really becomes the measures of the organization.

The first couple of years of our work was really around learning Lean and learning how to do it and practicing things. We really had an activity‑based Lean experience, if you will, in the first couple of years, but it served us well. We’ve now transitioned into moving from activities to results. While we’ve had results, now we’re really driving the results in a more powerful way, because we spent that time getting everybody up to speed on the principles, the processes, the tools, the understanding, the teamwork, all of those kinds of things.

Mark: One group, and we chatted a little bit before we started the podcast about engaging physicians. This is a really common question. People talk about engaging physicians, getting physicians involved in the Lean process. Can you share some of your experiences and thoughts, working with them in particular?

Rachelle: We’ve had a really good experience in terms of getting them engaged. They’re critical to the engagement, because when we’re focusing on the patients and so forth, this is really doctor‑slowing work. Of course, when we start using words like “standards” and things like this, that can make them a little uncomfortable, although, again, as we’ve gotten a couple of years into it and they see the results of the work that they’ve been doing, it’s just like there’s a tipping point, when they just automatically go to “We need a standard around this. We need everybody doing this the same way.” It’s helped us drive so much more. Again, our physicians here are employed, and so we can take them off‑line and put them in a team for a couple of days or something like that to help with that work. I think organizations have different setups or different challenges ‑‑ they may be employed, they may not be employed. I just think that that’s an investment of critical time, resource, and knowledge that you need, and the buy‑in, because if you don’t have that, the work that you do goes to naught anyway, often, because the physicians don’t understand why you’re actually making those changes. It’s their work, no different than any other staff.

I think we’ve tried to pick really important work ‑‑ by way of example, meaningful use, which everybody needs to do, every hospital needs to put in place. We took some really difficult issues ‑‑ things like problem lists and medication reconciliation and documentation ‑‑ and rolled that into our meaningful‑use work, which was all designed using our Lean processes and tools, and physicians on‑board driving all of that.

You just start seeing the really good results, and they all understand why they’re having to do that. You start doing it the same way. It’s not the clinical care they’re providing. It’s the documentation of everything, which is just a burden for all the doctors anyway, and how we can make that better and easier. Again, when they see the results of all of that, it’s like, “Let’s do more of this because that makes it easier for us.”

Mark: That sounds like a perfect example of providing benefits to the physicians.

Rachelle: Right.

Mark: Reducing burden and waste and problems they’re having to deal with. Like you said, of course they would want to do more of that if it’s helpful to them. I think, unfortunately, a lot of organizations are trying to force or pressure people into things, and so that question isn’t really so much about engagement as it is ‑‑ I think people say, unfortunately, they’re really asking, “How do we force people to do what we want?” That’s not what Lean is about, right?

Rachelle: You don’t. [laughs] Exactly. I think that’s exactly the point. You don’t force anybody into doing it. It’s by experience. Frankly, one of our early learnings was, every time we had people on teams and they were new, it was just like it opened up an entirely different vista for them about what was possible and how to think about problem‑solving. What we could target, then, was, “How do I get some naysayers like that on the team?” Really, without exception.

For example, one physician who I was talking to, who was kind of growly about the whole thing, and he said, “Oh yeah, we’re going to clean closets, and we’re going to move this over here and that over there, and that’s going to make a big difference.” He was kind of being sarcastic, and I said to him, “I would just ask you, for me, if you would just please be on one team. Just try it, because I can’t explain to you, in a way that is going to make sense to you, how powerful this is. If you would just agree to try it out.” He said, “For you, I will do it.”

He was on a team. I didn’t actually know that he had gotten assigned to a team. He agreed, and he was on it, and the team went forward and did all of their work that had to do with the clinic. I got a card from him a week or so after that that said, “Thank you so much for that opportunity. I had no idea. I have an entirely different way of thinking right now. I can’t be more proud to be a part of Winona Health. This was such an experience.” Which was an amazing experience for me to get a card like that, number one. Number two, he started showing up every day at the focus‑board meetings, which are like huddle boards, with the staff, and started removing the barriers for them.

Mark: That’s great.

Rachelle: It was just by virtue of being on a team and actually seeing how those discussions happen. He had whatever perspective he had before that, but he understood it entirely different. It is the experience. You can’t force people. We could say, “You must do this.” It doesn’t get use the results that we want. It’s by engaging them in a different way and having them actually have the experience of being there and saying, “Do you understand the problems as we see it?” I really do believe that most people will gravitate towards that and say, “This is a better way.”

Mark: Right. I want to transition, talking a little bit more about your role as a CEO in this process, think Lean transformation, if you will. You talk about engaging people and leading. You’re encouraging that physician to get involved and give it a try. First question is, as a CEO, there are so many pressures on your time and issues that you have to address. How do you prioritize things? How does Lean fit into your day or your typical week as a CEO in terms of the amount of time you’re spending on it or does it just become incorporated in what you’re doing?

Rachelle: It’s how we work. I think one of the really hard things for lots of organizations is thinking that Lean is somehow a separate or parallel way to do things. They keep them separated that way. Here, quite frankly, my job…Everything I do has to drive Lean. It isn’t a separate thing that I do. I’m the champion of it, I’m the driver of it. I’m the one who says, “It’s not going away.” I’m the one who says, “Where’s your E3 on this?” All of those kinds of things.

Until organizations really understand, it’s how we manage. It’s how we think. It’s a different culture. It’s a different way of doing business.

I’ve had some of my senior management, for example, staff say “I kept trying to do both, and I couldn’t keep up. I just had to give it up, and I just had to jump in and decide this way. It just made all the difference.”

You just start seeing the break through approaches that they have, the coaching, the mentoring roles that they take on. They have to give up control around a lot of things. There’s a lot of change that happens for management staff, I think, in particular.

Then, as you see, the other staff come up and really bloom, and taking ownership and really being empowered to do things. When you really see that happen, it’s a pretty powerful thing.

It is not for everybody. There are people that cannot be, or don’t want to work in this environment and will not be successful. We have had those kinds of changes here, in management and then, with staff, but the decision we have as an organization, is this is how we’re operating.

I changed the strategic planning process. We don’t do budgeting any more. We do forecasting, quarterly forecasting. We take away those kinds of tools that are the old traditional things, implement the new ones. Our system and processes can then drive the work the way we need it done.

It is all the time, 100 percent of what I do, and how I do it. I guess that’s just probably, for me, when I think about what we really mean, and if you really want to have the power of truly Lean work, I think you have to do it full on.

Mark: That’s a really great point. I need to find somebody to do a whole separate podcast on this idea of getting rid of the budgeting process, or beyond the budgeting approach that Theta Care and others use. I’m sure when you said that half the people listening probably went, “What? Get rid of budgeting?” Maybe we can, if I can’t find another volunteer to talk about that, we could spend 20 minutes on that topic alone.

Let me just as a final thought and final question, Winona Health has been part of the Healthcare Value Network for a couple years now. I was wondering if you could share some thoughts on what you’re getting out of that process.

I believe you hosted a site visit. I know you’ve gone to other organizations. You’ve had people come and visit you. Can you talk a little bit about the learning that takes place through that?

Rachelle: One of the hardest things actually, as an organization starting new into this, is finding like minded people and organizations. People that really want to move the direction and understand the vernacular around this. Who understand the challenges around this. All of those kinds of things. What was really great about the Health Value Network was, there they are. By joining that and then linking into our cohort, the other ones that are out there, the tools, the messages, the examples that are out there.

Being able to go to other Gembas and see firsthand how other organizations are approaching these things, but they’re doing it using the Lean thought processes and approaches and so forth has been invaluable, really, for us. Because I can go to both state and national meetings of other healthcare organizations and there’s more of a tendency to ring our hands about everything that’s happening, but we don’t have the solutions. We try to do things.

I think even approaches that come out…I think about the governmental approaches, there’s no Lean thinking about that. It’s just, “Here, we’re going to do this” but there’s no design in that and no approach to it.

That’s the sort of the old and the new in trying to do it. For me, trying to break new ground and being a different type of organization that would be viable and successful in the new world of healthcare, I need to have us help us feed you if you have like‑minded organizations. That’s the biggest part of it.

Of course, and we have our directors here and other management staff that connect up. We go into the website. We pull tools out. We can call other organizations. We get calls sometimes for things that we’ve got or we’ve done. We all have to adapt them to our respective organizations, and there’s as big openness there for sharing.

This isn’t about competitiveness and things like that. It’s about not having to reinvent the wheel, and furthering our respective missions, because we all do really important work in caring for our community.

Having access to some of those things and not having to start from scratch, is enormous. It’s a huge benefit to us.

Mark: Talk a little bit about the process of having others come in and visit, because it’s a lot of work to put together a visit. It interrupts people’s days and week to have outsiders come in. What is that like having others that are working on Lean come through and take a look at some of the things that you’re doing?

Rachelle: I think it’s a really valuable process for the organization that’s being visited, partly because in all of the prep work, I think you’re taking some time actually because you’re going to tell your story. You’re really taking some time to celebrate and revisit what has been some pretty significant success. Then, I think as they actually go out into the Gemba, and are talking and have staff presenting things, it’s a real validation for them, too. Others are coming and trying to learn what we’re doing and asking questions.

Then, our staff asking a lot of questions. There’s a huge knowledge transfer type of thing that was going on.

While it’s work to put together, I think there’s a real pay off both from your own staff and just how they feel about it, and being able to tell their story and share things out there.

Then, I think, actually just seeing things operate and asking questions. It’s one thing, if you’re looking at some documents or something. It’s another thing when you see in real life, real time, full color. Here’s how it’s operating. Here’s how it looks, and stuff. It triggers lots of ideas for people.

For us, it was as much of a learning experience having people come here, as it was for them, to come to see what we did. When you lay out your plan again at the beginning of what you’re going to do, it’s not as much work.

I didn’t think it was as much work, maybe what many anticipate of hosting a group. I think people are pretty respectful of what it takes, and going around a facility, and all that kind of stuff. I would encourage anybody to do that.

Mark: Great. Rachelle, thanks so much for being part of the podcast and sharing some of your perspectives and experiences. It’s been a real pleasure talking with you.

Rachelle: It was my pleasure, too. Thank you.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.

MP3 File (run time 37:46)

My guest for podcast #174 is John Hunter, a long-time friend and fellow blogger – at his Curious Cat Management Improvement Blog and, more recently, as a blogger for the W. Edwards Deming Institute. John has recently published a book through LeanPub.com titled “Management Matters.”

In this episode, John joins us from Malaysia, where he has been living, and we talk about his quality background – growing up in Madison, Wisconsin, influenced by his dad (William Hunter), Brian Joiner, George Box, Dr. Deming, and others. John also talks about his book and work, why long-term thinking is such a rare commodity, and some of the lessons from Dr. Deming that mean the most to him.

For a link to this episode, refer people to www.leanblog.org/174.

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) at the top of the post 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.

A new way to listen to free streaming episodes of the podcast: Download the free Stitcher app and use promo code LEANBLOG for a chance to win $100.

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.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.

A woman has the wrong side of her brain operated on. The headline features the hospital’s name and the surgeon’s name. It seems the “name, blame, and shame” process has begun.

SSM Health Care St. Louis, Dr. Armond Levy face lawsuit after wrong-side brain surgery

In complex systems, like healthcare, is it overly simplistic to blame the surgeon? Probably. One could say the hospital system owns responsibility for the overall process and outcomes… but surgeons are often not employed by the health system, which complicates things.

Are we focused on learning and improvement, or blame and punishment?

From media accounts, what happened to the patient, Regina Turner?

A St. Ann woman went in for surgery on the left side of her brain, but the procedure was mistakenly performed on the right, and now the hospital is facing a lawsuit.

This definitely falls in the category of a so-called “never event” – a wrong-side/wrong-site surgery. They are called never events because they SHOULD never happen… but they do happen, sadly. If we had good processes and systems, errors like this would never happen.

So, when they do happen, do we shake our heads and say, “ah, human error… we’re human, so we can’t expect perfection… errors will happen.” Or, do we punish that “bad apple” so that individual can’t make the same error again? Would we strip the surgeon of their license? Throw them in jail? Either of those actions would probably result in a huge loss to society, removing a skilled surgeon who was involved in one mistake.

Writing “involved in” might sound like passive voice abuse… but the surgeon does not work alone. It seems overly simplistic to automatically attribute an error to a single person working in a team.

From this case, the news reports say:

• There was a surgical site marking (a good practice)
• The marking was done on the WRONG SIDE (so we’d then ask why this occurred… and how could we error proof the system to ensure this doesn’t happen again).

I thought the best practice was for the surgeon to personally mark the site. The surgeon should be familiar with the patient and the case, as to know whether they are supposed to operate on the left or right side of Regina Turner’s head. It’s easy to see where errors are more likely to occur if the surgeon is not involved, if the marking is done by a nurse.

I’ve thought it seems smart to also mark “NO” or “WRONG SIDE” in addition to marking the surgical site. Markings sometimes get wiped away or washed off during surgical prep (which gives us another “why?” to ask and another countermeasure to find).

Turner’s attorney said:

According to the Journal of Neurosurgery, Wolff pointed out, there have been 35 documented cases of wrong-side craniotomies ever in the U.S.

If the hospital and surgeon have a standard process that says the surgeon IS supposed to mark the site, and they did not, we’d want to ask “why?” The surgeon might have been under time pressure. But, surgeons and physicians have a lot of power and relatively high levels of autonomy, so I’m less forgiving of a surgeon who feels pressured into rushing or cutting corners. I’m more forgiving of a nurse or somebody lower in the traditional hierarchy.

In the Turner case:

“Sometimes the x-rays can be flipped,” he explained. “Sometimes the doctor doesn’t look at the medical records. Sometimes the surgery comes off late and everybody’s in a rush. Sometimes, if a doctor has a whole lot of surgeries, let’s say he’s got eight knees to do that day, and he’s got four right knees and four left knees, and the first knee cancels and they start moving everybody up, the wrong knee goes in the wrong room.”

Some of the errors:

• X-ray was flipped — why? Can this be prevented through process or technology?
• Sometimes MD doesn’t look at the medical records — why?

What’s the right balance in “holding the MD accountable” and recognizing they work in a system?

• Sometimes things run behind schedule and “everybody’s in a rush” — why are things behind schedule? why is everybody in a rush?
• If a patient cancels, is there a good process to ensure that everything else stays in sync to prevent wrong-patient mixups??

Whose responsibility is it to make sure people don’t rush? I had outpatient surgery a few years ago and things were running at least three hours behind schedule. The surgeon apologized, but I agreed that it’s better to do quality work on all the other patients, as I didn’t want the surgeon rushing through my case either.

If the “rush” is driven by the behavior of an individual surgeon, we might hold them more personally accountable.

But, what if the “rush” was driven by something more complicated? Maybe the department had targets or incentives (or punishments) that resulted from on-time case starts or some other metric? What if the scheduling template wasn’t realistic and cases weren’t scheduled with enough time? What if the surgeon had been yelled at previously for taking too long in the O.R.? Does management ever get held accountable for their behavior that might cause people to rush and cut corners?

This could be far more complex than “bad surgeon.”

The patient’s attorney said:

“I hope everybody who is operating on people pays a lot more attention because more healthcare providers are really, really good,” Wolff added.

I agree that healthcare providers are generally outstanding people – smart, caring, motivated, and hard working. I disagree that asking people to “pay a lot more attention” is a good root cause countermeasure. We need to design better systems, not just say “be more careful” with warning signs and slogans.

As I blogged about yesterday, the patient is a victim here, but the surgeon and the entire surgical team might be “second victims,” as well.

The system issued this statement:

“St. Louis SSM Health Care and SSM St. Clare Health Center sincerely apologize for the wrong-site surgery in our operating room. This was a breakdown in our procedures, and it absolutely should not have happened. We apologized to the patient and continue to work with the patient and family to resolve this issue with fairness and compassion.

“We immediately began an investigation. We have since taken steps to be even more vigilant to prevent such an error from happening again.

“Medicine is a human endeavor, and sadly, people and systems are not perfect. When an error occurs, it is tragic for the patient, their loved ones and the medical team.

“Our SSM St. Clare Health Center team is made up of dedicated health care professionals who are devastated. We can and will do better. That is our commitment to the community.”

I hope the system understands why there was a “breakdown in procedures” so it can be prevented in the future. I hope those steps include process improvement and not just greater “vigilance.” Dedicated, vigilant professionals are a good start – but not wholly sufficient.

We can and must do better. What has your hospital done to ensure that wrong-side / wrong-site / wrong-patient surgeries cannot occur? How does your words about commitment to your community manifest in process improvement actions?

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.

This week, May 6-13, is National Nurses Week. It’s always important, but it’s especially good to thank and recognize all of the talented, caring, hard working nurses out there.

Nursing is important, difficult work. Sadly, the work is made more difficult than it should be due to bad processes and waste in the healthcare system. I’ve always sympathized with nurses who are forced to jump through these hoops every day (often not getting a proper lunch break, as they should). I very much enjoy working with nurses who participate in Lean and Kaizen activities to help fix the systems they work in.

This article caught my eye yesterday: “Medical errors leave devastating impact on families, professionals.”

The first victims of medical errors, being harmed or killed, are, of course, the patients and their families.

Health care workers say they are traumatized by preventable errors in what’s known as the “second victim” phenomenon. Doctors or nurses who struggle after a medical error, death of a child or other unexpected event can lose confidence, have flashbacks and feel like abandoning their careers.

When so many problems are preventable, if we had better communication, processes, and systems, it’s understandable why nurses (or others in healthcare) might be devastated when they are involved in a medical error.

Nobody comes to work with the intention to do a bad job.

We owe it to the patients to provide the best quality care. That’s why we also owe it to nurses to not put them in a bad position where they might be involved in a systemic error. That’s why we need error proofing instead of just asking people to be careful. We need to reduce waste to free up time so that nurses aren’t fatigued or distracted, conditions that make errors more likely to occur.

When people ask me what motivates me about Lean healthcare – helping the nurses comes a close second after helping the patients.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.

I’d read before that Apple’s supplier (Foxconn) was having trouble assembling iPhone 5s to Apple’s standards… but this article contains some shocking stats: “Apple Returns Millions of Defective iPhone 5 Smartphones.”

Millions… 5 to 8 million defective phones returned. Foxconn has only been able to achieve an 80% quality rating… suggesting 2 in 10 have some sort of problem. What were Apple’s expectations? Shockingly low.

The agreement between Apple and its outsourced manufacturer allegedly states that a 90 percent quality rate is required (meaning only 1 out of 10 iPhones are allowed to be broken).

I’m pretty shocked that Apple expected (or allowed) a 10% defect rate.

The bad working conditions at Foxconn have been well documented (including this previous blog post of mine).

This goes to show there are multiple definitions of quality, including:

Fitness for use: Does the product, as designed, meet the customer’s needs?

Lack of defects: Not having physical problems or electrical problems

This is a VERY high defect rate for manufacturing. That’s hardly a six sigma quality level.

Having to take back the defective product add costs and hurts profit margins for Foxconn.

Last Monday, I blogged about a Canadian hospital CEO who stated they were hurting “8 to 10%” of the patients who walk through the door.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.

I first held a public registration workshop based on the book “Healthcare Kaizen” in Denver last month. I’m going to repeat the workshop in the Dallas / Fort Worth area on the afternoon of June 25. Of course, being a practitioner of Kaizen, the workshop, while well-received, will be improved.

It’s a fun afternoon of education, discussion, and an interactive exercise that brings daily continuous improvement to life. Ron Pereira, from Gemba Academy, will be my special guest and one lucky attendee will win a free subscription to the online Gemba Academy training series.

If you’re in the DFW area (or a short/inexpensive flight away), I hope you will consider attending. Click here or the photo below to learn more and to register.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.

Here’s a fascinating article: “How Toyota brought its famed manufacturing method to India.”

The piece starts with a story about a classic Toyota management practice — “Genchi Genbutsu, or on-site inspection, which is at the core of the Toyota Production System (TPS). Nakagawa, who has been a TPS practitioner for four decades, doesn’t believe in seeing things on his computer screen – he prefers to go where the action is. “Can a computer smell? Genchi Genbutsu is very important because only on-site will your sensory organs be alert – smell, sound, vision,” he says.

There’s a great diagram that breaks down the two core pillars of The Toyota Way into more specific detail:

“Respect for People,” in particular, can be such a vague expression…

The diagram breaks it down into seven components:

1. Respect others
2. Make effort to understand each other
3. Take responsibility
4. Do your best to build mutual trust
5. Stimulate personal and professional growth
6. Share opportunities for development
7. Maximize team and individual performance

I think this is further proof that “respect” in the Toyota framework is a active choice that we all should make – it’s a choice in your daily behaviors and actions. You actively show and demonstrate respect for others, rather than it being just a vague notion in one’s head. Edit: Arguably, as Bob Emiliani states so well in his comment (and in his books), respect for people is really an organizational requirement if you’re going to have a truly Lean culture.

The article also talks about the connections between standardized work and kaizen:

While the process is continuously monitored to improve, the standard work ensures the process is checked and completed so that there is a continuous improvement toward the target. In other words, it is always a moving target with room for improvement.

Besides, there is much stress on PDCA, or Plan, Do, Check and Action, across the company. “A lot of companies are very good at planning but few can act and check on the plan, many can’t even identify what went wrong with the plan and the action rarely takes place. Toyota processes tie down all aspects,” says Kirloskar, adding that weakest link in the chain when it comes to Indian companies is maintenance, which Toyota’s PDCA executes rather deftly, as is evident from even top management visits to the gemba( place of work) to adhere to Genchi Genbutsu.

Be sure to check out all the pages of the article. It also touches on topics including:

• andon cords and the ability for workers to stop the line
• heijunka (level loading)
• A3 management
• just in time parts delivery (8 times per day)
• production being driven by demand

It’s nice to see applications of these ideas consistently around the world.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.

MP3 File (run time 29:36)

My guest for podcast #173 is Alan Gleghorn, CEO of Christie Clinic in central Illinois. Alan is one of the keynote presenters at the upcoming Lean Healthcare Transformation Summit, to be held June 5-6, 2013 in Orlando. Alan has been CEO for 14 years, leading Christie Clinic in their Lean journey that started in 2005 when he saw ThedaCare’s current CEO Dr. Dean Gruner present at a conference.

In this episode, Alan talks about how they got started with Lean, what they learned from Autoliv and the Shingo Prize assessment process (being the first healthcare organization to do that). He also talks about his Summit keynote and how their work with Accountable Care Organizations is leading to better value and outcomes for patients.

For a link to this episode, refer people to www.leanblog.org/173. You can also listen to an interview I did with Alan two years ago for the Healthcare Value Network podcast.

This podcast was produced in conjunction with the Healthcare Value Network as a continuation of their previous podcast series.

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) at the top of the post 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.

A new way to listen to free streaming episodes of the podcast: Download the free Stitcher app and use promo code LEANBLOG for a chance to win $100.

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.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.

I had a chance to attend the Lean Kanban North America conference this week. It was a different “tribe” to be a part of, as the topics focused on software and IT settings, including agile development, “kanban” project management, and broader lean management topics.

I gave a talk on “lean healthcare,” which is always an interesting challenge when it’s not an audience of healthcare professionals.

Here are notes and links that I cited in my slides, including data and key references:

You can also view this as a Google Doc.

• 98,000 deaths due to preventable medical errors
  • Institute of Medicine: http://bit.ly/IOM-report
• One in seven Medicare patients harmed in hospital
  • HHS Report: http://1.usa.gov/YiSez5
• One in 300 patients dying due to hospital errors
• Collected stats on quality and patient safety problems worldwide
• Collected stats on IMPROVEMENT
• Institute of Medicine Report on healthcare waste
  • $765 Billion of $2.5 Trillion annual U.S. healthcare spending wasted
• Hand washing data
  • 38.7% average hand hygiene compliance
• “Ask me if I’ve washed my hands”
  • http://www.AskMeIf.com
• UPenn data on reduction in Central Line Associated Bloodstream Infections
• ThedaCare improvement of Cardiac Bypass surgery patient data
• Two pillars of the Toyota Way management system
  • “Respect for people”
  • “Continuous improvement”
  • Blog post
  • Toyota web site
• Mary McClinton case at Virginia Mason Medical Center
• Virginia Mason patient safety alerts
  • Book on their Lean journey
• Darrie Eason case
  • More on pathology errors
• Seattle Children’s hospital Lean Design
  • New tower
  • Outpatient surgery center
  • Book on their Lean journey
  • Book on “Lean Design” process
• John Toussaint & Kim Barnas (ThedaCare)
  • Journal article
  • Book on their Lean journey
  • My podcasts with John (episodes 54, 62, 72, 146, 159)
• Paul O’Neill’s three questions

1. Are my staff and doctors treated with dignity and respect by everyone in our organization?
2. Do my staff and doctors have the training and encouragement to do work that gives their life meaning?
3. Have I recognized my staff and doctors for what they do?

• My podcast with Paul
• Lean vs. L.A.M.E.
  • My original post
  • More blog posts
• Article about bad 5S in the British news

Picture via Twitter.

Tweets about the talk:

TonianneDeMariaBarry ‏@Sprezzatura 

1/3 of healthcare spending = waste (including medical errors which are preventable) – @MarkGraban #LKNA13 #lean #healthcare

Marc Johnson ‏@marcjohnson

CEO’s aren’t asked to wear a badge saying “why are we understaffed?” Yet doctors are asked to wear one for hand washing #lkna13 @MarkGraban

Pawel Brodzinski ‏@pawelbrodzinski

Lean tools are just a tip of iceberg. Org culture, mindset and mgmt system are underwater part – not seen at 1st sight @markgraban #lkna13

Michael Mumau ‏@Mumau

Managers, are we looking for bad apples to blame when we should be looking for bad processes? @MarkGraban #lkna13

Pawel Brodzinski ‏@pawelbrodzinski

Being careful is not sufficient. Would careful deva create bug-free software? @markgraban #lkna13 same as “do the work right at 1st attempt”

Eric Willeke ‏@erwilleke

#lkna13 “The Five Who’s” — @MarkGraban the result of a name/shame/blame culture

Pawel Brodzinski ‏@pawelbrodzinski

And on cord is not only to stop the line. It’s a call for help in the first place. @markgraban #lkna13 Same as blockers on Kanban board

If your managers say things like “My people are very careful”, this is an indication that you have a systemic quality problem #lkna13

TonianneDeMariaBarry ‏@Sprezzatura

W/#lean,hospitals able to double amt of time nurses have bedside. Improves quality/curbs waste (less waiting/falls) – @MarkGraban #lkna13

Pawel Brodzinski ‏@pawelbrodzinski

The ultimate arrogance is to change the way people work without changing the way we manage them @markgraban #lkna13

Derek W. Wade ‏@DerekWWade

#LKNA13 Child at risk story from @MarkGraban illustrates 1 issue w lean adoption in software: our risks are seldom as grave (death, harm)

Nayan Hajratwala ‏@nhajratw

Great talk by @markgraban on lean healthcare. Nice job! #lkna13

Thom Leggett ‏@thomleggett

Inspiring talk from @MarkGraban on lean in healthcare. Plenty of transferable thoughts. Important to get an alternative perspective. #lkna13

Eb ‏@eikonne

The goal is not #Lean or #Agile or #Kanban. I hope we can continue to remember that. #lkna @markgraban

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.

There’s an excellent blog post on the Virginia Mason Medical Center site: “Does respecting co-workers make patients safer?”

As a leader in adopting and adapting Toyota management methods to healthcare, Virginia Mason understands that “respect for people” is a core part of this philosophy (as I’ve recently blogged about). Respectful behavior is an active choice we make each and every day. Disrespectful attitudes and behavior can interfere with providing the best patient care.

They quote patient safety expert Dr. Lucian Leape:

“A substantial barrier to progress in patient safety is a dysfunctional culture rooted in widespread disrespect [including] … disruptive behavior; humiliating, demeaning treatment of nurses, residents, and students; passive-aggressive behavior; passive disrespect; dismissive treatment of patients; and systemic disrespect.”

They quote Leape as saying that these behaviors are a threat to patient safety and VMMC is working to replace these negative behaviors with positive, respectful behaviors. Their blog post describes a theatrical production was created to illustrate ten key behaviors, including:

• Listen to understand
• Share information
• Walk in their shoes

A key question in all of this is whether or not an organization can really influence the behavior of their employees and medical staff. From my experience, it helps to have senior leaders modeling behaviors they want to see through the rest of the organization. When the CEO stops “naming, blaming, and shaming” in response to errors or problems, leaders at lower levels see that it’s OK to react that way themselves. But, can everybody change? Can enough people change?

See this related article from FierceHealthcare: Hospitals have had it with misbehaving docs.

One of the reasons hospitals are losing their tolerance for this behavior is guidance issued by The Joint Commission, warning hospitals that intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and adverse outcomes, increase the cost of care, and force medical personal to seek new positions.

“To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team,” The Join Commission wrote in the guidance.

An example:

Physician executive and Hospital Impact blogger Jonathan Burroughs, M.D., recounted an episode early in his career that illustrates the kinds of concerns communicated by The Joint Commission. After berating a nurse for not knowing what epinephrine and atropine were, Burroughs, upon reflection, concluded that his medical training had failed him in this situation, according to a Hospital Impact blog post. “Treating people with disrespect and shame will not improve human performance nor will it help patients to have better outcomes,” he wrote.

I hope hospitals have also had it with misbehaving executives and managers, as well! Disrespectful behavior from leaders is corrosive to an organization and a team environment… and this certainly impacts quality, safety, and other important factors in healthcare organizations (and any type of organization).

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.

It’s free online (at least for the moment), so go check out Steve Blank’s Harvard Business Review cover story on “Why the Lean Start-Up Changes Everything.”

Blank, who teaches at Berkeley and Stanford, is author of the excellent book “The Four Steps to the Epiphany: Successful Strategies for Products that Win.” His HBR piece is a nice summary and introduction to the ideas that are expanded upon in The Lean Startup by Eric Ries and The Lean Entrepreneur: How Visionaries Create Products, Innovate with New Ventures, and Disrupt Markets by Cooper and Vlaskovits.

Check it out.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.

“Approximately 8 to 10% of the individuals who walk through our doors are being hurt by us,” says David Musyj, CEO of Windsor Regional Hospital. That’s one of the first things you hear in this CBC program “Rate My Hospital,” which aired earlier this month in Canada. See also this page on the investigative report.

The patient safety challenges are pretty universal across modern Western countries. This isn’t just a Canada problem. You see similar estimates of patient harm in Canada, the U.S., England, Germany, the Netherlands, etc.

From the CBC text:

Unlike the United States and the U.K., Canada remains one of the few developed countries that has kept basic information on how well hospitals care for you largely hidden from public view.

The data and information are “largely hidden from public view” in the U.S., generally speaking. The grass always seems greener…

The story talks about the “thousands” of Canadians who die each year from hospital acquired infections. There’s one particular story about a woman who died just weeks after contracting a c. diff infection through getting routine surgery at a Vancouver hospital. The widower says people at the hospital were “compassionate” but “nobody took any responsibility.” The hospital didn’t publish infection rates (something that’s not common here either) and, while some provinces share data, it’s not always expressed in equal terms. The UK’s NHS has a national website that can be searched to view infection rates allowing people to see where mortality rates are highest.

Dr. Dick Zoutman (who I have met in my travels through Ontario) says hospital acquired infections could be the FOURTH leading cause of death in Canada. 220,000 will get infected each year. They expect between 8,000 to 12,000 dying each year from this “preventable” disease.

About seven minutes in, the story goes to Saskatchewan, where they are “using methods perfected by the automaker Toyota” to fight these super bugs. Maura Davies, the CEO of the Saskatoon Health Region, says “This is like nothing we’ve ever experienced. We used to report our results and make excuses… and now we have to have a corrective action plan that says here’s how we’re going to turn it around.”

The hospital uses DAILY data (discussed in management huddles) to drive improvement. “Are people washing their hands? Do we know if they are washing them the right way?” asks Davies.

You can hear a person being taught to wash hands using the Training Within Industry methodology, as they reference “key points” and “important steps.” Read more in this book Getting to Standard Work in Health Care: Using TWI to Create a Foundation for Quality Care. They actually have people observing to see if it’s being done the right way. Hand hygiene reports are posted online… transparency leads to pressure to get better.

In the third segment, they talk about an iPhone app for emergency departments in Alberta. A woman chose to go to a hospital that had posted an 18 minute waiting time to see a doctor, choosing that over their preferred hospital that posted nearly a three hour time. At the “18 minute” hospital (supposedly a real time piece of data), they actually waited three hours to be seen and then waited hours more to be admitted… but, in the mean time, bled to death due to an aneurysm.

“Is the app an improvement or a distraction?” The daughter of the woman who died says she thinks the app seems more like an effort to look good or to be “fake.” The app won’t tell you if patients are “parked” in the hallways. A doctor says the most dangerous thing in Alberta hospitals is the waiting times.

From a survey of nurses across Canada, ”

• 40% feel burnt out” and they feel “stretched to the limits” and “it’s impossible to provide safe care when you’re so tired.” 62% feel like they are understaffed. “Our equipment is falling apart” and attempts to fix things are met with “punitive measures” and the government only cares about “cutting costs and saving money.”

“To speak up is to risk being bullied and being threatened with job loss.”

Those are all very serious cultural problems that get in the way of improvement… again, not just Canada. Randomly running a bunch of improvement events or using just some Lean tools won’t fix these problems if we don’t address the culture and eliminate the culture of fear.

The CBC host says that provincial governments  in many cases, encouraged hospital CEOs to NOT respond to questions about what they are doing to prevent surgical errors or infections. But, the CEOs of “132 hospitals responded to us anyway.” 75% of the CEOs didn’t respond.

The last piece shows CEO David Musyj in scrubs in the workplace, “not an Undercover Boss per se” (as we had an misunderstanding about before). I give him credit for being “embarrassed” by low hand hygiene numbers and for working to improve things rather than hiding the problem, bringing rates up from 40% to 90% (and they are still working to get to 100%).

Musyj says meaningful change will happen once Canadians start demanding answers.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.

Here’s the latest in my “What I’m Reading” series, where I clear out some of the inventory of articles I’ve read, but haven’t blogged about.

NY crime lab improves efficiency with ‘Lean Six Sigma’ process

It’s great to see Lean used to help improve government operations – productivity AND quality.

If someone said you could increase the efficiency of your jurisdiction’s crime lab by 200 percent, you’d probably initiate an investigation into possible illegal use of controlled substances.

Veterans’ wait time for benefits is ‘too long,’ VA official concedes

I blogged about this before. But, sadly, it’s not any better. We need to improve flow in this approval process to take better care of our vets.

…the number of veterans waiting more than a year for their benefits has skyrocketed, from 11,000 in 2009 to 245,000 in December 2012, a jump of more than 2,000%. The VA states the average wait time after a veteran files a claim is 273 days.

Hospital infections kill 30,000 a year

This isn’t just an American problem (100,000 a year killed) — it’s also a problem in Germany. Read more statistics I’ve compiled on patient safety problems in the U.S. and around the world.

A “Wrong Patient” Surgery in France

Translated from French via Google. it appears a hospital needed to rush a man into surgery after a CT scan… except the wrong patient ended up on the O.R. table, somehow.

Ottawa Hospital C. difficile outbreak blamed on clutter, poor cleaning

Is this really so hard to fix?

Problems that encouraged the disease’s spread included cluttered rooms, cluttered nursing carts, improper handwashing stations in some of the units, and a lack of training among cleaning crews… The report also found that there was “no process to distinguish if equipment was clean or dirty” and that cleaning of equipment shared among patients was only being done when an outbreak was declared.

Brigham and Women’s airing medical mistakes

Brigham and Women’s is published stories about mistakes in an employee newsletter in an attempt to encourage people to speak up and work on preventing future problems.

“Open-faced transparency is really valuable to staff at an institution because it causes them to know themselves better,” said Paul O’Neill (my podcast with him), a member of the Lucian Leape Institute at the National Patient Safety Foundation, a nonprofit research organization based in Boston. But few, if any, other hospitals are doing anything like what the Brigham does, he said: “Unfortunately, I would say it’s highly unusual.”

Hospital workplace safety means better patient care

“To the extent that people are unhappy in their work, or feel unappreciated or disrespected, they are less likely to be focusing entirely on patients and on making sure they do everything correctly, following the safe procedures and not cutting corners,” Lucian L. Leape, M.D., patient safety researcher and adjunct professor at the Harvard School of Public Health, told American Medical News.

Feel free to comment on any of the articles below…

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus.