Lean thinking in healthcare

Please visit my (translated) Dutch blog

noreply@blogger.com (Marc Rouppe van der Voort) — Wed, 10 Oct 2012 16:07:00 +0000

This weblog used to get frequent translations from my Dutch blog. It is however not updated anymore because Google Translate does a pretty good job at it. I still blog weekly in Dutch on http://leandenkenindezorg.blogspot.com/ and you can use this link to have it translated into English.

What is leadership?

noreply@blogger.com (Marc Rouppe van der Voort) — Sun, 01 May 2011 07:28:00 +0000

Inspired by Stephen Parry

Resolution

noreply@blogger.com (Marc Rouppe van der Voort) — Sat, 15 Jan 2011 13:34:00 +0000

Learning to see

noreply@blogger.com (Marc Rouppe van der Voort) — Fri, 12 Nov 2010 19:48:00 +0000

Nurses: what is the meaning of lean for you?

noreply@blogger.com (Marc Rouppe van der Voort) — Wed, 20 Oct 2010 19:14:00 +0000

To prepare for a training, the Elisabeth Nursing Surgery Ward (B2) posed all nurses the following question:

What is the meaning of lean for you?

This offers the opportunity to get an idea of how lean thinking is experienced by nurses. Before interpreting their answers, it is good to know that they have had a basic introduction of lean thinking one year ago, and especially started to employ 5S for Workplace Organization with enthusiasm. Furthermore they have put the Lean principles impressively into practice during the development of care pathways. However it was not explicitly communicated to the nurses that they were applying lean (and that explains why you don't see that in their answers).

Their answers to the question per nurse:

- Work more efficiently with less storage supplies; to have more time for the patients, less space clogged, because of less storage space needed; less costs; less walking; less disposals; things will not expire.

- Improvement chart: improving small things on your department, within your own sphere of influence, which do not cost a lot of money.

- Have the supplies in a logical place.

- Lean. I have not been present on the day of the Lean introduction, so I must confess that - although we are employing it on our department- I still do not have the ‘feeling’. When I think about Lean, I think about logic. Supplies have to lay on a logical place, however this is not the same for everyone of course.

- Lean means for me to work efficiently, knowing what you are doing and do your things in the easiest way possible, without hodgepodge.

- To me Lean means, (possible to make adaptations to) work as efficiently as possible, without losing valuable time.

- Lean is working with a minimal of interrupting factors and unnecessary stuff around you. Everything is stored in a way that it is easy to grab.

- To obtain a clear and logic work environment.

- Less walking to gather all necessary resources for a certain operation. Thus a logical division of materials.

- Keep the operational stock always sufficient. Thus a well developed system to supplement and order while the stock is not extraordinary huge.

- To save time and to do not forget any materials for a nursing operation.

- Less stock, effective workspace division, less walking.

- Employ my daily tasks as efficient as possible. Good communication and fine tuning of the activities of your team.

- Lean means to me that the materials I need for a certain operation are within arm’s reach.

- Work more focused, less double work, less overlap, less time waste. Further concise and clear report in the patient files.

- Think more consciously about where and why certain materials are stored on a certain place.

- Work as efficient as possible.

- Work as efficient as possible. This can be on a micro and macro level. It is possible to implement Lean to a big extent into a lot of elements.

- Efficient working, and to arrange resources and materials which are necessary to work as efficient as possible. So we do not have to walk 10 times to and fro for a certain operation.

- System which focuses on the elimination en prevention of waste. Central is the factor time, because handling waste in the time factor, leads to direct improvements of stock, quality and speed.

- Working organized and structured

- Logical working: What I want, what do I need for it, how am I going to handle this to make it logic and with the least overlap and to give time gains for me as well as for the nursing and to make everything well organized for the client. It is necessary to plan, to make things happen according to certain planned steps, so everyone can keep operating and does not loose time with cases that could have been handled long time ago or write so much that the overview is lost.

What do you notice?!

P.S. My gratitude goes to Nynke Reitsma for translating my Dutch blog

Book: Toyota Kata

noreply@blogger.com (Marc Rouppe van der Voort) — Fri, 10 Sep 2010 19:37:00 +0000

I started reading the book Toyota Kata by Mike Rother and I read the first three chapters so far. He argues that the world has only looked at the visible aspects of Toyota, the processes, methods and principles. He stated that you should not look at those aspects, because the real explanation what makes Toyota so special is invisible. He refers to way of thinking and the routines that are normal at Toyota: the Kata’s. This is a Japanese term, normally used in martial arts for patterns that are repeated again and again into perfection. The book describes two Kata’s at Toyota:

The Improvement Kata
The Coaching Kata

If you get past his slightly arrogant introduction that he finally figured the real secret out, he offers a number of rich insights. He explains quite well how organizations keep repeating the same mistake when they want to change something: they fall in the blind implementation mode. The consequence is that they try to make the change process as predictable as possible. We find it hard to accept the fact that organizational development is an inherently unpredictable process.

It is the art to release the urge to want to control what changes at what moment (I recognize that this can be difficult). It is the art to continuously adjust the direction based on new insights. In an implementation mode, there are unpredictable events and problems that distract you from your goal. But those unexpected events are always there. How many time is spend on making plans and how much time is spend on explaining why they are not implemented as planned?

A wise strategy would accept the inherent unpredictability of development processes and would seek strength in the adaptive capacity of the organization. You need some method that provides the needed confidence that good progress will be made. And that method is often lacking as one falls back into the implementation mode.

He states it is exactly the ‘Improvement Kata’ and ‘Coaching Kata’ that enable Toyota to adapt adequately. Rother described how Toyota makes improvement very specific in three conditions:

1. Current condition
2. Target condition
3. True North

True North is deliberately vague and unattainable. It is about the principles that you set above everything. Such as one-piece-flow. Toyota will never attain full one-piece-flow, but she tries to get closer to the ideal situation step by step. Toyota even has sessions where they discuss what they will offer the world for the next 500 years. They end this type of session with what the outcome implies for the next steps they have to take tomorrow. The result of the session 500 years has a shelf life of one day. The goal is not to predict the future, but to get you out of your comfort zone and the essence is to better determine the next step.

The current condition is how the process works now, what you see when you are filming the process. The target condition describes the following situation that the process will reach on its journey to True North.

Is this different than what we are used to? The target condition is based on a thorough understanding of the current condition. It’s a concrete step forward, not an ambitious objective. However, it can be very difficult to achieve.

A simple example: in the laboratory of our hospital tubes of the another hospital are also processed. In our hospital and in the other hospital the same racks are used to place the tubes in. The carrier operates with a type of cooler in which other types of racks are placed. So the other hospital must transfer each individual tube in the cooler and we have to do this again from the cooler to our own racks. The leading analyst of the laboratory appointed this waste and set the target condition that the process must be improved so that no transferring of tubes is needed anymore. To determine which target conditions must be set, True North is guiding. If it is a step forward towards True North, then that direction is chosen. If not, then not. The way a step towards True North is made is thus the Improvement Kata.

The Coaching Kata is the way managers at Toyota coach people to apple the Improvement Kata. Once a target condition is stated for example often people tend to explain why it is not possible: the carrier in the example works for many other organizations and will never replace its coolers and racks for us?!

The manager coaches people to deeply investigate what the root cause of the problem is. Which assumptions hinder creative countermeasures? He coaches the improvement and learning process.

Improvement must be seen as something you need to exercise, like a team of top athletes who are coached to perform better every time. That is the main task of an executive at Toyota.

Clear and appealing book so far, I'm curieus how he will elaborate further on the Kata’s.

P.S. My gratitude goes to Nieki Peerbooms for translating my Dutch blog

Article: 'Approach to efficiency is not well thought through'

noreply@blogger.com (Marc Rouppe van der Voort) — Mon, 02 Aug 2010 15:13:00 +0000

Recently, an article ‘Approach to efficiency in healthcare is not well thought through’ (Aanpak effieicny in de zorg is ondoordacht) appeared in 'Medisch Contact' by W.H. van Harten, E.W. Hans en W.A.M. van Lent. In this article, they assess the business methods of the last years in Dutch hospitals, including lean management. They conclude that the methods are often accidentally or fashionably chosen. They also argue that there is little scientific evidence for the methods. Click here to read the whole article (in Dutch).

What I like about the article is the long-term perspective with which they look at the application of the methods. I also l and that they base this on the current problems of individual hospitals and they thus emphasize the importance of customization. Their final conclusion is:

“The variety of combinations of organizational development, type of problems and available methods requires a customized solution. Approaches that stress a culture of continuous improvement and that leave room for personal interpretation, such as lean management, seem therefore to offer currently the most perspective and besides that, they are easy to maintain. And that is very important, because introduction takes years in large organizations.”

I illustrate a few statements about the various methods:

“Theory of constraints (TOC): Addressing the most pressing problems in health care processes sounds sympathetic and will lead to results when there is only one bottleneck. Processes are usually complex, various departments are involved and there are connections between bottlenecks.”

Indeed, that is also my experience. Although, the methodology provides some good methods. In my experience it can be complementary to lean thinking.

“Six Sigma: This approach consists of two elements that can stand at odds with health care: the virtually 100% reliability that is rarely realized in medical processes and the hierarchical ‘belt-qualification’ that will, especially in the egalitarian Dutch organizations, face difficulties in the introduction.”

Indeed. Six Sigma is appropriate for only a limited number of processes. Currently, this is useless for most of the processes. Moreover, the approach does not fit in our culture. I do see several hospitals pursuing a sort of mix of lean and sig sigma and I am curious about the results.

The following is said about lean:

“Lean management: the philosophy behind lean management is rooted in the auto-industry (Toyota) and is about the elimination of waste, the application of techniques to improve the quality of the processes and to add more value for the customer. Creating and implementing improvements takes place at the work floor. Value adding, reduction of waste, direct observation and continuous improvement are key terms. It takes decades to implement an approach into the entire organization: success stories, based on a project of one year are therefore not reliable and are not representative for an organization-wide implementation. In the literature, we found 24 techniques that are rallied under LM. This gives the method a toolbox character and offers opportunities for adaptation to the care environment.”

I agree with their criticisms on the success stories on project management that never cross the full depth of lean. I also agree that the way lean is used and published often gets a toolbox character. I believe however that this is a pity, because in this way the essence of lean thinking is ignored and in this way it can never deliver a sustainable contribution for an organization. This is the reason why this web log is called ‘lean thinking’, to emphasize that it is a way of thinking and the tools are only of secondary importance. They interpret the toolbox character as positive, because a toolbox means that you can determine for every case which tools you need. And that is of course the power of lean. It has principles that can inspire you and a wide range of techniques that you can use depending on the situation.

Finally, they argue:

“Our experience is that when a method is imposed in a hospital with many self-employed professionals, in a a dogmatic and forced way, that this will rather lead to resistance (or pseudo-cooperative) than to successful (local) decisiveness.”

This seems obvious, but apparently it is not. I consider lean thinking and the principles of the Toyota Way as a source of inspiration that can help us to improve our organization and our processes. Because they are essentially different from one another, they provide innovative insights. This means that a serious translation is needed for the health care. Once the introduction of the principles and methodologies have become an goal itself, the current practices get out of sight and any right-thinking professional will start to offer resistance. And that is a good thing!

As for the title 'Approach to efficiency in healthcare is not well thought through' I can only speak for ourselves (the Elisabeth Hospital). In our hospital, lean thinking was applied independently by various departments in 2006. The departments were very enthusiastic and the approach seemed valuable. Extensive discussions were held and also other approaches were considered. We came to a pilot of four departments in 2007. This was evaluated in 2008 and lean was chosen to experiment further (but not yet as the central improvement approach).

Meanwhile, a V-team was created with four medical specialists and three managers who examine and foster the development of the principles in our hospital The V-team includes the chairman of the Medical Staff and the Chairman of the Policy Commission. We organized a symposium and work conferences and all (medical) managers have followed a course of Toyota. Based on these experiences we, as a hospital, have embraced lean thinking in 2010 formally as a source of inspiration and have connected it to our own developments (with as main focus: compassionate care). I have the impression that we certainly did think it well through before we chose to apply the lean principles.

How do you experience this? Do you feel addressed by the statement that hospitals choose their approach not very thoughtful?

How to mobilize an entire nursing unit

noreply@blogger.com (Marc Rouppe van der Voort) — Wed, 23 Jun 2010 08:05:00 +0000

A recurring question is how you can mobilize an entire team, unit or department to work with lean. Too often, I see small groups of enthusiastic people who are wondering how to get the rest involved. One element you can use is a training for the entire unit. For the department of Orthopaedics this seemed to work well.

Recently, the department of Orthopaedics organised one evening and one day training in the Lean principles and tools for the entire care unit (60 nurses). They were very well prepared! Four months before the training day, they started to prepare and work towards it. All three departments (secretary, nursery department and outpatient clinic) got a digital camera in November to photograph improvement points or irritations (based on an idea of Neruosurgery, see previous blog), which provided more than 50 photographs of concrete waste or unsafe or unpleasant situations. These pictures have been printed on A3 size and laminated. At the training a reward was given to the person with the most striking picture. These pictures were used as starting points for improvements. Smart, because in this way you directly got 50 points of improvements provided by the people themselves on which they want to work.

They also made a movie for the training. They have put the process in scene from the moment that the OR calls for a patient to come for surgery until the patient is ready to leave the nursing department. This process takes 15 minutes, because the patient must change clothes, visit the toilet, medication is given and the bed prepared. The movie showed a lot of types of waste (that were actually not put in scene, but really happened). Employees recognized these immediately. A few examples:

- Cotton balls were out of stock when the medication needed to be prepared, new cotton balls had to be taken elsewhere
- No IV pole available on the bed, had to be taken out of another room (and there the problem will start again with the next patient)
- No ‘parret’ or parrot on the bed (so that the patient can pull himself up in bed), this parrot was also removed from another bed in another room (where it will be gone for the next patient)
- The nurse had to walk up and down several times to get something which she could also get at the same moment. For example a glass of water for medications, OR clothing and bellovac medication.
- Nurse had to wait for the patient that went to the toilet. This could have been done parallel with other activities
- A call came in from the OR that they had forgotten to give the patient some medication.

All in all, the conclusion was that the activities can be done in half the time, seven or eight minutes. And this would save seven or eight minutes many timee a day. It became clear that filming a work process is a wonderful trainings tool.
The training itself was designed as follows:

Evening show: The whole care unit came together from 7:00 p.m. to 10:00 p.m. to learn more about the principles of lean thinking and a first exercise was done to apply the principles to their own practice (what is value, what is waste, what processes do you work in?). The introduction of lean thinking was done by Dirk van Goubergen, who put on a great show. At this evening also the prize for the most striking picture was presented.
One week later: “a day practicing with lean thinking”. We arranged this day by ourselves in the hospital (1/3 of the group, all disciplines together, one week later again 1/3 of the group and a week later again).
- Start interactively with post-its: what would you like the care unit to achieve with lean thinking?
- What is value and what is waste? A discussion about values in practice
- How to recognize the seven forms of waste? An exercise with a video recording with a practical (non-healthcare) example and participants are asked to call out any time they see a form of waste. After the video the group thought of improvements to increase value and effiiciency.
- How to analyze a process? The movie of their own process was used in groups of 5 or 6 participants. Create a (simple) process description and indicate where value is created. What types of waste do you see? What are ideas for improvement.
- Each team selects a problem and applied the A3 method:
1. What is the problem?
2. What is the current state/practice?
3. What causes the problem?
4. What is the ideal state/practice?
5. Then (!): What are possible countermeasures?
6. Concrete agreements how to test and evaluate a countermeasure

- In the afternoon the A3 method was applied again, but this time on a picture that the participants themselves created. A new element here is that in each team one person observes the team dynamics and whether or not the A3 method is applied appropriately and this person’s task is to appoint where the team can improve. Most mentioned points of improvement were not to jump to solutions, but to understand the problem first. Another point of improvement is to listen more carefully to each other.
- The group was then split into two sub groups:
o One group went to analyse the daily rhythm of the department: what do we at what time and which activities come in between other main activities? What is the busiest moment and are we able to perform those activities in another way or at another time? The group became enthusiastic, especially when regular rountines were questioned. At one point there was even asked why patients have to conform to the rhythm of the department rather than the other way around. They actually started an experiment on this subject, which will be discussed into more detail in a later blog.

o The second group went to a workplace to look how this place could be better organised using the visualization tool. To their surprise, a lot of concrete ideas were created.

- The training ended with a discussion of what had been learned that day and what the participants would remember at home. Besides a number of concrete actions created with the A3 method, the following aspects were mentioned: it is surprising to see how much room for improvement there is, it is nice to do this together, it is important to first understand a problem before we think of solutions, organising workplaces better (with visualisation) and to make a day rhythm more suitable for the patient.

Since the training, all kinds of things are happening: a photo board has been made on which three pictures are placed of waste and the way they are being improved, improvement boards are used (see previous blog), and the management is asking itself how to give more structure to all improvement initiatives. These are the better problems to worry about!

P.S. My gratitude goes to Nieki Peerbooms for translating my Dutch blog

Book: If Disney ran your hospital

noreply@blogger.com (Marc Rouppe van der Voort) — Tue, 18 May 2010 12:42:00 +0000

I finally got around to start reading the book “If Disney ran your hospital’ by Fred Lee. I have heard a lot about it last year, and I am curious whether it can help our lean journey. Or will my predisposition be confirmed that the approach to care will be too simplistic, as if we should just entertain the patients more? Well, the first chapter did not disappoint me. Fred Lee has worked in a hospital for a long time and his mother, sister, partner, and daughter are nurses. One can feel that he is used to think from a care perspective. The most important connection with ‘lean thinking’ is in the first place his reflection on ‘value’, the core of lean thinking.

Fred reflects on the value that is of importance to gain patients’ loyalty. The elements care providers have to pay special attention to in order to accomplish this loyalty are:
- Be alert on peoples needs, before they ask for it (initiative)
- Help each other (teamwork)
- Recognize the feelings of people (empathy)
- Respect the dignity and privacy of others (courtesy)
- Explain what is happening (communication)

Intuitive this list gives me a good feeling. However, does it offer new points of application for the care we are giving at this moment?
Regularly I see good examples of all five points, and I also see examples of situations where we could improve. Thus all five are relevant, however they do not cover any blind spot. We are already conscious of all of them.

Our hospital is besides with lean thinking also occupied with the theme ‘compassionate care’ (or literally translated: loving care). At the first sight ‘empathy’ and ‘politeness’ (dignity and courtesy) seem to match directly with this theme, and ‘communication’ indirectly. ‘Teamwork’ and ‘initiative’ are more closely linked to lean thinking. Though with some effort one can link all concepts with each other. ‘Respect’ is for example also one of Toyota’s core principles. When we train a team in continuous improvement, we underline the aspect of respecting each others ideas and giving each other room to experiment. First try to understand the other, before you want to be understood yourself.

As part of an improvement project, we recently interviewed a patient. This patient declared to be insecure about several aspects. He did not know who ‘his’ medical practitioner was (because he had to deal with several medical practitioners), although it was regularly asked by others in the hospital (to fill in a form). Furthermore, he did not know when he would receive the results of medical examinations. He did not dare to ask for it for two days, because he did not want to be annoying. This resulted in insecurity and agitation by the patient. This interview confirms the importance of ‘be alert on peoples desires’ (initiative) and ‘communication’ for care providers. Although we think we put a lot of effort in these elements, patients have a different experience. I am curious how these concepts will be further elaborated on in the book.

Our care unit General Surgery is being trained on regular basis by trainers of the Efteling (large Dutch amusement park). At this moment they even have their own educated trainers as part of their theme ‘The customer is king’. They are very enthusiastic and make the combination with lean thinking in their development of care pathways. When working with them, I feel indeed an above average patient centered attitude and willingness to go an extra mile for the patient. We can come up with the best way to organize a care process, though for each patient we have to be alert on their individual needs. Vice versa, when the processes are not well organized, one can work as much patient centric as possible, however the patient will not experience good care.

Fred Lee makes the connection between improvement of ‘outcomes’ vs. improvement of ‘perceptions’ (the latter is thus where his book is about). He explains the two perspectives as:
- Focus on team responsibility vs. focus on personal responsibility
- Define and analyse processes vs. take action based on information – just do it
- Understand variation of processes vs. understand the perception of patients
- Improve the competence and skills of care providers vs. improve behaviour and attitude
- Emphasize what people have to do vs. emphasize what people have to say
- Search for measurable outcomes vs. search for impact on impressions
- ‘Make no mistakes’ thinking vs. ‘as well as possible’ thinking
- Eliminate inaccurateness vs. eliminate avoidance

The common application of the lean thinking principles has more resemblemnce with the left site, however also the right site is clearly recognizable. For example ‘taking action based on information – just do it’ fits with ‘continuous improvement’ as a regular aspect of the daily work. Furthermore the personal responsibility is emphasized many times. Nevertheless, lean thinking commonly has less focus on behaviour and attitude. I can see connections between ‘lean thinking’ and the story of Fred Lee, and I will curiously continue my reading.

P.S. My gratitude goes to Nynke Reitsma for translating my Dutch blog

Photo contest to bring lean thinking closer

noreply@blogger.com (Marc Rouppe van der Voort) — Mon, 12 Apr 2010 13:29:00 +0000

Part of lean thinking is activating and recognizing all grey areas in your team. The ward Neurosurgery of the St. Elisabeth Hospital created a beautiful intervention for this: a photo contest to visualize improvement opportunities.

They purchased a digital camera and placed it on an easily accessible place. Everyone of the ward was invited to take a picture of something that annoys them at that time. A few weeks later this resulted into 40 (!) photos. The prize for the best photo was two cinema tickets (cinema= seeing….of waste). Here is the winning photo:

Angela Rutten, who is quality officer of the department, gives an explanation of the photo:
“This is a photo of a bin which is on top of a medicine trolley. Medication that remains after a patient is released from the hospital, is removed from the intended boxes and is put into the bin on top of the medicine trolley, as seen on the photo. However, this bin is not intended for left over medication, and the consequence of this is that medicine is easy accessible for everyone, which is unsafe. In addition it turns out that this waste container is seldom cleaned out, resulting in an increasing pile of medication.

We have already taken a countermeasure. We have introduced a suitable plastic container in which all the medicines are gathered that does not have to be given to a patient anymore. The night shift will empty this container during the standard process of preparing the medication and will also dispose the waste medicines in the proper way.

As a result no (large quantities of) medicines are lying around, it is not easy to grasp and someone is responsible for disposing of the remaining medicine. Another pleasant advantage is that the nurses from the day and evening shifts are not bothered anymore by a bin with medicines which must be cleared, but now have the time to do it in a safe and correct manner”.

This ward is working with the Improvement Chart. Since the contest, photos are put on the Improvement Chart one by one and on the basis of this photo, countermeasures are taken to tackle the underlying causes. In the coffee room a digital photo frame is present which shows the other photos, waiting until they are addressed too.

The intervention turned out to be a particularly fun way to involve everyone. This way of working is also works well because countermeasures are taken for concrete matters within the direct influence of the team. In this way, the team will notice quick results and improvements on subjects that they are interested in and this makes it fun to improve continuously.

P.S. My gratitude goes to Femke van de Pol for translating my Dutch blog

Flow in the hospital: Aravind Eye Hospital

noreply@blogger.com (Marc Rouppe van der Voort) — Fri, 26 Feb 2010 20:52:00 +0000

One of the key principles of Lean thinking is the creation of flow. Flow as in no waiting time if it has no added value (time to think and reflect or time to process bad news are examples of waiting times with added value).

What would a hospital look like without waiting time? So far, I have only seen this question answered as a “what if…” exercise. However, there appears to be a hospital in India, which seems to know the answer to this question.

On November 13th, Hanneke Molema defended her phd thesis on ‘Hospital system design: creating variabilitiy to match demand variability’. Chapter 5 describes the flow of patients at the Aravind Eye Hospital in India. When you fly to India and visit the hospital without an appointment, you get your diagnosis the same day and when you want a surgery you are asked: When would you like your surgery? Tomorrow?

Her thesis raised the following questions (the responses as described in the thesis can be found behind the questions):

“Right, well I’m sure that only counts for the rich people? They probably have a lot of overcapacity?” This, however, is not the case. Their mission is as follows: “a social organisation committed to the goal of elimination of needless blindness through comprehensive eye care services” (check their website). They operate mostly poor people. Furthermore, people can decide for themselves how much money they can pay for their surgery. 60% of the people is not able to pay and gets the surgery for free. The other 40% have more money and take care of the other 60%. In this way they are able to achieve their mission.

“They probably do not treat many people then? With only a few patients per day I am also able to do this”. At their location called Madurai, they performed 581.000 outpatient consultations and 91.000 surgeries in 2008. For comparison, the largest eye hospital in the Netherlands is in Rotterdam and performed 139.000 outpatient consultations and 12.600 operations that year.

“Because of their large numbers there is almost no variation?” The number of patients ranges from 800 to 2000 per day. This is similar to our hospital, if it is not even more difficult for them, because it is pure naturally variation they have to deal with (it depends on the patients choices). The fluctuation of the number of patients per day in our hospital is for a significant part a result of the way we organize (e.g. patients are told to come back three months later for a check up).

“The quality must definitively be below acceptable standards?” International benchmarks show they can compete with Western hospitals. They provide excellent quality.

“In that case, they probably have more staff?” The same international benchmarks show that they need significantly fewer people to provide the same quality and to realise an even better flow. In Madurai Aravind 983 people work, including 46 senior doctors and 94 junior doctors. In contrast, 313 people, including 29 senior doctors, work in the eye hospital in Rotterdam. While Aravind carries out seven times more operations.

“How do they do this?” Their approach differs on several aspects:

Way of working

- Far-reaching standardization: everyone performs the same actions in the same manner. Individual preferences are subordinate to the interests of the whole.

- Far-reaching task delegation: specialists are only doing specialist work. A cataract operation takes five to ten minutes (this varies indeed per surgeon). A specialist operates 60 patients in one morning.

- Processes are being improved step by step and this refinement process continues. They reduced the time between the end of an operation and the start of the next operation to only a few seconds.

Planning and reaction

- Strong anticipation: from previous experience (numbers) they know how many patients will come at what month and at what day of the week. They prepare for this by increasing capacity at busy days.

- Strong reactive capacity: the planning processes are designed in such a way that it is immediately visible when demand is greater than predicted at a moment in time. The employee who sees this gives a signal to people from other departments who are asked to come and help immediately.

Flexibility

- People are trained to work in different departments. People are constantly trained not only to deliver better quality care and to improve skills, but also to further increase flexibility.

- Attitudes: people need to work together to ensure that the patients gets what he needs. Not self-interest, not their own department, but demand determines who works at what place (according to knowledge and skills).

An interesting case! I do not know if the methods, used at Aravind, could also be implemented in the Netherlands, but I know no other hospital in the world that comes so close to flow as characterized by Toyota. Take a look at the thesis ‘Hospital system design’ for more information. Click here to contact Hanneke Molema.

P.S. my gratitude goes to Nieki Peerbooms for translating my Dutch blog

How do you start with lean?

noreply@blogger.com (Marc Rouppe van der Voort) — Sun, 14 Feb 2010 08:37:00 +0000

I am frequently asked how to make a start with lean and how to determine the objectives when starting with lean. First of, lean is an improvement strategy. So there are no lean objectives. There are only team, division or hospital related objectives. The lean principles, instruments and way of thinking, can be used to accomplish these objectives. Where to start, thus depends on what you want to accomplish with a team, division or hospital.

Are your issues for example:

A declining number of patients?
Enough patients, financially healthy, but we want to improve quality and service delivery, because this is our vision and/or we want to achieve stronger patient loyalty?
The workload is too high; the work of the care providers does not provide enough fulfillment anymore?
We see the world changing, and are worried whether we are able to change rapidly enough to keep up with these changes? We want to become more flexible and improve on a systematic basis.

Are you making a start with lean only to solve short term problems? The use of a few relevant instruments will be sufficient. Or do you desire to develop your team or organization on the long run? Do you want to work on the DNA of your organization? Your answers to these questions are relevant for how to make a start with lean.

No matter what answers you may provide: start today. Everyone who wants to make a start with lean thinking is able to apply one of the lean principles or instruments today. They are concrete, in many books and articles well described and applicable for every (care)process and team. Give an answer to the questions raised above, however do not wait for the answer.

The way to learn lean is putting it into practice, which can be accomplished by making (especially) small efforts. As soon as it starts to work, point your effort at the most important issues. Certainly mistakes will be made, because you have insufficient experience or you are not able to oversee everything. When you are able to learn from these mistakes, you will achieve a lot more then when you keep on searching outside the daily work.

Certainly do not start with a lean project if you want to work on the DNA. Lean thinking can not be achieved by projects, because that contradicts with the lean principles. By creating lean projects, lean is stated as something special, which causes a disconnection from the daily work. Then you can expect issues with regard to ‘communication, resistance to change, and assurance/safety’. Lean is about involving everyone, every day.

When you want to make a start in daily practice, without knowing the answers yet to the questions raised above, there are two good instruments to introduce lean thinking:

The improvement chart (See previous blog)
5S workplace organization methodology (The core of this methodology is that a team cleans up the workspace, arranges the workspace reasoned from a process perspective, and visualizes and standardizes in order to improve work practices for everyone. Click here for further explanation http://en.wikipedia.org/wiki/5S_(methodology))

These two instruments offer a few strong benefits to start with:

They are easy to explain to your team and offer the ability to start today.
They do not request any investment.
They deliver direct visual results for everyone.
They involve the entire team. Everyone can participate individually (clean up workplace, make notes on the improvement chart), but the results are collective (collective decisions about the workplace organization, collective decisions with regard to countermeasures at the improvement chart).
In this way they extend the ownership of the improvement approach and the work processes.
They ensure that improving becomes a part of the daily work.

These benefits are worthy of consideration when thinking about how to make a start with lean. Certainly lean principles and instruments can also be used in improvement projects. Value stream mapping is for example a good instrument in order to improve processes. However, do realize that using this instrument does not mean you are making lean thinking an aspect of everyone’s daily work. The more success you accomplish with it, the harder it consequently will be to make lean small and valuable for everyone.

I do not believe in the statement that one should first reach results with projects before everyone is convinced. What you can do is organize projects in a way that really involves everyone and make improvement in small steps. In this way the project becomes a learning environment and by practicing, learning will be achieved and collective meaning will be attached.

How did you start? (How are you about to start?) Why? And what have you learned?

P.S. my gratitude goes to Nynke Reitsma for translating my Dutch blog

Toyota in trouble

noreply@blogger.com (Marc Rouppe van der Voort) — Sat, 06 Feb 2010 15:55:00 +0000

Last week Toyota announced their unprecedented worldwide recall of millions of cars. What does this mean? Is this a sign that the Toyota Production System does not function well after all? Should we be more critical of lean thinking?

I think that Toyota is indeed in trouble and suffers a fundamental problem in their quality system. This can also be deducted from the statements Toyota itself makes. Aiko Toyoda, grandson of the founder of Toyota and CEO since 2009, stated recently:

"Toyota is no longer a winner"

What happened? What can we learn from this? Recently Takeshi Uchiyamada, vice-president of Toyota and responsible for research and development recently, stated that Toyota has been:

"thinking of market share first and only then of the development of products"

Earlier, in October, Aiko Toyoda went even further in an interview. He stated:

"Toyota is a step away from capitulation to irrelevance or death. The company is grasping for salvation."

Until the end of the last century Toyota was known for the extraordinary way they were able to think from the customers point of view. Somewhere in the beginning of this century this has shifted towards becoming the biggest car manufacturer in the world. In 2008 they achieved this (they sold more cars then any other car manufacturer), but now it seems at the expense of the quality system. A conclusion could be that the principles and instruments only work if your main focus is not market share or profit. They only work if you truly think from the point of view of the customer (or in healthcare from the point of view of the patient) en really focus on quality from a long term perspective.

As noted by John Shook, it' makes sense to distinguish between the Toyota Production System (TPS) and Toyota's production system. TPS are the principles and methods that Toyota developed over the years and until recently Toyota has been world class in applying them. Toyota's production system however has declined recently because of loosing the core values that made the company special. That does not make TPS less powerful, but it does mean that we should look differently towards current Toyota for inspiration.

The statements of Toyota give confidence that the top level acknowledges the extend of the problems and that they are already working on going back to the core values. If they manage to achieve this, it will certainly be interesting to study and learn from how they become world class again.

Continuous improvement with the 'improvement chart'

noreply@blogger.com (Marc Rouppe van der Voort) — Sun, 10 Jan 2010 10:39:00 +0000

When we our lean journey in the St. Elisabeth Hospital en we read about 'continuous improvement' we first thought that it implied that we will be running much more improvement projects. We have come to understand that Toyota acts very differently. At Toyota everybody works continuously on improvement. Put differently: improvement is part of your daily work. You perform your activities to create value and you think about how you can do it a little bit better tomorrow.

Which methods support this? Toyota uses many methods, but one of the most well known is the 'andon'' chords. When someone sees that a process is not performing as it should, they pull the chord. A specific music starts to play and several people come and analyze on the spot what the problem is and which countermeasures can be taken to prevent it to occur again. At the picture the arrows point at the 'andon' chords.

This is difficult to apply when treating patients. We can't just stop the care process (or maybe we can, but at this moment it is hard to imagine). That's why we embraced an instrument that has proven to perform a similar function very well in our hospital: the 'improvement chart'. The picture below shows an example of the improvement chart on the Neurosurgery ward.

The chart on the picture is in Dutch. The headings translate in to:
- Date
- Problem
- Countermeasure
- Action: who does what?
- Evaluation date

The method is:

When someone can't perform his or her work as it should be, he or she writes it on the chart. E.g. this patient has been twice to the ED and has been treated by two different neurologists. I need to book a follow-up appointment, but I don't know with which Neurologist.
Every day or several times a week the whole team gathers at the improvement chart for 15 minutes. People who wrote on it explain the problem. There is a check: is the problem clear?
The team discusses the cause of the problem. Do we understand why this problem occurs?
The team discusses possible countermeasures. What can we test to prevent this from occurring again or what can we agree so that the next time we know what action to take?
The team decides who does what and when they will evaluate the effects of the test.

The decided actions of the former discussions are reflect on:

Those who too actions tell the team what they did. The team evaluates the effects they have experienced and decide whether the new way of working becomes the new standard or whether further tests are needed.
If it is the new standard, it is removed from the improvement chart and on a second chart, the 'This is how we work' chart, the new method is written down. If relevant, it becomes a procedure ow work instruction. It is also noted on a digital chart so that later all improvement activity can be reviewed.
periodically the team evaluates the improvement chart and discusses which theme's keep occurring on it. They can decide themes to improve on.

The underlying principles correlate with an earlier blog: 'the art of making things small'.

The first improvement chart was tested in October 2008. One year later there are over fifty improvement charts in use in our hospital, in every type of department. Almost every week a department requests support to also introduce it in their teams. Apparently it addresses a strong need and appeals to the teams.

We also learned that about a third of the teams struggle to use it well. They sometimes tend to make problems big, turn the improvement chart in a complaining chart and consequently don't see enough progress. They sometimes don't have (nor create) enough time to work on improvements. Sometimes they lack the skills to apply the method thoroughly.Sometimes also they chart is to isolated. If the team works too much on improvements that are not a priority for the department, the support diminishes.

Despite these problems, the improvement chart is very popular and clearly the most applied instrument in our lean journey untill now. It's indicative that it spreads itself by word of mouth.

The chart enables teams to draw problems into their sphere of influence. By visualizing problem and having a format handle them they become much more productive in the improvement efforts. They experinece it as an intuitive method. Improvement indeed becomes a normal part of everydays work.

Lean leadership

noreply@blogger.com (Marc Rouppe van der Voort) — Tue, 29 Dec 2009 11:06:00 +0000

How do managers lead at Toyota? When we (two groups of doctors and managers from the St. Elisabeth Hospital) were trained in the Toyota Training Centre in the Netherlands it became clear that Toyota has a very different leadership style then what we are used to. For example, progress is reported with three symbols:

A circle: progress is good
A triangle: progress is problematic, but I'm working on it
A cross: I don't know what to do, help!

At first, it felt similar to the traffic light symbols we see often in dashboards in Dutch hospitals, usually based on system measurements: green is above the norm, orange is below the norm, but within a close margin, red is too far below the norm. The three symbols of Toyota however are a personal reflection: that is how I think progress is. Furthermore, they are about 'progress', not status.

In the Dutch culture (Western culture?) I'm used to it that management wants to see as much green as possible. The more green, the better. Reporting on orange or red is something to be avoided. You try to solve your problems before you need to report them. When this does not work, the temptation is strong to influence the numbers to reach the green levels. People get a compliment for green. Conversations become difficult when there's orange and red to talk about.

Learning from problems
At Toyota the circles are pushed aside. They are not interesting. The triangles, they are interesting. How are problems dealt with? How are they analyzed? How are countermeasures searched for and how are they being tested? How does the team learn? The manager coaches on the application of the methods and principles when dealing with problems. Do they go to the source? Are tests fully evaluated?

Their approach is that someone who reports a lot of green does not stretch the boundaries, he does not learn much. The do not give compliments for green, but for the learning process at orange. But what if you are very effective and your results are simply good? If a process is stable (green), a manager at Toyota might take away either ten percent of the time that is spent on the process or ten percent of the throughput time. This will make the process unstable (orange). Then the operational manager coaches the team to stabilize the process again (green). The manager of the operational manager coaches him or her on that learning process. There lies the essence of quality thinking at Toyota. It can always be just a little bit better tomorrow.

Their philosophy is: be hard on the process en soft on the people. This works with very short cycles. Coaching happens on a weekly or even daily basis. Crosses are almost never reported before a triangle has been reported before. Upper management is already involved in solving problems when they are small. Surprises are rare.

Another difference: they coach on the shop floor. By visualizing their processes, the problems and the countermeasures as they occur (for example with colors and improvement boards) they directly see the triangles in the processes. That enables them to coach from a deep understanding of the situation en conclusions can be applied directly.

To enforce the methods and principles of lean thinking, we will also need to address the way we lead and the way we develop leadership in healthcare.

Can you relate to this?

The art of making things small

noreply@blogger.com (Marc Rouppe van der Voort) — Sun, 29 Nov 2009 20:10:00 +0000

There are different ways to improve processes. 'The art of making things small' refers to the choice to reach your goals in small steps. This relates to principle 14 of the Toyota Way: "Become a learning organization through relentless reflection (hansei) and continuous improvement (kaizen)". Why would you want to make things small? Because a pitfall of projects is that we discuss for weeks or even months before anything changes. The risks with this approach are:

The longer it takes for the first change to take shape, the more people who experience the problem loose faith that it will be resolved. The support for any change crumbles.
Many of those who perform the work in the process where the problem occurs are not involved in the thinking process. This means that you need good communication (which is often problematic) and often the much feared 'resistance to change' starts to take shape.
The solutions are developed separate from the work floor, separate from the (physical) place where the problem occurs. That means there's a real risk that the solution will not exactly fit the complexity of the situation where it's supposed to work.
Perhaps the solution will be piloted, but by now those who are in favor of the solution have argued for weeks or months to promote it and they now have to prove that it works.They have connected their personal reputation to the solution and will not like to see that it fails. Those who are not in favor of the solution hope that it will not work, they might even influence the results of the test to make it not work. Will this be a good test?

Recognizable? I have seen this happen over and over again. The art of making things small is a method that approaches it very differently. It is based on the teachings of Roger Resar on Reliability. The essence is simple: reduce changes to a size that you can literally test tomorrow. A team can use the next steps do achieve this:

Define the process where change is needed.
For example: it takes too long before general practitioners receive the letters form the specialist about the results of patients.
Describe the process in four or five steps.
For example: appointment - dictate letter - write letter - send letter.
Define where a problem occurs. If necessary: describe this step in four or fives steps.
For example: time between appointment and dictating takes too long.
Define a change that you can test tomorrow. Choose the most easy circumstances for the test.
For example: one specialist will dictate one letter for one patient right after the last appointment on the less busiest day of the week.
Evaluate whether the test worked. Just yes or no. Evaluate why it did or did not work. Define the next test.
Keep on testing the idea or new ideas until a good countermeasure has proven itself in practice. Make this the standard new way of working.

To solve the complete problem of the total throughput time, the time between the appointment and dictating is probably only part of the problem. There are likely to be multiple causes. The idea is that more then one test run simultaneously. If a team is experienced, four tests can run at the same time, each test lasting one day or week.

Except addressing the risks as described above, there are other reasons to apply this method:

By making changes smaller, they are pulled into the sphere of influence of the team. They can achieve more changes themselves.
There will be more learning. Learning by doing is more effective.
Decisions are more based on facts, more based on experience. Opinions and emotion become less influential.
Changing becomes more fun, because the people that undergo the change decide and evaluate the change themselves. There is more ownership, more pride.
Less time is spent on meetings.

This method is based on the 'plan-do-check-act' cycle of Deming or perhaps more accurately from Shewart. Reread the six steps above to recognize them.

There are also pitfalls with applying the art of making things small:

Not enough analysis why there is a problem
Suggestion: you do need an understanding of the cause of the problem. Often this is clear enough and you can start testing directly. But sometimes you do need further analysis to assure that you are not addressing aspects that are not relevant to the problem.
Not enough coordination of the tests. The team goes testing changes without keeping track of the effect on the problem that needs to be solved.
Suggestion: keep going through the complete cycle (see above). Not only for each test, but for the complete problem. Someone is responsible for the coordination (the owner of the problem).
Reluctance to start testing because the person that does the test is not convinced it will work as the new method of working.
In the example the specialist might not want to test dictating directly after the session for one patient, because she expects it might work for one patient per session for one test, but not for all patients every day.
Suggestion: test anyway! Doing a test is no obligation to keep doing it, also not if it works. You can only judge whether the idea is feasible after the test. Then you can decide based on facts instead of imagination. More importantly, doing the test can lead to a better idea that is feasible.

Achieve great things by making them small!

The tendency to erect a wall around lean

noreply@blogger.com (Marc Rouppe van der Voort) — Tue, 24 Nov 2009 13:47:00 +0000

Recently I reflected with two teams on their progress with applying the lean principles. Both teams stated that the past months nothing had happened.

Nothing?

We discussed that they did not have time due to illnesses in the team and different other reasons why they were so buried under work that they did not have the opportunity. Then someone asked whether a period like that doesn't create a pressure to make changes to keep everything running. Sure, was the answer. And to the question how they had managed that they gave a range of examples how they had made improvements that reduced the time needed for activities, so that they could perform the work with less people. Different scheduling of nurses, different scheduling of patients, other task division, stop unneeded activities.

Nothing?

If that's not working on lean, what is?

They soon concluded that they did apply the principles. Why did they at first answer that they had done nothing? It became clear that they work 'on lean' when it explicitly carries that label. They apply lean when:

a change is introduced by the 'lean team' that regularly meets and thinks of new things
a change is decided on a workshop or so that carries the name lean in the title
or when it is directly connected to one of the instruments of lean

Changes that are made that reduce waste, increase value, improve flow etc., but without explicitly being labeled lean were, until now, not considered lean.

Ah, now I understand 'nothing'!

Why do we erect a wall around lean? Why do we create boundaries to say when activities are part of lean and when not? In this way lean can only have a very limited effect. We do not systematic lean from experiences that are relevant, but not labeled as lean. We do not acknowledge good progress that's made. We do not integrate the principles with other activities. We get less close to the hearts of people, because lean stays something foreign, that needs a label to work on. Every team has reduced waste or improved their working conditions etc. If we recognize those improvements as good examples of lean thinking, we can integrate the principles with daily practice. We can integrate it in the DNA of the team. So, we lack so far in this ability?

I consider lean thinking as a set of principles, a coherent way of thinking and seeing that can be inspiring. Lean asks questions why you do things as you do. Lean gives examples from other organizations that give food for thought, not least examples from Toyota. Lean challenges you to reach higher. lean thinking also describes instruments that have proved themselves, but that is secondary. But apparantly that's not how we communicate it?

In my view, embracing lean thinking means that you systematically elevate your efforts to reach higher levels of performance. Lean thinking means per definition that you apply the way of thinking onto everything where it can be relevant, even in your private life. If you think according to the principles, you cannot not-apply them.

Do you recognize the tendency to erect a wall around lean? What causes this tendency? What is the root cause of 'nothing'?

What is your first association with lean?

noreply@blogger.com (Marc Rouppe van der Voort) — Sun, 15 Nov 2009 10:38:00 +0000

Often I ask people what their first association is with lean. I invite you to answer that question for yourself. What is your first association with lean?

................. .............

The answers I get usually are synonyms for 'reducing waste' or 'improving efficiency'. That was also my first association when I started to dive into lean. By now I regret it. My first association is now 'value'. I'd state that if you don't take 'value' as the starting point of lean, your efforts sooner or later will work against you. A personal anecdote:

As a physiotherapist, my mother often treated people at their homes. When I came out of school, I often went with her. One day, we visited a woman that was not able anymore to move her fingers well. My mother asked her what she would like to do again with her hands. She said shet would love to play bridge again with her friends. My mother asked whether she had a deck of cards in the house en I got them. Then my mother invented exercises with the cards.

Care providers connect to a person asking a personal question. They try to understand what is of value for this person. It does not make much sense to reduce waste if this process is not well understood. It can be useful to consider two types of value:

The reason why someone asks a question to a care provider. What's happening to me? What should I do? Why? Activities that help answer those type of questions add value, for example a consultation, diagnostic research and an operation.
That what is important for a patient during the process. Comforting a restless patient, touching a confused patient, giving attention during vulnerable moments. These are not activities that help answer the questions that the patient came for to the hospital, but at that moment they are of value.

If we reduce waste without first understanding value we start of the wrong side. The risk is real that reducing waste will become a goal in itself. Perhaps the biggest risk of introducing lean is becoming anorexic. Few people working in healthcare have a passion for reducing waste. They want to be of meaning to other people. From that motivation, they are willing to improve processes and to reduce waste so that they can spend more time on valuable activities. But in that order.

I'd state that the effects of lean should not be measured by how much waste is reduced, but how much more or better value is created.

What was your first association with lean? How does that relate to value? I invite you to share your association!

Lean thinking and compassionate care

noreply@blogger.com (Marc Rouppe van der Voort) — Sun, 08 Nov 2009 22:11:00 +0000

Recently O&I published an interview (in Dutch) with Jacob Caron, Orthopedic Surgeon and chairman of the medical staff of the St. Elisabeth Hospital in Tilburg in the Netherlands. Jacob talks about the relation between 'lean thinking' and 'compassionate care'. A reflection on several quotes using the 14 principles of The Toyota Way.

"...it's typical of 'lean thinking'' not to think from big, future plans, but to initiate change process from problems and issues in the current processes. By staying close to the existing processes, changes are kept small."

Principle 5: Build a culture of stopping to fix problems, to get quality right the first time

Fixing problems directly can only be done by the people that encounter the problems. That implies that every team member considers improving a normal part of every days' work. By keeping lean thinking small you bring it into the zone of influence of teams.

"... this approach creates a deep learning process that leads to sustainable change, because the change process does not limit itself to fighting fires, but is aimed at adressing the root causes"

Principle 14: Become a learning organization through relentless reflection and continuous improvement

Relentless reflection is confronting. Our (health care) culture tends not to show that you have a problem. To learn deeply, people need to be able to make themselves vulnerable so that root causes can be addressed and more fundamental change processes can take place. Trust is a basic condition. To create a culture of trust is very demanding of leadership.

"...it's important to anchor the 'lean thinking' philosophy in a long term vision on excellent care. This vision must include the core values of the hospital and gives direction to the process of continuous improvement that 'lean thinking' initiates. The St. Elisabeth Hospital chooses as a core value: 'compassionate care'.

Principle 1: Base your management decisions on a long-term philosophy, even at the expense of short-term financial goals

The long term philosophy will need to be so well connected to what the hospital stands for and what the environment needs that it will also provide direction in difficult times. In good times buffers need to be created that enable to hold on to the principles in the more difficult times.

It might seem contradictory that the earlier quote he stated that lean thinking does not start from a big future plan, and here he states that a long term philosophy is important. The difference is that, for me, a future plan is not value drive, but control driven. It's oriented at what is not. A long term philosophy is based on values and that provides direction to take decision in the here and now. It's oriented on what is. A future plan takes away initiative from most and gives it to a few. A long term philosophy can and increase initiative.

"Administration and leaders must stay connected to the primary processes and let that feed the vision."

Principle 12: Go and see for yourself to thoroughly understand the situation

Going to the source to base decisions on observations and experience from the work floor. This is extra difficult in health care, because many actions literally take place behind closed doors and because many steps are not taking place right after another (and many should not be). That makes it the more important to do effort to go to the source in health care. For example by attending daily or weekly (short) gatherings of teams that reflect on the day or week.

"In summary, 'lean thinking' creates space for compassionate care if the change process is anchored in a long term philosophy on excellent care. Compassionate care is part of the core value that is being optimized with 'lean health care'."

Principle 1: Base your management decisions on a long-term philosophy, even at the expense of short-term financial goals

"You need to understand your patient, what he wants and expects. Try then, each time again, to meet that expectation perfectly."

Principle 14: Become a learning organization through relentless reflection and continuous improvement

By connecting the first and the last principle it becomes full circle: relentless reflection on the way value is created, related to the changing expectations and values of patients, feeds the continuous, steadily improvements to deliver better value.

How does 'pull' work in a hospital?

noreply@blogger.com (Marc Rouppe van der Voort) — Sat, 24 Oct 2009 20:22:00 +0000

The 'pull' principle is probably the most important logistical innovation of Toyota. Because it uses a different way of thinking it already requires some effort to understand the principle in a factory. But how can you apply it in a hospital?

How does 'pull' work in a factory of Toyota?
The traditional way to manufacture is in stock. Production is based on demand forecasts, or sometimes just as much as possible, then we'll try to sell it. Because there are many different versions of a product (e.g. different colors and options for a car) a lot of supply is needed to prevent that you can't produce enough of each version of your poduct. This is part of the reason why so much money is tied up in the stock in factories. This is also one of the reasons that led Henry Ford to his classical quote: 'You can order any color T-Ford, as long as it is black'. The less versions of your product, the less stock you need to produce it.

In the nineteen fifties Toyota understood that the future lies in more variations of cars. At the same time Toyota was in deep financial problems and spend a lot of money on their stock. For both reasons they wanted their production processes to become flexible, so that customers can get their preference fast, with minimal stock. Inspired by American supermarkets where the shelves were filled with the same quantaties that were just 'pulled' out by the customers, Taiichi Ohno translated that 'pull' principle to the Toyota factory. An example how that works:

Imagine you make door handles. Pete next to you puts the handles in the doors. Between you and Pete is a table with three drawings of door handles. When you finish one, you put it on the drawing. Pete takes them from the table. Now imagine that Pete is falling behind because the doors don't reach him anymore. He can't install your handles. Soon the three drawings are filled with three handles. You can't produce any handles anymore, because you can't put them anywhere. You stand still untill Pete starts again to take one away (or better yet, you help the team that builds the doors). Thát is the essence of 'pull': the step after you gives you a signal that you can do your part. Because the whole factory works like this, there are no stocks. The system simply makes this impossible. Also, not one car leaves the factory that is not ordered by a customer. Because 'pull' starts with the order of a customer.

It took Toyota fifteen years before the deceptively simple 'pull' principle was applied in one complete factory. Now, 35 years later, all car manufacturers and many other companies try to work according the 'pull' principle. Between delivery of the 20.000 different parts from many suppliers and the assembly of each part in one Toyota now is on average four (!) hours. They manage this with their 'pull' system.

How does 'pull' work in a hospital?
A hospital can't produce in stock (let's put twenty CT scans in stock?), so the problem of large supplies is unknown to hospitals. Is the 'pull' principle relevant in a hospital?

We don't have any stock, but we do have a lot of waiting in between steps in care processes. The throughput time from first contact until diagnosis often takes weeks if not months. Despite that the addition of the time spend on each step often is less then a day or only several days. From the perspective of a patient our care processes are a stop-and-go experience. The cause lies in the 'push' way of organizing the characterizes hospital flow.

Essentially 'pull' is:

respond to demand

When care is 'pull' organized the demand determines where care providers spend their time on. In hospitals we currently determine where time is spent on long before care is demanded (= 'push' logistics). Some examples of 'push' logistics:

The number of sessions in an outpatient clinic depends on the availability of specialists and perhaps of supporting staff. It is not based on current demand.

Sessions are programmed with fixed appointments, for example six new patients and twelve follow-up appointments. These programms are not based on actual demand, but on the preferences of the care deliverers. The numbers of each type of appointment will not respond to actual demand in a given week, resulting in unnecessary waiting times.

Supporting staff of outpatient clinics are scheduled two months in advance, when the number of sessions is not yet definite. Often sessions will be canceled or added afterwards. It will be difficult to reschedule the staff (and they will not like it). This results in overstaffing and shortage of staff. Also, the canceling of sessions is not based on less demand, but absence of care providers.

The number of OR (operating theaters) for a specialism per week is determined every year with a fixed planning for each week (on Mondays General Surgery has three OR's, Orthopedics two etc.). This is done before any patient is known. Why? In the words of professor Frits van Merode: the division of OR capacity is not a planning instrument, but a 'peace treaty'.

These are all symptoms of 'push' logistics: demand has to comply to our scheduling of capacity, instead that we respond to demand (by the way, that's why my phd research is about the 'reactive capacity of hospitals').

What would 'pull' logistics look like in a hospital? An example:

If in January more patient request an appointment for a Gynecologist, he or she takes more time to see patients and gets more staff support for the extra sessions. Later he or she performs more operations for these patients and gets more OR capacity to do so.

OR capacity is not divided anymore per specialism, but on actual demand. OR capacity is given to individual patients.

This requires a large flexibility from the system. It also requires trust from the care providers in the system 'I'll receive OR capacity for my patients when they need it'.

How can you recognize the consequences of a 'push' system?

General practitioners call to arrange priority for their patients ('push')

This lab result needs priority ('push')

The surgeon needs to call the radiologist to make sure his patient gets a MRI slot sooner ('push')

Or more in general:

'I push todays demand to tomorrow, because today I'm full" ('push')

Instead of:

'I do todays work today' ('pull', as proposed by general practitioner Mark Murray in his 'Adanced Access' concept)

Push and pull in a hospital
I don't believe that a hospital can be organized completely 'pull'. There are two major reasons why 'push' is for some part inevitable:

Uncertainty what the value stream will be. When I order a car the factory knows exactly the specifications before the car is assembled and all steps required to build it. In care processes next steps are often determined during the process (for example: only after diagnosis treatment can be determined). Better yet, often steps change during the process because of complications or because a patient changes his or her mind.
Natural variability in care processes. Installing a door handle can be repeated each time in the same time. The same operation will take more time with this patient then the other because one body is not the same as the other.

Because of both factors a hospital cannot create complete work load leveling ('heijunka'). To organize care processes completely 'pull' unacceptable levels of overcapacity are needed. That's why a mix of 'push' and 'pull' will be required. However, it is evident that a lot more 'pull' is needed. For the benefit of patient flow, but also for the benefit of care providers. 'Push' systems lead to strong tensions (who gets how much capacity? Why do my patients need to wait for your department?). 'Push' systems tend to stimulate people to look after their own interest, even at the cost of the common interest.

'Pull' is not better then 'push'. They are two logistical principles that both can be useful, depending on the situation. The interest is to create 'flow': no unnecessary waiting. And that every care provider can spend as much time as possible on providing care (instead of pushing patients through the system or to claim as much capacity as possible). The interest is to have patients experience care as one, fluent process.

How to start?
A good starting point is the planning processes and policies (e.g. scheduling staff, scheduling sessions, programming sessions, OR capacity planning etc.). Use these questions:

do we base our decisions on actual demand, or on internal (non-demand related) criteria?
which information do we use concerning actual demand? If there is none: how can we get it?
does this policy change increase or decrease the flexibility to respond to actual demand?

Finally, we should improve the flow of care processes in respons to the problems that are experienced on the work floor ('pull').

Pitfall of lean

noreply@blogger.com (Marc Rouppe van der Voort) — Sat, 10 Oct 2009 20:29:00 +0000

Lean is one of the most widely used and proven management approaches. Yet, also with lean applications there are many organizations that do not achieve a real lean journey. Projects might deliver results, but they rarely lead to a sustainable development. After a while the attention drops away. What are the pitfalls of lean? A first exploration.

What characterizes the (popular) literature on lean? The approaches are largely based on a rational, predictable approach to organizations. Read the most common lean method another time:

1. Determine value
2. Identify the value stream
3. Create 'flow'
4. Let the customer 'pull'
5. Continuously improve
(Womack en Jones, Lean Thinking)

Step 1. Determine value
Could it be that different caregivers often think differently about what is of value to a patient? And that patients themselves have a completely different view? Hoe do you handle a great diversity of views? An example:

A department realized that they offer a poor service by giving their patient their date to be operated just shortly before the operation. Therefore they started a project to offer every patient their operation date directly in the outpatient clinic when the operation is decided. A nice improvement. Yet something felt not right. A later study showed that 95% of the patients indeed highly appreciated the new service. 5% however is very nervous before the operation and can't sleep anymore as soon as they have the date. They prefer to be called as shortly to the operation as possible. Determining value is often more nuanced than at first glance.

Step 3. Create 'flow'
Could it be that many forms of waste are related to historical patterns and relationships? That it can be threatening when this is analysed? Or that in itself rational process improvements create uncertainties for stakeholders? An example:

An outpatient clinic had problems with no shows, pressure of phone calls from patients and GPs requiring priority, much work with rescheduling sessions, and surprisingly enough, also many unused appointment slots. A major cause appeared to be that they used various types of appointments on fixed times in the sessions. E.g. always a new patient at 9am, 9.40am, 10.20am. This offers insufficient flexibility because every week there is a different numer of patients requiring a specific type of appointment. Just stop using fixed slots and plan flexible. The group of doctors however did not allow this. Why did they use fixed slots? Because they wanted to be sure that every specialist sees an equal number of new patients, thereby ensuring that each specialist contributes the same to the group. This had gone wrong in the past. From a flow perspective, the current planning method is a (minor) disaster and there are other solutions, but they would not let go because they feared that the old quarrel would come back.

Step 5. Continuously improve
What are your experiences when you suggests an apparantly good idea? Is it often not put to practice as quickly as you can imagine? An example:

On an outpatient clinic the relations had gone from bad to worse. There was much dissatisfaction. They saw many things they did not like, but they were not able to improve them. Interviews revealed that the assistents perceived that the specialists hold all the power and blocked any improvement. The specialists however said they had many good ideas, but they needed the assistants to realize them. Since the specialists did not have any formal power over the assistents they were not able to influence them. The specialists felt powerless.

With a sense of reality
The examples are not intended to indicate that the lean principles do not apply there. To the contrary. Lean however pays little attention to the non-rational side of change processes. Even thoug they often determine the progress. In the words of Marcel Boonen, manager of a care department: "after the logic starts the confusion".

With a lot of external pressures (higher management, program management, etc.) the rational approach can deliver results. Continuous improvement, a cultural change is something different. Lean thinking can not be implemented. For the non-rational side, to reach inside, other interventions are needed. This starts with the recognition of different views on value and problems and investigating them with a sense of reality. As a secretary once spontaneously shouted during an improvement session:

Do you mean that from now on you are going to take our ideas seriously!?

Never try to change something

noreply@blogger.com (Marc Rouppe van der Voort) — Sat, 19 Sep 2009 13:29:00 +0000

One of my favorite statements is:

"Never try to change something if you don't love it as it is now"

What drives you to change something? What is your motivation?

When your make a statement about something that you want to change (eg waiting in a department or the willingness to help each other), do you disqualify the current situation? Do you speak about how it should be, without a deep understanding of why it is as it is now?

Lean thinking is based on systems thinking, which comes down to:

"Every system is perfectly designed for the results it gets"
(Paul Batalden)

If the results are not good, what is the cause? Improving results requires insight into why the current system performs the way it does.

Principle 12 of The Toyota Way (as described by Liker) is:

"Go see for yourself to thoroughly understand the situation (Genchi Genbutsu)"

A common strategy used in change management is to make people very dissatisfied with the current situation. To make it clear that everything is bad and that everything must change. The jargon for this is 'to create a burning platform'. Then people will have to jump.

When is that a wise strategy? Cetrainly not if you want to improve the way Toyota does. Perhaps it is wise if the current system is so sick that you need a radical change? I doubt it.

Each organization that exists over a longer period has values that under the surface that establish cohesiveness and provide continuity. In terms of Teun Hardjono: that feed the intellectual and social capabilities of organisations.

A burning platform gives momentum for change, but usually the baby is thrown out with the bathwater by also disqualafying what is good.

A deep understanding of the current situation clarifies why the current approach does not lead to the value that you want to create together. In there lies, often dorment, the motivation for every careprovider to do things differently.

To understand the situation thoroughly, and to connect to the experiences of the people involved you must throw yourself into the work processes. To investigate. To understand.

Which motivation fits with this? In any case, not by disqualification of the current situation. Then you do injustice to the people and you distort a clear view on the system.

"If you do not love what you are trying to change, do something else"

Lean Healthcare Transformation Summit 2009 - Highlights

noreply@blogger.com (Marc Rouppe van der Voort) — Wed, 16 Sep 2009 10:21:00 +0000

On July 10 the Lean Healthcare Transformation Summit was held in London with 170 participants from 12 countries, organized by the Lean Entreprise Acadamy(LEA). On www.leanuk.org under 'events' all sheets ánd video recordings of all presentations can be viewed. What stood out? What made me think?

Visualization
Almost all presentations contained strong examples of visualization of care processes. The presentations themselves also used many pictures and self made movies that made much more impact than just sheets. Some examples of visualization:

Thedacare: each department has its "Visual Tracking Center": a wall that visualizes daily how the department performs on (e.g.) Safety, Quality and Cost, including effects of improvement activities.
The Emergency Department uses 'real-time flow visualization' for each patient (!). Horizontally you see for each patient the steps and the expected flow. Below that the actual flow is indicated..If it's later then expected, it is circled red. A blue post-is hows where the patient currently is.
A3 analysis of problems are filled in with colored visualizations: value streams, fish bone charts, spaghetti diagrams etc.

A surgeon summed up the importance of visualization: "We used to say: 'if you can't measure it you can't improve it'. Now I think: "if you can't see it you can't improve it'".

Thedacare (USA) - John Toussaint, MD, CEO

Very strong and inspiring story. He told his story with the same approach how Thedacare applies lean thinking in her 'Thedacare Improvement System':

1. Purpose
2. Process
3. People

1.Purpose
After five years applying lean thinking they translated their mission into three objectives (he states it should be three to achieve a strong focus). For Thedacare it is:

1. Each year 50% less "defect rates", e.g. infections
2. Each year 10% more productivity (they achieve 6% so far)
3. Each year more more improvement ideas from the work floor

2. Process
John talked about outpatient multidisciplinary teams setting up a treatment plan together with the patient. He also gave examples of "check points": points in the care process where the care provider determines whether all conditions are fulfilled before the next stage of the process is entered. He stressed the importance of transparency of their results, both internally and externally. They created a website: http://www.wchq.org where you can see how they perform relative to other providers in their state. They also keep accurate track of how many improvements are made. So far, 5300 A3's realized.

3. People
Every manager joins every week the discussion of the 'visual tracking centers' and coaches teams with questions.

Applying lean thinking

Dan Jones spoke of the convergence of :

Top-down vision, with
Bottom-up improvement of processes, with
The development of value streams.

Value Streams
Many examples and stories were given about improving entire value streams across departments. Also on managing value streams, including the position of a 'value stream manager'. Main task is to gain front to back 'agreement' on the right actions for the value stream, (no line responsibility over the value stream). A value stream manager also gave a presentation. Interesting but not convincing. Hospitals with long lean thinking experience are also still searching for the right approach.

How do people learn?

A demonstration made (hilariously) clear that learning works best when you see it (visualization) and a detailed explanation is given in small increments and you can practice it. Training Within Industry is an old and proven method for this purpose that's is underestimated.

Focus is more on processes and continuous improvement, less on people
There were frequently referrals to the people aspect of the application of lean thinking and there were good examples. Considering the whole however, the people aspect remains subordinate to the improvement of processes. E.g. how people can have different views on reality and how to deal with this is not covered. Even though Toyota teaches us that 'respect' combined with 'challenging people' is one of the two core values of Toyota (the other is 'kaizen' or continuous, steady, improvement). In the lean thinking movement the people aspect remains secondary.

Royal Boston Hospital NHS Trust (UK) - Fill David Ingham, CEO
Besides many examples of the application of lean thinking he gave four stereotypes of the people they encounter in their lean endeavors:

Positive outlook on life, but no grip on reality: naive idealist
Negative outlook on life and no grip on reality: embittered cynic
Negative outlook on life, but grip on reality: disillusioned skeptic
Positive outlook on life and grip on reality: enthusiastic pragmatist

The lean drivers obviously are in the last category. They to get the others in that category by:

Rigorous application of lean methods
Convincing data
Experience by applying, e.g. three-day "rapid improvement events"
Ratify through change management and leadership

He concluded that slow progress is not because people are obstructive, but because they insufficiently understand what they are trying to do with lean. The only way is by steadily progressing, head strong.

Leadership
Both CEO's considered the most important aspect of leadership: Genchi Genbutsu. Or: go to the source to thoroughly understand the situation. Every Thursday and Friday the day starts at the visual tracking center "(see above) of a department. Also, the CEO's regularly participate in overnight improvement events ('with the phone off'). The aim is to understand what is going on and why. By asking 'why?' again and again departments are coached while the director or manager understands what is happening in the organization. Main purpose of leadership: developing people and creating conditions for experimentation and learning.

Push - pull
Finally, a surgeon defined the complicated 'pull' principle very elegantly::

"pull means responding to demand''

('push means that demand must comply with our supply").

All in all a very informative day with many powerful examples. Several hospitals demonstrated how much difference lean can make after 7 to 10 years' application of the principles. Yet is also clear (and they say so themselves) that they really only just begun. It takes a truly long-term focus and a lot of perseverance. After this day I feel energized again!

Lean and compassionate care

noreply@blogger.com (Marc Rouppe van der Voort) — Sat, 29 Aug 2009 20:57:00 +0000

Two hot topics in Dutch healthcare are 'lean thinking' and 'compassionate care' (menslievende zorg). We agree that they are related, but we have little understanding how. Therefore some thoughts about this from the perspective of lean thinking, based on: value, respect, time pressure and system thinking.

Value
Conceptually lean and compassion come together in the concept of value. Lean thinking means that every activity and process is viewed from the question: what value does it add? Compassionate care is a core value of our existence as a hospital and therefore a natural question to ask when improving processes: is this process compassionate? If not, why not?

If an acceleration of a process or standardization or another change is at the expense of compassionate care it is basically not an improvement.

Respect
One of the two core values of Toyota is: respect (besides Kaizen). Respect for customers, employees, supply chain partners and society. This translates, among others, that everyone is well equipped for their tasks and that everyone is challenged to perform a little better tomorrow. Respect is a core value from lean thinking that relates well to compassionate care.

Time pressure and system thinking
Why is care (sometimes / often?) given less compassionate than we would like? The academic hospital UMC Utrecht performed a study that is published in Journal for Nurses (Tijdschrift voor Verpleegkundigen), April 2009, 4. A quote from p.45:

"Nurses experienced obstructing factors to practice compassionate care. Time pressure was the main factor. Interviewees indicate that it's no excuse, but the amount of duties and hectic of the situation and basic care gets priority over the relationship with the patient."

Lean thinking focuses on reducing non-value adding activities, which can reduce the workload. One of the core principles is: hijunka. It aims to evenly distribute the workload throughout the day and the week. Health professionals often speak of running and standing still as their day rythm. It is conceivable that it is particularly difficult to provide compassionate care during peek levels of workload. Evenly distributing the workload with fewer disruptions can lead to more attention to patients

Compassionate care addresses directly the intrinsic motivation of individual care providers. Lean thinking can add: why does the system lead to inadequate compassionate care for our patients?

Example why there is no 'flow'

noreply@blogger.com (Marc Rouppe van der Voort) — Sat, 29 Aug 2009 20:34:00 +0000

Recently I visited a PA lab and one of the analysts gave an example of a lack of flow:

Why does it take several weeks for the results of a smear for "cervical cancer' to get back to you? (Partly) because the smear is delivered only once a week by a courier from the pharmacies to the hospital. Then a big batch comes in. If you have bad luck it takes up to a week between the visit to your general practicioner and the the test getting into the hospital.

The hospital then has a week to process the whole batch (because it must be completed before the next batch comes in). If you have bad luck it takes another one week before your test gets into the process and you have waited for two weeks with, untill now, not one action that added value.

Why are the tests deliverd by courier in batches? Previously this did not happen, the general practicioners used to sent it by mail, which was literally a smear. A while ago, however, a new and better technique was introduced with tubes that do not fit through the letterbox. The GP therefore can not mail it anymore. Therefore, he (or an assistant) has to bring it to the pharmacy (which often also takes several days by the way), and a courier has to pick it up there again.

Suggestion of the analyst: ask the manufacturer of the tubes to create a smaller tube type that will allow to be mailed daily again, taking out more then two weeks of processing time.

His story shows nicely how you can look at processes from a (one-piece-) flow perspective. It shows the problem of batching, it uses root-cause analysis with '5 x why?" and reduction of unnecessary steps. A good example also how poor flow (weekly courier) leads to more bad flow (one week to process the tests).