As we move into the holiday weekend, I’m taking some time off from the blog (I know I promised that before, but I’m serious this time). It’s a long weekend as a reminder to think about those who have given their lives for our country…

I’m also swamped as, today, movers are packing up our things and prepping to load a truck. As of Tuesday, my wife and I will be residents of San Antonio, Texas. I’m looking forward to being a part of the Lean communities in San Antonio (with the Toyota plant) and an hour north in Austin, with the big tech and Lean Startup scenes. If you are in those cities, please drop me a line.

I hope everybody has a nice weekend.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and the upcoming book Healthcare Kaizen. He is also the Chief Improvement Officer for the technology startup KaiNexus.

No, this isn’t a post about the the 80s Chicago tune “Hard Habit to Break.” It’s about individual habits related to problem solving that are hard to break.

As Charles Kettering (the famed engineer of General Motors and the namesake for my dad’s alma mater, Kettering University, the former GMI) said:

“A problem well stated is a problem half solved”

In Lean problem solving models, including PDCA/PDSA and the A3 methodology, the focus is on not jumping to solutions to quickly… and it’s a hard habit to break, for all of us.

Defining a problem well includes understanding the current state. We need to understand the gap between what should be happening and what is actually happening. We then work to understand the root cause of the problem…

Immediately jumping into solutions brainstorming can really short circuit good problem solving. We can waste time going down rat holes, discussing ideas that don’t address the root cause and won’t really address the issue we’ve come together to discuss.

I’ve tried focusing on this approach for a long time, but I still find myself jumping to solutions at times… but I generally try to be aware of it.

I think people tend to go through this progression:

1. I’m unaware that I’m jumping to solutions
2. I’m aware of it, but I keep talking about solutions anyway
3. I’m aware of it and I can stop and refocus on problem definition

Does anybody ever get to a “step 4″ of never jumping to solutions? I think that would be the sign of a really disciplined Lean problem solver.

What’s your own experience with this?

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and the upcoming book Healthcare Kaizen. He is also the Chief Improvement Officer for the technology startup KaiNexus.

Dr. Robert Wachter has a great column in today’s USA Today: “Column: Gregory House M.D.: RIP” and it’s republished on his blog, with its own comment section.

I wrote a comment, which is await moderation, and I’ll repost it here…. also curious to hear your comments on his blog or here on mine.

From his column:

Hospitals were co-dependent. All too aware of their heavy reliance on the physicians’ control over their revenue stream, hospital administrators learned to coddle doctors, with everything from prime parking spots to a personalized menu of surgical equipment. This kept the doctors happy, but also led to wildly expensive and sometimes risky variations in practice, even within the same institution.

This reliance also made everyone tiptoe around the dysfunctional behaviors that Dr. House so memorably illustrated each week. In one survey of more than 700 nurses, 96% reported seeing doctors engaging in disruptive behavior, and almost half pointed to fear of retribution as the reason such acts went unreported. Another survey found that one in four doctors and nurses believe that disruptive behaviors are associated with preventable deaths. I agree, having seen cases of medical errors in which a scrub nurse or physician trainee suspected that a senior doctor was about to commit a terrible error, but kept quiet rather than risk the physician’s ire.

My comment:

Great piece, Dr. Wachter. I grew tired of the show and the character… he’s a drug addict, but he’s talented. He’s misanthropic, but boy we sure need him.

As somebody who was an outsider to healthcare seven years ago (from an engineering background), I was blown away by the disruptive behavior that was reported and tolerated in hospitals… behavior that wouldn’t be tolerated and excused in most workplaces.

You say hospitals “were” dependent on physicians for their revenue stream… I think that’s still often true in the current tense.

As more hospitals embrace the “lean” management methodology, they learn that one of the two pillars, from Toyota, is “respect for people” — and how that mutual respect is required to have an environment of safety and quality. It will be interesting to see how healthcare reconciles the old mindsets with the new mindsets of lean and the modern patient safety movement.

Your thoughts and reactions?

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and the upcoming book Healthcare Kaizen. He is also the Chief Improvement Officer for the technology startup KaiNexus.

After the date had been previously pushed back to July 27, due to some delays on the publisher’s side, I”m happy to announce that my upcoming book (with Joe Swartz) Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvements has been brought back up to June 27. You can pre-order the paperback today via Amazon, Productivity Press, or BN.com.

We are really excited about the book. It is going to be printed in full color, with over 200 real examples of Kaizen-style improvements from hospitals around the world, most of which having before and after photos.

You can sign up online to receive, via email, a free PDF that contains Chapter 1 of the book along with a summary of the rest of the book’s chapters - and a discount code for 20% through Productivity Press!

The book is hopefully going to be available at the same time (if not earlier) in Kindle format. Because the book is so graphics and picture-intensive (over 200 examples of Kaizen-style improvements), it will likely published as a Kindle textbook – the same treatment as my friend Naida Grunden’s book Lean-Led Hospital Design. Unlike books that have the text converted for the Kindle format (which often makes graphics hard to read), this approach will basically present the book “as printed,” page for page, like reading a PDF. This format works brilliantly on an iPad, Kindle Fire, PC, or Mac. It just doesn’t work on “e-Ink” Kindle readers. We hope this is OK with most readers.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and the upcoming book Healthcare Kaizen. He is also the Chief Improvement Officer for the technology startup KaiNexus.

Episode #148 is a conversation with a returning guest, Naida Grunden (previous episode) and her co-author Charles Hagood (of Healthcare Performance Partners), talking about their new book Lean-Led Hospital Design: Creating the Efficient Hospital of the Future. It’s an outstanding book and I was happy to endorse it, as did John Toussaint, MD and many others.

In the podcast, we talk about what lean-led hospital design entails, including getting staff involved, how to tie processes and space together, and how to collaborate with architects and construction companies to build space and processes that best serve the patients and healthcare professionals.

For a link to this episode, refer people to www.leanblog.org/148/.

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

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

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

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

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and the upcoming book Healthcare Kaizen. He is also the Chief Improvement Officer for the technology startup KaiNexus.

I’ve been a happy DirecTV customer since 2007, when I switched from cable so I could get the Big Ten Network when it launched (Go ‘Cats!). My wife and I are moving to San Antonio, where we will be in a condo. I don’t feel like cluttering up our balcony with a dish, so I’ll be starting with AT&T U-Verse (which also carries all of the football “overflow” channels, so I can watch Northwestern games this fall).

DirecTV runs a ton of ads about how it’s easy to move your service and get set up in a new location. Unfortunately, their “cancel because you’re moving” process has a glaring weakness.

I called a few weeks back to let them know I was canceling as of May 25 and that I wouldn’t be taking their service to the new address. I knew I would have to return my receivers to them, so I wanted to get the pre-paid shipping boxes sent to our house before the move.

I was told by the representative, ” We will send the boxes approximately 10 business days after you stop service.”

I replied, “Um, well I won’t be at the house anymore… why can’t you ship the boxes in advance.”

I heard the famous words that are anathema to good customer service: “It’s our policy to send the boxes after service is stopped.”

I pleaded, but they couldn’t overturn the policy to send the boxes in advance.

So, I had the choice of canceling service at the moment (which cuts into their revenue a bit) and that still wouldn’t guarantee that the boxes would arrive before May 25, necessarily (or that was my fear). And, I didn’t want to cancel service that early… I wasn’t going to change what I wanted to work around their dumb policy.

I gave them my new San Antonio address so they could ship the boxes there. That would mean my wife and I moving the DirecTV gear unnecessarily (talk about “waste of transportation”).

Later that night, we had people over and I wanted to put on the Rangers baseball game in the background… I couldn’t find our local channels. It turns out that putting the address change into the system (for future use) meant we were now getting San Antonio local channels…. near Dallas.

That, of course, led to another phone call… and means I have to call again on May 24 to switch the address BACK to San Antonio. More “waste of motion” and the “waste of overprocessing” on their part.

I’m still half afraid the boxes will come to the old house…. AFTER we move.

Bets on how many more phone calls this takes?

Does it have to be this difficult? Is it that unreasonable that customers would want the boxes sent BEFORE their move? Is DirecTV hoping I will just “give up” and decide to get their service at our new home?

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and the upcoming book Healthcare Kaizen. He is also the Chief Improvement Officer for the technology startup KaiNexus.

After meeting him at a conference a few years back, I consider Patrick Anderson, executive director of Chugatchmiut, to be a good friend in the Lean world. He graciously endorsed Healthcare Kaizen, as he is working hard to create a culture where everybody participates in improvement. Patrick has also been a guest on my Podcast (episodes #53 and #71) and I share his “Lean in Alaska” blog posts via my Twitter feed, as he writes about Deming and Lean.

I was happy to discover that Chugatchmiut was the subject of a story on Alaska public radio: “New Management Style Allows Health Organization To Improve Care.”

There is no transcript, but hopefully you can listen to the audio, which runs about five minutes.

Anderson and a staff member talk about using Lean to improve processes. As reporters seem to like doing, a good amount of it focuses on straightening up desks, but Chugatchmiut is also doing a lot of process improvement in business processes and patient care.

The story, without giving too many details, discusses how the five-member medical staff quit a few years back because they didn’t like the Lean approach. But, Chugatchmiut continues on. Anderson wrote about this on his blog yesterday, saying, in part:

The one negative comment about clinical outcomes is from a disgruntled former employee. What we are actually finding are significantly improved clinical outcomes. We are having an impact on reducing damaging behaviors like smoking. Patients are starting to exercise, take better care of themselves and have started the process of addressing the most damaging health care we face: unresolved trauma experienced during childhood and the toxic stress it causes.

When asked why it makes sense to adapt a management system based on Toyota, Anderson answers that the traditional management system in healthcare is based on Ford and General Motors.

You can read more about their Lean initiatives on the Chugatchmiut website. You can also read about Anderson’s recent presentation at the TWI Summit. As he discussed in Podcast #71, they are working to create “a fact-based, non-judgmental, no blame, no shame culture.” Anderson believes, and I agree that, “There are patients who are dying needlessly because of good people working in bad processes.”

Anderson said, in his post:

Are we perfect? Absolutely not. But we are willing to learn, to make mistakes and to try to continuously improve the work we do for the benefit of our patients.

Are any of us perfect? Of course not. Leaders and organizations that are more aware of their imperfection seem to be the most likely to improve.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and the upcoming book Healthcare Kaizen. He is also the Chief Improvement Officer for the technology startup KaiNexus.

As a very frequent flyer on American Airlines, I’ve learned not to expect much from the company and its employees in terms of customer satisfaction (yet alone anything that would unexpectedly delight a customer). It seems like a company culture of cost cutting — especially on the backs of pilots, flight attendants, and crew. The company has a pattern of getting into financial trouble and then forcing big pay cuts on workers… and then the executives give themselves big bonuses for “saving” the company.

No wonder many flight attendants are grumpy, if not downright hostile. It’s not bad people, it’s the system (I try to remind myself).

But, occasionally, you might find an American employee who still has that spark that leads to service and creativity…

One thing I don’t expect on a flight is good coffee. If it’s hot and drinkable, that’s fine. When coming back to pour refills, the flight attendant said:

“I did a little something different with this pot… tell me if you like it. I took the small in-room Starbucks pack from my hotel room this morning and I added it to the regular coffee. Tell me if it makes a difference.”

She had identified a problem (“the coffee’s not very good normally, is it?”) and she implemented a classic “kaizen” style improvement — it was a small, low-cost, low-risk improvement that would benefit customers. She had a sense of pride that she was trying to do something nice, to make an improvement.

She then tested the change, at least by asking my opinion (it was better).

I wonder if she will make this part of her regular routine (at least on the first flight of the day)?

One thing that’s lacking (I’m assuming) that would be part of the kaizen model is the flight attendant collaborating with her supervisor or manager on the improvement — not to get “approval” per se, but to bounce the idea back and forth in a collaborative way. A kaizen-style supervisor can help share and spread good ideas to other flight attendants, if American had a kaizen culture.

American’s purchasing department is probably buying the cheapest coffee that would be barely passable by the customers (they are probably not heeding Dr. Deming’s advice to “End the practice of awarding business on the basis of price tag alone”).

Does American have a staff suggestion program? Is there a formal way for this flight attendant to share her idea with others? Is there a way for them to recommend that American spend a tad bit more on coffee to improve quality??

I’m hesitant to say what flight I was on, because I fear American would react by punishing the flight attendant for not following procedure (our coffee might be bad, but at least it’s made according to a consistent process). They might punish her for “tampering” with the coffee.

But, as a customer, I’m glad she took the initiative and, as a Kaizen promoter, I’m happy to see people taking initiative. It’s too bad American can’t build a culture where everybody works together instead of management starting wars with their employees, killing cooperation and any hope of improving service.

Read more about this sad history of airline worker mistreatment at American…

“The same management team that took hundreds of millions of dollars in bonuses while the airline was losing money now wants workers to pay a high price for their mistakes.”

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and the upcoming book Healthcare Kaizen. He is also the Chief Improvement Officer for the technology startup KaiNexus.

Thanks to blog reader Justin Lewis for sending me a link to a post on his hospital’s blog — from Memorial Health System in Colorado Springs: “Lean Effort Pays Big.” Justin leads Memorial’s “Lean Team” and shared their success story.

They applied the dual Lean/Toyota Production System principles of continuous improvement and “respect for people” to address problems related to radiology patient flow, leading to improvements in patient flow and financial performance.

Some of the results:

• CT scans increased by 5 scans per day (with additional capacity to schedule another 5 per day)
• Reductions in waiting times for CT scheduling and registration
• Process improvements that led to fewer insurance billing denials and increased billing — millions of dollars per year in financial impact

I’d love to know more about the details of the process improvements that are allowing them to bill more… seeing revenue increases in addition to cost reduction is a great outcome… far more palatable than resorting to the traditional healthcare cost cutting and layoffs.

The blog post describes how the team used the PDCA improvement model — first studying their existing process and working to properly frame the problem instead of jumping to solutions.

From the post:

And, out of the gate, there were longtime associates who criticized the project, saying: “We’ve been down this path before – we already know what the problems are.”

The response, Lewis said, was: “Well, that is exactly the reason why we are here because that kind of thinking has resulted in this problem over and over again.”

In a quarter mile of process maps, employees also began to see where processes – not people – fell short.

We often talk about “jumping to solutions” being a bad thing in problem solving and process improvement… but “jumping to a problem statement” can also be problematic. Instead of assuming we know the problem, going to the Gemba (where the work is actually done) to observe the process and talk to customers (internal customers or patients) can be very powerful and eye opening. The actual problem we should be solving isn’t always the same as the initial definition. It takes discipline to make sure we are understanding and framing the problem properly.

As the famed Charles Kettering, of the olden days of General Motors, famously said:

“a problem well-stated is half-solved.”

Thanks to Justin and the Memorial team for sharing their work — the process, the lessons learned, and the results.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and the upcoming book Healthcare Kaizen. He is also the Chief Improvement Officer for the technology startup KaiNexus.

As I’ve heard people say, Lean management isn’t necessarily complicated – it’s just very different.

In an organization that is undergoing a “Lean transformation,” leaders need to shift from being controlling to:

• Coaching
• Coordinating
• Collaborating
• Challenging
• Caring

Are your leaders making this transition?

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and the upcoming book Healthcare Kaizen. He is also the Chief Improvement Officer for the technology startup KaiNexus.

I had an article published in a California newspaper and it will hopefully be picked up by others. The headline is “Scared to Death: Worry about hospital errors, not pink slime.”

The article starts:

The public is continually subjected to health-related scares, such as food packaging and water bottles that contain BPA, a chemical that has been linked to cancer. The media also highlights food additives that aren’t harmful, but just sound unappetizing, such as so-called “pink slime” in ground beef and the use of dried insects to color beverages at Starbucks.

Yet our nation’s hospitals are the one place where people actually have the most reasons to be scared and to demand change.

I will provide some links and footnotes, context to the article here in this post.

I wrote about the so-called “pink slime” scare a few weeks back. That whole episode isn’t a great example of scientific problem solving on a societal level. It’s more a matter of hysteria. Is pink slime appetizing? Not really. But neither are chicken nuggets, hot dogs, and other products that I personally try to avoid.

I wrote another post comparing the deaths from “pink slime” (none that we know of) to deaths from preventable medical mistakes (100,000 a year) and hospital-acquired infections (another 100,000 or so).

See more links and data about medical harm here.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and the upcoming book Healthcare Kaizen. He is also the Chief Improvement Officer for the technology startup KaiNexus.

Episode #147 is a part two of a conversation with Scott Patten and Peter Armstrong from LeanPub.com (listen to part one in episode #140). They want to be THE website for publishing “in-progress books”. In this episode, we are talking about how they are applying the concepts of the Lean Startup methodology to their service and their business. We’ll talk about some of my own experiences as an early adopter and later as an actual user — what have they learned along the way and how do they use lean methods to be innovative?

Conflict of interest disclosure: I have published two blog compilations via their service, a Best of Lean Blog 2011 book and a Best of 2012 book that is being published incrementally throughout the year. I’m a huge raving fan of their service…

For a link to this episode, refer people to www.leanblog.org/147.

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

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

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

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

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and the upcoming book Healthcare Kaizen. He is also the Chief Improvement Officer for the technology startup KaiNexus.