When I was in Sweden recently, we had a lot of good discussion about the Lean concept of “standardized work.”

There was a lot of agreement from different presenters at the Lean laboratories conference, and from the hospital people we visited, that standardized work isn’t a robotic form of cookbook medicine or cookbook processes. Standardized work isn’t “mindless conformity” as Bill Marriott writes about in regards to the hotel chain.

We found an interesting example of a situation where thinking is required.

Let’s say a process for phlebotomy (drawing blood from a patient) says that it’s preferable to draw blood from the patient’s left arm. Having a standardized process doesn’t mean we ALWAYS draw from the left arm.

Somebody asked, in an extreme situation, “what if the patient is an amputee and they don’t have a left arm?” Clearly, the phlebotomist should be empowered to make a decision — draw from the right arm! Even if the patient just expresses a preference to using the right arm (because they are left handed and don’t want that arm to hurt), the phlebotomist could be allowed to make a judgment call, even if the standardized work doesn’t spell out this choice.

As I’ve heard in other contexts: the role of an employee is:

1. Follow the standardized work – unless there’s a good reason not to!
2. Make contributions to improve the letter and the spirit of the standardized work (because the standardized work is defined by those doing the work, not the bosses)

To point #2, Dr. Göran Ornung, a cardiologist and emergency physician said, in their work:

“Standardized work is not what top management says, it’s what staff says.”

If people are afraid to use their judgment and make decisions, maybe the standardized work document (and more importantly, the training) should specify that you are not leaving your brain at the door!

Final thought – there’s a difference between not following the standardized work for a justifiable reason and not following it because you didn’t feel like it. See this article about cardiac surgeons defining standardized work and their guidelines about choosing to not follow it.

What do you do in your training or management to make sure standardized work doesn’t mean “mindless conformity”?

Many of these same ideas are expressed in Dr. Atul Gawande’s book The Checklist Manifesto: How to Get Things Right. More on that later in a full review of the outstanding book.

Here is a nice 5-minute introduction to the topic without too much mockery from Jon Stewart!

Stewart even makes a Star Wars reference – an example of people with high responsibility following checklists to avoid mistakes:

“Even Han and Chewie go through a checklist… and they’re traveling through hyperspace!”

Link to the video is here.

Stewart ends with a funny, but sad line:

“It’s so simple… it may never be implemented!”

Gawande’s outstanding book: The Checklist Manifesto: How to Get Things Right

For a number of reasons, I’ve decided to re-read my copy of one of the most influential books I’ve ever read: Out of the Crisis by the late, great Dr. W. Edwards Deming.

In the light of Toyota’s recent quality problems, it’s been suggested by some that Toyota has gotten away from the teachings of Dr. Deming that were so influential in their development of the Toyota Production System after World War II.

What would Deming say? It’s time to dig back into his book. My goal is one chapter a night. I’ll be tweeting some notes as I read (using the hashtag #Deming). Is anyone else going to read along with me?

As I re-read Chapter 1, in <140 character bursts of quotes and thoughts:

• “Folklore has it in America that quality and production are incompatible: that you cannot have both.” -- #Deming (tweet)

Folklore, indeed. Just because that idea is so prevalent doesn’t mean that it’s true. We are still fighting that notion in healthcare today. It’s so engrained that better quality means higher costs. That is true if quality means more inspections and more technology. With lean and process improvement methods, better quality leads to lower costs. Hospitals like ThedaCare are proving that quite often now.

• Dr. #Deming, of course, taught that improving quality increases productivity -- less wasted effort, happier people, more jobs (tweet)

This all goes hand in hand -- cost, quality, and employee happiness (“joy” as Dr. Deming would say). Controversial to some, Dr. Deming certainly thought it was an important purpose of organizations to provide jobs -- for the sake of society and our economy.

• Toyota should re-learn #Deming: “Defects and faults that get into the hands of the customer lose the market…” (tweet)

This was certainly true for General Motors. Their famed quality problems let to an irreversible market share decline. Once you have damaged your reputation for quality, it’s very hard to get that back even once you have improved (as GM did and has).

• #Deming wrote the U.S. was the “most underdeveloped nation in the world” because our employees’ knowledge is underused (1982) -- still true? (tweet )

What do you think? Is this still true? A few people on Twitter thought so. I’ve heard too many sad variations on “they want us to just do our jobs and not say anything” in healthcare the past few years. So much wasted potential and probably one reason that healthcare costs are so high and quality is so poor.

• #Deming (1982) -- 15 to 40% of a manufacturer’s cost is waste. Same is often said of hospitals in 2010, 30 to 40% wasted effort/cost.  (tweet )

The same is often said in healthcare  - by experts including Donald Berwick, John Toussaint, and Patricia Gabow (MDs, all). The idea being that we can reduce costs by improving quality and productivity, not just by slashing the price paid by the government or insurers (and the government will soon pay >50%).

• #Deming (1982) “Eventually quality improvement will reach not only the production of goods… but the service industries (hospitals )as well” (tweet)

Dr. Deming could see that his methods would eventually be needed outside of manufacturing and industry. Hospitals often know of PDCA/PDSA and Dr. Deming’s name, from earlier training, but there’s often little evidence of his ideas being taken to heart or put into use. His ideas, and the extension of them as “lean” are being used more often in healthcare today, thankfully, for the benefit of patients, hospitals, and staff.

• #Deming “Outputs cannot be considered without considering the goals they are designed to achieve.” Start 1st w/ purpose, then improvement. (tweet)

This sounds like what Jim Womack says through the Lean Enterprise Institute -- start first with purpose. Dr. Deming told a story in his book that would have required much more than 140 characters. Thomas Edison invented an automated voting machine for Congress, to instantly tabulate votes. When he presented this to Congress, they were appalled and said it was the last thing they’d want. It turned out that much of the legislative process, the give and take and negotiating, was based on the votes rolling in over a period of time. Edison did not understand this when inventing his machine -- without understanding the purpose, it had no use.

I’m most of the way through Chapter 2 now. I’ll continue tweeting and will summarize the tweets and expand on them in occasional blog posts. I’d invite you to do the same via the blog comments.

And a recent video posted by Wiley Publishing with quotes from Dr. Deming:

Hat tips to the blogs Lean is Good and Curious Cat… tonight is the debut of the new CBS reality show “Undercover Boss” a show where CEOs go to the front lines to work as their employees do.

Will you be watching? Will America be watching? This doesn’t seem like typical post-Super Bowl fare… but I’ll probably watch (or DVR it for later).

Here is the preview video:

Knowing they are on TV, I’m sure the CEOs will have the sense to demonstrate respect for the people and the work. Will this just be “say the right things” superficial respect or something more meaningful? Why can’t the CEOs go see people work without a reality TV show?

But will they really listen and get the perspective of employees in a way that would allow the CEO to help improve the system? Will they see barriers that get in the way of people doing their work, inspiring them to lead change? Or, will they just go back to the board room after getting their free publicity for themselves and their companies?

The first CEO is Larry O’Donnell, of Wate Management. He used to be partner in a law firm, so he’s hardly worked his way up the ladder. We’ll see what happens… in the preview he is afraid he “messed something up” on a trash conveyor belt. Was he trained properly? Was he given a job that was realistically achievable?

In a second preview scene, O’Donnell is asking for what lean or “Training Within Industry” practitioners would call “key points” about how to do the job and the foreman says, “You’re just picking up paper, Randy” (his fake name).

The fact that an employee time policy “doesn’t seem very fair” to O’Donnell — will that lead to change? The preview implies that it will and that O’Donnell says he’s “going to be a different manager” because of what he’s seen. Should be interesting to watch and follow up on. What do you think in advance or after seeing the show?

I try to keep things light here on Saturdays… one of my favorite sites is failblog.org and their related blogs. Although they normally document problems and bad designs and mishaps that would constitute a “FAIL,” they often have something that might be considered a “WIN,” such as this airport window washer in the video below.

As one of the YouTube commenters asked, “how else is he supposed to wash it?”

Good point. I’m curious if this is the standard practice (probably) or is it an example of “kaizen” from employee creativity.

Either way, have some fun watching the video and others over on FailBlog.

When I was in Sweden, the one hospital I visited had an automated coffee machine that made a variety of drinks. In getting a cup of coffee, or trying, I found an example of everyday error proofing.

When I first put the mug under the spout and pressed the coffee button, nothing happened. I thought the machine was broken, so I tried its twin sitting to the right. Same problem. Then, I realized, I had been outsmarted by the error proofing.

Based on the visual of the machine, I set the mug in what I thought was the correct place, as shown below.

As it turns out, that’s actually the drain and the correct place to set the cup is above on the black holder that juts out from the machine.

The machine was mistake proofed, as it sensed that there was no mug sitting on the correct spot. If there had been no mug at all, that would have created a big mess. Having a mug sitting where I had it might have made a little mess, as hot liquid would have splashed through the black holder above the mug. Maybe they could have had a sensor on the bottom grate, but that adds cost (well, so did the mistake proofing logic).

This is a mistake you don’t make twice, once you learn how the machine works.

Below is a picture showing where the mug should have gone (above the original mug):

What do you think — clever error proofing or overly engineered?

You could also argue, maybe, that it should have been more visually clear where to put the mug… then maybe error proofing wouldn’t have been necessary. Maybe I would have been more likely to get the right spot if the drain had been black and the mug holder had silver?

A few updates about where you can hear me yakkin’ away online – the “Lean Nation” radio show and a webinar through the Healthcare Financial Management Association.

I’m going to be the guest on Karl Waddensten’s “Lean Nation” radio show on Thursday, February 11 from 4 to 5 eastern. I’ll be in studio there in Rhode Island to talk about lean healthcare, after I get a chance for a closer look at the “gemba” there at VIBCO. My friend Ankit Patel is also appearing as a guest on Monday, February 8. Please listen online and feel free to call in with your questions.

On Thursday, February 18, I am doing a webinar for the HFMA called Lean Healthcare: What CFOs Need to Know and What They Need to Do. The webinar is free if you are an HFMA member, otherwise it costs $245.

This story is from Wisconsin Public Radio talks about Lean at Aurora Health Care, based in the Milwaukee area. (“Hospitals Turn to Lean Management to Save Money“).

The story talks about how the health system improved the discharge process, leading to shorter patient stays. Shorter length of stay, given the current-state conditions with quality in healthcare, leads to better patient safety. Rather than being kept longer for more observation, your odds are better getting out of the hospital:

“Unfortunately, hospitals can be risky places for patients. The longer they stay, the greater the risk of things like infections and falls. So I think across the board, most people would agree that as soon as the patient is medically able, it’s usually a good idea for them to leave the hospital,” Hallisy [the President of the Empowered Patient Coalition] says.

There are already many good examples of Lean healthcare in Wisconsin, including two members of the Healthcare Value Leaders Network – ThedaCare and Gundersen Lutheran.

My only wish was that the headline didn’t focus so much on saving money, since that’s not the only benefit from Lean! Quality, waiting time, and staff morale are also very important benefits and goals.

Mark’s note: This is a guest post made available for me to post by Barnes-Jewish Hospital.

by Laurie Wolf and Nancy Sigillito

The full article is available as a PDF download at the bottom of the post.

From the intro of the article:

For years, a constant struggle existed to get patients at Barnes-Jewish Hospital (BJH) the right medical equipment promptly.

As one nurse described, “our process of providing our patients with necessary equipment was broken. We had no mechanism for tracking equipment that was ordered, no feel for if our inventories are adequate, no follow-up for broken equipment, and most importantly, no way of ensuring that equipment got to patients in a timely manner.”

This broken process resulted in a classic “work-around” by nursing staff. In the case of IV pumps, nurses would be fast to claim a pump from a discharged patient’s room, do a quick cleaning off the record, and use it for their just-admitted patient. Or, they would go to a neighboring unit to “borrow” one— without really intending to return it. Needless to say, nurses were extremely frustrated at the lack of readily available equipment.

(PDF Link)

Benefits from the improvement work included:

“Since introducing the process throughout Barnes-Jewish, the wait time for equipment has improved considerably. The time to get an IV pump ranged from 40 minutes to 4 hours, 36 minutes (with a mean of 2 hours, 7 minutes). With the new par levels, the wait time is completely eliminated. In addition, the rate of lost equipment dropped almost in half (from 12% to 6.9%).”

I just finished Dr. Atul Gawande’s latest book, The Checklist Manifesto: How to Get Things Right. I believe that this book is the single most important book of the year for ANY Lean leader, not just people working in healthcare.  I’ll share more of my thoughts on the book in another post, but I wanted to address a recent review in the WSJ.

There’s room for intelligent disagreement on issues like this, but the conclusions drawn by the WSJ reviewer really makes me question his reading comprehension skills or his agenda.

The title of the review signals its negativity: “Problems with Protocols: Checklists, although valuable in some settings, are a menace in others.”

The reviewer, Philip K. Howard, an attorney, gives rightful credit to the lifesaving impact that checklists have in healthcare. But, it seems that Mr. Howard suffers from the same ailment that Dr. Gawande attributes to many physicians – that just because you’ve gone to school long enough you are therefore above checklists and, what we’d call in the Lean world, “standardized work.”

Dr. Gawande, in his book, states that checklists would have a positive impact in legal work (to prevent frequent legal errors in simple filings) and in investing and venture capital. It seems Mr. Howard is allowing emotion and defensiveness to get in the way of considering Dr. Gawande’s approach.

Mr. Howard tries to counter Dr. Gawande’s argument for checklists, where he cited how Wal-Mart (which allowed managers to be creative) outperformed FEMA (which relied on bureaucratic rules) in Hurricane Katrina relief by saying:

“But giving someone the authority to use her judgment means relying on individual creativity and improvisation—the opposite of a checklist.”

This is exactly the OPPOSITE of the point that Dr. Gawande makes in the book, saying:

There must always be room for judgment, but judgment aided—and even enhanced—by procedure.

Mr. Howard also writes:

“But bureaucracy is nothing but checklists. That’s part of what’s wrong with modern government—officials go through the day with their heads in a rulebook, dutifully complying with whatever the lists require instead of thinking about what makes sense.”

Mr. Howard really has it mixed up. The bureaucracy of FEMA is NOT the result of checklists. Checklists, as Dr. Gawande writes, free up people from mundane decisions to 1) help prevent errors and 2) allow people to apply their critical thinking skills to important decisions. Dr. Gawande writes convincingly of how Captain “Sully” Sullenburger and First Officer Skiles both landed US Air Flight 1549 because they used checklists to handle the mechanics of the situation, freeing up Sully to remain calm and make the one important decision of WHERE to land the plane.

Mr. Howard rails against a real problem in modern education:

“Teachers, for example, are shackled to lists and protocols that prevent them from doing their jobs properly (e.g., disciplining students).”

This is not a “checklists” problem. Not letting teachers exercise professional judgment is a MANAGEMENT problem. If you institute checklists in a culture where you don’t let people think, I’m sure you’ll have a lot of problems. But this is FAR from the culture that Dr. Gawande advocates. How Mr. Howard missed that is beyond me.

Mr. Howard again tries to argue against checklists:

“But most people can think of only one thing at once: If they’re thinking about a checklist, they may not be focusing on solving the problem at hand.”

Again, this argument is clearly refuted by the US Airways case and Dr. Gawande’s O.R. mishap that nearly killed a patient (and would have, if not for the checklist). Checklists can, in the case of US Airways, provide structure for solving an unintended circumstance or they can, in the case of Dr. Gawande, provide a “pre-flight check” to ensure that there is enough blood on hand even if the surgeon didn’t anticipate cutting a patient’s artery. The US Airways crew didn’t anticipate a bird strike, but checklists benefitted them (and the passengers) and didn’t mean their creative brains were shut off. The cockpit checklist did NOT say “Step 7, land in the Hudson River.” That was pure creativity enabled by a checklist.

Mr. Howard tries to dispute this by saying:

“It was undoubtedly a good thing that every member of the crew had been drilled in various procedures. But the “miracle on the Hudson” happened because Capt. “Sully” Sullenberger focused on flying the plane, not a checklist on how to fly the plane.”

Mr. Howard misses the key point that so many missed – it wasn’t just Sully who landed the plane. It was a team effort where he and the First Officer (who was following a checklist to try to restart the engines) worked together to avoid catastrophe.

Mr. Howard tries to use the skilled hero model for Sully by quoting William Langewiesche:

“Across a lifetime of flying, Sullenberger had developed an intimacy with these machines that is difficult to convey. He did not sit in airplanes so much as put them on. He flew them in a profoundly integrated way, as an expression of himself.”

Sully himself, as stated clearly in Dr. Gawande’s book (again, something Mr. Howard missed), dismisses the notion that he was uniquely skilled or that his experience, heroism, or decades-old glider experience were important factors. From Dr. Gawande:

As Sullenberger kept saying over and over from the first of his interviews afterward, “I want to correct the record right now. This was a crew effort.” The outcome, he said, was the result of teamwork and adherence to procedure as much as of any individual skill he may have had.

Mr. Howard makes his world view clear in a final comment:

“Accomplishment is personal. That’s why giving people the freedom to take responsibility is so important.”

He clearly doesn’t understand the impact of systems, nor does he realize that we all (including lawyers) work in a system. He holds to the heroic notion that our success is completely due to our own individual exceptionalism.

Mr. Howard seemed to push his own agenda against being stifled by checklists or standardized work instead of simply reviewing Dr. Gawande’s book. Maybe Mr. Howard works for unenlightened managers who DO equate standardized work with not thinking. Or maybe he’s a Taylorist at heart, himself.

Lean thinkers, I believe, wouldn’t buy his argument. I rest my case.

Rather than assuming that checklists would be damaging, has Mr. Howard tried them in his own practice? Has he tried using them in an environment that still values and allows professional judgment and creativity?

I give credit to Dr. Gawande, and others around the world, who have been willing to try something new (checklists) – not turning aside data that shows that they work.