Other Posts That Might Add Value:

• LeanBlog Podcast #83 – Jim D’Addario, CEO of D’Addario
• LeanBlog Podcast #79 – Eve Yen, CEO of Diamond Wipes
• Podcast #97 – Bob Sutton, PhD, “Good Boss, Bad Boss”
• Another Hospital CEO Talks Lean Culture
• Podcast #96 – Pascal Dennis, “The Remedy”

Today’s post is an interview I conducted via email with Justin Holland, Managing Principal of GE Healthcare Americas. Before joining GE, he was most recently Vice President of Business Performance at Cleveland Clinic.

In this interview we cover topics including how GE integrated lean with six sigma, how healthcare organizations are striving to have a “lean culture,” and some of the successes and challenges facing hospitals and other healthcare organizations.

GE is known primarily for Six Sigma. When did lean become part of the approach at GE Healthcare?

Lean started to be a key focus within GE Healthcare around 2004. Part of the impetus was looking at examples set by Toyota and Herman Miller and other organizations to improve customer impact and productivity.

From our success with implementing Lean internally, we’ve also found parallels and opportunity for our clients. Helping hospitals implement Lean practices supports our commitment to working with healthcare providers to address some of their greatest challenges and provide more efficient and effective care.

Generally and broadly speaking, how has GE Healthcare benefited from lean? Can you share a specific example?

Lean has focused our leadership on improving our strategic capabilities. We found that much of what gets in the way of operational excellence is when information falls through cracks because we aren’t working cross-functionally. For example, we took a more critical look at the whole of our operations, from initial customer inquiry through to order fulfillment and lastly payment remittance. This external focus approach is aided by a more proactive culture of employee problem solving. Again, we are able to share with our clients in healthcare what we have learned through projects like improving our installation cycle time, next generation product development cycle and contact to transaction process, as well as many others.

How does GE Healthcare integrate lean and Six Sigma methods and principles? Is it a matter of using lean tools in the DMAIC model and Six Sigma culture or is it different than that?

Over the years, GE Healthcare has incorporated a number of continuous improvement methodologies, including Lean and Six Sigma, into our pursuit of operational excellence.  Today, as performance improvement work is being done, our experts have a larger bag of tools to pull from. But what we’ve found underlies all of these efforts is the need for a culture based on a commitment to improvement that starts and ends with our customers. In other words, the people part is essential – both in terms of seeing things from our customers’ perspective and fostering a climate that subordinates our individual interests to those of the broader organization. A strong change management process underlies the use of all the tools used in GE.

In implementing Lean, we’ve found there is a shift to the customer dictating the process, rather than debating between two internal departments. When the cue is taken from the customer, efforts become unified and grounded in literal feedback. We’ve found a lot of value getting people together who are on the front line and closest to the customer to gather that institutional knowledge and debate ideas, learn new perspectives and get a better understanding of where bottlenecks happen. This information isn’t necessarily statistical analysis, but is extremely valuable.

Many organizations talk about moving toward a “lean culture.” Are you seeing this trend increase in the healthcare setting? How do you see the culture or management system changing with lean within healthcare?

A strong example is the concept of evidence-based medicine, which calls for more than simply a clear process and standard approach to measurement, and also involves providers that are committed to letting data drive decision-making seek to prespecifiy anything that makes problems visible. And the best providers do this not just in the clinical setting, but also in admissions and the business office – anything that touches the patient in a material way. Taking a Lean approach means thinking about the patient as the customer, and viewing process as the journey of their care — from the time that patient enters the ED, or is first seen by the admitting physician, to when they are discharged and later have a follow-up appointment. Medicine is highly specialized, but it is also a system that requires all moving parts working together to be truly effective. This seems very obvious when you look at it from the perspective of the patient. When hospitals take a patient-centric view of improvement decisions, they stand to increase patient satisfaction in addition to operations or quality and safety. More and more hospitals are focusing on the patient perspective for driving a more holistic and integrated strategy. (interview continues below the ad)

Can you share an example of GE Healthcare working with a hospital to teach them and work together on lean improvements?

GE Healthcare has worked with hospitals across the country to improve their operations and the care they provide patients by implementing lean strategies.

Brigham and Women’s / Faulkner Hospitals teamed with GE Healthcare for training on lean practices in early 2009. A key change in their approach was involving front line staff rather than relegating lean projects to a small, select team of upper management. This led to a lean culture at the hospital and more comprehensive process improvement, resulting in significant gains. In one specialty practice, staff was able to improve patient phone access by recognizing and addressing the underlying sources of dropped calls. The hospitals were also able to increase the number of copays collected by 21 percent and decrease prescription refill turn-around by 88 percent, which increased patient satisfaction and had a true bottom-line impact.

Ochsner Health System in New Orleans weathered millions in damages and lost staff following Hurricane Katrina. In its recovery, Ochsner sought to eliminate waste and improve the patient experience in nursing units (unnecessary overstock of supplies, safety issues with expired supplies, improperly used space, non-standardized RN stations and excessive RN search travel). On one floor alone, Ochsner has been able to further reduce on-hand supplies from $4,500 to under $1,500, which also freed space, improving capacity. Ochsner’s overall Lean initiative has resulted in $200,700 in savings and $400,000 in cost avoidance.

Huntington Hospital in Pasadena, California, recently implemented Lean Six Sigma framework for two projects: freeing up Critical Care Unit (CCU) capacity by ensuring patients in the nursing unit met the criteria for care and stemming financial losses in the spine sub-service line through cost reductions. Within six months, CCU bed identification cycle time decreased from four hours to 40 minutes on average and the patient discharge process was accelerated by three-plus hours. The annual cost savings from more effective patient flow is projected to be $1.3 million.

What are the biggest challenges hospitals face implementing lean?

Traditionally, healthcare providers are accustomed to “triaging highest risk” and taking a wait-and-see approach. Implementing Lean practices requires challenging this conventional wisdom.

Hospital leadership often needs to take a leap of faith and embrace the lean journey fully. The initial investment of training and implementing Lean, a fear they will have to add staff to make it happen and the time commitment from leadership dissuades some organizations. But, the reality is that the return on investment in Lean can pay dividends when a hospital commits to it fully.

Why do some healthcare institutions fail in their implementation of lean?

Some healthcare institutions may fail with implementing lean because managers may bring in some lean tools, but do not fully commit to changing the culture and overall process. Over time, this lack of cultural commitment renders these tools less and less effective. Another pitfall is keeping information and tools for lean projects in a silo and only training a few people rather than engaging all staff. Some hospitals fail because they think they’re done once they complete a few rounds of Kaizen events. In other words, Lean is viewed as a means to an end, or a project/certification to be checked off a list, rather than an ongoing commitment.

What is your favorite piece of advice for hospital leaders or those who are just getting started with implementing lean practices?

Figure out who your customer is and what’s important to them. It’s important not to get too wrapped up in jargon and philosophy regarding Lean, because it’s not significant to the customers, the patients. What matters is how long they had to sit in the waiting room at the ED, or how easily they could make a follow up appointment after an acute episode. Perhaps it’s human nature to get caught-up in pedantic nuisances and terminology in the course of developing proficiency in Lean. But this is to miss the very point – it’s not about us. It’s about the patient. The interests of every other type of healthcare “customer,” whether it is the referring physician or payor, exist for the purposes of the wellbeing of the patient.

Thanks to Justin for taking the time to be interviewed! I’ll try to engage Justin in comments discussion and a follow-up interview if the comments and questions merit it.

GE Healthcare has recently started blogging actively, including this post on Lean and waste in healthcare: “I spy with my Lean eye.” Here is a post written by Justin: “Evidence-Based Management: Are Hospital Administrators learning from their Physicians?“

Other Posts That Might Add Value:

• TED Video: Dan Pink on Motivation
• Of 777s and Heart Rate Monitors
• Bad Behavior Kills – in Hospitals?
• USA Today Features Lean in Hospitals
• Article about Lean in Canadian Cataract Surgery and More

I’d like to welcome a new advertiser to LeanBlog.org — it’s 5S Supply, found online at www.5Ssupply.com.

I’ve talked with the owner, Tony Manos, and he’s serious about Lean and he’s serious about providing good service and good value to people who need supplies for their Lean journey.

From his website:

About 5S Supply

5S Supply was born from the idea that there had to be an easier way to gather the necessary supplies for a successful 5S event and program in a timely fashion, with no hassle.

This was readily apparent several years ago when one of our founders was frustrated trying to find items needed for 5S events. As an expert in Lean and 5S he thought that there should be a one-stop shop for 5S items. Many 5S events are slowed down because items have to be hunted down, researched, selected, paid for, delivered or picked-up; often from many different suppliers and sources. At 5S Supply we’ve done the hard work for you. Instead of looking through several catalogs or performing tireless searches on the internet, our 5S and Lean experts have packaged items together to make it easy and convenient to order and get the things you need for your 5S event quickly!

And here’s a fun video they made (and you can see more via their 5S Supply YouTube channel):

Thanks to Tony and 5Ssupply.com for their sponsorship of my blog!

Other Posts That Might Add Value:

• New Free iPhone App – “Lean Daily” Now Available
• Reader Question: Rapid Response Teams (Oops, We Don’t Have the Items)
• Weekend Fun: Depiction of the Lack of Hospital “5S”
• My Lean Message Board is No More
• Happy Birthday Frank Gilbreth; Reducing Waste in Hospitals… Green is Lean

My city in Texas signed a contract with a new trash/waste company that starts on September 1st. The new bin is green (pictured at left). I already had two blue bins from the old company. The bins work just fine.

I’m honestly not the biggest environmental zealot out there, but I don’t like waste, regardless of where I see it. I called the new company and asked them about the new bin… was basically told that’s what they do and that the old company should pick up the old bins. I set them out at the curb today (for the last trash pickup of the old company) and, sure enough, they didn’t pick up the bins. So do I throw them out? Keep them as planters??

So, to create a bit of a mid-week laugh, I made this video:

This is from the same service made famous by the popular “iPhone/Android” video (warning, rated R language).

Warning, my video uses the “S word” three times… and it’s a bit of an exaggeration of the conversation I had with the trash company…

Honestly, it does seem to defeat the purpose of Reduce, Reuse, Recycle.

Back to the usual stuff tomorrow…

Other Posts That Might Add Value:

• Weekend Fun: Depiction of the Lack of Hospital “5S”
• New Book: “Laugh, Sing, and Eat Like a Pig”
• Saturday Fun: Social Media on “The Office”
• “Win”-dow Washing: Standardized Work or Kaizen?
• Funny UPS Ad Parodies from SNL

photo credit: Stewart

A number of readers emailed me a link to this New York Times article: “U.S. Inaction Lets Look-Alike Tubes Kill Patients.” The headline emphasizes the lack of governmental oversight, but I’d rather talk about the poor system design that allows deadly errors to occur.

The article describes an error where food was mistakenly injected into her veins:

… the hospital mixed up the tubes. Instead of snaking a tube through Ms. Rodgers’s nose and into her stomach, the nurse instead coupled the liquid-food bag to a tube that entered a vein.

Putting such food directly into the bloodstream is like pouring concrete down a drain. Ms. Rodgers was soon in agony.

So is this a one time fluke? It seems not:

Their deaths were among hundreds of deaths or serious injuries that researchers have traced to tube mix-ups. But no one knows the real toll, because this kind of mistake, like medication errors in general, is rarely reported. A 2006 survey of hospitals found that 16 percent had experienced a feeding tube mix-up.

Why are errors rarely reported? That’s a topic for a different post. I think the question here is why there’s such a risk of systemic mixup.

Hospitalized patients often have an array of clear plastic tubing sticking out of their bodies to deliver or extract medicine, nutrition, fluids, gases or blood to veins, arteries, stomachs, skin, lungs or bladders.

Much of the tubing is interchangeable, and with nurses connecting and disconnecting dozens each day, mix-ups happen — sometimes with deadly consequences.

Interchangeable, identical looking clear tubing – that’s a mistake just waiting to happen, isn’t it?

I saw, last week, a presentation about a chemical factory that had made huge strides in improving worker safety. One of the risk factors the engineers identified is that the pipes through the factory were all gray — somebody’s idea of aesthetics. But, in an emergency, not having pipes clearly labeled could be deadly.

So if this is fixable in a chemical factory, why not in our hospitals?

It’s not a new idea that there are systemic risks. Again, from the article:

Experts and standards groups have advocated since 1996 that tubes for different functions be made incompatible — just as different nozzles at gas stations prevent drivers from using the wrong fuel.

But action has been delayed by resistance from the medical-device industry and an approval process at the Food and Drug Administration that can discourage safety-related changes.

It’s often said that it takes 19 years for a change to make its way from idea to widespread implementation in healthcare. So we have a few more years left on that clock…

If it’s far too easy to mistake a food line for an intravenous line, can’t we fix that today? Isn’t there an opportunity for simple labeling and visual controls? Do we really need to let the FDA get in the way of this? I’m asking a question I don’t completely know the answer to  — what do the clinical readers have to say?

One paragraph in the article that I agree strongly with is this:

“Nurses should not have to work in an environment where it is even possible to make that kind of mistake,” said Nancy Pratt, a senior vice president at Sharp HealthCare in San Diego who is a vocal advocate for changing the system. “The nuclear power and airline industries would never tolerate a situation where a simple misconnection could lead to a death.”

So when a systemic mistake occurs (one that’s predictable), what happens? Often, a person gets blamed — and the article brings up the case of a nurse, Julie Thao, who was convicted after a fatal error (and I blogged about it a number of times over the fast few years).

The article talks a lot about failed legislative attempts and failed regulatory efforts — so my question (and there may be a good answer) is why hospitals don’t each individually fix this tomorrow?? If we can’t change the equipment, how can we change the process to avoid the error? Does the FDA really get in the way?

It’s a shame we have this dynamic:

“The regulators have been waiting for the manufacturers to come up with a solution,” Ms. Pratt said, “and the manufacturers won’t spend the money to design and produce something different until the regulators force them to. And now the international standards organization is taking forever to get the whole world onto the same page.”

Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association, agreed, “These things are hard to change when you have to get so many different organizations to act in concert.”

I guess that makes it much more complicated than a chemical factory, which is also regulated? People are dying, unnecessarily, during this delay. How can we avoid this suffering?

Other Posts That Might Add Value:

• Another Pathology Mishap
• Liveblogging the Quaid Patient Safety Documentary
• Dennis Quaid and Patient Safety – Upcoming Documentary
• Of 777s and Heart Rate Monitors
• Teachable Moments from PRHI

You might know of and already be a fan of Pascal Dennis (read more about him and listen to my recent podcast with him here). He has a new book out (The Remedy) and his firm, Lean Pathways, has published a cool set of “mental model pocket cards” (the first set of more to come).

Pascal and Lean Pathways have generously offered to give away a copy of The Remedy and the cards, both autographed by Pascal.

So, here’s how to win:

• Follow both @LeanBlog AND @LeanPathways on Twitter (if you are not already following both)
• Send out a tweet that says exactly this text: 
  • I’ve entered to win autographed book & #lean cards from @LeanBlog & @LeanPathways – http://lnbg.us/1TJ - pls RT!
• Your tweet MUST contain all of the text above to be considered an eligible entry. And, again, you MUST be following both @LeanBlog and @LeanPathways to be eligible to win.

That’s it. All you have to do is Tweet… and you might walk away with an autographed book and card set from Pascal Dennis sent right to you.

The winner will be announced on LeanBlog.org on Tuesday, September 7 at 2 pm EDT and via Twitter.

More books from Pascal:

• Lean Production Simplified
• Getting the Right Things Done: A Leader’s Guide to Planning and Execution
• Andy & Me: Crisis And Transformation On The Lean Journey

Other Posts That Might Add Value:

• Podcast #96 – Pascal Dennis, “The Remedy”
• Contest for a Set of Free Signed Books from Bob Emiliani
• A New App to Download, Events to Attend, and a Book to Read
• Book Giveaway Winners Announced
• Lean Books Giveaway (Register Now)

People often ask “So where did the term ‘lean’ come from?” It didn’t come from Toyota. And the term isn’t an acronym (so no need to type it as LEAN or L.E.A.N.).

The term came from John Krafcik, who was a graduate student at MIT, working for Lean Enterprise Institute founder Jim Womack on the research for the book The Machine That Changed the World. See comment #5 where I added more detail about that.

Where is Krafcik today (pictured at left)?

Krafcik, 48, is now CEO of the Korean automaker Hyundai. Maybe GM made a huge mistake in not hiring him instead of promoting yet another finance guy to the head of that troubled company? Maybe there’s still a chance he can take over after the next CEO-of-the-quarter is done at GM.

Krafcik was featured in a recent USA Today article, “Hyundai’s John Krafcik isn’t your typical CEO type“).

From the article:

Krafcik got his first auto break with a venture Toyota and General Motors were setting up in Fremont, Calif., to build small cars for both companies. New United Motor Manufacturing (or NUMMI) was a chance for GM to learn Toyota quality methods and for Toyota to try operating a U.S. plant.

And he saw the difference between GM and Toyota at the time:

Hired as a manufacturing engineer, Krafcik says the experience “was just awesome,” especially his Toyota-trained boss, who wanted him to see what makes an auto plant succeed or fail. Krafcik was dispatched to GM’s plant in Oklahoma City, where he says he saw half-built cars backed up and workers napping on the job. Then he went to Toyota City in Japan, a plant he says was so well laid out and efficient he could see across it to the other side. There was little inventory, with parts arriving from suppliers only hours before they were needed.

Krafcik is described as a disciplined, data-driven engineer, but one who is innovative and keeps connected to customers (personally calling an upset customer each day, something I wish American Airlines Gerard Arpey would try, but that’s beside the point).

I wonder how GM would be different with Krafcik in charge? Do you think he could make a difference?

Regardless of your workplace, what’s the ideal “lean CEO”?

Other Posts That Might Add Value:

• Read this Book – But Don’t Copy ThedaCare
• NPR on the “End of the Line” at NUMMI and My Story About an Interviewee
• Toyota Leaders Get a Lecture From a Toyoda
• Video Interview with LEI’s Jim Womack
• Meeting Newt Gingrich, a Lean Champion

Here is a nice little (under 2 minutes) news video from New Zealand talking about one hospital (in Auckland) and their implementation of the “Releasing Time to Care” program that was started in the British NHS. Other hospitals across New Zealand are doing this too, apparently

The story talks about how nurses were spending on 33% of their time with patients at the bedside. It’s such a systemic problem – the interruptions and waste – that the number is almost always between 30 and 33% in studies done around the world.

But it’s possible to double time at the bedside with this Lean-based program.

The story, “Nurses back by the bedside” highlights getting staff involved in identifying waste and improving processes. Before, patients were sometimes afraid to call the nurse because they saw the nurses were so busy. That changes with RTtC.

“The nurses appear happier and the ward seems less rushed and the patients feel like they’re getting better care,” says one nurse. One hospital also reports a 10% shorter length of stay, as a result.

Watch the video by clicking on the photo below:

Other Posts That Might Add Value:

• A Lean Nursing Example in New Zealand
• My Interview with Justin Holland, of GE Healthcare
• Lean Healthcare Featured in Sunday NY Times Business Page & I Got Quoted
• Two Extreme Sides to Every Story in Politics *and* Lean??
• ThedaCare, Lean, and Primary Care in the News

I’m currently in Minneapolis, where today is Day 2 of our Healthcare Value Leaders Network “Gemba Visit” to Park Nicollet (read more about these visits here). Dr. John Toussaint, author of the book On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry, is here with us as always (pictured at left during part of our visit to their “3p mockup area” used for space and process design work.

We’ve had a great visit so far, including seeing the newly-designed cancer center that I blogged about before (including a YouTube video about the center where “care comes to the patient”).

I’ll have more thoughts to share about the visit next week (including the value of learning and collaborating without copying), but I’ll link today to two recent interviews with John.

Business901 Podcast with Joe Dager

Listen to John being interviewed by Joe Dager (who has also previously interviewed me before about lean healthcare and about social media).

You also have option of reading the interview with John as a free e-Book instead of listening.

iSixSigma Interview

You can read an interview with John titled “Is Lean the Secret to Curing Healthcare?“

From the interview:

Terry: What are the biggest challenges to implementing Lean in a hospital setting?

Toussaint: I think part of it is that staff members aren’t familiar with any of these concepts. We never get trained on any of this stuff in our [career] training programs. So people are quite unfamiliar with these quality improvement tools and with the concepts of getting decision making and improvement down to the level of the frontline worker. It’s actually fascinating to me that that isn’t the case in healthcare. We have a very highly educated workforce that goes through years of training, but the fact that they don’t get any training in continuous improvement and they don’t have a clue how to do a Plan-Do-Study-Act improvement cycle – it’s really quite shocking actually. So we have to overcome that by retraining – both physicians and nurses and others – in this very basic set of continuous improvement principles.

And then, we touched on before, this issue of the cultural component. Healthcare is full of, what I describe in the book as, the “shame and blame” – if you make a mistake, you’re a bad doctor or a bad nurse. But in fact, 99 percent of [mistakes] are process problems. The processes in healthcare are perfectly designed to get the results they’re getting – which are lots of errors and massive cost problems. That’s what’s great about the Lean methodology…it takes all the blame away and really starts to focus in on what’s the process change that needs to occur in order to improve the result. And that’s easier said than done, but I think that’s one of the biggest issues – to be able to change the culture from shame and blame to continuous improvement and using data to make decisions.

Read the whole interview at iSixSigma.com. Your thoughts?

Other Posts That Might Add Value:

• Two Extreme Sides to Every Story in Politics *and* Lean??
• Great Guests on “The Lean Nation”
• Dr. John Toussaint Talks Lean Healthcare on The Lean Nation Show
• Lean Healthcare at Denver Health is Front-Page News
• A First-Person Lean Leadership Story from John Toussaint, MD

Here are a few events I’ll be a part of in the next few months, maybe I’ll see you there:

• Cindy Jimmerson’s “Big Sky” Lean Leadership Retreat, Sept 20-22
• Michigan Lean Consortium’s Lean Healthcare Event, Sept 28
• LEI “Key Concepts of Lean in Healthcare” Workshop, Oct 11-12

More details follow:

“Big Sky”

I’m excited to be attending Cindy’s event for the first time and I’ll be presenting. I think my talk will be a fun one and, considering the importance of healthcare quality and patient safety, it will have a lighthearted feel. The topic is “error prevention in healthcare” but the title of my talk is Warning: Signs! From Cautionary Circulars to Proactive Prevention.

I’ll talk about how it doesn’t count as “mistake proofing” or “visual management” to hang a bunch of warning signs around the hospital. I’ll illustrate the point with a lot of pictures and discussion of Lean alternatives that work better and exhibit “respect for people.” Mistake proofing (error proofing) is one example of a Lean concept that works better, checklists can help too (instead of signs that say “don’t forget to…”).

Maybe as a discussion point for this blog — do you see this as a problem in your organization, the abundance of signs? I actually see each sign as an opportunity to improve a process someplace. You can see some examples of signs like this on my photoblog “Be More Careful,” including examples like:

• No! No! No!
• Don’t Let the Door Hit You, or Others
• “Do Not” Inject Patient with Wrong Syringe

These are signs that don’t quite get to the root cause of the problem – in some cases, somewhat silly problems and, in some cases, serious ones.

Dr. Richard Shannon will be presenting, as well. Sign up at Cindy’s Lean Healthcare West site.

Michigan Lean Consortium

I’m appearing at an event in my home state of Michigan to give a 4-hour introductory lean healthcare workshop. You can learn more and sign up at the MLC website.

As I was quoted in a blurb about the event:

“As someone who grew up in Livonia and still has parents and friends there, I always hope for the best for Michigan. It should be a source of pride that Michigan has some of the early success stories of Lean healthcare, thanks to involvement of people from the auto industry,” said Mark Graban, author of Lean Hospital. “I am glad I can give back to further the spread of Lean thinking in Michigan and I’m looking forward to participating in the event.”

LEI Workshop

I’ll also be teaching my two-day introductory workshop at the LEI office in Cambridge, MA on October 11 and 12. You can sign up at the LEI website and here is me blabbering about the workshop a bit:

Hope to see you there… but not all three events, that would probably be a bit weird :-)

Other Posts That Might Add Value:

• Liveblogging the Quaid Patient Safety Documentary
• Dennis Quaid and Patient Safety – Upcoming Documentary
• Of 777s and Heart Rate Monitors
• This Will Happen Again, Unless…
• Signs are not Error Proofing