Lean Healthcare Exchange

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On January 24, 2012, USA Today printed an article in the Travel section on the growth of people-watching in airports.  Yep, more and more people are “watching” other people while sitting in an airport (you know you do it!).  It is acceptable now—you can watch other people without feeling guilty.  What an interesting new American pastime when you’re stuck in a place you can’t get out of, you have nothing to do, and your flight is delayed… again.

Watching people in an airport is a lot like “observation” in Lean Healthcare improvement efforts.  Using your eyes and ears to observe people walking, shopping, struggling with their luggage, noticing how many people ignore the little motorized carts rolling down the aisle blowing their horn, and counting how many people are wearing red shirts is all similar to watching people do their work… or as we say in Lean, watching the work being done.

In Lean Healthcare observation, there are some important differences between people watching with no real objective and watching work being done with the objective of making the work easier to do.  In Lean Healthcare observation efforts, you should be looking for certain things:

1. 8 Wastes common to all processes:

• Defects – We make it incorrectly (or, “it doesn’t work!”)
• Overproduction – We make more than we need (or, “why do we have so many…”)
• Waiting – We are waiting for others to complete their tasks (or, “the lab is so slow!”)
• Not Clear (Confusion) – We don’t know what to do (or, “I thought that was your job.”)
• Transporting – The things we need travel great distances (or, “the meds are on their way…”)
• Inventory – We store too much (or, “throw it away, it expired”)
• Motion – Our people move around a lot to get things done (or, “we’re not ready for Mr. Jones now.  Wheel him back.”)
• Excess Processing – We are duplicating efforts (or, “someone else already asked me those questions.”)

2.  Broken Connections between work tasks – Where is Mrs. Smith?

You may ask, “Why stand here, in one place, watching work being done?”  Good question.  Have you ever wondered what your work looks like from the customer’s point of view?  What part of your work do they experience?  How do they experience it?  What does it feel like to them? They fill in a lot of blanks when you’re not in their direct line-of-sight.

It just so happens that observation is the beginning of most scientific studies and research, including Lean Healthcare continuous improvement efforts.  Observation is always the beginning of process improvement.

“What does the current situation look like and how does it work?” We don’t need to know how it is supposed to work. What we really need to know is how it really does work.  The only way to really know, is to watch the work, observe it, and keep an eye out for the eight wastes, the connections (or lack thereof), and how the work or customer flows through the process.

Until we know what’s happening now, we will not know how to make it better.  Any improvement effort will be a shot in the dark.  As Will Rogers once said, “People’s minds are changed through observation and not through argument.”

True observation watches with purpose looking for certain happenings, or absence of happenings.  Lean Healthcare observation sees the process from the customer’s point of view, oftentimes actually following the customer through the very process being observed.

If you have ever done any Lean observation, you can’t help observing work and processes being done everywhere you go.  Being a customer of many processes myself, as soon as I hit a “No Value” segment of a process designed to serve me, I immediately begin to observe what is going on, what is not going on, and wondering if anyone in the process knows what is going on.  In the meantime, as the customer, I wait.

In Lean Healthcare, we take the time to observe so we can make the process better.  Making the right work easier to do should be the order of the day.  Where is it written that excellent service or patient care requires processes that are complicated and hard for staff to do?

Try some observation in the area you oversee.  Spend an hour or two observing by going to where the work is being done.  Let your staff know you are not watching them, but watching the work they have to do.  Let them know you want to help them make their work easier to do.  What did you see?

This week’s blog was written by Matt Hanrion, Senior Manager with HPP.

Matt has more than 30 years experience with Lean and provides consulting services in a variety of areas within healthcare.  He is a lead trainer with HPP and has coordinated TQM teams within every area of a hospital system, developing and rolling out TQM education to staff.  Matt has a B.A. from Westminster University with a double major in Computer Science and Biblical Studies, and a M. Ed. in Education from Columbia International University.  In addition, Matt served in the US Pacific Naval Submarine Fleet as a Missile Launch Systems Petty Officer and is a Vietnam Veteran. 

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When was the last time you had to call a repair service to your home?  Plumber, electrician, AC repair, the list could go on and on.  When something breaks in my home I want it repaired immediately.  This is how I’m wired when it comes to tasks.  It makes me feel good when a problem gets fixed, even if I’m not directly involved in the repair.  If there is a delay in the repair, I’m not afraid to inquire about the reason for the delay: replacement part on order, need a special tool, or specialized assistance.  Once a potential solution has been identified, you’ll feel elated (with a varying amount of frustration,  depending on how fast it can get done).  The bigger the change, the stronger the feeling.

Lean Healthcare Kaizen, or rapid improvement, events allow you to experience the power of “doing it now” and the elation of accomplishing something quicker than expected.  This “do it now” attitude is a habit that can be learned and is part of building a sustainable Lean Healthcare culture.

So what qualifies as something that should be done now?  It’s really the tasks associated with the details of a implementing a solution that your team has agreed on.  The prescribed solution is your mandate to tackle related issues without hesitation.  Trust your gut.

A great example is a Lean Healthcare 5S exercise.  If you are in the middle of reorganizing a storage room as part of a 5S solution, find a home for all of the items right then and there even if it takes calling other people who aren’t involved.  If a vendor needs to be called to take something away, call that person right away.  If you think IT should come take some old computer equipment, call them.  Putting off tasks like this will only cloud your head with unneeded stress.  Or worse, you might forget to follow up.  When it comes to taking action, don’t ask yourself, “Should I do this now?” ask, “Is there a good reason I should not do this now?”  This is why it’s called a rapid improvement event.

Being conscious of this will make your work more rewarding.  Many people find it difficult to switch from the group input mode that’s encouraged in value stream mapping to being personally decisive during implementation.  The good news is, this is a habit that can be learned.  Conventional wisdom says that it takes 30 days to develop a habit and after a year, it’s ingrained.

So, why not start now? Harness the power of your Lean Healthcare organization and make at least one change today!

Linda leads Lean Healthcare transformation engagements for HPP. She has nearly 30 years of experience in business leadership, program management and lean transformation.  Prior to joining HPP, she worked for Vanguard Health Systems as a process improvement specialist providing leadership and support for regional and hospital level process improvement teams.  Linda holds a Bachelor’s degree in Industrial Engineering from the University of Evansville.

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A few weeks ago, I attended a large healthcare conference in Las Vegas.  Much of Thursday’s group general session was devoted to honoring extraordinary individuals who had done (or are doing) some extraordinary things.  All the stories were incredibly impressive, and each of the people honored make the world better.

While I was watching these awards, I couldn’t help but put on my “lean healthcare consultant” hat.  When we teach, train, or coach teams in lean healthcare methodology, we are ultimately working towards the development and/or improvement of operational systems that generate the outcomes we want, reliably.

To achieve that end, we look at how long the steps in a value stream take. We know that one sign of waste is if the time required to complete a step varies considerably based on the person doing the job.  Ideally, in a successful lean healthcare transformation, we want to develop a system that is not dependent on specific individuals; that with the proper training and time, it is the system that brings about the desired outcomes.   We want to create a system where “the right work is easier to do.”  Therefore, completion of that “right work” should not be reliant on the heroic efforts of individuals willing to go above and beyond to get it accomplished.

However, in many instances, particularly in our healthcare system, we have set ourselves up to require just that–people have to perform extraordinarily to achieve the desired outcomes from our broken systems and processes.  Particularly as a user of the healthcare system, I do not want a successful outcome to be contingent on extraordinary effort. And if that *is* required, then successful outcomes are certainly not regularly replicable and/or sustainable.

We certainly want to honor extraordinary people, but the best way to do so may be by creating better systems, ensuring that they use their gifts for something over and above just making a system function.  Imagine what these extremely high performers could do if we enable their work ethic, entrepreneurship, and innovative spirit.  Functional systems will enable more revolutionary innovation.

This week’s blog was written by Jamie Wilson.

Jamie is a Senior Manager with HPP and has more than 10 years of healthcare experience, spanning management consulting, hospital administration, business development, and hospital operations performance improvement. She currently leads Lean Healthcare transformations and performs specialized consulting for HPP.  Jamie received her B.A. in Sociology with a dual concentration in Health and Medicine, Deviance and the Sociology of Law, graduating Summa Cum Laude from University of Pennsylvania. Additionally, Jamie received a M.S. in Healthcare Management and Policy from the Harvard University School of Public Health.

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While participating in a recent Workplace Organization event, I was reminded of how the red tag process in Lean Healthcare can suddenly become an issue.  So, I thought it would be good to revisit.

During the sorting step of 5S (if you are unfamiliar with 5S, read about it here), unnecessary items are removed from a work area. Because teams are often created ad hoc, there is the potential for someone to inadvertently remove an item that is actually needed in providing a service or in patient care. The Lean Healthcare red tag process helps eliminate sorting errors.

The red tag process follows this basic flow:

• A person identifies an item in question.
• The person fills out a red tag and attaches it to the item.
• The person waits for input on the action of red tagging the item.
• If another person questions the red tag, the people or decision makers for the area determine whether to keep the item or not.
• If the item is to be kept, the red tag is removed.
• If the item is not to be kept, it is disposed of, often to a red tag area. This is basically a holding area for items with value but no homes. An item that is not needed in one area may still be put into use in another area. Some organizations require approval to remove a red tagged item.
• Items in the red tag area that are not claimed by a designated date should be removed to prevent the area from turning into a dump ground. The disposal can range from selling the equipment, to giving it/auctioning it to employees, to scrapping it.

The red tag system is a safety net that keeps overly eager improvement teams from taking necessary equipment from an area.  This is usually one of the main culprits in creating the confusion.  A big issue is when an item is only used intermittently, and can look like they are not needed for the service or in the patient care process.

If an item is red tagged and the tag is removed, the item should not just be left as it is. It should have a location designated, and the item itself should be labeled regarding its use. This will keep future teams from red tagging the equipment over and over.

How often does your workplace go through a 5S event?  Do you use red tags?  If not, tell us about your process:

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Which eye is your dominant eye?  If you are like me when I first heard this concept, you may be saying to yourself, “I didn’t know I had one!”  But indeed, you do.  Each of us has one eye which is dominant over the other one. The next question is: “Do we use our dominant eye to focus on the work that we have to do?”

Many times, we never think about using our dominant eye as we view the world.  Certainly we do not use this concept when we consider what Lean Healthcare can bring to our healthcare world.  Someone once said, “It is not so much how the world is, but more importantly it is critical how we view the world.”  That thought really speaks to me as I work in hospitals around the country.  While some people are focused and have Lean directly in their line of sight, a successful Lean journey requires that everyone involved focus on it with their dominant eye.

Could you be a little bit curious?  Just what is a “dominant eye” and what does it have to do with Lean?  First, let me suggest a simple way to determine your dominant eye.  Take both hands and touch the tips of your thumbs and the tips of your forefingers together to form a triangle.  Hold the triangle in front of your eyes.  While looking through the triangle, pick out an object 10 to 15 feet from you and look at it.  Now close one eye and continue to look at the object out of your open eye.  (Don’t move the triangle!)  Then, reverse the process.  The eye that stays focused on the object is your dominant eye.  If the object goes out of focus, your non-dominant eye has taken over!

Are you pursuing Lean Healthcare with your dominant eye?  Is your Lean journey in focus?  If you are viewing Lean with your dominant eye, it is much more likely that you will continue to make eliminating waste a priority throughout your facility.  It is more likely that all the people in your facility will be more committed to process improvement and problem-solving, as they follow your focused approach to process improvement.  It is also more likely that your team and facility will achieve its goals.

On the other hand, if you are viewing Lean through your non-dominant eye – allowing it to get out of focus – it will be difficult, if not impossible to maintain your commitment to continuous improvement throughout the facility.  It will be even harder for your employees to maintain their commitment.

So now with your increased awareness of your dominant eye, use it in your Lean journey.  Make sure your purpose and your objectives stay in focus.  Let your dominant eye be the guide to achieving both.  You will increase the odds of achieving your Lean Healthcare goals.  Your organization will be more likely to become a center of continuous improvement as you lead with your dominant eye.

This week’s blog was written by Jay Conner, Ph.D., a Senior Manager at HPP.  

Jay has more than 30 years of experience in communications, human resources, and human resources development.  He has worked in both higher education and in the private sector.  In healthcare, he has consulted in training and development, executive and managerial coaching, recruiting and hiring, employee relations, performance management, compensation, employment law compliance and employee manuals and handbooks.

Jay holds a B.A. from Georgetown College and an M.A. and Ph.D. in Communications from LSU. 

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I recently was part of a ‘move in’ effort at a brand new healthcare facility…at about the same point in time, I began to read to the new book Lean-Led Hospital Design, Creating the Efficient Hospital of the Future, written and published this year by my friends Naida Grunden and Charles Hagood. What a unique coincidence for me, reading a first class discussion about the application of Lean Healthcare concepts and tools to new healthcare buildings while intensively working to get an existing healthcare organization up and going in their brand new, sparkling facility!

From the beginning, Naida and Charles point out some unique ideas about the why and how of Lean Healthcare construction, including some ‘basics’ that everybody who is thinking about construction should take to heart! Three beginning points to contemplate:

1. The Building is Not an Excuse! Dysfunctional buildings never qualify as a legitimate excuse to not strive for continuous process improvement within the existing walls. Grunden and Hagood point out that while fairly recent healthcare quality outcomes for Cuba and the U.S. are very similar, the U.S. has the most expensive healthcare system in the world while Cuba’s has one of the lowest! Healthcare facilities in Cuba are nowhere near as good as what we have here but those buildings don’t seem to serve as excuses for their efforts for perfection.
2. Build Only If It Creates Value! Grunden and Hagood suggest that an appropriate time to build is when you note diminishing returns from existing process improvement activities. When your process improvement teams note the existence of more and more facility ‘monuments’, you’re probably ready to begin the ‘design and build process’!
3. If You Build or Remodel, Be Prepared to Invest Up Front! Investing in the involvement of those that perform the ‘regular’, everyday work in the design effort costs time and money. However, their participation typically results in better outcomes and  greater ‘buy in’  of the final design. Grunden and Hagood also suggest that a Lean–Led design effort means taking the ‘long view’ when we consider investment in buildings. This requires us to consider not only the initial costs but also the on-going or recurring operating expenses. If our new design allows us to minimize waste, we should clearly see those benefits in our continuing cost structure!

Good luck on your building or remodeling effort! Lean-Led design, combined with Lean Healthcare principles, certainly makes sense to me!

This week’s blog was written by HPP consultant and engineer David Krebs.

David, a Six Sigma certified engineer, oversees various HPP projects and Lean Healthcare transformations for clients throughout the USA. David is also a Licensed Professional Engineer in the state of Tennessee, with over 30 years of experience in a variety of process and systems intensive industries, as part of firms in the U.S, Germany, and France.  David has achieved and maintained QS-9000 and ISO-14001 certification & received Nissans’ “Quality Master Award” on three occasions.  He holds a Bachelor of Science degree in Mechanical Engineering from the University of Detroit & an MBA from the University of Notre Dame. 

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Recently, I had the opportunity to discuss the differences between Lean Healthcare and Lean manufacturing with a group of hospital executives.  Several things stood out for me as we each reflected on our experiences and observations of each:

Lean Manufacturing

1. Tasks in Lean Manufacturing are broken down and defined into the smallest detail using job instruction sheets located where the work is done.
2.  “No defects” means accepting no defects, making no defects, and passing on no defects.  So problems are identified at the source and an immediate response occurs to a call for help to solve the problem. 
3. Performance measures are available in real time and everyone is aware of what the current performance is and if missed, why it missed. 

Lean Healthcare

1. We have made great strides in accepting evidenced based practice and standardizing much of our work and yet the task of creating job instruction sheets for each activity is overwhelming.  I find that using job instruction sheets for high-risk, problem prone tasks to be meaningful. 
2. In healthcare we have created complicated processes, some necessary, perhaps some not so.  The first step to making no defects is to simplify and eliminate unneeded steps in a process. 
3. We have a great deal of data in Lean Healthcare and yet little information on real time performance.   Even less information is available on performance to those who actually do the work.  Despite increasing technology, the best knowledge of performance still requires collecting simple data at the source, making it visual for all to see, and implementing immediate response to problems. 

Each of these challenges we face in implementing Lean Healthcare is possible if we remember to K.I.S.S.—Keep It Simple & Standardized (no not that other “S” you may have heard before).  What processes have you ”kissed” lately?

This week’s blog was written by Maureen Sullivan, a senior associate at HPP.

Maureen has over 28 years of healthcare experience in clinical nursing, management and quality leadership to Healthcare Performance Partners.  As a registered nurse, Maureen’s clinical experience is in medical surgical nursing with progressive responsibilities in nursing management at the front line, middle management, and administrative levels.

Maureen has an associate degree in Nursing from Joliet Junior College and a bachelor of science in nursing with an emphasis in healthcare management from Metropolitan State College in Denver, Colorado. Maureen achieved certification from the National Association for Healthcare Quality, certified professional in healthcare quality (CPHQ), Colorado State University in process mapping, and University of Michigan in Lean Healthcare.

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In trying to teach the essence of Kaizen, one of my esteemed Lean coaches would frequently remind me to “not let best get in the way of better.”  How simple.  How practical.  I have used this phrase hundreds of times in Lean Healthcare since learning it.  Even more powerful, is that it is now a common phrase used at every level of my company. 

Kaizen loosely translates into “continuous incremental improvement.”  This is not an easy philosophy to understand or follow—especially in Lean Healthcare.  We all want the biggest return on our limited resources’ time.  We need big savings quickly.  However, Lean, being the paradoxical system that it is, turns this thinking on its head.

Experimentation is a practical necessity in Lean.  Even more important is that people must experiment daily so they can learn which ideas truly eliminate waste.  Rapid experimentation and implementation leads to big savings faster than the big bang approach, as it is easier to eat an elephant one bite at a time.

Consider this: There is no perfect solution, only the pursuit of perfection.  The good news is that Lean has a definition of perfection or the Ideal State: Defect-free, One-by-One, On Demand, Immediate Response, No Waste, and Safe.

So the next time you are holding out for the best solution, “don’t let best get in the way of better.”

This week’s blog was written by Dwayne Keller, Executive Vice President of Operations at Medical Reimbursements of America (MRA).  Dwayne is leading the implementation of Lean in MRA’s revenue cycle operations. Prior to MRA, as COO of Healthcare Performance Partners (HPP), he coached hospital executives and all levels of leadership in the implementation of Lean Healthcare, resulting in significantly improved outcomes.

Dwayne also served as a General Manager over two manufacturing plants at Alcoa in which fifty percent of the floor space was freed up using Lean principles and tools. He was also responsible for driving business results through Lean implementation in five Alcoa business units as an Executive Lean Coach.

Dwayne holds Master’s and Bachelor’s degrees in Mechanical Engineering from Bucknell University and a MBA from Clemson University.

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Muda, Muri, and Mura: sounds like a set of cartoon characters to me, not too dissimilar to Huey, Dewey, and Louie.  However, unlike Scrooge MacDuck’s nephews, they are intangible co-conspirators that rob customers of value and an enterprise of productivity.  Most proponents of Lean Healthcare will recognize these as forms of waste that can pervade systems and enterprises.

Many in pursuit of a Lean Healthcare journey recognize the first triplet: Muda.  These are the eight wastes present in work activity: Defects, Over Production, Waiting, Not Clear (Confusion), Transporting, Inventory, Motion, and Excess Processing.  Relentless elimination of these is often the focus of many healthcare delivery systems’ lean journey.  Often overlooked or receiving less attention are Muda’s partners in crime, Muri and Mura.

Muri is waste driven by over-burden.  When demand exceeds capacity or when required throughput exceeds processing capability there is over-burden.  This over-burden reduces flow, increases errors and undermines desired outcomes.  When we try to push volume through a pipeline that exceeds the load-rating of the pipe, flow will actually decrease.

Conspiring with Muri, Mura is waste associated with unevenness.  In manufacturing, there is significant focus and opportunity with regard to level-loading, or “evening out,” demand and thereby reducing Mura.  “Ha, try that in an emergency department on Friday night,” you say?  Yes, level loading of demand will present with challenges in some areas of healthcare.  However, not all areas of the enterprise share the same degree of challenge as an ED.  In cases such as the ED where we may not be able to pace the arrival rate of the work, we can build in the capability to rapidly flex up or down to avoid over-burden.  If this tactic is coupled with predictable processes and predictable cycle times, it becomes even more effective.

Just as many have expanded their thinking of Muda’s eight wastes to include others such as talent waste (using an RN to perform a task within the capabilities of a CNA) or resource waste (leaving the lights on), we must also expand our thinking with regard to over-burden waste.  When we, as leaders, challenge the frontline team to eliminate Muda and to perform root-cause problem-solving within the current stream of work, we often over-burden that resource by failing to allocate time and other necessary support.

While the elimination of Muda is largely a front line staff concern, the elimination of Muri and Mura is the focus of mid-level and senior management.  In fact, often the front line’s ability to eliminate Muda is challenged by the presence of Muri or Mura at a system level.  With mid and senior management focused on the elimination of Muri and Mura, and through the intentional reinvestment of the time savings captured, the frontline becomes truly empowered to solve problems.

Think of the day when all those committee meetings you attend are vehicles for rapid institutionalization of learning and best-practice as opposed to a primary problem solving vehicle; that’s empowerment in action!

Has all this talk about waste left you feeling animated? Let us know in the comments about your challenges overcoming Muda, Muri, and Mura in your organization’s daily work.

This week’s blog was written by Brad Schultz, a Vice President with HPP.

Brad serves as a Lean Healthcare facilitator, business consultant, and executive coach internationally with HPP.  Brad began his career in manufacturing with GE Healthcare and joined GE’s Performance Solutions during its infancy and remained with the business unit for seven years. He provided significant leadership to adapt the firm’s products to the unique needs of healthcare clients and to translate the firm’s published materials into the language of healthcare.

Brad’s educational background includes a B.S. in Business Administration from Cardinal Stritch University in Milwaukee, Post Graduate Certification in Quality Engineering from Milwaukee School of Engineering, a M.A. in Business Administration from Marquette University in Milwaukee, Six Sigma Master Black Belt Certification from General Electric, and Front-Line Leadership Development Certification from Achieve Global.

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I have consulted in many hospitals over the last 10 years and there are some that definitely stand out.  What makes them stand out?  To me, it is the friendliness and helpfulness of the hospital staff.  The memorable, stand-out hospitals create an environment that makes patients, family, and visitors feel at home and at ease.  In my opinion, creating a calming and friendly environment will, indirectly, contribute to better patient outcomes. 

Hospitals are relatively confusing places to navigate.   In the most customer-oriented hospitals, employees will always stop to assist a confused patient or family on where to go.  The best not only tell them how to get there, they actually take the time to walk the person to the correct location.  Now that is customer focused service!

The staff at these stand-out hospitals are also overly friendly.  When you pass a staff member in the hall, you are very likely to get a big smile and “good morning” or “how are you today?”  Have you seen the recent Liberty Mutual “Do the Right Thing” commercials?  They show a person stop and do a friendly or kind act—and someone else sees the kind act who then also delivers a kind gesture to another—and so on.  Similar to these commercials, this friendly attitude in hospitals is contagious and spreads to patients and visitors alike. 

How does this impact hospital budgets and Lean Healthcare?  By being customer focused and openly attentive to patients’ personal needs, hospitals demonstrate their devotion to customer service.  This pays huge dividends in the increasingly important customer satisfaction surveys.  In the near future, these surveys will also tie into reimbursements — further impacting the bottom line.  In addition, hospitals that have become more customer-friendly are strengthening their Lean Healthcare journey.  Lean Healthcare is centered around a patient and customer approach — delivering customer needs in a timely manner.   By interacting with the patients and customers in this friendly, helpful manner, it becomes easier for all levels of staff to participate in the Lean Healthcare journey.  They will be able to actively see and eliminate waste and in turn help the hospital improve processes.   In addition, it is a great start to change the hospital culture that is necessary for a complete Lean Transformation.

Do you agree?  How do you see friendly, helpful staff relating to the Lean Healthcare journey?  Do you think a friendly, helpful environment contributes to better patient outcomes?

This week’s blog was written by Bob Watson, a Senior Manager with HPP.

Bob leads Lean Healthcare transformations for HPP and provides consulting services in a variety of areas within healthcare. Bob has developed training for Lean, Six Sigma and DFSS. He has also spoken at several Healthcare, APICS and ASQ functions He is a DMAIC Six Sigma Master Black Belt (ASQ and Juran certified).

Bob received a Bachelor’s and Master’s degree in Industrial Engineering at Rensselaer Polytechnic Institute.

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