Lean Healthcare Exchange

The Joint Commission recently released the list of the 2009 National Patient Safety Goals. The NPSGs, as they are fondly known, promote specific improvements in patient safety by providing evidence-based guidelines on persistent patient safety issues to healthcare organizations.   

Two of the 2008 goals were published with timelines to be met: teams put in place by April 1, work plans fashioned by July 1, piloting to begin by October 1 and full implementation by January 1, 2009. These two goals require an anticoagulation management program (3E) and selection of a method to directly request additional assistance from specially trained individuals when the patient’ condition appears to be deteriorating (Goal 16). Although the goal does not require a Rapid Response Team (known to many people as a Kaizen team), this is a common implementation strategy.  

Three of the 2009 goals also come with the same timeline, with full implementation required by January, 2010: implementation of evidence-based practices to prevent healthcare associated infections due to multiple drug-resistant organisms, central line bacteremias, and surgical site infections.

How do these goals, as well as the other National Patient Safety Goals relate to “standard work?” The Joint Commission requires processes (procedure) and policies (which often reflect the process) as a measure of compliance with these goals. The Joint Commission is not prescriptive about what those processes are to be, however. Standard work, a Lean Healthcare cornerstone, establishes an agreed-upon method and procedure for the best sequence and timing to perform a process or step in a value stream. Standard work establishes the best method that we currently know, to perform a task which provides the best patient care and reduces waste.

3E, or the anticoagulation management goal, requires 3 key elements: approved, evidence-based protocols for warfarin, low molecular weight heparin and unfractionated heparin. Protocols are a form of standard work:  dosing, timing, monitoring, target therapeutic ranges (of the INR). It also requires training for staff, providers and patients. The manner in which patients are educated should also be process-driven. Who does it?  When?  Where? Standardized content and a way to evaluate the patient’s understanding. If the patient is discharged from the hospital, but fails to understand that they must refill their prescription after 30 days, get ongoing monitoring, and follow a stable diet, all the best intentions of everyone may end in a negative and tragic outcome because of a stroke or bleed.

The new 2009 goal to prevent central line bacteremias follows work already being done by the IHI and various healthcare organizations. There are a variety of central line procedural checklists available already, which outline the process before, during and after central line insertion. Implementing a checklist at the time of insertion will help ensure that all processes are carried out for each central line placement, making the process reliable. This is another example of standard work, which is advocated as essential by Lean Healthcare champions.

The timelines (standard work for us) force us to be very intentional about what we are doing: establishing the best future state, mapping processes, development strategies and materials, building evaluation tools, piloting, revisions, final implementation and evaluation. These things take time, but because the approach it consistent, it is reliable. It is quite clear where Joint Commission is going with this; we can smile and understand. As we work with our teams, we can continue to stress the value of standard work and help with team members’ understanding of the structure of these initiatives.
Standard work: timelines, protocols, checklists, procedures and the NPSGs assist to promote ”IDEAL” patient care, that is defect-free and exactly as requested. Care can be customized to each patient, on demand as requested. Responses to problems or changes in condition are timely and appropriate. Standard work promotes safety for patients, staff and providers: physically, emotionally and professionally.

This week’s blog was written by Bill and Janice Lowstuter. Bill Lowstuter has been a Sr. Consultant with HPP since its inception, and has worked with healthcare clients throughout the USA.  Bill previously worked with HPP’s parent company, The ACCESS Group (TAG) for seven years prior to joining HPP.  Bill has overseen the implementation of Lean within numerous facilities and industries, and has a Bachelor of Science degree in Engineering from the University of Illinois. He has also conducted numerous seminars and conferences in Kaizen principles and Lean. Bill’s multi-disciplined background includes direction over functional organizations such as operations, quality assurance, materials management, purchasing, environmental, health and safety, and human resources. His experience in these areas provides a unique perspective that allows perfect complimenting between strategic and tactical plans.  Janice Lowstuter is the Regulatory Readiness Coordinator at St. Anthony Central Hospital, a Level 1 trauma center in Denver, CO. Janice’s professional background includes critical care and post-anesthesia care nursing, staff education and performance improvement. She holds undergraduate degrees in home economics and nursing and an MBA in Health Care Administration from the University of Colorado.

Throughout my career I have heard leaders talk about having to deal with competing priorities.  In fact, as a General Manager in a major corporation, those words flowed from my mouth routinely.  As I began to understand Lean Philosophy more deeply over the last seven years, I had an “ah ha” about this critical leadership issue.  When it comes down to it, the bigger issue is not competing priorities; it is competing methodologies to meet those business priorities.

I recently facilitated a two-day Lean Leadership training session with one of our clients who is 18 months into its Lean Transformation.  What became evident to these leaders was the tremendous amount of Waste that they were creating by using both traditional and Lean methodologies to achieve their outcome objectives.  It wasn’t a new revelation for most of the 30 leaders in the room.  However, it took getting all 30 of the top leaders in the hospital dedicating the time to see this waste as a team and decide to eliminate it by choosing A3 Problem-solving as their sole problem-solving methodology.  It was a pivotal moment in their Lean journey that could not have occurred without the Lean experiences they have had over the last 18 months to change the way they think about how they do their work.

As the belt-tightening continues during this difficult economy, leaders with traditional thinking will make very different decisions than those with Lean Thinking.  Traditional leaders will look for places to eliminate resources (assets) because the impact to the P&L is immediate.  Lean leaders will focus existing resources on aggressively eliminating waste in their processes, which will result in both immediate and long term impact to all outcome metrics (including the P&L).  This is not to say that Lean organizations don’t temporarily freeze hiring and asset purchases during economic downturns.  However, they don’t abandon Lean as their Operating System – they become even more aggressive with Waste Elimination so they are prepared to beat the pants off of their competition when the economy picks up again.  Oh, and by the way, they beat the pants off of the competition during the downturn as well.

Making Lean your operating management system is a decision.  It is not something you do in one department and not another.  It is not something you do only in good times or only in bad times. It will not sustain itself.  If it did, everyone would be doing it.  The beauty of it is that Toyota has proven over the last sixty years that it is the most effective and efficient operating model in the world and it applies anywhere there is work and flow.  The plant manager of the Toyota plant in San Antonio was quoted in the newspaper as saying: “This downturn in demand for light trucks will give us the opportunity to better train and develop our people.”  What will your decision be during the economic downturn?

This week’s article was written by Dwayne Keller, the Vice President of Healthcare Performance Partners (HPP). Dwayne has overseen the introduction and implementation of Lean Healthcare in various hospital and clinical systems throughout the USA. He coaches at all levels of Healthcare organizations, from CEO to front line staff to deliver improved outcomes via Lean. His deep understanding of Lean as a holistic process improvement “system,” and leadership guidance in connecting Lean implementation to each organization’s specific business case needs in a visual way, sets him apart in the industry. Dwayne has also been a speaker and lecturer at various Lean Enterprise conferences as well as a presenter at the Shingo Prize Conference. Dwayne began his career with DuPont as an Engineer and as an Industrial Engineer & Production Manager at Michelin Tire Corporation, he introduced Just-In-Time and Teamwork into two of their largest manufacturing operations. After earning his MBA, he spent three years in Michelin’s Marketing Department helping to transform it into a customer-focused research and data-driven organization. Dwayne joined Alcoa’s AFL Telecommunications Division as Plant Manager and later Director of Operations and drove implementation of the “Alcoa Business System” (ABS), which is its Lean Enterprise system, to meet business goals. Dwayne holds Master’s and Bachelor’s degrees in Mechanical Engineering from Bucknell University and a MBA from Clemson University.

Is lean just a set of tools to go implement?  5S program, check.  Tape on the floor, check.  Label my supply room, check.  Visual management boards, check.  Do you know the buzzwords, can you speak the lingo?  Am I lean now?  Did you calculate the ROI?
I see many companies make a big splash, show some quick gains, but is it sustainable?  Time after time I see organizations start a lean initiative and implement the tools only to fizzle out without any long term impact.  “This doesn’t work in our industry.”  “Lean does not work for this type of process.” “Just another program of the month.”
What is missing?

Lean enterprise leaders will tell you that it is 20% tools and techniques and 80% philosophy.  You cannot call in a surgeon to perform a “mind replacement”, so what are you going to do?  I see process changes languishing on the bathroom bulletin board (the only place some staff have time to even read them).   Management focus is on covering today’s caseload instead of identifying the problems that are killing staff (figuratively), if not the patients (literally).  They have not made the change in thinking that must go along with changing the processes.  Staff are frustrated because they see more problems now that were hidden by “that’s the way we’ve always done it” before the Kaizen event.  (The problems were always there–just “invisible” to the old way of thinking.)
Change Happens
Leadership at all levels must change their thinking.  Over time, a shoot-the-messenger management style begets a wait-until-told employee behavior.  Then we wonder why they “check their brains at the door.”  An organization that relies on a top-down, command and control operational style now has competitors where every team member is thinking about the process, identifying problems, looking for leverage. 
However, it is not a free-for-all with management just trying to appease everyone using the “Keep them happy and they will do the right thing” style.  Leaders must think and communicate strategically.  What are the priorities?  I have a limited amount of resources, where should I focus?  We cannot fix everything at once, so some problems may just have to wait.
Problems Surface
Many lean tools don’t fix problems.  Instead, they help make problems visible.  This creates an internal stress on an organization to make the problems disappear.  Is it OK in your organization to have problems?  Do you celebrate problems?  Can you identify and prioritize problems, translating your efforts into sustainable gains demonstrated in patient outcomes and business results?  Can you get to the root cause, even if it turns out to be that organizational dead moose on the table?  (Note for our international readers “dead moose on the table” is an American idiom meaning the issue that everyone knows about, but no one wants to point out and address… everything from the million dollar software that doesn’t work to the surgeon that is always late for first case starts.)
You can read a book, go to a class, but what you really need is someone experienced in implementation that can coach, challenge, and encourage you through the thinking processes required to manage that new process.  If not, your current thinking will bring you back to your current results.
Lean Thinking
Management must change their thinking-change their minds.  What better time to break old habits than when you change that process and move those supplies?
Remember that book “Lean Thinking”? –it wasn’t about Lean Tools.

This week’s blog was written by Richard Tucker a director with HPP who assists clients throughout the USA with Lean Healthcare transformations. Richard has over sixteen years of experience in business and industry fields in operational and leadership positions. His experience includes new program installation and launch, operations improvement, lean manufacturing implementation (internally and with suppliers), leadership development and supplier program management from prototyping through launch. Additionally, he has many years of Lean experience having worked with a major Japanese automaker, and received much of his experience and formal training in the Toyota Production System, Lean Manufacturing, and Shainin Statistical Engineering while in Japan. Richard’s educational background includes BS and MS degrees from Tennessee Technological University in Cookeville, Tennessee.

A recent news report from NPR (6/27/08) touted the World Health Organization’s (WHO) use of checklists in 8 different hospitals around the globe to reduce surgical errors.  According to the report, a simple checklist of 22 items has helped these facilities improve the rate at which they performed surgery without error or omission from 33% to approximately 66%.  The checklist covers all aspects of the patient’s procedure and is divided into three phases: before anesthesia, before incision and before the patient leaves the room.  With over 230 million major surgical cases per year, these results reveal opportunity on a massive scale.  The checklist is reminiscent of those used in the airline industry almost religiously to ensure the safety of the aircraft prior to takeoff.  While this concept is not new in the surgical arena, the report did spark a few thoughts on a key Lean principle, error proofing.

First, the power of the checklist lies in its simplicity.  In a world in which complex devices and systems are typically the first line of defense, it seems almost unconscionable that a sheet of paper and a pen could be the remedy for so many errors.  As the story reports, many questioned the initial effectiveness of the tool because of its simple nature until they personally experienced the benefits of the checklist (i.e. avoided significant errors through the use and verbalization of the tool).  However, it is through these new experiences or “saves” that new beliefs are formed which ultimately result in new actions/behaviors.  Many of the checklist’s original detractors have now become its greatest champion.

As a community of continuous improvement practitioners we must also ask, “How do we get from 66% to 100%?”  It is this question and many like it that challenge us as we work with surgical staff across the country to improve the safety and quality of care.  Certainly, there is more in the error proofing toolbox than checklists.  A deep dive into the root causes of error can lead to an array of error proofing devices and process changes.  Once processes are stable and standard work is in place, Six Sigma methodologies should also be considered to further drive out variation, the precursor to defects and error.  While the WHO’s success is unquestioned, there is much work ahead to translate potential to reality.  The use of a wide array of error proofing methodologies will be one of the keys to realizing these goals as we continue to make strides toward the ultimate goal of defect free healthcare. 

For more information on NPR’s coverage of the WHO, follow the link below: 

http://www.npr.org/templates/story/story.php?storyId=91945517
(Follow links from this page for an audio report from NPR and free downloads of the WHO’s checklist and implementation manual).

This week’s blog was written by HPP’s Marshall Leslie. Marshall, a Six Sigma Blackbelt, oversees various HPP projects and Lean Healthcare transformations for clients throughout the USA.  As a former multiple year “top-ten percent” performer at General Electric, Marshall brings clients the much needed tools and techniques needed in any industry, including healthcare. Marshall is a graduate of General Electric’s Operations Management Leadership Program; he has experience in various supply chain capacities including quality engineering and global sourcing for both GE and Procter & Gamble. Marshall’s expertise in both Six Sigma and Lean enables him to apply a broad spectrum of process improvement tools tailored to the healthcare industry’s needs. He holds a degree in Industrial and Systems Engineering from Georgia Tech. 

For several years now I have been in different hospitals observing processes. I look and ask why do it that way? Often the reply is, "That has been identified as a best practice and we decided to implement it at our facility." Of course my follow-up question is then, "Who decided it was Best Practice?" The standard answer is one of many; Joint Commission, JORN article, NEJM article, a Local Steering Committee, a Board of Trustees and many other different entities or publications. A series of other questions pertaining to the success of the "Best Practice" often leads to a conclusion that it was not actually a "Best Practice" but only a "Best Known Practice."

In Lean Healthcare, we encourage people to participate in "Best Practice" forums and share their examples of success. A group of individuals, hospitals, or regional peers present their own process improvements following the A3 format to one another. Then there is an open session to ask why and to develop ideas for further improvement for one another. Participants then use the information gathered by the forums to reflect and report back to their own work group the findings.

The one key point of the Lean Healthcare Best Practice Forums is that an ideal solution is not identified for processes such as Verbal Orders, Medication Reconciliation, Door-to-Balloon Time, Hospital Acquired Infections, or any of the other common problems. The "Best Practice" that is identified is the methodology that led to the solution and not the solution itself. The focus is how did you develop the solution and not what did you develop as the solution. This philosophy of "Best Practice" in Lean Healthcare has been repeated many times over. Lean is not what you do, but how you do it.

There are several examples of implementing a solution without adhering to the Lean methodology. The most recent one that I can state was for Medication Reconciliation. In fact, Med Rec has been a reoccurring theme for several of my examples. A hospital was having trouble meeting the requirements for Medication Reconciliation as prescribed by Joint Commission. A Kaizen Value Stream Analysis team was assembled to do a Future State Value Stream Mapping Event. The team went through the current state and identified the opportunities for the future state. Several sub-groups were set-up to implement the future state. Metrics for success were established. A trial period was scheduled. At some point after the initial future state mapping, the methodology was abandoned. Some members of the team had found out about a "Best Practice" for Med Rec and decided to follow that solution. Unfortunately after implementing the "Best Practice", the results actually showed no improvement and even in some areas decreased performance. Once again, the "Best Practice" turned out to be only the "Best Known Practice."

There are many reasons why a solution in one area will not work at another area. There could be cultural, IT, management, facility or other differences that prevent the copying of a solution. Most of the time, the reason for failure is in the execution of the implementation and not in the solution itself. Even worse, leaders and staff have not taken the time to truly understand and quantify the problem they are trying to solve and the corresponding causes of that problem in their processes.

Lean Healthcare recognizes that every solution is unique to the people, place and problem. The methodology identifies that the true process experts are not the people at another facility or at the university. The true process experts are the people on the nursing floor caring for patients on a daily basis. They are a vital part of the planning and implementation. By following the A3 format, the process experts have a common problem solving methodology to follow and to serve as a communication tool to others.

Thus, "Best Practice" then becomes not the solution but the methodology of developing a solution. That "Best Practice" is the Lean Healthcare A3 format. It enables your process experts to determine and implement a solution unique to their process that is truly best and not just best known.

David Pickens is the author of this week’s article.  David is an HPP Lean Healthcare facilitator, consultant, trainer, and certified lean six-sigma Master Black Belt. Dave has a B.A in Statistics and M.B.A., and is currently working on his DBA.  Dave has worked with HPP healthcare clients throughout the USA by assisting them with their Lean Transformations. Dave has years of industry experience from his time in the automotive and consumer goods industry, including time with Panasonic, Allied Signal and BOSCH. He has trained with Matsushita in Hong Kong, Japan and Singapore in Japanese Manufacturing Management.

It’s amazing how some of Granddad’s old sayings ring true. I don’t know that I fully understood all of them at the time, but, when the moment arises, they spring forth from the depths of memory to remind me of the seeds of wisdom planted long ago.

I was trying to explain a recommended improvement to the staff on a unit where I had been observing and was banging my head against reason after reason why none of my suggestions would/could/should work–or were worth even a trial. In my mind, I was proposing a rational solution, based on lean healthcare principles, that would eliminate the wastes that I observed. I believe that in their mind I was just another outsider trying to tell them what to do. Their unit was different and I just really did not get it.

Sure, I could get them to comply while I stood there and watched, but what happens when I walk away? I find that people will generally do what they understand and if forced to do something that does not make sense (or hasn’t been fully explained), they will start smoothing off the edges (a.k.a. “cutting corners”) to make it easier for themselves.

In a complex and highly interdependent system, many problems arise on the handoffs and interfaces. The nature of these problems is that a step skipped in one area may not have a direct negative effect in that area, but cause chaos in another area. The person causing the problem may be completely unaware of the damage they are doing.

• You tell them to do something that they don’t fully understand. (Usually because the impact is noin their field of view.)
• They comply while you are close by.
• When you are no longer following up so closely, the corners get cut.
• There is no apparent impact (because the effect is not local to the cause).
• Compliance dwindles until a problem occurs.
• You blame the person who quit complying.

In reality, the root cause lies with the leadership method. There are too many tasks to follow-up and audit every detail. Healthcare is a highly complex environment, where there are many highly-motivated people acting individually and autonomously within a set of guidelines and boundaries. Processes flow across people, location and time, making it difficult to see the impact of individual actions, much less understand the total system. Richard’s Rule of Thumb is that “People will not continue to do what they do not understand.”

“People’s minds are changed through observation and not through argument. “ — Will Rogers

Leaders must constantly coach the “Why” behind the “What” when driving change. One of the best ways to get people to understand a complex process is to have them observe the process themselves. (Maybe even them draw a picture of the process, highlight the issues, collect some data… sounds like A3 Problem Solving-wink,wink)

You have to change their understanding, their opinion, to have even a hope of sustaining improvements. Ironically, forcing change seems to work, because you can see the immediate compliance, but as Grandad always said, “A man forced is of the same opinion.”

This week’s blog was written by Richard Tucker a director with HPP who assists clients throughout the USA with Lean Healthcare transformations. Richard has over sixteen years of experience in business and industry fields in operational and leadership positions. His experience includes new program installation and launch, operations improvement, lean manufacturing implementation (internally and with suppliers), leadership development and supplier program management from prototyping through launch.  Additionally, he has many years of Lean experience having worked with a major Japanese automaker, and received much of his experience and formal training in the Toyota Production System, Lean Manufacturing, and Shainin Statistical Engineering while in Japan. Richard’s educational background includes BS and MS degrees from Tennessee Technological University in Cookeville, Tennessee.

Teaching Lean principles does require knowledge and experience. Patience is not just a virtue but a necessity. We at HPP are continually introducing new words, phrases, and analytical tools to professions that never heard of these before. We talk about value added and non-value added, spaghetti diagrams, work sampling and other tools. The phraseology sounds like we are going to try eating at a new Italian restaurant!

Healthcare is in the nascent stages of Lean methodology. HPP knows the benefits of using Lean, but our job is to facilitate and instruct how and when to use the various components available. We want to leave our customer well equipped to face the everyday challenges and tasks with a formidable plan. They should be able to effectively organize strategies to attack problems and solve them. Their everyday activities should include new habits that include everyone working for the common good of the patients (customers).

Over the years I have facilitated many projects at businesses that wanted to introduce and use Lean principles. Many times there were people there who had read about Lean principles or even gone to seminars about these concepts. Their approach when putting these to use was like a person going up to the shallow end of a swimming pool and putting their toe in the water to try and test the water. Our focus at HPP is to get businesses swimming in the deep end of the pool as soon as possible. We want to have our customers immersed in Lean principles and understanding. We want them to realize that a value stream map is not a drawn picture of a river but a picture of the real events, actual times, and people involved in processes that flow together serving customer needs.

In two recent kaizen activities we introduced job instructions (standard work) at two facilities. This was similar at both because the instructions concerned scanning documents to the pharmacy to process medication requests. Both places were rife with frustration and some anger because the pharmacy could not understand why nurses were unable to scan documents in the way the pharmacy needed to receive them, and nurses could not understand why the pharmacy did not respond in a timely manner. Everyone was doing what they thought was right, but the value stream map showed some real areas of improvement. One of these was to write detailed job instructions on how a document should be scanned to the pharmacy correctly. These instructions with pictures were attached to the scanner and provided the nurses an error proofing system to ensure the orders were scanned correctly.

The above example eased the “F” factor. Tornadoes are measured on the Fujita scale and rated from F1 to F5 according to their wind speed. The F factor in healthcare is not so indifferent. Frustrations caused because of lack of communication, not understanding why or just doing things because we have always done them that way are irritants and cause many problems. Lean principles require us to do something about these things and end or greatly ease the negative effects. We shouldn’t stand at the side, put our toe in the water and say “Maybe”. Dive into the problems at the deep end of the pool and solve them; don’t stand on the side and wonder why.

Don Bingham is a Sr. Associate with HPP and brings over twenty years of experience in automotive manufacturing to Lean Healthcare. This includes seventeen years with Nissan Motor Manufacturing where he made strides in industrial engineering, supervision, supplier development and Lean Manufacturing. Don was instrumental in Nissan’s Lean Manufacturing techniques where he taught Kaizen Methodology, utilizing tools such as 5S and Standardized Work. While at Nissan, Don spent time in Japan on new vehicle model projects, benchmarking Japanese vendors and training. Don was with General Motors for three years, where he helped to implement their Lean Global Manufacturing System at St. Catharine’s Engine plant in Ontario, Canada. Don holds a Bachelor of Science in Industrial Technology and Math from Middle Tennessee State University in Murfreesboro, TN and earned a Six Sigma Black Belt Certification in 2007.

This year’s 3rd Annual Lean Healthcare Conference in Denver demonstrated the growing interest and activity of Lean in healthcare. With all of the 44 presenters, the sophistication of topics and depth of experience was evidence of Lean’s solid position in current process improvement strategies.

Presenters and participants from 4 countries and 22 states convened to share research, new methods and organizational experience with traditional and modified Lean principles. An excerpt of the keynote presentations of the conference can be reviewed at:

http://leanhealthcarewest.com/video/conference_review_denver.html

The next event sponsored by Lean Healthcare West and Healthcare Performance Partners will be the 4th Annual Lean Leadership Retreat, August 18-20, at Big Sky Montana. This event focuses on leadership roles and opportunities, sustainability techniques and challenges, and cutting edge expansions of Lean applications. More details can be viewed at:

http://leanhealthcarewest.com/leanhealthcare_workshops.html?workshop_key=55

3rd Annual Art of Innovation Award Winner

One exciting element of the Annual Lean Healthcare Conference is the presentation of the Art of Innovation Award. This recognizes the Lean efforts of an organization in the following areas:

1. Leadership engagement
2. In-house education program
3. Percentage of employees trained/engaged
4. Efforts to share learning in-house and out
5. A great activity description!

This year’s winning organization was Northern Arizona Healthcare. Their parent organization, Flagstaff Medical Center, initiated their journey in 2007 after 2 years of diligent self-education and persistence by Steve Spravzoff, VP for Process Improvement. The newly appointed CEO, Bill Bradel, saw the opportunity to incorporate Lean into his leadership strategy and truly led in the Toyota model, by attending the education and improvement activities himself. The rest of his team shared his commitment and physicians report feeling truly involved with the hospital management for the first time.

The dedication and skill of the staff also stood out. They were ready to use the lean framework and tools to improve work processes. The surgery team removed $360,000 in waste and immediately proceeded to expand their efforts. They now spend 2 hours every other week making on-going improvements. The favorite quote heard by Mr. Bradel: "This is the best thing to happen to health care since penicillin!"

Congratulations to all of the staff and management at Northern Arizona Healthcare!

Cindy Jimmerson, who leads HPP’s affiliate company Lean Healthcare West, is a pioneer in Lean healthcare, having initiated her work with a grant from the National Science Foundation, 2001-2004. She is the author of the Lean Healthcare West Review© Course and many journal publications. In addition, as part of the HPP’s Lean Healthcare West team, Cindy travels internationally speaking on the subject and organizes the National Lean Healthcare Conference. Cindy has been featured in Industry Week, Business Week, and numerous business and healthcare periodicals for her work in Lean Healthcare and has been a featured lecturer on the subject at the Harvard School of Medicine.

No doubt that sometime in your history of process improvement you have run across the phrase, “you get what you measure.” Makes sense, doesn’t it? Things tend to get better when they are being watched. This is typically referred to as the Hawthorne Effect. The term “Hawthorn Effect” was coined in 1955 by Henry A. Landsberger when analyzing older experiments from 1924-1932 at the Hawthorne Works outside of Chicago, IL. Landsberger noted that people’s behavior and performance changed following any new or increased attention.

By merely adding new measures at the end of an improvement activity, one can expect improved process performance. But it brings to mind additional questions: What do you want? What should we measure? What is the desired outcome? How will we measure it? How does it support overall organizational goals?

In other words: What is the plan?

Plan? Now if that sounds familiar, it should. Let’s journey back a bit further into our Quality History 101 books. The PDCA (Plan, Do, Check, Act) Cycle was originally developed by Walter Shewhart in 1930’s, and later adopted by W. Edwards Deming. The model provides a framework for the improvement of a process or system.

During an improvement activity such as a Kaizen Event, we are often guilty of wanting to rush to results. We can’t wait for the report out to show the progress that has been made in a particular area. We see graphs on the wall showing great progress and improvement.

While measures are a key component of sustainability, we have to be careful not to short circuit the PDCA process. The Planning Phase of any improvement activity is a critical component of success. As an example, let’s look at the structured method of A3 Problem Solving. Notice that the first 8 of 10 steps are all part of the Planning Phase! Although it typically goes on in the background and unnoticed, the Planning Phase is a critical component of success. I like the following quote from Dwight Eisenhower… “In preparing for battle I have always found that plans are useless, but planning is indispensable.” Prepare for your battle!

Steps of the A-3 Problem Solving Process

• Step 0: Identify a problem or need
• Step 1: Conduct research to understand the current situation
• Step 2: Conduct root cause analysis
• Step 3: Devise countermeasures to address root causes
• Step 4: Develop a target state
• Step 5: Create an implementation plan
• Step 6: Develop a follow-up plan with predicted outcomes
• Step 7: Discuss plans with all affected parties
• Step 8: Obtain approval for implementation
• Step 9: Implement plans
• Step 10: Evaluate the results

This week’s article was written by Tom Stoffel, a director & consultant for HPP. Before joining HPP, Tom served as President of Transformation Group, Inc,. Tom developed TGI Healing Healthcare – a brand of Lean Healthcare training tools designed to make lasting improvements. Tom has led healthcare organizations in both the development of high-level Lean Strategies down to hands-on implementation of Lean in a clinical setting. Tom has achieved the levels of Certified Lean Specialist from the Business Improvement Group and the National Institute of Standards and Technology (NIST), along with being an ASQ Certified Quality Engineer. These certifications build on an Engineering Degree from the University of Michigan. Training experience includes Lean, Quality, and Leadership Training, as well as serving as an Adjunct Faculty Member at Waubonsee Community College.

One of my responsibilities in the Quality Resources Department in the hospital where I work, is to sometimes do our department presentation at Care Provider Orientation – for nursing personnel both licensed and unlicensed, pharmacists, respiratory therapists, and all the physical medicine folks – physical, occupational and speech therapy. One of our slides asks if we can promise 100% reliability with the following: no patient misidentifications, no medication errors, no wrong patient, site/side surgery, no unnecessary tests/treatments and no sponges left inside patients. In a group of the usual 20 or so orientees, there are at least a couple who are certain that we cannot promise those things 100% of the time, even though we have robust, standardized processes to prevent each one of these potential errors.

“Why?’ I ask. “Because of human error,” is the response I typically receive. “Human beings are involved,” they say, “so mistakes are inevitable.” “What about 99.9%?” I ask. Heads still shake in an emphatic “No.” We proceed through the 99.9% conversation, including that a 0.10% error rate would represent about 1,750 medication errors in our facility annually. Inevitably, they come to the realization that our goal should be 100% reliability, achieved through processes required by the Joint Commission National Patient Safety Goals, standardized in our policies and procedures and that are the right thing to do for every patient, every time.

This has become deeply personal for Bill and for me. Our grandson Alan was born with a very serious, single-ventricle heart defect in September and has been hospitalized for months in his short life. His mom Jenna diligently watches the care he receives. She his not a healthcare professional but she asks appropriate questions, has caught and prevented potential errors. I do not believe that the nurses caring for him intended to make an error. They did not, however, follow the hospital’s standardized processes and as a result, there were potential errors. Thankfully, there have been very few.

Alan is currently supported on a ventilator which breathes for him. It would not be very comforting if we expected that ventilator to operate correctly only 99.9% of the time, especially if we didn’t know when the 0.10% (or 86 seconds/day) might happen. We might not know what the failure would be – that it would not deliver breaths, or not at the right oxygen level or at the correct volume or pressure. Some human built that ventilator and it thankfully operates without failure, 100% of the time. It performs reliably and we are very thankful that it does.

A study was published in the New England Journal of Medicine in June, 2003 (McGlynn, et al) about the quality of healthcare delivered to adults in the United States. In that study, 439 indicators of clinical quality of care were reviewed from the medical records of 6,712 patients, for 30 acute and chronic conditions, plus prevention. In that study, participants received 54.9% of scientifically indicated care. The conclusion: the “defect rate” in the technical quality of American healthcare was, per this study, approximately 45%. This is not anything close to 0.10%.

At my end of the time with the orientees, I think that most are believers and that we have made progress. We focus on what that 0.10% could mean to their loved one: their mother, father, brother, sister, wife, husband, child, grandchild or wonderful friend. I tell them that if they do not remember anything else, that they are to remember, “Process, process, process.” Learn the process and follow the process, without diversion, without workarounds, every patient, every time, and we can prevent errors.

This week’s article was written by Janice & Bill Lowstuter. Janice is the Performance Improvement Coordinator, Quality Resources at St. Anthony Central Hospital, a Level 1 trauma center in Denver, Colorado. Janice has responsibility for implementation and monitoring of the Joint Commission National Patient Safety Goals. She facilitates a number of clinical effectiveness and performance improvement teams and has experience in marketing research, critical care nursing, nursing education and patient education. Janice holds undergraduate degrees in Home Economics and Nursing. She completed an M.B.A. with emphasis in Health Administration from the University of Colorado in Denver in 2001. Bill has been a Sr. Consultant with HPP since its inception, and has worked with healthcare clients throughout the USA. Bill previously worked with HPP’s parent company, The ACCESS Group (TAG) for seven years prior to joining HPP. Bill has overseen the implementation of Lean within numerous facilities and industries, and has a Bachelor of Science degree in Engineering from the University of Illinois. He has also conducted numerous seminars and conferences in Kaizen principles and Lean.