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Lean-Led Design is a systematic approach to healthcare architectural design that focuses on defining, developing and integrating safe, efficient, waste-free operational processes in order to create the most supportive, patient-focused physical environment possible. 

Steven Spear identified the Four Rules-in-Use that permeate processes in his 1999 book, “Decoding the DNA of the Toyota Production System.”  The four rules have since become known as the fundamental building blocks for defining and optimizing the complex, multifaceted process steps that are inherent in today’s Lean healthcare delivery system.  As more attention is given to healthcare architectural design to support Lean processes, the four rules are a logical platform for articulating the characteristics of a supportive Lean-Led Design Project. 

The Lean Led Design Principles below align with Spear’s Four Rules to optimize the Healthcare Delivery System: 

Rule 1: Activities

• Think system, not silos. Look for opportunities for sharing spaces between services, for example, prep and recovery rooms that serve all invasive procedures.  If possible, co-locate exam room spaces between two departments with opposing peak census needs, such as Pre-admission Testing and the Emergency Department.  This will result in increased capacity for both.
•  Standardization in design promotes defect-free, standard work. Standardize configurations to reduce variations in work processes and promote long-term flexibility.  In shared workspaces such as medication rooms, a standardized layout permits instant familiarity and reduces the potential for error.

Rule 2: Connections

• Create a visual workplace. Build in visual cues that permit the staff to instantly determine normal from abnormal in their workplace. Designate parking places for frequently used equipment to prevent time spent searching when it is in use.
• Caution! Waiting is waste. Carefully scrutinize waiting rooms beyond the point of entry (public lobby and reception areas).  Don’t design sub-waiting areas to queue patients: rather than shift the wait from one area to the other, strive to move patients through the system with smooth, one-piece flow.

 Rule 3: Pathways

• Pathways should be direct. Make way-finding intuitive.  Make it easy to visualize the destination from the point of entry.  Remember that straight corridors make stretcher travel easy with minimal motion waste. 
• Design in smooth flow and motion. Design the layout for smooth flow, where work proceeds in one direction and the start and end are in proximity.  Consider how the work starts and ends and consider the hand-offs and travel in between.  For example, are the patient and family member arriving for imaging able to enter and exit the same door near their car? 
• Make the trip to the toilet a Lean journey.  Configure patient rooms with the toilet room on the same wall as the headwall to reduce travel, promote patient autonomy, and reduce the risk of injury to patients and staff through falls. 
• Space should be intentional.  Design for every square foot needed and no more.  The belief that space will solve problems is a myth:  excess space leads to increased travel distance (motion waste) and stockpiling of supplies and equipment (inventory waste).  Process redesign solves problems. 

Rule 4: Continuous Improvement

• Make the environment easy to change.  Consider using standardized modular equipment, casework and workstations on wheels to provide flexibility for continuous improvement.  Make storage accessible, flexible, visual and temporary.  Create long, shallow equipment rooms to keep items from being lost and prevent having to move items reach equipment behind. Designate visible parking spaces for each piece. 
• Think quality at every step. Design in inspection (quality checks) before the product/patient/service is passed on to the next level. Incorporate ways to visually communicate real-time progress toward continuous improvement goals.

Whether it’s a small department renovation or a large hospital replacement project, when Lean Healthcare processes and a supportive building work together the result is the same – higher quality at a lower cost. 

Interested in Lean Design? Check out www.leanledhospitaldesign.com for more information on Lean-Led Hospital Design: Creating the Efficient Hospital of the Future, the new book from Naida Grunden and Charles Hagood, available March 2012.

This week’s blog was written by Teresa Carpenter, RN, Director, Lean Clinical and Facility Design.

Teresa brings a unique perspective to lean healthcare as a registered nurse with extensive architectural design and facilities planning experience as well as move-in expertise.

Teresa assists hospitals and healthcare systems in all aspects of applying Lean to the master plan, design, and operational aspects of a facility design or clinical expansion. Teresa serves as an educator, advisor, advocate, and interpreter for Lean healthcare integration into a wide range of clinical and hospital design, renovation, construction, and move-in projects.

Following more than 12 years in acute care, Teresa transitioned to clinical operations coordinator for an internationally recognized leader in healthcare architectural design. Among her project experience, she was the lead planner on the nationally recognized St. Joseph’s Hospital in West Bend, Wisconsin, the world’s first hospital designed to reduce medical error.

Teresa holds a B.S. in Business Administration from the College of Charleston, and a B.S. in Nursing from Trident College in Charleston, South Carolina.

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SAVE THE DATE

Lean Healthcare PowerDay

April 9-10, 2012

The Mandalay Bay Resort

Las Vegas, Nevada

Join us for the Lean Healthcare PowerDay!  Hear from and interact with preeminent Lean Healthcare industry leaders who are transforming organizations into safe, high-quality, high-performing healthcare delivery systems.  Learn how others have overcome challenges including changing culture, sustaining results, and surviving transitions in leadership. 

Gain insight into how implementing an effective Lean system can help you improve quality outcomes in delivery and transition of care, which are becoming increasingly important measures for reimbursement in the wake of health reform. 

Featured Presenters:

Lean Healthcare PowerDay
Tuesday, April 10, 2012

The PowerDay is the best way for you to get caught up on Lean Healthcare’s rapidly progressing, constantly changing practice.  This full-day of session presentations provides knowledge on how to implement Lean Management Systems, address struggling transformations and leverage specialized Lean Tools and Methods for Healthcare Facilities Design. 

The Charge (Optional Introductory Educational Session – Register Separately)
Monday, April 9, 2012

This half-day educational session provides Lean Healthcare training and an introduction session to attendees. Held on Monday, April 9, The Charge will present a broad brush of key concepts for healthcare providers new to Lean Healthcare, or for those who need a refresher on basic tools and techniques used in the practice.

Event Agenda

Tuesday, April 10, 2012 

SAVE YOUR SEAT:
 

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Many healthcare organizations are embracing Lean Healthcare as a methodology for improved flow and efficiency.  However, many of these organizations are overlooking Reliability and Safety when it comes to patient care.  The elimination of defects, in regards to patient safety, in Lean Healthcare is called Reliability and Safety.

2012’s goals and objectives are in full swing.  Many have set targets for Ventilator Associated Pneumonia, Central Line Infections, Wrong Site Surgery, and other core measures and many of these targets will sound like, “Reduce by 25%” or “Lower percentage than 2011.”  These goals cause me to reflect back to when I was a young executive leader of an operation. 

Through our annual goal setting process targeting the corporate breakthrough objectives, we set a target of a 50% reduction in lost time accidents.  Ed Novonty, one of my early mentors, rejected this target through our ‘catch ball’ process.  I still recall his words, “Joe, I cannot accept that you are targeting to hurt 5 people next year.”  By saying this, Ed challenged me to look at the goal as though I were responsible for hurting these people, as opposed to generically reducing injuries.  My leadership team’s incentive was tied to meeting these goals.  Ed inquired about our process for accident investigation and about our leading indicators for such an objective.  After much discussion our target became zero.

This dialogue played out again when Cindy McDonald, Vice President for FirstHealth of the Carolinas, pitched to the board that we were embracing a strategy of ‘Achieving Zero.’  She explained that FirstHealth had made great strides.  Achieving linear improvement was not going to deliver patient expectations.  It required a new way of thinking and approach.  One event that could be prevented was one too many.  Who would volunteer their family member to be one of the patients that acquired Ventilator Associated Pneumonia or develop a Surgical Site Infection while still meeting target?  I observed physicians stepping up to become team leaders.  Each event was investigated in detail, leading indicators were developed, response teams were established, and Six Sigma was applied to the potential patient population.

According to Weick and Sutcliffe in their breakthrough book “Managing the Unexpected:  Assuring High Performance in an Age of Complexity,” FirstHealth was taking the next step in their three year journey of Just Culture to a deeper Mindfulness.   Reliability and Safety is an integral part of Lean Healthcare.

So, the question remains: “What is your healthcare organization’s target for hurting patients this year?”

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Too often I lead teams whose goal it is to improve the workflow of caregivers, only to find that the team is hamstrung by a facility design that doesn’t support that team’s vision.  There are all kinds of explanations for how these physical design barriers come to be, but I won’t try to list them all.  I would rather focus on one of these explanations and leave the other hundred or so for another blog posting.

By now, readers of the Lean Healthcare Exchange know that the focus of Lean healthcare is waste elimination.  It is also widely accepted that two of the most prevalent forms of waste in healthcare are motion and transportation.  A common cause of both these types of waste is searching for supplies and equipment.  It is my experience that the way we design our facilities creates an environment where we are destined to have significant searching.  Many well meaning healthcare designers have actually exacerbated this searching by using typical design paradigms regarding the use of casework and cabinetry.   Let me explain:

In healthcare design, there is a tendency to furnish most workspaces with plenty of cabinetry and casework.  Often, there seems to be a “more is better” approach and designers endeavor to squeeze as many cabinets and drawers as possible into a given space.  I want to challenge this approach.  The number and size of cabinets and drawers in a work space should be defined by the work flow in that space.  Sometimes this means that we will have fewer cabinets and drawers than the space will accommodate.  I realize that this is a counter-intuitive assertion.  I know because from care givers I hear, “we never have enough cabinets to store all our stuff.”  And from designers I hear, “in the interest of the staff, I look for opportunities to maximize the use of casework so that there will be plenty of storage.” 

Let me also clarify that for purposes of this discussion, I am referring to clinical care areas rather than public spaces or even areas where patients will spend a lot of time. 

Certainly, cabinetry serves a useful purpose.  It serves to hold the stuff that we wish to store near the point of use.  It can also provide a level of security and safety for our stuff and our patients.  Cabinetry also provides an aesthetical benefit by obscuring the negative appearance of clinical supplies.  But, in these clinical areas, where patients rarely go, safety, security and appearance are secondary or tertiary considerations.  The primary consideration instead, is quick and efficient access to care supplies for purposes of restocking and providing care.  In this case, more visibility to the supplies rather than less visibility is desirable.  Cabinetry and casework are tools that limit visibility.  The result is more searching and an unnecessary barrier to ensuring reliable replenishment. 

The design of casework and cabinetry should be purposeful.  There are certainly appropriate applications of casework and cabinetry but, its use should not be the default in all situations.  It is the front-line staff, with their intimate knowledge of the workflows in a workspace who should inform the placement of design elements.  Favoring more open, visible storage will provide for a more efficient workflow by easing access to the supplies and increasing the likelihood of proper replenishment.

Given that I have no architectural or design expertise, how can I recommend a new paradigm in healthcare design?  It is the front-line staff that I have worked with that have, through observation of their waste-filled current state processes, pointed out this built-in waste.  They have, on several occasions, recommended a more open and visible storage in work spaces such as Medication Rooms, Nourishment areas, procedure rooms and the like.  But, by the time these counter-measures are requested, it’s too late.  The prospect of replacing cabinetry valued at several thousand dollars is a non-starter with most leaders.  So, they continue to deal with an inefficient process and develop other workarounds.

What is the solution? Engage front-line staff earlier in the design phases of a hospital construction or remodel project.  By doing so, we can eliminate some of this built in waste.  This is just one example but there are many potential benefits that can be realized by applying Lean Healthcare principles during the design of a healthcare facility. 

Interested in Lean Design? Check out www.leanledhospitaldesign.com for more information on Lean-Led Hospital Design: Creating the Efficient Hospital of the Future, the new book from Naida Grunden and Charles Hagood, available March 2012.

This week’s blog was written by Jeff Wilson, a Director with HPP.

Jeff leads Lean design, new facility move-in preparation, and Lean transformation engagements with healthcare clients. He has developed Lean transformation plans, facilitated Rapid Improvement and 3P events and developed training materials for numerous client companies in healthcare. Throughout Jeff’s career, he has delivered and applied progressive management and process improvement tools to help organizations reach new levels of performance. The industries span from healthcare to manufacturing, financial consulting and accounting. Most recently, Jeff served in a consultant role with the Manufacturing Extension Partnership where he had the opportunity to support other organizations as they seek to improve processes by implementing Lean. Jeff has a Bachelors Degree in Economics from Western Kentucky University. He also holds a Certificate in Production and Inventory Management (CPIM) designation.

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“Teaching would be great if it wasn’t for the students!”
“Management would be easy if it wasn’t for the employees!”  

These statements, spoken half – jokingly and half – seriously, usually reflect frustrations encountered in our relationships with fellow employees.   We may even believe those statements as we make them.

The people we work with really are critical to our success in Lean Healthcare.  Even more importantly, is how we treat them, respect their skills and abilities, and show our appreciation.  This week I would like to focus on how we treat the people in our organizations and how this affects our Lean journeys.

When he wrote The Toyota Way in 2004, Jeffery Liker had much to say about people and the people factor at Toyota.  His comments included:

• “At the center of the Toyota Production System is people.” (175)
• “The absolute core of the Toyota Philosophy is that the culture must support the people doing the work.” (176)
• A common phrase heard around Toyota is, “Before we build cars, we build people.” (182)
• “It is about challenging and respecting employees at the same time.” (186)

Articles and books written since Liker’s landmark publication continue to focus on people.   At HPP, we stress the importance of dealing honestly and openly with people at all times.  As we work with our clients to develop productive observation techniques, we urge anyone doing observation to “Go and See, Ask Why and Show Respect.”  I recently heard a speaker who reinforced those ideas by reminding me that three key words/phrases used frequently in successful relationships are, “Please, Sorry and Thank You.”

As we work in different healthcare settings, we find that there are indeed constants in the way people behave.  People have concerns, get their feelings hurt and act on the basis of emotion.  We know that there is territoriality, fear of loss, resistance to people changing what we do, etc.  Thankfully, there are positive behaviors as well.  We often work with people who are open to change, interested in new and better ways to do things and are willing to champion new ideas.  But whether positive or negative, emotions and feelings are a part of every workplace and every lean initiative.

Whether your role is that of an internal or external consultant, an executive, a manager, charge nurse, etc., Liker’s comments continue to ring true:  People are the key to the success of Lean Healthcare.    How we treat people and work with their characteristics and behaviors determines the success of our efforts in developing the improved processes that must be a part of healthcare in the 21^st Century.

A recent experience brought these thoughts and principles into focus.  A cross-functional team was formed to eliminate waste and improve processes within a lab.  As we worked, we were reminded that we must always remember the human factor and how people react to what we want to do.   This is true of both the people who work to improve processes as well as those that are affected upstream and downstream of those processes. 

The intent of the project was to improve a process within the lab, but as we worked, we began thinking—without realizing it—that, “if they would do their job in the ED, the lab’s job would be simple.”  In our desire and zeal to make it things better, we somehow lost focus on what we were responsible for and began to look at what “they” were doing as the main issue.

It was not until we began to communicate our plans and encountered resistance, irritation and even anger, that we realized what we had done.  When we approached the ED employees with our “plan for them,” we got immediate pushback, because our action plan was about what they should do.  It did not take long to realize that we had sparked protectionism, territorialism and defensiveness in our fellow employees – all of whom were directly impacted by our plans.  

It became obvious that we had lost focus and in some respects were blaming others for our issues.  Team leadership realized that we were on the road to accomplishing nothing and we quickly regrouped and redirected our focus – to what we could do within the lab to improve how we worked.  We concluded that once we had  implemented our improvements, then we could go to the ED, explain and demonstrate what we had done and ask for their thoughts on how we could work together to continue the improvement process.

While it was never the team’s intent to create animosity or blame others, the reaction was a clear reminder of the importance of always respecting people – both personally and professionally.  It is very difficult, if not impossible, to tell others how to improve their processes until you have improved your own.  Additionally, we realized that when you can demonstrate the value of your own improvements, others will listen more readily to your suggestions and plans.   

No matter what process you are attempting to improve or what Lean tool you are using, the moral of the story is to always show respect, and use those three words often:  “Please, I’m Sorry and Thank You.” 

Have you encountered “The People Factor” in your organization?  Do you agree that this is an important component of a Lean transformation?

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Many years ago, I was the Quality Director at a large automobile assembly plant in the Midwest.  When I was first promoted to the job and moved into my new (and much nicer) office, I found on the wall next to the desk a plaque with these words on it:  “In God We Trust, Everybody Else Bring Data.” 

This was the early 90’s and Toyota was far ahead of the curve in the learning, teaching and application of the Toyota Production System and lean methodology.  My company (which shall remain anonymous, but referred to in this article only as GM), had not yet embraced lean but was very active in their problem-solving efforts through the use of statistical process control tools or SPC.  X-bar & R charts and control charts were everywhere and terms like data and metrics were part of our daily language. 

But now many years later, as my focus on improvements has shifted to the arena of healthcare, at times I feel like I have stepped back into time when we talk about data and metrics.

It is not that the healthcare organizations do not have data; they often have reams and reams of data.  It is more to the point of how that data is used—first to know where the problems are and second to understand what the data is really telling you when it comes to continuous improvement and countermeasure activities.

Recently I was working with a hospital that had issues (as many do) with unplanned readmissions.  I was asked to work with the compliance office and facilitate a Kaizen event focused on decreasing unplanned readmissions.   One of the first things I asked for as I prepared for the event was the data.   “What does the data tell us?”  “Why does the organizational leadership consider this a problem?”  “What is the objective?”

The data I was given told us the hospital was last in the hospital’s organizational group of six hospitals in percentage of unplanned readmissions.  That answered the question of why the hospital considered this a problem.  So at least one of the metrics seemed fairly straightforward – reduce unplanned readmissions.

But as the team started to examine the data and understand the current condition, it quickly became apparent why the problem had existed with little change for quite some time.  When it came to the data – that was basically the extent of the data – we are last in our group and this is our percentage of unplanned readmissions. 

There was no Pareto chart of the top reasons why patients were returning to the hospital.  There was no internal data being gathered to understand what was happening.  There was no data…just a perceived problem.

Essentially, what we had was not uncommon in healthcare organizations.  The data and metrics were at a very high level that caused concern and reactive actions.  There was no follow-up or “drilled down” data to help us understand what and where the issues really were.

The focus of the Kaizen now had to shift.  Before the team could designate where emphasis could be focused on specific issues and problems, we had to first obtain and then analyze the data.

What we knew at this point was that any patient that returned within thirty days of discharge was considered a readmission and reported as such.  If that patient was not at the time of discharge scheduled for readmittance, then it was considered an unplanned readmission.  But any further information on why the patient returned was not readily available.  The compliance personnel would early in a month go through the records of the previous month and define these returning patients as planned or unplanned (as best they could) and report that information to corporate.  But since this could be up to forty days after the incident, even with studying the medical records it was difficult to understand the circumstances; it was very time-consuming to gather any information.

The team developed a flow chart tool to analyze the information.  It started with two pathways, clinical issues and patient issues.  From there the tool analyzed options allowing the information to be drilled down and sorted to form a Pareto of the top issues affecting unplanned readmissions.  Now the team was able to schedule further problem solving on the root causes of those issues.

The key was the process had now changed to be data driven.  The initial data was now being reported to the compliance office on the day of readmittance.  The analysis of why the patient had returned was now being examined in a standard manner through the flowchart parameters and entered into the data where it could be compared on a Pareto chart.  For example, one immediate result was the confirmation that infection was a primary reason for return.  When a team focused on that particular issue and gathered more data through direct observation, it was discovered that the instructions for wound care given to the patients at discharge were not consistently applied and contained little descriptive information (no visuals) to guide the patient.  The packet and instructions were changed and the staff was retrained as initial countermeasures. 

Data.  It is defined as “Factual Information, often in the form of facts or figures obtained from experiments or surveys, used as a basis for making calculations or drawing conclusions.”

Some of you may remember the old Dragnet TV series from the 60’s.  (Dun ta dunt dunt…Dun ta dunt dunt…daaa!).   One of the two detectives, Joe Friday, when questioning the witnesses or the perps, every week would say, “Just the facts, ma’am, just the facts”.  That is what data is all about….not speculation, not I think, not passing judgment, not jumping to conclusions or being reactive….just the facts. 

Through the use of data and data driven metrics, anyone—including healthcare organizations, are able to prioritize problems, develop countermeasures to address the problems and use the data as the basis for the metrics to measure the change.   In God we trust…everybody else bring data.

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This week’s blog was written by Dave Munch, M.D. and HPP Senior Vice President and Chief Clinical Officer

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Let’s explore coaching for a moment.  What are we talking about when we say coaching?  According to Sir John Whitmore it is the following:

“Coaching is unlocking people’s potential to maximize their own performance.  It is helping them to learn rather than teaching them.”

There is an important distinction between coaching and instruction.  Both are necessary and neither is sufficient to “hard wire” new skills into regular, reliable practice.  Instruction involves imparting new knowledge into a person based on a specific curricula and standard work.  There is a very effective approach to instruction that is strongly evidence based and was developed during and before World War II through the Training Within Industry (TWI) program that is called Job Instruction Training.  This will be the subject of a future blog.  For now, let’s get back to coaching.  Coaching is the process of taking what a person knows in their head and turning it into the actions they perform.  Coaching is done in the work, either in practice or application.  It cannot be done in a classroom. Its power comes from the development of critical thinking skills in the person being coached, the coachee.  The most effective approach to coaching is the Socratic method, asking questions.

The coach’s job is to ask the right question not give the answer, even if it is the right answer.  Asking a question forces the other party to think.  Telling someone what to do requires no thinking, just compliance.  When you do this you deny the other person the opportunity to contribute and it establishes you as the keeper of knowledge and answers.  They don’t have to think because you will do that for them.  Unfortunately you immediately become the bottleneck and can quickly be overwhelmed by all of the ideas you must distribute based on the complexity of the work.  It is better to develop a team of thinkers that can share the burden and contribute to the problem solving that is so critical in our complex settings.

Good coaching is not just about asking questions, it’s about asking the right questions.  The right question is a powerful question that prompts thinking.  It typically starts with what, why or how. A weak question is one that can be responded to with a yes or no answer.  It typically starts with does or will.  For example, if you are trying to improve your hand washing practices in your hospital you could approach this in three ways:

1. You could tell the person to wash his or her hands next time.  That will be a temporary fix at best.
2. You could ask the person “Will you wash your hands next time?”  That will be met with a “yes” and similar temporary success. 
3. If, however, you were to ask the question “What got in the way of you washing your hands?” you are likely to prompt some level of thinking and reflection that can lead to the discover of a barrier that can be addressed like; “The hand-washing pumps are not close to the work flow and it is a hassle to find them.” or, “I wasn’t planning on touching the patient.”  Both of these allow for a dialogue to fix a barrier or to provide more insight into the hand washing practices.

It is much easier and seemingly less time to just tell someone what to do.  The problem is that it is not effective, at least long term.  Caregivers have been trained to give answers, over and over again.  It will be hard to break these habits but well worth the effort.

In the next blog, we will cover the 5 characteristics of effective coaching in part II of this two part series.

This week’s blog was written by Dave Munch, M.D. and HPP Senior Vice President and Chief Clinical Officer

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With the holidays approaching, family travel time is here for many of us.  My own travel now includes a couple of grand-kids whose car behavior pretty much duplicates that of their parents (my own children). Even though long car trips are now much more “electronically enhanced” some things do not change; inevitably 30 minutes into the journey, someone will ask, “Are we there yet?” 

It is also a great time of year to ask the same question about our own organizations’ Lean Healthcare journey.  Recently I’ve been reviewing Lean Hospitals, by Mark Graban.  His thoughts on “How would we describe a Lean Hospital” could be considered great tests of:  Are we there yet?

Graban suggests that some of the traits that characterize a Lean hospital are:

• Lean efforts and goals are tightly integrated with hospital strategy and vision 
• A realization exists that success comes not only from technology and clinical excellence but also by employee engagement and operational excellence 
• Lean leadership models and methods are taught and practiced at all leadership levels 
• Collaborative relationships are promoted and exist with all partners and stakeholders including physicians, vendors and payers 
• A passionate and meticulous focus on patients and families exists, aimed at providing perfect, harm-free care while respecting patients and their time 
• There is recognition that employees are the true source of value for patients 
• Employees understand that not all activity is value-add and that by eliminating waste, it allows the staff to be more focused on patient care 
• Every employee is engaged in improving their work and is aware of how their work fits into the value stream in which they participate 
• Systematic efforts to break down departmental silos are visible, including a ‘steady push’ for cooperation across the value streams 
• An appreciation for standard work methods as a means of improving safety, quality and productivity is prevalent 
• Dissatisfaction with better-than-average results is understood, with a recognition that perfection is a difficult goal to reach, but the only acceptable goal in healthcare 
• All functions are working to create a facility that is physically designed to minimize waste for both staff and patients 
• The organization strives to implement process technology, automation and information systems that make work easier and less error prone

Quite a long list, but remember, this is a ‘big trip’, and like the long ride home to visit for the holidays it is usually worth the effort!

Are you there yet?  If not, leave a comment to let us know where you are, what your successes are, and where you may have hit a bump in the road.

Happy Thanksgiving to all our readers!

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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