R-E-S-P-E-C-T: Find out what it means to me

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Toyota Chairman Fujio Cho famously said, “Go see.  Ask why.  Show respect.”  These 3 statements are regarded by many as the foundational principles of a Lean culture.  Simple words.  Powerful impact.

While I was facilitating a recent Lean Healthcare coaching workshop, the group and I had quite a lively discussion of the role respect plays in a Lean organization.  As we debated and challenged each other on the concept, it occurred to me that though we use the term respect often, we don’t all agree on how respect looks in an organization.  Like a good Lean practitioner, I decided to do some research and gather some data.

I asked 20 colleagues and friends to finish the following statement:  “I know my organization respects me when….”  Some respondents gave a singular response.  Others listed several components of their view of respect.  Below is the Pareto chart of the responses summarized into categories.

Lean Healthcare Pareto Chart of what employees view as organizational respectI found the responses enlightening.  There is diversity in the comments which says we are all different.  We have differing needs and the leadership of a Lean organization MUST seek to see its workforce as trees and not a forest.  However, the big bar on the Pareto is also telling.  Well over half of the respondents said that it was a strong sign of respect to seek the ideas of and listen to the ideas of others.  In addition, it was also of note that 10 of those 12 were completely silent on the issue of whether or not those ideas were ultimately adopted or used.  Further, one particularly eloquent colleague said, “I know my organization respects me when the actions and behaviors of my colleagues make it clear that my opinion is valued. Whether or not it is used is irrelevant.”  My theory on this is  that although we would all like to have our ideas put into action, if our thoughts and feelings are at least heard, acknowledged, and considered, we feel respected.

I know this study is small and perhaps biased by the Lean, quality and improvement inclinations of my colleagues and friends, but I still find it to be powerful inspiration.  It is so easy to forget that we must find the time to seek and listen to the opinions of each other, we must seek others’ richness of individuality, and we must challenge and support each other to learn, grow and do our best.

Now that’s respect.

Blair Nickle, Senior Manager for Lean Healthcare and Process Improvement at HPPToday’s post was written by Blair Nickle, executive director at HPP.

For more than 20 years, Blair has dedicated her career to the improvement of processes, quality, safety, patient satisfaction, employee engagement, physician satisfaction, and financial vitality in healthcare organizations.  Her content areas of expertise include instructional design, performance measurement and improvement methodologies, information systems implementation,strategic planning and deployment, project management, and human resource development.

Blair holds Master of Business Administration and  Master of Science in Library and Information Science degrees from the University of Tennessee.  Her undergraduate work was performed at Emory & Henry College. 

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Agility vs. Speed – Moving Beyond the Basics of Process Improvement

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LeanHealthcare_goslowtogofast copyIs slow ever better than fast?   In most cases, speed wins.   Speed to introduce new products; speed to implement a new computer system; speed to recovery for a patient.  As well, as part of implementing the tools of Lean Healthcare, we are often trying to improve the speed of processes by removing waste.

For healthcare organizations, I prefer agility over speed. By definition, agility is the ability to move quickly and easily.  In healthcare, we face a future that is changing at an unprecedented rate.  For healthcare organizations to survive, thrive and continue to serve the needs of their communities, they need to possess the ability to change, and quickly.   We must constantly adapt to new payer demographics and government regulations.   We must quickly adopt new technologies to care for our patients.  There is an ever-increasing slope to the change curve.

However, as we start to move organizations beyond the basics of process improvement to the implementation of Lean Healthcare management systems, slowing down is a critical component to remaining agile.  While we must address problems quickly, we must slow down our urge to jump quickly to solutions before we deeply understand problems.

There are two key steps to driving change in healthcare organizations:

One: Have the ability to identify problems quickly.  We are typically in such a hurry that we work around problems and don’t stop to acknowledge them.  As leaders, it is hard to know when problems occur because they are regularly worked around by employees and not solved.  This is one of the goals of a visual management system—to distinguish abnormal from normal operating conditions.  Visual controls allow the ability to know immediately that we are not operating in a normal way.

As an example, patient volume in a clinic might be an important measure of success.  We might expect to see 16 patients per day in a clinic with a visual board that tracks volume.  Without visual controls, a clinic manager sees a full waiting room daily and sees this as “normal.”  However, by tracking the information visually, we can see that at 11 a.m. we have only seen five patients and the waiting room is full. This is below the goal of eight patients for the half-day session.   We know sooner than the end of the day (or months later during a patient survey) that we are running behind.

Two: Besides knowing that a problem exists, we must ask why it is a problem.   During problem solving is the time for taking things slowly, in order to avoid jumping to conclusions based on our experience. For the above example, we could jump to conclusions and reprimand the providers for moving too slowly, or we could add more staff to try and reach our daily volume goals.   However, without deeply understanding the root cause of the problem, quickly jumping to solutions is rarely successful.  This is where a formal problem-solving approach (A3 or PDSA) can help slow down the process.  By getting to root cause, problems will be solved for good.   Through good problem solving, the waste can be removed and flow improved.

In order for organizations to become more agile, they have to understand where the problems exist.  Slowing down and forcing ourselves to understand the problem and consider root cause is critical to organizational agility.  It is hard to be agile when carrying around excess baggage such as waste and problems.  Do you have an example of slowing down?  I would love to hear about it.  Share a comment below.

Tom Stoffel, Vice President for Lean Healthcare and Process Improvement Consulting at HPP

Today’s blog was written by Tom Stoffel, vice president with Healthcare Performance Partners.

Tom leads healthcare organizations through transformation into self-sustaining Lean enterprises. In addition to hospitals and hospital systems, Tom also leads transformation of subsidiary and independent clinics, physician practices and other outpatient organizations through Lean transformation.

Prior to joining HPP, Tom owned a Lean consulting and training firm which developed healthcare associates through hands-on learning techniques. Tom is an ASQ-Certified Quality Engineer. 

Tom holds an Engineering Degree from the University of Michigan.

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All About Speed

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Lean Healthcare One Piece Flow ExampleFaster turnaround times. Shorter lengths of stay.  Improved throughput.  These are all terms that everyone in healthcare is aware of because they define a new normal.  But how are we to meet the new goals?  To improve these measurements of performance, first, we have to understand the current state.  Do this through observation.  As you observe various work processes, ask yourself what is the batch-size of work that is moving through? More than likely you are going to see healthcare professionals sorting their work into large batches and then tackling it all at once.  After all, I should draw all my blood samples and then send them to the lab.  Or I should get all my medications form the ADC before administering to my patients. Or I should make rounds on all my patients before I document.  That is the best way isn’t it?

Maybe not.  Let’s look at moving crowds of people as an example.  Think about how you move through an airport, a convention center, or a sports stadium.  In every case, the engineers and architects have installed escalators and moving sidewalks as the preferred method of moving people through the venue. Why?  It’s a Lean concept called single piece flow.  Overall cycle time increases as batches build and increase in size.  If everyone has to use the elevator, the batch will increase while waiting for the next car.  And once the car arrives, there is no guarantee that if you enter first, you will be let out first.  In fact, often times you are first in and last out and your cycle time is the longest.  However if you had gotten on an escalator, you would not have had to wait (no batching) and you would have been transported directly to your intended destination (shorter cycle time).

Translating this back to healthcare, we have to understand that single piece flow is ideal, but may not be practical.  However, in order to meet our goals, we need to strive to process our work in smaller batches.  So, phlebotomists, send samples to the lab after every two to three patients.  Nurses, take medications from the ADC for one patient and then administer.  Physicians – see a patient then chart a patient.  In the end, the overall cycle time will be less, goals will be met, and patients will be happier.

Today’s blog was written by Dan Littlefield, director at HPP.

Dan has 30 years of healthcare experience in many clinical and leadership roles. He leads Lean and process improvement consulting engagements for HPP.  His experience includes deploying Lean across numerous healthcare disciplines including imaging, laboratory, nursing, pharmacy, and physician offices.  Dan began his healthcare career as a nuclear pharmacist and has also served as director of operations, responsible for 13 facilities.  He has been a featured speaker at a variety of healthcare industry events.

Dan holds a Master’s Degree in Business Administration from the University of Pittsburgh, a Bachelor’s Degree in Pharmacy from Purdue University and a Specialty Certification in Nuclear Pharmacy from Butler University.

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How to Partner with your Suppliers to Improve Care and Reduce Costs

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Lean Healthcare Supplier Partnership ProgramHealthcare organizations have made remarkable improvements using Lean tools and methods.  Eliminating waste from key, value adding processes has enabled hospitals to improve a host of performance measures, including enhanced patient care and reduced cost.  As organizations advance in their Lean transformation, focus should be extended outward to include suppliers in bi-directional improvement efforts.

The term customer-supplier partnership has been used loosely over the years, and it often has a narrow connotation that suppliers will simply keep lowering their prices in order to reduce hospitals’ costs.  Cost cutting alone is not a tactic that can be sustained for very long.  But with a mindset that suppliers are an extension of your hospital, you can (and should) work with your supplier partners to improve the acquisition and flow of products and services into your organization, as well as to most effectively use the products and services purchased.

Such a partnership requires a commitment by both parties to work together for mutual benefit over the long-term.  This includes sharing relevant information as well as the risks and rewards of the relationship, which requires a clear understanding of expectations, open communication and information exchange, mutual trust, and a common direction for the future.  The ultimate goal of such partnerships should be to improve quality and reduce waste within both the supplier and customer organizations.

The benefits from supplier partnerships should include tangible measures (e.g., cost savings, improved quality, etc.) along with intangible benefits such as increased trust and confidence.  We believe the value proposition will also include standard work using best practices, decreased variability, and better management of risk factors.  Improved operational efficiencies of the supply chain will be another outcome through channel optimization, product standardization, automation, and error reduction.

  1. Suppliers – Include suppliers of clinical and non-clinical products and services for which you have an ongoing need.  Suppliers who provide one-time products and services (e.g. construction) or independent contracts (e.g. physicians) should not be included.
  2. Approach – The rollout of the supplier partner program should start small.  It should be considered an ongoing and targeted undertaking that will occur in phases.
  3. Prioritization – Externally, high leverage suppliers prioritized by spend and volume should be approached, and partnering relationships built or enhanced.  Internally, end users should be brought onboard as needed, especially in the clinical areas.
  4. Focus – Early on, collaboration can be a hard sell.  Therefore the focus should be on developing the initiative, getting people on board with the partnerships, and gaining some momentum.  Avoid focusing on technology too early.  Once supplier collaboration has gained some momentum, technology can be a significant enabler of information sharing.
  5. Communication – At least initially, information about the supplier partnership program should not be widely communicated internally or externally.  The intent should be to minimize disruption of clinical and non-clinical work activities within your organization as well as to minimize angst among the suppliers not initially chosen to participate.
  6. Willingness to Change – The hospital must be willing to change.  A partnership is not only about the supplier making changes.  Hospitals must learn to listen to suppliers and act on their ideas.
  7. Physician Support & Buy-In – At some point, getting physicians on-board and participating in the partnership will be critical.  Many physicians already have strong relationships with sales reps of various products, and this can present significant challenges when making changes.  Physicians may also be weary of adopting a single supplier for fear they may fall behind technologically.  We recommend initially focusing on clinical areas that would be open to partnering with their suppliers and who would provide success stories to share with others.
  8. Calculating Savings – You will need to determine how cost savings from the supplier partner program will be calculated and verified.  Your Purchasing Department can verify any price reductions arising from the supplier partner program.  But a more challenging issue pertains to the other value added savings you will realize from expanded partnership arrangement.  It will be much more difficult to determine the exact cost savings of more efficient systems, standardization of supplies, lower utilization of product due to standard work, or better patient outcomes.
  9. Use of Savings – Pre-define what will happen with realized savings generated from your supplier partner program.  This will let everyone know how the program savings will be used and will encourage and reinforce participation.  For example, a percentage of achieved savings could be redirected back to:
    • the hospital itself
    • the department where the savings originated
    • new equipment
    • physician priorities
    • Lean training
    • the supplier
  10. Reviews & Accountability – Both hospital and supplier organizations should be held accountable to each other via a comprehensive scorecard to be used to guide periodic (at least quarterly) business reviews.  Such reviews will ensure that issues are resolved and that both partners stay on track.
  11. Manage the Relationship – Supplier partnerships take time and effort, and like any relationship, require care and feeding.  Mutual respect and understanding, a two-way flow of information, and listening are important to sustain a partnership.  Ideally there should be alignment between the organizations on the value of the relationship, business ethics, standards of excellence, and commitment to continuous improvement.

Aaron Fausz, Director for Lean Healthcare and Process Improvement at HPP

Today’s blog was written by Aaron Fausz, Ph.D., director at HPP

Aaron has twenty years of experience helping organizations align and improve their personnel and technical systems to accomplish strategic business objectives.  He has consulted with leading healthcare organizations across the country and has proven success guiding organizations through strategically driven changes and enhancing business performance.  Aaron also has significant experience in needs assessment, best practice analysis, performance measurement, process improvement, and behavioral change management. 

Aaron holds a Ph.D. in Industrial/Organizational Psychology from the University of Tennessee with a minor in Industrial Engineering.

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The Lean Journey…Observation is Key!

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Observation is key in Lean Healthcare“Do you know where my __________ is?”  I’m sure you can fill in the blank with various items from shoe, saxophone, car key, purse, blanket, hockey stick, and the list goes on.  Being a mother and wife, I hear this question at least one time a day.   I also hear it in EVERY hospital I walk into.  We all know searching is a type of waste and creates stress in our day, whether it is at home or work.  In a Lean Healthcare setting, the goal is to eliminate waste to provide a safe, high quality, efficient, and positive experience for the patient.

Recently, while working with a hospital executive team, I heard the VP of nursing say, “Our staff doesn’t search for anything, maybe four years ago we did, but not today.”  As you can imagine, colleagues in the room began challenging her thinking.  As an observer in the room, I continued to listen to the conversation.  Dialogue continued back and forth with differing views.  Some executives felt their staff had eliminated searching because of implementing 5S principles, and others explained they thought the searching had decreased since the 5S implementation, but “thought” it was still happening.  A nursing director who entered the room a few minutes late quickly was brought up to speed on the conversation that was taking place.  She was immediately proud to share her team’s improvement, that at one time they documented nurses could search for up to 10 minutes for an IV pole on an inpatient unit, and after implementing 5S nurses were no longer searching for the poles.  Another woman in the room commented that she’s been with the organization for one year, and she sees nurses searching for poles every day.  I had several thoughts going through my head at this point, and wanted to get involved in the conversation, but instead, I quietly asked the VP of nursing if she wanted to take a walk.  She was extremely happy for the escape, since the conversation was taking up the entire meeting, which was scheduled to discuss patient census.  Sound familiar?

As we left the room, I asked her to take me to one of her nursing units.  On the way to the unit, we talked about the importance of going to the “Gemba” (Japanese term for where the work happens) to observe and problem solve.  We shared our thoughts together and had a great conversation around truly understanding what is happening vs. assuming what is happening.  She reminded me the organization was in the 5th year of their lean journey, and was confident 5S was in practice to prevent searching.

We arrived to the surgical inpatient unit and together, we observed one RN for 30 minutes.  After the 30 minutes, the VP decided we needed to get back to the meeting.  As we walked back to the meeting room, I asked her what she had learned.  Her exact words were, “I need to get out to the Gemba every day.  I learned more in 30 minutes than I’ve learned in my office this entire week.”   We continued to talk about what we had observed, and I could tell she was in deep thought, but I had no idea what was about to happen next.  We arrived to the meeting room where the conversation about missing IV poles was still being discussed.  As we entered, the VP walked to the front of the room and said, “I lied – we ARE still searching here, not only for supplies, but for co-workers, patients, and charts.  I just observed all of this on one unit in 30 minutes.”  She then proceeded to adjourn the “patient census” meeting and challenged her colleagues to go to their departments and observe the work.  She promised, “You will learn more in 30 minutes than you did in this two hour meeting.”

Today’s blog was written by Nicole Einbeck, lean design consultant with HPP.

For nearly two decades, Nicole has worked in the healthcare field; from Human Resources and Risk Management, to Occupational & Employee Health, Safety/Wellness, and Process Improvement.  Most recently, Nicole spent the last five years assisting in the Lean Transformation process at Monroe Clinic, in Monroe, WI. 

Today, Nicole works primarily in healthcare lean led design revolving around new construction and move-in services, focusing her effort towards improving work flow and documenting new standards for clients. Her recent experience as the Move Project Manager and Process Improvement Specialist allows her to see the effectiveness of Lean tools furthering her development, understanding and expertise in coaching others to think and see differently. Nicole has a Bachelor’s degree in Health Promotion/Wellness and Psychology from the University of Wisconsin Stevens Point.


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It’s Elementary, my Dear Watson

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Lean Healthcare ObservationThe highly successful revival of the Sherlock Holmes phenomena is a testament to the popularity of Sir Arthur Conan Doyle’s stories.  PBS’ updated version of “Sherlock” was a shining star at the 2014 Emmy Awards, winning the most awards (seven Emmys) by the end of the night.

Doyle made Sherlock Holmes a household literary name beginning in 1887 with his novels and short stories.  Holmes became famous for his astute logical reasoning and his use of forensic science to solve difficult cases.  He was noted for drawing valid conclusions from his observations.

In the short story, “A Scandal in Bohemia,” Holmes demonstrates and discusses his powers of observation in the following exchange with Dr. Watson:

“Then, how do you know?”

“I see it, I deduce it.  How do I know that you have been getting yourself very wet lately, and that you have a most clumsy and careless servant girl?”

“My dear Holmes,” said I, “this is too much.  It is true that I had a country walk on Thursday and came home in a dreadful mess, but as I have changed my clothes I can’t imagine how you deduce it.  As to Mary Jane, she is incorrigible, and my wife has given her notice, but there, again, I fail to see how you work it out.”

He chuckled to himself and rubbed his long, nervous hands together.

“It is simplicity itself,” said he; “my eyes tell me that on the inside of your left shoe, just where the firelight strikes it, the leather is scored by six almost parallel cuts.  Obviously they have been caused by someone who has very carelessly scraped round the edges of the sole in order to remove crusted mud from it.  Hence, you see, my double deduction that you had been out in vile weather, and that you had a particularly malignant boot-slitting specimen of the London slavery.

I laughed at the ease with which he explained his process of deduction.  “When I hear you give your reason,” I remarked, “the thing always appears to me to be so ridiculously simple that I could easily do it myself, though at each successive instance of your reasoning, I am baffled until you explain your process.  And yet I believe that my eyes are as good as yours.”

“Quite so,” he answered. “You see, but you do not observe.  The distinction is clear.  For example, you have frequently seen the steps which lead up from the hall to this room.”


“How often?”

“Well, some hundreds of times.”

“Then how many are there?”

“How many?  I don’t know.”

“Quite so! You have not observed.  And yet you have seen.  That is just my point.  Now, I know that there are seventeen steps, because I have both seen and observed. “

How often have you seen and yet not observed?  If you are like me, many times.  One of the key concepts of Lean Healthcare is the importance of learning to observe and not just see.  Even though I teach the concept and the value of observation and how important it is to observe before drawing conclusions, I learn more every day about how to be an effective observer.  While going to the Gemba, or where the action occurs, is an important step, it does not guarantee useful and accurate observations and information.  Even if we go and see, it is still critically important to observe carefully and thoroughly what is actually occurring.

I have accompanied many project teams to observe and ensure that that they were making valid observations and gathering accurate data. I learn more every time I observe.   As is true in all of Lean Healthcare, we can continue to improve our skills while we are actually practicing them.

I recently asked a friend who is the CEO of a local Nashville hospital if I could come and observe his employees in both the ED and on a nursing floor.  He and the CNO graciously invited me into their workplace and I subsequently spent a number of hours in the ED and on the nursing floor.

This observation exercise reminded me of how much “action” occurs in both places on the part of multiple caregivers and just how much effort goes into taking care of patients and even patient families.  It enhanced my ability to observe what the caregivers actually had to do to ensure that patients were cared for.

No matter where you are in your Lean Healthcare journey and no matter what you are doing to eliminate waste and enhance the patient experience, insightful observation is critical.  While we may never be as astute an observer as Sherlock Holmes, never let it be said that, “You see, but you do not observe.”

After all, “It’s elementary, my dear students of Lean Healthcare!

Jay Conner, Senior Manager of Lean Healthcare and Process Improvement at HPPToday’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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A3: An Antidote to the Drama Triangle

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Recently, I observed an A3 training session comprised of front line managers from several ambulatory clinics. The participants were asked to break into small groups and identify an issue they were having in preparation for practicing A3 problem solving.  As each group shared their issue it became apparent that the entire group had an “issue” with the IT department.  With the sharing of each “issue” the large group became more animated and pointed with comments regarding IT, “They don’t understand what we do,” “They don’t realize how difficult it is for us,” “They seem intent on making our day miserable,” and so on.  By the end of the sharing the entire group was sufficiently worked up.  The simple exercise of identifying an issue applicable to A3 problem solving had become a considerable gripe session.  What had just happened?

The group unknowingly chose to entire the Drama Triangle, a phenomenon identified by Stephen Karpman.  The Drama Triangle is a place where individuals and/or groups choose to relinquish their ability to solve a problem by blaming someone else for their “misfortune.”  The following diagram depicts the roles played within the Triangle:

Lean Healthcare Drama Triangle

This group, all deemed by others as effective managers, chose to play victims and considered the IT department, either intentionally or not, to be persecuting them.   As the discussion went on, the group sounded more and more helpless in the face of IT.  And then the third character in this drama was introduced: the rescuer. “Administration needs to do something about IT.”  “Yes, administration can solve this by ‘fixing’ IT so they won’t make our daily work so difficult.”

As the group became more entrenched in its victimhood, sounding more and more helpless, a manager spoke up. He shared that he had a similar IT issue with registering patients after listening to his staff and analyzing the registration performance metrics.  He was initially convinced that IT was in some way deliberately sabotaging his staff’s daily work.  As he too began to enter the triangle, he stopped himself, asked what he and his group could do about this and proceeded to engage in A3 problem solving (though he didn’t realize he was using A3 problem solving at the time).

He gathered his staff and asked them to explain the issues they were having with completing their work activities.  Based upon this input and observations he conducted, he reached out to his counterpart in IT. Together, the two managers identified a small group of front-line staff from both departments to map the current state. The group then identified broken pathways, selecting two that were occurring most frequently and causing the most work stoppage and rework.  From here, the group began to ask why these pathways were breaking down.  Once this team identified the root cause of the breakdowns, they defined the target condition for the registration process.  Based upon their analysis and desired future state, they jointly identified the action plan necessary for success:  what changes needed to be made, who was responsible, when the changes were to be completed and how they would measure the effectiveness of their plan.

The ambulatory manager shared that they had to return to the plan more than once given that some of the changes did not achieve the desired results.  But, the willingness of this team to do so was something he had not experienced before.  More so, he noticed more of his staff engaging in similar activity with IT and other groups.  His staff, as well as those in IT, had shifted from being victims to active problem solvers and partners.  As my colleague David Emerald[i] explains, they chose no longer to be victims, but creators, in improving their work.  The manager’s staff began to challenge long-standing work practices seeking to improve how the work was done.  Finally, he began to see his work role more so as a coach and not a rescuer.

This manager, as have countless others, identified an effective antidote to the Drama Triangle – A3 problem solving.

i David Emerald, The Power of TED

Today’s post was written by Bill Kirkwood, Ph.D., director at HPP.

Bill has 30 years of healthcare leadership experience in both system and individual hospital settings in the Midwest and Northeast. He has overseen change management activities and Lean transformation engagements.  His experience includes serving in an executive capacity in quality, operations and human resources. 

He holds a Masters in Health Administration from Xavier University and a Doctorate of Philosophy in Organizational Behavior from the Union Institute and University. 


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Leading the Way with Leading Indicators

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LeanHealthcare_leadingindicatorsHCAHPS. Employee Satisfaction. FTE numbers. Readmissions. Overtime. Press Ganey. Length of Stay. Market Share. Infection Rates. And on and on and on.  Data.  We are inundated with data in healthcare.

Data is a good thing.  No, actually, that is great thing.  There have been many blogs written about the power of data:  how to use it to make good decisions, how to use it for prioritization in problem solving, and how to use it as the fundamental driving force for our organizations’ strategies and plans.  As we progress down the pathway of Lean Healthcare, data has indeed taken the role envisioned by the early advocates of every process improvement strategy from Total Quality Management to Lean Management Systems.

But there is one important aspect of data understanding and usage that is largely misunderstood by many organizations at all levels from the senior leadership to the front-line staff.

All of the indicators mentioned above—HCAHPS, readmissions, all of these numbers that we seem to live and die with every week and every month—are outcomes.  They are the outcomes of our processes for quality.  Outcomes of our processes for control.  Outcomes of our processes for really everything we do every day.  They are, by definition, lagging indicators.  This data, these outcome measures, are the result of the actions and things we do every day.  We focus on these outcomes and we measure as often as we can to try to understand what that the final metric at the end of the month on our scorecard will be.  Why?  So we can solve problems, adjust, then measure and measure again.

That is where the key point is missed.  Our HCAHPS scores, for instance, are not improved by the multiple questions we ask our patients and our customers every day as we go to the gemba.  Our length of stay is not improved by examining in detail the discharges every day.  We can and do chart those results. Then, we rejoice or agonize over those daily results, cross our fingers and hope that the end of the month will reflect our daily outcomes.

The key point is that these interim outcome measures are not important.  It is the behaviors that drive these interim outcomes and final outcomes that are important.  That is what we must measure daily and as often as possible in the course of our work to drive the improvement that we are seeking.  The behaviors!

All of the A3’s that we worked so hard on to define our countermeasures; all of the kaizen events that gave us action plans and new processes; we didn’t do this great work to come up with more interim measures of outcome.  We did this great work to define where and how to change our behavior.  By changing our behavior, we drive process improvement.  That behavior change is what we need to measure every day.  Because if we are correct in defining the basic behavior change, guess what?  The metrics and measures that we live and die with, will follow!

This is the misunderstood application of data.  Defining and measuring a true “leading indicator.”

Leading and lagging indicators are difficult to understand.  Profit is a lagging indicator and an outcome.  It is driven by two leading indicators: revenue and expenses.  But those two “leading indicators” are also lagging indicators and outcomes.  Expenses are the lagging indicator of leading indicators like supply cost, FTE cost, overtime cost, etc.  But again, these are also lagging indicators and outcomes as well.  We can measure these indicators every day and not show improvement.  But if we define the behavior that drives overtime and change that behavior, then improvement will follow.  And by holding accountable and measuring that behavior every day, we are now able to be confident about what the lagging indicator or outcome will be at the end of the month.  Here is the real kicker – it is much easier to monitor and measure behavior than it is to measure those interim outcomes we agonize over.

Let me give you a non-healthcare example that has helped others to understand these phenomena that are leading indicators:

I want to lose weight.  I have charted my weight for the past year and have an average weight of 200 pounds at the end of each month.  I have a range between 195 and 210 pounds (holidays and vacation).  My weight at the end of each month is a lagging indicator and an outcome measure.  So I decide I am going to draft an A3 on my weight loss.  It is a good A3 and it clearly defines the root cause and subsequently countermeasures of a 2,000-calorie diet and daily exercise.

I now decide that I am going to weigh myself not monthly but every single day.  So I do that and I chart the results.  202, 201, 199 (Hurrah!  A cause for celebration), 204 (dang, two much celebration apparently) and on and on.  I weigh myself every day and I chart it religiously.  I have meetings to discuss the results and I agonize over what the metric will be at the end of the month.

These daily measures are a “leading indicator,” just like expenses, revenue or daily overtime.  But they are not behavioral based leading indicators; they are still outcome measures.

So a revelation occurs:  I now begin to chart two things every day.  I chart whether I met my calorie goal and I chart whether I met my exercise goal.  Diet and exercise are two key behaviors that I defined as countermeasures on my A3.  My assumption is that if I can change my behavior by eating right and exercising, I will lose weight.  Weighing myself everyday will not drive weight loss, it is only an outcome of the diet and exercise.  I measure whether I exercise and diet every day and if the chart shows 0/2, 0/2, 0/2, etc. my weight is not going to change, but I will not be surprised at the end of the month.  If the chart shows 2/2, 2/2, 2/2, etc., I have confidence that at the end of the month my outcome will improve.  By measuring behaviors, it is much easier to course correct and problem solve immediately if the behavior is not being followed:  I may need to change my schedule to allow time to exercise or stop the bedtime snack.  I can be proactive in making a change to allow me to be accountable to complete the behaviors.

The key is to define the behavior based leading indicators, hold them accountable, measure them daily and problem solve and adjust if the behaviors are not being adhered to.

I was working with two units that were focused on eliminating patient falls.  Both did excellent A3’s on the subject.  Both identified multiple countermeasures like fall risk assessment, fall risk patient identifiers at the room, regularly scheduled toileting of fall risk patients, and so on.  Both had excellent visual management boards that they huddled on every shift.  Both charted the monthly fall rate and also the “leading indicators” on the board and discussed it in the daily huddle.

But here was the difference.  Unit A, for a leading indicator charted and discussed in the huddle whether they had any falls the previous day.  If they did, they did the appropriate follow-up and problem solved with the use of their A3 what had “gone wrong.”  All are good processes, but very reactive.  The leading indicator was clearly an outcome measure.

Unit B charted and discussed whether three behaviors were followed the previous day.  Were all new patients assessed for fall risk?  Did all fall risk patients have their rooms identified as such?  Were all fall risk patients toileted on a regular schedule?   Their chart showed 3/3, 2/3, 3/3, etc. by shift every day.  When there was a behavior that was not adhered to, that drove real time specific problem solving in the huddle.  “Why was the fall risk assessment not done?  What will we do today if that situation occurs?”  Why were there patients that were not toileted on the schedule?  What can we do differently to drive the completion of this behavior?”

Guess which unit showed the greater success?

These measures didn’t need to be a 100 percent audit of these behaviors, but they needed to be a sample of the behaviors that was gathered in the course of the daily work and part of the leadership standard work.

The message was clear on the visual management boards and in the huddles.  Our problem solving has defined the behaviors we feel will be effective in reducing and eliminating patient falls.  If we follow these behaviors every day, we feel that we will reach the outcome measures we desire (lagging indicator – monthly fall rate improvement).  We are charting these behaviors every day to drive accountability into our processes and ensure the behaviors are followed.

These behavior based leading indicators often seem hard to define, however they are very simple. Look at the right side of the A3:  The countermeasures and action plans are full of behaviors that need to be changed or developed.  Changing or developing these are the leading indicators that will drive the improvement.

Drilling down to a behavioral based leading indicator and then driving accountability by measuring it every day is a part of a very proactive process improvement methodology.  As part of a Lean Management System approach it is integral with A3 deployment (defining the root cause and the behavioral countermeasures), standard work (defining how to complete the behavior), leadership standard work (verifying the behavior occurs) and visual management (visually showing the link between the behavior and the outcome measure for the staff to understand and discuss).

Define your leading indicators and let them truly lead your process improvement!

Steve Taninecz, Director for Lean Healthcare and Process Improvement at HPP

Today’s blog was written by Steve Taninecz, director at HPP.

Steve has 40 years of experience in manufacturing and healthcare organizations.  Steve’s work in the healthcare field began as an educator, trainer and coach for the Pittsburgh Regional Health Initiative, then as part of a New England for-profit health system overseeing, counseling and coaching culture change to the hospital system’s leadership for the successful implementation of lean.  Steve holds a Bachelor’s Degree from Youngstown State University in Industrial Management and a Master’s Degree in Organization Leadership from Geneva College.


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The Case for Lean Led Information Technology, Part Three: Basic Support

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Lean Healthcare Information Technology - HITECH ActThis is the third blog in a four part series on Lean Led Information Technology.  In part one, I presented some very scary statistics regarding the staffing requirements necessary to implement and support the requirements of the HITECH Act.  In a period of declining reimbursements and systemic overburden, the requirements, in a word, are unsustainable.  In part 2, I illustrated how Lean Healthcare tools and techniques may be leveraged to drive waste from key support processes.

The remainder of this blog will focus on the use of Lean principles and tools to drive defect-free implementation of new IT products and services.

One of the challenges of systemic overburden (Muri) in healthcare IT departments is that it tends to drive suboptimal implementation of new products.  This has a tendency to appear in three critical places:

  1. Development of technical requirements for implementation
  2. Consideration of work-flow impact and work-flow redesign
  3. Pre-go-live testing

Failure in these three critical aspects of new product implementation can have very serious consequences and will drive substantial demand for support services, exacerbating the overburden.

A powerful Lean Healthcare tool that can aid in alleviating these issues is the 3P methodology (product, preparation, process).  Think of 3P as a systematic method of concurrent design where the product (or service), the process for building or delivering, and implementation planning are performed concurrently instead of in a cascaded method.  By taking on these tasks in a concurrent (as opposed to a cascaded) approach, implementation times can be shortened while simultaneously maintaining high levels of implementation quality.  This approach alleviates the overburden.

The basic steps in applying the process in the context illustrated above include the following:

  • Understand the voice of the customer: The team seeks to understand the core customer needs that need to be met in the future state.
  • Translate the voice of the customer into service delivery requirements.
  • Analyze current state or known existing methods of achieving the above requirements and describe the changes or transformation to be made at each key point within the service delivery model.
  • Translate the desired changes or transformation into a set of functional requirements.  This should be approached from both a technical and process perspective with form following function.
  • Generate several ways to meet the functional requirements.  This is often referred to as a 7 Ways exercise.
  • Design and evaluate the service delivery model based upon the best elements identified within the 7 Ways exercise.
  • Review the design concept(s) selected for further refinement with customers and key stakeholders.
  • Develop the implementation plan.

The above steps may be organized into 3P events which are typically three to four days in duration and require the full attention of a dedicated team during their execution.  Very complex projects such as an eHR implementation may be broken into a series of events.  By leveraging the 3P process to perform design and implementation tasks in parallel with structure and rigor, we are able to implement with speed and fewer resources.  By careful flow-down of customer critical-to-quality parameters into service delivery requirements and, ultimately, functional requirements for the technical and workflow components of the design, we move closer to defect-free implementations.  Collectively, these are powerful drivers in reducing systemic overburden within Lean Healthcare IT departments.

Interested in learning more about Lean Led IT?  New Hanover Regional Medical Center will be presenting a breakout session at the upcoming Lean Healthcare PowerDay on how they are meeting the challenges of the HITECH Act while improving IT infrastructure.  www.LeanHealthcarePowerDay.com 

Brad Schultz, Vice President for Lean Healthcare and Process Improvement Consulting at HPPToday’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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Overcome Inertia in your Lean Efforts

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Lean Healthcare - Overcome Inertia in your Lean EffortsToyota’s success has inspired numerous industries and countless organizations to adapt and adopt some form of a Lean program. Lean thinking involves the constant pursuit of improvement with the goal of eventually reaching perfection.   With the focus of Lean Healthcare on the customer and the value stream, this concept of continuous improvement occurs by giving the customer more value added activity and constantly eliminating wasteful activity. If your organization is serious about excellence or perhaps even embarking on a Lean Healthcare transformation, make sure that inertia doesn’t stall your efforts.  Here are some key considerations for avoiding lapses in progress during your pursuit of perfection:

  1. Create short term wins.  In successful change efforts, empowered people create short term wins – victories that nourish faith in the change effort, are emotionally rewarding and build momentum.  Without sufficient wins that are visible, timely and meaningful, change efforts stall. Get the win, even if it seems small, and get the ball rolling.  Remember that improvement begets improvement—an accumulation of small changes can add up to significant gains.
  2. The Enemy of good is better.  Teams encounter inaction because of pursuit of “better.”  Often passing up immediate gains from “good” change because “better” is lurking around the corner.  When “better” involves a significant cash outlay, the time required to travel through the approval process and implement can be lengthy.  Avoid doing nothing until conditions are perfect.   Waiting for the “perfect” time to move forward often means staying where you currently are.
  3. Empower frontline action and give staff permission to act.  Empowerment is not just about giving people new responsibilities and then walking away.  A new environment with old habits won’t lead to the establishment of behaviors and daily practices necessary for ongoing improvement.  Empowerment is about removing barriers.  As Dan Cohen said in “The Heart of Change,” “You take a wind in their faces and create a wind at their backs.”
  4. Manage improvements visually. Change can be fragile and require active management.  Simple visual controls and real-time data, that do not require a trained eye to read and interpret, goes a long way towards keeping the change out in front and current.  Visual controls heighten focus on process, accountability and engagement—three factors that are absolutely necessary for continued progress.
  5. Focus.  Five instead of 50 provides focus which allows more to be achieved quickly and effectively.  This type of focus often follows on the heels of strategic alignment within the organization where there is a clear and common understanding of business objectives and improvement efforts have the appropriate level of priority.

As you can see, the elements listed above are not overly complex, which is the case with most Lean concepts.  However, successful execution requires a tremendous amount of effort, which is also typically the case with most Lean transformations.  Once the ball is put into play, the elements described above will help maintain momentum so that inertia doesn’t stall the great work that’s happening within your organization.

Janet Dozier, Senior Manager for Lean Healthcare and Process Improvement at HPPToday’s blog was written by Janet Dozier, senior manager with HPP.

Janet has more than 20 years of Lean and process improvement experience in healthcare and manufacturing.  She has led lean transformation efforts in clinical, non-clinical, and business operations of hospitals. Prior to her work in the healthcare industry, Janet was in the automotive industry for 10 years where she was a lead instructor of Lean principles for the Ford Production System.

Janet received her Master’s Degree in Engineering from Case Western Reserve University and undergraduate degree in Industrial Engineering from North Carolina State University.

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