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Lean Healthcare Information Technology - HITECH ActThis is the second blog in a four part series on Lean Lead 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 over-burden, the requirements, in a word, are unsustainable.  In part one I proposed a three tiered approach to meeting this challenge as follows:

  1. Use Lean principles and tools to eliminate waste from basic support processes to free resources for strategic implementation.
  2. Use Lean principles and tools to drive “defect-free” implementations.
  3. Implement a functional governance structure to drive strategic alignment and improve management of the IT investment portfolio.

The remainder of this blog will focus on the use of Lean principles and tools to eliminate waste from basic support processes; the first point in the three tiered approach above.  For Lean Healthcare delivery systems, this will be less daunting as many have recognized tremendous improvement in cost, quality, service levels and patient satisfaction by using Lean to make quality the operating system.

Meeting the challenges of the HITECH act will require healthcare IT departments to shift resources from basic support to strategic implementation.  Currently, 80 percent of the average healthcare system’s IT resources are engaged day-to-day in providing support.  This leaves only 20 percent for strategic implementation.  The demand, going forward, will require closer to a 50-50 split of these resources.  Herein lay both the opportunity and the challenge.

Practitioners of Lean Healthcare are familiar with the concepts of direct process observation, process mapping and value-stream mapping.  When these tools are applied to the hospital’s IT support processes the results can be very insightful.  The example below illustrates the process by which new employee accounts were provisioned at an institution:

Lean Healthcare IT application

 

A few items to note in the current state:

  1. This is only one of five different work flows followed
  2. There are 13 primary process steps
  3. 0 percent of these are automated
  4. This has prompted multiple control and tracking points
  5. These controls are all manual spreadsheets requiring substantial update effort
  6. There is significant rework in assignment of correct applications
  7. There is significant end-user confusion and wait

Compare this to the future state depicted below where:

  1. There is only one flow
  2. 13 primary process steps are collapsed into 9
  3. 90 percent of these are automated
  4. There is a single, automated control point
  5. These is no need for manual spreadsheets requiring substantial update effort
  6. There is significantly less rework in assignment of correct applications
  7. There is significantly less end-user confusion and wait

Lean Healthcare IT application

 

This is only one example of countless potential opportunities.  Mapping the support processes and using direct process observation to identify sources of waste and where they occur in the process are fundamental building blocks.  These techniques are simple, easy to learn and very directional to the design of new processes or countermeasures.   Other areas within support to consider include:

  • Repeatable standard work for infrastructure maintenance, including major upgrades
  • All aspects of identity management including sign-on and password reset
  • Repeatable standard work for Help Desk and Service Desk issues
  • Analysis of Help Desk and Service Desk requests to identify high-value opportunities

Application of these techniques and practices can lead to substantial reductions in waste within the processes involved.  This can lead to productivity increases of approximately 20 percent. In many cases the productivity increase could be greater if the enterprise is willing to challenge the collective, conventional wisdom by exercising critical scrutiny in classifying tasks (value-add versus non value-add) during the observation and mapping process.  The next blog in this series will focus on the use of Lean principles and tools to drive “defect-free” implementations.

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 


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

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

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

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LeanHealthcare_RulesinUseCartoonRecently, helping to facilitate a simulation at the Belmont University Lean Healthcare Certificate Program, I observed a participant simulation team describe their simulated work process to the rest of the class.  Someone asked, “When you experience a defect in your process, how to you handle that defect?”  The team explained that one team member receives all process defects, investigates their cause and then attempts to fix the defect.  The next question asked was, “What does that person do with the information gathered about the defect (i.e. how did the work team get information about how and why the defect occurred)?”

In a real world example, I recently witnessed a noncompliance (defect) to an antibiotic delivery process, resulting in the patient getting more antibiotics than recommended and the organization losing a portion of their reimbursement due to the noncompliance.  Information about the defect flowed from a data abstractor to a quality analyst, who was assigned to verify that the defect was legitimate prior to sending defect information to the unit.

True to form, the Joint Commission showed up unannounced the next day and the analyst was consumed with audit support and audit corrective action, leaving the defect information on his desk for 27 days.  Unit leadership was asked by the CNO, who received a report of the fallout in her quarterly report, why the unit didn’t conduct a root cause analysis and subsequently correct the source of the defect.  The unit staff never received any notice of the defect.  Information was “siloed,” getting stalled in the quality department and then reported late to the nursing officer without communication to the unit.

How does Lean Healthcare help an organization with typical problems as the one just described?  Let’s look at the 4 Rules in Use:

Rule 1: Activities

Defines the work in terms of content, sequence, timing, location and outcome, making it easier to identify defects due to establishment of well-defined standards.

Rule 2: Connections

The connection between every “customer (unit)” and “supplier (quality analyst)” must be highly specified to be direct, simple and paced with critical time elements.

Rule 3: Pathways

Must contain a signal if a prescribed pathway (analyst informing unit of defect) is not followed.

Rule 4: Improvement

All improvements must be performed closest to the problem by those doing the work.

In this process example, where data abstractors are more than 95 percent accurate in their identification of defects, should the defect have been communicated directly to the unit when discovered, eliminating the review of the quality analyst?  Furthermore, could the unit, without waiting for abstraction of a patient’s record, incorporate metrics that flag when a defect might occur?  One health system, using Lean Healthcare practices, adopted a PACU-to-unit nurse handoff process where they discussed the number of antibiotic doses remaining to be administered and whether those doses will extend beyond the prescribed time.  If the answer is yes, the unit nurse contacts the attending physician to modify the dosing or requests needed documentation of why the antibiotic will be given for extended periods.

Lean Healthcare helps an organization study their flow of information, breaks down silos and pushes defect identification as close to the source as possible.  Information flow would then occur in a process without silos where pre and/or post defect information gets to the work group in the timeliest manner, preventing that defect or any future defect from occurring.


Today’s blog was written by Rick Beaver, Director with HPP.

Rick has more than 25 years of experience leading process improvement and change management in the healthcare, manufacturing, insurance and pharmaceutical sectors.  He has previously served as senior leader and vice president of performance improvement and support operations for a two-hospital, 550-bed health system.  Additionally, he has served as an examiner for both the Pennsylvania and U.S. Malcolm Baldrige Board of Examiners.

Rick earned a degree in Chemistry from the University of Pittsburgh. He earned a Master Black Belt in Lean Six Sigma from Air Academy Associates.

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A core component of A3 thinking (and Lean Healthcare in general) is to methodically expose root cause. Typically in facilitating a kaizen team, this will get conveyed early on with language that discourages “jumping to conclusions.”  The intention is to focus the team first on the current state and an analysis of the problems.  Only then are we armed with the knowledge to start developing proposed solutions.

Sometimes participants take that suggestion and try to apply it by saying:

“I know I’m not supposed to jump to a solution, but…” or,

“Yeah, but we can’t fix that.”

Jumping to conclusions is a common issue, but one that generally sorts itself out pretty quickly in an improvement activity, as it becomes clear that we are trying to problem solve only once we get to a better understanding of the actual cause.

My historical approach to counteract “jumping” comments is to respond along the lines of, “All we need to do right now is identify problems.  We’ll worry later about how to fix/improve/mitigate it.”  This approach has mixed results. Some people get on board with that fairly quickly, but others who aren’t sold immediately can get frustrated with discussing issues that they think are a waste of time to even discuss.

More recently, I’ve tried using a tactic from CBS’ How I Met Your Mother when these sorts of comments get made. In one episode, roommates Ted and Marshall are deciding which one of them will get their NYC apartment after Marshall and his girlfriend get married.

Marshall: So, when Lily and I get married, who’s gonna get the apartment?

Ted: Oh, that’s a tough one. You know who I think could handle a problem like that?

Marshall: Who?

Ted: Future Ted and Future Marshall.

Marshall: Totally. Let’s let those guys handle it.

In the next scene, Future Ted is sitting in a bar, with no time left to avoid a difficult conversation and decision:

Ted: Damnit, Past Ted.

I’ve started paraphrasing the scenes above and use it to try to get more people on board.  I say, “You know who I think could handle a problem like that? Wednesday’s team.”

We’re not putting decision making and change off forever, so we don’t find ourselves in a later situation of “Damnit, Monday’s team.”  We’re simply timing it to when the team has the correct exposure and context to tackle a problem.  Some of the issues identified really are difficult nuts to crack.  But, we get much further using Past Ted and Past Marshall for problem analysis, and Future Ted and Future Marshall for countermeasure development and implementation.

It is precisely because we don’t quite know what our issues are or what might work that we apply the structured approach of A3 thinking. This is why we start.  It is the process itself that helps us get our arms around the problem and develop solutions when we are in the best place to do so.

Do you have a preferred method to avoid jumping to conclusions? Share it in the comments.


WilsonJamieRSToday’s blog was written by Jamie Wilson, Senior Manager with HPP.

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

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Those of us who spend our lives in the world of Lean Healthcare, preach, teach, and use the 5 whys and root cause thinking daily.  It is part of the mantra of improvement and we know that it is important to distinguish causes from symptoms.  However, I was recently at a rare disease conference when it struck me that root cause thinking can literally be a life or death situation.

For context let me share that I have been blessed with my first 3 grandchildren over the last year and a half.  What a joy it has been!  In the midst of this joy there have been a few twists and turns. Our darling “middle” grandchild was diagnosed with a rare disease called Alagille Syndrome (ALGS).  Without going into too much detail, ALGS is a genetically-induced mutli-system syndrome that most often affects the liver, heart, and kidneys, along with a host of other issues.  Those who have ALGS face a lifetime of large and small health issues and may endure multiple surgeries including organ transplants.

To learn more about current clinical research and to see how other families deal with the myriad of health and social issues, I recently attended a symposium targeted to this rare disease.  As I listened to the clinicians and researchers, the evidence of root cause thinking was clearly evident (or not) in a variety of comments I heard.

To illustrate, one of the most common manifestations of ALGS is severe itching.  Children itch so badly and constantly that they will scratch their skin raw, injure their mouths and throats by scratching them with forks and knives, and become severely sleep deprived because the itching prevents any rest.  You are probably asking yourself, “Why do they itch so badly?”  You have just asked the first why.  Here is the causal chain as we understand it today.

leanhealthcare_rootcauseanalysis

 

The researchers and clinicians talked about a variety of countermeasures (medical and surgical) that hit this causal chain at a variety of levels.  Here are a few interventions they suggested and how they match to the causal chain.

LeanHealthcare_countermeasure

 And then there were the following comments which reinforced that sometimes we have a countermeasure that may work in some cases and not in others, but because we don’t understand the causal mechanism we don’t know why it does or does not work.

“We use this medication to attack the itching and it sometimes works.  We really don’t know how or why.”

“Every medication we currently use for itching has been poorly studied or not studied in ALGS patients.  If it works for any particular patient we really don’t know why.”

Clearly the Holy Grail in ALGS is a lower-risk treatment that would work consistently at the root cause problem of bile duct inadequacy:  that medical treatment that would regenerate bile ducts without surgery.  That would not only cure the itch but also the related bile back-up issues such as liver scarring, nutritional inadequacies, and extremely high cholesterol levels.  But until such time as that treatment can be developed, understanding at what depth of symptom or cause a treatment is aimed is helpful for patients and their families trying to make decisions about the best countermeasure (or course of treatment) to pursue.  It is important to know when you are directing treatment at a symptom and not a cause.

Root cause analysis can be life or death.


Today’s blog was written by Blair Nickle, Sr. Manager at HPP.
 
For over 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 performance measurement and improvement methodologies, information systems implementation,strategic planning and deployment, project management, and human resource development.
 
Blair holds both a Master of Business Administration degree and a Master of Science in Library and Information Science degree from the University of Tennessee.  Her undergraduate work was performed at Emory & Henry College. 

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Lean Healthcare Information Technology - HITECH ActHere’s some scary news for you—two independent studies indicate that for the healthcare industry to fully meet the requirements of the HITECH Act by 2015 a 30 percent increase in staffing of information technology resources will be required (Studies conducted by the Bureau of Labor Statistics and the Office of the National Coordinator for HIT).

What is the HITECH Act?  The Health Information Technology for Economic and Clinical Health (HITECH) Act was signed in 2009 to improve American healthcare delivery and patient care through an unprecedented investment in health information technology.  To date, participation is voluntary and CMS grants incentive payments to eligible hospitals who demonstrate meaningful use of a certified EHR system.  However, if eligible hospitals fail to join by 2015, they will encounter negative adjustments to their Medicare reimbursements.

Not scared yet?  Once the requirements are implemented and healthcare becomes more “wired,” will maintenance costs increase or decrease?  There is compelling evidence that the difference in maintenance costs at the Stage 1 level of implementation where ancillaries (lab, radiology, pharmacy) are installed and Stage 4 where CPOE (computerized physician order entry) and CDSS (clinical protocols) are fully implemented, represent a two-fold increase.  In other words maintenance and support costs double between Stage 1 and Stage 4.  This scares me; in a period of declining reimbursements and systemic over-burden, it is in a word, unsustainable.  This is the first part of a blog series describing how some advanced Lean healthcare delivery systems have faced this challenge.

For Lean healthcare systems and organizations, this will be less daunting.  Many of these institutions have recognized tremendous improvement in cost, quality, service levels and patient satisfaction by using Lean to make quality the operating system.  Many have also recognized that continuous improvement efforts are relying a greater extent than ever on the integration of (the right) technology and well designed (Lean) workflow.  Fewer have turned the focus of their Lean transformation on how IT is purchased, implemented and supported.

To meet the challenges described above, healthcare IT departments will be required to shift resources from basic support to strategic implementation.  Currently, 80 percent of the average healthcare system’s IT resources are engaged, day-to-day, in providing support.  This leaves only 20 percent for strategic implementation.  The demand going forward will require closer to an even split of these resources – herein lie both an opportunity and a challenge.

In general, this division of resources leaves the enterprise over-burdened on the strategic implementation side.  So what happens?  People do the best they can.  When it comes to implementation of new technology or major upgrades, over-burden leads to short-cycled and, as a result, sub-optimal implementations.  Areas often overlooked include fully understanding technical requirements, adequately surfacing the voice of the customer and translating it into the design and implementation requirements, and solid pre-go-live testing and validation.

Moreover, few organizations look back post-implementation and validate the cost-benefit analysis that justified the implementation in the first place.  As a result, implementations are often suboptimal.  This drives increased demand for support, which in turn inhibits moving from an 80-20 split to a 50-50 split between support and strategic implementation resources.  It is a vicious cycle that feeds on itself to rob the organization of productivity and increases the cost of information technology ownership.

So how can Lean help?  First, many of the support processes have significant waste embedded within them.  Much of this is driven by a lack of standardization in the delivery of the service.  By aggressively and relentlessly eliminating waste from these processes, the enterprise positions itself for success in shifting resources from support into strategic implementation.

The next step in the process is to dramatically improve the way that new technology is implemented.  By implementing solid process rigor and by leveraging Lean tools such as 3P to design the technology and workflow “package” and implementation plan, we move closer to “defect-free” implementations.  This in turn reduces the post-implementation support requests and demand on support resources, enabling the shift from just keeping the lights on to strategic implementation.

In part two of this series we will turn our attention to eliminating waste from the support processes, enabling a shift in resourcing toward strategic implementation.  In part three we will discuss the use of solid process rigor combined with Lean tools such as 3P to drive “defect-free” implementations, thereby reducing demand for post implementation support and again enabling the shift from just keeping the lights on to strategic implementation.  Part four will focus on driving ROI, and more importantly, being intentional with the reinvestment of the benefits derived from strategic implementations.

It is my intent through this series to leave you with a solid conceptual framework for assessing your IT operations and driving the improvements necessary to meet the resource challenges described earlier.

Continue Reading:

The Case for Lean Led Information Technology, Part Two: Free-up Resources


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

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

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

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Coaching

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By John Shook – Chairman and CEO of Lean Enterprise Institute, Inc.

I’m a long-time fan of Brasilian futbol (or as some of us call it, soccer). This World Cup, I’ve been won over by the Mexican team. Why? Coach Miguel Herrera. Why? His passion is infectious. As a fan, I love it.

Coaching, though, isn’t just one thing.

Coach John Wooden: Everyone Is a Teacher. Everyone Is a Coach.

John Wooden was arguably the most successful, probably the most influential, and certainly the most studied coach in the history of US sports. His UCLA basketball teams won 11 national championships over a 13 year span. But, his influence is more than a matter of wins and losses. He spoke very little about “winning”. Winning – the final numbers of the scoreboard – was the result of a process, of doing things the right way. And it was theway he coached that made a difference and led to his phenomenal results.

“Success is the peace of mind which is a direct result of the self-satisfaction in knowing that you have made the effort to become the best of which you are capable,” said Wooden when asked to define success.

Wooden’s approach was unique, according to researchers Richard Gallimore and Roland Tharp, who studied the processes of many coaches. They found that Wooden gave very few “motivational” speeches and rarely got overly emotional, whether up or down. What he did was simply … teach.

In their study of Wooden, Gallimore and Tharp recorded 2,326 discrete acts of teaching, which they categorized as:

  • Compliments: 6.9%
  • Expressions of displeasure: 6.6%
  • Pure information (what to do, how to do it): 75%

Coach Wooden taught via what he called the “whole-part” method; he would teach an entire move or play and then break it down to work on its essential elements. That will sound very familiar to you if you know anything about TWI – Training Within Industry program – and its “job breakdown” process.

Swen Nater played for Wooden at UCLA from 1970-1973 and wrote a book with Gallimore about Wooden’s coaching/teaching style called You Haven’t Taught Until They Have Learned.

Swen says the heart of Wooden’s process was condition (moral, mental, and physical), skill, and team spirit. For Swen, “Steady improvement in several areas continued to provide me with motivation to reach my personal best, but nothing motivated me more than enhanced conditioning, skill, and team spirit. The better my conditioning, the harder I could work to improve my skills. The better my skills, the better I could give them to the team. As all three were improving simultaneously, I could literally see daily improvements. It was exciting. I felt good about myself.”

Coaching – Improving Performance and Developing People

Any leader’s job is to get the work done and develop the people doing the work at the same time. To accomplish these two objectives as separate activities is difficult if not impossible. So the lean leaders’ solution is to develop people through getting the work done. And one key means by which lean leaders do that is coaching.

Personal and Organizational Transformation: Capability for Capability Development

Lean transformation is personal and organizational. Swen’s story of learning from Coach Wooden is a great example of personal transformation. How does this relate directly to the organizational side of transformation?

Taka Fujimoto, the foremost scholar of Toyota in the company’s home country, distinguishes between competing through price or product with competing through organizational capability. In his book, Competing to be Really, Really Good, Fujimoto notes that capability building is in itself a process with three layers: routine work capability, routine improvement capability, and evolutionary capability.

“Capability building is a step-by-step process,” he writes. “Organizational capability in regard to manufacturing comprises three layers. The base layer is routine manufacturing capability. That is the capability of producing the same product as competitors at lower cost, at higher quality, and with shorter delivery lead time.

“The second layer of organizational capability is routine improvement capability: the ability to achieve continuing improvements – kaizen – in productivity, quality, delivery lead times, and other facets of deep competitiveness. That capability consists of an organizationally ingrained capacity and predilection for undertaking problem-solving cycles continually, which drives relentless improvement in products and in production processes.

“Sitting atop routine manufacturing capability and routine improvement capability is the third layer: evolutionary capability; in other words, capability-building capability. That capability, anything but routine, is the capacity for tossing up new capabilities out of the soup of organizational chaos.”

Taka notes that gains are realized at different timeframes from these different processes – that capability-building is an “emergent process”, one whose pace cannot be rushed. Taka uses the phrase carefully to suggest “complex phenomena that arise from simple rules.” Through careful, mindful, repeated practice of specific methods, a systemic change occurs over time.

How to Develop Individual and Organizational Capability

The Organizational Learning movement, led by Peter Senge and others, has long taught about the powerful structure of double-loop learning: learning which questions deep assumptions in an organization – a conscious practice of reflection and inquiry that surfaces hidden, tacit attitudes in a way that they can be framed and addressed productively.

More recently, Mike Rother has led a movement that embodies lean thinking to actualize the structure and principles of double-loop learning in real-world practice. Practice that can be practiced and learned. Through theImprovement Kata and the Coaching Kata, a learner practices basic moves (work routines) while an experienced coach observes, checks, provides instruction as necessary to lead the learner to proficiency. “The Improvement Kata’s practice routines teach a scientific meta-skill that aims to change our habits of mind so our capabilities come to greater fruition. Practicing the Improvement Kata develops and mobilizes our creative capabilities and makes us better at achieving our goals,” according to Mike.

David Verble relays his own learning from Toyota’s Fujio Cho, who coached leaders to:

1. Give them the job as their own.
2. Let them think; let them try.
3. Help them see.
4. Force reflection.

And, essential to coaching in any style, any individual you try to coach has to be open to being coached … by YOU. As David says,

“Helpful coaching is a balancing act for the coach. On one hand you want to help the ‘coachee’ to be successful by making her more aware of what she knows and how she knows it and by prompting her to look at what she is thinking and consider what it is based on. On the other hand you have to allow the coachee to stay engaged in her own line of thinking without taking over the problem-solving thinking with your coaching or your own ideas.”

Learning to Coach

Coaching isn’t one thing; it’s many things, requiring multiple skills. Sometimes coaches provide the most detailed of instruction: “here is how you attach the part … this is how you handle the ball in this situation … here is how you change the oil …” Other times, we offer the most thoughtful of observations or questions to “force reflection” and lead to new levels of thinking, often far beyond what we – as questioning coach – may have been thinking. For coaches there is a “directive instruction zone” and an “open counseling zone.”


Today’s blog was written by John Shook – Chairman and CEO of Lean Enterprise Institute, Inc.  Originally posted on www.Lean.org – re-posted with permission.

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Lean Healthcare - Standard Work, Airline exampleOn a recent business trip I received an upgrade to a seat in the first row. I was thrilled. Free upgrades are a big deal for business travelers; I would be able to get what I want for lunch since options are limited and the flight attendant begins taking orders in the first row.

So as I made my way through a busy day with no time to eat before boarding the plane, I was feeling pretty good about my first row seat.  Upon arrival at my gate and scanning my boarding pass, the machine beeped and reassigned me.  I had been moved to row four.  Darn!  Now I will be relegated to whatever lunch items are left over.

To my surprise, the flight attendant began taking orders before we left the gate.  She took an order in row five, then two, then three; then she came to me.  I had the pleasure of ordering my choice for lunch.  As I was enjoying my lunch, my Lean mind began to think about the process I had just observed.  In the spirit of Lean thinking, I knew I needed more data before I could make a judgment so I began to talk to the flight attendant.  She told me that she serves her most frequent fliers first based on the passenger manifest.  That is her way of making sure that the airline’s most loyal customers get the service they expect.  But why don’t I see this happening on all flights?  Her response was, “I don’t think we have a standard way of serving, so this is what I do.”

The next time I was in this situation, the flight attendant started taking orders in the last row.  The flight after that, row one was first.  What’s going on?  Once again, in the spirit of understanding the process, I talked to the flight attendants to gather more data.  “We do have standard work,” they informed me.  “On odd numbered flights, we are to take orders starting with the last row.  On even numbered flights, we start with row one.”  Now isn’t that interesting?  It was not apparent to me that a standard was being followed.

Why is that?  It all comes down to communication and follow-up.  When we use lean thinking to improve a process, often times we create standard work to improve the process and reduce variation.  That’s the easy part.  What we typically struggle with is how to communicate the expectation to all front line workers.  Nor are we good at auditing the process to ensure that the standard work is being followed.  These are two critical parts of managing lean processes after the improvement is made.

For the communication plan, follow the Who, What, How, and When principle.  Who do we need to communicate with (typically called stakeholders)?  What do we need to tell them (The new process and standards)?  How are we going to tell them?  When will we have this completed?  Be aggressive with the timeline so that the new process takes hold in a short timeframe.  Then audit the process.  The key to effectively doing this is to create a schedule whereby you observe small data sets on a regular basis.  For example, if you have 50 employees using the standard work and you observe five daily, you will have seen all 50 employees in action every two weeks.

So remember, for standard work to be successful, everyone needs to know and we have to audit to follow up.  After all, it is only a standard if everyone is following it.


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 severed 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, Bachelor’s Degree in Pharmacy from Purdue University and a Specialty Certification in Nuclear Pharmacy from Butler University.

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Lean Healthcare - Respect for Teammates, Avoid the Blame GameEveryone knows the definition of respect. Often times I find that “respect” extends easily to people, roles and responsibilities for which we have an understanding and an appreciation.  In healthcare, it takes many people and processes to create an exceptional experience for a patient.  Caregivers do a wonderful job demonstrating respect for their patients, but in my experience, they can have a hard time demonstrating respect for the people, roles and responsibilities with which they are not familiar, especially if there is a perceived or real hindrance caused by the unknown. This is often manifested as “blame.”

Healthcare teams throughout an organization are working to achieve the same goal.  Sometimes, without even realizing it, blame is placed on co-workers or other departments.  Often this occurs because roles within the process are not always clear.  Have you ever been a patient where you’ve witnessed your caregiver place blame on another role, process or department?  If so, how did that make you feel?

I’ve experienced this as a patient, and it made me feel uncomfortable and question the quality of care I was receiving.  My experience was in an Ambulatory Care Unit.  I was being prepped for a routine GI procedure.  The GI nurse arrived to take me to the procedure room, and realized my IV had not been placed.  Her comment was, “They do this to me all the time, every time I come up to receive my patient, they’re never ready.”   Immediately I started thinking: whose role is it to place the IV? How does the GI nurse know the patient is ready? Has the GI nurse ever observed the work of an Ambulatory Care nurse and vice versa?  In a Lean Healthcare setting, having respect for your teammates and understanding the work in the value stream can help eliminate confusion and placing blame.

The easiest way to gain respect is to go to the Gemba to understand what is actually happening.  In a Lean Healthcare organization, understanding and appreciating the current state by all who touch the process allows you the opportunity to ask “why?” respectfully, and helps to clarify roles and responsibilities.  If the GI nurse were able to spend an hour or two to observe the role of the Ambulatory Care nurses, she may have a better understanding of why her patients are never ready when she arrives.  By understanding the “why,” she will have respect for the work that is happening prior to her arrival, and will have the ability to problem solve, creating an ideal process for the patient and the staff.

Whether you are a nurse in a clinical department or a member of a clinical support team, remember the importance of respecting your teammates.  Go to the Gemba to understand and solve problems to achieve an exceptional experience for the patient and the caregiver!


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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Often I hear questions about the ideal span of control (the average number of subordinates reporting to a supervisor) for Lean organizations.  While there is not a universally applicable span of control that is optimum for all situations, I find that the ideal span of control for organizations pursuing Lean is no more than 10 people.

Front-line staff should be the focal point for ongoing problem solving efforts.  In a Lean Healthcare organization, one of a front-line leader’s primary responsibilities should be teaching and coaching problem identification and problem solving methods to staff.  In order to provide adequate time for this, as well as allow sufficient time for day-to-day managerial duties, a relatively small span of control is ideal.  A small span of control enables expedient communication in both directions regarding outcomes and results, performance problems, their causes and their solutions.  A small span of control also encourages mutual respect and a cooperative attitude toward improving performance.

Fortunately, achieving this span of control does not require adding new layers of management or additional staff.  It is typically possible to reorganize front-line supervisors (often called Team Leaders or Patient Care Leads) around care teams of approximately 10 staff that are focused on serving patients.

Lean Healthcare - Ideal Span of Control

Such positions are enriched in the sense that they encompass both traditional managerial duties (creating staff work schedules, editing staff timecards, performing staff orientation and on-boarding, providing oversight and guidance to staff regarding company policies and procedures, etc.) and Lean-related tasks (leading continuous improvement projects, using Lean tools to drive operational improvements, coaching staff in the use of Lean tools, facilitating the development of A3 project plans, etc.).  The people selected to fill these positions will experience a broader and more enriching scope of responsibilities, will be able to maintain their clinical skills, and often find their jobs more meaningful and fulfilling.

Of course, the same is true for all levels of leadership.  Since coaching and mentoring one’s direct reports is a key component of every leader’s job, a smaller span of control allows leaders to mentor and support their direct reports in both Lean related skills as well as general leadership skills.  This also allows time for leaders to effectively handle their administrative roles and responsibilities.

What has been your experience with span of control?


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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Lean Healthcare CultureAs spring moves closer to summer, I am spending my free time nurturing my vegetable garden.  This is only my second year of tending this particular garden, so I am on a journey learning my role in cultivating and what will grow best.  At the same time, I am privileged to work with many healthcare leaders who are attempting to grow a lean culture within their organizations.  Lean Healthcare is not a seed you can plant and then walk away; it requires attention from the leaders in order to grow a culture which provides increasing value and decreasing waste.

Starting from seed or purchasing plants

This spring was busy, so I chose a mixed approach.  I purchased some plants from the garden center and started some from seeds.  You might relate to growing your Lean Healthcare program—where a blend of investing in your own staff training and a bit of external knowledge and skills infused into your organization may be needed to either jump start or reinvigorate your Lean Healthcare transformation.

Preparing for growth

In both cases I needed to prepare the soil.  Much like with any change we implement within our organizations, we need to prepare for change.  Making the business case occurs with each improvement activity at all levels of the organization.  Whether you are looking at a small specific problem using A3 problem solving or a large strategic initiative, the first place to start is to identify the business case for investing time and talent in the improvement.  The business case, or what we call the Value Diamond, will consider satisfaction, quality, cost and time.  Solutions will eliminate waste and bring improvement to all four quadrants of the diamond.  An improvement that only improves one quadrant has not truly eliminated waste and much like your garden preparation, may not yield high value.

Daily attention

The month of May is always a little interesting for weather in Colorado and this particular spring has definitely challenged my gardening skills.  Our weather has varied from beautiful sunny, dry days in the high 80’s to thunderstorms with hail and even snow.  To ensure the successful growth of my vegetables, I have to pay attention to key metrics—which give me early warning of problems that I can address with countermeasures.  In my garden, that means I need to pay attention to the weather forecast and plan for countermeasures of either watering or not watering, covering or not covering the plants, and removing the weeds.  If I wait for the storm to actually strike, I will miss the opportunity and my plants will suffer the consequences of a freeze or hail damage.   So is true with Lean Healthcare, daily attention to critical metrics is required.  Systems and structures need to be put in place including:  leadership standard work, gemba walks and team huddles to identify problems early and implement countermeasures.

I could continue on with this analogy, but I think you get the point.    What are you doing this summer to grow your Lean Healthcare garden?


This week’s blog was written by Maureen Sullivan, a Senior Manager at HPP.

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

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

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