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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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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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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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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. 

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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Toyota’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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Lean Healthcare Middle Manager RoleFront-line supervisors and middle managers play a critical role in successful Lean Healthcare transformations.  Without them, the improvement efforts will not be sustained despite the best of intentions of the improvement team.  Why?  Because newly developed processes will deteriorate over time unless there is someone taking measures to maintain them.  That responsibility must fall upon the shoulders of those consistently present on those units — the managers.

In organizations that successfully deploy and maintain their improvements, the manager’s most important job is to ensure that the newly designed work is performed as intended, now and in the future.  The problem?  Middle managers’ plates are already very full—possibly too full.  Many things are competing for their time and attention.  Adding new tasks to the manager’s plate will not work well unless we support them in developing the skills and finding the time to perform them.

I had the privilege of working with Steven Spear recently in a program engaging middle managers in quality.  A question we received from the group was, “How can a manager (middle or senior) devote time to fixing broken processes?”

Steven Spear’s response was:

Let me reframe the question to: How can a manager not devote time to fixing broken processes given the enormous toll on patients and staff that ill executed work exacts? 

For example, when we shadowed nurses in clinical settings, we found that 1/3 to 1/2 of their time was spent doing nursing work – assessment, treatment, follow-up, education. 

The remaining 1/2 to 2/3 was spent doing the scut work of finding materials, supplies, people and information.  Why? 

The relentless burden of “operational failures”:

    • Work directed at the wrong or an ambiguous target 
    • The wrong person in the wrong place at the wrong time 
    • Input arriving in form, content, location, or timing that required substantial re-work
    • A flawed but well-meaning approach to a task 

All this sucked time, energy and resources like a famished vampire at the blood bank. 

By stepping back from the regular doing of work (and working around all the impediments) for even a few minutes per day to engage in:

    • Work up – what went wrong? 
    • Assessment – why did it go wrong? 
    • Planning – what should we do differently?
    • Implementation – try it!
    • Follow up – how did it work? 

Staff found that time was pouring back to them, like being downstream of an opened dam during spring thaw. 

In sum, we naturally worry how to manage limited time given the time sucking processes in which we are embedded rather than working to liberate time so that we can do so much more value creation with so much less exertion. 

The key to that liberation of time, people and resources is: See, solve, sustain and repeat without end.

The issue of manager overburden is very real and needs to be addressed if organizations are going to be successful in sustaining quality.  Time management becomes very important.  What if you were to perform process redesign (a kaizen event, rapid improvement event, A3, etc.) on the manager’s work itself?  Observing and measuring time, task, and waste is likely to bear fruit, giving the manager the time to be redeployed to other work like observation, visual management, daily management and coaching.  My favorite waste for managers comes in the form of countless meetings with little being accomplished for the effort.  Instead, reallocate that time working on the broken processes in their areas of responsibility. Then they aren’t constantly putting out fires caused by poor reliability of ineffective processes.   Over time, the critical middle manager becomes an integral part of the improvement team.  They gain the ability to see, solve and sustain, as Spear describes.

A few questions to ask yourself:

  1. Do our Lean Healthcare efforts include the engagement of our middle managers in driving and supporting improvement?
  2. Are we supporting the middle managers in these efforts by taking tasks off their plate or redesigning their work to take the waste and frustrations out of their workflows such that they have the capacity to engage?
  3. Do our executive leaders realize that the support, development and coaching of middle managers in quality is their responsibility?  If not them, then who?

If you are not able to answer yes to all of these questions then you have more work to do.  Taking waste out of your managers work flows and giving them the skills to drive improvement are fundamental to success.

I wish you success in your lean healthcare efforts.

Today’s blog was written by Dave Munch, M.D., HPP senior vice president and chief clinical officer.

Dave oversees all of HPP’s clinical and Lean Healthcare engagements. He plays a lead role in new services development and HPP’s continuous adaptation to the healthcare industry’s ever-changing needs.  Dave previously served at Exempla Lutheran Medical Center as their Chief Clinical and Quality Officer.   Dave has been a frequent speaker on the subject of leadership effectiveness and Lean transformation for a number of healthcare organizations including Institute for Healthcare Improvement, The University of Rochester Medical Center, Yale-New Haven Health System, Tulane University Medical Center, Pittsburgh Regional Health Initiative, Institute for Clinical Systems Improvement, and the Voluntary Hospital Association.  Dave has served on the Agency for Healthcare Research and Quality’s High Reliability Advisory Group, has an extensive background in hospital operations, health plan governance, physician organization governance and clinical practice in internal medicine. 

Dave received his M.D. from the University of Colorado’s Health Sciences Center. He is a faculty member for the Belmont University Lean Healthcare Certificate Program.

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Lean Healthcare Integration with Baldrige CriteriaMany healthcare organizations have applied Malcolm Baldrige’s Baldrige Criteria for Performance Excellence to guide achievement of breakthrough performance gains, and in some instances, greatness.  The Baldrige Criteria are a scientific, data-based, longitudinal approach to establishing criteria for achieving performance excellence.

Baldrige Criteria are assessment-based. The Criteria identify “opportunities for improvement” but do not recommend an action plan.  The Criteria are also non-prescriptive; they do not recommend a specific improvement methodology.

How does Lean integrate with the Baldrige Criteria?  Deployment of Lean systems and practices can provide a powerful action plan to serve as a companion to a Baldrige assessment.  Lean can effectively address opportunities in each of the Baldrige categories.  Arguably, Lean Management Systems and accompanying deployment planks are the most holistic, effective way to improve Baldrige scores, and consequently progress toward performance excellence.

Thousands of high performing organizations have been systematically assessed by national Baldrige examiners and by dozens of state Baldrige organizations for more than 25 years.  In some states, an assessment involves more than 400 hours of examiner time and a similar amount of time from the organization being assessed.

One of the deliberate outcomes of assessments is development and enhancement of the Baldrige Criteria.  The Criteria are common characteristics among surveyed organizations that deliver superior, sustained and measured strategic performance.  Criteria are categorized by:

  1. Leadership
  2. Strategic Planning and Deployment
  3. Customer Focus (Patient Focus)
  4. Measurement, Analysis, and Knowledge Management
  5. Workforce Focus
  6. Operations Focus
  7. Results

The Baldrige Criteria are enhanced every one to two years based on new learning.  For example, an emerging characteristic of highest performing organizations is a deliberate focus on innovation.  As this characteristic emerges, it is integrated into updated Criteria and scoring.

Many Lean Healthcare organizations have partnered the Baldrige assessment with a Lean Healthcare action plan.  If your organization is striving for performance excellence, this may be the your most effective path.

John DeVries, Senior Manager of Lean Healthcare and Process Improvement at HPPToday’s blog was written by John DeVries, senior manager with HPP.  

John has more than 30 years experience in Lean Healthcare, Six Sigma, continuous improvement, and productivity improvement.  As a Master Black Belt and deployment leader, he has led Lean and Six Sigma skills transfers to a large organizations resulting in widespread, breakthrough, strategic improvements.  John also has experience assisting healthcare facilities integrating Malcolm Baldrige-based organizational assessments, Lean and Six Sigma.

John holds a Bachelor of Science in Industrial and Systems Engineering from the University of Alabama, Huntsville.

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You may have heard that A3s should be living documents in order to derive value from them.  An A3 completed in a single sitting, or in an hour or two, cannot drive learning about the process in question or the correct application of the scientific method (problem-cause-solution-action-measure).  A3 development should create more questions than answers.  These questions can only be answered properly with first-hand observation and data.  This is the only way to understand the causes of the problem you are trying to solve. If you have not gone out to where the value is added to see what is actually happening, your A3 will only have in it what you already know. If you have not learned anything new in the development of an A3, you have not done it properly.

This is particularly important when using proposal A3s to deploy your strategic and business plans.  These A3s should answer the question of how each part of the organization will improve its processes to meet the outcome metric goals established in the business case.  Improved outcomes come from improved processes.  In the catch-ball process, direct reports should bring multiple iterations of their A3s to each meeting and discuss what they learned since the last meeting about how they can improve their processes to meet the new goals. These meeting should go on throughout the year, evolving from A3 development to implementation review, with key process and outcome metrics updated for each review.  This is what is meant by a living A3 document.

Go and see, draw your processes, and review them with key stakeholders to make your A3s come alive.  Otherwise, they probably are not worth the proverbial paper they are written on.

KellerDwayneRSToday’s blog was written by Dwayne Keller.

Dwayne has more than 20 years’ experience in executive leadership positions. He has led a variety of projects to include Lean transformation, strategy deployment, and Lean-led facilities design, connected to each organization’s business case. His breadth of experience combined with a deep understanding of Lean allows Dwayne to effectively mentor client leadership teams through the Lean transformation process. Prior to HPP, Dwayne served as Executive Vice President of Operations with Medical Reimbursements of America (MRA). Healthcare executive teams visit MRA to learn from the Lean Revenue Cycle Management System Dwayne implemented.

He is an executive faculty member and instructor for Belmont University’s Lean Healthcare Certificate Program. Dwayne holds Master’s and Bachelor’s degrees in Mechanical Engineering from Bucknell University, and a MBA from Clemson University.

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Many healthcare organizations have discovered that Lean Healthcare methods can be applied to improve the patient experience.  Pulling waste (rework, errors, redundancy, etc.) from healthcare processes improves quality, safety, timeliness, access and costs.  As a result, the patient experience becomes better and patient satisfaction rises.  That’s all good stuff!  But simply applying Lean methods at the front line of healthcare processes isn’t enough to sustain patient experience improvement.  There is a leadership missing link if an organization doesn’t also install a focused Lean Management System.  A comprehensive lean management system builds accountability, sustainability, and long term viability into patient experience excellence.

An effective Lean Management System contains the following six components:

Strategy deployment:  The patient experience imperative must be part of the organization’s vision and cascaded through a systematic strategy deployment system.  An effective strategy deployment system connects frontline operations and improvement to the strategic direction of the organization.  It incorporates an ongoing PDSA of the plans and progress.  It enables prioritization of the many competing opportunities for improvement that present themselves daily.

Deployment and sustainment of standard work:  Translation of best service practices into documented standard work is critical.  Service delivery as standard work helps all associates know how to translate their internal dedication to the patients and their families into behaviors that demonstrate that dedication and into actions that foster development of strong personalized relationships with those they serve.

Visual management:  The use of highly visual information helps manage the status and flow of patients, informs about current performance on key service delivery indicators, and keeps the workplace organized through visual cues.  All of these contribute greatly to an orderly and efficient workplace focused on those elements important to the patient customer.

Deployment and sustainment of continuous improvement and problem solving:  When leadership develops and supports an army of improvement experts across the organization, tolerance for sub-standard processes and less-than-excellent patient experience shrinks.  All workers join forces to drive out waste and improve service through large and small ideas and interventions.

Leadership standard work:  Leaders must hold themselves accountable for being present and available in the gemba.  This engagement with and support of the workforce and the goals of the organization must be clearly defined as standard work for leaders, vigorously maintained, with performance made visible.

Daily management systems:  Translation of the strategic patient experience imperatives into daily patient experience goals and metrics enables the front line workers to maintain direct line of sight from how their work is of worth to the direction of the organization.

With effective leadership enabled by a comprehensive Lean Management System, improvement of the patient experience can be consistent and sustained.

For additional training on Lean Management Systems join us for the Accelerating Performance with Lean Management Systems workshop at the Lean Healthcare PowerDay! November 13-14 – more information and registration at

Today’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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Gemba coaching and questioning in healthcareSome people are naturally good at asking questions. For those who don’t have that innate ability, asking great questions is a skill that can be learned with some thought and practice.

At the Denver Health Lean Academy Executive Site Visit earlier this year, I got into a good discussion about questions – specifically questions in leader rounding or gemba visits.

What I have found is, if you ask questions without really understanding the coaching context, you may cause more harm than good.

To break the tendency to jump to suggestions when coaching on the implementation of Lean Healthcare tools and concepts, I ask myself, “What is the question that my suggestion answers?”  And ask that question.

As an example, when coaching on performance board implementation to sustain improvements, after getting some tracking metrics up, I often have to push to get a Pareto chart of problems that are preventing success.

I ask myself, “What question does that Pareto chart answer? What does that information do for me?”

Given that the Pareto chart helps me prioritize where to focus my Lean Healthcare efforts, I just ask, “How did you prioritize what problems you will work on?”  Amazingly enough, the individual being coached may be able to answer that question, just in a different way.  “We have a tick sheet of problems, but I don’t know how to make a Pareto chart.”

“OK.  Why don’t you put your tick sheet up on the board and circle the top priority items.”

We could spend some time working on putting the data in a spreadsheet and making a Pareto chart, but if I have already answered the question of prioritizing in a meaningful way, do I have to have the Pareto chart right now?  Perhaps the spreadsheet skills are a development opportunity?

A few things to avoid:

  • Making suggestions in the form of a question.  “Have you thought about <particular solution that I have in mind>?”  Not really a question.
  • Or, “What were you THINKING?!?” spittle flying.  Not really a good coaching question either.  A bit berating?  A better way might be, “Can you walk me through your thought process on how you arrived at that?” with a mindset of genuine interest in discovery and understanding.  This also gives the opportunity to coach on the problem solving thought process.
  • If you get too hung up on ONLY asking questions, you may never offer suggestions when it is appropriate (i.e. when coaching someone who gets “stuck”).

Even if you have a particular answer in mind, you must be open to alternate responses that do answer the underlying question.  This respects and enables the learner and you might just learn something yourself along the way.

Lean Healthcare coaching is not just an art, but also a skill that can be learned — to ask good questions, probe for understanding and know when to make suggestions.

And, as Granddad used to say, “Experts know the answers; wise men know the questions.”  “But remember,” Grandma would add with her mischievous grin, “there’s a fine line between a wise man and a fool.”

If you want to learn more about Coaching in Lean Healthcare, join us November 10 – 14 at the the Denver Health Lean Academy as they host the Coaching for Optimal Lean Performance workshop, followed by the Lean Healthcare PowerDay.  Get more information on and register for the coaching workshop at Get more information on and register for the PowerDay at

Today’s post was written by Richard Tucker, Vice President with HPP.

Richard serves as a coach, facilitator, and project manager for healthcare clients in the training and implementation of Lean Healthcare tools and Lean management systems. Prior to joining HPP, Richard had more than 16 years of business and industry experience in operational and leadership positions.  In addition to his ongoing support of healthcare organizations in their lean journey, Richard is a founding faculty member of Belmont University’s Lean Healthcare Certificate Program. Richard’s educational background includes BS and MS degrees from Tennessee Technological University in Cookeville, Tennessee. Richard has attended formal training courses in Lean Manufacturing, Leadership Development, and Shainin Statistical Problem Solving.

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