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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.



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.


 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.

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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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 – 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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Lean Healthcare - Coaching Changes in Standard WorkI’ve told those nurses what to do, they just don’t listen…they just don’t care…

These are some of the comments I hear from hospital support staff who are trying to improve their metrics and need the nursing staff to modify their activities in order to improve.

When I think about all of the people in a healthcare environment trying to make changes via the nurses, it’s staggering.   IT, Quality, departmental leadership, performance improvement teams, HR, Safety, and others all need the nursing staff to change standard work in order for their improvement activity to be successful.

The process used by many to drive change in the nursing role is to communicate to the nurse educators about the change.  The educators are then responsible for “training” the nursing staff.  (In most cases, I have found this to be more of a communication activity versus a training process.)  Then, the support staff follow-up by reviewing their metrics and/or observing the nursing staff to see if they are doing what they were trained to do and providing some sort of report identifying the non-compliant activity.

In a Lean Healthcare environment, communication and training are vital steps in the process to change standard work but, the key to sustaining it is coaching.  Coaching is defined as a training or development process by which an individual is supported while achieving a specific competence result or goal.  For every change that is made to someone’s standard work, a coach should be assigned to support the individual and insure standard work is being implemented.  The coach should explain why the new way is important, and when observing, ask why they couldn’t do it the new way.  (“What is preventing you from implementing the new standard work?”)  An effective coaching method I’ve observed for sustaining new standard work requires daily observations and coaching for about three weeks, then reduced to once a week for about a month, then monthly for at least 3 months or, until there is no regression.  If regression occurs, the coach should revert back to the previous level of coaching.

If you are in a leadership or support role and need to improve metrics by changing the nursing standard work, first, remember nurses care deeply about the welfare of their patients and the metrics that drive the system of care for those patients.  Second, there are many in the chain demanding assistance for many kinds of changes.  If it’s important enough to implement the change, provide the necessary resources to coach them through the change.  Otherwise, don’t be surprised when the change is not sustained.  In a Lean Healthcare environment, sustainment is the key to success.  Coaching is the sustainment step in the process to educate nurses on changes in their standard work.

This week’s blog was written by Linda Duvall, Director with HPP.

Linda leads Lean Healthcare transformation engagements for HPP. She has nearly 30 years of experience in business leadership, program management and lean transformation.  Prior to joining HPP, she worked for Vanguard Health Systems as a process improvement specialist providing leadership and support for regional and hospital level process improvement teams.  Linda holds a Bachelor’s degree in Industrial Engineering from the University of Evansville.

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Lean Healthcare - Uber sets examplePicture a bunch of entrepreneurs, software programmers, and taxi cab customers in a room, listing on a white board all the problems customers have using taxi cabs:

  • You have to find the phone number of a local taxi company to call the dispatcher.  The dispatcher has to call the taxi closest to you.
  • You don’t know what quality of cab or driver you will get (e.g., does the air conditioning work).
  • You don’t know when they will arrive to pick you up, unless you call in advance.  Even then, you cross your fingers they will show up.
  • When you arrive at your destination, you hope they take credit cards.
  • You hope the credit card machine works.
  • You hope they don’t compromise your card.
  • You hope it doesn’t take 10 minutes to pay by card.
  • If you want to use cash, they hardly ever have the right change.

Sounds like lots of waste.  This is the business case for Uber, a company taking the taxi and limousine market by storm.  They developed a disruptive technology and service that solved all of these problems and came up with an attractive financial model for customers, taxi drivers, and Uber.

What resonated with me when I first used Uber was that whether they intended it or not, their solution is very Lean.  They addressed all of the Quality and Connections (Rule 2 of Rules in Use) issues listed in the business case above.  Uber implemented Standard Work (Rule 1 – Activities) to ensure high quality:  All drivers must drive black cars that meet certain year and condition specifications, meet professional dress codes, have a professional attitude, and offer customers a bottle of water.  After the ride is over, customers receive a one question survey via the Uber app to rate their driver on a scale of 1 to 5.  Drivers not maintaining a certain average rating are taken out of the Uber network.  The driver’s average rating is shown when the customer requests an Uber vehicle.  This is a closed loop, real-time quality control system.

Rule 2 states that all Connections should be direct (with no intermediaries between customers and suppliers), binary (have yes or no simple responses to customer requests), and paced (let the customer know when their request will be filled). The Uber app tells customers real-time how long it will take for the closest Uber vehicle to reach them.  They push one button to request the driver, and a text is sent to their phone immediately letting them know the drive is on his way.  Now here’s the kicker—the driver gets the customer’s location via GPS and the customer can watch the Uber vehicle approach their location on their phone.  When the driver is arriving, another text alerts the customer.  Since customers are required to preload their credit card information with Uber, a receipt is emailed to them within an hour after the ride is complete.

Uber developed disruptive software as the “enabler” to this excellent service, which is what software should be.  Most healthcare organizations are investing millions of dollars deploying significant new software platforms or upgrades to meet new performance requirements.  Is your new software an enabler to the best known methods to deliver excellent quality and service at the lowest cost?  Have you done the process improvement work needed to solve business problems before deploying the software? If your software is automating poor processes laden with waste, consider applying Lean tools and principles to improve the outcomes.

Today’s blog was written by Dwayne Keller,  Senior Vice President with HPP.

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 Course. Dwayne holds Master’s and Bachelor’s degrees in Mechanical Engineering from Bucknell University, and a MBA from Clemson University.

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Lean Healthcare - Product PeopleI recently watched an interview of Steve Jobs, performed around 1996 after Apple re-hired him.  As many know, after he was fired in 1985, the company was on a downward spiral and at risk of bankruptcy.  Jobs’ return was credited with saving the company and making it the dominant player in the market it is today.

The interview lasted about 30 minutes and was a fascinating account of why the company lost so much ground in his absence and what it took to bring it back.  In his opinion, John Scully, the CEO during that time, took his eye off the ball with respect to the quality and value of Apple’s products.  He became complacent, just like monopolies can do.  Jobs talked about the mindset and culture of monopolies and why they are vulnerable to ultimate failure.

If you are a monopoly, what is the consequence of delivering a poor product?  For the most part, there is none.  People will still buy your product because they have no alternative.  They will have to settle for mediocrity.  A company can even believe and claim that they have good products because there is no effective comparison to what better looks like—which was the case a number of years ago with General Motors.  They had the “best cars made” until new entrants like Toyota and others proved them wrong.

The parallels to healthcare are extraordinary.  We have been able to perform as monopolies.  Hospitals were not only immune to poor quality services, they were rewarded for them.  Readmissions have been lucrative.  A singular focus on market share has been a very successful business strategy in healthcare.  On the other hand, focusing on quality, efficiency and ultimately value have not been common business models because historically they had not been necessary.  There are many reasons why we ended up in our current position—misaligned payment systems, lack of transparency of performance and cost, and many others.

Things are changing.  Our society is beginning to push back and demand quality and value.  CMS’ Value Based Purchasing program, readmission penalties and hospital acquired condition penalties are adding up to some real dollars and getting the attention of hospital administrators.

The key questions are:

  • Do hospital leaders know how to respond? If so, will the response happen quickly enough for them to save their organizations?
  • Do they know how to steward their organizations to pursue value, better healthcare, better experience, and lower cost or will they continue to focus on market share growth and delegate the service quality to others?

Apple’s success was and is predicated on developing good products that provide value in the customer’s eyes.  Steve Jobs was a product person and led his company that way, constantly driving product innovation and quality.  He was not concerned with acquisition as a growth strategy.  His growth strategy was innovation and value.  The same type of product leadership and focus is needed in healthcare if we are to successfully meet the challenges we face.

It will be interesting to see which healthcare organizations prevail in this future and which ones do not.  It will require leaders to drive value and continuous improvement as their highest priority.  It will require what Steve Jobs describes as product people, likely the very people reading this Lean Healthcare blog.  It will require a serious comprehensive focus and commitment, not just dipping of the proverbial toe.

Those who are successful will go beyond lip service and invest their time and organizational attention to the pursuit of value, both higher quality and better efficiency.  In my opinion, success will require an intentional, evidence based approach to value.  It will require Lean Healthcare.

This week’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 (IHI), The University of Rochester Medical Center, Yale-New Haven Health System, Tulane University Medical Center, Pittsburgh Regional Health Initiative, Institute for Clinical Systems Improvement (ICSI), and the Voluntary Hospital Association (VHA).  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 also a faculty member for the Belmont University Lean Healthcare Certificate Program.

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