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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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Lean Healthcare Information Technology - HITECH ActThis is the second blog in a four part series on Lean Lead Information Technology.  In part one, I presented some very scary statistics regarding the staffing requirements necessary to implement and support the requirements of the HITECH Act.  In a period of declining reimbursements and systemic over-burden, the requirements, in a word, are unsustainable.  In part one I proposed a three tiered approach to meeting this challenge as follows:

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

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

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

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

Lean Healthcare IT application


A few items to note in the current state:

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

Compare this to the future state depicted below where:

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

Lean Healthcare IT application


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

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

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

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

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

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

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

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

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

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

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

Rule 1: Activities

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

Rule 2: Connections

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

Rule 3: Pathways

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

Rule 4: Improvement

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

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

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

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

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

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

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

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

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

“Yeah, but we can’t fix that.”

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

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

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

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

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

Marshall: Who?

Ted: Future Ted and Future Marshall.

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

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

Ted: Damnit, Past Ted.

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

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

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

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

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

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

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

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

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

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



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.

Continue Reading:

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

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

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

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

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