Lean Healthcare Exchange

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While recently explaining Lean Healthcare concepts, I was told that we were just repackaging old concepts.  I think the individual who made the comment was looking for me to protest.  However, much to their surprise, I agreed.  I shared that Lean Healthcare is built on proven principles that have been around for decades.  Specifically, I referred to Deming’s 14 Points.

To those who aren’t aware of Dr. Deming, he is widely known as the “father of quality”.  He is perhaps best known for the “Plan-Do-Check-Act” cycle popularly named after him.  In Japan, from 1950 onward, he taught top management how to simultaneously improve service and quality as part of the U.S. government’s efforts to rebuild Japan after World War II.  Deming is credited with helping revive Japanese manufacturing and was seen as somewhat of a hero in Japan.  Ironically, in the United States we didn’t widely accept Deming’s philosophies until the end of his life in the late 1980′s and early 1990′s.

You can find out more about Deming’s 14 Points in this previous post, and here as well.

I believe you will find many parallels between Lean Healthcare principles and Deming’s Points.  I especially like the 14th  point:

“Put everybody in the company to work to accomplish the transformation.  The transformation is everybody’s job.”

This concept includes ideas such as:

• Improve your overall organization by having each person take a step toward quality improvement
• Analyze each small step, and understand how it fits into the larger picture
• Use effective change management principles to introduce the new philosophy

So many people that are new to implementing Lean Healthcare focus only on the tools such as Kaizen, 5S, or 3P.   However, by taking some lessons from the past we can learn to look beyond the tools.  We can look for transformation.  Thanks, Dr. Deming!

What is your organization doing to take Lean beyond tools?

Today’s blog was written by Tom Stoffel, Vice President with HPP.

Tom has led healthcare organizations in both the development of high-level Lean Strategies down to hands-on implementation of Lean in a clinical setting.  He has achieved the levels of Certified Lean Specialist from the Business Improvement Group and the National Institute of Standards and Technology (NIST), along with being an ASQ Certified Quality Engineer.  Tom is the developer of TGI Healing Healthcare – a brand of Lean Healthcare training tools designed to share lean principles through hands-on learning. 

Tom holds an Engineering Degree from the University of Michigan.

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Just around the corner is the New Year’s Day football tradition.  We are big sports fans in our house.  When we are watching a sporting event in person, we always like to have a good view of the scoreboard.  In fact, if you watch people walk into a stadium, the scoreboard is one of the first places most people look.   It is important to know if our favorite team is winning or losing.

How about in your hospital or clinic?  What is your scoreboard telling you?  One of my favorite questions to ask organizations new to Lean Healthcare is, “How do you know if you are winning or losing?  How does frontline staff know they are succeeding?”  I often get the response, “As long as no one dies, it’s a good day.”  Have we really set the bar that low?!

As we begin to implement Lean Healthcare principles in an organization, we utilize visual controls in order to help drive continuous improvement and prioritize problem solving activities.  A good visual board contains three key components:

There are two common pitfalls that leaders can make when using a system of visual controls:

1. No leadership support.  Leaders have to check the scoreboard—they must make it a part of their everyday work to get out to the areas in which they oversee.  This will allow them to review the data boards and the associated problem solving by their staff.   A leader’s job is to coach and remove roadblocks the teams are having in their problem solving efforts.
2. Requiring all visual controls to look the same.  Often times leaders latch on to the principle in Lean Healthcare of standardization.  However, requiring that all visual boards in the organization “look” the same shows a lack of understanding of the reason behind the visual controls.  Allowing areas to own their own data boards and with the History, Pareto, and Problem Solving components should be the standard.  The information that gets tracked and subsequently improved can be left up to each functional area of the organization.  This typically allows for more creativity and better problem solving. 

So how does your department, clinic, or hospital score with Visual Management?  Tweet pictures of your examples (good or bad) to @LeanHealthcare using #visualmanagement.

Today’s blog was written by Tom Stoffel, Vice President with HPP.

Tom has led healthcare organizations in both the development of high-level Lean Strategies down to hands-on implementation of Lean in a clinical setting.  He has achieved the levels of Certified Lean Specialist from the Business Improvement Group and the National Institute of Standards and Technology (NIST), along with being an ASQ Certified Quality Engineer.  Tom is the developer of TGI Healing Healthcare – a brand of Lean Healthcare training tools designed to share lean principles through hands-on learning. 

Tom holds an Engineering Degree from the University of Michigan.

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Much of the focus in a Lean Healthcare transformation regards changing the way people think about their work. Yes, changing the way people think is important but, the culture of an organization is key to success or failure. One of the best known cultures in the business world is that of Southwest Airlines—it is run with three main principles: Warrior Spirit, Servant’s Heart, and Fun-LUVing Attitude.

The above video clip  is a great example of how Southwest’s Fun-LUVing attitude shines through each day.  It’s no wonder that Southwest regulars often become groupies.  Their customer service has created a loyal following. 

Southwest’s recent acquisition of Airtran Airlines will make for some interesting challenges on merging the two cultures. Gary Kelly, Southwest CEO, discusses the “Importance of Culture” in a leter written to Airtran employees this month.

During the Lean Healthcare transformation process, our job is to use tools and data to help mold the culture of a healthcare organization into an army of problem solvers. However, this work is done subtly. Culture is not a word used in most business settings. To quote Kelly, “Twenty years ago, most companies and business schools didn’t talk about Culture. In fact, most folks thought Culture had to do with Beethoven or fine French wine.”

Organizations that look only at the Tools of Lean Healthcare are missing out. The tools are extremely effective at targeting and eliminating waste. However, they do not define you as an organization. Culture is an extension of the vision of the organization and is, therefore, owned by Leadership. Kelly stresses to employees, “Your business plan is what you are, but Culture is who you are. Culture needs support from Leadership and the Frontline Employee. Without both, it will surely wither.”

For long-term sustainability, we must pay specific attention to key components of culture and develop a plan to improve it. How do leaders spend their time? How do we handle problems that arise in everyday work? How do we know if we had a good day or bad day? These are simple elements of culture – but critical to long term success.

Rapping flight attendants or not, how does your organization’s culture shine through in your employees?  Comment below to let us know OR join the discussion on our Lean Healthcare Exchange LinkedIn Group.

This week’s article was written by Tom Stoffel, a director & consultant for HPP. Before joining HPP, Tom served as President of Transformation Group, Inc,. Tom developed TGI Healing Healthcare – a brand of Lean Healthcare training tools designed to share lean principles through hands-on learning. Tom has led healthcare organizations in both the development of high-level Lean Strategies down to hands-on implementation of Lean in a clinical setting. Tom has achieved the levels of Certified Lean Specialist from the Business Improvement Group and the National Institute of Standards and Technology (NIST), along with being an ASQ Certified Quality Engineer. These certifications build on an Engineering Degree from the University of Michigan. Training experience includes Lean, Quality, and Leadership Training, as well as serving as an Adjunct Faculty Member at Waubonsee Community College.

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Many healthcare organizations have launched a concentrated improvement effort with the goal of reducing costs and improving service patients.  Lean Healthcare has proven itself as a useful weapon to target the wastes that have burdened the healthcare delivery system for decades.  However, as some organizations begin their Lean journey they are not taking full advantage of the powerful Lean thinking that can accelerate the rate of change within an organization.  This limited view of the full improvement cycle focuses on Kaizen events or ‘Blitzes’ that begin with a big splash, but fizzle out without focus or follow-up.  Here is one of the keys to long term success in Lean Healthcare: the improvements do not end with the focused events.

I would like to share two examples to contrast the success of subtle differences in implementation.  Let’s start with Hospital A.  This group has launched an improvement team in the Emergency Department.  A team was formed to address wait times which were impacting both patient safety and patient satisfaction.  A facilitator led a cross-functional team through a week-long improvement event.  After some arguing about the cause of the problem during the week, many improvements were identified.  Some were implemented.   Assignments were made and the team celebrated some minor changes by the week-ending report out to senior leadership.   However, the team members went back to their areas and had to play catch up from spending the previous week out of pocket.  The excitement from the report out quickly gave way to the reality of high patient volumes and fire-fighting.  Some of the improvements stuck, but others encountered resistance with staff who were not trained in the changes.  A month later, there was little evidence of improvement in the wait times.  Team members that were once excited, now downplay the improvement process. 

Now let’s contrast Hospital B.  This group was tackling the same problems.  This group studied the problem and conducted observations of the process.  They also conducted a week-long improvement event with a cross-functional team.  This team used the observations and data collected prior to the event to focus and quickly brainstorm ideas for improvement.  During the event week, the teams tested some of the improvements and discovered that their ideas were close, but not perfect.  The team changed and modified the improvement plan based on what they learned.  This team also celebrated and reported out to senior leaders at week’s end.  However, before the team wrapped up their week, they scheduled two key activities.  One was a training session for those key staff not involved on the team.  The training was conducted by those team members who were on the team and had learned from their trial runs conducted during the event week.  The second key activity was a set of observations conducted by the team members after the changes were to have taken place.  This was a chance to see the changes through and see how they were accepted by the remainder of the staff.  There was an opportunity to “coach” fellow staff.  Some of the changes the team had planned to make needed to be modified.  Other improvements not even planned were identified and implemented quickly. 

You can see the diverging pathways of the two groups in the examples above.  Subtle changes in planning and follow through can make a significant difference in the overall success to transform the way people see their work.  Simply going through the motions of conducting Kaizen events does not guarantee the success of Lean Healthcare.  Problem solving must become part of everyone’s daily work.  Just as learning any new skill, having a good coach can be a key to making the subtle changes necessary for success.

This week’s article was written by Tom Stoffel, a director & consultant for HPP. Before joining HPP, Tom served as President of Transformation Group, Inc,. Tom developed TGI Healing Healthcare – a brand of Lean Healthcare training tools designed to share lean principles through hands-on learning. Tom has led healthcare organizations in both the development of high-level Lean Strategies down to hands-on implementation of Lean in a clinical setting. Tom has achieved the levels of Certified Lean Specialist from the Business Improvement Group and the National Institute of Standards and Technology (NIST), along with being an ASQ Certified Quality Engineer. These certifications build on an Engineering Degree from the University of Michigan. Training experience includes Lean, Quality, and Leadership Training, as well as serving as an Adjunct Faculty Member at Waubonsee Community College.

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I was working in an operating room last week with a team of OR staff.  We were improving operating room turnaround times using Lean Healthcare principles.  Part of the process was to identify how long it should take to set up the next case.  As you may guess, the overwhelming answer was, “it depends.”  In fact, the team observed and identified that the amount of time it takes to turn over a room depends on many factors. 

However, you could have knocked me over with a feather when the OR charge nurse commented, “If we had access to this room turnaround data, we could review it weekly.  We could look at it and recall what happened in particular cases to cause the turnaround time to be longer than expected.  Then we could address those issues in the moment.”

Here is the back story to explain why I was so pleasantly surprised:

First of all, for those that have studied Lean Healthcare you recognize that Lean is a problem-solving methodology.  We like to remind the staff with whom we work that Lean Healthcare is about “making the right work easier to do.”  Of course, a prerequisite for effective problem solving is that we know why something is a problem.  Previous to our Lean efforts, operating room statistics, including turnaround time, were published monthly.  The data was posted on the wall near the break room and was promptly ignored by staff (I refer to this as autopsy data.  The patient is already dead and we are just finding out the cause of death).  Nobody cared about the data because it seemed irrelevant.  There was no connection between the data and the daily pulse of the OR.

Secondly, we had been working at this particular facility for months trying to pull together data in order to provide clean statistics for room turnaround.  We had progressed from the monthly posting of data to weekly.  We had the ability to break down the turnover times by operating room and by staff.  In fact, the OR had even included the data in their weekly newsletter.  And yet, turnover times had only improved marginally.  Front line staff members were still waiting for the Lean team to solve their problems.  It wasn’t until the charge nurse brought the data closer to the problem — a weekly review with key staff and anesthesia — that they made the connection between the data and the day-to-day. 

There is much evidence that the current healthcare system is in crisis. There are countless problems plaguing a system which spends too much and delivers too slowly.  A key component to transforming healthcare will be tapping into the natural problem-solving skills of the frontline workers.  Data and reports may be reviewed regularly by top leaders at a facility, however, when we move the data closer to the problems – day-to-day problems – we are closer to making lasting and necessary improvements possible.

This week’s article was written by Tom Stoffel, a director & consultant for HPP. Before joining HPP, Tom served as President of Transformation Group, Inc,. Tom developed TGI Healing Healthcare – a brand of Lean Healthcare training tools designed to share lean principles through hands-on learning. Tom has led healthcare organizations in both the development of high-level Lean Strategies down to hands-on implementation of Lean in a clinical setting. Tom has achieved the levels of Certified Lean Specialist from the Business Improvement Group and the National Institute of Standards and Technology (NIST), along with being an ASQ Certified Quality Engineer. These certifications build on an Engineering Degree from the University of Michigan. Training experience includes Lean, Quality, and Leadership Training, as well as serving as an Adjunct Faculty Member at Waubonsee Community College.

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I am the type of person that has to see something to believe it.  So for all that we have heard and seen about pending changes to the healthcare delivery system, it is hard to distinguish between fact and fiction.  In general, we can be sure of one thing:

Healthcare Organizations will be asked to do MORE with LESS.

So in searching for some clarity I headed to the true source of wisdom: the Web.  Maybe it is a sickness, but I enjoy reading complex standards and guidelines.  So I was overjoyed to stumble across all 906 pages of the Patient Protection and Affordable Care Act legislation that was enacted earlier this year by the One Hundred Eleventh Congress of the United States of America.  What I was encouraged to discover was what seemed like a ringing endorsement for pursuit of an improved healthcare delivery model (a.k.a., a Lean Healthcare Delivery Model). 

What?  You missed it?  How could you?!?  It was clearly stated in Sub Title F, Sub Part II, on page 390.  Maybe you didn’t get that far.  A summary of the text is included.  There are a couple of key points in the legislation which are truths — regardless of the direction the government goes:

1. We need to work on the healthcare delivery system to “Identify, Measure, and Improve.”  Maybe the answer is not going to be Lean Healthcare for all organizations, but it is the best set of tools and philosophy to develop lasting improvements.
2. We have to transform the “culture and system design of healthcare organization[s].”  Lean Healthcare addresses both the necessary improvements, and the underlying culture of the healthcare delivery system.
3. We need to consider “sustainability” of our results.  Sustainability holds a direct correlation with Leadership development.  Organizations that are only conducting improvement activities and NOT addressing the Leadership Development aspects of a full Lean Healthcare transformation will not be able to hold long term gains.

If you don’t believe me, you can check it out for yourself.  All 906 pages of the Act are posted here.

This week’s blog was written by Tom Stoffel, a Director at HPP. Before joining HPP, Tom Stoffel served as President of Transformation Group, Inc,. Tom Stoffel developed TGI Healing Healthcare – a brand of Lean Healthcare training tools designed to make lasting improvements. With over 10 years of continuous improvement experience, Tom has helped hundreds of organizations make lasting improvements. He has developed an excellent working knowledge of Lean practices and principles by working with a diverse client base – Fortune 100 companies down to less than 15-employee manufacturers. In the healthcare environment, Tom has led healthcare organizations in both the development of high-level Lean Strategies down to hands-on implementation of Lean in a clinical setting. Tom has achieved the levels of Certified Lean Specialist from the Business Improvement Group and the National Institute of Standards and Technology (NIST), along with being an ASQ Certified Quality Engineer. These certifications build on an Engineering Degree from the University of Michigan. Training experience includes Lean, Quality, and Leadership Training, as well as serving as an Adjunct Faculty Member at Waubonsee Community College.

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I have seen a shift over the past year in the discussions  that I have with Healthcare leaders.  We are facing considerable financial pressures in the Healthcare Industry  today – increased demand on an already overburdened system with skyrocketing technology costs.  With well documented results from Lean Healthcare implementation around the world, leaders are taking into consideration the time tested philosophy and methods of Lean.  However, leaders are increasingly concerned with one question – What will my Return on Investment (ROI) be for Lean Healthcare implementation? 

First, let’s start with the basics.  Without spiraling into a discussion of Net Present Value (Google it if you don’t know about NPV), the textbook method for calculation of ROI would look like this: 

(Profit – Investment)/ Investment

It simply answers the question of will we make (or did we make) money on an investment.  It can be used when making business decisions such as whether to purchase a new piece of equipment.  Will it make us more profit than it costs us?  Or in other words, what is the Return on Investment?

However, ROI calculations for Lean Implementation can be incredibly complex because of the many variables on both the Profit and the Investment (expense) side of the equation.  In healthcare organizations, employee expenses (fulltime and supplemental labor) make up a significant percentage of the expense side of the equation.  In fact, full time and contract labor can make up between 50 – 60 percent of a hospital’s expenditures. 

Hospitals under considerable financial strain have traditionally looked at their largest expense category, labor, to identify savings.  With a short-term focus on cash, organizations may be cutting short the true benefits of Lean Healthcare implementation.  For example, under a Lean Healthcare program we look to identify and eliminate wasted time, effort, and resources.  The CFO rightfully questions,”Where are my savings? “  Unfortunately, it is not that easy.  I have reviewed many healthcare income statements and have yet to see where “wasted time” is captured on the current list of expenses.  Waste is hidden.  It is woven into the fabric of the organization.   So if waste is eliminated, where can we carve out savings from the P&L?  No savings = no ROI, right?

Not so fast.  A long-term view of Lean Healthcare implementation would see that additional service growth can only come from additional capacity.  By eliminating wasted time, effort, and resources through Lean Healthcare, we effectively increase an organization’s capacity.  In fact, it is the lowest cost capacity because we are already paying for it!  If we can do more procedures with the same staff without people feeling like they are working any harder, then we can show significant returns on the waste elimination efforts.  Service is better, patients are happier, and profits grow with increased volume flowing through the existing cost structure.

This week’s article was written by Tom Stoffel, a director & consultant for HPP. Before joining HPP, Tom served as President of Transformation Group, Inc,. Tom developed TGI Healing Healthcare – a brand of Lean Healthcare training tools designed to share lean principles through hands-on learning. Tom has led healthcare organizations in both the development of high-level Lean Strategies down to hands-on implementation of Lean in a clinical setting. Tom has achieved the levels of Certified Lean Specialist from the Business Improvement Group and the National Institute of Standards and Technology (NIST), along with being an ASQ Certified Quality Engineer. These certifications build on an Engineering Degree from the University of Michigan. Training experience includes Lean, Quality, and Leadership Training, as well as serving as an Adjunct Faculty Member at Waubonsee Community College.

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I am not sure about you, but around our house, we enjoyed watching the “Undercover Boss” television program.  Because my world is filtered through Lean eyes, I am sure that I enjoyed it for different reasons than some.  If you did not get a chance to see the show, I can summarize it for you quickly.  A top-level executive dresses down and “applies” for a job at his/her own organization.  I believe that the show uncovers a couple of simple truths that we can all stand to learn and apply in our Lean Healthcare journeys.

The first truth that I found amazing was how many times an executive could go into their own organization without being recognized.  I know that in a large organization, not everyone is going to spend time with the C-suite.  However, it was common for the undercover individuals to not be recognized by a whole store or division of their own companies.  It made me wonder if these leaders ever left their offices.  One of the few Japanese terms that has carried over into Lean Healthcare vernacular is used to describe the area where the work happens, or “Gemba.”  One of the significant challenges for healthcare leaders is getting out of meetings and into their healthcare organizations to meet with staff and patients. In a Lean organization, we work with leaders to go to Gemba.  The currency of leaders is T-I-M-E.

The second truth that was fun for a Lean Healthcare geek was to see the executives learning how things truly work in their own organizations.  The undercover bosses would work side-by-side with employees and learn the true challenges related to the work. Often times the leaders would see how their decisions were or were not communicated down through the organization.  However, this skill should not be limited to going undercover.  As a leader in an organization, problem solving is a significant part of the job.  As part of Lean Healthcare leadership coaching we teach leaders a simple three step process: Let’s-Go-See.  Go see how work happens, how problems look from the patient’s perspective, how staff understands mission and vision. 

This week’s article was written by Tom Stoffel, a director & consultant for HPP. Before joining HPP, Tom served as President of Transformation Group, Inc,. Tom developed TGI Healing Healthcare – a brand of Lean Healthcare training tools designed to share lean principles through hands-on learning. Tom has led healthcare organizations in both the development of high-level Lean Strategies down to hands-on implementation of Lean in a clinical setting. Tom has achieved the levels of Certified Lean Specialist from the Business Improvement Group and the National Institute of Standards and Technology (NIST), along with being an ASQ Certified Quality Engineer. These certifications build on an Engineering Degree from the University of Michigan. Training experience includes Lean, Quality, and Leadership Training, as well as serving as an Adjunct Faculty Member at Waubonsee Community College.

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You have probably heard the phrase – a picture is worth a thousand words.  It is certainly quite true.  Trying to describe a situation or improvement during a Lean Healthcare kaizen event is much easier through pictures.  The Lean tool of visual controls leverages this principle by clarifying through use of pictures.  However, just as Yogi Berra states, “You can observe a lot just by watching”.  While a picture is better than words, nothing beats seeing it for yourself. 

I was reminded of this last week during my first visit to London, England.  I had seen pictures of the famous sites, but was blown away in my short visiting time squeezed in between Lean Healthcare work.  Nothing will replace the memories of seeing Trafalger Square, Big Ben , and London Tower with my own eyes.  I tried to bring back pictures to describe the experience to my family (who did not accompany me on this trip).  However, I could not muster the emotion of the experience through my iPhone photo gallery. 

This principle applies equally to the Leadership teams that we coach during a Lean Transformation engagement.  It was telling this week to hear a team member from a Kaizen Event Team say how refreshing it was to see a hospital “O” on the floor during improvements.  It is easiest to truly understand the care being delivered to patients by watching it happen.  Getting leaders out of offices and into “gemba” (Japanese for actual place) is a key component of Leading in a Lean environment.  You might find you can observe a lot just by watching.

This week’s article was written by Tom Stoffel, a director & consultant for HPP. Before joining HPP, Tom served as President of Transformation Group, Inc,. Tom developed TGI Healing Healthcare – a brand of Lean Healthcare training tools designed to share lean principles through hands-on learning. Tom has led healthcare organizations in both the development of high-level Lean Strategies down to hands-on implementation of Lean in a clinical setting. Tom has achieved the levels of Certified Lean Specialist from the Business Improvement Group and the National Institute of Standards and Technology (NIST), along with being an ASQ Certified Quality Engineer. These certifications build on an Engineering Degree from the University of Michigan. Training experience includes Lean, Quality, and Leadership Training, as well as serving as an Adjunct Faculty Member at Waubonsee Community College.

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While many organizations have begun to look at Lean Healthcare as a strategy to improve the overall business case, the long term benefits of Lean remain elusive to many organizations. Many groups simply look at Lean Healthcare as the application of tools to identify and eliminate waste. However, the true benefits of Lean come through the shift in thinking which comes from leading an organization into a new way of thinking.
 
As organizations begin to bring Lean Healthcare into the organization, many look at the simple application of Lean Tools (Kaizen, 5S, Standard Work, etc). Some institutions are looking for the “recipe”. Those leadership teams that suggest “Go make my teams Lean out their processes.” Somehow, in this version, Lean becomes a verb and there is a switch that we are supposed to flip which will make the organization’s processes more effective.
 
While the application of Lean Tools is a key component of a Lean Healthcare Transformation, there is much more to becoming “Lean”. There is a shift in thinking required for organizations to truly realize the long term benefits of Lean Healthcare Transformation. The shift in thinking is very dramatic for some organizations. We must begin to regularly expose and solve problems. While we may be able to harvest some early wins by finding low hanging fruit within the value streams of the organization, true benefits come from the systematic identification and elimination of waste from the entire facility. Waste needs to be exposed through visual controls and metrics. Improvements need to be made through leveraging the Rules in Use. Leader Standard work needs to develop accountability and disciplined adherence to the process.  If the steps described here are already in place in your organization, great. If what I mentioned in the previous couple of sentences sounds like a foreign language, find a coach. Lean Healthcare Transformations require a new way of thinking.
 
This week’s article was written by Tom Stoffel, a director & consultant for HPP. Before joining HPP, Tom served as President of Transformation Group, Inc,. Tom developed TGI Healing Healthcare – a brand of Lean Healthcare training tools designed to share lean principles through hands-on learning. Tom has led healthcare organizations in both the development of high-level Lean Strategies down to hands-on implementation of Lean in a clinical setting.

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