Lean Healthcare Exchange

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Steve, a Lean healthcare facilitator in a hospital I recently worked in, always starts his training the same way.  Everything has to be organized and laid out just the way he wants it—neat and in order.  It became very clear to those who participated in any of Steve’s training and coaching sessions that they were in for a treat.  His impeccable organization skills and his high energy, along with his charming and witty personality, added an extra element to learning and made the engagement more interesting.  I always looked forward to seeing what trivia, trick, theme or curve ball Steve had added to the training to get the participants thinking and seeing the big picture.  When listening to Steve from the back of a room, I couldn’t stop smiling at Steve’s development into someone who is one of the new leaders and champions for improving patient care in his organization.

It was 18 months ago when I first met Steve.  At first he was very soft spoken, shy at times, and very critical of himself.  It was evident that he was a perfectionist and you could see that his biggest fear was to fail or look like he didn’t know what he was doing or talking about in front of his peers.  The question that Steve often asked me was, “Alex, when do you think I will be ready?”  I would always respond, “Sometimes your best teacher is just going at it on your own. You have a lot of the right knowledge and mechanisms, not to mention your heart is in the right place.”

“Am I ready?”  It’s a question that most facilitators have asked themselves at one point or another.  I know I did, and I’m still learning and discovering new methods that help me develop my own Lean healthcare facilitation skills.

I often see organizations get caught up in relying on “the expert” and no less.  Experts are needed on some occasions to drive key operational functions of the organization.  A Lean facilitator must have experience, however, I believe that one can enhance skills and make improvements with guidelines from a coach.  At one time or another, most facilitators, coaches, and teachers started with a coach of their own, someone guiding them (For more on coaching, read The Blind Spot).

Many traits and skills must come together to create an effective Lean facilitator.  Danny Beckett, Jr., entrepreneur and start up blogger, outlines a list of successful facilitator traits in his article 6 Tips for Being a Good Facilitator:

GOOD FACILITATORS ARE EXPERTS AT:

1. Stimulating discussion
2. Generating ideas
3. Fostering curiosity and excitement
4. Simulating dialogue
5. Separating neutrality from passivity
6. Producing outcomes
7. Listening, listening, listening

I agree with Beckett’s list and would like to add a few applications specific to facilitating a Lean healthcare rapid improvement project:

Keep the team focused on the scope:  Don’t get caught up in someone’s issues or agenda.  The focus should be and only be about improving patient care and the patient experience (Remember the lesson of “Defective” Facilitation.)

Don’t talk too much: This is hard for me sometimes. Talking too much sometimes seems like you’re pushing your solution to the team.  The goal for you, the facilitator, is to coach the team towards finding their own solutions and process improvements—not to mimic yours.

Learn the tools and material:  You don’t have to be an expert on every tool and topic, however, be knowledgeable and share your own experience with the team.  I often see this one overlooked.   I’ve heard, “Alex, if I see it once or twice then I can do it.”  Really?!  What about, “I have done it 10-15 times and I’m still learning.”  I can still hear my college coach saying, “Learn something new today, study it after practice, implement it on Saturday, and review and celebrate on Sunday.”  Again, you don’t have to be an expert.  Never stop testing new possibilities and ideas.

Stop sand bagging:  I’m not saying you have to be hard on yourself or the team.  However, we tend to often leave opportunities and better outcomes on the table.  Caving in to your environment can lead to okay results and not great results.  Coach and provoke positive thinking so the team and organization can test new possibilities and create high standards.  Don’t get stuck on good enough or benchmarks, it will only result in being as good as everyone else and not setting yourself apart.

Three months ago I said my goodbyes to Steve, not for good, but for now.  I sat in on a rapid improvement team’s  report out and saw someone bursting with confidence.  Little rattled Steve, no matter what the questions or challenges the audience asked him or the team, had a plan or answer for each one.  He was also confident to say “we don’t know” if something was asked that was not covered during the week.  It was very clear to everyone that the process was 100 percent better now that it was on day one.

Steve didn’t know everything about Lean or if he was going to be a great facilitator and he definitely made a lot of mistakes along the way.  What you could see in Steve is that he has moved from one level of performance to a level where the organization depended on his knowledge.  My last question to Steve was, “So, Steve, when did you know that you were ready?”  He looked at me with a corny smile.  “I’m not sure Alex!  That’s not my focus now. I’ll just keep doing and learning.”

In Lean healthcare you don’t have to become the smartest person in the organization, gain multiple graduate degrees, or become an expert with every tool and process.  Start learning something new today, practice it, implement it, and then observe the patients benefiting from it.  Oh, and don’t forget to celebrate!  So when are you going to be ready?

As a follow up to this post, John DeVries’ article, How to Eliminate Predictable Post-Event Disagreements will post on the LHE.com on Tuesday to continue this series on effective Lean event facilitation.

Today’s blog was written by Alex Maldonado, a Senior Manager with HPP.

Alex’s professional experience includes process improvement, operational, and leadership positions in the medical delivery systems and appliance manufacturing industries with Baxter Healthcare and Whirlpool.  Alex has had a successful track record in improving results-driven processes with an emphasis in personnel training, project leadership, and operating systems designed to improve customer service and sustainability.  He has led the development and implementation of processes to support Lean initiatives that reduce critical path lead-time, reduce expediting costs, capital improvement projects, inventory reduction, and trained and educated staff/employees in Lean Methodology.

Alex has a B.S. in Industrial Technology Engineering from Mississippi State University and has also completed the Six-Sigma black belt program.

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How many Kaizen events should we do per year?  Is completing 5 A3’s per week enough?  What areas should we focus on?  Should we do multiple quick wins and see what happens?  What approach should we use to communicate to our staff that this is the new vehicle the organization has decided to continue with improving the system?  When will we know that we are there or that this new philosophy and way of thinking is working and making a difference?  What’s next?

These are common questions I often hear or get asked from organizations that have done a number of lean activities and are starting on their own with lean healthcare.

As we say in six sigma “It depends”…  Yes! It really depends on many things.  It depends on what your organization wants to accomplish and needs to accomplish.  There are many questions that you can ask about your healthcare setting and team to form your lean roadmap.  What is the scope, and what are your outcomes and expectations?

• How mature is your culture to new ways of thinking and at what speed can these principles be digested and implemented?
• What tools and metrics are you currently using to guide you to process improvements and do they fit the issue to outcome?
• Do we really know and are we honest about our strengths and weaknesses as an organization?
• What was good and what could have been better about the last several KPI?
• What’s the level of commitment and accountability?
• Are your lean engagements and activities aligned to your yearly business case?
• Where should your organization be now and where should it be 1, 3, and5 years from now?

There’s no lean-o-meter or recipe out there that will clearly tell you that you need x number of Kaizen events per year, or this and that number of lean activities per week, month, and per year.  When determining what your facility needs are, always remember that you can apply LEAN in your organization.

Leadership:
Most things start and end with leadership.  A ship never sails without a captain.

Eliminating Waste:
Focusing on the things that adds no value to patients, staff, physicians and the system as a whole.

Acting Now:
Yes! Take action now… Some issues don’t need a committee or another meeting to be solved.  Patients and staff experience and see it every day.

Never ending:
Meeting or exceeding the benchmark should not be your only goal.  Nature never stops changing and adjusting to survive.

This is an individual process for each organization.  If you can answer these questions truthfully and apply the LEAN principles, you will have your individual roadmap or recipe for success with lean.

Today’s blog was written by Alex Maldonado, a Senior Manager with HPP.

Alex’s professional experience includes process improvement, operational, and leadership positions in the medical delivery systems and appliance manufacturing industries with Baxter Healthcare and Whirlpool.  Alex has had a successful track record in improving results-driven processes with an emphasis in personnel training, project leadership, and operating systems designed to improve customer service and sustainability.  He has led the development and implementation of processes to support Lean initiatives that reduce critical path lead-time, reduce expediting costs, capital improvement projects, inventory reduction, and trained and educated staff/employees in Lean Methodology.

Alex has a B.S. in Industrial Technology Engineering from Mississippi State University and has also completed the Six-Sigma black belt program.

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I have come to believe that one of the most important expectations for patients and patients’ family members is information.  During observation and coaching sessions I often ask the team to note the number of times they observed or heard the following:

“Nurse, where is my doctor?”
“Where are my meds?”
“When will I see someone? I have been waiting a long time.”
“When can we go?” 

These questions, along with family members just looking for an update on their loved ones’ outcomes, can become lengthy at times.

To begin, I ask the team to compile the list.  After compiling and prioritizing the list, I challenge them to improve or eliminate 10 percent of the list and develop a plan of action based on what remains.  This challenge is often met by strong resistance, similar to pushing on a massive boulder that isn’t going to budge.  Then I ask them to improve or eliminate one more item from the list.  I follow up by asking the team, “What’s holding us back from eliminating this request from the list of patient questions?”

I hear, “Well you see Alex, the staffing metrics are not correct,” or, “I often wait on my patient’s meds, lab results, physician’s orders, and I often search for equipment or supplies, there is poor communication between departments,” or, “ I’m often searching for charts and when we find them there’s a lot of documentation to do.”  A new list is then created from the first list. In Lean Healthcare we sometimes call this exercise the “5 Why’s.”  Sometime the above list does cause errors and poor quality outcomes, and often, patient dissatisfaction.

Okay, team, let’s focus on the small rocks that we can move, and start from there…

The Challenge:

We all agree that meeting patients’ requests or exceeding their expectations is only one of the outcomes we are charged to deliver.  However, for patients and patients’ families, sometimes information or updates of where they stand in the process is all they really want. 

Increasing caregiver time with the patient is the challenge; the solution should be created and molded in the daily fibers of every member in the organization.   

Some methods and tools that can be applied and used:

• Visual controls
• Align staffing metrics with daily tasks and demands
• Exceptional shift and ongoing hand off
• Support by external departments on the unit goals
• Make everyone aware of expectations through clear communication, including external supporting departments
• Increase staff involvement and support – physicians, nurses and others
• Implement daily “Gemba walks” by leadership – rounding with a purpose
• The ship must have a captain at all times:  A unit coordinator that insures all the pieces are moving, correct, and complete when needed.
• Take small but key countermeasures to eliminate waste as it happens.

The Goal: Increase caregiver time with patients

The Result:  Everyone wins!

This week’s blog was written by Alex Maldonado, a Senior Manager with HPP.

Alex’s professional experience includes process improvement, operational, and leadership positions in the medical delivery systems and appliance manufacturing industries with Baxter Healthcare and Whirlpool.  Alex has had a successful track record in improving results-driven processes with an emphasis in personnel training, project leadership, and operating systems designed to improve customer service and sustainability.  He has led the development and implementation of processes to support Lean initiatives that reduce critical path lead-time, reduce expediting costs, capital improvement projects, inventory reduction, and trained and educated staff/employees in Lean Methodology.

Alex has a B.S. in Industrial Technology Engineering from Mississippi State University and has also completed the Six-Sigma black belt program.

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One of the most common observations I make just about everywhere that Lean Healthcare takes me is how often patients are not ready for procedures.  If I could open a hospital’s rooftop like a can of sardines and just observe patient movements, staff workflow, and all the activities needed for patient care, I would. I would see how work is performed, communication is carried out, supplies and materials are handled, how areas are managed and how improvements are made.  I think patients not being completely prepped for a procedure would be at or near the top of the list.  Here’s a recent real example I experienced:

Gloria: We received a call from this department five minutes ago notifying us that a patient is ready for us to start their procedure.  Guess what—the patient was not ready!  I spent three minutes walking to their department, two minutes talking to them about the patient, and three minutes walking back to our department empty handed.   Not to mention the wasted time it took for all the multiple calls between the two departments.  As you can see, Alex, this really frustrates everyone involved.

Alex: So, what are you going to do next?

G: Well, we can start another procedure or wait until the patient is truly ready.  But if we start another patient it will push this procedure to a later time.  Then they will blame us that we’re the ones who aren’t ready and that we are the ones who are causing all the delays.

A: How often does this happen?  And what are the common reasons for a patient not being ready?

G: Patients not being ready is a daily issue, but as far as the reasons, well, it ranges from not being able to find a patient chart to incomplete chart information or even wrong information.

A: So, Gloria, can you tell me what the process is?

G: We should call them when we’re ready for a patient; we normally call them after the procedure is complete to let them know that we are bringing the patient back.  We waste everyone’s time on a daily basis and it just really frustrates the staff and the working relationship.  Physicians are screaming at us, wanting to know if orders have been completed.  Not to mention, the patients are waiting for value added work to be performed.  I have seen patients wait as little as 25 minutes and as much as 2 hours or more.

A: So what does “ready” really mean?

G: I guess different things to different people.

A number of things pop in my mind as I listen to Gloria.
• How long has this issue or breakdown been going on?
• What is the real standard work and is the standard work clear and understood by both departments? 
• How much time is wasted in a week, or year, for both departments?
• What are the current satisfaction scores for patients, staff, and physicians?
• Why hasn’t anyone solved these obvious issues?

Gloria and I sit down and start discussing plans and brainstorming ideas for the next Lean activity.

Alex: Let’s start identifying the key people from each area first. Everyone’s input and voice is key for this improvement.  Gloria, I will start with the following questions:

1. Do you have a standard for this process, Yes or No?
2. If Yes, do the staff members deviate from the standard? (If you don’t have a standard, then we will create a standard.)
3. What visual tools do you currently use to indicate when, who, what, and how to perform work? (It should indicate that I need to do “this,” next, or if what I’m doing meets the standards all at a glance.)

Next, let’s look at the Four Rules-in-Use:
4. Are the activities in sequence, timely, at the proper location, and providing proper outcomes?
5. Are the connections made in a direct manner with a consistent pace?
6. Are the pathways simple and clear, with no looping or forking?
7. What improvement methods do you currently use to solve problems?

Finally, Gloria, in order for Lean Healthcare to work, we need to highlight the true value for this improvement and the opportunities it can have on the overall Business Case. I’m talking about the impact it can have on Satisfaction (everyone involved), quality outcomes, potential time improvement, and potential financial benefits.  You know what that means.
 
Gloria: Yes! We will have to measure the process and continue to measure them.  Put miter gauges, so to speak, to see what’s working or what needs adjustments.

A: Very good, Gloria!  There are many ways and many tools in Lean Healthcare we can use to solve these issues.  I know that you want for this particular issue to go away “yesterday” and be fixed permanently. However, let’s start with what we know and what we need, fixing and improving one “why” at a time.

G: So, Alex, why do you think that no one has fixed this issue?

A: I am not sure, Gloria, but we need to let everyone know the true pain the current state is causing and the true potential impact it can have on each individual involved in the processes and on the organization as a whole.

G: The patients are definitely ready for us; that’s why they are here.  We just need to be ready for them at all levels.

This week’s blog was written by Alex Maldonado, an associate with HPP. Alex’s professional experience includes process improvement, operational, and leadership positions in the medical delivery systems and appliance manufacturing industries with Baxter Healthcare and Whirlpool. Alex has had a successful track record in improving results-driven processes with an emphasis in personnel training, project leadership, and operating systems designed to improve customer service and sustainability. He has led the development and implementation of processes to support Lean initiatives that reduce critical path lead-time, reduce expediting costs, capital improvement projects, inventory reduction, and trained and educated staff/employees in Lean Methodology. Alex is well recognized in the following areas: Value Stream Mapping, Hoshin Strategic Planning, Office and Floor 5S, Total Productive Maintenance (TPM), Process Failure Modes and Effect Analysis (PFMEA), Quality Improvements and Mistake Proofing, Six Sigma, Cellular Design, Standardize Work, Pull Systems (kanb an), Equipment Design and Installation (DFLMA), and Safety Programs. He has a B.S. in Industrial Technology Engineering from Mississippi State University and has also completed the Six-Sigma black belt program.

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How many times have you heard, or said, these exact words? In my experience, this phrase begins to echo during brainstorming or when solutions are being created by a team during a rapid improvement activity.

Another common statement is, “We met, talked about some of these same issues and discussed potential solutions…”

However, nothing happened next.

I myself can recall saying the same things.  So, if solutions have been known or pointed out in the past, why hasn’t anyone solved them? Why is it taking us so long to solve them, and why does it seem that the same issues keep coming back?  A key question to ask is, “Who will start solving these issues or breakdowns that have been hanging around and are chipping away from our productivity and goals?”  Well, these are all great questions and often the solutions are not that easy.

I can remember a wonderful and talented director I coached a few years ago. Sherri was handpicked by an executive member to change things around in the department.  She was in one of my A3 classes and she was definitely a star student.  At the end of one of the sessions she invited me to tour the department.  She gave me a quick history and tour of the department and clearly pointed out processes, procedures and areas where she had led and implemented changes.

“Things are a little more stable now, however, on a daily basis it seems that I get intertwined with all sorts of fire fighting from light bulbs needing changing, to billing process with errors, all the way up to patients and physicians being dissatisfied.  It just seems that the minute I walk in those doors, I put a fire hat on, and boy, I start running.”

Sherri was a well respected leader and everyone in her department was excited to have her as their leader.  So, I looked at her and asked her with a smile, “How can I help you Sherri?”

“Well Alex, I will be honest with you, today in the A3 class I was a little embarrassed when one of my staff members brought out an issue that she has never shared with me before, but she felt very comfortable sharing it to the class.  She also added that she has been telling leadership about this particular issue for years.  She’s a great employee with great ideas and a great attitude.   I want my staff to feel comfortable to come up to me and tell me things.   I don’t want them to think or feel that I’m the same old run of the mill leader.”  I was very impressed with Sherri’s desire to win, and not being afraid to try new things. 

“Well Sherri, A3 is a great tool to use in solving issues and eliminating them, but let’s start with you.  In a way, you have become the one with all the answers, the one to go to when any issues arise no matter the size of the issues.  Everyone expects for you to fix everything every time.  For you, this will only frustrate you and eventually burn you out.  For them, they will receive very little coaching and development structure from you and both the staff and the department will never achieve and operate at their full potential.”

While there are many ways to start correcting and changing these behaviors, I got Sherri started with the following:

• Change and challenge your daily actions and activities often.  Ask yourself, ‘does what I’m doing really focus on improving patient care? Am I creating a proactive team that takes steps to solve problems as they emerge?’ Become the compass.
• You must share and communicate clearly both what the right work should be and its purpose.
• Create a simple, realistic, and manageable platform that you can review on a daily basis.
• Establish responsibility and ownership. Provide them with the right tools and training to win, but first start with one tool.  This means that some staff members will challenge your actions and decisions.
• Celebrate your wins and successes. Reward your team for their accomplishments.  Make it big and known to all.  In healthcare this is often a missed action item.

“Please remember Sherri, this is just a start.  As your team starts to function as potential championship contenders, your role will then be to create a climate where your staff’s worth is determined by their willingness to learn new skills and grab new responsibilities, thus perpetually reinventing their jobs.  The question then becomes not what they have known or what they have been saying for years, but rather how much they have improved their work for years.”

“The day soldiers stop bringing you their problems is the day you have stopped leading them.  They have either lost confidence that you can help them or concluded that you do not care. Either case is a failure of leadership.”

— Colin Powell, Ret. Gen. & Chairman of the Joint Chiefs of Staff

This week’s blog was written by Alex Maldonado, an associate with HPP. Alex’s professional experience includes process improvement, operational, and leadership positions in the medical delivery systems and appliance manufacturing industries with Baxter Healthcare and Whirlpool. Alex has had a successful track record in improving results-driven processes with an emphasis in personnel training, project leadership, and operating systems designed to improve customer service and sustainability. He has led the development and implementation of processes to support Lean initiatives that reduce critical path lead-time, reduce expediting costs, capital improvement projects, inventory reduction, and trained and educated staff/employees in Lean Methodology. Alex is well recognized in the following areas: Value Stream Mapping, Hoshin Strategic Planning, Office and Floor 5S, Total Productive Maintenance (TPM), Process Failure Modes and Effect Analysis (PFMEA), Quality Improvements and Mistake Proofing, Six Sigma, Cellular Design, Standardize Work, Pull Systems (kanb an), Equipment Design and Installation (DFLMA), and Safety Programs. He has a B.S. in Industrial Technology Engineering from Mississippi State University and has also completed the Six-Sigma black belt program.

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It’s was a typical Tuesday morning in the Outpatient Service department. By 6:30am, the staff members have already pulled the supplies needed for the day, and organized their workstations to fit the needs of the patients. Patients’ orders and schedules, which were pulled the day before, have been verified and checked for errors or to see any potential delays that might be caused by lack of information, missing information, incorrect information, or orders that needed clarification. The smell of fresh brewed coffee and the sound of the morning news broadcast put calmness in the department. Everyone seemed calm, focused, and ready to “win”.

I couldn’t help but notice that everyone first checked with a nurse named Samantha before signing off to their work stations or assigned areas. Her role seemed to be the “captain of the ship” so to speak. Like everyone else, I too checked in with Samantha. I introduced myself and proceeded in asking Samantha a few questions. She replied, “Follow me, young man, and talk to me as we walk.” Wow! I like Samantha already.

I asked her about the processes and if she could walk me through the Value Stream.

“Sure,” she said, looking at me with a smile. “You see, things weren’t like this several months ago. Our patients were complaining that they were waiting too long to get registered and processed. Things were really disorganized, the staff was frustrated, and it just seemed that we couldn’t ‘win’ on a daily basis.”

My antennas went up when I heard the word win. “‘Win?’ What do you mean by ‘win,’ Samantha?” I could tell that Samantha was well aware of all the potential breakdowns and how easily things can become undone.

“Well,” she said, “one of the first things we did was to fix the things that were very obvious and we could fix right away—the low hanging fruit. We also relied on an internal patient survey. We wanted to know what our patients were saying and where to spend our energy. Alex, please excuse me while I help this patient.”

As Samantha proceeded in assisting a patient, I started glancing around the department and noticed evidence of improvements. The one that really caught my attention was a small board that indicated each patient time from arrival to completion of registration. The board also indicated the reasons for delays, who, when, what, where, and other features that told the staff if they were winning or losing per their set goals. All this information was available at a glance. What really impressed me was the simplicity of the board. The staff updated it, communicated through it, and managed it. It clearly highlighted the areas for improvement. Very little to no technology was needed to maintain the board. No worries if someone forgot their password or the system was down, the staff just kept on marching. All that was needed was a marker and pen to generate the information to execute action.

I started having déjà vu from my many Lean events which I have facilitated and teams I have coached over the years on similar solutions and outcomes. Often in Lean Healthcare, many teams and leadership members feel or believe that the solutions will become too expensive to solve or too deep to dive into, that adding more staff would be the most helpful, or that installing the latest technology device on the market will completely resolve the issues.

While these concerns may be valid in some circumstances, in many cases the opposite situations are true. This team demonstrated that by visually posting metrics so the entire department can see where attention is needed, a target was set for each member to want to achieve the set goal. The board itself may only be a board, but the information it exposes are real issues in real time that navigate and guide the staff in which direction to shift or study the process to “win.”

“What do you think?” Samantha asked me with a confident smile.

“About what, the board or the information?” I replied.

“I mean the entire process, and especially the board.”

“I really like it, Samantha,” I said. “I’m proud of you guys for exposing the data and making the numbers visible for the entire staff to see.”

“Well, Alex,” she replied, “I will be honest with you. At first it was difficult to get the staff to see the need for posting the information and updating the board. They thought it would take more time and cause further delays in the processes by writing down information and managing the board. However, it was the only simple tool that we could try immediately and see if the changes were working or not, without adding cost and resources. We went from patients waiting an average of 22 minutes to now only waiting an average of 6 minutes. Today no one in the department has to ask another for information and data or wait for the monthly staff meeting to get this information.”

“Samantha,” I asked, “Were you and the staff a little hesitant at first about posting the data? And, was the staff worried about you posting information?”

“Yes, and yes! However, when they saw that we were acting on the issues and involving them in the improvements, and the numbers started to improve, their beliefs started to change. The board and information input is owned and managed by the staff, and in fact they have also added others’ information that they thought would be helpful and important. It did take some time, Alex, and there’s still much more to do. But you can see that some standards have been put in place.”

Posting metrics or exposing issues in the work areas can be an uncomfortable practice to do. The fear of people knowing what your breakdowns are—or that you might highlight that your department is the bottleneck in the process—is a scary thing, and you may feel that it may insinuate that you’re a poor leader. In fact, it’s a big part of a leader’s development. Samantha and her team made a decision that they were going to do everything to improve and exceed patients’ expectations.

Since then, they have not looked back.

This week’s blog was written by Alex Maldonado, an associate with HPP. Alex’s professional experience includes process improvement, operational, and leadership positions in the medical delivery systems and appliance manufacturing industries with Baxter Healthcare and Whirlpool. Alex has had a successful track record in improving results-driven processes with an emphasis in personnel training, project leadership, and operating systems designed to improve customer service and sustainability. He has led the development and implementation of processes to support Lean initiatives that reduce critical path lead-time, reduce expediting costs, capital improvement projects, inventory reduction, and trained and educated staff/employees in Lean Methodology. He has a B.S. in Industrial Technology Engineering from Mississippi State University and has also completed the Six-Sigma black belt program.

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Management of any kind can get so tied up in their job that they can overlook the foundation of their role: the people that report to them.  When we are driving to work we don’t count the houses with red roofs because we are not looking for them.  In the same way, we can forget to talk to our employees because we may not see them.  This is one of the great principles of Lean Healthcare, direct employee communication.

The employees doing the work — the nurses, unit secretaries, orderlies and others — want to hear from management and want to have contact with them.  Toyota and other successful Lean businesses have the mindset that every employee is important to the business. This contributes a lot to their success. When employees feel like they have a relationship with their management, they are more likely to be happy in the workplace. Happy workers make for a happy and more successful work environment.

So, let’s make them feel important!

Establishing more open lines of communication can become the greatest asset to eliminating waste and building trust within the organization for any manager. This strengthens a company’s overall performance and employee base.  This also increases employee satisfaction and reduces turnover.  I can remember spending hours observing a particular process in search of a root cause, yet oftentimes having a 10 minute dialogue about the process with the “experts” doing the work will have ideas and answers popping up like popcorn in the microwave.   

How do I start?  Get out of the office.  Pick one place to go and force yourself to go there.  Pick out one individual, introduce yourself and get their name and then ask the following questions: 1) How is it going? 2) What’s going well? 3) What’s your biggest problem? 4) What are you doing about it? 5) How can I help?  Start doing this once a week and then make it once per day and in time you will not only meet many employees but you will know exactly what is going on.  You will have direct contacts for communication.  These are people with whom you can now share your information about how the hospital is doing overall, what areas are strong, and where improvements need to be made. One of the biggest outcomes to this communication practice is that the staff then feels that you are truly partnering with them and their frustration and issues are being supported by upper management.

One of the hardest things for human beings to do is change habits.  A long time is spent creating habits.  A long time may be spent changing habits.  This is how we improve as managers, workers, and as humans.  We can become addicted to the desk, computer, meetings, and telephone.  Getting away from these habits can be tough but the results will be tremendous and rewarding for everyone, as well as the organization.

This isn’t a final answer.  This is a simple start to a great end.  A baby learns to turn over, then crawl and then to walk.  Changing management habits are the same way.  We are getting out of the comfort zone that we’ve established.

We all know communication is important.  And in a Lean Healthcare organization it is essential. Take a moment to reflect on how you like communication. Establishing direct communication with the people actually doing the work is so very important.  Try it, you might be surprised by what the reports and meetings you sit through are not telling you. 

“‘Management by walking around’ is hardly ever effective. The reason is that someone in management, walking around, has little idea about what questions to ask, and usually does not pause long enough at any spot to get the right answer.”
–W. Edwards Deming, “Out of the Crisis,” MIT Press, 1982

This week’s blog was written by Alex Maldonado, an associate with HPP. Alex’s professional experience includes process improvement, operational, and leadership positions in the medical delivery systems and appliance manufacturing industries with Baxter Healthcare and Whirlpool. Alex has had a successful track record in improving results-driven processes with an emphasis in personnel training, project leadership, and operating systems designed to improve customer service and sustainability. He has led the development and implementation of processes to support Lean initiatives that reduce critical path lead-time, reduce expediting costs, capital improvement projects, inventory reduction, and trained and educated staff/employees in Lean Methodology. He has a B.S. in Industrial Technology Engineering from Mississippi State University and has also completed the Six-Sigma black belt program.

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As leaders we often refer to waste as what is happening or not happening out there “The Floor”.  The key focus then becomes what processes, individual(s), or areas are in need of improvements. Although that may be true, we fail to acknowledge that we ourselves are key contributors to the creation of waste and lack of improvements.  This mind set often clouds the true understanding of what the lean principals and methodology are meant to construct.

Jon Miller, in his January post “Top 7 behaviors to change in 2010” makes a defining statement to one of the biggest obstacles to success which all of us face ourselves. As Jon puts it “The human mind is an incredibly powerful thing, the means to control which is in our hands, yet we use it to delude, divert and distract ourselves in various ways.”  Our behaviors are a clear reflection of what’s really happening or not happening on the floor.  Here are a few key personal behaviors to consider changing or improving on in the form of DOWNTIME.

Defect(s) / Error(s): Tolerating them to continue: I’m not saying that we are all ok with defects or errors, but we often see the same defects/errors over and over again.  I myself have been in the same boat. I can recall a time of being in my own department and being aware of an error for months and not acting on it in a timely manner.  In my lack of daily management and Plan Do Check Act (PDCA), I made every excuse that I had bigger fish to fry and diverted my time and energy elsewhere. It’s essential for us as leaders to lead and develop our staff and teams as problem solvers to find the root cause to these errors.  Start with one, and together with your team beat on it with no mercy.

Over Production:  This one hides very well.  It appears as if it is contributing to the overall business process and adding value for the patient and staff, when it’s really robbing time and adding potential cost from our daily work.  We as leaders must value stream our work to better understand the deeper purpose of the work we do on a daily basis. Ensuring that every valuable minute is allocated to the patients’ needs.

Waiting:  waiting for the right moment to act on improvements.  It’s never too late or too early to start with process improvements. We are often fearful to act due to the potential exposure of issues and setbacks that might surface or in some cases the mammoth that is front of us.   Waiting is often at the top of patients’ dissatisfaction list. Be the first to lead the change you want to see in your organization. This beast must be handled one lean event at a time, big or small.  

Not Clear:  I believe this is the mother of them all.  Unclear communication about where the ship is going and the purpose of the journey falls on us as the “Captain”.  Poor communication, lack of standardization, little to no visual controls, lack of team work in the department, and unclear and undefined direction as to the outcome of each process is a rust that will feast on your ships’ (organization) purpose to grow and keep you from sailing the high seas.

Transport: Walking by waste and doing nothing.  Ouch!! This one hit me hard. Within 5 minutes of the floor tour my sensei stopped me and asked me why I have failed to recognize and accepted waste as the norm. In my mind I was thinking “well this is not my area and my plate is full” but I knew better than to state such a cynical remark.  He then asked me if my counterparts did the same.  We often forget that we are all connected to the success and failure of the patient’s outcome experience.  I believe Team do should be the new theme.

Inventory:  Too much, too little, or none at all equals no control.  Identifying what staff members’ real needs are to perform their tasks with confidence and reliability each time is a measure of daily management working just in time.  Not supplying your team with the right tools, training and guidance will lead to chaos.

Motion: Convoluted process and wasteful motion.  As Jon puts it; “we may be working on the right things, however, we may be working on too many things”.  If you’re like me, sometimes I think I can work on multiple things at the same time and be very successful at them all every time.  Wrong!  Have you ever reflected on your day from the time you walked in the door till the time you made it home and asked “what did I really accomplish today?”  Well, you might think…   I took care of a lot of employee issues, made all of my meetings, responded to all my emails, took care of patients complaints, and was available to everyone if I was needed. It was a typical day at work.  So the question is, what real impact did we have on eliminating waste, building system thinking, what was the root cause of the complaints and how can we get employees to see the true value of ownership of their own processes and outcomes?  Well! This one will take time.  But here’s a small step. You must lead, act, and listen differently!  Boy, I still have some work to do.

Effective follow up of the process: Not following up on the follow up. I mention earlier that “Not Clear” was the mother of all waste; well this one is the grand daddy of them all. Leadership’s standard work includes verifying that the standards created with the team are being followed; members are not deviating from the standards, or determining if a new standard is needed.  A standard follow up also indicates that we as leaders are truly committed and have made the event and engagement a priority in our daily work.  The success of the department lies on how well we follow-up on the follow- up. 

Each time I write a post I will try to recommend a book that  might be helpful to you and your team in your lean journey. In “Results From The Heart” Kiyo Suzaki talks about building a “mini-company” within your company that can have a positive impact on employees to ultimately establish ownership of the processes and outcomes. It’s a fresh new way of thinking to find both the purpose and the meaning in the way we work and can contribute to the success of the people we lead.

Endnote: Jon Miller; from Gemba Research LLC in his January post “Top 7 behaviors to change in 2010”                                                                      

This week’s blog was written by Alex Maldonado, an associate with HPP. Alex’s professional experience includes process improvement, operational, and leadership positions in the medical delivery systems and appliance manufacturing industries with Baxter Healthcare and Whirlpool. Alex has had a successful track record in improving results-driven processes with an emphasis in personnel training, project leadership, and operating systems designed to improve customer service and sustainability. He has led the development and implementation of processes to support Lean initiatives that reduce critical path lead-time, reduce expediting costs, capital improvement projects, inventory reduction, and trained and educated staff/employees in Lean Methodology. Alex is well recognized in the following areas: Value Stream Mapping, Hoshin Strategic Planning, Office and Floor 5S, Total Productive Maintenance (TPM), Process Failure Modes and Effect Analysis (PFMEA), Quality Improvements and Mistake Proofing, Six Sigma, Cellular Design, Standardize Work, Pull Systems (kanb an), Equipment Design and Installation (DFLMA), and Safety Programs. He has a B.S. in Industrial Technology Engineering from Mississippi State University and has also completed the Six-Sigma black belt program.

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A few years ago I was discussing plans for an upcoming 5S event with an area supervisor whose department was pretty well run on a daily basis. The supervisor stopped me in the middle of the conversation and asked me the following. “What is 5S? No really, what is 5S and what will it do for me and my staff?” She continued by adding  that her time and the staff’s time was very valuable to the organization, and allocating time for an event would have to be carefully planned and defined before moving forward. She showed me all of the previous 5S training material and even stated each “S” and what all she learned from the events and other lean training. I stopped and thought for a second before responding. It was evident that the department has had some success and the tool 5S was nothing new to them. No one had ever asked me about 5S in that manner before. Most of the leaders I have talked to have heard about 5S before, and they have done an event with little to no success. I asked the supervisor if she had a few minutes to walk on the floor and I would try to show her a better example of how 5S could work. She agreed. On our way to the floor, she quickly stated the 5S (Sort, Set in Order, Shine, Standardize, and Sustain) and noted that for the most part, most of the staff had embraced the 5S tool, but there was a few who always seemed to challenge the system.

Once on the floor, the first thing I asked her to do was to walk me through the system (as it was called) on a very high level. This took less than 10 minutes.  At the end of the process, I then told her that the both of us would spend about 5 minutes observing the process and each of us would write down what waste we saw and ask ourselves what is normal and what is abnormal. After the 5 minutes, we had written down a combination of 20 items we observed and agreed that they added no value or were just simply waste. We then categorized them into the 8 waste categories. Before I could even go into discussing what 5S was and what we as a team should focus on for the event, the supervisor looked at me as if saying “Alex I get it” you don’t even have to say anything. She started pointing out and showing me the current labeling and cleaning processes, some organized shelves and rooms, tape on the floor and racks to mark where items should be or belong, and even a 5S communication board that showed the departments’ accomplishments and score trends. What she said next is what really got me thinking and excited, “We did 5S, well the first three “S’s” very well. However, we really did not set or have a solid foundation to build on.” I asked her what she meant by that. She said, “Well, we did a 5S event and then washed our hands from it so to speak, hoping everyone would follow the new changes and hoped for the best.  Some of the items we wrote down were highlighted during the 5S event. We did a poor job planning the event; in fact we called a meeting and did everything in a conference room. Alex, P for “planning to see” should be the first S and O for “Ownership” should be the last S in 5S. The event should have been clearly planned on: what will be sorted, how things should and will be straightened, how, who, and when to do shining, how to simplify the standards so defects and errors are clearly visible and noticeable, and establish an owner(s) for the new changes to ensure sustainability. If our objective from our first 5S would have focused on improving 5 key things that added value to the process and sustain them, it would have been better than changing 15 things we are not even able to follow or sustain. Five improvements are so much easier to manage and follow-up on than 15 changes. We never established owner(s) in each step of the process and I never gave them the support to become presidents of their process. If each team member, including myself, would just own one improvement and educate the others on it, we would be so much farther along.” I thought she was a little too hard on herself, but it was very clear that she wanted to move the department from good to great. We set a follow-up meeting to come back to the floor at another time to complete the planning. 

I thought about what all she had said and especially the P and O in 5S. I couldn’t have agreed with her more. 

In lean healthcare, caregivers and leaders often relay to me that during a 5S event there’s always a high level of energy and everyone feels that things are really going to change and the improvements will be sustained, just to find out that the new changes must be managed somehow and by someone. Very little time is spent and thought is given in planning the outcome of the event. In fact, I can remember a time or two were I could have done a better job at planning. My sensei once told me that he has spent more than 50 years planning and doing 5S and he is still on the 4th S (standardize). He said that 80 percent of your time should be spent planning, 10 percent should be spent executing, and 10 percent follow-up. You should think about every process as a mini company and every company has a president. This is where the ownership is established so that when one improvement is made, the outcome benefits the company and ultimately the patient as well. 

5S events should be seen and managed as eliminating defects, errors, and confusion, and most importantly be about building a lean culture in your organization, even if it’s just 1 or 5 key improvements at a time. There’s much more than just pretty labeling, tape on the floor, or getting rid of unneeded items. It’s about system thinking, and waste should have no part in it. Cultivate a plan that will set in order ownership in your 5S program that will shine throughout the workplace. 

This week’s blog was written by Alex Maldonado, an associate with HPP. Alex’s professional experience includes process improvement, operational, and leadership positions in the medical delivery systems and appliance manufacturing industries with Baxter Healthcare and Whirlpool. Alex has had a successful track record in improving results-driven processes with an emphasis in personnel training, project leadership, and operating systems designed to improve customer service and sustainability. He has led the development and implementation of processes to support Lean initiatives that reduce critical path lead-time, reduce expediting costs, capital improvement projects, inventory reduction, and trained and educated staff/employees in Lean Methodology. Alex is well recognized in the following areas: Value Stream Mapping, Hoshin Strategic Planning, Office and Floor 5S, Total Productive Maintenance (TPM), Process Failure Modes and Effect Analysis (PFMEA), Quality Improvements and Mistake Proofing, Six Sigma, Cellular Design, Standardize Work, Pull Systems (kanb an), Equipment Design and Installation (DFLMA), and Safety Programs. He has a B.S. in Industrial Technology Engineering from Mississippi State University and has also completed the Six-Sigma black belt program.

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Observation is where it should begin for any event or anyone trying to do problem solving. Often it’s one of the most crucial steps left out or paid very little attention to when trying to solve an issue. Most of us in healthcare are problem solvers, and start right away in what we believe will make the problem go away. A friend once told me that this approach is like squeezing a balloon from one end and finding that it will just pop up at the opposite end. I really don’t believe people intentionally go around squeezing balloons just to clear the problems from their area(s) or that they don’t care where it pops up. But often I see that most people really don’t observe the issues as they happen within the flow of work. Not having enough time to observe is the issue that I often hear, and observing the process is replaced by holding a meeting to discuss the solution. So why is it that we don’t do it every time an issue arises?

A question I ask when someone is describing issues about process flow is “Did you observe the process or are you just relaying what you have heard from others about the issues”. My intent is not to put them on the spot, but to see if they are closely engaged in the process. If you are closely engaged to your process and have first-hand knowledge of issues through observation, then your discussion making and the redesign work is more concrete. Observation is about learning how to make things better and not about evaluating employee’s performance. You should clearly see or hear what really doesn’t make sense in the process. Find what the bottlenecks are, and the 8 wastes should not be present in the process anywhere. Here are some tips you can use when performing an observation:

• Let area staff members know what you are doing and ask for their input.
• Observe and listen first before writing things down.
• Find what safety and quality opportunities need attention immediately.
• What visual controls are needed or need improvements?
• How request for service and the delivery of the service takes place?
• Is standard work in place or followed?
• Ask and observe what frustrates staff members on a daily basis.
• Who or what is making decisions for smooth flow?
• Teach others to observe.

Continually honing in on the process to see what other waste can be removed is important. Once the process is standardized and clear and you have achieved the outcomes, make sure you measure it. Making observation and data collecting part of your daily problem solving will construct a solid sustainable platform where you can at a glance see opportunities and not issues.

This week’s blog was written by Alex Maldonado, an assoicate with HPP. Alex’s professional experience includes process improvement, operational, and leadership positions in the medical delivery systems and appliance manufacturing industries with Baxter Healthcare and Whirlpool. Alex has had a successful track record in improving results-driven processes with an emphasis in personnel training, project leadership, and operating systems designed to improve customer service and sustainability. He has led the development and implementation of processes to support Lean initiatives that reduce critical path lead-time, reduce expediting costs, capital improvement projects, inventory reduction, and trained and educated staff/employees in Lean Methodology. He has a B.S. in Industrial Technology Engineering from Mississippi State University and has also completed the Six-Sigma black belt program.

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