Richard P. Shannon, MD, is the Frank Wister Thomas Professor of Medicine at the University of Pennsylvania School of Medicine and Chairman of the Department of Medicine. Although he was trained as a traditional academic cardiologist, Dr. Shannon is now best known for his pioneering work in reducing health care–associated infections, first at Allegheny General Hospital and now at Hospital of the University of Pennsylvania. Since he is one of the first chairs of a major academic department whose career has focused on quality and safety improvement, we asked him to speak with us about safety in academic medical centers.
Information from Agency for Healthcare Research and Quality, 2010.
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.
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.
Seldom if ever do we recycle our newsletter material. We want to keep our newsletters both fresh and innovative. But, this week we couldn’t resist, plus we’ve added over 3000 subscribers around the world since our last release of this article. I’ve had a number of conversations this past week at various sites about COW’s. You know, those computers on wheels. I thought we’d re-run a popular article from a couple years ago and republish it, which takes a humorous but oh so true look at this subject. Enjoy! And, don’t forget to join us in Nashville on May 18th at Belmont University for our National Lean Healthcare Powerday. Slots are limited and are going fast, plus we anticipate the event to be sold out. Charles Hagood, President of HPP, Inc.
“Tech support, this is Alex,” he answered, sipping his mocha double latte.
“Hello Alex, this is Hazel up on Cardiac 6 West. We have a dead COW up here.”
“A dead COW?!?!” he sputtered.
“You know, COW, Computer On Wheels. They were supposed to help us monitor meds.”
“Sorry, Hazel. I’ve been in tech support for seven years and just got into healthcare. I have never heard a computer called a COW! But anyway, what can I do for you?”
“I told you it was dead.”
“OK, let’s see here,” as he pulled up the troubleshooting guide for the MCD/Mobile Computing Device, thinking to himself, “Why can’t we at least use common terminology?”
“Let’s see…are you plugged in or mobile?”
“I would say mobile right now. Before you get started, let me tell you that we know the script for restarting these things. Restarted the application, check. Plugged it in (the battery might be low), check. Tried to repair the wireless connection, check. Disabled and re-enabled the wireless manager, check. Rebooted from complete power down, check.”
“Great, did you…”
“Did you know I can go get vitals and chart them quicker than I can do all this stuff? I AM a nurse! Can you assess a patient, start an IV?”
“Uh, no. What else did you do?” Alex asked tentatively.
“Well, I pretty much exhausted MY tech support skills, so I fell back on my nursing skills.”
“Yep, I pulled a saline IV and started a drip.”
“On the computer?”
“Yep, stuck it straight in the USB port. That didn’t help much, so Karen and I decided to call a Code.”
“Yep, Code Blue. Cardiac arrest. We grabbed the defibrillator and shocked it three times to restart the CPU. That’s when it started smoking.”
“Yep, after the third one we heard a loud POP. So I tried manual compressions on the keyboard. We worked for 30 minutes right there in the hall before we stopped. So now we have a dead COW… and a bunch of exhausted nurses—we did everything we could. Probably even broke the cart.”
After a long pause, Alex offered, “Uh, let me get my supervisor.”
From a lean healthcare perspective, clinicians fighting technology creates waste. Patients wait. Staff members get frustrated taking valuable time (and mental focus) away from providing patient care.
Is “support” a verb in your organization? Does the technology support the caregivers and their work? Or does the caregiver become “tech support” (a noun) instead of caring for patients? Ask yourself these questions the next time you are out on a gemba walk.
This week’s blog was written by Richard Tucker. Richard is a Director with HPP and has served as a coach, facilitator, and project manager for healthcare clients in the training and implementation of Lean Healthcare Tools and Methodologies. Prior to joining HPP, Richard had over sixteen years of business and industry experience in operational and leadership positions. With his work in healthcare, Richard has lead teams in the utilization of lean healthcare tools to eliminate waste, giving back precious time to the front line caregivers to focus on their patients. One project eliminated over 2 miles of walking (and one hour of time) per nurse each shift by relocating frequently used supplies closer to the point of use. A critical care team standardized the care of central line catheters to significantly reduce blood stream infections and improve staff satisfaction with the new process. 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 Course. 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.
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.
Please take a few minutes to view this Teachable Moment, connecting you directly with the daily work of clinical champions. Like most of us involved in quality improvement and healthcare reform, you can get immersed in large data sets, randomized trials, flow charts, projections and theories. Our journalistic sources of information reinforce this.
We are removed from frontline teams making breakthroughs. As a result, these small discoveries don’t spread and inform others nationally and even globally.
We’ve created a series of Teachable Moments to inspire you with the work of real clinical champions as you pursue your own contributions to health reform. Hopefully, these new ideas will motivate others to explore the frontiers of discovery. Just click the link below and spend a moment at the frontline.
Karen Wolk Feinstein, PhD
President and Chief Executive Officer
Pittsburgh Regional Health Initiative(PRHI)
Below is a commentary that speaks to the power of Lean Healthcare, Kaizen, and having a strong facilitator to drive rapid process improvement and deliver results. I hope it resonates with you.
While the week is still “fresh” in my mind I thought I’d write you a note, including some of my perceptions after the Kaizen event week. As you may or may not know, I took the position of Chief Operating Officer of our Behavioral Health Campus in February, 2007, so have been here 15 mos. The campus continues to be in transition from the acquisition by a proprietary healthcare company of a faith-based, non-profit hospital. This explains some of the resistance to progress over the last three years. Many of our long-term staff continue to grieve what was, even in the face of much needed change.
The Options Dept. is the Department most likely to contribute to either the success or failure of this organization going forward. It is ripe for change and its new manager needs support as she executes the necessary changes. This Lean Healthcare event lent great support to her. The Options staff selected to participate are staff with significant personal power in the department so the selection was strategic.
I was initially cautious about enthusiastically embracing this event, for fear it would be a “flash in the pan” of yet another aborted start of something good, or fail to follow-through with the work necessary to assure its success.
What I found the first day was a facilitator highly skilled in leading groups, operationally knowledgeable about the “mechanics” of the process, an excellent listener, and an empowering leader with a sense of humor, timing, focus and a drive toward time management and outcome. He was direct in his feedback, honest in his criticism (which was always constructive), and unafraid to call us on a less than helpful dynamic.
As the administrator of newly acquired hospital, I feared the cost/benefit ratio might prove to be less than I hoped for. I was delighted and surprised! Not only was our department united, but the relationship-building with the emergency department was well on its way to healing by the end of the week. The “hands-on” approach to quickly trying a new idea, rather than creating a week of theoretical, but untested constructs, made a believer out of me!
I came to the hospital this weekend and was anxious to see if the new board in Options was being used consistently and if there was “ownership” by the Options staff in the new process. I received a thank-you note from one of the participants who was also working this weekend. In his email, he thanked me for allowing him to participate in the process. I can’t wait for the 30-day return to evaluate progress made and explore additional opportunities to improve the department. I believe that the Kaizen event has allowed this department to become “unstuck”, physicians to become engaged in the admissions process, and that the outcomes will have measurable volume and revenue gains.
Thank you for providing this exceptional experience.
This commentary was written by Kay Delage, Chief Operating Officer at Skyline Medical Center located in Madison, Tennessee. Skyline is a part of the TriStar Division of Hospital Corporation of America. Kay holds both Bachelor’s and Master’s degrees in Nursing and has 27 years of behavioral health experience as a nurse, Director of Nursing, Chief Executive Officer and Chief Operating Officer.
2008 Art of Innovation Award
3rd Annual Lean Healthcare Conference
April 21-22, 2008
Don’t miss the opportunity to nominate your organization (or an individual) for the Art of Innovation Award at this year’s Lean Healthcare conference in Denver.
Recognition for efforts to improve is sometimes overlooked in the “busy-ness” of daily work. Please take a few moments to reflect on the good endeavors of your teams and submit a candidate!
A panel of judges will review the nominations and choose one healthcare organization or individual to be recognized at the conference for their creative and diligent applications of Lean methodologies. The selection is based on the overall efforts of the organization to improve healthcare delivery and the description of one Lean activity that exemplifies their work.
A lovely piece of art from a local Colorado artist will go home with the honoree. Make your nomination on line today at:
The deadline for this year’s entries is April 1st, so don’t miss this chance to see your nomination in the spotlight!
Cindy Jimmerson, President of Lean Healthcare West
It was George Carlin, the irreverent comedian of the 60’s and 70’s who said “Just because the circus has left town it doesn’t mean the monkey is off your back!”
In many ways, process improvement is the same way. When an initial effort begins to change the way organizations do business, there is normally a lot of fan fare and excitement. In some ways, it becomes the “flavor of the month” and will fizzle out unless an organization can keep the “monkey” visible.
At Sumner Regional Health Systems, a dedicated staff member of Value First (SRHS’s in house process improvement program that utilizes lean principles taught by HPP) continues to ask 4 basic questions in order to uncover improvement activities:
1. What matters most to your next in line customer and why is that important? (Your purpose)
2. What stops you from achieving your purpose?
3. What do you need to achieve your purpose?
4. How can you measure how well you achieve your purpose?
These 4 questions provide the basis or blueprint that identifies a process to be changed, the barriers that are present, solutions to remove the barrier and measurements for effectiveness.
Without an answer to each of these questions and continual prodding by more dedicated staff members, process improvement cannot be sustained once the circus has left town. The monkeys will always be there but a smart leader learns to manage the monkeys to keep them off their back.
This week’s blog was written by Monte Wright. Monte is the Value First Coordinator at Sumner Regional Health System in the Nashville, TN area. He has prior experience as a Director of Food and Nutritional Services for a national foodservice contract provider in various healthcare facilities in Alabama, Tennessee, Ohio, Kentucky, Michigan, Georgia, North Dakota and Nevada. His experiences in food management led him to “lean” efforts because of a desire to always provide customers quality- quickly and at a competitive price. Monte holds a BS degree in Restaurant, Hotel and Institutional Management from Purdue University, West Lafayette, IN.