Lean Healthcare Exchange

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The year was 1847 and mothers who gave birth in an Austrian clinic began to reap the benefits from Lean Healthcare and Six Sigma practices. In fact, up to 30 percent of mothers, who would have died from puerperal or childbirth fever, survived thanks to the problem solving work of a Hungarian physician who swarmed a problem by analyzing data to find the contributing factors, tried countermeasures and measured the impact.

Mothers were dying due to this hideous infection casued by something that no one could see with the naked eye. Dying after giving birth in hospitals was especially alarming because mothers were dying while being treated by experienced physicians—while mothers assisted by midwives survived at a much higher rate.

Fortunately, the physician mentioned above applied a scientific approach to this problem. You may know the problem solver to be Ignaz Semmelweis (1818 – 1865). Dr. Semmelweis was a Hungarian obstetrician and the life-saver who introduced antiseptic prophylaxis into medicine, a.k.a. hand hygiene. The prophylaxis was simply washing one’s hands prior to entering a mother’s room after performing surgery or an autopsy. Dr. Semmelweis’ countermeasure reduced the death rate from an average of 12 percent to less than 1 percent. However, there is a sad twist to this story which we will get to later.

Lean Healthcare succeeds today in part because of the same scientific problem-solving methods that Dr. Semmelweis practiced. Going to where the work is performed (Gemba) was essential in his correlation of a scalpel cut received by a colleague performing  surgery with his colleague’s death from infection.  In the 1840’s and earlier, no one knew that pathogens passed from the morgue to the mother because the pathogens could not be seen.  Dr. Semmelweis saw the scalpel incident because he was there.  Physicians before him had not connected infections with surgeries and the delivery of babies. Data collection (remember our discussion on data) was key to validating if hand hygiene really had an impact.  Looking at the chart, is there any doubt?  This same practice of measuring the current state to know if improvement really occurs is the core of Lean Healthcare, Six Sigma, and any scientific problem-solving approach.

Now the sad twist: Dr. Semmelweis’ work was debated, poorly spread, and did not sustain. Does this inertia sound familiar in some of your problem-solving efforts? The countermeasure of washing hands to reduce the cross contamination of pathogens is achieved in many hospitals today, yet there are many that continue to fail to achieve 90% compliance and most do not sustain.

What is common in healthcare organizations that succeed and sustain? They utlilize the 3Ms: Measure, Manage to Measure, and Make-it-Easy.  

1. Measure frequently. We have yet to see sustainment if measurement is stopped.
2. Manage to the measure. Dr. Semmelweis rewarded those who washed and reinforced others to do so who did not wash. We call this Just-In-Time coaching. We also found we need to teach how to coach for better stakeholder acceptance.
3. Make-it-easier to wash. Often, it could be easier to wash or sanitize hands. We use spaghetti diagrams to show where hand washing dispensers should be placed in the path of the healthcare professionals. There are even easier ways to measure eliminating all excuses for measuring what hand hygiene compliance really is.

Lean Healthcare works because it combines the science of problem solving with the “3Ms” as stated above. Dr. Semmelweis had the measure right, but, his ability to lead change was lacking in managing to the measures and making it easier to do the right thing. In Lean Healthcare, we focus on all three Ms, and especially on managing and making it easier. Try the 3Ms in your problem solving and see if you don’t experience improvement too.

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Many healthcare organizations are embracing Lean Healthcare as a methodology for improved flow and efficiency.  However, many of these organizations are overlooking Reliability and Safety when it comes to patient care.  The elimination of defects, in regards to patient safety, in Lean Healthcare is called Reliability and Safety.

2012’s goals and objectives are in full swing.  Many have set targets for Ventilator Associated Pneumonia, Central Line Infections, Wrong Site Surgery, and other core measures and many of these targets will sound like, “Reduce by 25%” or “Lower percentage than 2011.”  These goals cause me to reflect back to when I was a young executive leader of an operation. 

Through our annual goal setting process targeting the corporate breakthrough objectives, we set a target of a 50% reduction in lost time accidents.  Ed Novonty, one of my early mentors, rejected this target through our ‘catch ball’ process.  I still recall his words, “Joe, I cannot accept that you are targeting to hurt 5 people next year.”  By saying this, Ed challenged me to look at the goal as though I were responsible for hurting these people, as opposed to generically reducing injuries.  My leadership team’s incentive was tied to meeting these goals.  Ed inquired about our process for accident investigation and about our leading indicators for such an objective.  After much discussion our target became zero.

This dialogue played out again when Cindy McDonald, Vice President for FirstHealth of the Carolinas, pitched to the board that we were embracing a strategy of ‘Achieving Zero.’  She explained that FirstHealth had made great strides.  Achieving linear improvement was not going to deliver patient expectations.  It required a new way of thinking and approach.  One event that could be prevented was one too many.  Who would volunteer their family member to be one of the patients that acquired Ventilator Associated Pneumonia or develop a Surgical Site Infection while still meeting target?  I observed physicians stepping up to become team leaders.  Each event was investigated in detail, leading indicators were developed, response teams were established, and Six Sigma was applied to the potential patient population.

According to Weick and Sutcliffe in their breakthrough book “Managing the Unexpected:  Assuring High Performance in an Age of Complexity,” FirstHealth was taking the next step in their three year journey of Just Culture to a deeper Mindfulness.   Reliability and Safety is an integral part of Lean Healthcare.

So, the question remains: “What is your healthcare organization’s target for hurting patients this year?”

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Every fall I have the distinct honor of participating in one of the most prestigious golf tournaments in the Southeast, known as the “Brawl in the Fall”.  In truth, this tournament is little more than some old college buddies getting together to hit golf balls into the woods of north Georgia, however; giving it a name does seem to add a level of “polish” to the event.  As we worked our way around the course this year (and through the woods, into the water, out of the sand, etc.) I could not help but think about the parallels between what I was witnessing on the course and what I see implementing Lean Healthcare every day.

In the interest of sportsmanship, we use a handicap system to allow even the worst players to have a shot at winning the trophy.  The system classifies each player as either an “A”, “B” or “C” golfer. 

“A” Golfers:
The “A” Golfers are the best players in the tournament.  They practice constantly, are the first ones to the practice tee and must hit practice puts before beginning their round.  As I watch them play (this means that I do not belong to this group!), it is evident that they have a method and process for how they approach each shot.  In effect, they have created standard work for every element of their game.  Most importantly, they know when they have created a defect (poor shot) and stop to fix the problem before moving on to the next shot.  We see these same characteristics in organizations who have implemented all aspects of the Lean Healthcare management system.  Standard work is present and in use, normal operating rhythms are in place, processes support the work and abnormal conditions are easily spotted to name a few.

“B” Golfers:
The “B” group can best be described as “descent”.  They play frequently on their home course, can score predictably well and when the stars align might even beat an “A” golfer.  These players take lessons occasionally and practice when they are getting ready for an event but do not make it a routine. Ultimately, they are the most frustrated player on the course because they have seen their potential on that magical day when they beat the “A” golfer but can’t consistently perform.  Other activities are a priority and as a result the golf score suffers.  Many who are in the early stages of their Lean Healthcare journey will find themselves relating to these players.  The standards, processes and operating rhythms needed to consistently excel have not been fully developed. While they experience great success in individual areas of their Lean Healthcare implementation, these accomplishments are dulled somewhat by inconsistent performance.

“C” Golfers:
The “C” players are an interesting group in that they are happy to be playing but complacent about their performance.  Hitting drives into the woods and earning triple boagies are a normal part of the exercise.  The “C” group happily rides around the course either not seeing the Waste that they create or not understanding that they don’t have to perform this way.  Their game is in such trouble; they don’t see a path forward to playing good golf and have resigned themselves to the “C” ranks.  Often we see organizations who have attempted to raise their performance in the past through Lean, Six Sigma or other improvement methodologies only to fall back to average.   They remain in this state either because they can’t see that better service could be delivered or they don’t have a clear vision/drive to get to “A” performance.

To take the analogy one step further, you must ask: “Which golfer represents your organization?”   If you are an “A” golfer, how will you continuously improve?  If a “B” player, what must be done to make your gains more sustainable and consistent?  If a member of the “C” ranks, are you prepared to take on the hard work needed to elevate the performance of your organization?

This week’s blog was written by HPP’s Marshall Leslie. Marshall, a Six Sigma Blackbelt, oversees various HPP projects and Lean Healthcare transformations for clients throughout the USA.  As a former multiple year “top-ten percent” performer at General Electric, Marshall brings clients the much needed tools and techniques needed in any industry, including healthcare. Marshall is a graduate of General Electric’s Operations Management Leadership Program; he has experience in various supply chain capacities including quality engineering and global sourcing for both GE and Procter & Gamble. Marshall’s expertise in both Six Sigma and Lean enables him to apply a broad spectrum of process improvement tools tailored to the healthcare industry’s needs. He holds a degree in Industrial and Systems Engineering from Georgia Tech.

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In past editions of the Lean Healthcare Exchange we have discussed the complementary use of Lean and Six Sigma to solve problems and improve process performance. For many who are in the initial phases of their improvement journey, Lean methodologies are all that is needed to drive significant change throughout the organization.  However, as you continue in your Lean journey, some issues may survive initial Lean efforts and linger unresolved.  Our experience has shown that Six Sigma is the complementary toolkit best suited to drive improvement for these more complex, multivariable issues.  Ultimately, the question is not If you will need Six Sigma, but When.

Read the Instructions First……

With Christmas on the horizon, it is likely that many of us will receive a myriad of electronic gadgets in our stockings.  For example, new digital cameras will be found under many Christmas trees this year and if you are like me, you will open the box, find out where the batteries go and begin experimenting without ever looking at the User Manual.  At my house, there is a high likelihood that the manual will be thrown out with the discarded wrapping paper later that morning!  The problem: I’ll be able to take pictures immediately but I’ll never learn how to do more than point, click and download my photos.  All of those wonderful innovations and features that could have made me the Picasso of modern photography have gone to waste because I didn’t take the time to learn how and when to use the tool properly.

It is common to see organizations that make the same mistake in utilizing Six Sigma.  All too often we are guilty of attempting to apply an improvement methodology in an “across the board” fashion without thought for which tool is best in a particular situation.  Just as you don’t use a 10 pound sledge hammer to hang pictures in your home, Six Sigma is not always the most direct avenue to your goals.  The key is to know when and where the use of Six Sigma is appropriate and best suited for the task.  In many cases, it is helpful to seek the help of someone with a deep understanding of both Lean and Six Sigma to assist in project selection and overall guidance of the initiative.  Typically the projects most ripe for Six Sigma application are those in which “common sense” solutions have failed (in some cases multiple times) and intense analysis of performance data is needed to discover hidden interactions driving the true root causes.

It’s being done…..

With a working knowledge of how and when to properly utilize Six Sigma, some healthcare organizations across the country are finally solving many of those nagging problems that were thought impossible to solve.  In one documented case, a lab used Six Sigma methodologies to conduct a Design of Experiments targeted at accessioning errors.  The issue had survived many other improvement efforts, but using Six Sigma the facility was able to identify hidden interactions and drive dramatic improvement. 

On the other side of the equation, insurance providers have used Six Sigma to attack issues such as mental health related readmission rates.  In one documented case an insurance provider discovered previously unknown correlations that lead to recommendations of more proactive and effective interventions for mental health patients. The end result was cost savings for the insurance provider and increased satisfaction for the patient.

These are only a few examples of successful Six Sigma application within the healthcare arena.  Six Sigma has proven to be a powerful problem solving tool in almost any transactional process and can serve as the perfect complement to any ongoing Lean initiative.

What issues have survived your facility’s process improvement efforts and defied all “common sense” solutions?  Is it time to consider Six Sigma?

This week’s blog was written by HPP’s Marshall Leslie. Marshall, a Six Sigma Blackbelt, oversees various HPP projects and Lean Healthcare transformations for clients throughout the USA.  As a former multiple year “top-ten percent” performer at General Electric, Marshall brings clients the much needed tools and techniques needed in any industry, including healthcare. Marshall is a graduate of General Electric’s Operations Management Leadership Program; he has experience in various supply chain capacities including quality engineering and global sourcing for both GE and Procter & Gamble. Marshall’s expertise in both Six Sigma and Lean enables him to apply a broad spectrum of process improvement tools tailored to the healthcare industry’s needs. He holds a degree in Industrial and Systems Engineering from Georgia Tech.

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It is more obvious to me than ever after spending some time this week at the Lean Healthcare Europe Conference in Denmark, with some of the brightest and most progressive thinkers that I’ve ever met, that Lean is alive and well internationally.  In addition, our very own Cindy Jimmerson just returned from a three week tour of numerous hospitals in Australia where the energy and traction for true process change is taking hold. It is amazing how far this approach to leading, operating, and managing healthcare organizations has come in the past two years.  It has a very long way to go, we have much to learn, but it is moving forward and change is happening.

HPP-LHW’s European partners, Lean Healthcare Europe, brought together administrators, leaders, physicians, nurses, quality and process improvement leaders, researchers, and members of academia  from all over Europe to share their Lean successes, failures, lessons learned, and opportunities for the future.  Those in similar positions from the USA also joined the conference to share.

Sure national health systems, for profits, non profits, academic facilities, socialized systems, and the like are all different in many ways for various reasons.  But remove the format of the business entity, the location, and the language from the equation and you would probably be inclined to conclude that in many ways (not all) that we’re all part of one large world hospital system.  Why you ask? Because one leader after another presented that they too are struggling with skyrocketing costs concurrent with shrinking revenues, long wait times, too little capacity for their burdened system, poor patient satisfaction scores, increasing government interference, and most important of all, poor quality outcomes and medical errors.   Sound familiar?

The purpose of this web based exchange of Lean Healthcare ideas is not to make political statements or to discuss healthcare policy.  I’ll leave that to much smarter people than I, although I can’t help but note that the majority of healthcare issues for the most part will not be solved via socialized medicine and certainly not with the government getting more involved to “help us”.  The answer is to eliminate waste, reduce unevenness, and reduce overburden.  That’s Lean! That’s what Lean Healthcare is at the core!!!

Progressive systems are beginning to focus their attention on that which they’ve neglected for years…their systems and processes.  It’s messy…it’s hard…it’s time consuming…it requires an investment in human capital…it’s not a “silver bullet”, and it ultimately must be done.  Not just a six pack of Kaizen or a case of Six Sigma with a side order of 5-S and A3 (which are all great tools).  It’s total Lean transformation from top to bottom that is needed and we’re beginning to see it in its early stages take hold. But, it is even more obvious that we have long way to go. Some have just started this journey which is the hardest part for many.

A quick overview of some of the points made this week at the Lean Healthcare Europe conference include:

Kate Sylvester of the UK discussed the National Health System in Great Britain and the work of her team on the issues the system is facing and the Lean activities taking place.  She made it obvious that you can’t spend enough to create capacity when processes/systems related problems exist.  Their health system increased spending two times plus in recent years in order to create additional capacity, but the problems of availability and waiting months to see a specialist only became worse.  Only in those areas where lean principles are being applied are they beginning to see a difference.

Evald Krog, the Denmark Chairman of Neuromuscular Diseases, has truly put himself in the role of patient and its value streams.  Mr. Krog has MD himself and is both an advocate for the organization and the patient.  Leadership must put themselves into the perspective of the patient to understand the problem.

Isabell Manz is the Director of SR Hospital in Germany, which is a 600 bed facility that began its Lean journey two years ago. She shared lessons learned that included, “you must understand that you can’t move too fast or it will fail…top management must lead the effort and new rules (standard work) for leaders must be developed.  People must be put first in a Lean operation.”

Dr. Miles Shore, a Professor at Harvard Medical School (accompanied by his wife, Dr. Eleanor Shore, also of Harvard Medical School) gave a wonderful presentation on the management of change. He reminded the Lean leaders in the room that, “All change is loss!  The leaders must be the chief mourner, but you must keep the work going for the benefit of the organization.”  As he made that statement it brought back memories to me of past Kaizen or A3 problem solving events where tears were shed by the nurses involved.

There were many, many others with great insight and lessons learned including, Jens-Otto Jeppensen, CEO of Odense University Hospital in Arhus, Denmark which is the largest hospital in Denmark with a staff of 7,700 and includes treatment, research, and training of medical staff.  Also presenting was Mr. Kim Mikkelsen, Financial Mgr. (CFO) and Chair of Lean Project Development of Aalborg University Hospital, an 800 Bed/6000 employee facility, Jorgen Pederson also of Odense University Hospital, Dr. Jim Nesbitt of Alaska Medical Center, Delish Patel, Dr. Dave Munch, Inge Holck and Rene Goduscheit, Dave Sorenson of Utah MEP, Dr. Rich Sorenson of USAF, and many, many others that added a great deal as attendees.

It is incredibly exciting to see that small steps are being taken everyday in this effort. As many know, it won’t happen overnight nor will it be easy, but it has to be done and it is making a difference around the world. We hope to see many of these folks presenting along with leaders and clinicians from throughout the USA at our Global Lean Healthcare Conference in Denver, Colorado on April 21-22, 2008 so that we may all continue to learn from one another as we continue on this journey of Lean Healthcare transformation.

Special thanks to Inge and Erik for being leaders for the Lean effort on the European front and for organizing a splendid forum.  You’ll want to join them next year.

By Charles Hagood (from Denmark)-CEO of Healthcare Performance Partners

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