Lean Healthcare Exchange

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I have recently worked in a hospital where historically the leaders were expected to make most, if not all, decisions.  Many of these leaders were promoted because of their ability to fire fight and quickly solve problems, and thus incented to continue that behavior.

Even if a solution was developed by front-line staff, the leader still had to approve any changes.  It helped maintain control at the top and avoided any risk for the lower levels to potentially make mistakes.  One leader told me she would often provide solutions for problems but then was confused when the solutions didn’t always solve the problems.

She came to find out that she did not have the full context of the problem, which is necessary to properly solve it.

In a Lean Healthcare environment, leaders must be coached on how to facilitate improvements while avoiding the temptation to jump to conclusions. By avoiding the temptation, it becomes possible to focus on identifying the real problem – the root cause – before prescribing a solution.  One of the best methods for teaching leaders how to facilitate instead of dictate is to instruct them to simply ask questions when confronted with a problem.  By asking the right set of questions, the leaders are engaging their staff in the lean process.  This ensures that the problem is completely understood by everyone and avoids a hasty and uninformed quick fix.

I spend most of my time as a facilitator in a Kaizen event asking “why” and teaching others the importance of asking questions.  Some see asking questions as a form of weakness in their facilitator, thinking I should be leading them with solutions and ideas.  This perception quickly changes when it becomes apparent that many people in the event also cannot answer the question.

It is important to convince leaders that asking questions is not a sign of weakness, but a key step in learning to facilitate problem solving.   Many times I am simply asking questions to get the team to think deeper about the root cause of a problem.

My role as a facilitator is to teach the team and team leaders to use the process of a Kaizen event to develop solutions to their problems and then quickly implement them.  I am not there to provide them with solutions; rather, I am there to help guide them to the solution, whether or not I think I know the answer myself.

As Lean Healthcare leaders better understand this philosophy they will inevitably become better facilitators. Think back to a recent problem you’ve had – did you or your colleagues apply the quick fix? Or did you dig in deep to find the root cause of the problem? Share your story in the comments.

Linda leads Lean Healthcare transformation engagements for HPP. She has nearly 30 years of experience in business leadership, program management and lean transformation.  Prior to joining HPP, she worked for Vanguard Health Systems as a process improvement specialist providing leadership and support for regional and hospital level process improvement teams.  Linda holds a Bachelor’s degree in Industrial Engineering from the University of Evansville.

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Many hospitals have experienced very successful, sustainable Lean Healthcare activity. As well, many hospitals have also participated in Lean activities that have not gone as planned or have been followed by deteriorating results over time.

No attempt at improvement is a complete failure, as long as we learn and strengthen our approach for the next process improvement effort. It is healthy to stumble, then to reflect on what caused the failure. Here is a hard question that I first heard from a Lean colleague, Dave LaHote, president of Lean education at LEI.:

What is the most common or root cause of failure?

As with any good coaching question, it isn’t easy to answer. It requires a lot of reflection. Mr. LaHote would advise you that lack of agreement is the answer. While a spirited debate on the answer to this question could certainly be held, for now let’s accept it as true.

That being the case, how do we get to agreement? In many cases, agreement can be achieved with dialogue and reasoning. If disagreement persists, the application of the scientific method can help. The most important piece of agreement is the understanding that it takes time to reach. People have a tendency to resist change, and typically they cannot be convinced of the value of change overnight. Launching into the work with a plan to achieve buy-in from involved parties later will result in long-term failure of the effort.

By allocating the time for agreement before engaging staff in improvement, we set a foundation for long-term success. We need to go slow to go fast.

I’ve seen many Lean Healthcare events fail due to a lack of agreement in the chartering or planning process. Successful improvement requires allocating time to achieve these things in order to avoid failure:

• Participation at every level of the organization.
• Determining the activities that each level must perform and when.
• Communicating role and responsibility to each level.
• Gaining agreement and a commitment to performing these responsibilities reliably.
• Addressing the above issues before the improvement work is launched.

Here is an example:

An improvement team working on timely transfer of patients from the emergency department to the floor is preparing for a rapid improvement event.

A critical aspect of this work will be the willingness of the med-surg floor to accept the patient within a certain amount of time, say 30 minutes.

The process will need to be developed. The staff in med-surg will need to have the support of their managers in the change, which means they will need to find the capacity to do this work, and there will need to be measures and coaching from these managers.

Have the managers agreed to do their part of this work ahead of time? If not, we know what will happen. The managers won’t have this implementation as a priority with all the other tasks they need to do throughout the day. That means that the measures and coaching won’t occur. This in turn will lead to sub-optimal implementation and it will be unlikely that the goal will be met or sustained over time. It is better to have that conversation with the managers before starting the work, surface the problems or barriers that the managers have in accepting these responsibilities and resolve them beforehand.

Similar conversations and agreements will need to occur with the executive team members, the improvement team lead, the facilitator, the team members and the frontline. They all have specific roles to play in the success of the improvement.

Getting to agreement on roles and responsibilities before a project is launched will significantly increase your chances of success. Investing the time before the event is well worth it. Otherwise, you will spend extraordinary amounts of time following implementation dealing with the problems based on confusion or lack of agreement of roles and responsibilities. In the worst-case scenario, you will have spent the time and energy of many people to attempt an improvement that has not sustained itself. Morale is low and you’ve created a self-fulfilling prophesy that Lean doesn’t work.

With just a bit more time invested up front in getting to agreement, this doesn’t have to be the case.

Go slow to go fast.

Dr. Munch will be facilitating a workshop at the upcoming Lean Healthcare PowerDay – Improving Quality Management to Prepare for the New Healthcare Environment.  This workshop will cover requirements and tools for leaders and staff to improve processes that deliver safer, more reliable care.  Participants will learn how to dismantle a culture of “blame,” and how to reward the right behaviors to prepare for CMS’ Value-Based Purchasing and Hospital Readmission Reduction Programs.  For more information on all PowerDay workshops and sessions visit www.LeanHealthcarePowerDay.com .

Today’s blog was written by Dave Munch, M.D. and HPP Senior Vice President and Chief Clinical Officer.

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Nothing is more disheartening in Lean Healthcare than spending a week on a process improvement event, having a team that devoted time and energy to finding solutions, enjoying the satisfaction of saving time or money—just to realize in the weeks after the event that the solutions will not be implemented.  Although there are many reasons this could happen (from miscommunication to personnel changes), most can be prevented by taking a few extra steps in the event planning phase.

My colleagues have recently discussed the Guidelines for a Successful Kaizen Event along with the 5 phases of a process improvement event (Planning, Preparation, Training, Execution, and Follow-up) and the importance of the Follow-up Phase in the success of the event (Kaizen Events Don’t End on Friday).  Although the Follow-up phase is the most critical, if you begin preparing for implementation problems in your Planning phase, then the follow-up and implementation will be easier.

It is fairly safe to assume, especially if your organization is early on in its Lean Healthcare journey, that there will be bumps in the road following an event which will hinder your success. They could be caused by such issues as personnel disagreements, miscommunication, attrition, or misaligned priorities. If you think you might fall victim to these or other post-event hindrances, then you may want to have the entire team enter into a contract as a countermeasure.

A contract, to quote Merriam and Webster, is a voluntary, deliberate, binding agreement  between two or more parties. In terms of an improvement event, a contract may include:

• A charter
• An implementation plan
• A commitment to 30, 60, and 90 day improvement follow-up reviews
• A commitment to developing and following the new standard work

If you visualize an upcoming improvement event, you can often anticipate potential disagreements and misunderstandings among team stakeholders.  If you can anticipate a disagreement, there is a high likelihood that you can work with team members to preempt the disagreement through thoughtful contracting.  I have outlined a few examples:

Disagreement Example 1:

A hospital initiated a series of patient flow initiatives that required a rather extensive data set including actual-to-goal cascaded performance on cycle times for various key process variables.  Additionally, discharge related line item times were needed to enable coaching of bedside nurses and charge nurses who were not performing to standard.  Following event completion, the data set request was placed in a long queue of IT requests and was delayed, seriously delaying effective implementation and leadership standard work.

Contracting Countermeasure: 

Rigorously anticipate needed resources during the Planning phase of the event.  Specify all resources, including data reporting/analysis needs in the charter.  Prioritizing of IT requests will often require event Champion or Sponsor intervention.  If your Champion and IT understand and agree up front that the data set is a requirement for the event and will be provided at the time specified in the Charter, your team will be weeks or months ahead of the game.

Disagreement Example 2:

Shortly after the completion of an event, there was a management change within the subject department.   The new director disagreed with the team’s Implementation Plan and stated the intention to cancel implementation of most of the actions.  The director’s rationale was that his substitute countermeasures would achieve the team’s performance goals better than the team’s countermeasures.  The director’s executive supported the director’s position.  This placed event effectiveness at risk.

Contracting Countermeasure:

Keep the implementation plan intact!  If responsible parties on the implementation plan are allowed to edit the plan at will, then it will become watered down and the team’s effectiveness will be compromised.  If a building contractor contracted to build a house addition, then, after the contract was finalized began eliminating windows, expensive fixtures, and other features, the contract would hold him accountable to the initial agreement.  Your implementation plan should have similar integrity.  Your review structure will monitor the effectiveness of the director’s substitute countermeasures, and if they do not deliver the target condition, there will be strong pressure to implement the team’s countermeasures.

Disagreement Example 3:

An improvement event eliminated many hours per week of wasted labor activity.  It was suggested to the process owner that a benefit be realized from the eliminated waste, but the process owner felt it did not need to be dealt with, and finessed avoiding accountability.  Department staff self-selected what to do with their newly available time, and the organization did not realize a benefit from the eliminated waste.

Contracting Countermeasure:

If it is expected that an event will result in elimination of many hours of waste, specify in the charter that the process owner will devise a written plan to reallocate or otherwise realize the benefit, and that this plan will be integrated with the implementation plan and be subject to the same rigor and reviews.  This establishes a formal expectation and accountability to follow up on agreed actions.

Improvement teams in Lean Healthcare are typically composed of a matrix organization with mixed lines of authority.  In the absence of a clear management hierarchy, we must rely on other constructs to reach an agreement and move forward.  Contracting can be a powerful tool that is at your disposal.

Today’s blog was written by John DeVreis, a Senior Manager with HPP.

John has more than 30 years experience in Lean Healthcare, Six Sigma, Continuous Improvement, and Productivity Improvement.  As a Master Black Belt and deployment leader, he has led Lean and Six Sigma skills transfers to a large organizations resulting in widespread, breakthrough, strategic improvements.  John also has experience assisting healthcare facilities integrating Malcolm Baldrige-based organizational assessments, Lean, and Six Sigma.

John holds a Bachelor of Science in Industrial and Systems Engineering from the University of Alabama, Huntsville.  Additionally, he has completed the GE Healthcare Lean Six Sigma Master Black Belt Development Program. 

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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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Why are some change messages in Lean Healthcare Kaizen events successful while others fail to connect to the staff involved in making the change happen?

At the start of any Kaizen event or, for that matter any change process, we often start the communication with a business case—which is a “case for change” or a “burning platform” message.  These messages normally start with facts and figures that are intended to convince us of the need to change.  We assume that in presenting these facts people will choose to change based upon the rational position the facts demonstrate.  Yet the use of facts and figures at the outset of the message can derail the message, despite what is perfectly logical.

Several years ago I was given the opportunity to design and facilitate a medication administration improvement initiative at a 250-bed community hospital.  The Institute of Medicine’s “To Err is Human” report had just been released and the hospital’s CEO was determined to use the report as a burning platform to reduce medication errors at his hospital.  The resulting one-day performance improvement event was a blend of Lean concepts including waste reduction as well as large scale change methodology.  A 60 member interdisciplinary team was assembled for a highly structured improvement process.

I asked the CEO to lead off with a few comments on why he had chartered the group.  At first he wanted me to create a PowerPoint, the classic “communication” approach.  I offered that he speak without the use of PowerPoint, that he directly address the group.  After a back and forth conversation he agreed to speak directly using a few prepared notes and I would prepare a PowerPoint with “facts and figures.”

The morning of the event after everyone, including nurses, physicians, pharmacists, pharmacy techs and everyone else assembled I nodded to the CEO to kick things off.  He hesitantly started to talk about the IOM report sharing some of the facts and figures and then he abruptly stopped.  After a long pause, he shared the following:

“Last night as I was reading the various pre-workshop material including the report on Dana-Farber’s medication error that cost a patient her life I looked down at my two grandchildren who were playing at my feet.”  The CEO, a very stoic man, took in a deep breath.  As I looked at him I thought he seemed to be in a completely different place and then I saw a few tears rolling down his face.  Gathering himself he continued “What if this happened to one of my grandchildren at my hospital.  How could I forgive myself? We as caregivers have a great responsibility to protect those who come to us for healing and care.  This is very important work we are doing here today and I want all of us to fully engage so that we are sure that our patients are safe.  I am confident that we can make this hospital a place where no patient has to think twice about the care we are providing.”

He then proceeded using the PowerPoint, to ever so briefly share both national and hospital specific data on medication errors.

Make no mistake, everyone saw the look and tears on the CEO’s face and heard the change message. The room had an electric feel with a palpable energy at every work table.  At day’s end, an improvement plan was assembled with accountabilities and timelines established.

When asked for feedback, both formal and informal, the participants retold the CEO’s brief story — and their own! The CEO’s story provided a path for the participants to emotionally connect to the imperative to change the current state.  The subsequent performance data collected by the team added facts to make a complete case for change.  Yet it was the emotional connection that galvanized the group and process.

Today, there are different and more effective approaches for leaders of Lean Healthcare to make the case for change.  The CEO utilized this approach by telling a simple and short story.  He conveyed a negative – the Dana-Farber story, and then personalized it to link in a concrete way to his life. This allowed others to connect to their own personal stories.  He then positively spoke of the people in the room, affirming his faith that they in their collective genius could affect positive change in the medication administration process to assure a safe reliable practice.  Finally, he shared concrete facts to support the case for change.

Comment below – How do you motivate your organization’s teams to embrace improvement? Is it through facts and figures? Or are you able to connect them emotionally to the right work?

Bill has 30 years healthcare leadership experience in both system and individual hospital settings in the Mid-West and North-East, and oversight of change management activities and Lean Transformation engagements.  This experience includes serving in an executive capacity in Quality, Operations and Human Resources. 

He holds a Masters in Health Administration from Xavier University and a Doctorate of Philosophy in Organizational Behavior from the Union Institute and University.  

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My last blog explored the Lean Healthcare “do it now” attitude. (The Power of Doing it Now) However, it’s hard to do everything now when you rely on others to complete tasks.  There is an art to asking for help (or flat out asking somebody to do something).  Doing it right will inspire others to meet your expectations. Doing it wrong could backfire and come off as dictatorial and pushy.

Confidence is essential.  Be confident in yourself, be confident in other peoples’ abilities and assume others are aligned with you.  Think of Ronald Reagan asking Mikhail Gorbachev to tear down the Berlin Wall. Through his inflection, the subtext of Reagan’s request was, “This is the right thing to do and you’re the man to do it.”  In this way, it was less of a command and more of a pep talk.  If your formal responsibility is making the workplace better, most people will be aligned with your cause.  Asking politely with confidence, relaying the importance of the task, and giving a clear timeline will normally elicit a positive response.

Displaying confidence in others can cleverly soften a command and helps with those who may be resistant. It’s harder to say no to a confident person!

Opposite Reagan, during a recent Lean Healthcare improvement event, the team asked hospital maintenance staff to construct a short wall to limit traffic flow (it’s a well-kept secret that maintenance can construct or even remove walls to open up space with relative ease).  After the initial response from them that it was going to take a while to get that done, I jokingly responded “Ok, then, what time tomorrow can you get it done?”  They responded back that it should be done by late the next day because the wallpaper crew would not be available until after noon. You’ll be surprised what you can get just by asking the right way and playfully responding to hesitation.

Deadlines are important because they keep people from putting you off.  If you must ask someone to complete a task, kindly ask if it can be done (or started) today.  Many people are deadline-driven and need a sense of priority.  If you’re on a Lean Healthcare team, you have the license to pry a little if the answer is a “no” without adequate explanation.  Don’t be apprehensive about asking why.  Try asking, “What can I do to help this get done by…?”  This lets them know that it is important and that you are willing to help remove obstacles that would keep the task from getting done.  Asking in this way also makes you seem less “pushy” and helps to build an alliance with the group that needs to do the task.

As Lean Healthcare spreads throughout an organization, the sense of urgency will become more apparent.  Alliances and friendships will form between people that might have never crossed paths.  Eventually this will increase the momentum of your improvement efforts.  Immediately, however, there will be apprehension and those who seek to put limits on what can be done.  Sometimes this is just due to not knowing what is possible.  For this reason, it is imperative that you are confident and firm with your requests.  Don’t be afraid to say, “I need this now!”

Linda leads Lean Healthcare transformation engagements for HPP. She has nearly 30 years of experience in business leadership, program management and lean transformation.  Prior to joining HPP, she worked for Vanguard Health Systems as a process improvement specialist providing leadership and support for regional and hospital level process improvement teams.  Linda holds a Bachelor’s degree in Industrial Engineering from the University of Evansville.

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In trying to teach the essence of Kaizen, one of my esteemed Lean coaches would frequently remind me to “not let best get in the way of better.”  How simple.  How practical.  I have used this phrase hundreds of times in Lean Healthcare since learning it.  Even more powerful, is that it is now a common phrase used at every level of my company. 

Kaizen loosely translates into “continuous incremental improvement.”  This is not an easy philosophy to understand or follow—especially in Lean Healthcare.  We all want the biggest return on our limited resources’ time.  We need big savings quickly.  However, Lean, being the paradoxical system that it is, turns this thinking on its head.

Experimentation is a practical necessity in Lean.  Even more important is that people must experiment daily so they can learn which ideas truly eliminate waste.  Rapid experimentation and implementation leads to big savings faster than the big bang approach, as it is easier to eat an elephant one bite at a time.

Consider this: There is no perfect solution, only the pursuit of perfection.  The good news is that Lean has a definition of perfection or the Ideal State: Defect-free, One-by-One, On Demand, Immediate Response, No Waste, and Safe.

So the next time you are holding out for the best solution, “don’t let best get in the way of better.”

This week’s blog was written by Dwayne Keller, Executive Vice President of Operations at Medical Reimbursements of America (MRA).  Dwayne is leading the implementation of Lean in MRA’s revenue cycle operations. Prior to MRA, as COO of Healthcare Performance Partners (HPP), he coached hospital executives and all levels of leadership in the implementation of Lean Healthcare, resulting in significantly improved outcomes.

Dwayne also served as a General Manager over two manufacturing plants at Alcoa in which fifty percent of the floor space was freed up using Lean principles and tools. He was also responsible for driving business results through Lean implementation in five Alcoa business units as an Executive Lean Coach.

Dwayne holds Master’s and Bachelor’s degrees in Mechanical Engineering from Bucknell University and a MBA from Clemson University.

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Lean Healthcare PowerDay

April 9-10, 2012

The Mandalay Bay Resort

Las Vegas, Nevada

Join us for the Lean Healthcare PowerDay!  Hear from and interact with preeminent Lean Healthcare industry leaders who are transforming organizations into safe, high-quality, high-performing healthcare delivery systems.  Learn how others have overcome challenges including changing culture, sustaining results, and surviving transitions in leadership. 

Gain insight into how implementing an effective Lean system can help you improve quality outcomes in delivery and transition of care, which are becoming increasingly important measures for reimbursement in the wake of health reform. 

Click Here for Pricing, Registration, and Accommodation Information

Featured Presenters:

Lean Healthcare PowerDay
Tuesday, April 10, 2012
8:00 a.m. – 5:00 p.m.

The PowerDay is the best way for you to get caught up on Lean Healthcare’s rapidly progressing, constantly changing practice.  This full-day of session presentations provides knowledge on how to implement Lean Management Systems, address struggling transformations and leverage specialized Lean Tools and Methods for Healthcare Facilities Design. 

The Charge (Optional Introductory Educational Session – Register Separately)
Monday, April 9, 2012
1:00 – 5:00 p.m.

This half-day educational session provides Lean Healthcare training and an introduction session to attendees. Held on Monday, April 9, The Charge will present a broad brush of key concepts for healthcare providers new to Lean Healthcare, or for those who need a refresher on basic tools and techniques used in the practice. 

Networking Reception
Monday, April 9, 2012
5:00 – 6:00 p.m.

Included with The Charge or PowerDay, this reception will be a great opportunity to network with peers and PowerDay speakers.

Event Agenda

Tuesday, April 10, 2012 

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Many years ago, I was the Quality Director at a large automobile assembly plant in the Midwest.  When I was first promoted to the job and moved into my new (and much nicer) office, I found on the wall next to the desk a plaque with these words on it:  “In God We Trust, Everybody Else Bring Data.”

This was the early 90’s and Toyota was far ahead of the curve in the learning, teaching and application of the Toyota Production System and lean methodology.  My company (which shall remain anonymous, but referred to in this article only as GM), had not yet embraced lean but was very active in their problem-solving efforts through the use of statistical process control tools or SPC.  X-bar & R charts and control charts were everywhere and terms like data and metrics were part of our daily language.

But now many years later, as my focus on improvements has shifted to the arena of healthcare, at times I feel like I have stepped back into time when we talk about data and metrics.

It is not that the healthcare organizations do not have data; they often have reams and reams of data.  It is more to the point of how that data is used—first to know where the problems are and second to understand what the data is really telling you when it comes to continuous improvement and countermeasure activities.

Recently I was working with a hospital that had issues (as many do) with unplanned readmissions.  I was asked to work with the compliance office and facilitate a Kaizen event focused on decreasing unplanned readmissions.   One of the first things I asked for as I prepared for the event was the data.   “What does the data tell us?”  “Why does the organizational leadership consider this a problem?”  “What is the objective?”

The data I was given told us the hospital was last in the hospital’s organizational group of six hospitals in percentage of unplanned readmissions.  That answered the question of why the hospital considered this a problem.  So at least one of the metrics seemed fairly straightforward – reduce unplanned readmissions.

But as the team started to examine the data and understand the current condition, it quickly became apparent why the problem had existed with little change for quite some time.  When it came to the data – that was basically the extent of the data – we are last in our group and this is our percentage of unplanned readmissions.

There was no Pareto chart of the top reasons why patients were returning to the hospital.  There was no internal data being gathered to understand what was happening.  There was no data…just a perceived problem.

Essentially, what we had was not uncommon in healthcare organizations.  The data and metrics were at a very high level that caused concern and reactive actions.  There was no follow-up or “drilled down” data to help us understand what and where the issues really were.

The focus of the Kaizen now had to shift.  Before the team could designate where emphasis could be focused on specific issues and problems, we had to first obtain and then analyze the data.

What we knew at this point was that any patient that returned within thirty days of discharge was considered a readmission and reported as such.  If that patient was not at the time of discharge scheduled for readmittance, then it was considered an unplanned readmission.  But any further information on why the patient returned was not readily available.  The compliance personnel would early in a month go through the records of the previous month and define these returning patients as planned or unplanned (as best they could) and report that information to corporate.  But since this could be up to forty days after the incident, even with studying the medical records it was difficult to understand the circumstances; it was very time-consuming to gather any information.

The team developed a flow chart tool to analyze the information.  It started with two pathways, clinical issues and patient issues.  From there the tool analyzed options allowing the information to be drilled down and sorted to form a Pareto of the top issues affecting unplanned readmissions.  Now the team was able to schedule further problem solving on the root causes of those issues.

The key was the process had now changed to be data driven.  The initial data was now being reported to the compliance office on the day of readmittance.  The analysis of why the patient had returned was now being examined in a standard manner through the flowchart parameters and entered into the data where it could be compared on a Pareto chart.  For example, one immediate result was the confirmation that infection was a primary reason for return.  When a team focused on that particular issue and gathered more data through direct observation, it was discovered that the instructions for wound care given to the patients at discharge were not consistently applied and contained little descriptive information (no visuals) to guide the patient.  The packet and instructions were changed and the staff was retrained as initial countermeasures.

Data.  It is defined as “Factual Information, often in the form of facts or figures obtained from experiments or surveys, used as a basis for making calculations or drawing conclusions.”

Some of you may remember the old Dragnet TV series from the 60’s.  (Dun ta dunt dunt…Dun ta dunt dunt…daaa!).   One of the two detectives, Joe Friday, when questioning the witnesses or the perps, every week would say, “Just the facts, ma’am, just the facts”.  That is what data is all about….not speculation, not I think, not passing judgment, not jumping to conclusions or being reactive….just the facts.

Through the use of data and data driven metrics, anyone—including healthcare organizations, are able to prioritize problems, develop countermeasures to address the problems and use the data as the basis for the metrics to measure the change.   In God we trust…everybody else bring data.

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This week I’m redistributing an email from my friend and major league Lean Thinker, John Shook of LEI.  John said he had no problem with me sharing this with you.  I’ve heard this question a lot in recent days.  ”Was Steve Jobs a Lean Thinker?”  or “Is Apple a Lean Company?”.   You read and decide yourself.  You may or may not agree. Regardless, as always, John’s emails are good reading and thought provoking.  Enjoy!  Charles Hagood

I don’t know that much about Apple. The only gemba I’ve visited are lots of Apple stores (I don’t know if they’re lean but they go far in solving customers’ problems) and a few (far from lean) suppliers in East Asia.

Since his death, comparisons of Steve Jobs with great innovators and industrialists have been plentiful, with Thomas Edison and Henry Ford mentioned most often. The Edison comparison is off the mark, since I consider Edison as an inventor first, and businessman second, with little interest nor aptitude for working the bridge between his inventions and commercialization.

Though known as innovators, the secret to the success of Jobs and Ford was not that they actually invented anything like light bulbs. Ford didn’t invent the automobile. Nor did he really invent the idea of flow production or interchangeable parts. Likewise, Jobs didn’t invent the PC, the graphical interface, the music player, music, the telephone, the tablet PC. What Jobs did, like Henry before him, was put it all together as a total package. And the packages they developed were innovative and complete beyond imagination.

Instructive parallels between Jobs and Ford come easily. Ford’s critical role in the history of lean thinking is well established – he was the first to achieve sustained flow production on a big scale and flow production is the operational aim of any lean operating system. Ford became the richest, most famous industrialist of his time through introducing a breakthrough product. But, what was truly revolutionary about Ford’s achievement was that he packaged his breakthrough product with an even greater breakthrough production process and business model.

Both men were also renowned for their infamous flaws. Demanding, abusive, confident to the point of being dismissive of the views of others – not exactly embodying the all-important lean principle of “respect for people.”

Jobs and Ford shared an unrelenting pursuit of improvement – as long as they were in charge. Daily kaizen practiced by everyone was a hallmark of the approach of neither; they didn’t necessarily value the views of the little man, certainly not of the workers who built their products. Ford is applauded for supporting his workforce through such grand actions as instituting his famous $5 per day pay and establishing the Ford English School to provide his workers with needed education. But those moves – while completely laudable – were mostly self-serving (nothing wrong with that, of course).  He needed to attract workers in numbers never before seen. He had done the math and knew he would have no problem paying the unprecedented day rate. The fact that the workers could then afford the products they produced was a nice plus. As for the school – workers learned English and even American manners so they could be better citizens – from Ford’s standpoint he was able to attract new (documented, I wondered?) immigrants to work effectively on his assembly lines.

One of the more interesting parallels between the two men can be found in their supply chain thinking. Ford became the most famous proponent of extreme vertical integration. Vertical integration was in Ford’s view a way to extend flow from end to end. Note, however, that Ford never extended the integration to dealers, as Jobs later did.

Similarly, Jobs famously kept far more operations in-house than anyone in his industry. He did hardware design, software, operating systems, web services, consumer devices, even retail, insisting on seamless integration throughout. And he held to that approach during an era when it was thoroughly discredited within his industry, and beyond, a time when academic theorists, consultants, and industry practitioners all preached the virtues of greater outsourcing of operations to focus instead on a few core competencies. (Interestingly, the Macintosh was first produced at a new state-of-the-art facility – reportedly using “just-in-time manufacturing” – in Fremont CA, walking distance from the NUMMI plant, starting in early 1984, exactly the same time Toyota and GM were preparing to reopen the old GM factory there.)

Regarding the production supply chain specifically, Jobs – unlike Henry Ford – did not try to keep his component manufacture in-house and is usually dismissed as simply following his industry’s model of chasing lowest global piece price. Actually, however, Jobs followed a modified vertical integration model not at all unlike Toyota. Toyota followed neither the extreme vertical integration model of Ford in actually owning his suppliers nor the modular supply model of Dell and others of shopping contracts around to the lowest bidders. Rather, Jobs chose to work closely with a small number of suppliers with whom (as I understand it) he would develop close relationships. This approach flew directly in the face of the Dell model which was the darling of investment analysts and MBA professors. Not unlike Ford’s actions with his workers, Jobs motives, weren’t altruistic; his objective was control of the situation.

That takes us back to that charge of the most “unlean” of practices: Jobs’ apparent lack of respect toward the workers who built his products on the other side of the world. While structurally Jobs’ supply chain had striking similarities with Toyota’s, in the case of the latter, great effort was expended to extend respect in the form of engagement of all employees, including factory workers. No old Fordist “check your brain at the door” —  engagement of the entire person in daily kaizen was encouraged and expected by Toyota.  

But, the most thought-provoking parallel between the two men was in their approach and phenomenal success with product-process innovation. Jobs, like Ford, was convinced he knew what his customers needed better than they did.

Ford is often quoted as saying: “If I had asked my customers what they wanted, they would have said a faster horse.”

Similarly, from Jobs: “You can’t just ask customers what they want and then try to give that to them. By the time you get it built, they’ll want something new.” Jobs liked to quote Wayne Gretzky as pointing out that you don’t skate to where the puck is, you skate to where it will be.

Both men made decisions based not on market research or customer feedback but a vision of what their products would do for people. They were solving for customer need, not want. By the way, Toyota also traditionally put more product decisions in the hands of chief engineers, relying much less than competitor companies on formal market research – no focus groups, please!

And, interestingly, products introduced by Jobs as well as Henry Ford and Toyota chief engineers were phenomenally successful, less because they introduced breakthrough technology but because they left out unneeded technology to create simple, user-friendly (which would have been said of the Model T had the term been around then) products and customer experiences.

Ford’s Model T was already a huge success before he figured out how to make masses of them cheaply with his assembly line. In addition to affordable personal mobility, the Model T provided a deeply personal connection with its users. It was personified, given names, treated like a member of the family.  There is a lot in common between the human-like bond created by the Tin Lizzy with its hand crank starter in 1907 and the Mac with its simple cursive, lower case “hello” start-up screen only 80 years later.

Steve Jobs and Henry Ford are important not because of any specific technical invention. Far more importantly, Jobs in his era and Ford in his grasped the social and technical situations of their respective eras so deeply and thoroughly that they were able to integrate product, process, and even business model in ways that were transformative for their customers, companies … even the world. One of Jobs famous quotes was, “Stay hungry, stay foolish.” Never be satisfied, always have fun. Sounds pretty lean to me.

Of course, whether or not Steve Jobs was lean is not an important question. But, how we think about that question may say a lot about what we think lean is. So, what do you think – was Steve Jobs lean?

John Shook
Chairman and CEO
Lean Enterprise Institute, Inc. 

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