Do any of the following three situations sound familiar to you?
An ICU, where a significant number of dialysis procedures are performed, set about decreasing the 25 minute lead time to begin the procedure. The majority of this time was motion waste spent searching for equipment and supplies. After implementing some solid 5S techniques, the lead time decreased to slightly more than five minutes. However, there were an additional two minutes and 15 seconds of work required to return the unit upon completion and to update a visual control. Thirty-days post implementation the new process was in disuse. When queried as to why, the team articulated; “It took too long to return the units and update the control.”
A nurse completed A3 training. Her first A3 delivered more than $86,000 in cost reductions to her unit on an annualized basis. Excited, she embarked on five others she felt would deliver equal or greater value, only to be told by her manager, “Spend more time on patient care and less time on this A3 stuff.”
A kaizen team developed an improvement that reduced excess processing and motion waste for nursing by 8,500 hours, annually. It required an additional 2,500 hours of EVS and SPD support, annually, to implement. At the interim report-out, the leadership of EVS and SPD were adamant: “There is no way we can support this, we simply do not have the budget.”
Anyone involved in implementing lean healthcare has their own examples of organizational insanity similar to the scenarios above. I’ve spent a significant amount of time trying to understand this dynamic and its causes. Each case involves a limited view of the work environment; an inability to see past the immediate and to the need to look at things from a systems-thinking perspective. Each example is characterized by a rigid adherence to a personal agenda. The rationale in each case is, respectively, “we don’t have the time,” “you don’t have the time,” “we don’t have the resource.” Yet, in each example, there is clear evidence of an improved future state, yielding more time and resource through the elimination of waste.
A fundamental principle of lean healthcare is that the right process will deliver the right results. When this principle guides behavior, people learn to see from a systems-thinking vantage point. While the above examples involve a lack of systems thinking, I do not believe this to be the root cause behind the behavior. Another fundamental principle of lean healthcare is that the purpose of the organization is to serve the patient, and therefore, the purpose of leadership is to serve those that serve the patient. While the above examples confound purpose and personal agenda, I do not believe this to be the root cause behind the behavior, either. I believe that at a root-cause level, we are dealing with a form of irrational behavior identical to that experienced by individuals in a life-and-death survival situation. I also believe that the root-cause prompting this behavior is overburden, or Muri.
While not always a reliable source, I love Wikipedia’s initial description of Muri as it certainly explains the power of this form of waste to drive irrational behavior and to sub-optimize systems:
“Muri (無理?) is a Japanese word meaning ‘unreasonableness; impossible; beyond one’s power; too difficult; by force; perforce; forcibly; compulsorily; excessiveness; immoderation’, and is a key concept in the Toyota Production System (TPS) as one of the three types of waste (muda, mura, muri). “
In many cases healthcare delivery systems, in response to economic forces, have been compelled to make very difficult choices with regard to resource management. This is not at all dissimilar to what manufacturing experienced in the 80s in response to globalization. The problem is that when cuts to resources occur without a corresponding improvement in process or reduction in waste, service levels suffer. This drives customer dissatisfaction and abandonment, decreased revenue, and more cuts—the classic death-spiral.
The first step in overcoming Muri is to end that portion of it which is self-inflicted. A key source of self-inflicted Muri is defects. It is not so much the defect itself, but rather the failure to recognize them for what they are, accepting them, and working around them that significantly contributes to the overburden. This effort is an unnecessary tax on resources. The organization must learn to see defects and eliminate them at a root-cause level, within the current stream of work, and as close to the point of origin in both space and time as possible.
The next step is to be very intentional in quantifying the impact of defect reduction activity and equally intentional in the reinvestment of the captured time. For example, if a department implements a countermeasure to a specific defect that yields a net time savings of 2,000 hours annually and then reduces labor by 2,000 hours annually…is it really better off? Cost per unit of service does decrease but our position with respect to workload, including overburden, remains the same. It is significantly better to reinvest the time captured to identify and eliminate more waste. Through sound reinvestment, our position with respect to overburden improves. As an organization we move out of survival mode and into stable operations. This is the key to combating organizational insanity.
What are your examples of organizational insanity? Tell us what happened and how you responded.
This week’s blog was written by Brad Schultz, a Vice President with HPP.
Brad serves as a Lean Healthcare facilitator, business consultant, and executive coach internationally with HPP. Brad began his career in manufacturing with GE Healthcare and joined GE’s Performance Solutions during its infancy and remained with the business unit for seven years. He provided significant leadership to adapt the firm’s products to the unique needs of healthcare clients and to translate the firm’s published materials into the language of healthcare.
Brad’s educational background includes a B.S. in Business Administration from Cardinal Stritch University in Milwaukee, Post Graduate Certification in Quality Engineering from Milwaukee School of Engineering, a M.A. in Business Administration from Marquette University in Milwaukee, Six Sigma Master Black Belt Certification from General Electric, and Front-Line Leadership Development Certification from Achieve Global.