Scene:  A small town local restaurant in the mid-south. A matronly waitress behind the counter. On the counter, a couple of one-gallon jugs (perhaps industrial-sized mayo containers?) filled with lemonade and tea.

“What would you like to drink?”

“Can I have half tea, half lemonade?”

“Sure.  Sweet or unsweet?”

Not having a particular preference, I point to the jug in front of her, “just the regular tea you have there.”

“Oh, I’m sorry, this is unsweet.”


Hmmmmm…..  So just what is REGULAR TEA?  Sweet or unsweet?

Having traveled throughout the various regions of this great country, I have noticed this interesting phenomenon when ordering tea. 

  • Here in Tennessee, ordering “tea” will generally be clarified with “sweet or unsweet.” 
  • Further south and away from the “big cities,” “tea” will get a default of sweet unless you specify “unsweet.”
  • I have even been to a restaurant in the southern lowlands where, after being served with a super-saturated diabetes-inducing syrupy tea concoction, I received suspicious glances from around the cozy dining area when I asked, “Do you have unsweet?”  (“You ain’t from ‘round here, are ya?”)
  • A bit north of Tennessee, “tea” will get you unsweet, unless you call for “sweet” (which IS available).
  • Continuing north, asking for “sweet tea” will trigger a dry sarcastic quip, “There’s sweetener on the table.”


So why does this make me think of Lean Healthcare? 

It is just a fun example of the confusion caused by people using the same word to mean different things!  I continue to find more examples of “Patient Ready” meaning “I am finished with what I have to do,” but the patient is not ready to go to a procedural area (i.e. no lab results). 

In a well-defined Lean Healthcare process, Rule 2 (Connections are direct and unambiguous) will be applied, “Ready” will be defined so that the downstream process can pull the patient to the next area without missing information causing rework and delays.  I see this pattern at multiple hospitals and multiple areas: surgery, cath labs, CT, transport pick-ups on nursing floors, the list goes on.

I also see this happen when bringing a cross-functional team together to apply the tools of Lean Healthcare. Each area is using the same or similar words to refer to their own process, but colleagues from other areas are misunderstanding the process description. 

“Pre-admission” is one of my favorites. The registration staff will call the patient prior to date of service to get basic demographics and call this “pre-admission,” the PAT (Pre-Admission Testing) staff will refer to the clinical assessment and labs run (again prior to date of service), and then the patient gets directed to Pre-Admission the day they come for their procedure for any final labs. I frequently hear, “I have already been pre-admitted,” when observing in registration areas. 

To prevent this confusion, I have found that it is best to apply another Lean Healthcare concept: “Go to the gemba!”  Ask clarifying questions!  If someone shows you the work that they are referencing, then there will be less confusion.  Not to mention the revelations of the team, “Oh, that’s what you were talking about!”


A final cautionary note: as you learn more about Lean Healthcare and process improvement, you will notice process problems all around you, even when you are not actively seeking them!  I refrained from having a conversation with the waitress about the Rule 2 violation (“broken connection”), but I feel compelled (a bit OCD, perhaps?) to share the moment with my Lean Healthcare colleagues.

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.  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.

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