Lean Healthcare Exchange

When I buy a Coleman tent, I am the ultimate judge of satisfaction with the product that Coleman offers. I decide, based on a number of factors, whether I will buy another Colman tent (if the one I have ever wears out).

When I purchase a Lexmark printer, I will ultimately judge my satisfaction with the printer. When the time comes to buy another printer, I will decide whether to buy another Lexmark.

When I go to Carrabba’s Italian Grill and enjoy the Pollo Rosa Maria, I will be the final arbiter of the quality of the meal. I will decide whether to order the Pollo Rosa Maria when I return to Carrabba’s. (Noticeably absent from the discussion is any question about whether to return Carrabba’s. That’s a foregone conclusion. My wife made that one.)

And so it is with most consumer goods and services. Coleman, Lexmark, Carrabba’s and all other producers must ensure they are listening to the customers. To be successful, they must ensure that they are constantly in tune with and responding to our collective voice.

Not so, in healthcare. Here are a couple of personal examples. I’m sure you could add several of your own.

When I go to Jewish Hospital Medical Center East for out-patient surgery, I am so pleased with the services provided by the excellent care-givers there. But, no matter how great my experience, I am not necessarily the decision maker for whether I return. Ultimately, others will make, or at least heavily influence my decision about whether to return to Jewish East for future procedures. My physician may choose to practice elsewhere. My insurance company may no longer include the Jewish Hospital system in its covered providers group. And myriad other factors may prevent me from choosing Jewish Hospital Medical Center for future procedures.

When I had labs drawn at LabCorp in advance of a procedure, I was so pleased with the friendliness of the staff, the cleanliness of the facility, and the minimal wait time that I would certainly choose LabCorp for future tests. But, it will not likely be my choice. A contract negotiated with very little consideration given to my satisfaction will likely determine where I go for future testing.

One of the fundamental tenants of Lean healthcare is to focus on the customer. These examples illustrate that in the application of Lean Healthcare, the patient is not always the customer. Every successful Lean Healthcare improvement event must include a proper consideration of the voice of the customer. Unfortunately, in health care, the customer is often not easily identified. A partial list of “Customers” can include  the patient, the patient’s family, the patient’s physician, the payer (private or public), numerous regulatory agencies (private or public), other caregivers and so on.  In some extreme cases, these customers have opposing criteria for evaluating the quality or value of a service. Criteria that are important to these customers may be of little or no concern to the patient. So how do we, as practitioners of Lean healthcare proceed?

It’s obvious that if we fail to properly consider the impact of our process improvements on patients, we will fail. So the voice of the patient must always be valued highly. But, Lean healthcare purists, who insist on focusing only on the voice of the patient, while ignoring the voice of other customers, run the risk of alienating those on whom they depend for success. 

For these reasons, it is important to be disciplined to include the full range of customers when implementing Lean healthcare solutions. Recognizing, early in the improvement process, that your customer may include more than just the patient, will help your organization to reach a solution that is mutually beneficial to all your “customers”. Engaging these other interests and considering their voices will help ensure that your team’s efforts optimize a greater part of the healthcare delivery system.

This week’s blog is written by Jeff Wilson. Throughout Jeff’s career, he has delivered and applied progressive management and process improvement tools to help organizations reach new levels of performance. The industries span from healthcare to manufacturing, financial consulting and accounting. His experience with Six Sigma and Lean goes back to the early days of his career while working with Colgate Palmolive. Jeff had the opportunity to use process improvement tools as a participant on project teams and was so impressed with the effectiveness of these tools he began to further develop his understanding of and expertise in the implementation and use of them. Throughout his career as a front-line Supervisor, Materials Manager, Logistics Manager and Plant Manager, Jeff has used and championed the use of Lean tools to deliver exceptional results.  Most recently, Jeff served in a consultant role with the Manufacturing Extension Partnership where he had the opportunity to support other organizations as they seek to improve processes by implementing Lean.  He has developed Lean transformation plans, facilitated Kaizen events and developed training materials for numerous client companies. Jeff has a Bachelors Degree in Economics from Western Kentucky University.  He also holds a Certified in Production and Inventory Management (CPIM) designation.

Doing Lean Healthcare? What does that mean? Well, it is a common question that is asked. My response has been “Making the Right Work easier to do”. So as not to mislead, I looked up the definition of right on Dictionary.com and found that it means “in accordance with fact, reason, some set standard” and the definition of work means “to exert oneself by doing mental or physical work for a purpose”. 

In Lean Healthcare the right work by a caregiver is to exert as much effort and time necessary to meet the expectations of the patient. The Value Added work performed in patient care can be classified into three different categories:

• Direct (ex. value add time with patient, medication administration)
• Indirect (ex. medication prep, consult orders, medication reconciliation)
• Regulatory (ex. giving report, charting)

Any other work other than the above classifications is considered as waste or Non-Value Added. In order to “make the right work easier to do”, we have to eliminate the waste that takes up so much time and effort for the caregiver. Some examples of waste that are typical in the healthcare environment are: Motion – searching for equipment, Waiting – patient waiting for bed at admission, and Excess processing – duplicate orders to pharmacy. 

The one reality taught by Toyota is that there is always more than one way to achieve a desired result. By teaching and coaching Lean Methodology to all levels, we can create an environment to learn, to think about what we have learned, to apply it, to reflect on the process and to continuously improve in such a way that the patient experience is a good one.

Early in a Lean Healthcare Transformation, it is critical that your Team be able to clearly express or define “Why are we doing Lean?” “Making the Right Work easier to do” will allow you to meet your organizational goals and most importantly improve patient care.

This week’s blog was written by Ken Lowe. Ken brings over twenty six years experience in manufacturing which includes sixteen years in the automotive industry.  He has a proven background to be a change agent utilizing business metrics to analyze and develop lean strategies that address the voice of the customer.   His professional experience includes successfully leading operations in various roles to include Controller, Materials Manager, Operations Manager and Plant Manager. He was introduced to Lean Methodology while working with Johnson Controls, a lead supplier for Toyota, where he was Champion of Lean Implementation at his plant. Ken most recently worked with Cummins Filtration where he teamed up to lead the adoption of Lean Methodology in manufacturing plants worldwide.  He has experience in the leading and the training of:  Kaizen events (Rapid improvement, Breakthrough, 2P), Value Stream Mapping, Standard Work, 5S, Total Productive Maintenance (TPM), A3 reporting and Visual Management (QCDS – quality, cost, delivery, safety). Ken has completed Six Sigma Green Belt – DMAIC training. Ken has a Bachelor of Science Degree from Bethel College with a focus in Finance.

Recently it seems that we’re seeing more and more “Rocks” in organizations as we train and guide healthcare organizations through Lean Healthcare Transformations.  I feel this week’s newsletter, which we initially released almost two years ago in Lean Healthcare Exchange, is more relevant than ever and I consider a must read for any organization.  Forward it to the leadership in your organization as well as those within your span of influence. I was in a Wisconsin hospital recently on a gemba walk to review the work of their great staff’s Lean Healthcare journey, and this article was framed and posted on the wall.  They even have “Rocks” identified that they’ve removed, many of which are indeed man made “rocks”! You’ll have to read the article to understand.  If you’ve read “The Rock” before, read it again and ask yourself what you’ve accomplished since last reading it. If the article is new to you, then ask yourself what you’ll be doing to remove “The Rocks” in your organization.  Thanks and enjoy! Charles Hagood

Our team was recently participating in a Kaizen event with a client who was deeply engaged in solving a problem with a very convoluted process.  The team was doing an excellent job and there were several discussions about going to where the work was being done (Gemba), surfacing this problem and getting to a true ‘root cause’ via a “5 Why’s” based approach,  an action rarely taken with past issues.  We were discussing the results of a lean implementation and the fact that by lowering the water level of waste we would uncover a lot of rocks that lay below the surface.  We referred back to a slide in our Lean Leadership presentation and agreed that they had indeed surfaced a rock and were well on their way to breaking it up – hopefully, to never be dealt with again.  The team was doing well…

The Search

Trying to be a good facilitator, I decided that a good visual prop for the team meeting room would be “a rock”. So, I took a walk.  In a grassy median in the parking lot, lay a single perfectly shaped and sized rock for our motivational icon in the training room.  Not only was it the right size and shaped rock – it was a man-made rock of concrete, gravel, and surface pebbles.  Wow – aren’t most of our problems ‘man made’.  This was the ideal visual aid.  I was really proud of myself.

So, I take my ‘perfect’ rock to the training room.  I carefully wrap a piece of tape around the rock to represent the “water level”. And, I write the name of the problem we are solving on the tape.  It does not get any better than this.  I am getting to the point that I may want to take the rock back to Nashville now – just to show it off.  I can’t wait for the next morning.

The Reveal

Bright and early the next morning, in comes the problem solving team. They all see the rock, like the rock, and stand in awe of this great visual aid I had come up with. But strangely, something unusual was happening that caught my attention.  As people began coming into the room, I started hearing: “Hey, I recognize that rock.  I know where that came from”. Of the first six people to come into the room, four had seen the rock and three of them knew exactly where it had come from.  The people at this facility had walked over and around this rock in the parking lot median on their way into the building for several years.  This rock, in reality a chunk of concrete in the middle of a grassy median, had been mowed around, and trimmed around to ensure the area looked neat.

With this, I became very aware that this was no ordinary rock.  This rock was “the poster child” of unsolved problems in our organizations that we walk around and work around, and maybe even make look neat – but it is the problem rock we never get rid of.  It becomes part of ‘the landscape’ – we see it every day.  We know where it is, we know what it is (a problem), and we may even know where it came from. It becomes so familiar to us that we do not even see it as a ‘rock’ anymore – it becomes part of our every day processes and systems.

This rock is the essence of the push for ‘continuous improvement’ and problem solving in a business environment. Lean Healthcare tools teach you to see and observe differently – especially those wastes or problems (rocks) that you see everyday but in fact you no longer see.

Wow!

What a rock.  If it did not weigh 30-40 pounds, I would send you all one. If you want a picture of my rock let me know.

P.S.

The Company liked the symbolism of this ‘rock’ so much they said “it was their rock” and I could not have it.  What a shame – now, if I could just get an inflatable rock to take on trips with me.

By Lean Healthcare Exchange Contributor, Mike Brown, with edits and input from Charles Hagood, Founder and President of HPP. Mike Brown was a Partner in  HPP.  Mike is an experienced Lean trainer and implementer. He holds a BS Degree in Engineering from the US Air Force Academy and an MBA from Troy State University, and was a former F-15 pilot in the USAF prior to his work in industry starting over 20 years ago.

Authors note:  This is an expansion on Rule 2 – Connections of the Lean Healthcare 4 Rules in Use.

<phone call>
Lab Tech:       “Lab, this is Loree.”
ED Tech:        “We never got the radiology results for Mr. Tucker.”
Lab Tech:       “Just look in the computer.”
ED Tech:        “I’ve been looking, but they were not there!”
Lab Tech:       “Look again.  They are there now.”
ED Tech:        “Yes, but I had already checked FIVE TIMES!  How am I supposed to know when they show up?!?!?”

Lab Tech:       <To coworker after hanging up.> “Idiots.  They never look.”
ED Tech:        <To coworker after hanging up.> “Idiots.  I think they wait for my call to put it in there.”

I frequently encounter problems like this during Lean Healthcare Kaizen activities that reduce down to bad connections.  One mental framework I have developed to help staff see the “broken-ness” of the connection is to break out the connection into two components — the information and the trigger to act.

In the phone call above, both the Lab Tech and the ED Tech are right from their individual point of view, but the connection is broken from a system point of view.  A good connection will provide both the information and a trigger for the next person to act.  Without the trigger, the process stops; or, the receiving party must continue to loop around to check if the information has been sent.

Examples of this are all around us.
The nurse waiting on a first dose to be tubed up does not know when the med is sent by pharmacy, so she must continue to check back to the tube station.  (And heaven forbid that some helpful soul puts it away in her med cart without letting her know… resulting in the inevitable call to pharmacy…)
The patient order that is delayed because the chart was left on the counter at the nurses station with nothing to trigger the unit clerk that orders needed to be entered.  (The chart sits, orders are not done, patient care is delayed, the doctor is frustrated by the length of time required to execute seemingly simple orders.)
The ED order for Radiology with the note “Patient not ready”.  So Radiology knows they need to execute the order, but have no way of knowing when it is OK to proceed.  (Of course ED complains about the continued calls to find out if they can get the patient.  And Radiology will be plagued by the long times from Order Entered to Result Ready that will surely be reported.)

Many times these delays can be eliminated with simple triggers for the next person to act.
Pharmacy text messages the nurse to let her know that an order was sent up.  A bit of extra work for pharmacy, but it also eliminates phone calls to find the med saving time for both the nurse and pharmacy.
The chart may need a simple flag system to indicate orders, or a specific place near the unit clerk that indicates orders need to be entered.  (As simple as this sounds, we have observed charts that have been languishing for 8 hours before orders were entered… and that was only after intervention by the Kaizen team that happened to be observing in that area.)
Perhaps a post-it on the door to reming ED to call Radiology when the patient is ready.

It also helps if more staff have been exposed to the Four Rules in Use and understand their part in making the system work as a whole, as opposed to just focusing on their task and not worry about the impact to the system.  (This also emphasizes the need for an abundance of Lean Healthcare coaches in an organization.)

The next time you are in the gemba, look around and look for connections.  If you see a delay, ask yourself how (or if) the next activity was triggered.  And look for a simple way to build that connection so value continues to flow.

For more information on the Four Rules in Use see another article called How Do They Learn?

This week’s blog was written by Richard Tucker a director with HPP who assists clients throughout the USA with Lean Healthcare transformations. Richard has over sixteen years of experience in business and industry fields in operational and leadership positions. His experience includes new program installation and launch, operations improvement, lean manufacturing implementation (internally and with suppliers), leadership development and supplier program management from prototyping through launch. Additionally, he has many years of Lean experience having worked with a major Japanese automaker, and received much of his experience and formal training in the Toyota Production System, Lean Manufacturing, and Shainin Statistical Engineering while in Japan. Richard’s educational background includes BS and MS degrees from Tennessee Technological University in Cookeville, Tennessee.

Transforming your healthcare organization into one that fully utilizes the Lean concepts and tools takes time. Many experts estimate that this Lean Healthcare ‘journey’ will lead to truly tangible results only after as much as 3 years of dedicated, transformation effort! Now the ‘good news’! I believe that the much anticipated changes associated with the proposed U.S. healthcare reform effort offer a perhaps “once in a lifetime opportunity” to create a clear case for major change in any healthcare organization that counts on government reimbursement as a major element of their revenue stream. If you are familiar with change management, you’ll remember that one basic element of change management is the need to identify and articulate, as clearly and forcefully as possible, the need to ‘do something different’ in order to assure survival.  Since it has never been very likely that U.S. healthcare services would ever be ‘outsourced’ to Mexico, finding a rationale for the absolute necessity to get better at improve the levels of healthcare quality and service have been few and far between!

Why now?  As I have consistently read the multitude of commentaries on pending healthcare reform, I have picked up on a few common threads:

1. Our government leaders have clearly focused the coming legislation on increasing the accessibility of health insurance, including that available from both government and non-government sources. Most reviews of the current healthcare reform proposals focus nearly exclusively on how many additional people will be insured through each of the various options. An additional 30 million insured healthcare consumers through these reforms seems like a popular estimate.
2.  The ‘quid pro quo’ of expanding the pool of insured people in the U.S. (and significantly increasing the demand for healthcare services) appears to be a long term series of big time price concessions (something like $150 billion, that’s billion with a ‘B’) via reduced government reimbursements, over the next 10 years. I’ve read that this represents about $2.7 million in annual concessions per hospital!

There you have it! The typical U.S. hospital will see significantly higher demand for services but receive less reimbursement for government paid for care; a true ‘burning platform’ for working smarter not harder! The proposition of providing more of something and getting paid less for it easily registers as a bad strategy for long term success!

Lean healthcare leaders, don’t let this opportunity to clearly state the need for change go by without capitalizing on it in your organization! Three years of effort is a formidable investment but if not now, when?

This week’s blog was written by HPP consultant and engineer David Krebs.  David, a Six Sigma certified engineer, oversees various HPP projects and Lean Healthcare transformations for clients throughout the USA. David is also a Licensed Professional Engineer in the state of Tennessee, with over 30 years of experience in a variety of process and systems intensive industries, as part of firms in the U.S, Germany, and France.  David has achieved and maintained QS-9000 and ISO-14001 certification & received Nissans’ “Quality Master Award” on three occasions.  He holds a Bachelor of Science degree in Mechanical Engineering from the University of Detroit & an MBA from the University of Notre Dame.

As hospitals and healthcare systems struggle to balance rising cost with reimbursement, capital investments such as building renovation and expansion must bring tangible savings through enhanced environmental and operational efficiency. Requests for expertise in Lean Design Services in architectural proposals or RFP’s are becoming very common.

It is true that new construction offers a unique opportunity to correct years of process workarounds and suboptimal space utilization.  Lean healthcare principles can be used effectively to guide the development of optimal future-state processes which can then be applied to create a supportive architectural design.  The opportunity for improved patient outcomes while reducing or eliminating waste can be unprecedented. Unfortunately, the benefits of Lean cannot be realized through Lean healthcare design alone.

Important considerations before employing Lean Healthcare Design:

• New facility design can support Lean processes, but it is essential that the organization’s leadership team be enthusiastically committed to beginning or continuing its lean journey toward waste-free work.
• Lean does not end with building completion. Lean healthcare processes must continually evolve after building occupancy and the design response must offer the flexibility necessary to accommodate change over time.
• The concept of “standard work” must be embraced throughout the organization at every level as part of its culture in order to achieve the full benefit of the Lean Design. This can be more difficult than it sounds. Department managers must agree to standardize work processes across departments. For example, unit secretary workstations and work processes are identical regardless of location within a facility.
• The comprehensive use of visual management tools and standard placement of supplies and equipment are necessary to promote and sustain Lean processes. Communication boards, visual kanbans, and designated parking spaces for mobile medical equipment promote seamless transitions between caregivers prevent staff from searching for needed items.
• Adequate staff preparation and Lean training is vital to patient and staff satisfaction as well as waste reduction. The staff must embrace the Lean processes that actually drove the building design. This cost is often underestimated.

If “going Lean” were easy, hospitals would no longer need waiting rooms. Nurses would not hoard supplies in the pockets of their uniforms and patients would never get hospital acquired infections. When a Lean healthcare organization can deliver healthcare in a supportive Lean environment, the successes achieved in the manufacturing world to eliminate waste and defects may actually be possible.

This week’s blog was written by Teresa Carpenter. Teresa is the Director of Lean Clinical Design with HPP and brings a unique perspective to lean healthcare as a registered nurse with extensive architectural design and facilities planning experience. Teresa began her career in healthcare working through the ranks from Admitting Clerk to Patient Care Director of various critical care units, medical-surgical units, and support departments such as Respiratory Therapy and Cardiac Rehabilitation in several South Carolina facilities. With over 12 years experience in theacute care environment, Teresa moved to Nashville where she spent almost a decade as Clinical Operations Coordinator for an internationally recognized leader in healthcare architectural design. Teresa facilitated process engineering services as a component of the design process for hospital renovations, as well as large-scale green field and replacement facility projects. Teresa assists hospitals and healthcare systems in all aspects of applying Lean to the master plan, design, and operational aspects of a facility design or clinical expansion. Teresa holds a bachelor’s degree in Business Administration from the College of Charleston, and a degree in nursing from Trident College in Charleston, South Carolina.

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.

Teachable Moment – Reducing Door 2 Balloon Time

Karen Wolk Feinstein, PhD
President and Chief Executive Officer
Pittsburgh Regional Health Initiative(PRHI)

Over the last decade significant strides have occurred in healthcare to elicit & listen to the expectations of our patient customers. In recent weeks, I had the experience of working with a group of caregivers to design a new process and physical space for pre & post procedure patient care, followed by an experience of staying with a friend before & after a procedure at a major teaching hospital. Interestingly, the second experience validated the design work of the previous week.  

The Lean Healthcare team started the event by attempting to understand the voice of the customer, from patient and family member stories. Several themes emerged from these stories; being informed and known by the caregivers, the need for privacy, space to move around for both the staff and the family, and amenities for family members all rose to the surface. The Director validated the consistency of these stories with the formal & informal feedback received from patients and their families. Lean Healthcare Design solutions centered around having the same staff and physical space for patients and staff, privacy provided by fixed walls instead of curtains or cubicles, flexibility with equipment on wheels and enough space to easily move around the patient.   

In particular the one design concept which stood out for me when I later was sitting with a friend was the need for privacy in pre/post procedure areas. Cubicle curtains were worthless in providing privacy to patients. Curtains by design have a gap to enter into the cubicle and frequently the gap is open at all the wrong times, leaving the patient feeling exposed. Anything being said behind the curtain can generally be heard throughout the unit.  

This simple example reinforces the need to involve our patients and family members as we use Lean Healthcare methodologies to design or improve processes. There are a variety of ways to obtain the voice of the customer when designing new processes, such as patient satisfaction surveys & complaint data, interviews, focus groups and patients as team participants. The key is to invite the customer’s voice into the process, listen to what is being said and respond by building in value as defined by the customer. 

This week’s blog was written by Maureen Sullivan, a senior associate at HPP. Maureen has over 28 years of healthcare experience in clinical nursing, management and quality leadership to Healthcare Performance Partners. Previously Maureen was the director of lean and quality improvement for Exempla Lutheran Medical Center and successfully led the implementation of Lutheran’s Lean production system from 2004 to 2008 demonstrating improvements in clinical quality, employee engagement, and financial stewardship. As a registered nurse, Maureen’s clinical experience is in medical surgical nursing with progressive responsibilities in nursing management at the front line, middle management, and administrative levels. Maureen began her quality management career in 1996, coordinating, facilitating and managing improvement and accreditation programs at a departmental, site and system level within Exempla Healthcare. Maureen has an associate degree in Nursing from Joliet Junior College in Joliet, Illinois and a bachelor of science in nursing with an emphasis in healthcare management from Metropolitan State College in Denver, Colorado. Maureen achieved certification from National Association for Healthcare Quality, certified professional in healthcare quality (CPHQ), Colorado State University in process mapping, and University of Michigan in lean healthcare.

A few years ago I was discussing plans for an upcoming 5S event with an area supervisor whose department was pretty well run on a daily basis. The supervisor stopped me in the middle of the conversation and asked me the following. “What is 5S? No really, what is 5S and what will it do for me and my staff?” She continued by adding  that her time and the staff’s time was very valuable to the organization, and allocating time for an event would have to be carefully planned and defined before moving forward. She showed me all of the previous 5S training material and even stated each “S” and what all she learned from the events and other lean training. I stopped and thought for a second before responding. It was evident that the department has had some success and the tool 5S was nothing new to them. No one had ever asked me about 5S in that manner before. Most of the leaders I have talked to have heard about 5S before, and they have done an event with little to no success. I asked the supervisor if she had a few minutes to walk on the floor and I would try to show her a better example of how 5S could work. She agreed. On our way to the floor, she quickly stated the 5S (Sort, Set in Order, Shine, Standardize, and Sustain) and noted that for the most part, most of the staff had embraced the 5S tool, but there was a few who always seemed to challenge the system.

Once on the floor, the first thing I asked her to do was to walk me through the system (as it was called) on a very high level. This took less than 10 minutes.  At the end of the process, I then told her that the both of us would spend about 5 minutes observing the process and each of us would write down what waste we saw and ask ourselves what is normal and what is abnormal. After the 5 minutes, we had written down a combination of 20 items we observed and agreed that they added no value or were just simply waste. We then categorized them into the 8 waste categories. Before I could even go into discussing what 5S was and what we as a team should focus on for the event, the supervisor looked at me as if saying “Alex I get it” you don’t even have to say anything. She started pointing out and showing me the current labeling and cleaning processes, some organized shelves and rooms, tape on the floor and racks to mark where items should be or belong, and even a 5S communication board that showed the departments’ accomplishments and score trends. What she said next is what really got me thinking and excited, “We did 5S, well the first three “S’s” very well. However, we really did not set or have a solid foundation to build on.” I asked her what she meant by that. She said, “Well, we did a 5S event and then washed our hands from it so to speak, hoping everyone would follow the new changes and hoped for the best.  Some of the items we wrote down were highlighted during the 5S event. We did a poor job planning the event; in fact we called a meeting and did everything in a conference room. Alex, P for “planning to see” should be the first S and O for “Ownership” should be the last S in 5S. The event should have been clearly planned on: what will be sorted, how things should and will be straightened, how, who, and when to do shining, how to simplify the standards so defects and errors are clearly visible and noticeable, and establish an owner(s) for the new changes to ensure sustainability. If our objective from our first 5S would have focused on improving 5 key things that added value to the process and sustain them, it would have been better than changing 15 things we are not even able to follow or sustain. Five improvements are so much easier to manage and follow-up on than 15 changes. We never established owner(s) in each step of the process and I never gave them the support to become presidents of their process. If each team member, including myself, would just own one improvement and educate the others on it, we would be so much farther along.” I thought she was a little too hard on herself, but it was very clear that she wanted to move the department from good to great. We set a follow-up meeting to come back to the floor at another time to complete the planning. 

I thought about what all she had said and especially the P and O in 5S. I couldn’t have agreed with her more. 

In lean healthcare, caregivers and leaders often relay to me that during a 5S event there’s always a high level of energy and everyone feels that things are really going to change and the improvements will be sustained, just to find out that the new changes must be managed somehow and by someone. Very little time is spent and thought is given in planning the outcome of the event. In fact, I can remember a time or two were I could have done a better job at planning. My sensei once told me that he has spent more than 50 years planning and doing 5S and he is still on the 4th S (standardize). He said that 80 percent of your time should be spent planning, 10 percent should be spent executing, and 10 percent follow-up. You should think about every process as a mini company and every company has a president. This is where the ownership is established so that when one improvement is made, the outcome benefits the company and ultimately the patient as well. 

5S events should be seen and managed as eliminating defects, errors, and confusion, and most importantly be about building a lean culture in your organization, even if it’s just 1 or 5 key improvements at a time. There’s much more than just pretty labeling, tape on the floor, or getting rid of unneeded items. It’s about system thinking, and waste should have no part in it. Cultivate a plan that will set in order ownership in your 5S program that will shine throughout the workplace. 

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.

This is part-two of a three-part series on developing strategies to stop upward delegation.   In many healthcare institutions across the country there are Managers whose daily work looks more like that of a Supervisor.  You will also find Senior Executives whose daily work is less focused on strategy deployment and more focused on resolving operational issues.  Most healthcare leaders are interested in breaking this trend, fewer know how.  Part-one of this series defined a strong prescription for stopping the process of upward delegation using three key concepts of the Toyota Production System (TPS or Lean).  The three key concepts included the appropriate deployment of:  Visual Management, Leadership Standard Work and A3 (Root Cause) problem solving. 

Part-one further illustrated the fact that outcomes cannot be separated from the processes designed to deliver them.  When processes are characterized by many “workarounds” outcomes are no longer predictable but, rather simply, a matter of chance.  This creates many small problems that evolve into bigger problems as customers demand higher standards of performance and care.  These become the sources of upward delegation.  By implementing a visual management system, care delivery teams begin to build a greater awareness of the impact of specific behaviors on outcomes.  Once identified, these behaviors can be managed on a daily basis.  Refer to Stopping Upward Delegation – Part 1 Visual Management, September 2009 for further detail on leveraging visual management.  The focus of Part-two is Leadership Standard Work.

Leadership Standard Work has been described as the “engine of lean” and as the “highest leverage tool in the lean management system” 1. Leadership Standard Work is based on the idea that all work should be “specified for content, sequence, timing, location and outcome” 2. This concept extends to include the work of leadership at all levels of the organization.  In simplest terms, Leadership Standard Work is a check-list of leadership activities to be performed on a daily, weekly and monthly basis.  What makes this tool exceptionally effective is that, when well defined, Leadership Standard Work drives process definition, disciplined adherence to process and daily accountability.  Remember, outcomes cannot be separated from the processes designed to deliver them.  When there is less than disciplined adherence to well defined process, then the outcome is, simply, a matter of chance.  This is a key difference between Lean Healthcare and typical Management by Objective (MBO) philosophies.  In an MBO context, if a bad process yields a good outcome…it’s a good thing.  In a Lean Healthcare environment, it means you got really lucky or worked really hard (excess processing waste) to overcome the obstacles of a bad process.  In Lean, the methods are equally important as the results.

Beyond being, simply, a checklist of leadership activities to be performed on a daily, weekly and monthly basis, Leadership Standard Work has three other key characteristics.  First, it is designed and built from the bottom to the top…not top down.  It must begin with managing the process.  Second, it has interlocking and layered accountability built into it.  This means that a portion of mid-level management’s Leadership Standard Work includes verifying functional adherence to front-line Leadership Standard Work.  This is not a process of micro-management.  Just as a well designed visual management system creates a line-of-sight between strategic imperatives and the specific behaviors necessary for their accomplishment; Leadership Standard Work creates a line-of-sight between those behaviors and the results.  Finally, it is dynamic.  As problem solving activities yield process improvements, Leadership Standard Work is modified to support these improvements.  New process in healthcare, typically, means new behaviors.  This should translate into new behavior based process metrics on the visual management system and updating Leadership Standard Work to drive disciplined process adherence.  These can and should be performed, very simply, within the natural stream of work.

If the connection between the behavior and the outcome is well understood and if it is tracked visually in a very simple way, no team member wants to be responsible for driving a miss by not performing to standard.  Performance misses become an opportunity for root cause problem solving, thereby reducing the number of “workarounds” and instilling both accountability and a disciplined adherence to process.  Process definition, disciplined adherence to process and daily accountability are further enhanced through the implementation of Leadership Standard Work.  Implementation of a well designed visual management system represents the beginning of the team’s journey into self-facilitation and begins to slow the rate of upward delegation.  Implementation of well designed Leadership Standard Work represents further commitment to self-facilitation and further slows the rate of upward delegation.  Together, these create a very close association and closed circuit line-of-sight between strategic imperatives, the behaviors necessary for their accomplishment and results.

Endnotes:
1.) See David Mann, Creating A Lean Culture; Tools To Sustain Lean Conversions.  Productivity Press, 2005.
2.) See Steven Spear, Decoding the DNA of the Toyota Production System. Harvard Business Review, 1999.

This week’s blog was written by Bradley Schultz, a director and consultant for HPP. Before joining HPP, Bradley was serving as Vice President of Operations & Quality for Infinity Resources Inc. where he pioneered the application of Lean, Six-Sigma, Work-Out™, and CAP (Change Acceleration Process) in the retail market sector. Bradley began his career in manufacturing with GE Healthcare and was working as a Manufacturing/Quality Engineer when GE adopted the Six-Sigma methodology from Motorola. In 1995, GE Healthcare began providing consulting services based upon these tools to its customers through its Performance Solutions business unit, pioneering the application of Six-Sigma in healthcare. Bradley joined Performance Solutions in 1996 during its infancy and remained with the business unit for seven years. Bradley’s educational background includes: a Bachelor of Science degree in Business Administration from Cardinal Stritch University in Milwaukee, Post Graduate Certification in Quality Engineering from Milwaukee School of Engineering, a Master of Arts degree 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.