Lean Healthcare Exchange

Richard P. Shannon, MD, is the Frank Wister Thomas Professor of Medicine at the University of Pennsylvania School of Medicine and Chairman of the Department of Medicine. Although he was trained as a traditional academic cardiologist, Dr. Shannon is now best known for his pioneering work in reducing health care–associated infections, first at Allegheny General Hospital and now at Hospital of the University of Pennsylvania. Since he is one of the first chairs of a major academic department whose career has focused on quality and safety improvement, we asked him to speak with us about safety in academic medical centers.

Click here to listen to the podcast of this interview with Dr. Richard P. Shannon, MD.

With the raging debate over health care, town halls all across America, have we lost sight of one of the most important goals, delivering better care while cutting costs? Griff Jenkins of Fox News sits down with the CEO of ThedaCare, Dr. John Toussaint in a one-on-one interview. They discuss the work that ThedCare has been doing and Lean tools and techniques such as Value Stream Mapping and 5S. Watch the complete interview below.

A lot happens in Kaizen events. Facilitators of the events must be aware of all of the different facets as they guide a group of people through the process. Facilitators can be swept into the process and begin to forget about important ingredients for success that lead to measurable outcomes. One of the key components that is easy to over look during an event is Team Building.

Team Building is the ingredient that can make or break Kaizen events. It begins even before the event begins. Then during the events, it is the engine that runs the creativity that leads towards successful ideas, communication and implementation. After the event itself is over, it is the catalyst that helps transform an organization and promotes follow through and continuous improvement.

Think about the situation for the facilitator, a small group of people is selected -some of whom may not have ever even met (including the facilitator). They are put together and expected to come up with a solution to a problem and implement as much as possible within five days. Then, to top it off, these same five people are required to continue to work together with a small action item list to complete the solution and even further improve it all while promoting its benefits to other people who were not even part of the team.

How can a facilitator accomplish this along with directing the group of people through the process? The answer is formal Team Building concepts and tools. The most important concept that is used is that teams go through several phases that lead to sustainability. These phases are called forming, storming, norming and performing. In Kaizen events, the facilitator must foster the team through these phases in a paced manner. The following is a guide for facilitators to use based upon a consecutive five day Kaizen event.

Day one is considered the forming day and should be very structured. Team members are brought face to face (some of them for the first time). Ask everyone to introduce themselves, tell the team their position, how long they are doing whatever they are doing and something interesting about themselves. Then use SPACER. It stands for Scope, Purpose, Agenda, Communication, Expectations and Roles (see previous blogs for more detail). After that, do some more structured activities such as training, simulations or direct discussions. This gives the team an opportunity to know one another in a controlled atmosphere. By the end of the day, begin some more unstructured activities such as walking the value stream and debriefing about observations. This fosters the team into the storming phase.

The storming phase is well named. Usually this occurs on day two. However, do not rush the team past this phase. If you do, the team will back slide later into this phase again. Since on day 2 the team usually talks about the current state, this will also bring out all of the frustration with the process. Team members who are part of the broken process will be defensive. Internal customers of the process will attack others. This is even truer in healthcare. Some team members will give their own predetermined solutions to the problem and go off on tangents. The most important part for a facilitator is to let everyone have “their fair share” in a constructive manner of the dishing out and the taking it. Keep the more vocal members restrained and the quiet members vocal. And oh yes, the facilitator must keep on track with the time table of having the current state defined and quantified for the report out by the end of the day. It is challenging, but very doable.

Day three is the norming phase. By this time, team members should be worn out from the previous day. Whatever energy they have recouped by the previous night’s sleep should be directed at finding solutions. Start the day by emphasizing the possibilities of the future state. All the reasons for the frustration they are empowered to determine how to eliminate. The team should be far enough in development to be able to break off into small self directed work groups. As a facilitator, it is imperative to give well defined time lines for reporting out to the larger team as they determine the future state improvements. By the end of the day, the team should be able to do most of the Future State report out to senior management with direction from the facilitator using a structured format. It is key to let the team leader be the master of ceremony for the report out. This will informally establish their authority.

Day four is the performing phase. The team should be able to work in sub-teams largely undirected. Just get them to be back at specific times to report on progress as they are preparing for the implementation. A facilitator should take note of the sub-groups who are having difficulty. The facilitator should go with the struggling sub-groups and foster their success. Mid-way through the day it is good to switch some team members around. This prevents the sub-groups from becoming sub-clicks of people instead of team members. It also encourages the switched team members to make sure the designed future state will flow seamlessly. By early to late afternoon of day four, the teams should be ready for trial runs of the future state. If time allows, have the team do a trial of the future state. This is where they actually “perform”.

On day five the performing phase continues with final trials and report outs. The team should be enthusiastic and able to develop their presentation material with quantified outcomes for the final report with assistance from the facilitator. Prior to the final report out, go over the roles of the team members going forward; their action items with timing and responsibilities; immediate expectations; and the expectations that they are to continue to perform as a team even after the event itself is over. Make sure the team leader is aware of their responsibility to keep the team moving.

The next time you are facilitating Kaizen events, keep these key points in mind. The success of the event reflects directly on the success of the team building effort. As they say, there is no “I” in team. As a facilitator, try to keep it that way.

David Pickens is the author of this week’s article. David is an HPP Lean Healthcare facilitator, consultant, trainer, and certified lean six-sigma Master Black Belt. Dave has a B.A in Statistics and M.B.A., and is currently working on his DBA.  Dave has worked with HPP healthcare clients throughout the USA by assisting them with their Lean Transformations. Dave has years of industry experience from his time in the automotive and consumer goods industry, including time with Panasonic, Allied Signal and BOSCH. He has trained with Matsushita in Hong Kong, Japan and Singapore in Japanese Manufacturing Management.

No, that is NOT a typo in the title.

Toward the end of a week long Kaizen Event and after her recent completion of the Lean reVIEW Problem Solving course, a unit manager made the comment to me that she wants her associates to bring her “solutions, not problems.”

I pointed out that this may be a popular management mantra, but in practice may backfire.

At the working level, an individual associate, working within a system, typically does not have a sufficient total-system view of a process to develop a solution that meets the needs of all stakeholders. People often implement with a  fire-ready-aim approach, and, while having the best of intentions, inflict a change that attempts to optimize their own process while causing unintended consequences up- and downstream in their value streams.

I proposed that this unit manager instead ask that the left side of an A3 Problem Solving form be filled out. (http://leanhealthcarewest.com/a3_problemsolving.html)  Issue, Background, Current State.  I also pointed out that the first question I always ask when presented with an A3 is “Who else have you reviewed this with?”  I want to coach the associate to discuss the issue with other players in the process to understand how the current work flows (or doesn’t flow) and why steps that may seem unnecessary are relevant (or not).  By taking a total-system/ holistic view of the problem and work flow involved, a solution can be found that improves the system as a whole instead of making a local improvement that may have a negative net effect to the value stream. 

Also, by fully documenting the current state with data and doing a detailed analysis (ask “Why” 5 times), I frequently find that solutions present themselves in a straightforward, logical manner.  Discussing again with affected associates lays the ground work for everyone to understand the rationale for change.  Do they really perceive this to be a problem?  Is the impact severe?  Does it happen often?  Can we catch the mistake when it happens? 

So my suggestion back to the unit manager is welcome problems, encourage involvement, and coach the A3 tool. 

This will lead to solving problems instead of implementing solutions that may not hit the mark.   That’s Lean!

This week’s blog was written by Richard Tucker. Richard assists HPP clients throughout the USA with Lean Healthcare transformations. Richard has many years of Lean experience having worked with a major Japanese automaker, and having received much of his experience and formal training in the Toyota Production System, Lean Manufacturing, and Shainin Statistical Engineering while in Japan.

Many of the regular readers of this blog are familiar with the 6 principles that define an Ideal state in the framework of Lean (the Toyota Production System). As a refresher, these are:

• Provide what the customer needs, defect free
• Provide the output of the process on a ‘one by one’ basis; customize as much as possible, to whatever each customer needs
• Provide what’s required on demand, exactly as requested
• Provide an immediate response to problems or required changes
• Provide what’s required with a minimum of waste
• Provide what’s required safely, both for the customer and the provider

Those of us who enjoy the mobility associated with modern day air transport recognize that airline travel could benefit significantly by employing the Lean concept of an Ideal process. If you look at each of the points above, you may recognize that the process of airline travel is often OPPOSITE the requirements of an Ideal process.

Recently I’ve run across several articles about Alaska Air’s process improvement effort to enhance their customer arrival process at the Anchorage International Airport. Process improvement is not new at Alaska Air; they were one of the first airlines to allow passengers to choose seats and print boarding passes via their internet site. When a new concourse was under consideration for the Anchorage terminal, a natural opportunity arose to conduct a detailed process investigation on this critical ‘front end‘ process. From what I’ve read about the outcomes of this effort, the new passenger arrival, check-in and baggage checking process will be a major improvement over what is typically available in most ‘lower 48’ airports.

When the new process is fully deployed, Alaska Air’s new terminal configuration and passenger arrival process will handle their annual 1.2 million passenger check-in’s with NO passenger lines (providing what every customer wants on demand, as requested). By focusing on process flow, Alaska Air has developed a strategy to process all passengers (even during their peak travel periods) without waits, utilizing 50% less terminal floor space than the prior process and eliminating significant passenger and staff travel and motion (providing what’s required with a minimum of waste)!  Alaska Air’s management team expected a 20 to 30% increase in employee productivity as an outcome of their process improvement effort, but passenger agent time per passenger has been reduced by something closer to 50%. Lost or misrouted baggage rates are also expected to  reduce significantly (providing what the customer needs, defect free). 

Their current efforts may not get them fully to the Ideal, but every step they take closer to Ideal rings waste out their processes for their customers and their business!  In Healthcare, organizations on a Lean journey moving toward the Ideal State are seeing significant improvements in patient and provider wait times, driving up satisfaction scores across the board.  Productivity improvements are lowering costs and making the work easier, while creating a safer environment for all.

Think about what’s possible in your organization!

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.     

Acronyms abound in the Lean world and it’s sometimes a challenge to remember the meaning behind all that vegetable soup!  But here is one that is growing in the realm of corporate social responsibility that deserves a pause for inclusion: the 3 P’s that should be making their way into our Mission and Values:

People
Planet
Profit

The obvious interdependency between the people (customers, suppliers, workers) and the planet (alarming recent exposes of human influence on the environment on which we rely) weigh heavily on our ability and methods for creating profit and sustaining our services.  Balancing the focus of our work to achieve  Ideal in all of these areas is going to be essential for success in this exciting century.

This week’s author is Cindy Jimmerson. Cindy leads HPP’s affiliate company Lean Healthcare West and is a pioneer in Lean healthcare having initiated her work with a grant from the National Science Foundation, 2001-2004. She is the author of the Lean Healthcare West Review© Course and many journal publications. In addition, as part of the HPP’s Lean Healthcare West team, Cindy travels internationally speaking on the subject and organizes the National Lean Healthcare Conference. Cindy has been featured in Industry Week, Business Week, and numerous business and healthcare periodicals for her work in Lean Healthcare and has been a featured lecturer on the subject at the Harvard School of Medicine. 

A critical part of Kaizen Events is Follow-up.  While every improvement idea possible should be tested and implemented during the 5-day Kaizen Event week, there are always follow-up action items that must be completed to achieve the new future state.  Actually, there are 5 phases to Kaizen Events: Planning, Preparation, Training, Execution (Event week), and Follow-up.  This blog is about the 30/60/90 Day Reviews in the Follow-up phase.

The purpose of these formal Reviews after each kaizen event is to:
1. Drive implementation of the action plan, and
2. Keep the kaizen team and leadership engaged in the kaizen process.

They are not a replacement for weekly meetings to check progress by the kaizen event owner (department director).  These meetings are to celebrate progress, expose problems, and make decisions about resources and priorities.  There is no place for blame in these structured and intentional meetings.  The meetings should not be longer than one (1) hour to force effective use of everyone’s time so that they can get back to delivering or supporting patient care.

The agenda for the 1 hour reviews is:

1. Review the kaizen event objectives and business case (why we did the event)
2. Review key metrics (use graphs to show any trends)
3. Review the status of every action item (visually note status green for on-schedule or red for behind) – action items should be presented by those responsible for implementation
4. Observe the improvements in the process to validate them (complete means there is a process in place to sustain change)
5. Request help needed/make additional support decisions
6. Share new learning and waste identified during action item implementation.

The participants include the kaizen event team, the department director, administration staff members and other department directors with departments that are supporting or are affected by the Kaizen Event, and the CEO (at least in the 30 Day Reviews).  The number of formal reviews is determined by how long it takes to complete all action items necessary to achieve and maintain the Kaizen Event objectives.

So, celebrate what was accomplished with the Kaizen Event team on Friday of the Event week, take a break over the weekend.  The real work begins on Monday and leaders must check and support progress after the Event.  Don’t wait until the 30/60/90 Day Reviews to do this, but don’t forget them either.

This week’s article was written by Dwayne Keller, VP and coach for HPP’s healthcare client companies. Before joining HPP, Dwayne spent many years with Alcoa in senior leadership roles and overseeing the Lean transformation of numerous facilities. Dwayne also worked with Michelin and DuPont in various management and engineering roles.  Dwayne holds Masters and Bachelors degrees in Mechanical Engineering from Bucknell University and a MBA from Clemson University.

As the “Lean Movement” has made a toehold in healthcare in recent years, the personal skills of healthcare workers are likewise becoming more sophisticated in the realm of process improvement.

In the minds of clinical providers and supporters the term “process improvement” once conjured visions of quality directors and engineers with clipboards, but education and experience is changing the way frontline workers look at work and how leaders lead.  While terms from manufacturing greats like Toyota once raised eyebrows in the clinical setting, those same phrases are now inspiring workers to take a hard look at opportunities to make their service and their jobs much more satisfying.

Experience with the simple but straightforward concepts and tools of Lean  has boosted frontline involvement in making the way we work “work” better.  Applying the soul-deep philosophy of Toyota, respect for workers and creating the motivation and expectation to change work when the necessity arises, is at the heart of changing the culture of our industry.  

There is so much more to discover in the application of “thinking Lean” that it is exciting to anticipate what upcoming professionals will create with this new skill and how it will change the face of healthcare in the future.

This week’s entry was written by Amy Jimmerson, an associate of HPP’s affiliate company, Lean Healthcare West.  Amy has worked with both hospitals and small to mid-sized medical practices throughout the West and Rocky Mountain states with the implementation of Lean Healthcare principles and assists in the facilitation of our Lean Review © course.

LEAN is about change and you cannot force anyone to change. I know because I tried to change people for almost thirty years, as a VP of Operations of 5 different companies. I was never successful in changing people. People do not accept change for many reasons such as: “I have been successful, so I must be doing something right, and I don’t want to risk it.” Another frequent reason is that: “Management won’t let us change, I tried that once before and it didn’t work. I told management lots of my ideas years ago and they did nothing.” There is frequently a culture of maintaining the status quo, avoiding risk, just working around the problem and continuing to firefight rather than change the process. People have to want to change themselves, as culture change happens one individual at a time. It is personal.

So how do we get people to embrace change? People accept change that they are a part of creating. It requires a shift in the paradigm from “I’ve always done it that way,” to creating a new process that will allow them to be more successful. They need to implement solutions that they believe will work better, provide better patient care, and make it easier for them to do their jobs.

New experiences are required to have new (better) outcomes. Here is a simple model to describe the change process. Change requires new Experiences, which leads to new Beliefs about how the work should be performed. The new Beliefs will lead to new Behaviors. The new Behaviors will create new Outcomes. This will allow the people doing the work to be more successful. Work becomes easier, simpler, with less stress, and greater job satisfaction.

During a Kaizen Event, we have the people who do the work observe their peers, collect data and draw spaghetti diagrams to see first-hand the inefficiency and waste in their present work processes. This begins the task of getting people to think there may be an easier, better way. During the week, the team develops new ways of thinking about the work and creates new processes. These new processes are then tested and data is collected to provide the new Experiences and Beliefs that the changes will make jobs easier, rather than harder. The participants begin to share their new Lean learning with their co-workers (new Behaviors) as they are now more open to change. At the end of the week, they return to work with some new Behaviors which will lead to improved Outcomes.

However, change is not always easy and it does not come without hard work and a team effort. During the week, there is often a roller coaster ride of emotions as the team goes through the development steps of: Forming, Storming, Norming and finally Performing. The week starts with everyone dubious about the value of the Kaizen Event. It can get more emotional from there as they wrestle with how these new concepts and tools will work in their areas. As the week goes on, new Lean ideas are generated and become the TEAM’S ideas. The new processes are proven by trialing the changes, observing the new way of doing things, and quantifying the savings. This is the basis for the new Experiences required for change. Shifting the team members’ paradigms and replacing them with new ways of working takes time. People think differently about their job and begin to have new Outcomes at the end of the five days.

Kaizen Events are one of the many new experiences that are needed to begin and sustain a Lean Transformation. The length of the events must be adequate to make real change and allow the participants time to absorb the new ways of thinking about and doing work. These are some of the key reasons why Kaizen Events are 5 days in length. Over time, as the new Lean knowledge and experience takes hold, they can be applied to smaller scope problems in 2, 3 or 4-day events. The important thing to remember is that Kaizen Events are as much about building Lean Capability in your organizations as they about getting improved outcomes.

Bill Lowstuter has been a Sr. Consultant with HPP since its inception, and has worked with healthcare clients throughout the USA. Bill previously worked with HPP’s parent company, The ACCESS Group (TAG) for seven years prior to joining HPP. Bill has overseen the implementation of Lean within numerous facilities and industries, and has a Bachelor of Science degree in Engineering from the University of Illinois. He has also conducted numerous seminars and conferences in Kaizen principles and Lean.

In today’s information age we are constantly bombarded with new discoveries.  We have become so accustomed to new thoughts and ideas being introduced that only rarely does a concept come along that so flies in the face of conventional wisdom that it is truly fascinating.  I was recently introduced to such an idea in an article from a May 2007 issue of Newsweek. 

The article (“Doctors Change the Way They Think About Death”) describes the research of Dr. Lance Becker, the Director of the University of Pennsylvania’s Center for Resuscitation Science.  Dr. Becker’s research on when and how cell death occurs challenges the traditional approach to heart attack treatment practiced daily in ERs throughout our country.  While I am certainly in no position to weigh in on the clinical merits or deficiencies of this work, I can say with confidence that this is one of many examples in recent history where medical research has challenged conventional wisdom to realize significant breakthroughs.

I Thought This Was A Lean Blog!

You may at this point be thinking, “Yes, an interesting article but how does this have anything to do with Lean and process improvement in healthcare?”  Simply put, research like Dr. Becker’s is a testament to the energy and innovation with which healthcare pursues improved methods of treatment.  As a Lean thinker, the question that this brings to mind is, “Isn’t it time to place the same level of energy and innovation toward HOW care is delivered?” 

As we work with healthcare providers across the country we see a consistent theme of modern treatment accompanied by out dated processes.  So often we observe processes and value streams that are an eclectic patchwork of personal preferences, regulatory guidelines and none other than conventional wisdoms.  In order to bring these processes up to speed with the treatment they deliver we must begin to question and innovate. 

Lean is the perfect tool to lead this new wave of innovation as it fosters the constant questioning of each step in the process and the value that it adds.  True innovation can occur through this process, transforming the patient experience while assuring the safety and efficiency of care.  The opportunities are abundant but in order to improve we must begin the hard work of challenging the conventional wisdoms of the industry to discover new and innovative ways to deliver care.

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