Lean Healthcare Exchange

I reach for the hand sanitizer station to disinfect after coming through airport security.  (Do I feel dirty because of the germs, or the way I have been treated?)

*Spffft-t-t-t*  Nothing

Again.  *Spffft-t-t-t*  Again, nothing.  (“It must be empty”)

Looking a few feet further, I see another sanitizer station.  (“Cool, a second one.  Just like a 2-bin delivery system… one is empty, another one waiting behind, ready to serve…)

*Spffft-t-t-t*     (“Can’t be empty, too.  Just needs…

*Spffft-t-t-t*     to

*Spffft-t-t-t*     be

*Spffft-t-t-t*     primed…)

Hmmmm….  (“Defect/Rework, one of the 8 Wastes of Lean Healthcare”)

I look around.  TSA agents swarming around.  A uniformed police officer diligently standing across the aisle. (Perhaps scanning for that 6 year old girl on the terror watch list?) 

My Lean Healthcare eyes kick in. 

• Problem one:    Empty sanitizer.
• Problem two:    Second empty sanitizer.
• Problem three:  No system to recognize that problems one and two even exist, and no response if they were pointed out.

Applying lean principles to this problem would require:

• First:   A standard.  (i.e. hand sanitizer comes out when hand under dispenser)
• Second:   A method to recognize the deviation from the standard at a glance.  (Maybe a mailbox flag attached to the side of the dispenser that is flipped up when it runs out?)
• Third:   A response.  (Think of Rule 4: Problem solving close to the work.)  Who is responsible for refilling these?

But, I have a plane to catch.  Who should I tell?  Would I be flagged as a trouble-maker for point out this problem?  (Perhaps added to the aforementioned list?)  Should I as the customer be troubleshooting this problem?

Having spent some time applying Lean Healthcare tools and philosophies to improve processes in hospitals, I ponder “What would a nurse do in such a situation?”  Of course!  Have my own back up supply!  I reach to the side pocket of my backpack where I keep my stash.  A 73ml bottle of 62% Ethyl Alcohol Gel. (Moisturizing!  With Vitamin E!  Keep away from heat and flame!)

Rubbing my hands together, I head toward my departure gate. 

Perhaps we should submit a proposal for some “Lean Hand Sanitizer” work to go along with our Lean Healthcare work?

If you haven’t already caught the Lean Healthcare bug, be duly warned.  Once you start seeing processes in this new light, you will see Waste and violations of the 4 Rules-in-Use behind problems you encounter every day.  Can you find similar issues in your own processes?  Are you going to take command of the situation, Eliminate Waste and apply the 4 Rules-in-Use to develop a system that always works? 

Don’t let your process be the one that is called out as a bad example in the Lean Healthcare blogs!

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. 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.

Seldom if ever do we recycle our newsletter material. We want to keep our newsletters both fresh and innovative. But, this week we couldn’t resist,  plus we’ve added over 3000 subscribers around the world since our last release of this article.  I’ve had a number of conversations this past week at various sites about COW’s. You know, those computers on wheels.  I thought we’d re-run a popular article from a couple years ago and republish it, which takes a humorous but oh so true look at this subject.  Enjoy! And, don’t forget to join us in Nashville on May 18^th at Belmont University for our National Lean Healthcare Powerday.  Slots are limited and are going fast, plus we anticipate the event to be sold out.  Charles Hagood, President of HPP, Inc.

“Tech support, this is Alex,” he answered, sipping his mocha double latte.

“Hello Alex, this is Hazel up on Cardiac 6 West.  We have a dead COW up here.”

“A dead COW?!?!” he sputtered.

“You know, COW, Computer On Wheels.  They were supposed to help us monitor meds.”

“Sorry, Hazel.  I’ve been in tech support for seven years and just got into healthcare.  I have never heard a computer called a COW!  But anyway, what can I do for you?”

“I told you it was dead.”

“Dead?”

“Yep.”

“OK, let’s see here,” as he pulled up the troubleshooting guide for the MCD/Mobile Computing Device, thinking to himself, “Why can’t we at least use common terminology?”

“Let’s see…are you plugged in or mobile?”

“I would say mobile right now.  Before you get started, let me tell you that we know the script for restarting these things.  Restarted the application, check.  Plugged it in (the battery might be low), check.  Tried to repair the wireless connection, check.  Disabled and re-enabled the wireless manager, check.  Rebooted from complete power down, check.”

“Great, did you…”

“Did you know I can go get vitals and chart them quicker than I can do all this stuff?  I AM a nurse!  Can you assess a patient, start an IV?”

“Uh, no.  What else did you do?” Alex asked tentatively.

“Well, I pretty much exhausted MY tech support skills, so I fell back on my nursing skills.”

“Nursing skills?”

“Yep, I pulled a saline IV and started a drip.”

“On the computer?”

“Yep, stuck it straight in the USB port.  That didn’t help much, so Karen and I decided to call a Code.”

“Code?”

“Yep, Code Blue.  Cardiac arrest.   We grabbed the defibrillator and shocked it three times to restart the CPU.  That’s when it started smoking.”

“Smoking?!?”

“Yep, after the third one we heard a loud POP.  So I tried manual compressions on the keyboard.  We worked for 30 minutes right there in the hall before we stopped.  So now we have a dead COW… and a bunch of exhausted nurses—we did everything we could.  Probably even broke the cart.”

After a long pause, Alex offered, “Uh, let me get my supervisor.”

From a lean healthcare perspective, clinicians fighting technology creates waste.  Patients wait.  Staff members get frustrated taking valuable time (and mental focus) away from providing patient care. 

Is “support” a verb in your organization?  Does the technology support the caregivers and their work?  Or does the caregiver become “tech support” (a noun) instead of caring for patients?  Ask yourself these questions the next time you are out on a gemba walk.

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. With his work in healthcare, Richard has lead teams in the utilization of lean healthcare tools to eliminate waste, giving back precious time to the front line caregivers to focus on their patients. One project eliminated over 2 miles of walking (and one hour of time) per nurse each shift by relocating frequently used supplies closer to the point of use. A critical care team standardized the care of central line catheters to significantly reduce blood stream infections and improve staff satisfaction with the new process. 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.

I frequently face a challenge when trying to coach Rule 4 of the Four Rules in Use (Improvement Close to the Work).  In lean healthcare, we want problem solving close to the work (in space and time) by those doing the work.  But many of the problem solving activities that we are doing in an initial lean activity (Kaizen Event or A3 Problem Solving in a reVIEW class) is really not what I would call “true” problem solving.  What we are modeling and demonstrating is really doing some basic clean up of fixing broken things and standardizing processes.  I have added several levels of problems, as a way to contrast what I am doing and where I want to get to eventually.

1. Broken things
2. No Standard
3. Standard Not Followed
4. Standard Not Ideal

When we do have a problem, the first question we will ask is “What happened?” and “Did we follow the standard?”  Of course, if there is no standard, we cannot have followed it.  If equipment is broken, that will prevent us from following the standard (had it actually existed to start with).
 
If there IS a standard process and our equipment works such that we CAN follow the standard, we must have some means to monitor if we actually followed the standard.  And, if we have followed the standard, we must ask ourselves if the standard is ideal (meets the customer requirement with minimal waste)
 
To sustain a change, we must monitor the process (such as tracking OR Turnaround Time or ED Patient In Room to Discharge Times).  As we monitor the process, results must be compared against the standard and problems documented when we deviate from that standard.  By collecting the problems, counting and prioritizing this information will direct us to the next, deeper level problem and lead us to a root cause to permanently put to rest.
 
We must change our thinking from a problem being broken items and bad outcomes, to the view that a deviation from a standard is a problem and continually move our processes back to that standard.  Only then will we sustain changes implemented in our lean healthcare activities. 
 
The highest level of process management in lean healthcare is to have a standard that is consistently followed and deviations from the standard are recognized, then the next question will be “How can we improve the standard?”  This 4th level of problem solving is the only true improvement.

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. With his work in healthcare, Richard has lead teams in the utilization of lean healthcare tools to eliminate waste, giving back precious time to the front line caregivers to focus on their patients. One project eliminated over 2 miles of walking (and one hour of time) per nurse each shift by relocating frequently used supplies closer to the point of use. A critical care team standardized the care of central line catheters to significantly reduce blood stream infections and improve staff satisfaction with the new process. 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.

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.

(Many of my article ideas come from questions posed to me, here’s the latest.)
 
There are 2 points of view in play here:

• The “purist” view
• The “pragmatic” view

As a lean purist, the Patient is the Customer.  They receive the benefit of the service.  With multiple other internal-external customer relationships.  All activities should be assessed with respect to the value to the patient.
 
Having worked in healthcare, there is also a pragmatic/realistic view of the situation.
A customer does several things:

• “Consumes” the product or service
• Pays for the service
• Possesses the Right to Select the provider

Clearly the patient is the “consumer” customer.  This would follow the purist view.
 
The insurer (commercial or government) pays for the service.  But from a process perspective, the payor is so far removed from the surgery process as too be irrelevant to any analysis of the current processes in most surgery departments.
 
In a situation where surgeons are independent contractors with respect to the hospital, they clearly have the Right to Select which hospital to perform surgery.  The typical patient does not even select the surgeon.  The access process would be a referral from the patient’s PCP to a particular surgeon that they are familiar with and/or are on the list (from the insurer) of acceptable surgeons.  And, while a patient or insurer may be the payor for a given surgery, the surgeon brings an enormous revenue stream to the hospital over the long run.
 
Another characteristic of a customer is that they “can complain and get a response”.  Would a hospital administrator be more upset if one patient decided to go to another hospital, or if one surgeon decided to take all of his revenue somewhere else?
 
The system drives the hospital to keep the high revenue surgeons happy, and many will wield this influence to get what they want and need.  Maybe at the expense of other priorities.
 
So what are the Lean folks to do?
I recommend a twofold approach.  First, you must keep the patient in mind as the primary customer.  They need a safe, effective, satisfying surgical experience.  Many processes can be optimized with this in mind.  Many “patient dis-satisfiers” could be eliminated by eliminating waste for the nurses.  Is my blanket warmer out of blankets (and it takes 30 minutes for them to get warm if I load it right now)?  Can the nurse find needed supplies?
 
But, you must also keep a keen eye on the surgeon’s perspective. 
Would you rather work with a hospital where:

• You can do 4 cases in 6 hours and leave, or where you are there all day to do 2 cases because everything is scheduled “To Follow” on a “First Come-First Serve” basis?  
• OR Turnaround is just chaos?  Equipment cannot be located, or pieces are piled on a shelf in the equipment room and staff has to scavenge through them like a rat at the trash heap?
• Hospital staff cannot tell you if your next patient is even in the building, much less prepped and ready to roll?  
• Your 9am patient is still in the waiting room, because all of the Day Surgery beds are filled with patients that are scheduled for this afternoon.
• The patient is “ready” but they cannot find the H&P your office faxed over yesterday?
• You wait on an inpatient because transport has been “optimized”, but an OR suite and crew wait for 30 minutes during peak transport periods. 
• Do you want to be up to your elbows in somebody’s gut and find out a needed supply is out of stock or cannot be found?
• Do changes get made to preference cards in a timely manner?  Or are there only a couple of scrub techs who know what I need for a case?

All of these are problems that can be approached with lean healthcare tools and methodologies.  And ultimately, if you fix these problems for the surgeon, you can also provider safer, higher quality care for more people with the existing resources.
 
Spend some time observing.  Listen to staff (surgeons, nurses, techs, clerks at the OR desk).  Just pick a place and start.  The clock is ticking.  Is it Value Added time that you spend on the philosophical question of “Who is really the customer?”

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. Richard’s educational background includes BS and MS degrees from Tennessee Technological University in Cookeville, Tennessee.

This question was recently posed to me and I could not help but jump at the chance to formulate a response.  From my personal experience, there are several aspects of the shortage of nursing that lean healthcare can address:

• Waste                                                                                                    
• Nurse Turnover
• Capacity/ Demand Mismatch
  (and I am sure there are others)

WASTE
As mentioned by many before, if a nurse is spending her time on WASTE (not wasting her time), it may look like you need more nurses.  I followed an ED nurse for several hours and found that storage locations required her to make a 200 ft round trip to get supplies.  She told me that she typically went for supplies about 5 times per hour over her entire 12 hour shift (this was consistent with my observations).  5 trips/hr X 12hr/shift = 60 trips/shift X 200ft = 12,000 ft per shift per nurse.  I hated to tell her in my debrief of the observation that she walked about 2 miles per shift for supplies.  To administer an IV antibiotic required going to a Med Room to get the antibiotic, Clean Utility to get the IV bag and the tubing was in the Omnicell near her work station.  (This was a large ED with multiple Nurse Stations). 

We trained staff in lean healthcare tools and methods and went through the supplies with a team made up of RNs, ED Techs, Pharm Techs and other ED staff.  We considered frequency of use, billing method (not wanting to create lost charges), reorder method (Omnicell trigger versus manual counts by ED secretary), reorder quantity (do you want to login and push a button every time you want a single tongue depressor?), type of med (Narcotic, etc.).  We also liberated premium space at the Nurses Station that was occupied by >6 months of forms.  (180 stacked inches to start, 9 inches were used in 10 days)  We made a video of before and after showed that the steps/time saved while getting the 3 supplies for an IV antibiotic was 89 steps/62 seconds.  Multiply this minute saved by 60 trips per shift gives you about an hour of nurses time that can be redirected to something constructive (like patient care).

NURSE TURNOVER
There was a recent article in USA today “Nursing shortage: 1 in 5 quits within first year, study says” [Google "Nurse First Year Turnover" to get more].  Not surprising given the chaotic work environment typified by lack of standards (in the sense of everyone doing things differently), broken systems, Unevenness and Overburden.  For RNs that have been there for years, they just “know where things are” (actually they know the popular hiding spots, but still have to search).  New nurses just have to figure things out for themselves after “shadowing” experienced RNs who typically all do the work differently.  What IS the right way?  Lives depend on you doing the right thing.  Not to mention the frustrated (if not burnout and cynical) staff, patients, physicians and hospital administrators that you have to deal with day in and day out.

Directionally, applying lean healthcare tools to remove waste and improve work flow will reduce nurse turnover, but it is a trend that will manifest itself over time.  I believe that one of the biggest potentials of process improvement is giving people hope that the system can actually be improved.  In one Kaizen Event, we found out on Wednesday that one of the nurses on the team had turned in her notice the previous Friday.  We were irritated at first that we were “wasting” this transformational event on someone who was leaving.  As it turned out, she decided not to quit based on the improvements we made that week and the hope that things could be improved.  [For the financial folks out there, research published by the Journal of Nursing Administration, Jones, 2005, estimated ~$65k to replace a nurse!]

Will having functional lean healthcare systems and standard work (where applicable—we are not making widgets) reduce nurse frustration and turnover?  Do nurses go to school to become “professional scavenger hunters” trying to find supplies, or to care for patients?  Is anything else working to improve the situation?  Can we let it just stay as it is now?

CAPACITY/ DEMAND MISMATCH
This is an interesting problem because of the “novelty” of looking at capacity/demand in healthcare.   (a basic lean manufacturing tool).  In ED’s, the problem presents itself as long waiting times.  However, you can’t fix the wait time, you must fix the capacity/ demand mismatch. 
IHI’s Web&ACTION, Using Data to Assess and Improve Operational Performance in the Emergency Department, is a great tool to start looking at where to focus your lean healthcare efforts in your ED.  By looking at the demand versus capacity for your primary resources  (Room, Triage, RN, MD), you can strategically apply your improvement efforts.  One way to increase nurse capacity is to hire more nurses, another is to eliminate waste.  If every RN spends 30 minutes per patient (including all patient interaction, supply gathering, charting, etc.)  One RN can manage 2 patients per hour.  If 10 minutes of waste can be eliminated, the “work content” is reduced to 20 minutes per patient and capacity is increased to 3 patients per hour, a 50% increase in RN capacity!  Is this realistic?  According to research funded by the National Science Foundation, “The national numbers for waste in health care are between 30% and 40%, but the reality of what we’ve observed doing minute-by-minute observation over the last three years is closer to 60%.” (Lean Healthcare?  It Works!, Industry Week, Nov. 2003, p36, Jimmerson)

I have also applied a similar model to improve patient flow in an Urgent Care Clinic, increasing patient throughput by about 20 patients per day across the existing resources (i.e. no additional RN’s).  In addition to eliminating waste in several processes and improving room utilization, we moved “non-nursing” work off of the nurses to other qualified staff to allow the nurses to focus on patient care.  We started this activity due to patient complaints and long wait times, but by eliminating waste and increasing throughput, we not only reduced wait times and increased patient satisfaction, but also increased revenue!  And because we used a “teach them to fish” implementation model, the staff has continued to make improvements for months after our initial activity.

Without the lean healthcare activities, the standard answer was to build more rooms and hire more nurses.  We spent less than $40 at the local office supply store to implement visual controls to better see the current state of RN  and X-Ray Tech activities.  All other countermeasures were process changes.

 “Can lean help to improve shortage of nursing staff?”  ABSOLUTELY!

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.

One of the trickiest things with leading lean healthcare improvement activities is resisting the urge to rush ahead with insights based on your knowledge and experience. 
 
I often find that I will run across a problem that has a similar “pattern” to problems that I have dealt with before and have this immediate “flash of brilliance” on how to solve the problem.  I have learned through experience that this is a sure fire way to have a problem blow up in your face. 
 
Experience tells me that one of two outcomes are highly likely:  

1.  you are correct, but no one else can see what you see, or
2. you are wrong and you go down the wrong path. 

There is also the remote possibility (a.k.a. delusional desire) that you are correct and everyone else immediately agrees with you and does exactly what you want.  (I once heard that this actually happened to the acquaintance of a friend of a co-worker’s cousin…)
 
In the first case, you are correct, but you cannot get anyone else to go along with your desired solution, because they do not see the problem as you see it.  So you spend your time trying to convince them, or, if you have the authority and/or leverage, just force them to do what you want because “I said so.”  Expected outcome– you will either stagnate because there will be no movement at all, or, for the passive-aggressive crowd offended by your lack of respect, people will “maliciously comply” to the letter of your request while avoiding/ignoring your intent and doing their best to make sure it does not work.  Thus proving that you really don’t know what you are doing and don’t need to be kept around. 
 
In the second case, people will follow you blindly, trusting your “individual expertise” (a dangerous concept in the world of process improvement in complex systems) and go happily down a path to failure.  The end of this cul-de-sac is a place where you can look like the fool that you have shown yourself to be.  The team has the plausible deniability of just relying on the “expert.”  Thus proving that you really don’t know what you are doing and don’t need to be kept around.  I have seen many a work team eliminate management folks that don’t work well with them by using just such tactics.
 
The key to the situation is to let go of what you know.  You must go into each situation with a “beginner’s mind” and together with the team truly try to understand the current state without any experience based bias.  I would be amiss to say you must ignore your experience totally.  You may recognize a similar pattern from a previous problem, and you may use that knowledge to guide your analysis and selection of the proper tool/method to clarify the problem, but don’t be biased for or against a particular solution. 
 
Don’t play the role of the Lean Healthcare Expert who has all the answers.  Let go of what you know and play the role of the inquisitive lean healthcare student who truly wants to understand the process and respect the people along the way.  Here you will find that by tapping into the knowledge of the entire team you will cause change to happen because the team understands the problem and the need for change.  And, if you have approached them in a constructive and respectful way, they will be open to your guidance on possible solutions. 
 
This will lead to a desire to improve and a commitment to succeed. 
 
Let go of what you know and let the lean healthcare knowledge and process expertise grow out of the team and the improvement process.

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.

I was sitting at the stop light and just as the light changed, my wife said “There’s a blue light.”  So I hesitated before going, checking for a police car.
“Why didn’t you go?” she asked. 
“Because you said there was a blue light.”
Confused, we both let the conversation fade away.

After several instances of this, I asked her why she kept telling me she saw a blue light and she asked why I didn’t go when the light turned blue. 
“When the light turned blue?”  Hmmm.  Sounds like we have a failure to communicate.

My wife is from Japan and in Japan, the shade of green used on some traffic lights here in the United States (a bluish, aquamarine sort of green) would be called “blue”.  I think I would call the “go” light on a traffic light “green”, even if it was purple, because for me “green” and “go” are synonymous.  Unfortunately, I cannot convey in writing the big “ah-hah” feeling we both had when we finally figured this out.

So it must be because of the language difference, right?  Maybe not.  You would be amazed to see the number of times we see communication problems because of unclear definitions and using the same word to mean different things in healthcare.

A recent value stream mapping exercise brought out the fact that one root cause of patient flow problems in a surgery department was that “ready” did not mean the same thing to everyone. 
For a surgeon or circulating nurse, “ready” meant “the patient can roll to the OR”. 
For an outpatient nurse, “ready” meant “I have done everything that I am supposed to do.” Patient prepped, IV started,  labs drawn and sent to lab.  But, the lab results may not be back and H&P needs to be signed.  Was she wrong?  Not really.  From her perspective, she was “ready” to move on to the next patient.

So you can imagine the communication problems that resulted from this.

But this is not an isolated incident.  I have seen this same “ready” problem at hospitals in two different states.  I have seen heated discussions over what was and was not happening in a process only to find out (after 3 days!) that the root of the miscommunication was using the same word to mean different things. 

The doctor tells the patient that they have “discharged” them.  For the doctor this meant they wrote the order.  But the nurse may have to draw final labs and give discharge instructions before the patient can leave the building.  Transport will say they have discharged the patient when they take them to their car.  Bed Control may say the patient was NOT discharged even if the patient is gone because the discharge is not entered into the electronic tracking system.  You’ll get three or four different answers depending on who you ask.  And the patient feels like they have been kidnapped because they can’t leave even though the doctor already “discharged” them.

So the next time you are trying to understand a process, don’t assume you know what people mean. Listen to make sure that they are not using the same words to mean different things.  You may have a few ah-hah moments of your own.

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.

“Why didn’t you tell me?”  Not an uncommon question for a lean coach.  (I thought I did tell you.)

You’ll often hear that lean healthcare is best learned with a “Learn by doing” approach.  There is a shift in thinking required with lean that cannot be fully explained.  I cannot count the times that I have told someone something and they never really got what I meant until they tried it for themselves. 

• Sometimes this was because they were an experiential learner and I am using words to describe something that they have never seen or experienced. 
• Sometimes the word just does not fit for a given person.  (We’ve been talking about Rule 2 –Connections for weeks, but until she asked, “You mean handoffs… kind of like passing the baton?”, did we finally connect on this concept.)
• And, sometimes they “have done something like this before” and “know what I am talking about”, so they really are not listening or trying to understand.

Sometimes I am going to ask you to try because I cannot put meaningful words to the concepts I am trying to convey.  After you have the experience and “get it”, then we can apply the words to talk about it. 

If you are not listening, I may tell you a few times and then let you go ahead and do it your way.  If the rules are truly self-evident, you will come to them on your own.  (The great thing about lean healthcare is that the rules and concepts do make such sense.)
                                                                                                             
Either way, I find that letting someone make a trial run and then reflecting together is often the shortest route to lean thinking.  But, Try & Reflect is different than Trial & Error.  Trial & Error is an unguided path fraught with failure.  Try & Reflect is a guided learning process that allows the discovery of concepts that are difficult to convey in words. 

• What worked well? 
• What would you do differently?

A good lean healthcare coach may let you fall forward and do some guided self-correction, but we are not going to let you fail.  You only fail when you quit trying and stop learning.

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.

Is lean just a set of tools to go implement?  5S program, check.  Tape on the floor, check.  Label my supply room, check.  Visual management boards, check.  Do you know the buzzwords, can you speak the lingo?  Am I lean now?  Did you calculate the ROI?
I see many companies make a big splash, show some quick gains, but is it sustainable?  Time after time I see organizations start a lean initiative and implement the tools only to fizzle out without any long term impact.  “This doesn’t work in our industry.”  “Lean does not work for this type of process.” “Just another program of the month.”
What is missing?

Lean enterprise leaders will tell you that it is 20% tools and techniques and 80% philosophy.  You cannot call in a surgeon to perform a “mind replacement”, so what are you going to do?  I see process changes languishing on the bathroom bulletin board (the only place some staff have time to even read them).   Management focus is on covering today’s caseload instead of identifying the problems that are killing staff (figuratively), if not the patients (literally).  They have not made the change in thinking that must go along with changing the processes.  Staff are frustrated because they see more problems now that were hidden by “that’s the way we’ve always done it” before the Kaizen event.  (The problems were always there–just “invisible” to the old way of thinking.)
Change Happens
Leadership at all levels must change their thinking.  Over time, a shoot-the-messenger management style begets a wait-until-told employee behavior.  Then we wonder why they “check their brains at the door.”  An organization that relies on a top-down, command and control operational style now has competitors where every team member is thinking about the process, identifying problems, looking for leverage. 
However, it is not a free-for-all with management just trying to appease everyone using the “Keep them happy and they will do the right thing” style.  Leaders must think and communicate strategically.  What are the priorities?  I have a limited amount of resources, where should I focus?  We cannot fix everything at once, so some problems may just have to wait.
Problems Surface
Many lean tools don’t fix problems.  Instead, they help make problems visible.  This creates an internal stress on an organization to make the problems disappear.  Is it OK in your organization to have problems?  Do you celebrate problems?  Can you identify and prioritize problems, translating your efforts into sustainable gains demonstrated in patient outcomes and business results?  Can you get to the root cause, even if it turns out to be that organizational dead moose on the table?  (Note for our international readers “dead moose on the table” is an American idiom meaning the issue that everyone knows about, but no one wants to point out and address… everything from the million dollar software that doesn’t work to the surgeon that is always late for first case starts.)
You can read a book, go to a class, but what you really need is someone experienced in implementation that can coach, challenge, and encourage you through the thinking processes required to manage that new process.  If not, your current thinking will bring you back to your current results.
Lean Thinking
Management must change their thinking-change their minds.  What better time to break old habits than when you change that process and move those supplies?
Remember that book “Lean Thinking”? –it wasn’t about Lean Tools.

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.