Lean Healthcare Exchange

I admit it! I am in love with my iPhone. It is my single most important travel accessory—no—life accessory I possess. I have not always been so passionate about a cellular device. I have been an extreme business traveler for over 10 years. Yes, there have been others that have brought me momentary pleasure; that excitement that only comes from being among the first to get the latest smart gadget or palm perfect tool.  None have sustained my desire like the iPhone.

My adoration recently went much deeper than the iPhone’s simple intuitive function or the endless assortment of apps to solve any problem that exists. It is now a loyalty that transcends the hardware. I knew it was true love the day I had to take my beloved in for service at the Apple Store’s Genius Bar.

Previous wireless providers had left me severely scarred by the painful memories of crowded stores, long lines and unending frustration. Seriously, at what point does waiting for the root canal become more painful than the root canal itself? After some reassurance from my 23-year-old daughter, I made an online appointment with the Genius Bar at the Apple Store. From that moment, as they say in the iPhone ads, ‘This changes everything.’ I became a diehard Apple loving convert.

As I entered the Apple Store at 4:35pm, I immediately noticed the large number of customers in the store. There was no greeter – no information desk or sign-in kiosk, no lines and yet the many customers inside were moving about, stopping to interact with the various Mac products on display. There was no overhead paging. There was no waiting room with a TV or prominent service counter lined with computer monitors for these “Geniuses” I was to meet. Instead, there were two large wall-mounted monitors that displayed the first name, and last initial for the appointments in queue. My appointment was scheduled for 4:45pm. There were five people in front of me. My instincts told me, ‘This is going to be like a trip to the DMV,’ but, fascinated by the customer flow before me, I moved to a neutral corner and just observed the action.

The large monitors rotated through valuable quick tips for improving the use of various Mac devices while returning to the appointment queue about every 30 seconds. There were well behaved children playing computer games at a kid-sized work table. Others walked in with their Mac Books and made their way to their scheduled education sessions at the Training Bar. Accessories lined the walls; a myriad of gadgets and gizmos for every iPhone and iPad need. At precisely 4:45pm, a young “Genius” named April emerged from a small group in the center of the store and called my name. “Teresa”? I walked closer to her as she introduced herself and shook my hand. April listened to my iPhone issue as I explained the symptoms. As she examined the “patient,” she pulled what looked like an otoscope from the tool pouch attached to her belt. Obviously very knowledgeable, April explained each step she was taking to determine the cause of the problem. April used her personal iPhone to look up my account and warranty information. Empowered to make decisions, she explained the steps she would take to resolve the issue and even printed a copy of the work order for my employer without ever stepping away from me. At 4:51pm my issue was resolved and I was on my way.

Now, as with any process, it was not entirely without waste; I left the Apple Store just in time to get stuck in Nashville’s rush hour traffic. The bumper-to-bumper drive home did give me time to ponder the same questions I now pose to you:

• Can this kind of experience be consistently achieved through Lean Healthcare initiatives?
• Are we promoting customer service or enabling inefficient processes by designing large waiting rooms with comfortable amenities?
• Have we really challenged ourselves to simplify access to the healthcare services we provide?
• What does the healthcare customer of tomorrow really want and how can we leverage Lean Healthcare thinking to provide it?

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. 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.

As a consultant in lean healthcare, I have the honor of working with individuals and teams who come together to improve their work and the care they provide to patients.  The reason I do this work is the brilliance of the front line staff never fails to amaze me.  I am totally jazzed when I see the light bulbs go on and an idea is transformed into reality that makes a difference.  Recently I observed the evolution of a front line supervisor from skepticism to total engagement as she adopted the principles of lean thinking into her daily work.  With the coaching of a colleague, I was reminded of the change cycle; and the impact on leader’s implementing lean healthcare. 

Uninformed Optimism
Exposed to the possibility of improvement in our everyday work, most of us will be at least a little bit open to change.  Early in a Lean journey, healthcare leaders hear words that philosophically they can embrace; increasing value/decreasing waste, increased satisfaction & quality, decreased cost & time, and increased decision making or empowerment of staff to name a few.  We do not know what will be expected of us, but we know the problems we are dealing with that we would like to go away.  Front line supervisors, generally demonstrate behaviors consistent with such optimism; attending leadership training sessions, volunteering staff to participate in kaizen events,  showing up at stakeholder meetings and asking good questions. 

Informed Pessimism
Following the first request to change our work, informed pessimism frequently takes hold.  Fixing one set of problems will often result in exposing more problems.  Lean healthcare supervisors, who previously made the change decisions, now have first hand exposure to staff making decisions and are confronted with a new reality to support change that was not their personal decision.  Part of supporting that change is holding staff accountable to new standards and coaching staff in solving the newly exposed problems using the scientific method.  It is at this juncture that lean leaders need to reflect on the areas they have control over, instead of looking to blame other departments and the “lean” process.

Informed Adoption
As leaders support the changes made by their staff they adopt valuable skills to promote the lean journey.  Critical to every lean healthcare transformation is leaders moving from asking “who” questions to asking “why” questions. One front line supervisor gave me a terrific example of her own evolution of moving from “who to why”. Following a kaizen event, she learned that clear expectations for what to document and at what time were not in place.  Working with her staff they identified that charting as they went instead of batch charting cut down the time information was available to other disciplines from an average of 32 minutes to 6 minutes.  On further examination, a few of her employees were outliers and appeared to be non-compliant with the new standards. When she went to talk to these employees to find out why, she learned that as night employees utilizing batch charting was difficult due to inadequate lighting on wireless laptops. After implementing new lighting these employees also were able move to one piece flow charting.

 Building Competencies
One lean event or change does not make a lean healthcare organization. Stringing together multiple improvements, such that leaders & staff begin to solve problems using lean principles every day at every level is a sign the organization is on its way. It is in coaching these improvements daily that leaders build their own competency in lean leadership.   Continually reflecting on and building our own competencies is essential to the growth of our organizations. Our organizations can only become lean as fast as we as leaders, including consultants embrace, and change our own behaviors, skills and competency in lean principles. 

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. 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.

After finding out my flight had been delayed, I took advantage of the opportunity to stop at one my favorite eating establishments. It was too late for lunch but too early for dinner. Nevertheless, the establishment was unusually crowded. Patrons queued at the hostess station, servers queued at the portal between the kitchen and dining area, advocating for their orders, while recently seated patrons waited to have their orders taken. The scene was nothing less than chaotic. Patrons began losing their tempers and this only added to the chaos as the harried staff responded to the frustrated requests. Eventually, what occurred could only be described as a total service breakdown and the manager was summoned from a back office.

It was amazing to me how quickly the manager was able to restore order. With a very methodical approach, she began directing the team to alleviate the bottle-necks in the process from the back of the line to the entry point. I began to observe her correct subtle deviations from standard process that had been abandoned in the chaos. Her actions were focused, directed, and confident. It was clear, that she had been here before and knew exactly what was required. This seemed to have a calming effect on both the staff and the patrons. It was a magnificent example of service recovery.

Naturally, as both a lean healthcare coach and as a life-long and avid student of human behavior the opportunity to observe this left me with a lot to ponder. Within nearly all healthcare institutions there are completely analogous breakdowns and recoveries that occur on a regular basis. This is especially true in services that encounter significant variability in demand. The two questions I was left pondering were: 1.) Why did it take a service breakdown to pull the manager from the back-office? 2.) Why was the manager able to restore order so quickly but the team could not? They are a lot of contributing factors that could be considered. I would propose that the primary concept for consideration in this case is the Andon.

So what’s an Andon? In the Toyota Production System (TPS) an andon is an indicator of status. This indicator is usually visual, at times audible, and is used to prevent a breakdown in process. These are often associated with highly automated processes but most definitely have their place in a lean healthcare setting. In fact, the essential concepts associated with andons are not new to healthcare and, collectively, are often referred to as a system of thresholds, triggers, and responses. So let’s apply the andon concept to the service breakdown described above and use the example to translate the concept to healthcare.

The first concept associated with the andon is that of a threshold. This is some visual indicator that helps the team to understand that a potential problem exists. In our case study above, the andon was a complaint reaching the manager’s office. Not the best possible andon, but an andon. In healthcare, one example of a threshold associated with an andon may be the number of patients within a waiting or service area; where an exceeded threshold serves as an indicator of abnormally high volume. The idea is to make this visual to the team to drive a change in behavior.  This leads to the second concept associated with andons, the trigger.

Who has the authority to pull the trigger? For the andon to be fully functional, authority to pull the trigger must reside in the individual(s) best positioned to observe that the threshold has been exceeded. In many healthcare institutions, as in the case study above, the ability to pull the trigger lies exclusively with the manager. In our case above, only the manager had the authority to pull the trigger; to initiate a change in directed action. The down-side to this was that the team floundered until she was roused from her office by the complaint(s). Managing under these circumstances becomes habitual fire-fighting. Implementing a well designed system of andons removes the manager from the fire-fighting role into a coach and resource allocator role. This leads us to the final concept associated with andons, the response.

Once the trigger has been pulled, proactively and in advance of service failure, a systematic and well defined set of actions are executed in response to the trigger to prevent service failure. In our case study, the manager’s approach to service recovery was focused, directed, and confident. It was clear, that she had been here before and knew exactly what was required. However, the team did not have a common understanding of her method and, basically, just followed her lead. Sound familiar?  After-all wasn’t it her experience that landed her in the manager role? The success of her actions in restoring service, however, is not unique. They are, in fact, possible to duplicate, document, and coach. It is, often, the fundamental failure to duplicate (test), document, and coach that inhibits the team from being able to proactively anticipate and course correct.

Returning to the original questions my experience left me to ponder: 1.) Why did it take a service breakdown to pull the manager from the back-office? 2.) Why was the manager able to restore order so quickly but the team could not? Consider the following:

• Andons are informal and undocumented versus andons are well defined, documented, trained, coached and evaluated on an ongoing basis.
• Thresholds are intangible and not easily identified versus thresholds are defined and easily observed.
• Triggers are informal, not clearly visible and only invoked by management versus triggers are defined and visible with authority delegated to resources best positioned in the service process to observe and invoke.
• Thresholds and triggers predict and prevent service failure versus thresholds and triggers are in response to service failure.
• Responses are informal, undocumented, understood by few versus responses are well defined, documented, trained, coached and evaluated (tested) on an ongoing basis.

The above list is not intended to be exhaustive, but rather, thought provoking. If the experience described in the case study above is frequently analogous to experiences within your department, a well designed and implemented system of andons may serve to empower the team to course correct independently while simultaneously transitioning managers out of the fire-fighter role and into a coach / resource allocator role. 

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’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.

As HPP guides our clients through their LEAN Healthcare transformation, we constantly refer to the Four Rules in Use introduced by Steve Spear and Kent Bowen in their Harvard Business Review article ‘Decoding the DNA of the Toyota Production System’.   In the article, they describe the four principles or rules that Toyota uses to teach the scientific method to workers at every level of the organization. 

RULE #1:   All work must be specified according to content, sequence, timing, and outcome. 

In facilitating Kaizen events, standard work documents are typically created, and I have found that job aids are also very popular supplements.  A job aid is a storage place for information OTHER THAN MEMORY which…is accessed in REAL-TIME ON-THE-JOB; is written at a level of detail to minimize trial and error; reduces necessary amount of recall from memory; and gives directions on WHEN and HOW to perform the work.  For example, a job aid as simple as a phone list of critical numbers attached to an employee badge.  This quick reference guide can eliminate excess motion, confusion and searching for critical phone numbers.

In a LEAN Healthcare environment, Job Aids work well when high complexity tasks are being performed, low frequency or unpredictable frequency tasks are performed, or especially when tasks carry important or devastating consequences; i.e., EMERGENCIES; and consequences of error are intolerable.  Another example of a job aid is ICU lab specimen collection chart.  The job aid can include vital information such as test description, billing category, procedure, tube color to be used, amount required, etc.  This can eliminate confusion of how much specimen to collect, of defects in using the wrong sample tube and of excess processing in having to recollect specimen due to sample error.

Job Aid Methodology is a unique way to convey expert knowledge to performers on-the-job. Job Aids are most significantly — on-the-job INFORMATION.  A Job Aid represents a superior way to achieve performance improvement because it directly affects performance WHERE it counts — on-the-job — and WHEN it counts —at the time performance occurs which is so critical in improving patient care by applying LEAN principles in Healthcare.

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 has a Bachelor of Science Degree from Bethel College with a focus in Finance.

The answer to that question depends on the philosophy that drives them and the activities that surround them.

Lean Healthcare Kaizen events are without question transformational activities that fundamentally improve the performance of any process.  Yet, one of the nagging questions in Lean transformation is why do so few of these improvements sustain over time? To answer this question we have to look closely at what happens around and between these events.  I will illustrate this concept with an example regarding the health and well-being of two fictitious individuals:

Our first person, let’s call him Bob, lives his life without much thought to a healthy lifestyle.  Bob’s philosophy in life is to get through the day and pay the bills.  His primary measures of a successful life are financial.  He generally eats and drinks what is available and rarely exercises, making excuses that there is no time because he is too busy working hard. Physical stress from an unhealthy lifestyle leads to mental stress, compromising Bob’s ability to think clearly and maintain the high energy level that is required to work smarter.  In time he begins to gain weight and tax functions of his body requiring frequent medical intervention.  These medical procedures, while they greatly improve his current condition, only hope to restore Bob to a functioning state.  After the procedure he resumes normal lifestyle only to repeat the vicious cycle of decline recovery.  His physical condition translates into a poor disposition, decreasing performance, and frequent absenteeism, all of which end up interfering with his primary goal of earning money.  Bob’s overall quality of life gets increasingly worse with time.

Our second person, “Kate,” has chosen a healthy lifestyle. Kate’s philosophy is to continuously improve her mind and body to assure a long term healthy existence. She watches what she eats and regularly exercises.  She monitors key indicators such as weight, blood pressure and cholesterol, making enhancements to diet and exercise if these indicators go outside healthy control limits.  Kate always finds time for her healthy routine by working smarter, and in turn her healthy lifestyle provides her with clear focus, energy and a positive disposition to help her work smart.  She even has energy at the end of the day to stay current on career-related journals to continually sharpen her mind.  Kate’s step function improvements come in the form of reaching major milestones like running a marathon or taking on new, challenging projects at work.  These feats not only push Kate to new levels of performance, but they motivate and inspire her to reach for even higher levels of performance that were once thought unachievable.  Her energy, mental sharpness, and positive can-do attitude lead to a long and a prosperous career and healthy quality of life.

Let’s now translate the human metaphors to an organizational perspective.  These fictional characters’ philosophies in life can be translated to an organization’s operating philosophy and management system.  Bob has chosen a traditional philosophy of simply making money with little thought to the most effective and efficient means by which to do so.  This short-term operating philosophy leads to mediocre, non-competitive performance of both an individual and an organization.  On the other hand, Kate has chosen a philosophy of continuous improvement. She believes that a healthy mind and body will lead to long-term success.  She uses process indicators to determine if her routine is achieving the goals of her healthy lifestyle and uses this information to continually improve her routine and performance. Keeping current with the latest knowledge represents the “learning organization” we associate with leading Lean Healthcare companies.

Both individuals experience transformational events in their lives.  From an organizational perspective this translates to Kaizen event type transformation. In the first case, these improvement events serve to bring Bob back to — at best — normal operating performance, only to suffer continued deterioration after each intervention because nothing changes in his life’s operating philosophy.  In the second case, Kate trains and prepares for these transformational events through daily improvement activities.  This could be compared to performing daily Kaizen to keep improvement skills sharp, readying the organization for major step function improvement.  She leverages the momentum from these transformational events, to not just maintain, but to continually improve toward the goal of becoming a world class performer.  Her commitment to her healthy lifestyle is holistic, translating into everything she does. 

The physical bodies of Bob and Kate could well represent the value added workforce in an organization.  In the first example, Bob’s body/workforce is not treated with respect, rarely exercised and thus its performance and general disposition worsen overtime.  In the second example, Kate’s body/workforce is treated with great respect and regularly exercised (involved in improvement).  In this case we have a high performance, high energy, fit and flexible body with a positive disposition, much like we see in the workforce of Lean Healthcare organizations. 

While both individuals experience transformational events in their lives, it is easy to see which one has adopted a Lean philosophy that translates into sustainable improvement.  The important question is does your organization more closely resemble Bob, or Kate?

This week’s blog was written by Gary Bergmiller, Ph.D. Gary brings 25 years of experience directing Lean system design, implementation and cultural transformation  Gary has served as the senior official leading lean transformations for world class companies such as GE, Philips, and Cox corporations. Prior to joining HPP Gary worked with Toyota Way series author Dr. Jeffrey Liker to develop a Toyota Way academy healthcare workshop. Additionally, Gary was hand selected by Dr. Liker to lead the implementation of the Toyota way for the entire western US and Canada Hertz operations. Gary’s expertise is in developing sustainable improvement cultures, lean strategy deployment, executive training, lean management systems, value stream based organizational structures, designing corporate wide lean programs, building teams of lean facilitators, and integrating lean and green systems for a holistic approach to waste elimination. He has authored a series of articles based on his research that have been cited in the EPA’s current research effort Lean and Environment: Next generation and Jeffrey Liker’s book Toyota Culture. Gary holds a Bachelors degree in Electrical Engineering from Northeastern University, a Masters in Engineering Management from University of South Florida and a Ph.D. in Industrial Engineering from the University of South Florida.

Economist John Kenneth Galbraith stated, “Faced with the choice between changing one’s mind and proving that there is no need to do so, almost everyone gets busy on the proof.”  These words ring loudly and clearly during Lean Healthcare Kaizen Events.  During these rapid change sessions, Lean Healthcare Change-Agents are typically barraged with unsubstantiated data-points cloaked in the lexicon of the Defenders of the Status Quo.  You may have heard them before…“We’ve tried this”, or “That won’t work here because”, and, my personal favorite, “We’re different”.  I share with you a simple phrase that can be a very effective problem solving tool in combating this resistance to change – “Yes, if”, instead of “No, because”.

I was introduced to this concept approximately nine years ago from a colleague and fellow Lean advocate.  This brilliant yet simple statement provides a great recalibration of one’s mindset from the negative to the affirmative.  “Yes, we can reach that intended Future State if…” now becomes the substitute for “No, we cannot do that here because…”.  As my colleague was not the author nor did he know who was, I am not sure exactly who to thank for these words of wisdom.  I am vaguely familiar with a book written in 2006 by former U.S. House Speaker Newt Gingrich and Nancy Desmond that sites the effective use of this phrase in transformations.  Still, the originator of this valuable nugget is unclear.  Regardless of its origin, the applicability of these words in Lean Healthcare implementation is immense.  Effective application of this terminology provides a unique counter to the traditional resistors of change while empowering all team members with a simple and impacting way to approach problem solving.

Best used…Early and often:
Successful Kaizen (or rapid improvement) events rely on the ability of participants to channel their innate apprehension to change, by relentlessly focusing on waste identification and elimination.  Thus, the most effective use of the “Yes, if” instead of “No, because” phrase is to make it a guiding principle or team expectation.  Establish with your team early-on that the spirit of solution-finding is to be pursued at all times.  

How used…As a teaching devise, not a stick:
Even with a solid introduction, it will be necessary for the Kaizen facilitator and/or team leader to remind participants to stay on the path of “Yes if…”.  But do so with the intent to remind and not reprimand.  This reminder emphasizes morale, respect and empowerment for every employee, which are fundamental tenets of Kaizen.  When apprehension and doubt arise regarding the feasibility of a Future State action item, simply ask the team for the “Yes if…” to its counter.  Now, all parties are refocused on a potential solution and you didn’t have to alienate anyone in the process. 

There is always room in Lean Healthcare for a simple tool that will help to refocus and refuel.  Strategic use of this phrase opens the door for true “robust dialogue” that will ensure all perspectives and potential solutions have been heard.  For years I have received positive feedback from using this phrase and I share it with as many people as possible.  Inevitably, I am asked, “Will this phrase work when dealing with passive dissenters and outright C.A.V.E. (Citizen’s Against Virtually Everything) people?”  My answer is simple and clear…Yes if.

This week’s blog was written by Matthew Davis. Matthew has nearly 20 years of professional experience, with many years devoted to Lean in a manufacturing and supply chain environment at Cummins, Inc.  Since being exposed to the Toyota Production System, Matthew has effectively facilitated Kaizen, Point Kaizen & 2P events, Value Stream Map training and implementation sessions, as well as 5-S and SMED globally (Brazil, France, Mexico, South Africa and the U.S.). Matthew’s functional expertise spans strategic and tactical experience in operations, sales, supply chain management and human resources. He also has leadership experience with diversity in management consulting and higher education roles. Matthew is recognized as an innovative change-agent, analytical team builder and motivational driver of results.  As a results-driven leader, he has the capacity to analyze and solve complex business problems utilizing a disciplined, data-driven approach.  Matthew is a graduate of Pitzer College with a bachelors in Political Studies, and Vanderbilt University with a Masters in Business Administration. He  is a certified Six Sigma Sponsor and Green Belt trained, and is a Certified Facilitator of Lean on the Shop Floor for Kaizen/Kaizen Blitz Events, 2P, 5-S, and Value Stream Mapping.

Management of any kind can get so tied up in their job that they can overlook the foundation of their role: the people that report to them.  When we are driving to work we don’t count the houses with red roofs because we are not looking for them.  In the same way, we can forget to talk to our employees because we may not see them.  This is one of the great principles of Lean Healthcare, direct employee communication.

The employees doing the work — the nurses, unit secretaries, orderlies and others — want to hear from management and want to have contact with them.  Toyota and other successful Lean businesses have the mindset that every employee is important to the business. This contributes a lot to their success. When employees feel like they have a relationship with their management, they are more likely to be happy in the workplace. Happy workers make for a happy and more successful work environment.

So, let’s make them feel important!

Establishing more open lines of communication can become the greatest asset to eliminating waste and building trust within the organization for any manager. This strengthens a company’s overall performance and employee base.  This also increases employee satisfaction and reduces turnover.  I can remember spending hours observing a particular process in search of a root cause, yet oftentimes having a 10 minute dialogue about the process with the “experts” doing the work will have ideas and answers popping up like popcorn in the microwave.   

How do I start?  Get out of the office.  Pick one place to go and force yourself to go there.  Pick out one individual, introduce yourself and get their name and then ask the following questions: 1) How is it going? 2) What’s going well? 3) What’s your biggest problem? 4) What are you doing about it? 5) How can I help?  Start doing this once a week and then make it once per day and in time you will not only meet many employees but you will know exactly what is going on.  You will have direct contacts for communication.  These are people with whom you can now share your information about how the hospital is doing overall, what areas are strong, and where improvements need to be made. One of the biggest outcomes to this communication practice is that the staff then feels that you are truly partnering with them and their frustration and issues are being supported by upper management.

One of the hardest things for human beings to do is change habits.  A long time is spent creating habits.  A long time may be spent changing habits.  This is how we improve as managers, workers, and as humans.  We can become addicted to the desk, computer, meetings, and telephone.  Getting away from these habits can be tough but the results will be tremendous and rewarding for everyone, as well as the organization.

This isn’t a final answer.  This is a simple start to a great end.  A baby learns to turn over, then crawl and then to walk.  Changing management habits are the same way.  We are getting out of the comfort zone that we’ve established.

We all know communication is important.  And in a Lean Healthcare organization it is essential. Take a moment to reflect on how you like communication. Establishing direct communication with the people actually doing the work is so very important.  Try it, you might be surprised by what the reports and meetings you sit through are not telling you. 

“‘Management by walking around’ is hardly ever effective. The reason is that someone in management, walking around, has little idea about what questions to ask, and usually does not pause long enough at any spot to get the right answer.”
–W. Edwards Deming, “Out of the Crisis,” MIT Press, 1982

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. He has a B.S. in Industrial Technology Engineering from Mississippi State University and has also completed the Six-Sigma black belt program.

I recently attended a large meeting of business executives where the presenter was using PowerPoint and a projector.  As he prepared, and the gathered crowd waited, he realized that he was unable to display his presentation.  After a few moments of nervously fidgeting with the connection and configurations, he quietly asked for help from a couple of folks who were near the podium.  They, including a couple of “IT types” moved to the front of the room and began to unsuccessfully trouble-shoot the problem.  A minute or two more passed and the meeting participants grew fidgety.  Tick tock, tick tock….  Participants became impatient, side conversations were initiated, emails are suddenly very important.  A few participants even saw this as an opportunity to make phone calls.  The audience was losing interest fast!  All the while, the well intentioned crew gathered around the laptop nervously tried the same or similar fixes over and over, with only the same dismal results.

After several minutes, a colleague of mine realized that he may have seen a similar problem in the past.  He confidently strolled to the front of the room, and asked if he could give his idea a try.  He leaned over the laptop and took an analytical look at the screen and keyboard.  Three keystrokes and less than five seconds later, the presentation appeared on the overhead and order was restored.  The waiting crowd literally cheered the results and suddenly, this man is a “rock star”. He had saved the day.

In the same way that my colleague became a rock star by finding an adequate work-around to the PowerPoint problem, many frontline care-givers achieve “rock star” or “super-performer” status by finding adequate work-arounds to the problems that plague the efficient and effective delivery of care.  Worse yet, healthcare leaders often expect all employees to work at this “rock-star” level.

With the application of Lean in healthcare, leaders must change their paradigms about who the real “rock stars” in their organizations are.  In fact, working around a problem or defect should become an unacceptable practice.  By identifying and solving the problems or defects that cause work-arounds in our processes, we can eliminate the waste that is embedded into our delivery systems.

When properly applied, Lean Healthcare offers a methodology to help your staff see the waste in their processes differently.  They will think differently about each step in their processes.  They will learn to ask why more often.  They will learn to identify and eliminate the root causes of defects—and eventually become true rock stars.

Organizations that succeed in their Lean Healthcare transformation are those that focus on supporting a cultural change in the way all staff members see their processes.  Organizations that struggle and eventually fail in their Lean Healthcare transformation are those that continue to celebrate the effective work-arounds and fail to support those who seed to eliminate root causes of waste.

This week’s blog was 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.

Imagine an existing hospital located in a large metropolitan U.S. city that is highly effective at delivering high quality patient care in an efficient manner. Those of us who are ‘on the voyage’ to achieving a truly LEAN organization maybe already familiar with this place. However, if you’re just beginning your LEAN healthcare ‘voyage’ maybe you’re not quite ready to venture a guess on who this is. However, I’m sure that you will all ultimately recognize the name!
 
Let me give you a few more hints:

• The 2008 Dartmouth Atlas of Health Care reported that of the 5 best ranked medical centers in this country, this location provided the most cost efficient care.
• This medical center works so well that its cardiac services ‘unit’ attracted over 39,000 ‘out of state’ as well as over 2,300 foreign residents from 102 countries. The revenues gained from these ‘out of towners’ easily offsets the poor margins that are associated with an even larger census of both Medicare and Medicaid patients.
• This facility is reported to be at the forefront of measuring and publicizing its results! This medical center is typically one of the few that that makes its own analyzed outcome data easily accessible to any interested party.
• This medical center has a fully staffed Continuous Improvement department led by a systems engineer with no healthcare experience. This department maps and analyzes every value streams that does not have outcomes that match the organization’s targets (i.e., the opportunities for improvement).
• This medical center has a fully implemented electronic patient charting system that not only includes order entry and routine patient charting but also provides “decision support” functions to clinical personnel that reduce med errors and allows real time IV medication effectiveness monitoring.

For those just starting the LEAN healthcare ‘voyage’, take heart! The Cleveland Clinic probably started their journey just as you have, uncertain of where it would lead them! Their LEAN healthcare journey probably isn’t complete but I’m certain that they (and their patients) are glad that they started.
  
Newsweek magazine highlighted these and other accomplishments of the Cleveland Clinic medical system in an article titled, “The Hospital That Could Cure Health Care’ written by Jerry Adler and Jeneen Interlandi in its December 7th edition. 

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.

Our beloved principle of “standardization” is frequently put to the test in the Lean Healthcare Design realm when outfitting a large number of repetitive rooms. Even creating a standard which includes placing a low cost item such as a suction regulator in each med surg room can add up quickly.

Creating an ideal state most often includes the development of a standard. Sometimes the trade-off for standardization is lower utilization. Let’s use the case of the suction regulator to illustrate:

1. Safety – Immediate availability of suction is one of those clinical interventions that can be a critical and unexpected need. It definitely meets the safety criteria.
2. Convenience – In many hospitals, regulators remain in the “last-used room” location. The nursing staff launches a scavenger hunt when a regulator is required in another room without one in place. It is certainly inconvenient and frustrating when trying to set up for a new admission or change inpatient condition. Numerous travel steps can be avoided by applying one of several lean tools.
3. Patient type – One of our community hospital clients recently estimated that only 10% of their med surg patients required suction. This hardly justifies the case for a suction regulator in every room. In med-surg, certain types of patients will require suction more often. Depending on how much you are able to cluster these patients, utilization may be higher – making 100% standardization more appealing for a smaller area.
4. Cost – Initial cost is probably more than you want to spend, but it is non-recurring. With the proper lean tools in place, you can be sure that replacement cost will be minimal.
5. Attrition – Without lean controls, small devices such as regulators have a tendency to disappear over time. They are like socks that go into the dryer. Where they go is anyone’s guess!

What if there is no money in the budget to have a suction regulator in every room? In this case it becomes even more critical to have a Lean system in place. Below are just a few ways to apply Lean Healthcare Principles to the suction regulator dilemma.

• Create a dedicated location for a suction regulator(s) on each hallway with a kanban system for replenishment when the item is put into use.
• Use visual management principles to create staff awareness when the item is missing and requires action for immediate replacement.
• Establish a process to remove suction regulators from rooms at the time of terminal cleaning to return them to the inventory cue. This could even be built into a check list used by Environmental Services.
• To manage the “critical need” issue, place a regulator on the crash cart as part of the basic inventory to ensure that no one is ever caught without a regulator in a time of crisis.

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.