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 more and more organizations gain experience in the application of Lean Healthcare methodologies, I frequently find myself involved in conversations that lead to the ultimate question of Sustainability.  During one of these recent talks, I was reminded of a 2006 blog post on the Lean Healthcare Exchange regarding Newton’s First Law.  For those who could use a refresher, Newton’s first law is commonly stated as, “Objects at rest tend to stay at rest and objects in motion tend to stay in motion unless acted upon by an outside force.”  At the time, the intent of the blog  was to encourage leadership to set their Lean journey in motion and address “How do we get the ball rolling?”.  For those who have started that journey, the question now is how to keep the momentum going or “How do we keep the ball rolling”.

When asked about their Lean Healthcare journey, most leaders will begin the conversation by describing the amazing improvements in both process and people that they have witnessed in the past few months or years.  They recognize the value that Lean Healthcare has brought to their organization but many have seen other initiatives with just as much promise lose traction quickly once the “new wears off”.  They have already begun to see that there are “outside forces” in their organization acting on this “object” or Lean journey that they have worked so hard to build. 

Some of these forces, like gravity, are naturally occurring and are found to act in consistent ways across almost all organizations.  As leaders, you have confronted them in every role you have held throughout the years.  These forces include a natural resistance to, or fear of change.  Because any change (even good change) involves a loss of some kind, this force will remain intact just as gravity is always at work in the natural world.  The good news is, once we know the force that we are encountering and its predictable behavior, we can counter it.  Just as we’ve developed tools, methods or machines to “cheat gravity” (i.e. airplanes) or harness  gravity to our advantage (the free fall ride at Disney World) we should use Leadership Standard Work (the defined routines and processes that leaders fulfill in managing the Lean system), Daily Management (the process level daily routines & metrics that front line supervisors use to drive standard work), Daily Problem Solving & Coaching to combat these forces and “keep the ball rolling”.  Just as working in the gym allows us to jump higher and higher (some of us at least), these countermeasures put in place a structure that allows the organization to work against naturally occurring resistance that will always be present.

Keeping with the analogy of a rolling ball, there is another “outside force” to be considered – friction. Unlike gravity, friction is a direct result of the environment and it varies based on the smoothness of the surface that the ball is rolling on.  With respect to Lean journeys, we find that this force varies widely between organizations and facilities.  When encountering this resistance, most leaders initially mistake it for “gravity” in that the natural resistance to change is overwhelming the ability of the organization to change.  On further investigation, we find that these forces are more a function of the specific environment and can be controlled and “smoothed”.  Friction can be generated when support services are not aligned to support improvement efforts (i.e. response time to move a Pyxis station is 30 days vs. 1 day), or communication is unclear around changes/improvements to the work (i.e. the “what” is communicated, not the “why”) to name a few.  A detailed understanding of what is happening at Gemba (the floor) is required to identify these sources of friction, but once seen, they can be managed, if not eliminated.  Often, these issues can be alleviated with a simple change to process or standard work.

There are many factors that can affect the sustainability of your Lean Journey and understanding the “outside forces” that are currently working to slow your momentum is critical to your long term success.  As leaders, it is important to diagnose these factors as either naturally occurring (like gravity) or a product of the environment (friction).  With this knowledge, we can select the appropriate treatment and put in place the structures that will allow for that ever elusive goal of Sustainability.

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

One of the essential elements of the foundation for an effective Lean Healthcare transformation is the implementation of a Workplace Organization or 5S system.  In my role as coach and facilitator I am often asked by leaders why their 5S initiatives are failing. My first, internal, response is “why don’t you ask your staff”?

Of course, I sanitize this terse response before putting it back to the questioner.  But, the message is always the same.  The key to improvement in 5S performance, like any metric, lies with the staff.  Go to the Gemba and ask them.

Assuming that all the pieces of a 5S program are in place, including a healthy audit system that yields quantifiable, actionable 5S results, leaders are ideally prepared to address 5S performance in the same manner that they might any of the other initiatives they are charged with. 

Leaders often make the mistake of assuming that failure to follow 5S standards is simply, at worst, an issue of non-compliance on the part of the staff or, at best, an issue of lack of training to the standard.  But, the root cause of failing to follow standards is almost always more complex.  Getting to the root cause requires a disciplined approach to problem solving.  The ideal tool to use when seeking to improve 5S performance is the A3. 

In one recent case at a Lean Healthcare facility, a leader noticed a downward trend in one her department’s 5S score.  She scheduled a stand-up meeting with some members of her staff to address the issue.  She chose to use an A3 approach.  She used the data from the department’s recent 5S audits to explain the issue and the background.  After some problem analysis, the team was able to hone in on one source of the point deductions but they still weren’t at the root cause.  They had learned that a consistent problem area is the improper storage of blood pressure cuffs on the headwall.  The standard was for these cuffs to be stored in casework in the exam room.  Further problem analysis, using the “5 Why” tool revealed that the some staff members had begun to store the cuffs on the headwall to avoid congestion.  (The casework is on the opposite side of the exam room, where another member of the team is often blocking access to the cuffs while using the computer to chart at the same time vitals are being taken.) As a countermeasure, the team decided to change the standard so that cuffs are now stored on the headwall.  Appropriate storage, with labeling, has been added. This change has been communicated throughout the staff and the team is no longer having points deducted on its 5S audit. In this case the audit findings pointed to a need to improve the standard.

When 5S performance, as measured by audit results, fall below the acceptable level, employing an A3 approach will help to point the staff to the true root cause and a solid countermeasure.  Nearly every failure to follow a 5S standard should elicit this type of problem solving approach.  Shortly, the failures to follow standards will fall away.  You can be reasonably sure that if your staff is failing to follow standards, it due to a hidden issue that can often be addressed at little or no expense.

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. 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.

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.

As a nurse with many years “in-the-trenches”, one of the most frustrating realities in the hospital is the inconsistencies associated with relatively standard spaces and work tasks. Two identically functioning rooms on the same floor such as a medication room can have unique features and inventory that force wasted motion and effort in order to complete the routine task of medication delivery.

Why can’t highly repetitive spaces such as a medication room, nourishment room or even a med-surg patient room be truly standardized so that no matter where you are deployed to work, you are instantly familiar with the environment and standard work is accomplished without the waste of searching for supplies and equipment?

There are many challenges associated with not only creating facility-wide standard work but more importantly sustaining it. Unless a facility was designed using Lean Design principles such as standardization, room sizes and shapes are rarely identical, forcing differences in work flow, cabinetry configuration, and ultimately storage capacity. Without established standards and a strategy to maintain them, rooms with the same purpose have general similarities but lack the structure necessary to sustain standard work conditions within a Lean Healthcare facility. Many times each day a single trip to a medication room turns into much more than the clinician bargained for – after rummaging through every cabinet and drawer for a syringe that was supposed to be routinely stocked in the room, the nurse finally gives up and walks to another medication room or the clean supply room to complete what should be a simple medication administration task.

Without a doubt, designing new construction using Lean Design principles is ideal. However, Workplace Organization can help mitigate the lack of physical standardization plaguing the healthcare environment. HPP recently got the opportunity to tackle both standardization and sustainment on a large scale by using Systematic Workplace Organization strategies in a new 125-bed community hospital. With military style planning, 40+ highly repetitive prototype rooms were identified and developed with the input of bedside caregivers.  The prototypes were then mass produced through a cloning process that spread workplace standardization over the entire facility using 5S and Visual Management principles.

As the hospital prepares for its ribbon cutting next month, the benefits and cost savings are becoming immediately apparent. Staff orientation to the new Lean environment is easier. There are fewer supplies in inventory than a facility of similar size and staff feedback regarding their satisfaction with their work environment is extremely positive. Most importantly, the hospital’s Lean Journey will continue forward on a foundation of widespread workplace organization.

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.

This is the third and final installment of a three-part series on strategies to stop upward delegation.  In many healthcare institutions there are managers whose daily work looks more like that of a supervisor.  You will also find senior executives whose daily work is less focused on strategy deployment and more focused on resolving operational issues.  Most healthcare leaders are interested in breaking this trend — however, few know how. 

Part One of this series defined a strong prescription for stopping the process of upward delegation using three key concepts of the Toyota Production System (TPS, or Lean).  The three key concepts included the appropriate deployment of Visual Management, Leadership Standard Work and A3 (Root Cause) problem solving.  Part One further demonstrated how a well designed Visual Management system can focus the front-line team’s efforts on those elements of process and those behaviors upon which successful outcomes depend.  In Part Two, the concept of Leadership Standard Work was introduced, illustrating its ability to drive process definition, disciplined adherence to process and daily accountability.  Remember, outcomes cannot be separated from the processes designed to deliver them.  When there is less than disciplined adherence to well defined process, then the outcome is, simply, a matter of chance.

This final installment of the series is focused on A3 deployment.  This is not a how-to guide on the ten-step problem solving process but rather a guide to getting A3 problem solving to occur spontaneously within the organization and in accordance with Rule 4 of the Rules-In-Use¹.

Rule 4 states that problem solving occurs: 1.) closest to the problem, 2.) by those who actually do the work, 3.) using scientific method, and 4.) supported by a coach.  Reflect for a moment on how problem solving occurs in your organization — does it meet these conditions?  I have often found that it does not.  Worse, I have often found that the ability to work around problems is highly valued and often a consideration in the promotion process, cementing this behavior into the organization’s culture.  We may get through the immediate moment, but the same issues recur over and over as the firefighting continues on.  When processes are characterized by many workarounds, outcomes are no longer predictable, but rather simply, a matter of chance. This creates many small problems that evolve into bigger problems as customers demand higher standards of performance and care. These become the primary source of upward delegation.

Deployment of A3 problem solving fell third in the lineup of this series for a reason.  Specifically, a solid visual management system and process focused Leadership Standard Work are enablers of A3 deployment.  In Lean Healthcare we learn to recognize three categories of problems:  1.) a standard does not exist, 2.) performance fails to meet the standard, and 3.) the standard needs to be tightened.  With these in mind, the Visual Management system becomes a powerful tool in driving A3 problem solving.  Challenge the team to solve the department or unit’s top three issues (performance does not meet standard) using A3 problem solving.  If all metrics meet standards, then, which ones can be tightened?

Leadership Standard Work also identifies opportunities for root-cause problem solving.  In simplest terms, Leadership Standard Work is a checklist of leadership activities to be performed on a daily, weekly and monthly basis.  When Leadership Standard Work is well defined and process focused, it becomes exceptionally effective because it drives process definition, disciplined adherence to process, and daily accountability.  Where does your Leadership Standard Work indicate less–than-disciplined adherence to process?  The answers to this question are opportunities for A3 deployment.  Deviation from established process is often a leading indicator that the process is not capable of yielding its entitlements and a network of workarounds is forming.  Again, challenge the team to solve these issues using the A3 method.

These three strategies combined — Visual Management, Leadership Standard Work, and A3 deployment — are very capable of stopping upward delegation and reversing the direction of strategy deployment.  To maximize the utility of these strategies they must become natural for the organization.  Initially, we have to challenge the team at each of the contact points described above.  This is an essential element of a pathway that leads to empowerment.  By issuing the challenge, we let the team know not only is it OK to surface and resolve problems, it is expected.  For this type of empowerment to thrive we must also create a blame-free environment.  When systems thinking and root-cause problem solving replace blaming and workarounds, the results have significant impact on outcomes.  When viewed from the outside, these can appear time consuming and daunting.  However, organizations that have adopted Lean Healthcare understand that there are ways to implement these strategies in the current stream of work.  When embraced, this approach to work becomes the way we work as opposed to incremental work.  In a Lean Healthcare environment, mid-level managers become coaches and resource allocators instead of firefighters, allowing executive leadership to focus more clearly on strategy deployment and positioning the organization to meet tomorrow’s competitive, economic and technological opportunities and challenges. 

¹Steven Spear, Decoding the DNA of the Toyota Production System. Harvard Business Review, 1999.

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

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.

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

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

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

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

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

This week’s blog was written by Alex Maldonado, an associate with HPP. Alex’s professional experience includes process improvement, operational, and leadership positions in the medical delivery systems and appliance manufacturing industries with Baxter Healthcare and Whirlpool. Alex has had a successful track record in improving results-driven processes with an emphasis in personnel training, project leadership, and operating systems designed to improve customer service and sustainability. He has led the development and implementation of processes to support Lean initiatives that reduce critical path lead-time, reduce expediting costs, capital improvement projects, inventory reduction, and trained and educated staff/employees in Lean Methodology. Alex is well recognized in the following areas: Value Stream Mapping, Hoshin Strategic Planning, Office and Floor 5S, Total Productive Maintenance (TPM), Process Failure Modes and Effect Analysis (PFMEA), Quality Improvements and Mistake Proofing, Six Sigma, Cellular Design, Standardize Work, Pull Systems (kanb an), Equipment Design and Installation (DFLMA), and Safety Programs. He has a B.S. in Industrial Technology Engineering from Mississippi State University and has also completed the Six-Sigma black belt program.

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

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

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

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

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

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

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

While many organizations have begun to look at Lean Healthcare as a strategy to improve the overall business case, the long term benefits of Lean remain elusive to many organizations. Many groups simply look at Lean Healthcare as the application of tools to identify and eliminate waste. However, the true benefits of Lean come through the shift in thinking which comes from leading an organization into a new way of thinking.
 
As organizations begin to bring Lean Healthcare into the organization, many look at the simple application of Lean Tools (Kaizen, 5S, Standard Work, etc). Some institutions are looking for the “recipe”. Those leadership teams that suggest “Go make my teams Lean out their processes.” Somehow, in this version, Lean becomes a verb and there is a switch that we are supposed to flip which will make the organization’s processes more effective.
 
While the application of Lean Tools is a key component of a Lean Healthcare Transformation, there is much more to becoming “Lean”. There is a shift in thinking required for organizations to truly realize the long term benefits of Lean Healthcare Transformation. The shift in thinking is very dramatic for some organizations. We must begin to regularly expose and solve problems. While we may be able to harvest some early wins by finding low hanging fruit within the value streams of the organization, true benefits come from the systematic identification and elimination of waste from the entire facility. Waste needs to be exposed through visual controls and metrics. Improvements need to be made through leveraging the Rules in Use. Leader Standard work needs to develop accountability and disciplined adherence to the process.  If the steps described here are already in place in your organization, great. If what I mentioned in the previous couple of sentences sounds like a foreign language, find a coach. Lean Healthcare Transformations require a new way of thinking.
 
This week’s article was written by Tom Stoffel, a director & consultant for HPP. Before joining HPP, Tom served as President of Transformation Group, Inc,. Tom developed TGI Healing Healthcare – a brand of Lean Healthcare training tools designed to share lean principles through hands-on learning. Tom has led healthcare organizations in both the development of high-level Lean Strategies down to hands-on implementation of Lean in a clinical setting.