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.

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.

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.

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.

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.

You have probably heard the phrase – a picture is worth a thousand words.  It is certainly quite true.  Trying to describe a situation or improvement during a Lean Healthcare kaizen event is much easier through pictures.  The Lean tool of visual controls leverages this principle by clarifying through use of pictures.  However, just as Yogi Berra states, “You can observe a lot just by watching”.  While a picture is better than words, nothing beats seeing it for yourself. 

I was reminded of this last week during my first visit to London, England.  I had seen pictures of the famous sites, but was blown away in my short visiting time squeezed in between Lean Healthcare work.  Nothing will replace the memories of seeing Trafalger Square, Big Ben , and London Tower with my own eyes.  I tried to bring back pictures to describe the experience to my family (who did not accompany me on this trip).  However, I could not muster the emotion of the experience through my iPhone photo gallery. 

This principle applies equally to the Leadership teams that we coach during a Lean Transformation engagement.  It was telling this week to hear a team member from a Kaizen Event Team say how refreshing it was to see a hospital “O” on the floor during improvements.  It is easiest to truly understand the care being delivered to patients by watching it happen.  Getting leaders out of offices and into “gemba” (Japanese for actual place) is a key component of Leading in a Lean environment.  You might find you can observe a lot just by watching.

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. Tom has achieved the levels of Certified Lean Specialist from the Business Improvement Group and the National Institute of Standards and Technology (NIST), along with being an ASQ Certified Quality Engineer. These certifications build on an Engineering Degree from the University of Michigan. Training experience includes Lean, Quality, and Leadership Training, as well as serving as an Adjunct Faculty Member at Waubonsee Community College.

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.

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.