Lean Healthcare Exchange

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.

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.

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.

As healthcare leaders begin to see with “Lean Eyes” they can quickly become overwhelmed with the amount of waste within their organization. At a recent training session, I was asked the question “Where do we start, there is so much waste?”  My answer tends to vary based on where the organization is in their lean healthcare transformation.  Fundamental to prioritizing areas to work, is looking for the impact that can be made to Quality, Satisfaction, Time and Cost.  No impact, not a good use of your time.

Early on in an organization’s lean healthcare transformation, leadership is focused on how to see waste, understand the tools of Lean, and learn how to support the changes which occur in Kaizen events. At this stage of a transformation, work can be done almost anywhere in the organization to achieve the goals of learning; however, leaders quickly become overwhelmed if Lean work is an add-on to “regular work”. Thus, work must be aligned with the organization’s mission, vision, and operating plan from the very start.  Lean healthcare organizations move on to develop staff in problem solving using the concepts and tools of A3 problem solving. At this phase of the transformation, I look for issues that fit 3 criteria to eliminating the waste:

• Will it matter to the patient (customer)?
• Will staff be less frustrated & thus have more direct time to spend with the patient?
• Is the process within our span of control? 

When first deploying lean problem solving, the key is to start small and build success with the tools. Secondly, whether problem solving is occurring in a Kaizen event or using A3 Problem solving, keep in mind to look for the critical few solutions to achieve the future state.

Mature lean healthcare organizations focus on developing their leaders to coach staff in improving the work on a daily basis. Lean becomes integrated into all aspects of the organization and particularly the tools of Hoshin planning are utilized to focus the strategic & operating plans on the critical few activities to move the organization closer to the stated vision.  

At any stage of a lean healthcare transformation, it is tempting to look for solutions that are outside our span of control. Lean leaders know that change comes best when it comes from within; so don’t wait, just START by eliminating one waste at a time!

This week’s blog was written by Maureen Sullivan, Sr. Associate with Healthcare Performance Partners. Maureen has over 30 years of healthcare experience in clinical nursing, management and quality leadership to Healthcare Performance Partners. Prior to joining HPP, Maureen served as the director of lean and quality improvement for Exempla Lutheran Medical Center successfully leading the implementation of Lutheran’s Lean production system from 2004 to 2008 demonstrating improvements in clinical quality, employee engagement, and financial stewardship. As a registered nurse with clinical experience in medical surgical nursing, Maureen has held 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 received her associate degree in nursing from Joliet Junior College, followed by a bachelor of science in nursing with an emphasis in healthcare management at Metropolitan State College in Denver, Colorado. Maureen achieved certification from National Association for Healthcare Quality, certified professional in healthcare quality (CPHQ).

Ever been on a flight next to someone? Normal conversation covers topics of family, weather, work, etc. Upon mentioning that I work implementing Lean Healthcare principles, I regularly field questions like, “What is going to happen under the new President’s administration?” To not discuss the pending Healthcare Reform plans would be like ignoring the elephant in the room. So while I don’t want to open a long debate about politics, I wanted to share some thoughts about the details coming out this week.

In order to keep the focus off of politics, I wanted to open the discussion to the following topics: access and cost. You’ll notice that I left coverage off the list. I think we can all agree that there are too many people in 2009 without adequate healthcare insurance coverage in the United States. Coverage (or lack of) is a complex issue to which I don’t propose to know the answer. However, there are two key areas in which Lean Healthcare principles will continue to have a profound impact on the state of healthcare in the United States.

Access
The first key area in which we are making significant progress with Lean Healthcare is access. One of the biggest concerns I have with the current proposal is turning on the floodgates by providing coverage for everyone. Many of the hospitals in which we work simply do not have enough capacity to handle the current patient population, with the problem possibly getting worse with the aging baby boomers. If we were to increase access to healthcare without addressing the capacity issue, patient wait times, overtime for hospital staff, and, therefore, costs would increase significantly. Lean is designed to create capacity within the existing resources by eliminating waste. The access issue is really a capacity issue. If we do not eliminate waste to create room for all these additional tests, procedures, etc. then the system will fail. Automation, Electronic Medical/Health Records, and many other things being proposed will not help if the process is not redesigned. Sure these things are needed but only after careful consideration of the processes and removing waste (i.e. Lean Healthcare).

Cost
The second area where Lean Healthcare is making an impact is cost. Through a rigorous and structured approach to reviewing healthcare processes and value streams, we have identified and eliminated wasteful practices which add cost to the system. Lean Healthcare Kaizen Events regularly yield savings in the six figure range, while A3 Problem solving activities can add up to millions in savings, $10,000 at a time. However, reducing costs must come from an equivalent elimination of waste. To mandate cost reductions or reduce payments will only hinder the progress being made in healthcare. This view is shared by many. In response to the infomercial regarding the new program last week, Karen Ignani, president/CEO of American Health Insurance Plans, told ABC, “If you look at the proposals that have been laid on the table thus far, it will bankrupt all of the major hospitals in the United States because it pays at public program rates, which are already significantly underfunding providers.”

So what do you think? How would you answer the person who asks, “what does healthcare look like in a few years?”

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 make lasting improvements. 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.

Whether you are facilitating a Kaizen Event or completing a problem solving A3 in your department, a deep understanding of the Current State is a requirement of any well planned Lean Healthcare activity.  In the effort to define the existing process, we find, almost without fail, that there are as many different versions of the Current State as there are people involved in the activity!  I have witnessed many different reactions to this realization over the years including shock, complacency and pride in the independence of staff performing the work in their own unique fashion.  Through these different reactions, a second prediction can be made just as easily: no one will stop to ask “Why?”

While there are many factors that contribute to this condition, my first answer to the question of “Why?” would be a lack of documented standard work.  While the development, creation and maintenance of these documents rarely receives the fanfare of a Kaizen event report out or Lean project that shows significant savings, they are arguably more important.  One of my associates uses the illustration of giving directions to the airport as a quick point lesson on the importance of knowing the current state and having standard work.  He asks the group to give him directions to the airport and then allows the audience to proceed with detailed and sometimes accurate directions to the nearest airport.  He then follows with the question, “How could you give me directions when I haven’t told you where I’m starting from?”  It is the same with the Lean activities described above.  We can’t get where we are going if we don’t know where we are starting from.  We don’t know where we are starting from unless we have standard work in the Current State.

Consider an organization that never reinvented the wheel, could move staff into new roles with minimal ramp up time, and always produced a predictable and quality outcome.  This vision is often the reason that healthcare facilities begin their Lean journeys and creating and maintaining standard work is an essential part of reaching these goals.  Maintaining standard work enables consistent knowledge transfer and lays the foundation that is necessary to accelerate organizational learning and ultimately leads to consistent quality outcomes. 

Does your organization use standard work?  Do you have a method for maintaining and improving this work?  Without it, we will continue to see many different versions of the Current State and struggle to achieve the quality outcomes that the organization works so hard to deliver.
 
This week’s blog was written by HPP’s Marshall Leslie. Marshall, a Six Sigma Blackbelt, oversees various HPP projects and Lean Healthcare transformations for clients throughout the USA.  As a former multiple year “top-ten percent” performer at General Electric, Marshall brings clients the much needed tools and techniques needed in any industry, including healthcare. Marshall is a graduate of General Electric’s Operations Management Leadership Program; he has experience in various supply chain capacities including quality engineering and global sourcing for both GE and Procter & Gamble. Marshall’s expertise in both Six Sigma and Lean enables him to apply a broad spectrum of process improvement tools tailored to the healthcare industry’s needs. He holds a degree in Industrial and Systems Engineering from Georgia Tech.

One of the Lean principles I constantly work on personally and professionally is “building a culture of stopping to fix problems”.  As a staff nurse and later in nursing management positions, I gained expertise in fixing process problems on a one time basis and often using “work- around solutions”.    Why?  The patient had a need and I, like most caregivers, was committed to meeting their need, right now; thus the problem solving had only two steps Problem >Solution.  Unfortunately, the root cause of the problem was not fixed and I and my peers were likely to face the process problem again and again.  Lean healthcare organizations encourage staff at all levels to solve problems with the scientific method.

Clinicians apply the scientific method of problem solving daily when patients present with a problem.  First, an assessment is done to understand the patient’s current state.  Testing is carried out to determine which differential diagnosis is the root cause of the problem.  A treatment plan is developed and implemented and follow up assessments are carried out. 

Lean healthcare practitioners quickly recognize clinical problem solving as A3 Problem Solving, both based on the scientific method.  In A3 problem solving, a problem is identified, which is a deviation from a standard.  The current state is assessed including asking the “5 Whys” to get to root causes of the problem.  A future state is designed and then an implementation plan is carried out.  Measurements are taken to see if the standard is now met, i.e. did we solve the problem.   There is connectivity in the problem solving steps; future state is based on the root causes, measurement is connected to the original problem (standard deviation).

It sounds easy, it makes sense and it takes discipline.  Why don’t we use it? Two reasons, I often hear  and I have personally used, “I don’t have the time, I need to take care of a crisis” and “I am the only one with the problem.”  With the exception of clinical emergencies, there are very few problems within healthcare that do not benefit from stopping to find the root cause.  Even in clinical situations, we have learned to conduct “debriefings or critiques” to identify process  problems and solutions  for future patients. The minimal time spent up front in looking for a root cause pays off in not re-working the solution to the problem time and time again.  The perception of being the only one with the problem is rarely true.  When the problem is brought to the surface, you frequently learn others have the same issue. 

My lean healthcare mentors have trained my brain to intuitively ask these five questions whenever I am with teams trying to solve a problem.  Try it the next time you find yourself discussing a solution, it may help you to “stop and fix the root cause”.
 
1. What is the problem?
2. What is the current process?
3. Why is the problem occurring?
4.  Does the planned solution address the root causes of the problem?
5. How will I know the problem no longer exists?

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 and successfully led the implementation of Lutheran’s Lean production system from 2004 to 2008 demonstrating improvements in clinical quality, employee engagement, and financial stewardship. 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.

 By now you might have a couple of Kaizen or 5S events under your belt as part of your lean healthcare journey.   Some teams might have established sustainable measures in their areas and Leadership is conducting gemba walks regularly.  The 30-60-90 day follow-up and the lean momentum are progressing and visible.  There is clear evidence that the objectives set by the team(s) are being met and the metrics are headed on the right track.  Small teams are solving problems using A3 thinking.  So what’s next? Continue with the lean improvements? Absolutely.  Spread the lean healthcare methodology throughout the organization, most definitely. Lean is a never ending journey and your focus should always be the goal of zero waste.   In all this good news there should be more good news. Could there be more? Yes, celebrate!  Celebrating wins and successes are just as important as achieving a target.  It’s a common step that I often see organizations leave out of the events and the entire transformation.  I don’t believe it’s done intentionally, but rather that so much focus and energy is directed on meeting the objectives or that there is little belief that lean will work or that lean can really work in a well established organization.

In the first two years of my lean journey we seldom stopped to “smell the roses” so to speak and celebrate all the wins and successes we accomplished in each event.  In fact, celebrating wins and recognizing team or members’ achievements was never in our yearly strategic lean plan or Hoshin pPanning.  I came to believe that part of the reasoning was because we have tried so many different tools, education programs, and process improvement projects in the past, and were not sure if each event was going to be a success or even if lean was going to work in our work environment.  It’s not that management did not want to recognize people or celebrate wins, we really did not know how or when, and by the time we got to it the teams the members had already moved on to another project or event.  A common phrase that I often heard and later I picked up myself was “you’re doing a good job but!”, and like many others, I too only remember the BUT part.  Leaving the team or members feeling that what was just accomplished was good but more is needed and not completely appreciated. 

A few years ago, I revisited a team who I had coached and trained on Standardized Work and the 5S tool.  The first thing that caught my eye was a 4 feet by 8 feet white board that the team placed in front of the department’s entrance that told the story of the department’s lean journey and where they were before the lean engagement, the current state, and what their ultimate future target was.  At a glance, I could tell that the team had integrated visual control and standardized their daily work.  A second board displayed leading metrics trends from inventory reduction to reducing lead time and the defects (waste) the team was working on. The supervisor proudly guided me to the 5S board which indicated that the 5S score had improved by more than 40%.  The supervisor also shared with me that both the work environment and morale had improved. As I listened and observed all the creativity the team had come up with to eliminate waste and sustain progress, I turned to the supervisor and asked if the team, along with management, had stopped to celebrate all these successes.  He looked at me and then paused before answering the question and, seconds later, he turned to the team apologizing to them. “You know, we really have not done that. Thanks have been said during events and follow-ups but not a celebration of recognition to the team and individuals who have gone beyond the call of duty.” I realized that I had unintentionally put the supervisor in a tough position but it allowed him, the team, and management to reflect on a wonderful story and transformation process the department had gone thru.  At first, little attention was devoted to improving the department’s process issues, and the department stuck out like a sore thumb on the overall Value Stream Map. However, today it was a different story, not because of what I did, but because what the team had done, and what the team was doing to take ownership of their area.  Before leaving the department, a time and date was decided by management and the team when and where the celebration would take place.

When celebrating wins and recognizing members, it’s more than just the delicious snacks, drinks, and the nice thank you speech.  You are celebrating a new beginning, the collaboration of team work, the success of each individual on the team who at one time might have had doubts about lean and the will to change.  By celebrating success, you are feeding the growth for change and cultivating a safe environment in which individuals would want to add more value to their daily work.  My mentor once told me that very little is mentioned about celebrating wins because most teams and organizations really do not believe they can win and they certainly do not believe they can succeed after a failure.

As you continue in your lean healthcare journey it is important to celebrate and share success from kaizen and 5S events, and A3 problem-solving. Don’t forget to involve the people whose jobs have changed. They helped make the organization better, and deserve to share in the celebration. There will always be more waste to eliminate and in turn more celebrations.  So stop and smell the roses every chance you and your team get.

This week’s blog was written by Alex Maldonado, an assoicate 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.

For several years now I have been in different hospitals observing processes. I look and ask why do it that way? Often the reply is, “That has been identified as a best practice and we decided to implement it at our facility.” Of course my follow-up question is then, “Who decided it was Best Practice?” The standard answer is one of many; Joint Commission, JORN article, NEJM article, a Local Steering Committee, a Board of Trustees and many other different entities or publications. A series of other questions pertaining to the success of the “Best Practice” often leads to a conclusion that it was not actually a “Best Practice” but only a “Best Known Practice.”

In Lean Healthcare, we encourage people to participate in “Best Practice” forums and share their examples of success. A group of individuals, hospitals, or regional peers present their own process improvements following the A3 format to one another. Then there is an open session to ask why and to develop ideas for further improvement for one another. Participants then use the information gathered by the forums to reflect and report back to their own work group the findings.

The one key point of the Lean Healthcare Best Practice Forums is that an ideal solution is not identified for processes such as Verbal Orders, Medication Reconciliation, Door-to-Balloon Time, Hospital Acquired Infections, or any of the other common problems. The “Best Practice” that is identified is the methodology that led to the solution and not the solution itself. The focus is how did you develop the solution and not what did you develop as the solution. This philosophy of “Best Practice” in Lean Healthcare has been repeated many times over. Lean is not what you do, but how you do it.

There are several examples of implementing a solution without adhering to the Lean methodology. The most recent one that I can state was for Medication Reconciliation. In fact, Med Rec has been a reoccurring theme for several of my examples. A hospital was having trouble meeting the requirements for Medication Reconciliation as prescribed by Joint Commission. A Kaizen Value Stream Analysis team was assembled to do a Future State Value Stream Mapping Event. The team went through the current state and identified the opportunities for the future state. Several sub-groups were set-up to implement the future state. Metrics for success were established. A trial period was scheduled. At some point after the initial future state mapping, the methodology was abandoned. Some members of the team had found out about a “Best Practice” for Med Rec and decided to follow that solution. Unfortunately after implementing the “Best Practice”, the results actually showed no improvement and even in some areas decreased performance. Once again, the “Best Practice” turned out to be only the “Best Known Practice.”

There are many reasons why a solution in one area will not work at another area. There could be cultural, IT, management, facility or other differences that prevent the copying of a solution. Most of the time, the reason for failure is in the execution of the implementation and not in the solution itself. Even worse, leaders and staff have not taken the time to truly understand and quantify the problem they are trying to solve and the corresponding causes of that problem in their processes.

Lean Healthcare recognizes that every solution is unique to the people, place and problem. The methodology identifies that the true process experts are not the people at another facility or at the university. The true process experts are the people on the nursing floor caring for patients on a daily basis. They are a vital part of the planning and implementation. By following the A3 format, the process experts have a common problem solving methodology to follow and to serve as a communication tool to others.

Thus, “Best Practice” then becomes not the solution but the methodology of developing a solution. That “Best Practice” is the Lean Healthcare A3 format. It enables your process experts to determine and implement a solution unique to their process that is truly best and not just best known.

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