Lean Healthcare Exchange

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

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

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

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

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

This week’s blog was written by Maureen Sullivan, a senior associate at HPP. Maureen has over 28 years of healthcare experience in clinical nursing, management and quality leadership to Healthcare Performance Partners. Previously Maureen was the director of lean and quality improvement for Exempla Lutheran Medical Center. As a registered nurse, Maureen’s clinical experience is in medical surgical nursing with progressive responsibilities in nursing management at the front line, middle management, and administrative levels. Maureen began her quality management career in 1996, coordinating, facilitating and managing improvement and accreditation programs at a departmental, site and system level within Exempla Healthcare. Maureen has an associate degree in Nursing from Joliet Junior College in Joliet, Illinois and a bachelor of science in nursing with an emphasis in healthcare management from Metropolitan State College in Denver, Colorado. Maureen achieved certification from National Association for Healthcare Quality, certified professional in healthcare quality (CPHQ), Colorado State University in process mapping, and University of Michigan in lean healthcare.

I have seen a shift over the past year in the discussions  that I have with Healthcare leaders.  We are facing considerable financial pressures in the Healthcare Industry  today – increased demand on an already overburdened system with skyrocketing technology costs.  With well documented results from Lean Healthcare implementation around the world, leaders are taking into consideration the time tested philosophy and methods of Lean.  However, leaders are increasingly concerned with one question – What will my Return on Investment (ROI) be for Lean Healthcare implementation? 

First, let’s start with the basics.  Without spiraling into a discussion of Net Present Value (Google it if you don’t know about NPV), the textbook method for calculation of ROI would look like this: 

(Profit – Investment)/ Investment

It simply answers the question of will we make (or did we make) money on an investment.  It can be used when making business decisions such as whether to purchase a new piece of equipment.  Will it make us more profit than it costs us?  Or in other words, what is the Return on Investment?

However, ROI calculations for Lean Implementation can be incredibly complex because of the many variables on both the Profit and the Investment (expense) side of the equation.  In healthcare organizations, employee expenses (fulltime and supplemental labor) make up a significant percentage of the expense side of the equation.  In fact, full time and contract labor can make up between 50 – 60 percent of a hospital’s expenditures. 

Hospitals under considerable financial strain have traditionally looked at their largest expense category, labor, to identify savings.  With a short-term focus on cash, organizations may be cutting short the true benefits of Lean Healthcare implementation.  For example, under a Lean Healthcare program we look to identify and eliminate wasted time, effort, and resources.  The CFO rightfully questions,”Where are my savings? “  Unfortunately, it is not that easy.  I have reviewed many healthcare income statements and have yet to see where “wasted time” is captured on the current list of expenses.  Waste is hidden.  It is woven into the fabric of the organization.   So if waste is eliminated, where can we carve out savings from the P&L?  No savings = no ROI, right?

Not so fast.  A long-term view of Lean Healthcare implementation would see that additional service growth can only come from additional capacity.  By eliminating wasted time, effort, and resources through Lean Healthcare, we effectively increase an organization’s capacity.  In fact, it is the lowest cost capacity because we are already paying for it!  If we can do more procedures with the same staff without people feeling like they are working any harder, then we can show significant returns on the waste elimination efforts.  Service is better, patients are happier, and profits grow with increased volume flowing through the existing cost structure.

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.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This is a common problem we run across with Kaizen teams. The improvement team is working diligently on a process; understanding and analyzing current state, performing tests of change, developing counter measures and an implementation plan. They gave management and staff the opportunity to check in with the teams during the Kaizen event. Attendance at these stakeholder sessions is sparse, by both management and floor staff. When it comes time for implementation the Kaizen team is told a certain group needs to approve the new process before they can implement. The Kaizen team feels unsupported and possibly angry after all the hard work they put into this effort. Their understanding is that the future state that they developed would be implemented. This type of dilemma is not uncommon and there are very important issues illustrated in this example that deserve comment.

The 14 Lean Principles as described by Jeffrey Liker, in their entirety, will guide successful implementations. Focusing on a few of them and ignoring others welcomes the risk of failure. It is easy to lose site of this, to pay attention to the more technical aspects of this approach ignoring the adaptive and behavioral principles. The thirteenth of these principles describes the importance of achieving consensus, Make Decisions slowly by consensus, thoroughly considering all options; implement rapidly. This is achieved through dialogue in a process of “catch-ball”. The more people that understand and agree with the future state, the more likely implementation will be successful. This is what the stakeholder sessions on days two and three of the Kaizen event are designed for. 

So, in the scenario above, if the Kaizen team exercises “authority” and imposes the implementation, it is likely to fail over time because consensus was not achieved. On the other hand, if the decisions of a diligent Kaizen team must go through layers of approval by groups or councils that did not observe the current state, they will likely suffer the fate of “Death by Committee”. Failure is likely either way. 

Kaizen events, or rapid improvement events are just that, rapid. It is critical for the management and staff to take advantage of the time given during the stakeholder sessions to have the necessary dialogue and gain consensus such that the improvements are not bogged down in layers of committees and approvals. The Kaizen team must have support by the rest of the organization and it is leadership’s responsibility to see to it that the support is given. It is management’s responsibility to give the support. That means presence at key times during the Kaizen process to understand the activity and recommendations. It means showing up with active listening and inquiry, being open to the changes that have been developed. It means dialogue around the areas of valid concern and disagreement until consensus is achieved such that the Kaizen teams recommendations can be implemented right away. It means supporting the Kaizen team by addressing organizational barriers that are all too common in hospital environments. It means understanding the standard work that has been developed and actively coaching this change to the front line staff. Successful implementations must be owned by operations. Absolving themselves of this responsibility and delegating this to the Kaizen team or the “quality department” without the above support will prove to be fatal to the events success.

Consensus in the above context does not necessarily mean a majority. It means critical mass. Critical mass is that number that is sufficient to drive success. W. Edward Deming stated that the number of people to achieve critical mass with most changes is the square root of N,  N being the number of people who must change. For a group of 9, the critical mass is 3. For a group of 100, the critical mass is 10 and so on. These aren’t just people who approve of the change, they are the ones who lead the change. These are the people who have passion for the change and are willing to have the interactions with the rest of the team to drive the success. 

Taichi Ono’s advised developing leaders in his organization to “Lead is if you have no authority.” That requires dialogue, listening, inquiry and consensus building.  It is far more effective than command and control.  It takes more work in the beginning, but far less work in the end. The 13th principle.

This week’s article was written by Dr. David Munch, Chief consulting and clinical officer at HPP. He comes from Exempla Lutheran Medical Center as their Chief Clinical and Quality Officer. At Exempla, Dr Munch led their Lean Production applications resulting in substantial improvements in both clinical and non-clinical processes. Dr. Munch is an instructor for the Belmont University Lean Healthcare Certificate Course, and was previously an instructor at the University of Michigan’s Lean Certification Program and has been a frequent speaker on the subject of leadership effectiveness and Lean transformation for a number of healthcare organizations including Institute for Healthcare Improvement (IHI), The University of Rochester Medical Center, Yale-New Haven Health System, Tulane University Medical Center, Pittsburgh Regional Health Initiative, Institute for Clinical Systems Improvement (ICSI), and the Voluntary Hospital Association (VHA). Dr. Munch has served on the Agency for Healthcare Research and Quality’s High Reliability Advisory Group, has an extensive background in hospital operations, health plan governance, physician organization governance and clinical practice in Internal Medicine. 

Often during a Kaizen event, teams discover an area of conflict between individuals, departments, disciplines, or even leadership.  Someone recently asked me if I get tired of dealing with conflict.  The question caused me to reflect on the work done in Lean healthcare organizations and my belief that dealing with conflict effectively is vital to creating an environment where improvement can happen. 

Most of the best Lean Healthcare Kaizen events I have had the privilege to facilitate are made up of cross functional team members.  Each participant brings an expertise that adds value to the patient.  A frequently occurring comment is, “I didn’t know you did that or needed that”.  As changes are discussed, most teams come to a point of having a difficult conversation, otherwise known as conflict.  One reason for the conflict is resistance to change which  is natural and to be expected.  It is often easier to expect others to change before coming to the realization that change is needed in our own work.  I have heard it said, “Change is easy, you go first!”.  It is usually when discussing changes that teams must work their hardest to respect each individual. Conflicts are present even when we do not acknowledge them and only when they are brought to the surface do teams make truly meaningful change.

Lean healthcare organizations grow respect  for people by focusing on the customer/patient, using inquiry to understand each other’s point of view, and exploring options to achieve the best solution & implementation for all involved.  Focusing on the customer/patient is a common goal all team members can get behind and helps to eliminate blame in our conversations.  Teams that inquire to understand a suggested solution, will learn what thinking is behind a solution.  Conversations that uncover each team members thinking  frequently develop solutions that all members can support. 

As  Lean healthcare organizations grow and mature, conflict becomes an expected and productive part of the journey. Leaders and teams know that working through conflict with respect for each other brings increased value for all involved.  Avoiding the conflict will generally lead to countermeasures that are ineffective and an environment that stifles improvement.  Conflict is an opportunity to show respect for the people who make a difference everyday with their expertise, care, and compassion.

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.

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

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

So, let’s make them feel important!

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

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

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

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

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

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

This week’s blog was written by Alex Maldonado, an associate with HPP. Alex’s professional experience includes process improvement, operational, and leadership positions in the medical delivery systems and appliance manufacturing industries with Baxter Healthcare and Whirlpool. Alex has had a successful track record in improving results-driven processes with an emphasis in personnel training, project leadership, and operating systems designed to improve customer service and sustainability. He has led the development and implementation of processes to support Lean initiatives that reduce critical path lead-time, reduce expediting costs, capital improvement projects, inventory reduction, and trained and educated staff/employees in Lean Methodology. He has a B.S. in Industrial Technology Engineering from Mississippi State University and has also completed the Six-Sigma black belt program.

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

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

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

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

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

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

This week’s blog was written by Jeff Wilson. Throughout Jeff’s career, he has delivered and applied progressive management and process improvement tools to help organizations reach new levels of performance. The industries span from healthcare to manufacturing, financial consulting and accounting. His experience with Six Sigma and Lean goes back to the early days of his career while working with Colgate Palmolive. Jeff had the opportunity to use process improvement tools as a participant on project teams and was so impressed with the effectiveness of these tools he began to further develop his understanding of and expertise in the implementation and use of them.  Throughout his career as a front-line Supervisor, Materials Manager, Logistics Manager and Plant Manager, Jeff has used and championed the use of Lean tools to deliver exceptional results.  Most recently, Jeff served in a consultant role with the Manufacturing Extension Partnership where he had the opportunity to support other organizations as they seek to improve processes by implementing Lean.  He has developed Lean transformation plans, facilitated Kaizen events and developed training materials for numerous client companies. Jeff has a Bachelors Degree in Economics from Western Kentucky University.  He also holds a Certified in Production and Inventory Management (CPIM) designation.

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.