Lean Healthcare Exchange

It’s that time of the year! Football time is here in the state of Tennessee but I know that Tennesseans certainly don’t have any kind of monopoly on the excitement and anticipation associated with this sport season. No matter where I go, many of the people that I run into are anxiously awaiting their team’s opening game. It’s hard to miss the level of enjoyment that comes from this annual fall activity!

All team sports generally have one thing in common: a coach who is committed to making their team as successful as possible. Organizational improvement efforts, like applying Lean Healthcare concepts and tools to the improvement of regular healthcare value streams and work processes, need coaches too! Lean Healthcare initiatives can have a successful ‘kick off’ if leadership—especially at the middle management levels—accepts and relishes the opportunity to ‘Coach ’em Up.’

When we think about coaches of athletic teams, we typically can all agree on several of a good coach’s basic attributes:

• Knowledge of the game
• Ability to organize practices
• Capability to develop game strategies
• Interest in developing the skills of the team members
• Recognition of team strengths and weaknesses, and the ability to make appropriate adjustments when required

A successful Lean coach certainly needs the skill set listed above. However, Lean coaches who are focused on improving team performance often need a few additional skills. These include:

• The ability to resolve differences
• An interest in building relationships
• A drive to pursue creative solutions
• The talent and commitment to motivate and empower those on the team to improve how they do their work

How does this list differ from what we typically expect from our supervising level of employees? Our observations often reflect that the typical supervision situation might be almost exclusively focused on accountability (i.e., “Let’s get it done!”). There is certainly nothing wrong with this. Even in a mature Lean operating environment, supervisors are always responsible for adherence to work standards.

However, Lean success requires a more balanced role for supervision, one that includes actively coaching for improvement. For supervisors, the Lean coaching begins with a clear recognition of performance gaps (perhaps through process performance metrics), and moves toward the empowerment and motivation of those who do the regular work to respond with improvement ideas. We coach to make sure that these ideas include the appropriate Lean concepts and tools!

Coaching requires practice, but good coaching almost always begins with an attitude: “We’re good but never good enough!”  As always, the commitment to ‘Coach ’em Up’ is the vital first step!

This week’s blog was written by HPP consultant and engineer David Krebs. David, a Six Sigma certified engineer, oversees various HPP projects and Lean Healthcare transformations for clients throughout the USA. David is also a Licensed Professional Engineer in the state of Tennessee, with over 30 years of experience in a variety of process and systems intensive industries, as part of firms in the U.S, Germany, and France.  David has achieved and maintained QS-9000 and ISO-14001 certification & received Nissans’ “Quality Master Award” on three occasions.  He holds a Bachelor of Science degree in Mechanical Engineering from the University of Detroit & an MBA from the University of Notre Dame.

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.

Recently it seems that we’re seeing more and more “Rocks” in organizations as we train and guide healthcare organizations through Lean Healthcare Transformations.  I feel this week’s newsletter, which we initially released almost two years ago in Lean Healthcare Exchange, is more relevant than ever and I consider a must read for any organization.  Forward it to the leadership in your organization as well as those within your span of influence. I was in a Wisconsin hospital recently on a gemba walk to review the work of their great staff’s Lean Healthcare journey, and this article was framed and posted on the wall.  They even have “Rocks” identified that they’ve removed, many of which are indeed man made “rocks”! You’ll have to read the article to understand.  If you’ve read “The Rock” before, read it again and ask yourself what you’ve accomplished since last reading it. If the article is new to you, then ask yourself what you’ll be doing to remove “The Rocks” in your organization.  Thanks and enjoy! Charles Hagood

Our team was recently participating in a Kaizen event with a client who was deeply engaged in solving a problem with a very convoluted process.  The team was doing an excellent job and there were several discussions about going to where the work was being done (Gemba), surfacing this problem and getting to a true ‘root cause’ via a “5 Why’s” based approach,  an action rarely taken with past issues.  We were discussing the results of a lean implementation and the fact that by lowering the water level of waste we would uncover a lot of rocks that lay below the surface.  We referred back to a slide in our Lean Leadership presentation and agreed that they had indeed surfaced a rock and were well on their way to breaking it up – hopefully, to never be dealt with again.  The team was doing well…

The Search

Trying to be a good facilitator, I decided that a good visual prop for the team meeting room would be “a rock”. So, I took a walk.  In a grassy median in the parking lot, lay a single perfectly shaped and sized rock for our motivational icon in the training room.  Not only was it the right size and shaped rock – it was a man-made rock of concrete, gravel, and surface pebbles.  Wow – aren’t most of our problems ‘man made’.  This was the ideal visual aid.  I was really proud of myself.

So, I take my ‘perfect’ rock to the training room.  I carefully wrap a piece of tape around the rock to represent the “water level”. And, I write the name of the problem we are solving on the tape.  It does not get any better than this.  I am getting to the point that I may want to take the rock back to Nashville now – just to show it off.  I can’t wait for the next morning.

The Reveal

Bright and early the next morning, in comes the problem solving team. They all see the rock, like the rock, and stand in awe of this great visual aid I had come up with. But strangely, something unusual was happening that caught my attention.  As people began coming into the room, I started hearing: “Hey, I recognize that rock.  I know where that came from”. Of the first six people to come into the room, four had seen the rock and three of them knew exactly where it had come from.  The people at this facility had walked over and around this rock in the parking lot median on their way into the building for several years.  This rock, in reality a chunk of concrete in the middle of a grassy median, had been mowed around, and trimmed around to ensure the area looked neat.

With this, I became very aware that this was no ordinary rock.  This rock was “the poster child” of unsolved problems in our organizations that we walk around and work around, and maybe even make look neat – but it is the problem rock we never get rid of.  It becomes part of ‘the landscape’ – we see it every day.  We know where it is, we know what it is (a problem), and we may even know where it came from. It becomes so familiar to us that we do not even see it as a ‘rock’ anymore – it becomes part of our every day processes and systems.

This rock is the essence of the push for ‘continuous improvement’ and problem solving in a business environment. Lean Healthcare tools teach you to see and observe differently – especially those wastes or problems (rocks) that you see everyday but in fact you no longer see.

Wow!

What a rock.  If it did not weigh 30-40 pounds, I would send you all one. If you want a picture of my rock let me know.

P.S.

The Company liked the symbolism of this ‘rock’ so much they said “it was their rock” and I could not have it.  What a shame – now, if I could just get an inflatable rock to take on trips with me.

By Lean Healthcare Exchange Contributor, Mike Brown, with edits and input from Charles Hagood, Founder and President of HPP. Mike Brown was a Partner in  HPP.  Mike is an experienced Lean trainer and implementer. He holds a BS Degree in Engineering from the US Air Force Academy and an MBA from Troy State University, and was a former F-15 pilot in the USAF prior to his work in industry starting over 20 years ago.

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

Understanding the complexity of healthcare payment systems is not something that most people understand.  In most businesses, a product or service is delivered to a customer in return for a pre-established price.  My research for answers turned to the internet.  I found promise in a white paper titled, “Principles of Healthcare Reimbursement”.  However, I quickly realized that I was looking for the Healthcare Reimbursement for Dummies version. 

While conducting a Lean Healthcare Kaizen Event recently, the team was excited to have identified significant improvements which resulted in a gross revenue increase of just over $1.0 million.  However, the complicated, mulit-variable equation which determines how much the hospital would actually see reduced the net gains to less than $100,000.  The “missing” $900K is not profit; it is the reduction in top line revenue healthcare organizations face every day from reduced reimbursements, payor mixes, fee schedules, DRGs, etc.

So what is a Lean Healthcare practitioner to do?  While we let Washington D.C. sort out the payment and coverage issues, some of us continue to focus our improvements on the Healthcare System.  A Lean friend, Christy G., helped me understand the healthcare reimbursement model with the following description. 

Healthcare provides a basket of care for a bucket of money.

We control what goes into the basket.  Our job as we study processes and drive out waste from the basket of care.  We use Lean Healthcare as our primary tool to review what’s in the current basket (Value Stream Mapping) and design a better basket (Ideal Care).  Nonetheless, what about the bucket?  Well, just as I learned from Sesame Street all those years ago…”there’s a hole in the bucket, Dear Liza, Dear Liza”.   There is a big hole!  The healthcare payers (including Medicare) are shopping for bigger drill bits and more powerful drills in order to make bigger and bigger holes.  As reimbursements continue to shrink, we have to get more and more creative.  We have to look for the best way to take care of the patient while making sure we don’t gift wrap the basket full of unnecessary tests and care for which the hospital will not get reimbursed. So I guess, like Dear Henry from Sesame Street, we will fix it Dear Liza, Dear Liza, Dear Liza…

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.

If we want to improve a process, we have to be able to measure it. Data collection and measurement are cornerstones of a well-researched, scoped, and defined Lean Healthcare Kaizen event.  Data collection allows us the ability to utilize any number of statistical tools to describe how a given process can be expected to behave.  Standard deviations, regression analysis, trending, and averages all provide useful descriptions of processes.  A measurement system provides us a means to determine if changes have resulting in improvement and if so, the impact on the process.

However, numbers and data can often have a sinister side. How often do we find ourselves immersed in discussions that involve managing data rather than processes? These discussions cleverly hide the waste that comes with them. The discussion might start out by describing that part of the process that is outside of our control. We are being penalized because the numbers reflect things we cannot change nor have influence on. Perhaps we need to develop additional spreadsheets to be able to more thoroughly drill down into the information. We, of course, seemingly always require additional data and information about processes before we can effect a change.  Analysis paralysis sets in and prevents teams from going forward on the things that can be improved.

So why all the fuss about numbers and data? We have to have them right? Of course we do. However, isn’t it ironic that we often immerse ourselves in wastes that are Non Value Added to the Lean Healthcare process we are trying to improve? The focus should be on “moving the ball” in the parts of the process where we can exert significant influence. Honestly, do we really care if the process is measured at 152 or 156 or 145 when we have opportunity to improve the process by 40%. Instead of focusing on the parts within our control where we can make improvement, we spend untold hours changing the way we collect data, massaging the data and discussing why we need better data.  If you think you have at least a 50% chance of success, implement an experiment and measure the results. Teams do not have to be 100% sure that a solution will work before they try it, it can be an iterative process towards the ideal state.

Bottom line, focus on the areas where we expect to have large rapid improvements. I do not believe our patients, employees and other stakeholders care if the number is 56 or 66. They care that we have improved a process by 40% in a way that is sustainable and part of a never-ending process improvement for Lean Healthcare. Improve the process in a way that clearly contributes to patient care, improves the human condition and the rest will follow.

This weeks article was written by Bryan Webb. He is the Director of Facilities Management and the Lean Coordinator at Skyline Medical Center in Nashville TN. He received a BSME from Tennessee Technological University in Cookeville TN. He also has a MBA and Masters of Accountancy from Belmont University in Nashville TN.

Employees of healthcare institutions who have undertaken the adoption of the Toyota Production System, often referred to as TPS or Lean, will be all too familiar with the following sequence of events.  The kaizen event was a big hit with the team.  The rapid deployment of well developed, tested countermeasures, designed by those who actually do the work has paid off and a dramatic improvement has been realized.  The team comes to the understanding that things can change and that their ideas and involvement can make a difference.  As a result, more ideas begin to surface.  Perhaps this is the first time that the team felt, truly, heard and empowered.  Now, the ideas are really flowing but not all of them are implementable right now.  So where do they go?

Sometimes, these ideas are captured in follow-up action plans or in “parking lots”.  More frequently, however, they run the risk of evaporating.  Uncleared, “parking lots” become bone-yards and idea generation becomes less enthusiastic.  Implementing Lean Healthcare is not easy.  As the kaizen team returns from the event they find that, initially, making this improved process “the way we work” takes some follow-up effort.  Moreover, in a truly Lean operation the team is executing very precisely to a pre-defined takt time.  Together these influences lead to the question; “Where are the resources to act upon these ideas?”  The following are three suggestions to keep the idea generation process alive and vibrant through action.

1.) As waste is eliminated from the process, resources become more available.  Unless this availability is understood and reinvested, wisely, it runs the risk of being applied to more non-value-added work.  With less defects and the seemingly requisite fire-fighting, charge nurses, team leaders and supervisors win back time to focus on further improvements.

2.) A well executed gemba walk process is another Lean Healthcare tool that may be very successfully leveraged to keep ideas flowing and transforming operations through action.  Often, this process can replace less effective operating mechanism and therefore not involve incremental work.  It is not uncommon, in this process, to see the departmental dashboard augmented by A3’s on the top issues.  Add to this an “on deck” area where ideas may be captured and subject to an ongoing process of prioritization for implementation.  This may be as simple as a white board area or designated Post-It™ note space.  What is more important is that the gemba walk process leads to ongoing evaluation and selection from these ideas.  In this format there are no suggestion boxes to maintain.  There are no expensive and bureaucratic committees to manage.  Instead a very simple process of ongoing evaluation, selection, testing and perfecting of ideas takes place naturally and within the stream of daily work.

3.) Notice that the sequence of events illustrated above begins with evaluation.  With that in mind, the Lean tool of Reflection can be as powerful in implementing lean healthcare as it is simple.  By simply taking the time as a team or in smaller, natural, work groups at key points in time to reflect upon what worked and what could be better, a habit of evaluation and idea generation may be established.  Add these to the idea board mentioned above to fuel the selection for implementation process on an ongoing and very natural way.

Collectively, these three simple steps can serve as a powerful catalyst for change and as a control tool. Ultimately, the team begins to understand that focused evaluation, supported by idea generation, testing and ultimately action are not confined to kaizen events, but rather, an integral part of daily work.

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.