Authors note:  This is an expansion on Rule 2 – Connections of the Lean Healthcare 4 Rules in Use.

<phone call>
Lab Tech:       “Lab, this is Loree.”
ED Tech:        “We never got the radiology results for Mr. Tucker.”
Lab Tech:       “Just look in the computer.”
ED Tech:        “I’ve been looking, but they were not there!”
Lab Tech:       “Look again.  They are there now.”
ED Tech:        “Yes, but I had already checked FIVE TIMES!  How am I supposed to know when they show up?!?!?”

Lab Tech:       <To coworker after hanging up.> “Idiots.  They never look.”
ED Tech:        <To coworker after hanging up.> “Idiots.  I think they wait for my call to put it in there.”

I frequently encounter problems like this during Lean Healthcare Kaizen activities that reduce down to bad connections.  One mental framework I have developed to help staff see the “broken-ness” of the connection is to break out the connection into two components — the information and the trigger to act.

In the phone call above, both the Lab Tech and the ED Tech are right from their individual point of view, but the connection is broken from a system point of view.  A good connection will provide both the information and a trigger for the next person to act.  Without the trigger, the process stops; or, the receiving party must continue to loop around to check if the information has been sent.

Examples of this are all around us.
The nurse waiting on a first dose to be tubed up does not know when the med is sent by pharmacy, so she must continue to check back to the tube station.  (And heaven forbid that some helpful soul puts it away in her med cart without letting her know… resulting in the inevitable call to pharmacy…)
The patient order that is delayed because the chart was left on the counter at the nurses station with nothing to trigger the unit clerk that orders needed to be entered.  (The chart sits, orders are not done, patient care is delayed, the doctor is frustrated by the length of time required to execute seemingly simple orders.)
The ED order for Radiology with the note “Patient not ready”.  So Radiology knows they need to execute the order, but have no way of knowing when it is OK to proceed.  (Of course ED complains about the continued calls to find out if they can get the patient.  And Radiology will be plagued by the long times from Order Entered to Result Ready that will surely be reported.)

Many times these delays can be eliminated with simple triggers for the next person to act.
Pharmacy text messages the nurse to let her know that an order was sent up.  A bit of extra work for pharmacy, but it also eliminates phone calls to find the med saving time for both the nurse and pharmacy.
The chart may need a simple flag system to indicate orders, or a specific place near the unit clerk that indicates orders need to be entered.  (As simple as this sounds, we have observed charts that have been languishing for 8 hours before orders were entered… and that was only after intervention by the Kaizen team that happened to be observing in that area.)
Perhaps a post-it on the door to reming ED to call Radiology when the patient is ready.

It also helps if more staff have been exposed to the Four Rules in Use and understand their part in making the system work as a whole, as opposed to just focusing on their task and not worry about the impact to the system.  (This also emphasizes the need for an abundance of Lean Healthcare coaches in an organization.)

The next time you are in the gemba, look around and look for connections.  If you see a delay, ask yourself how (or if) the next activity was triggered.  And look for a simple way to build that connection so value continues to flow.

For more information on the Four Rules in Use see another article called How Do They Learn?

This week’s blog was written by Richard Tucker a director with HPP who assists clients throughout the USA with Lean Healthcare transformations. Richard has over sixteen years of experience in business and industry fields in operational and leadership positions. His experience includes new program installation and launch, operations improvement, lean manufacturing implementation (internally and with suppliers), leadership development and supplier program management from prototyping through launch. Additionally, he has many years of Lean experience having worked with a major Japanese automaker, and received much of his experience and formal training in the Toyota Production System, Lean Manufacturing, and Shainin Statistical Engineering while in Japan. Richard’s educational background includes BS and MS degrees from Tennessee Technological University in Cookeville, Tennessee.