e-HealthExpert.org - Primum non nocere

One of my colleagues from across the Pond, James Marsh at Sheffield Hallam University, is currently researching his PhD exploring Lean Six Sigma and its environmental benefits and/or tradeoffs. For his thesis, James is analyzing the key differences among different industry sectors and departmental functions, and he would like to connect with the widest cross-section of global companies possible – the more data, the better for his research project.

James created a survey for users of Lean and/or Six Sigma. It takes 5-10 minutes to complete and it is completely anonymous. Please participate and also feel free to pass on to colleagues, contacts or friends who are active members of the Lean and/or Six Sigma community.  I appreciate your help;  please follow the link below:

http://www.psychology.nottingham.ac.uk/staff/sea/LSS

Lean and Green, the wave of the future.  And that’s the way I see it.  Adam Zak

Note from Mark: If you don’t know Adam, check out his new video Lean Blogger profile at YouTube

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The final keynote talk at the recent Society for Health Systems / ASQ Healthcare conference was given by Dr. Barry Silbaugh, a former hospital executive and the current CEO of the ACPE – The American College of Physician Executives. Silbaugh is a big proponent of Lean in healthcare, listing Lean as one of the major trends for 21st Century healthcare saying “everyone needs to” use Lean methods and thinking.

From his bio:

Silbaugh has studied the Toyota Production System, visited the Georgetown, Ky., Toyota plant twice, and used lean principles to improve work processes in healthcare.

In his talk, he shared some thoughts on Lean and a story that really illustrates what can be broken in a healthcare organization’s culture.About Lean, one of the key concepts that resonates with Dr. Silbaugh is understanding the entire “value stream” from the patient’s point of view. Of this, he said:

This is what’s missing in healthcare!

Looking at healthcare quality, Dr. Silbaugh realizes that the focus needs to be on systems that allow people to make mistakes. This is very consistent with the Lean approach to quality, that we can’t blame individuals after the fact. We’re human, we make mistakes, so systems need to be designed accordingly.

Dr. Silbaugh told the audience that the only healthcare processes that can be characterized as “high reliability” are level 1 anesthesia (minimal sedation) and blood administration (transfusions). These processes are relatively safe because the healthcare industry reacted to enact systemic improvements after major incidents that occurred in the past. For other processes, quality is not nearly as good as the public thinks. Dr. Silbaugh said the general public, when surveyed, thinks there are 5,000 deaths a year in the U.S. due to medical errors, when the real number is estimated to be between 44,000 and 98,000.

Many proceses don’t offer the reliability we should expect. For example, he cited a report that said 76 patients in Springfield, Missouri received radiation overdoses — not just one day, but over a period of years due to faulty machine calibration.

Dr. Silbaugh told one final story, I’ll do my best to paraphrase it accurately.

While he no longer practices medicine regularly, Dr. Silbaugh was filling in for a friend and went to visit some patients at a hospital. Working with a nurse for the first time, he examined a patient and gave an order for Vitamin K to be administered orally.

A few minutes later, he realized that he should have ordered an injection, that it would be more effective for the patient. He tracked down the nurse and said, “I misspoke, I meant to say an injection.”

The nurse said, “I knew you were wrong!”

Dr. Silbaugh asked the nurse why she didn’t say that he was wrong…

The nurse asked, “Can I say that????”

Dr. Silbaugh responded, “Next time, I insist….”

Having never seen Dr. Silbaugh before, the nurse was scared to speak up. That says a lot about how far healthcare needs to come in terms of creating a culture where people can speak up – in the name of quality and patient safety – without fear.

As Dr. Deming said, we need to eliminate fear from the workplace.

Thanks to Dr. Silbaugh for sharing that story and for his leadership around lean, quality improvement, and high-reliability organizations!

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Jim Womack visited Lantech, a manufacturer of stretch wrappers and other packaging equipment. While there and visiting the “gemba,” Jim was interviewed about Lean, what he saw at Lantech, and Toyota’s recent problems.

You can see the interview here, in five separate parts, or you can see the whole interview below, via YouTube.

In the coming week, I’ll blog about Jim’s keynote at the LEI Lean Transformation Summit, where he challenged the audience to focus more on “Lean management” (as opposed to Lean tools). He also challenged the Lean world to quit “floating in the wake of Toyota” -- focusing more on experimental PDCA; figuring out what works from your own experience instead of just copying Toyota or doing things because Toyota says so. You may have read a similar message in his latest “e-letter.”

Here is the full video, via YouTube:

What do you think, of the video comments or his e-letter?

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After two visits and gemba walks, I’ve become a big fan of the Lean work that’s taking place at VIBCO, a manufacturer in Rhode Island. The best thing that I’ve seen is not the use of Lean tools, but the culture change. For example, having production associates show me the ideas they’ve implemented and seeing the pride on their faces is pretty special.

Their President, Karl Wadensten, is a strong advocate for Lean, not just inside VIBCO, but in the broader R.I. business community and he’s also working to promote Lean in healthcare through is radio show, “The Lean Nation” and other activities.

One of those is a site visit that he hosted on December 1 at the VIBCO facility. Here, we’ll start to share some video from that afternoon.

From the VIBCO Lean website:

Under Karl’s leadership, VIBCO is now a high performing business culture where lead times for over 1,300 SKUs have dropped from 4-6 weeks to “same day, next day”, inventory has been reduced by more than 50%, over 10,000 sq. ft. of manufacturing floor space is now freed up to accept future growth, and sales are well above industry trends.  These impressive improvements are the result of a workforce that is empowered to improve every day and understands the power of Lean Thinking.

Here are the first two videos from the December 1 day that I was able to participate in:

Karl’s introduction to the event and the series:

Q&A #1: Engaging physicians in Lean (with Mark Graban and Joe Murli):

The audio on the Q&A isn’t great… I cleaned it up the best I could. It’s an improvement  opportunity for VIBCO in the future to have a microphone right at the table. I’m sure they will do that.

Stay tuned for more videos in the series.

Here is one more short video about VIBCO, as an overview, including a quote from a visiting plastic surgeon:

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Keeping things light on a Saturday… New York Magazine has a funny photo story series of President Obama on tours of different factories and laboratories (hat tip to @counternotions on Twitter). The series is called “A History of Obama Feigning Interest in Mundane Things“). I use the term “gemba” (for those who don’t know it) since it’s a common term in the Lean methodology (a Japanese word) that means the place where work is done – the shopfloor in a factory or the point of care in a hospital.

As with any executive visit, a staged “dog and pony” show likely doesn’t show a real reality. As a British friend says:

“The Queen of England thinks the world smells like fresh paint.”

I know the point of the President touring these places isn’t to inculcate a Lean notion of management and process improvement… but it’s funny see these pictures that are reminiscent of any bad factory tour. Photo #20 in the series reminds me of the famous Toyota concept — the “Ohno Circle.” The Ohno Circle (more from Industry Week) was invented by Toyota’s Taiichi Ohno. A new manager or other student would be made to stand in a chalk outline that Ohno had drawn on the ground. The person would have to stand and watch, often, for an entire shift. You would observe and see a far greater level of detail and more waste than you would see in a short “drive-by Gemba,” as some people call them, where you just walk through quickly and don’t see anything in a significant way.

The New York Magazine’s funny caption for Photo #20 said that President Obama resented having to stand in a red square.

In a way, it could also look like “Bad 5S” or “L.A.M.E. 5S” (as in this case from a UK accountancy) if the tape square had been labeled “Commander in Chief”!!!

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Our friend and Lean Blog sponsor (in that order), Bob Emiliani has a contest and an offer you might be interested in. Go to his website via this link and you can enter to win a set of all eight books, pictured at left, all signed by Bob. You have to write up to 150 words telling Bob why you want the books and what you hope to do with what you’ll learn.

Bob’s books are full of straight talk about lean leadership or historical significance, or both. I recommend them highly, especially for those who have been working at this for a while and need a boost and some tips to figure out what might be going wrong (from know Bob’s work, it might be due to having a “zero-sum mentality” or because you’re ignoring the “respect for people” principle).

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Hello from the start of Day 2 of the annual LEI Lean Transformation Summit, my seventh consecutive day of wearing a convention badge around my neck. I love the meetings, but not the thing hanging around my neck!

Yesterday, I had a chance to see some bloggers who you might recognize as guest bloggers here and/or from their own blogs…

If you want to follow what people are saying at and about the summit, follow us on Twitter via the hastag #LEI10 (you can read without having a Twitter account).

Bloggers!

In this picture, you see me with Dan Markovitz, a guest blogger here (right), and Joe Ely of the “Learning About Lean” blog (left). I had never met Joe before, so it was a real pleasure. He started his blog in 2002, believe it or not! The first lean blogger? Here is his blog post about Day 1 of the Summit.

Tweetup!

In this next picture, you see a number of Lean “Tweeple” (what a strange term), some of whom are also bloggers. Tweetup is also a silly term, but oh well. From left to right are:

• Liz Guthridge, a guest blogger here (@lizguthridge)
• Dan Markovitz (@timeback)
• Kirk Nelson (@ArcaTechOEM)
• Me (@leanblog)
• Ted Stiles of Stiles & Associates
• Adam Zak, a guest blogger (@leanthinker)
• David Drickhamer  (@leanroi)

What fun to have a drink with these lean thinkers.

Some of the highlight comments from Day 1, via Twitter:

leanblog Toyota says people are satisfied by being given responsibility and authority. #LEI10 How many organizations do that 4 all?? #lean

LeanThinker #LEI10 #HR #Lean thought for the moment: there is no job security in doing non-value-added work. Adam Zakabout 15 hours ago from UberTwitter

ArcaTechOEM #LEI10: @lantechcom “Management is there to provide the tools to allow people to solve their own problems.#lantech #lean

LEIevents Jim Lancaster from @LantechCom at #LEI10: Daily management to maintain the current state frees up time to work on improvement projects #lean

And I had a chance to practice a little quick kaizen:

leanblog @fastcap – my daily improvement at #LEI10 summit, this board was blowing over when doors opened. A little tape:http://yfrog.com/1awuaj <— picture link

It was ugly, but it worked! It was quick, cheap, and it worked.

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I’m about conferenced out! First was the excellent SHS/ASQ conference on healthcare operations improvement (read my posts), then the HIMSS conference focused on heathcare information systems, now the LEI Lean Transformation Summit that starts today (follow our tweets). As a Myers-Briggs “introvert” (a chatty introvert), I’m ready for some recharge time… this weekend. In this post, I’ll tell you about some of the people I saw, an example of bad flow, and a nice lean-related product feature that I discovered.

I saw a number of old friends at HIMSS and made some new ones, including:

• Naida Grunden, author of the outstanding book The Pittsburgh Way to Efficient Healthcare: Improving Patient Care Using Toyota Based Methods (her website)
• Dr. Ted Eytan, from Kaiser Permanente, who I met in person for the first time after years of phone calls and emails (my podcast with him when he was with Group Health, his blog and his tweets)
• “e-Patient Dave,” who I only knew from his tweets and comments on Paul Levy’s blog (Dave’s blog).

I’ll write about Naida’s talk on Lean and patient safety in my next post. e-Patient Dave gave a touching talk about his near-death experience with cancer and his fight to make information available to patients and to include them in hospital improvement activities. The most stirring line from his session, answering a question about the ROI that’s measured from patient involvement:

There’s a special section of hell for people in healthcare who ask ‘What’s the ROI of doing what patients want?’”

And this comment comes from a very upbeat, cheery guy.

Now to the bad flow example:

HIMSS was held this year at Atlanta’s convention center, the Georgia World Conference Center. This is a huge conference (30,000 attendees), so it’s understandable that it’s a big space. But I’ve never seen a convention center with so many ups and downs required to get from point A to point B. Lots of escalators. Tons of escalators.

Compared to elevators (a batch-and-queue system), escalators have continuous flow. But having flow isn’t enough if you don’t have capacity. There were HUGE backups of people waiting to get on the escalators. If you ever wondered what a bottleneck looks like, see the bottom of the escalator. This doesn’t even begin to convey the massive number of people waiting around the corner.

The flaw with the setup here (and other places) was that there were no stairs. Just the escalator. Areas that had escalators AND stairs had no bottlenecks. Seems like a better design…

Finally, the product design issue.

Nurses and patient care techs often use “Computers on Wheels” (COWs) — often called “Workstations on Wheels” (WOWs) since I heard of a story once where a patient heard the nurses talking about “cows” and the patient got offended because they thought the nurses were talking about them!

These mobile computers require charging. Normally, the charging process means the device is no longer mobile! It’s stationary and plugged into the wall. This either keeps nurses away from the patients if they’re charting or means they have to walk to access information – lots of waste involved, if anyone notices (other than the nurses themselves).

There must have been 10 vendors for these mobile carts (not a very differentiated product, it seems!). Almost all of them have an electrical cord coming from a sealed metal (or plastic) box, which houses a battery. A fixed, very hard to access battery, as pictured below. These batteries often don’t last an entire shift – they clearly don’t support the nurses and staff members and their needs!

One vendor had a very unique design. Instead of a single, fixed battery (typically “a car battery – lead-acid,” said the rep) that requires a stationary charge, this COW/WOW had batteries that were:

• Lithium-Ion (saving 35 pounds and giving better ergonomics)
• Removable (they snapped out and into a charger like a cell phone batter, well except iPhones)
• Multiple (2 batteries that could be removed separately)
• Long lasting (9 hours per batter — EACH — the rep claimed)

It’s pictured below, I’m pointing to the two removable batteries in the base.

These batteries are a new feature in their product. I wasn’t able to ask if they saw the need based on observing users at the “gemba” where the product was in use. Either way, it seems like a brilliant helpful innovation. I don’t know if it costs more than a regular COW/WOW. I’d lean toward these just because it seems to meet the minimum requirement for allowing staff to be productive and patient-focused. Less hassle, less frustration — do you know anyone who is using these carts with removable batteries? I bet it’s a huge time saver for the staff… seems like a great idea unless you’re breaking Dr. Deming’s rule and buying based on price alone. Is cheapest usually best?

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Last Friday at SHS/ASQ, I heard a talk by Michael Riordan, the CEO of the Greenville Hospital System in South Carolina.

He is one of what must be a very small number of Industrial Engineers who made it to the CEO level at a health system. I wonder if there’s any study that shows how those hospitals perform compared to MD CEOs and CEOs with other healthcare administration backgrounds. I’m sure there aren’t enough data points to be statistically significant.

Riordan made a number of great points about leadership that might sound “like lean” or at least philosophically aligned with Lean.

One dysfunction that Riordan highlighted is a real big-picture problem:

“We are paid for what we do, not for keeping people healthy.”

Healthcare is still often a very piece-work system, what some call “sickness care.”

Riordan said his goal was “Creating a culture of engagement and curiosity”, not just focusing on engineering and measures. This reminds me of the goals of organizations like ThedaCare and the University of Michigan Health System, who talk about having every employee be a problem solver and a process improver. If you’re engaged and you’re curious, that’s a good start toward working on quality and process improvement.

He also added a somewhat provocative thought:

“I’m not there to make our employees happy.”

But real engagement leads to employee satisfaction and patient satisfaction, Riordan says. I think this is the essence of the idea of “Respect for People.” It doesn’t mean being nicey-nice all of the time. Engagement, respect, and collaboration on improvements that matter to employees are more important than being nice and making people happy. We can make pepole happy, superficially, in a number of ways that don’t lead to long-term sucess for the organization.

Riordan added:

It is OK to say “no” to employees. Don’t leave them hanging. Treat them like adults, they can handle it.

Again, this sounds like Respect. Don’t give them lip service… provide servant leadership to meet their legitimate needs, but don’t necessarily say yes to just anything.

Riordan reminded me of the philosophy from St. Elisabeth in The Netherlands. The Dutch talked about their philosophy of Lean leading to “loving care.”

Riordan said that, in order to be most effective:

“We need to connect our employees to purpose and love.”

I think that’s really important in healthcare, that emotional and social connection that people can make to their work.

The final idea he raised that was interesting was his question about the things in your organization that are “the undiscussables“?? To drive meaningful improvement, Riordan said you should list the undiscussables out. Why not discuss them? What would happen? What could happen?

I was impressed with Riordan’s leadership style and what he’s trying to encourage in his organization…

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On Friday, I co-presented at the Society for Health Systems / ASQ Healthcare Division conference in Atlanta. It was the first time this was done jointly and it seemed we had more physicians and other clinical people around, which is great. I presented with Dr. Peter Patterson, a pathologist from Arizona. Our topic was the use of the Training Within Industry program in healthcare, including a case study from a lab in Yuma.

Here’s a shot of us after our talk:

I gave the first part of the talk, which included some historical context of where TWI started (as a U.S. government program in WWII) and how it became a core part of the Toyota Production System. I also talked about how it was applied to healthcare during the war, citing journal articles that were related to nursing and other hospital processes.

Some links and references for those who attended, or in general:

• I wrote about TWI and the 31 problems in healthcare from 1944 in this TWI Institute article.
  • Fuller reference is : United States, Hospital Adaptation for the Job Instruction Manual, August 1944, Subgroup 211.22.3 General Records of the Training Within Industry Service, Records of the War Manpower Commission (WMC), Record Group 211, National Archives Building, Washington, DC.
• 1944 American Journal of Nursing article “We Cannot Afford to Hurry“
• WWII TWI Healthcare Manuals – Job Instruction
• Article on Job Methods:  WASTED HOURS, Hospitals 1943
• Tebbetts article on lean / TWI methods and cosmetic surgery

Dr. Patterson gave an impressive case study about improving quality through TWI Job Instruction methods in a histopathology lab:

Dr. Patterson told the story of how the lab went through six different people in three years in a specimen receiving and processing role. Error rates were high and employees either left out of frustration or got let go. In a traditional management mindset, the lab lamented that they couldn’t find good people (or so they thought).

Having discovered TWI, for the 7th employee, they created a formal Job Instruction document and used it to train the employee in the formal 4-step TWI approach:

1. Prepare the worker
2. Present the operation
3. Try out their performance
4. Follow up their work

This is a practical, hands-on, on-the-job training approach that’s far better than just telling people verbally what to do or making them just read thick SOP manuals.

This chart shows how quality improved dramatically. The 7th person is still working. They are now working on figuring out how to achieve a true “zero defects” process.

Impressive results, all through pretty basic methods. Amazing work! The defect rate fell from 33.5% to just 2.6%. That’s still too high, but it’s far better than before. Defects included things like administrative errors (omitted one of the physician’s names) or clinical errors (incorrect name on specimen).

TWI was also being used in the context of a fuller Lean implementation that also had a large focus on staff engagement and “respect for people.”

Here are our slides via slideshare.net:

SHS/ASQ Training Within Industry :Let My People Grow

At the conference, I finally met Bob Wrona and Patrick Graupp from the TWI Institute. They are authors of the outstanding book The TWI Workbook: Essential Skills for Supervisors (with CD). I’ve recommended this book to many hospitals and I’m glad to have finally met them in person:

They were giving out articles including this whitepaper: TWI in Healthcare.

Do you have examples or success stories of your own related to the TWI methodology?

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Earlier this morning, I attended a presentation at SHS/ASQ about Lean implementation in multiple emergency rooms in a large health system. There were a lot of positives and one red flag that I heard that might be worth discussion.

A few positives (among the many in the talk):

• There was a large emphasis on the front line staff owning the process design with a high level of reinvigorated patient focus
• They didn’t use the circumstances and culture of the E.D. as an excuse to not use kaizen (or, really, the typical 5-day kaizen event). Much as Barnes Jewish got creative with their 6/3 process, this system developed a 2-day kaizen event model that would work for them.

The red flag, which comes back to an issue of management commitment and senior leadership focus:

The presenters said, basically, that “strict productivity guidelines” get in the way of having time for process improvement. Yes, productivity is important (quality is more important, but then again these things go hand in hand). Productivity is important, but productivity measures, goals, targets, and guidelines are NOT the end goal.

Why would you let your productivity goals get in the way of freeing up time for improvement? How else are you going to improve productivity if you don’t give nurses and staff enough time to work on the process? You’re NOT going to improve productivity by setting more goals and different targets. You have to staff properly so you can take care of patients (of course) and work on improvements. Too many hospitals habitually underinvest in improvement time and resources it seems.

Productivity goals are NOT a matter of federal law. These goals are set by management. Management can change them — IF they’re serious about Lean (and, more importantly, if they’re serious about improvement).

Seems like senior leadership at this organization doesn’t get it (or doesn’t realize the dysfunction their goals are creating). Do you see similar dysfunctions in your organization? Have you been able to influence your senior leaders or have they managed to see the light?

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One of the key principles of Lean thinking is the creation of flow. Flow as in no waiting time if it has no added value (time to think and reflect or time to process bad news are examples of waiting times with added value).

What would a hospital look like without waiting time? So far, I have only seen this question answered as a “what if…” exercise. However, there appears to be a hospital in India, which seems to know the answer to this question.

On November 13th, Hanneke Molema defended her phd thesis on ‘Hospital system design: creating variabilitiy to match demand variability’. Chapter 5 describes the flow of patients at the Aravind Eye Hospital in India. When you fly to India and visit the hospital without an appointment, you get your diagnosis the same day and when you want a surgery you are asked: When would you like your surgery? Tomorrow?

Her thesis raised the following questions (the responses as described in the thesis can be found behind the questions):

“Right, well I’m sure that only counts for the rich people? They probably have a lot of overcapacity?” This, however, is not the case. Their mission is as follows: “a social organisation committed to the goal of elimination of needless blindness through comprehensive eye care services” (check their website). They operate mostly poor people. Furthermore, people can decide for themselves how much money they can pay for their surgery. 60% of the people is not able to pay and gets the surgery for free. The other 40% have more money and take care of the other 60%. In this way they are able to achieve their mission.

“They probably do not treat many people then? With only a few patients per day I am also able to do this”. At their location called Madurai, they performed 581.000 outpatient consultations and 91.000 surgeries in 2008. For comparison, the largest eye hospital in the Netherlands is in Rotterdam and performed 139.000 outpatient consultations and 12.600 operations that year.

“Because of their large numbers there is almost no variation?” The number of patients ranges from 800 to 2000 per day. This is similar to our hospital, if it is not even more difficult for them, because it is pure naturally variation they have to deal with (it depends on the patients choices). The fluctuation of the number of patients per day in our hospital is for a significant part a result of the way we organize (e.g. patients are told to come back three months later for a check up).

“The quality must definitively be below acceptable standards?” International benchmarks show they can compete with Western hospitals. They provide excellent quality.

“In that case, they probably have more staff?” The same international benchmarks show that they need significantly fewer people to provide the same quality and to realise an even better flow. In Madurai Aravind 983 people work, including 46 senior doctors and 94 junior doctors. In contrast, 313 people, including 29 senior doctors, work in the eye hospital in Rotterdam. While Aravind carries out seven times more operations.

“How do they do this?” Their approach differs on several aspects:

Way of working
-         Far-reaching standardization: everyone performs the same actions in the same manner. Individual preferences are subordinate to the interests of the whole.-         Far-reaching task delegation: specialists are only doing specialist work. A cataract operation takes five to ten minutes (this varies indeed per surgeon). A specialist operates 60 patients in one morning.-         Processes are being improved step by step and this refinement process continues. They reduced the time between the end of an operation and the start of the next operation to only a few seconds.
Planning and reaction-         Strong anticipation: from previous experience (numbers) they know how many patients will come at what month and at what day of the week. They prepare for this by increasing capacity at busy days.-         Strong reactive capacity: the planning processes are designed in such a way that it is immediately visible when demand is greater than predicted at a moment in time. The employee who sees this gives a signal to people from other departments who are asked to come and help immediately.
Flexibility-         People are trained to work in different departments. People are constantly trained not only to deliver better quality care and to improve skills, but also to further increase flexibility. -         Attitudes: people need to work together to ensure that the patients gets what he needs. Not self-interest, not their own department, but demand determines who works at what place (according to knowledge and skills).
An interesting case! I do not know if the methods, used at Aravind, could also be implemented in the Netherlands, but I know no other hospital in the world that comes so close to flow as characterized by Toyota. Take a look at the thesis ‘Hospital system design’ for more information. Click here to contact Hanneke Molema.

P.S. my gratitude goes to Nieki Peerbooms for translating my Dutch blog

I’ve always enjoyed my discussions with Sami Bahri, D.D.S., the “World’s First Lean Dentist.” One concept he talks about, most recently in our video podcast, is the application of the Lean concept of “single-piece flow” to dentistry and his patients.

Dr. Bahri’s brilliant question was to ask, “Why does the patient have to come back for multiple visits to receive their complete care?” This led him to change processes to take care of almost everything in a single visit – find a problem, fix a problem.

I got an email from a reader of a similar primary care situation:

I listened to the podcast with Dr. Bahri.

My wife was at the doctor Friday for what appears\ed to be heartburn / indigestion. They ran an EKG, which was normal. As defensive medicine, I suppose, they want to run an echocardiogram. They could have done it at the doctor’s office at the same time as the EKG, but the insurance company won’t pay for it there, so she has to take this afternoon off to go to the hospital instead.

So much for single piece flow – so much for taking care of the customer’s needs in a convenient way. In this case, it sure sounds like the dysfunction comes from the insurance rules. I’ve heard of similar dysfunctions where outpatient physical therapy has a different rate than inpatient physical therapy — different pay for the same work.

Have you run into similar situations? Dr. Bahri was able to improve his patient flow since there wasn’t a financial impact, it seems – same pay for the same work done in one visit or multiple visits.

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Random thought related to those from the Big 3 Detroit 3 who are happy to see Toyota suffer, I think I’m coining a term (I can’t find it, or this spelling, via google anywhere):

I think I’m coining a phrase: “detroidenfreude” = the pleasure Detroiters derive in the misfortunates of Toyota.

I say I’m coining it, because nobody has really used the term “detroitenfreude” either, ala the German word Shadenfreude. The only reference on Google right now is my original tweet.

If this term already exists out there, let me know. It just occurred to me thinking about the glee expressed, the desire of some to kick  Toyota while they’re down after decades of being kicked around my home town area – Detroit.

What are your examples of detroidenfreude? You can often find them in the local papers the Detroit News and the Detroit Free Press. Post links in the comments.

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I only watched a few minutes of Toyota CEO Akio Toyoda’s live testimony (thanks to online cable news streaming), but the first things I heard prompted me to Tweet about it and I’m following up with a quick post.

You can read his full prepared comments or a news article summary.

The very first words (I joined in progress) that I heard were ones I passed along in the first tweet:

Akio Toyota – “The key to making quality products is developing quality people” — the very 1st thing I heard in the webstream #lean

This is a familiar refrain from those of each teaching Lean management and the Toyota Way. How did Toyota lose sight of this?

The next quote speaks to the fact that Toyota got away from their core principles, things that are taught as Lean thinking. It’s not that TPS failed (or what some people think is TPS), Toyota got away from the TPS mindset.

Akio Toyoda blames growth that was “too quick.” Toyota priorities traditionally 1) safety 2) quality 3) volume. Priorities got confused.

So if TPS  / Toyota Way / Lean is about developing people so they can improve quality, Toyota got away from that when their goal was to become #1 in sales:

Akio Toyoda says they pursued growth over the speed at which they could develop people and org., he regrets that led to safety problems.

Since Toyoda is relatively new to the job, do we blame him?

Since taking the job, Akio Toyoda has placed focus on re-emphasizing quality over quantity. #lean (live testimony)

My colleague John Toussaint also blogged recently about Mr. Toyoda and his response to the recent challenges.

On Twitter, follow Matthew E. May and the NY Times’ Micki Maynard as they’re each tweeting about this from their perspectives.

And why is the company name not the same as the family? Find out from Jalopnik.

Updated: Random thought related to those from the Big 3 who are happy to see Toyota suffer, I think I’m coining a term (I can’t find it, or this spelling, via google anywhere):

I think I’m coining a phrase: “detroidenfreude.”

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Episode 84 is audio from Video Podcast #10 (available on iTunes, YouTube, or leanvideopocast.org). This is a conversation with Karl Wadensten, President of VIBCO, a manufacturer in Wyoming, R.I. Here, we talk about his radio show, “The Lean Nation,” which airs on AM 790 in Rhode Island and streams live on the web everyday weekday at 4 PM eastern — www.790business.com.

I’ve been able to get from Boston to VIBCO twice now and I’ve been impressed with what I’ve seen on my gemba walks each time. I’ll blog about this in more detail in the future, but it’s great seeing the pride on their employees faces when they describe and show you the improvements they’ve made on the shopfloor. I’ve seen this first hand:

Under Karl’s leadership, VIBCO is now a high performing business culture where lead times for over 1,300 SKUs have dropped from 4-6 weeks to “same day, next day”, inventory has been reduced by more than 50%, over 10,000 sq. ft. of manufacturing floor space is now freed up to accept future growth, and sales are well above industry trends.  These impressive improvements are the result of a workforce that is empowered to improve every day and understands the power of Lean Thinking.

Here are links for more about their “True North” and Lean journey.

This is also available as Video Podcast #10.

For earlier episodes, visit the main Podcast page, which includes information on how to subscribe via RSS or via Apple iTunes.

You can use the player (use the VCR-type controls) at the top of the post to listen to a “streaming” version of the podcast (or click here for the streaming audio and RSS subscription). The streaming link is faster for one-time listening (hardly any delay to start listening). Or you can use the download link to put it on your iPod or other MP3 player.

If you have feedback on the podcast, or any questions for me or my guests, you can email me at leanpodcast@gmail.com or you can call and leave a voicemail by calling the “Lean Line” at (817) 776-LEAN (817-776-5326) or contact me via Skype id “mgraban”. Please give your location and your first name. Any comments (email or voicemail) might be used in follow ups to the podcast.

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Episode #10 is a conversation with Karl Wadensten, President of VIBCO, a manufacturer in Wyoming, R.I. Here, we talk about his radio show, “The Lean Nation,” which airs on AM 790 in Rhode Island and streams live on the web everyday weekday at 4 PM eastern — www.790business.com. This is the same discussion as the audio LeanBlog Podcast episode #84. For more info about Karl and VIBCO, visit that post.

You can also go to YouTube to watch (the full series can be found there.)

Video:

If you have feedback on the podcast, or any questions for me or my guests, you can email me at leanpodcast@gmail.com or you can call and leave a voicemail by calling the “Lean Line” at (817) 776-LEAN (817-776-5326) or contact me via Skype id “mgraban”. Please give your location and your first name. Any comments (email or voicemail) might be used in follow ups to the podcast.

For audio podcast episodes, please visit www.leanpodcast.org. For video podcasts, visit www.leanvideopodcast.org.

You can subscribe by searching “Lean Blog Video” in the iTunes Store Podcast Directory (or via RSS feed)

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You heard enough from me yesterday… today I want to share some other voices with you and their thoughts on Lean. First, familiar voices (John Shook and Jeff Liker) and someone who might seem like a new voice in the Lean world (Stephen Covey).

Familiar Voices:

I wish I could have been a fly on the wall for the coffee shop chats between John Shook and Jeff Liker, talking about and debating the recent and current Toyota crisis. John Shook writes about it here, on his LEI blog management column (“Toyota Trouble: A Dialogue with Jeff Liker“).

It’s too bad they didn’t record this as a podcast or a video podcast. I’ve been reading it and will likely read it again to absorb their thoughts and perspectives. You can share comments on their discussion over at lean.org or share them here if it’s easier.

New, Yet Familiar, Voice:

Utah State University recently announced that the famous author and guru Stephen Covey (of The 7 Habits of Highly Effective People fame) is joining the faculty of the Huntsman School of Business, the home of the Shingo Prize for Operational Excellence.

In that new role (he is already guest lecturing), it appears that Covey might be taking an active role in promoting Lean? He was already announced as a keynoter at this year’s Shingo Prize Conference (where I’ll also be giving a talk on Lean healthcare).

Now, this video has appeared on YouTube, with Covey talking about Lean in very human terms — not tools, but principles of integrity and respect for people.

Do you think Covey will introduce Lean to a new audience? Will he have an impact on the new folks and the existing Lean movement in helping everyone understand that Lean is about people, not just tools? What are your expectations?

Have you incorporated Covey’s “7 Habits” into your own professional development or formal Lean efforts?

I’m not the biggest Covey-phile, but I can see the connections (and remember enjoying his book and seeing him speak 12 years ago): Habit 1 (Be Proactive) certainly fits with Lean (identify possible problems in the process rather than reacting when things go wrong. Habit 2 (End in Mind) speaks to purpose and goals — why we work at Lean transformation. Respect for people includes Habits 3,4, 5, and 6 (integrity, win/win/ seeking first to understand, and cooperation). Habit 7 (sharpen the saw) speaks to “kaizen” or continuous improvement and development.

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I’ve written about many of these ideas and themes before in various blog posts, but I wanted to consolidate my thoughts on the Lean concept of “standardized work” in a single place. This is partly for my own personal reference (and future linking), but also can prompt some discussion amongst my friends, the Lean Blog readers.

What I’m documenting here is consistent with what I’ve been teaching and coaching people on in healthcare the last five years, especially. The concepts described here are directly influenced by Toyota (especially the book Toyota Talent: Developing Your People the Toyota Way) and, I believe, is very consistent with what’s expressed in Dt. Atul Gawande’s The Checklist Manifesto: How to Get Things Right). These points are also expressed in the chapter on Standardized Work in my book, Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction.

This is a looong post, so the quick bullets:

• Standard-IZED
• Don’t standardize for the sake of standardizing
• It’s created by the people who do the work
• It’s not always a detailed procedure
• It’s not restrictive or limiting
• It’s not permanent
• You don’t beat people up for not following it

Standard-IZED

In the past, I used the term “standard work.” In fact, the tag I use here on the blog (look at the bottom of this post) is “Standard Work,” not “Standardized Work.” I’d also accept “Standardised Work” for those who speak the Queen’s English.

I think that one syllable makes a huge difference. “Standard” implies fixed and inflexible. “Standardized” reflects, to me, a spectrum. David Meier, through his books and personal conversations, confirmed the idea that it’s important to understand WHAT you standardize and to what DEGREE you standardize it.

Is more standardization always better? Probably not always. You can take things too far, to an extreme that’s not beneficial. If somebody in a laboratory is walking from one station to another, does it matter which foot they take their first step with? Of course not, there’ no need to standardize that, no benefit.

Is there benefit to making call center staff read a script like robots, not letting them deviate or do what’s necessary to serve customer needs? Probably not. Then again, working with one hospital, the radiology scheduling team created standardized work for how and when and what they communicated to parents of patients who were coming in for sedation and an MRI. By communicating in a more standardized way (not 100% scripted, but having key points), they significantly reduced process defects where parents came to the wrong location or the children had mistakenly eaten that morning, meaning they couldn’t have their procedures.

I’ve found, that in many cases, healthcare (and patients) from more standardization. Experience and published evidence confirms that.  In many healthcare settings, highly skilled people are working hard in what some describe as a “process-free zone.” There is a lot of evidence (see Gawande’s books, including Better: A Surgeon’s Notes on Performance) that standardized work leads to better patient safety and better quality outcomes.  See ThedaCare’s work in improving “door to balloon” time for “Code STEMI” patients and how they receive faster care (therefore, better outcomes) through standardization of work processes and care decisions.

Don’t standardize for the sake of standardizing

I’ve always taught that standardizing is NOT the goal. The goals are better safety, quality, access (waiting time), cost, and staff morale — these are the usual goals of a Lean organization. Since we’re very concerned about staff morale (especially since staff satisfaction correlates very well to patient satisfaction in healthcare), we have to think about how people would feel if they’re FORCED to follow an arbitrary procedure – is this good for morale? Probably not, especially among highly-skilled professionals.

There must be a clear “why?” statement for standardizing in a certain way. High-level example: Why is doing it consistently good for quality? Again, consistently doesn’t mean robotically identical.

Back to the laboratory example above, I can think of one example from my past where it DOES matter greatly —  a marching band. Fellow band geeks will know you always take your first step with your LEFT foot. Beats “1″ and “3″ in a song are always your left foot. Why is this important? Visually, for the marching band performance, it looks better when people are stepping in unison. When you march in a line, you stay better aligned. Does it matter in almost any other setting NO? You always have to understand the purpose and the context of what’s being done.

It’s created by the people who do the work

“Work standards” are the old-school approach – inflexible, detailed procedures pushed on people by managers, engineers or experts. This is the old Taylorist approach that separates thinking from doing. This is not the Lean approach, as I’ve learned it.

Lean standardized work is created by those who do the work. It was the case at Geisinger in Pennsylvania, where a cardiology group created standardized work for better cardiac bypass surgery care.

Standardized work was created Dr. John Tebbetts, a Dallas cosmetic surgeon, and he specifically credits Lean and Toyota in his peer-reviewed medical journal articles. Be warned if you go downloading his journal articles, they have some “NSFW” before and after photos. That point aside, HE created standardized work for how he performs surgery and his patients get better results. He owns the standardized work, since he created it and it has clear benefit.

It’s not just doctors. I’ve worked with folks in many different hospital departments that created their own new standardized work.

It’s not always true that everyone gets to have their way on everything, it’s more complicated than that. In the marching band, the standardized work (left foot first) was dictated to me. In the case of safety glasses in a factory or gloves in a medical laboratory, this is not optional – it’s standardized work that you must follow for your own safety. We don’t let the staff vote or decide on their own.

But very generally, people don’t like to be told what to do, they don’t like to be forced into an inflexible way of doing things, regardless of their education level. But if you do have to “dictate” the standardized work (and this had better be done rarely and judiciously), give them a good reason why. Treat them like adults, don’t just bark orders. You can’t depend on just blind compliance.

It’s not always a detailed procedure

Standardized work doesn’t always mean a long, detailed document. Organizations, especially hospitals, usually have no shortage of procedures. But they’re pretty useless – they weren’t written by the people who do the work, they’re often out of date, and they’re often just a bunch of binders on the shelf. In a Lean approach, you might update those documents and make sure they reflect reality.

The “Checklists” approach (from aviation and now in medicine) emphasizes simple single-page documents that have just the “key points” (to use a word from the Training Within Industry approach) – the important things that shouldn’t forgotten, due to the impact on the patients.

Instead of huge documents, you might also create guidelines — rules of thumb, even — that might be documented in a simple way. I think standardized work is about three questions:

1. Who does what?
2. When do you do it?
3. How do you do it?

The old procedures approach usually focuses very heavily on the detail of #3. The other things are important too — asking the staff to re-evaluate and determine who does what. Should nurses be dragging bags of dirty linens down the hallway? No, they decide that should be done by a tech — and management and the team also make sure that the tech hasn’t been overloaded with a 120% job. It’s not about just dumping work on others, it’s about making the best of use talent (often, it’s scarce talent).

When should you do things? Why do the first shift laboratory technologists shut the testing machine down for maintenance at 7 am – a busy of time of day when test results are delayed?? Because it’s the start of their shift. Habit. If it needs to be done once daily, the team can decide to do it at 10 am, when it’ s a very slow period.

In all of these cases, people sh9uld understand why. Why does it matter who does what? Why does it matter when you do it? Why does it matter how you do it?

It’s not restrictive or limiting

I love the quote from Bill Marriott that says, at the hotel chain, procedures (they don’t call it standardized work) don’t lead to “mindless conformity” from employees. Standardized work doesn’t eliminate the need for judgment, it doesn’t mean shut your brain off at the door. From a review of the book:

Emerson once disparaged “foolish consistency” as the “hobgoblin of little minds.” But Bill Marriott has not confused mindless conformity with thoughtful standard-setting. Consistent systems and procedures are main engines for the company’s success – and at the heart of “Marriott’s way”:

“At the most basic level, systems help bring order to the natural messiness of human enterprise. Give 100 people the same task-without providing ground rules-and you’ll end up with at least a dozen, if not 100, different results. Try that same experiment with a few thousand people, and you end up with chaos. Efficient systems and clear rules help everyone to deliver a consistent product and service.”

It helps. Procedure manuals don’t create good service. Thinking people do. At Marriott, and Toyota, the idea is to standardize what you can so you can have the mental energy left to focus on UNUSUAL situations and problem solving. Do their manuals cover EVERY situation that could possibly occur? Not possible. As a pilot friend of mine says, “checklists don’t fly the airplane.”

In the Geisinger case, the cardiac surgeons are allowed, of course, to deviate from the standardized method. But they have to be able to articulate and defend a clear medical need. It’s not just a matter of you woke up on the wrong side of the world and didn’t feel like giving an antibiotic before surgery.

There’s a guy who criticizes my advocacy for standardized work because (I think) he assumes that I am advocating “mindless conformity.” That’s never been the case and if he read my book or really read my blog, he’d have a chance of seeing that. Then again, he makes blind blanket statements like standardized work is always bad for services or lean doesn’t work. We agree that the wrong-headed application of the concept is harmful, but he takes it to an extreme that it’s always bad because it’s sometimes misapplied…

It’s not permanent

In any Lean setting (and this is true in the checklists approach), standardized work is NEVER permanent. It’s just the best way we know how to do the work today. Even Henry Ford said almost 100 years ago that every process is experimental. Today’s standardized work is the basis for tomorrow’s kaizen (or continuous improvement). This is clearly taught by Toyota and it’s being taught in healthcare.

As Toyota teaches – every employee has two jobs:

1. Do the work
2. Improve the work

With Lean, we follow a scientific method for improvement – the “Plan Do Check Act” cycle.

You don’t beat people up for not following it

One final point – what happens when a manager sees somebody not following standardized work?

You don’t yell. You don’t make a thoughtless remark that pressures them into conforming. You don’t make a face that says “what’s wrong with you?”

The best thin you can do — ask WHY? Maybe there’s a good reason (and that’s OK). Maybe the employee doesn’t understand the standardized work and they need more coaching – be a coach, not a cop. Maybe the person is experimenting with a new, better way.

If you force blind conformity, you’ll kill kaizen. Your organization starts to die. Back in my days at GM, the UAW guys had a term — “malicious obedience.” Managers yelled at them and told them to follow orders, to not think. The workers said, “OK” and did things that were often bad for the product quality because the bosses told them to. And you wonder why GM had such problems? We don’t want hospitals, or other organizations going down the Lean path, to have such problems.

Thanks for reading – thought on any of the points? This post will evolve over time as I better document some of the references, particularly to the Toyota source material that I don’t have right in front of me.

If you agree with these points, which ones do you see violated most often?

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Oh no, it seems like a L.A.M.E. (“Lean As Misguidedly Executed”) story on NPR’s All Things Considered program. No wonder some people hate the idea of Lean when stories like this appear (“Do You Waste Time Walking To The Printer?“).  Thankfully, the “efficiency expert” who was featured didn’t use the L-word, but he did mention 5S and the 8 types of waste… and seemed, at first glance, to lack any use of the “Respect for People” principle.

“Efficiency expert” is such an old-school Fred Taylor / Frank Gilbreth sort of word. In the old Taylorist approach, you had educated managers or engineers hovering over workers, trying to come up with a better way to do the work (as you see pictured to the left, where it even appears to be sexist). In this old approach, there’s a separation between thinking and working, between system design and daily execution. Lean is all about engaging the people who do the work, teaching THEM how to make improvements. The guy in that story seems to miss that. Or maybe it’s just his company that forces him to operate in that style.

Matt LeBlanc, an efficiency expert at a global shipping company, is a kind of special ops guy. His company drops him into its locations armed with a stopwatch, equations and a mission to save the firm hundreds of thousands of dollars.

An engineer with a stopwatch, a guy from corporate “here to help” (doesn’t that make people scurry??), and a cost-cutting mission. That doesn’t sound like Lean to me.

He stands and watches people work, watching them unload trucks. It’s described as “weird.” Of course it is.

In a Lean approach (and this has been my style in my previous consulting), you teach the people who do the work about Lean concepts and you let THEM figure out improvements that they own. Make their work easier and provide better value to the customer. People can figure this out. You don’t need that old-style of efficiency expert.

What happens when the efficiency expert goes away? I bet things go back to the old way, the old methods. The so-called “cost savings” probably dry up and disappear.

Not surprisingly, people don’t always like when LeBlanc shows up. They don’t like to be told they’ve been wasting time. They worry he might find that their whole job is unnecessary.

“I’ve been physically threatened in a meeting once by someone because I moved their desk from one side of the room to the other,” he says. The lesson: “You can’t just move people’s desk, staplers. You have to move people along.”

Not that I’m justifying threats and workplace intimidation, but it’s understandable, eh?

Let me be clear about this — you don’t go moving people’s stuff without involving them. Period. LeBlanc claims he has learned a lesson — is he acting differently now? The story seems to tell it both ways — he’s the guy who tells people what to do, yet he understands you need to get people involved. Which is it? I’ll admit to similar mistakes earlier in my career… before I fully appreciated the Respect for People principle from Toyota.

The audio talks about the fear of layoffs from productivity improvement — of course, people are afraid of this sort of thing. That’s why a lot of Lean organizations have a “no layoffs due to Lean” philosophy. You redeploy people for business growth or career growth – it’s the right thing for a business for the long term (as long as sales haven’t completely gone into the crapper).

Some of the ideas he expressed make sense. Yes, I *do* put creamer in the mug before coffee when I make it for my wife (I drink my coffee black). Moving printers to reduce walking can be a time saver. But, the employees can figure these things out when you create an environment for improvement of work. When THEY figure it out, they take pride in their improvements. When it’s some guy from corporate who tells them what to do, they get pissed off. Go figure.

Another point from the piece:

People like LeBlanc are one reason why things are so cheap. If he reduces labor costs, then the price of MP3 players can come down.

No, no, no. In the Lean approach (and as taught by Toyota), prices are set by the market, by the consumers (in most cases – monopolies and health care are weird exceptions). If you reduce labor cost, that means more profit for the company. You don’t base your prices on costs. If you lower your costs below the market, you’re giving money away (unless that’s your strategy to undercut the market to build market share). Does Apple lower the price of the iPhone if they found manufacturing and supply chain efficiencies? I doubt it! More profit for Apple and Steve Jobs.

p.s. My spice rack is NOT alphabetized, by the way. And I don’t have my bathroom toiletries lined up in the order I use them in the morning.

Another thought – the audio gives a little more balanced view of things. The web story makes him sound like a real Taylorist. The audio makes him sound a little more self-aware when you really hear him speak.

Other posts that may add value:

• LEAN or LAME?
• Once Again, Prices are Set by the Market, Not Your Costs
• Starbucks Pricing on Cost or Value??
• Like Lean: Solving Health Care Problems By Design
• Companies Use Lean to Offset Cost Increases

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