e-HealthExpert.org - Primum non nocere

I’d like to welcome a new advertiser to LeanBlog.org — it’s 5S Supply, found online at www.5Ssupply.com.

I’ve talked with the owner, Tony Manos, and he’s serious about Lean and he’s serious about providing good service and good value to people who need supplies for their Lean journey.

From his website:

About 5S Supply

5S Supply was born from the idea that there had to be an easier way to gather the necessary supplies for a successful 5S event and program in a timely fashion, with no hassle.

This was readily apparent several years ago when one of our founders was frustrated trying to find items needed for 5S events. As an expert in Lean and 5S he thought that there should be a one-stop shop for 5S items. Many 5S events are slowed down because items have to be hunted down, researched, selected, paid for, delivered or picked-up; often from many different suppliers and sources. At 5S Supply we’ve done the hard work for you. Instead of looking through several catalogs or performing tireless searches on the internet, our 5S and Lean experts have packaged items together to make it easy and convenient to order and get the things you need for your 5S event quickly!

And here’s a fun video they made (and you can see more via their 5S Supply YouTube channel):

Thanks to Tony and 5Ssupply.com for their sponsorship of my blog!

• New Free iPhone App – “Lean Daily” Now Available
• Reader Question: Rapid Response Teams (Oops, We Don’t Have the Items)
• Weekend Fun: Depiction of the Lack of Hospital “5S”
• My Lean Message Board is No More
• Happy Birthday Frank Gilbreth; Reducing Waste in Hospitals… Green is Lean

My city in Texas signed a contract with a new trash/waste company that starts on September 1st. The new bin is green (pictured at left). I already had two blue bins from the old company. The bins work just fine.

I’m honestly not the biggest environmental zealot out there, but I don’t like waste, regardless of where I see it. I called the new company and asked them about the new bin… was basically told that’s what they do and that the old company should pick up the old bins. I set them out at the curb today (for the last trash pickup of the old company) and, sure enough, they didn’t pick up the bins. So do I throw them out? Keep them as planters??

So, to create a bit of a mid-week laugh, I made this video:

This is from the same service made famous by the popular “iPhone/Android” video (warning, rated R language).

Warning, my video uses the “S word” three times… and it’s a bit of an exaggeration of the conversation I had with the trash company…

Honestly, it does seem to defeat the purpose of Reduce, Reuse, Recycle.

Back to the usual stuff tomorrow…

• Weekend Fun: Depiction of the Lack of Hospital “5S”
• New Book: “Laugh, Sing, and Eat Like a Pig”
• Saturday Fun: Social Media on “The Office”
• “Win”-dow Washing: Standardized Work or Kaizen?
• Funny UPS Ad Parodies from SNL

photo credit: Stewart

A number of readers emailed me a link to this New York Times article: “U.S. Inaction Lets Look-Alike Tubes Kill Patients.” The headline emphasizes the lack of governmental oversight, but I’d rather talk about the poor system design that allows deadly errors to occur.

The article describes an error where food was mistakenly injected into her veins:

… the hospital mixed up the tubes. Instead of snaking a tube through Ms. Rodgers’s nose and into her stomach, the nurse instead coupled the liquid-food bag to a tube that entered a vein.

Putting such food directly into the bloodstream is like pouring concrete down a drain. Ms. Rodgers was soon in agony.

So is this a one time fluke? It seems not:

Their deaths were among hundreds of deaths or serious injuries that researchers have traced to tube mix-ups. But no one knows the real toll, because this kind of mistake, like medication errors in general, is rarely reported. A 2006 survey of hospitals found that 16 percent had experienced a feeding tube mix-up.

Why are errors rarely reported? That’s a topic for a different post. I think the question here is why there’s such a risk of systemic mixup.

Hospitalized patients often have an array of clear plastic tubing sticking out of their bodies to deliver or extract medicine, nutrition, fluids, gases or blood to veins, arteries, stomachs, skin, lungs or bladders.

Much of the tubing is interchangeable, and with nurses connecting and disconnecting dozens each day, mix-ups happen — sometimes with deadly consequences.

Interchangeable, identical looking clear tubing – that’s a mistake just waiting to happen, isn’t it?

I saw, last week, a presentation about a chemical factory that had made huge strides in improving worker safety. One of the risk factors the engineers identified is that the pipes through the factory were all gray — somebody’s idea of aesthetics. But, in an emergency, not having pipes clearly labeled could be deadly.

So if this is fixable in a chemical factory, why not in our hospitals?

It’s not a new idea that there are systemic risks. Again, from the article:

Experts and standards groups have advocated since 1996 that tubes for different functions be made incompatible — just as different nozzles at gas stations prevent drivers from using the wrong fuel.

But action has been delayed by resistance from the medical-device industry and an approval process at the Food and Drug Administration that can discourage safety-related changes.

It’s often said that it takes 19 years for a change to make its way from idea to widespread implementation in healthcare. So we have a few more years left on that clock…

If it’s far too easy to mistake a food line for an intravenous line, can’t we fix that today? Isn’t there an opportunity for simple labeling and visual controls? Do we really need to let the FDA get in the way of this? I’m asking a question I don’t completely know the answer to  — what do the clinical readers have to say?

One paragraph in the article that I agree strongly with is this:

“Nurses should not have to work in an environment where it is even possible to make that kind of mistake,” said Nancy Pratt, a senior vice president at Sharp HealthCare in San Diego who is a vocal advocate for changing the system. “The nuclear power and airline industries would never tolerate a situation where a simple misconnection could lead to a death.”

So when a systemic mistake occurs (one that’s predictable), what happens? Often, a person gets blamed — and the article brings up the case of a nurse, Julie Thao, who was convicted after a fatal error (and I blogged about it a number of times over the fast few years).

The article talks a lot about failed legislative attempts and failed regulatory efforts — so my question (and there may be a good answer) is why hospitals don’t each individually fix this tomorrow?? If we can’t change the equipment, how can we change the process to avoid the error? Does the FDA really get in the way?

It’s a shame we have this dynamic:

“The regulators have been waiting for the manufacturers to come up with a solution,” Ms. Pratt said, “and the manufacturers won’t spend the money to design and produce something different until the regulators force them to. And now the international standards organization is taking forever to get the whole world onto the same page.”

Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association, agreed, “These things are hard to change when you have to get so many different organizations to act in concert.”

I guess that makes it much more complicated than a chemical factory, which is also regulated? People are dying, unnecessarily, during this delay. How can we avoid this suffering?

• Another Pathology Mishap
• Liveblogging the Quaid Patient Safety Documentary
• Dennis Quaid and Patient Safety – Upcoming Documentary
• Of 777s and Heart Rate Monitors
• Teachable Moments from PRHI

You might know of and already be a fan of Pascal Dennis (read more about him and listen to my recent podcast with him here). He has a new book out (The Remedy) and his firm, Lean Pathways, has published a cool set of “mental model pocket cards” (the first set of more to come).

Pascal and Lean Pathways have generously offered to give away a copy of The Remedy and the cards, both autographed by Pascal.

So, here’s how to win:

• Follow both @LeanBlog AND @LeanPathways on Twitter (if you are not already following both)
• Send out a tweet that says exactly this text: 
  • I’ve entered to win autographed book & #lean cards from @LeanBlog & @LeanPathways – http://lnbg.us/1TJ - pls RT!
• Your tweet MUST contain all of the text above to be considered an eligible entry. And, again, you MUST be following both @LeanBlog and @LeanPathways to be eligible to win.

That’s it. All you have to do is Tweet… and you might walk away with an autographed book and card set from Pascal Dennis sent right to you.

The winner will be announced on LeanBlog.org on Tuesday, September 7 at 2 pm EDT and via Twitter.

More books from Pascal:

• Lean Production Simplified
• Getting the Right Things Done: A Leader’s Guide to Planning and Execution
• Andy & Me: Crisis And Transformation On The Lean Journey

• Podcast #96 – Pascal Dennis, “The Remedy”
• Contest for a Set of Free Signed Books from Bob Emiliani
• A New App to Download, Events to Attend, and a Book to Read
• Book Giveaway Winners Announced
• Lean Books Giveaway (Register Now)

People often ask “So where did the term ‘lean’ come from?” It didn’t come from Toyota. And the term isn’t an acronym (so no need to type it as LEAN or L.E.A.N.).

The term came from John Krafcik, who was a graduate student at MIT, working for Lean Enterprise Institute founder Jim Womack on the research for the book The Machine That Changed the World. See comment #5 where I added more detail about that.

Where is Krafcik today (pictured at left)?

Krafcik, 48, is now CEO of the Korean automaker Hyundai. Maybe GM made a huge mistake in not hiring him instead of promoting yet another finance guy to the head of that troubled company? Maybe there’s still a chance he can take over after the next CEO-of-the-quarter is done at GM.

Krafcik was featured in a recent USA Today article, “Hyundai’s John Krafcik isn’t your typical CEO type“).

From the article:

Krafcik got his first auto break with a venture Toyota and General Motors were setting up in Fremont, Calif., to build small cars for both companies. New United Motor Manufacturing (or NUMMI) was a chance for GM to learn Toyota quality methods and for Toyota to try operating a U.S. plant.

And he saw the difference between GM and Toyota at the time:

Hired as a manufacturing engineer, Krafcik says the experience “was just awesome,” especially his Toyota-trained boss, who wanted him to see what makes an auto plant succeed or fail. Krafcik was dispatched to GM’s plant in Oklahoma City, where he says he saw half-built cars backed up and workers napping on the job. Then he went to Toyota City in Japan, a plant he says was so well laid out and efficient he could see across it to the other side. There was little inventory, with parts arriving from suppliers only hours before they were needed.

Krafcik is described as a disciplined, data-driven engineer, but one who is innovative and keeps connected to customers (personally calling an upset customer each day, something I wish American Airlines Gerard Arpey would try, but that’s beside the point).

I wonder how GM would be different with Krafcik in charge? Do you think he could make a difference?

Regardless of your workplace, what’s the ideal “lean CEO”?

• Read this Book – But Don’t Copy ThedaCare
• NPR on the “End of the Line” at NUMMI and My Story About an Interviewee
• Toyota Leaders Get a Lecture From a Toyoda
• Video Interview with LEI’s Jim Womack
• Meeting Newt Gingrich, a Lean Champion

Here is a nice little (under 2 minutes) news video from New Zealand talking about one hospital (in Auckland) and their implementation of the “Releasing Time to Care” program that was started in the British NHS. Other hospitals across New Zealand are doing this too, apparently

The story talks about how nurses were spending on 33% of their time with patients at the bedside. It’s such a systemic problem – the interruptions and waste – that the number is almost always between 30 and 33% in studies done around the world.

But it’s possible to double time at the bedside with this Lean-based program.

The story, “Nurses back by the bedside” highlights getting staff involved in identifying waste and improving processes. Before, patients were sometimes afraid to call the nurse because they saw the nurses were so busy. That changes with RTtC.

“The nurses appear happier and the ward seems less rushed and the patients feel like they’re getting better care,” says one nurse. One hospital also reports a 10% shorter length of stay, as a result.

Watch the video by clicking on the photo below:

• A Lean Nursing Example in New Zealand
• Lean Healthcare Featured in Sunday NY Times Business Page & I Got Quoted
• Two Extreme Sides to Every Story in Politics *and* Lean??
• ThedaCare, Lean, and Primary Care in the News
• Lean Healthcare Examples from Seattle and the UK

I’m currently in Minneapolis, where today is Day 2 of our Healthcare Value Leaders Network “Gemba Visit” to Park Nicollet (read more about these visits here). Dr. John Toussaint, author of the book On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry, is here with us as always (pictured at left during part of our visit to their “3p mockup area” used for space and process design work.

We’ve had a great visit so far, including seeing the newly-designed cancer center that I blogged about before (including a YouTube video about the center where “care comes to the patient”).

I’ll have more thoughts to share about the visit next week (including the value of learning and collaborating without copying), but I’ll link today to two recent interviews with John.

Business901 Podcast with Joe Dager

Listen to John being interviewed by Joe Dager (who has also previously interviewed me before about lean healthcare and about social media).

You also have option of reading the interview with John as a free e-Book instead of listening.

iSixSigma Interview

You can read an interview with John titled “Is Lean the Secret to Curing Healthcare?“

From the interview:

Terry: What are the biggest challenges to implementing Lean in a hospital setting?

Toussaint: I think part of it is that staff members aren’t familiar with any of these concepts. We never get trained on any of this stuff in our [career] training programs. So people are quite unfamiliar with these quality improvement tools and with the concepts of getting decision making and improvement down to the level of the frontline worker. It’s actually fascinating to me that that isn’t the case in healthcare. We have a very highly educated workforce that goes through years of training, but the fact that they don’t get any training in continuous improvement and they don’t have a clue how to do a Plan-Do-Study-Act improvement cycle – it’s really quite shocking actually. So we have to overcome that by retraining – both physicians and nurses and others – in this very basic set of continuous improvement principles.

And then, we touched on before, this issue of the cultural component. Healthcare is full of, what I describe in the book as, the “shame and blame” – if you make a mistake, you’re a bad doctor or a bad nurse. But in fact, 99 percent of [mistakes] are process problems. The processes in healthcare are perfectly designed to get the results they’re getting – which are lots of errors and massive cost problems. That’s what’s great about the Lean methodology…it takes all the blame away and really starts to focus in on what’s the process change that needs to occur in order to improve the result. And that’s easier said than done, but I think that’s one of the biggest issues – to be able to change the culture from shame and blame to continuous improvement and using data to make decisions.

Read the whole interview at iSixSigma.com. Your thoughts?

• Two Extreme Sides to Every Story in Politics *and* Lean??
• Great Guests on “The Lean Nation”
• Dr. John Toussaint Talks Lean Healthcare on The Lean Nation Show
• Lean Healthcare at Denver Health is Front-Page News
• A First-Person Lean Leadership Story from John Toussaint, MD

Here are a few events I’ll be a part of in the next few months, maybe I’ll see you there:

• Cindy Jimmerson’s “Big Sky” Lean Leadership Retreat, Sept 20-22
• Michigan Lean Consortium’s Lean Healthcare Event, Sept 28
• LEI “Key Concepts of Lean in Healthcare” Workshop, Oct 11-12

More details follow:

“Big Sky”

I’m excited to be attending Cindy’s event for the first time and I’ll be presenting. I think my talk will be a fun one and, considering the importance of healthcare quality and patient safety, it will have a lighthearted feel. The topic is “error prevention in healthcare” but the title of my talk is Warning: Signs! From Cautionary Circulars to Proactive Prevention.

I’ll talk about how it doesn’t count as “mistake proofing” or “visual management” to hang a bunch of warning signs around the hospital. I’ll illustrate the point with a lot of pictures and discussion of Lean alternatives that work better and exhibit “respect for people.” Mistake proofing (error proofing) is one example of a Lean concept that works better, checklists can help too (instead of signs that say “don’t forget to…”).

Maybe as a discussion point for this blog — do you see this as a problem in your organization, the abundance of signs? I actually see each sign as an opportunity to improve a process someplace. You can see some examples of signs like this on my photoblog “Be More Careful,” including examples like:

• No! No! No!
• Don’t Let the Door Hit You, or Others
• “Do Not” Inject Patient with Wrong Syringe

These are signs that don’t quite get to the root cause of the problem – in some cases, somewhat silly problems and, in some cases, serious ones.

Dr. Richard Shannon will be presenting, as well. Sign up at Cindy’s Lean Healthcare West site.

Michigan Lean Consortium

I’m appearing at an event in my home state of Michigan to give a 4-hour introductory lean healthcare workshop. You can learn more and sign up at the MLC website.

As I was quoted in a blurb about the event:

“As someone who grew up in Livonia and still has parents and friends there, I always hope for the best for Michigan. It should be a source of pride that Michigan has some of the early success stories of Lean healthcare, thanks to involvement of people from the auto industry,” said Mark Graban, author of Lean Hospital. “I am glad I can give back to further the spread of Lean thinking in Michigan and I’m looking forward to participating in the event.”

LEI Workshop

I’ll also be teaching my two-day introductory workshop at the LEI office in Cambridge, MA on October 11 and 12. You can sign up at the LEI website and here is me blabbering about the workshop a bit:

Hope to see you there… but not all three events, that would probably be a bit weird :-)

• Liveblogging the Quaid Patient Safety Documentary
• Dennis Quaid and Patient Safety – Upcoming Documentary
• Of 777s and Heart Rate Monitors
• This Will Happen Again, Unless…
• Signs are not Error Proofing

Many of you may know of Paul O’Neill for the dramatic employee safety improvements at aluminum maker Alcoa and you may know of him from his work in promoting healthcare improvement (he is the “bureaucrat” in “The Nun & the Bureaucrat” book about lean and systems thinking in healthcare). He also worked with Dr. Richard Shannon in the PRHI healthcare quality efforts (read my post from Monday about a separate interview with Dr. Shannon).

I didn’t realize that, during his time as Treasury Secretary, the time required to close the nation’s financial books was reduced from 5 MONTHS to 3 DAYS. You’ll learn that and more in this article: “In a Perfect World.”

Part of O’Neill’s method is setting goals at the “theoretical limit,” for example, the goal that nobody should ever get hurt working at Alcoa. I’ve worked in many organizations were employee or patient safety goals were set as something greater than zero. They have a goal to hurt people?? Well, not exactly — they’ve set a goal that’s “realistic” based on past performance (normally a small percentage improvement).

These goals force you to radically re-think how things are done. You might wonder how I reconcile this (saying you need patient safety goals of zero), while I also write about how arbitrary targets are dysfunctional. A goal of zero, one that you can’t hit this year would be demoralizing, some would say. But I don’t think it has to be demoralizing if you have the right culture.

A reader asked me, via email, recently what the difference was between traditional “Management by Objectives” (MBO) and lean goal setting. I think the main difference is how management reacts when you don’t hit the goal. The traditional dysfunctional MBO setting says “hit the goal or else” (or else you get punished or don’t hit your bonus). A lean leader sees you haven’t hit the goal and works with you to identify causes for the gap – it’s mentoring and real leadership, not just punishment.

I agree with O’Neill that the only morally acceptable “goals” are zero. Now, we might have a statistically stable and “in control” system that predicts that, based on past performance, we can expect to have 2 employee injuries per month. That doesn’t mean we’re satisfied with a stable process that’s harming people, we work to improve it. And that goal doesn’t mean we fire leaders when the process is improved to where there’s only 1 injury per month. We keep working towards zero — maybe it’s better to call that a “vision” than a target.

In healthcare settings, O’Neill thinks the same setting can make a huge difference – leading to cost reductions of 50%. What’s statistically expected doesn’t have to be accepted, as O’Neill says:

At the microlevel, at Allegheny General Hospital and other places we’ve worked with, we’ve demonstrated that it’s possible to do this and, in effect, to break the conceit that it’s a God-given fact that 2% of the people who go through intensive care units are going to get an infection.

O’Neill is also right when he talks about weaknesses in benchmarking within an industry where everyone has what I would describe as “roughly the same about of waste and dysfunction” (my words not his). O’Neill says:

“The convention, for example, in health and medical care is to have measures across the country and measures for individual institutions to find out how they compare to the national averages. It’s very routine to find institutions that say, “We’re better than the national average, and it’s not possible to be better than we are.” So the establishment of the idea of national norms is the enemy of continuous improvement.”

Back to my earlier point about goals that seem unattainable, O’Neill says:

It’s particularly a phenomenon in the United States, I think, that people have a mind-set of, “We don’t want to set goals that we’re not sure we can attain.” So if you set goals that are referenced against some national level of performance, in effect you’ve set yourself a barrier that’s not too difficult to get over, and then can declare yourself superior.

Maybe hospitals can agree – let’s rely less on benchmarking and focus more on reaching the theoretical limit and reaching perfectly “ideal care.” We might not get there tomorrow, but keep working at it – you’ll get better.

It’s a long, interesting interview. O’Neill also touches on core issues of quality data transparency, why healthcare organizations are often afraid to share data and lessons learned — and he has a really radical idea (something I haven’t thought through) of getting rid of medical malpractice.

That’s very radical – interesting to think about. O’Neill says (as I’d believe) that people in healthcare very very rarely harm a patient intentionally (it’s problems with the system, not bad intent).

O’Neill says:

When someone is injured, we’re going to create an expectation that the injury or the length of hospital stay will be recorded in cyberspace within 24 hours so we can do a root cause analysis, and everyone in the world can learn from it in a short cycle of time. And in exchange for that, we’re going to have an economic arbitration process so that people who are inadvertently injured will be compensated to the extent of their economic loss, and we’ll pay for it out of general revenues of the federal government, because that’s the broadest base for tax support.

In exchange for that, we expect the people in the delivery system to report without fail, at a huge penalty if they fail to report, with an expectation that the professional societies will take a much more aggressive role than they typically have in disciplining and withdrawing privileges from people who have repeatedly failed to deliver the expected level of performance.

Would that system lead to better quality than our current system? I doubt we’ll ever get to do more than a thought exercise, no real opportunity for PDCA to see if O’Neill’s proposal would work or not.

Your thoughts?

• "No Blame" Doesn’t Mean "No Accountability"
• Great Op-Ed from Paul O’Neill on REALLY Improving Healthcare
• Words that Matter in Healthcare
• Traditional Improvement Methods Compromising Hospital Safety?
• Great Interview with Dr. Richard Shannon on Lean / Toyota Methods

By now, you may have read the news release and/or e-letter (scroll way down) from the Lean Enterprise Institute that announces founder and chairman James P. Womack is stepping down as CEO of LEI, to be replaced by longtime LEI senior advisor, and former Toyota manager, John Shook.

It’s an understatement to say that Jim has played an important role in helping share and promote lean thinking around the world – shifting from “lean production” to the lean enterprise and lean healthcare.

Thinking back, I first met Jim in 1998 as LEI was being formed. I was a graduate student at MIT and Jim came to his former stomping grounds to give a guest lecture. In 2006, I recorded a few podcasts with Jim via phone and, upon seeing him in person in 2008, he made the droll comment that it was good to see that “that blogger” was indeed a real person who took up physical space. I’ve worked for LEI since June 2009 and my very first day there was memorable, as it was the day GM declared bankruptcy and we were able to chat about that over lunch.

Jim books have taught me a lot and have inspired me to lead change and to think creatively to move beyond “the way things have always been done. The Machine that Changed the World opened my eyes to what was possible in the auto industry, Lean Thinking helped me understand more general concepts and thinking that could be used in other settings, and Lean Solutions (I book I think is unappreciated) helped me see how Lean thinking could help more broadly in services and healthcare.

I’m waiting for someone to call me a brown-noser, but I’m excited that John Shook is taking over, as he knows LEI well and has a deep understanding of the Toyota management system from his time working there. I’ve learned a lot from John about the Toyota culture and management styles, as well as methods like A3 thinking.

It’s time to recognize Jim’s role but to also look forward to continually improving LEI that serves the needs of the lean community — as well as the needs of those who still haven’t taken “the lean leap.”

You can read the LEI e-letter and press release here.

What are your thoughts and reflections during this transition? Your hopes for the future of LEI?

• Toyota Leaders Get a Lecture From a Toyoda
• Who Coined the Term “Lean”? And Where is He Today?
• Jim Womack: “Tipping Point” for Lean Healthcare?
• Guest Post: You Don’t Have to be Lean to be Good
• Read this Book – But Don’t Copy ThedaCare

If you’re not an iPhone user, I apologize for taking your time. If you’re reading this post on the new Lean Daily app, then I’ll also apologize for wasting your time as you already have the free app that’s brought to you by a coalition of lean bloggers. Learn more about it, see a simulator demo, or download it directly from the iTunes Store.

A number of us combined efforts to provide this as a free service to our loyal readers, so thanks go to:

• Jamie Flinchbaugh (Lean Learning Center)
• Matt May (In Pursuit of Elegance)
• Kevin Meyer (Evolving Excellence)
• Jon Miller (Gemba Panta Rei)
• John Hunter (Curious Cat)
• Ron Pereria (Lean Six Sigma Academy)
• Mark Graban (Lean Blog)

This app allows you to read a number of lean blogosphere sites in a simple app. You can also listen to and view some multimedia lean content, such as my Podcasts and Video Podcasts and the Gemba Academy sample videos in the app as well. You can also find lean news and some other feeds.

Frequently (OK, once) Asked Questions (Answered by Mark):

Q: Why did you do this?

• A:  I am a bit of a geek and I suggested this to the other bloggers, a group that has been friendly and collaborative over their years of blogging. It was an interesting experiment and a chance to learn something (I’ve got some of that intrinsic motivation that Dan Pink writes about… I did this because it was interesting and fun).

Q: Why is it free? You got money to burn?

• A: It was actually a pretty inexpensive project using a platform called AppMakr. We’re not trying to monetize this; it’s a service to our readers to make our content easier to get to and keep up to date on.

Q: But the app has ads…

• Part of the experiment is the placement of a small Google ad at the bottom of the app. Like I said, we’re not trying to get rich off this, so maybe the ad won’t stay. PDCA…

Q: How can I get my site and blog content into the app? Why didn’t you include me or other bloggers?

• I started working with the team of bloggers that I’ve known the longest. There are many other outstanding blogs out there, including a number of relatively new ones. We might consider putting more blog feeds into the app, if the charter group agrees.

Q: Ahem, I use Android (and I use BlackBerry!!!) — what about us?

• AppMakr has said they will do an Android version of their platform, we just don’t know when. As for BlackBerry, I really don’t know about that. We know more of our readers use BlackBerry than iPhone, but maybe this is a way to expose the iPhone crowd to more lean concepts.

I hope you’ll try the app and let me know what you think. Please email me with your feedback and please leave ratings and reviews in the iTunes Store.

And now, back to your regularly scheduled lean content… (another real post later this morning).

• Great Guests on “The Lean Nation”
• Guest Post: What It Means
• My Lean Message Board is No More
• Back from Vacation (Mostly)
• Gone Fishin’ – Guest Posts June 14 to 29

Today, I’m linking to a fantastic interview and discussion between two luminaries in the patient safety world – Dr. Robert Wachter (read his blog) and Dr. Richard Shannon (who is featured, among other places, in the “Good News: How Hospitals Heal Themselves” video and the companion book “The Nun & the Bureaucrat.“

Here is the discussion: “In Conversation with…Richard P. Shannon, MD.” There is a also an audio podcast version you can access directly via this link (or get to it from the text page).

Dr. Shannon talks about the application and adaptation of Toyota methods at the Hospital of the University of Pennsylvania. Dr. Shannon is helping recreate earlier efforts that, under his leadership, dramatically reduced central-line infections at Allegheny General Hospital in Pittsburgh.

From the interview:

“… the 26-bed unit in Pittsburgh where we did this effort has now gone 35 months without a central line infection. Once you ingrain the process as a culture, I think it is sustainable. By the same token, engaging people in rapid process improvement and being able to share with them the daily results—every member of this team gets a daily report on whether or not there’s an infection on their unit—begins to create a different type of process improvement science that I think people can at least begin to understand and appreciate”

Dr. Shannon understands that improvement work like this must involve the front-line staff (one of the inspirations from lean) and you must focus on sustaining improvement – this is done through the management system and culture. It’s not a simple one-time exercise.

Their early results at UPenn are encouraging:

The early outcomes here are quite astonishing. In the 6 months prior to the effort with central lines, 86 patients had central line infections in those four units. In the 5 months since we started, there have been four infections. So the concept of actually putting these tools in the hands of people who do the work, much in the way that Toyota does on its assembly line, is very effective.

This is quite arguably saving lives – 20% of these infections lead to patient death.

Beyond the quality and patient safety impact, there’s a direct connection to patient flow, hospital capacity, and cost. Payers are increasingly unwilling to pay for what are arguably preventable hospital-acquired infections.

Dr. Shannon talks about the impact of infections on flow:

• A patient who gets a central-line infection has a hospital stay that’s 17 days longer than normal. Patients with urinary tract infections stay 6 days longer than if they didn’t get an infection.
• Preventing infections creates bed capacity in the hospital.
• Freeing up this capacity might eliminate or minimize the need for hospital expansion

The final part I’ll share is Dr. Shannon talking about the general notion of “defects” in healthcare. The definition of a “defect” goes beyond something that causes patient harm. Dr. Shannon says:

That’s where the toolkit using lessons borrowed from Toyota is so widely applicable. The concept is to be able to identify defects in any domain—to understand your capability to identify the defect and solve it.

In the course of these observations, we encounter not only defects in the processes around placing, maintaining, and manipulating catheters, but we find defects in medication delivery. We find defects in laboratory blood draws and labeling of tubes. We find all these defects that we can begin to codify and do the same type of real-time problem solving around them. The problem at the start is that the number of defects is overwhelming. When you begin to codify them, it’s just staggering.

Our notion is to build upon some early successes by truly committing to an audacious goal of eliminating infections, and then build upon that success to begin to move into areas like medication errors, or timeliness of service delivery. I mean, how often when a patient is scheduled to be in a cath lab at 10:00 AM does it actually happen at 10:00 AM? That’s arguably a defect. Industry wouldn’t tolerate that imprecision. Looking at those systems across what we call the customer–supplier relationship between the cath lab and our inpatient medicine unit is the next opportunity that these skills can be applied to.

Great stuff. I hope many many hospitals, leaders, and clinicians are inspired by this work. If your lean efforts are focused on “how many pens are in the nurses’ station desk drawer,” you’re likely missing the full potential of lean healthcare.

I cant’ mention Dr. Shannon without also giving another endorsement for Naida Grunden’s outstanding book The Pittsburgh Way to Efficient Healthcare: Improving Patient Care Using Toyota Based Methods that goes into more detail about their success in Pittsburgh.

• "No Blame" Doesn’t Mean "No Accountability"
• "Dead by Mistake" Report Hits the News
• Interview with Paul O’Neill; The Right Goals in Healthcare
• Is Medical Education a Systemic Root Cause of Poor Quality?
• Another CEO Talk: “Can I Say That?”

A Mental Model

A few thoughts while waiting for a Sunday flight… at least it’s a Sunday flight towards home.

One reason traditional organizations (and traditional leaders) struggle with Lean is because the mental models are different. The problem isn’t understanding tools; the problem occurs when people are forcing Lean methods into a traditional setting. What might work great in a Lean culture, might cause nothing but trouble in a traditional setting – all because of the mental models. When we implement a new method from another organization, we might do well to ask  ”What existing mental models is this going to conflict with? What might the side effects be?”

A had a great chat with Pascal Dennis recently (check out my recent podcast with him) about mental models. His consulting group sells these cute “mental models” cards that illustrate some comparisons between traditional thinking and lean thinking mental models. One of those cards is pictured above.

Two topics that often raise ire related to Lean are standardized work and performance measures.

Traditional organizations love to control people (or feel like they have to) while Lean organizations believe their employees have intrinsic motivation and they deserve to be respected and engaged in improvement as responsible adults.

So when a traditional command-and-control organization hears of standardized work, they often leap to the idea that Pascal expressed, that too many organizations unfortunately think standardized work is just another way to control people. That’s wrong, that’s not Lean. If you don’t change your mental models, the “boss” will yell at people for not following the standardized process while a Lean manager seeks to understand the situation – asking why the person isn’t following the process (the process has changed, there was a good reason to not follow it in a certain case, or the person wasn’t trained properly, perhaps).

We have to shift from management = policing and being the boss to management = being a collaborative coach and leader.

Traditionally, performance measurements are used to rank people (pitting them against each other), to blame, or to punish.

So when a Lean consultant says an organization should measure the process more frequently, traditional managers think they are just blaming, ranking, and finding fault with people hourly instead of monthly. This is not progress.

As I tweeted earlier:

“Metrics and measures are the voice of the process, to be used for improvement, not for blame, ranking, and punishment.”

This is a different mental model. You don’t measure a physician’s infection rates so you can fire those with the worst rates. That sort of punishment and blame forces problems underground. We don’t just need “transparency,” we also need to work on improving systems and processes instead of blaming individuals.

Right tool, wrong mental model = disaster and grumpy people (and poor quality).

Your thoughts?

• TED Video: Dan Pink on Motivation
• Guest Post: Captain Sully Talks about Lean and Healthcare Safety
• Quaid Case Update: Whose Responsibility is Standardized Work?
• Interview with Paul O’Neill; The Right Goals in Healthcare
• Top 10 Signs You’re In a Fear-Based Workplace

Here is the latest of my Lean Healthcare parody commercials, in this streaming audio player (RSS readers will have to come to the website):

This time, I’m spoofing the overplayed GEICO commercials, where the gravely-voiced guy in the suit asks a series of funny rhetorical questions…

Updated : Here is a video version of my ad:

A real GEICO ad:

Have a great Friday and a great weekend.

And here is the beloved clip from the Steve Martin classic The Jerk:

• Audio Parody: “Lean Spice” Commercial
• Parody Audio: Marketing Lean Healthcare Like the iPad
• Weekend Fun: Depiction of the Lack of Hospital “5S”
• New Book: “Laugh, Sing, and Eat Like a Pig”
• Releasing Time to Care (Lean Nursing) in New Zealand

Mark’s note: I asked Dan to write a post about his upcoming class…

I’ll be teaching a class this fall at the Stanford University Continuing Studies Program on A3s — how to create them, how to review them, and how to coach others on them. The goal of the class is to help you learn to use PDCA thinking to improve performance.

The class will be held on Thursday evenings from 6:00pm to 7:50pm for five weeks, from September 23 to October 21. Each class will consist of a short lecture on the different parts of the A3, evaluation and critique of a sample A3, and then time to work on your own A3 with classmates.

You can read the full course description and syllabus, as well as register for the class here.

Special note: if you’re not interested/able to take the class but have experience with A3s, I’d love to have you be a guest reviewer for the students’ A3s during one of the classes. Please contact me if you’d like to participate: dan [atsign] timebackmanagement.com.

• Guest Post: You Don’t Have to be Lean to be Good
• Guest Post: Lean Lessons from the Non Profit World
• Guest Post: A3 = “Drive”
• Learn to Play Before Picking Up a Sax
• Management "Moonshots." Really?

I’ve had the chance recently to re-watch some of The Deming Library DVDs, thanks to my friends at CC-M Productions (found at www.managementwisdom.com). I’m watching some of the videos for the first time.

It’s always a joy for me to watch these videos, produced in the 1990s featuring interviews with Dr. W. Edwards Deming and clips of his seminars.

In one video, there was a point that I don’t recall from previous viewings. Dr. Deming was talking with Dr. Russell Ackoff about redesigning systems.

I’m paraphrasing, but Deming and Ackoff were talking about how if one is to try to change a system, how can you know what changes to make if you can’t describe how you would completely re-design the system from scratch, given the chance?

Ackoff and Deming talked about a scenario where your factory or organization (or we could say a hospital) were destroyed tomorrow. How would you re-build it? How would you design it given no current state constraints or limitations? That should be your vision for any tweaking or re-design that you’re doing on the existing system. Do you understand your system well enough to be able to articulate that vision?

I found that to be a very provocative and interesting idea. There’s some element of that idea in the further lineage of Lean thinking — one concept that’s familiar is the idea of the Future State Value Stream Map. This gives us vision for how the system “should” work if we were to redesign it (especially an “Ideal Future State” map, as opposed to a “Practical Future State.”).

Kaizen (continuous improvement) is an important concept, but we should often think about radical redesign (the word “kaikaku” in Japanese). Sometimes a number of small tweaks isn’t sufficient for the level of redesign that’s needed.

So this is somewhat grim, but imagine your workplace if it were destroyed tomorrow (nobody is hurt in the process). Do you have a clear vision of how you would rebuild it to be better?

• Top 10 Signs You’re In a Fear-Based Workplace
• Survey: Dr. Deming’s Influence on Lean and on Your Organization?
• Everett Clinc Video, Redux – The Need for SPC Thinking
• How to Design Poor Service – Expect 100% Utilization of People or Resources
• The Red Bead Game Applied to Medical Errors

Dr. W. Edwards Deming always said we need to drive out fear from organizations, as point 8 of the 14 Points said:

“Drive out fear, so that everyone may work effectively for the company.”

Too many organizations, including hospitals, are driven by fear. This is counterproductive and harmful. You can’t implement Lean in a fear-based culture, as instilling fear in employees runs counter to the “Respect for People” principles. MSNBC and BusinessWeek bring us this article, “Ten signs you work in a fear-based workplace.“

When people are fearful, they don’t speak up, they don’t question the boss, and they feel hamstrung to do the right thing if they fear getting in trouble. When people fear being punished or looked down upon for failure, they can’t take risks that lead to kaizen, and they certainly can’t take risks necessary to redesign whole systems.

You can get more detail and examples in the article, but their top 10 signs are:

1. Appearances are everything.
2. Everyone is talking about who’s rising and who’s falling.
3. Distrust reigns
4. Numbers rule
5. And rules number in the thousands
6. Management considers lateral communication suspect
7. Information is hoarded
8. Brown-nosers rule.
9. The Office’ evokes sad chuckles, rather than laughs
10. Management leads by fear

I like the summary paragraph article, it’s hard to say it better:

Chief executives know in their hearts that smart people, set loose to solve big problems, are responsible for every success and innovation industry has ever seen. Fear-trampled employees don’t do a thing for your business. Still, management by fear is a hard habit to break, because fear-whipped underlings don’t squawk. Meanwhile, your competitors may be hiring your best talent away and stealing market share while you make it easy for them to do so. Those meek, submissive, broken-down employees might blossom in your rival’s trust-based culture. Do you really want to find out?

Do you find fear a barrier to your Lean efforts? What are you doing to drive out fear in your organization, to build trust and collaboration? What are the biggest symptoms of fear in your organization?? Feel free to share your stories… you can always type “Anonymous” and a fake email address if you are fearful of your comment getting you in trouble with the boss.

• Lean Leads to Green, Which Supports Lean
• Guest Post: Deming, Lean, and Healthcare Transformation
• What Makes You Want to Do Better?
• TED Video: Dan Pink on Motivation
• Bad Behavior Kills – in Hospitals?

Via Google Alerts, I try to regularly scan and see where hospitals are posting jobs related to Lean. I found (OK, Google found) one posting last week that I shared on my “Move to Healthcare” networking site (free registration required to view and participate fully). You can also see the posting here on hotjobs.

One frequent topic of discussion on MTH is how some hospitals are very open to hiring experienced lean and process improvement people from outside of healthcare, while others are insistent on only hiring within the industry. This one position, for a fairly deep “Lean Specialist” job at a hospital in Connecticut not only calls for “7 years of health care experience” yet also says “Lean experience is a plus.” No joke. Read that again.

Now, I’m not saying that healthcare people can’t learn Lean. Not at all. I’m not saying that someone from manufacturing can automatically come into healthcare, either. From what I’ve seen, you need a mix of inside and outside perspectives to be successful with Lean in a healthcare organization.

In the case of this posting, I’m less flummoxed by the requirement for healthcare experience than I am the “lean experience is a plus” part.

This doesn’t sound like a job for a lean newbie, with responsibilities including evaluating and developing training materials and training others. This isn’t an entry-level lean facilitator role…

I’d think a better requirement would be “7 years of lean experience required, healthcare experience a plus.“

One can only hope that H.R. messed up the job posting and got things backwards… they might have a defective process.

The job description concludes:

The incumbent must be willing to challenge the status quo to ensure that Lean principles are implemented, as well as be able to understand the organizational change strategy and articulate this to external audiences.

Do you think somebody put into that role who is brand new to Lean is more likely to challenge the status quo or get steamrolled? Is this likely to lead to “L.A.M.E.” (Lean As Misguidedly Explained) instead of Lean?

• Lean Healthcare Featured in Sunday NY Times Business Page & I Got Quoted
• Two Extreme Sides to Every Story in Politics *and* Lean??
• Parody Audio: Marketing Lean Healthcare Like the iPad
• Notes from Dr. Brent James at the Shingo Prize, Part 2 – Comments on Lean
• Lean is “Taking Canadian Healthcare by Storm,” but Look Out for “L.A.M.E.”

I received an email from a reader that I’m sharing and commenting on with permission.

“Dear Mark: I am a lean coordinator for a manufacturing company and it was a real shock to see some of the waste during a recent hospital visit to see a dying family member. He was 92 years old and had a DNR in place. He was having trouble breathing and a Rapid Response Team was called into place. Now, again, he was dying, so my first thought was that this seemed unnecessary. But, as they were preparing to treat them, the waste and confusion was obvious.”

At two different points, nurses (I think they were nurses) were opening their cart (which seemed like a good point-of-use inventory method) and they couldn’t find what was supposed to be in there. Two different times, they had to leave the room to go find some tubing and to find some pads.

What is the point of the cart and the team if they don’t have what they need when they need it???

Thanks for writing about lean healthcare. It was always just a curiosity, but last week’s experience made this very concrete and real to me and our family.”

That sounds like an unfortunate situation, one that might have caused stress for the family and the hospital caregivers. Ideally, it should be viewed as a “nugget” – an opportunity for improvement so that came problem doesn’t occur again. What is the root cause of why the cart wasn’t properly / fully stocked?

It seems like it shouldn’t be that hard to keep a cart properly stocked so that it’s ready for use. If I were in the situation, I wouldn’t go looking for blame – I’d look for process (or the lack thereof) as I’ve seen in so many healthcare settings.

1. Why wasn’t the cart fully stocked? Keep asking why and address actionable causes and root causes (don’t look to blame an individual).
2. Is there a formal process or standardized work for how the cart gets restocked after items are used?
   • Note: Don’t tell me “who” is supposed to restock it (a specific name), tell me the process that ensures this happens regardless of which individual is working that day.
3. How do we know if the process is being followed? Is there a management checklist or verification to ensure that the cart has been restocked?
4. Are spot checks done at the start of the day or shift to ensure that the cart is ready to go when needed?
5. When there is a problem (such as missing tubes), what is the follow up other than running to go get the missing item.
   • Are we moving from only fire-fighting to also focusing on prevention and process improvement after the “fire” is out?

The questions I’ll pose for you, the readers:

• If you have direct ongoing experience working with RRT carts, what process do you use to ensure 100% availability of items?
• If you’re generally a Lean person, what others questions am I missing?

• Q&A #2 – Michael Balle, "The Lean Manager" – Nursing
• Standardized Working Toward Zero Infections and Getting There
• A First-Person Lean Leadership Story from John Toussaint, MD
• Guest Post: Lean Lessons from the Non Profit World
• Dennis Quaid and Patient Safety – Upcoming Documentary

There have been lots of people you would recognize on Karl Wadensten’s radio show “The Lean Nation” recently, including many of my guest bloggers. Take a listen to the on-demand or downloadable shows:

• Lean Nation 8-13-10 – Guest: Bob Emiliani in studio Topic: Five Reasons for Lean Failure
• Lean Nation 8-12-10 – Karl talks lean with Karen Martin
• Lean Nation 8-11-10 – Guest: Liz Guthridge – Founder + Managing Consultant of Connect Consulting
• Lean Nation 7-30-10 – Guest: Dave Meier – The Toyota Way Fieldbook + Toyota Talent Topic: Creating and sustaining a Kaizen culture
• Lean Nation 7-28-10 – Guests: Andy Carlino + Jamie Flinchbaugh “Lean Hitchhiker’s Guide” Topic: Effective Lean strategies and techniques
• Lean Nation 7-27-10 – Guest: Dr. John Toussaint – President + CEO Theda Care Topic: The Lean Health Care Revolution
• Lean Nation 7-19-10 – Guest: Dean Bliss – Lean Health Care Coach with the Altarum institute Topic: Lean Health Care
• Lean Nation 7-12-10 – Guests: Joe Dager – Owner of Business 901 Owen Blevins – VP Atlantic Concrete Equiptment + VIBCO customer Topic: Lean Marketing

• Dr. John Toussaint Talks Lean Healthcare on The Lean Nation Show
• My Thoughts on Standardized Work
• Lean Healthcare at Denver Health is Front-Page News
• A First-Person Lean Leadership Story from John Toussaint, MD
• Guest Post: What It Means