Lean meets Drinking Water

By Jason Turgeon:

This week is National Drinking Water Week! If that doesn't excite you, think about the Lean implications of this dreadful story about the deaths of 80 children last month in South Africa resulting from a breakdown in the local drinking water treatment plant. While everyone involved is busy pointing fingers at everyone else, I think a little digging would turn up plenty of opportunities for Lean--error-proofing, anyone?

Drinking water and wastewater treatment are the two crowning achievements in public health for our species--arguably more important than vaccines and antibiotics. We tend not to think about these plants until something goes wrong, which is fortunately not very often here in the US. But just because our water infrastructure tends to stay out of the news doesn't mean there's not plenty of room for Lean.

A story brought to me by my subscription to the SafeDrinkingWater.com newsletter this week illustrates my point nicely.

Where was the Lean approach in Arizona?

The state of Arizona recently handed down a fine to a local water company after an important water-purification system broke down and the company failed to act quickly to remedy the issue. The background is that Motorola and other unnamed companies managed to contaminate the local groundwater supply with TCE, a carcinogenic solvent used to clean grease off machines, several decades ago. The water utility is supposed to remove the TCE down to an acceptable level. The TCE-removal equipment failed, and the alarm that was supposed to let people know about the failure failed, and no one noticed for 16 hours. To make matters worse for the company, management decided not to notify the authorities until 9 hours after that, and in the subsequent investigation it came out that they were just dumping the TCE they'd removed back into a storm drain. The state cited a poorly designed system (PDF) and ordered changes to make sure it didn't happen again--a very Lean approach. Motorola, on the hook for some of the costs of the cleanup, says it was human error:

Operator error is blamed for a malfunction in January at a plant owned and operated by the Arizona American Water Co. that treats groundwater contaminated with trichloroethylene, a suspected cancer-causing chemical.

That is the conclusion of an investigation conducted for Motorola Inc. and other companies that were the source of the TCE contamination decades ago. The companies are paying for cleanup of the contaminated groundwater, including the treatment facility.

A separate investigation done for Arizona American concluded that the plant's systems and components were not designed or operated in an optimal manner.

So what's the solution? Well, the first thing I would say is that the most holistic Lean approach would be to reduce Scottsdale's water use to the point where they could discontinue use of these two contaminated wells. That's the most environmentally friendly thing to do, especially given Scottsdale's location in the middle of a desert. Coming down a level, Greenpeace has been hammering Motorola recently for continuing to use toxic chemicals in its products, although some of the more recent news (PDF) shows that the company is making some progress towards a toxin-free product line. As I noted in my last post, Lean practitioners can play a big part for the environment by urging their clients to get away from toxic chemicals. Finally, it looks like the state is pushing the facility in question to be a bit leaner, but I'm sure there is plenty of additional work that could be done to make this facility both more Lean and more green.

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"Real Lean," Volumes 1 and 2

I've had the opportunity to read Bob Emiliani's two collections of essays on "Real Lean" and I'm long overdue on posting about them. I'm especially late considering since Volume Three is coming out in June. These books are particularly recommended for those who already have a basic Lean education and some experience (or struggles) with implementing Lean.

Real Lean: Understanding the Lean Management System (Volume One)

In this book, Emiliani introduces the "Real Lean" concept, by which he means the real approach that focuses on both pillars of the Toyota Way:

1. Continuous Improvement
2. Respect for People

As Emiliani points out, far too many only focus on the first part -- the tools, improvement, and methods, without focusing on people. When people are implementing Lean with just a short-term focus -- focusing only on numbers or (even worse) slashing headcount, he calls this "Fake Lean." It's pretty similar to my "Lean vs LAME" construct.

Here is Bob's page about the book, with the list of essays and reader reviews.

Real Lean: Critical Issues and Opportunities in Lean Management (Volume Two)

This second volume covers more issues for those who are deep into their Lean journey. For example, chapter 6 is called "We're Beyond That." This is pretty common when a company is a few years into their Lean journey. A company has had success or maybe the executives are bored (or have moved on) and it's time to move "beyond Lean" (if I only had a dollar for each article or webinar that promised what's next "beyond Lean."). Bob emphasizes that Real Lean is a constant mindset and a constant way of managing a business.

Here's Bob's page on Volume Two.

Check out the "Emiliani" link below for discussion about his earlier books and his podcast episodes that we did together.

I'm going to spend some time re-reading some of these essays over the weekend and I might comment more on the ones that were most useful to me in my current Lean efforts. Definitely recommended reading.

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"Just In Time Patients??"

Medical Leave -- Offshore Medicine -- Fast Company

Interesting read here in the latest issue of Fast Company about a hospital in Thailand and one of the visionaries, Ruben Toral, who wants to globalize healthcare. The idea of patients flying halfway around the world for elective surgeries, taking advantage of lower labor rates, isn't exactly new.

"For someone such as Toral, the hypertrophied medical-industrial complex is just begging for a dose of disruptive innovation. He calls his vision the "Toyota-ization of health care," a metaphor so vast that it contains multiple readings, some fit for industry conferences and others he'll cop to only in confidence."

I'm not really sure what he means by that, Toyota-ization. Maybe one analogy is to compare the current American hospital industry to the Big Three automakers in the 1970's? Toyota, Honda, and others brought new competition to the market, bringing better quality AND lower costs. Much as the Big Three didn't believe you could have high quality and low cost (many thought Toyota was "dumping" products illegally below cost i the U.S.), you often have people in healthcare who don't believe you can have high quality and low cost.

There's often a mindset that healthcare is immune to "offshoring." Not that I'm advocating the practice of shipping people halfway around the world for medical care, but it will be interesting to see if this creates a crisis -- creating competition that creates more of a need for change. This can maybe spur improvements in quality AND cost in U.S. healthcare? These "medical tourism" hospitals are supposedly very clean and safe, run to very high standards.

"In order to ensure continuity of care," he goes on, "you'll never leave the system. What could be better than telling an American patient they're going overseas to an American-owned hospital? They're going to discover the same supply-chain advantages Toyota did when it created just-in-time manufacturing. We're going to have the same thing -- just-in-time patients. Hospitals are not going to spend any more money or any more time in the movement of that patient through the system than is necessary. They're going to get the patient in, get them on that global platform, and get them back. Now, how do they do that in a fast, efficient way where quality is kept, efficiency is gained, and prices don't go up? It's classic manufacturing and logistics."

The supply chain efficiency he describes sounds like local efficiency -- the idea of reducing waste reducing waste (eliminating patient flow time that is more "than is necessary"). But what about the supply chain at the global level? Toyota's approach is to be close to the customers. This approach, shipping customers halfway around the world, seems more like the notion of building product in China, shipping it halfway around the world. That's not necessarily Lean. Wouldn't it count as more movement than necessary, getting on a plane from Texas and flying to Thailand?

Toyota builds factories close to their customers (as evidenced by their North American expansion). Wouldn't a truly Lean medical model involve high quality care close to the customer, without waste or unnecessary time or expense? Flying everyone to Asia doesn't seem like a root cause solution to our problems with healthcare costs and quality.

It's interesting to think about, this global "patient chain." What would happen if the only care provided here in the U.S. were true emergency care? What if anything planned or non-emergent were being done in high-quality facilities in low-cost countries?

I'm not sure what it is, but I'm not sure it's "Lean" or something worth invoking the name of Toyota for, as Toral does. What do you think - about medical tourism, in general, or the somewhat shaky association to Toyota?

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Nursing Shortage Easing?

Slowdown's Side Effect: More Nurses - WSJ.com:

Not a Lean article, but a major issue for hospitals is a shortage of nurses. With the economy in its current condition, more nurses are returning to work. There's still a need for the reduction of wasted motion and wasted time in a nurse's workday... that's the Lean concept.

"Hospitals have also taken steps to keep older nurses in the work force by making their jobs easier, including replacing hand cranks used to lift beds with automated lift devices, bringing in lift teams so nurses don't strain themselves picking up patients, or putting supplies closer to patients' rooms to cut down on walking."

These are good practices, regardless of age. Lift assists are better ergonomically for nurses (preventing injury) and they can also help prevent patient falls. Reducing walking is good since that wasted time can be used in more productive ways (such as patient care).

Keeping supplies closer to rooms -- that goes against a previous trend toward centralized inventory cabinets (often automated) in a floor or unit. The advantages were all for materials management -- it was easier to restock and kept better control of inventory. But, optimizing materials management shouldn't be the primary goal. The nurses are providing "value added" care -- the job of the rest of the organization should be to support them in "making their jobs easier." There's a pretty direct parallel to a factory using material handlers to allow assembly operators to be more efficient.

You don't want assembly workers to stop, looking for parts. You don't want surgeons digging and searching for tools during a procedure (nurses or techs hand the instruments to the surgeon, an old idea that originally came from Frank Gilbreth). You also don't want nurses to be roaming around, searching for medications or supplies either. Systems and processes (and technology) need to support them in the way they do their jobs.

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The Power of Asking "Why?"

reportonbusiness.com: Asking 'why' again and again is harder than you think, but it works

It's kind of neat to see a column about the "5 whys" method in a general business publication (link above). The consultant and professor in the article gives proper credit to Toyota and Taiichi Ohno, but curiously calls it the "Japanese Manufacturing Technique" (as if that's a proper name). I've near heard that phrase... something he coined rather than just "Lean Manufacturing" or the "Toyota Production System?"

Anyway, the article gives a good example of a 5 Whys analysis from Ohno. In my experience, 5 Whys is hardly ever that neat and tidy (you can hit some dead ends or have multiple branches in the answers), but you can get some real breakthroughs.

Going through a 5 Whys exercise with a hospital group once, we asked "Why are hand hygiene practices not followed 100% of the time?" One real breakthrough was a comment "Our hands and arms are full when leaving a patient room sometimes." We asked why that was, and kept asking why -- turns out that carts were not always available, so the follow up would be a 5S initiative around proper storage locations for carts and having the discipline to keep them there. Instead of browbeating nurses for not washing, our job was to make it easier for them to do the right thing. We thought that was good problem solving -- or more effective than hanging more signs at least.

The linked article also talks about some of the downsides of asking why, especially if you're challenging technical experts or "lords," as he calls them. People can get defensive. You really have to watch your tone of voice when asking why. I've found it's better to ask "Why is it that...." instead of "Why do YOU..." because people take the latter as direct criticism.

Asking "why?" in private or 1x1 can also be less embarrassing than asking someone in front of a group. You always have to be aware of politics and sensitivity. Most of us aren't an Ohno, being comfortable yelling or screaming at someone.

What are your experiences with the 5 Whys, good or bad?

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LeanBlog Podcast #42 - Martin Hinckley, Mistake Proofing

This is LeanBlog Podcast episode #42 with Dr. C. Martin Hinckley, of the firm Assured Quality. He is the author of the book "Make No Mistake!: An Outcome-Based Approach to Mistake-Proofing," available through Productivity Press. We'll talk about his book and approaches for teaching people how to develop mistake proofing in processes.

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) below 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.

MP3 File Right-Click to "Save As"

LeanBlog Podcast #42 Key Points & Links

• Some mistake proofing examples from Dr. Hinckley's site


• Upcoming webinar on mistake proofing on May 15 (via http://www.visualworkplace.com/)

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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A Pharmacy's Long Turnaround Time?

Star-Telegram.com: | 05/06/2008 | LETTERS

OK, so we're piling on JPS Hospital at this point.. but this letter to the editor caught my eye today:

One glaring omission in your series was failure to critique the pharmacy. It's one of the worst parts of the JPS system.

One example: The pharmacy won't let us order refills until five days before our medications run out. But it often takes seven days or more to get the refills. Some patients need a continuous supply of life-or-death medications. The pharmacy seems to operate independently, with an air of indifference, as if it's not part of a patient-care facility.

I hope your series will prompt those officials in charge to act aggressively to fix the hospital's problems so you'll have plenty of material for your series on JPS's positive aspects.

Yikes. That's one anecdotal story, but still. A pharmacy's "value added" time (filling a prescription and having a pharmacist review) should really be measured in minutes, if not seconds. It shouldn't take one day, let alone seven, to get a prescription filled.

A standard Lean measure is the percentage of "Value Added" time to the total "cycle time" or "turnaround time." As with many non-Lean processes (whether in manufacturing or healthcare), the percentage of VA time is very low according to that story about JPS. The non-value added time is waste -- waiting due to not having enough capacity to get the work done or waiting due to batching and other systemic delays.

I certainly do hope there are JPS success stories in the future. Lean methods could certainly be used to improve processes, reducing turnaround time in the pharmacy.If there isn't enough capacity (people or equipment) to get each day's work done, Lean would focus on reducing wasted time so people can be more effective. Lean isn't about cutting corners or doing work too fast -- that might introduce more errors, something you don't want to do in a pharmacy, yet alone any process.

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"Loving Lean" is Way Better Than "Lean and Mean"

Health Care: Loving Lean -- Seattle Business Monthly

It's so nice to see a Lean overview article, yet alone Lean healthcare, that doesn't use the "Lean and Mean" cliche in the headline. This is a story from Seattle that discusses Virginia Mason and Seattle Children's and their Lean experience.

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