Does the Solo Doc = "Lean" Doc?

WSJ Article: Faltering Family M.D.s Get Technology Lifeline

While I was skeptical of Intel’s planned tablet PC for nurses, I’m much more positive in my first reaction to this WSJ article about small (or single MD) physician practices using technology (and process changes) to improve service and to reduce waste.

Hearing about stories like this, being an MD with a group practice owned by a large corporate health system, makes me think that being a doctor really wouldn’t be that great of a job:

"To increase revenue, the hospital pressured him to see more than 30 patients a day, usually for 15 minutes each. Many patients couldn't get appointments for weeks. Dr. Moore determined it took 19 separate actions and 253 feet of corridor-walking to order a prescription refill. He says he was so rushed he often failed to provide the best medical care, and once mistakenly prescribed a blood-pressure drug for a toddler."

30 patients a day. That’s really cracking the whip. With the doctor’s capacity being that highly utilized, from a queuing theory perspective, it’s no wonder that it takes a long time to get an appointment. I’m dreading calling my doctor’s office on Monday (if I’m still not recovering from this flu) in case I can’t get an appointment. Am I supposed to plan my illnesses in advance?

Look at the illustration of waste in the process – 19 separate steps and 253 week of walking to get a prescription ordered. Being so rushed also helped contribute to a near medical mistake. In any environment, whether its building cars of treating patients, any “worker” who is pushed to do too much too quickly is bound to make errors.

Dr. Moore took a risk to go out on his own to form what is often called a “micropractice," literally a small office that's staffed by only the doctor. That's right, no receptionist, no assistants, no medical staff other than the doctor.

So in early 2001, Dr. Moore took a risky step. He borrowed about $15,000 to start a solo medical practice in a tiny space with no nurse, receptionist or waiting room. He bought computer software to help him track patients' appointments, illnesses and medications, and to process insurance claims.

Patients at his "micropractice" can call or email to get appointments the same day. Visits last 30 minutes. Dr. Moore can be reached day or night on his cellphone. To refill a prescription, he walks "zero feet," he says, and taps a few keys on his laptop.

Less patient waiting, longer visits, and less waste in the process. Not bad, eh?

There are some tradeoffs. Many of the MD’s end up making less money, but they enjoy the quality of life and the freedom to do a better job taking care of their patients.

There are many technological tools that help a physician manage their own practice without an office staff or direct administrative support.

Initially, [Dr. Moore] didn't want to handle his own billing and insurance paperwork, because it would reduce time with patients. But he decided to pay $250 a month for five years to use software that combines electronic health records, patient scheduling, and electronic billing.

He also bought off-the-shelf "disease management" software, called DocSite, to track how well his patients are doing on key measures, such as cholesterol, blood pressure and blood sugar levels. For example, the software easily generates a list of patients who failed to follow through on a blood-pressure checkup, alerting Dr. Moore to call or email those patients to come in.

One other practice mentioned that reminds me of lean is the call to not overspend on equipment. More from Dr. Moore:

His most expensive purchases for medical equipment were a new exam table for $750, and an electronic thermometer for $250. He paid $100 to buy used furniture. While many doctors spend hundreds of dollars on wall-mounted eye- and ear-examining equipment, Dr. Moore says he pulled out hand-held versions that he used in medical school. His total outlay in that area was $20, for a rechargeable battery. "I advise other doctors to buy the minimum of what they need," he says.

Dr. Moore has reduced overhead costs AND increased patient satisfaction:

Dr. Moore estimates that his overhead costs make up 35% of his revenue. That compares with a figure of about 60% for other small primary-care group practices, according to Medical Group Management Association, an Englewood, Colo.-based professional association for doctors' practices.

I know if I have trouble getting an appointment the next time I'm sick, I’m going to seek out a “micropractice” physician (if I can find one in my area).

Websites about Micropractices:

IdealMicroPractice.com

Solo Doc Blog

The Solo Practitioner Blog

NPR Stories on New Toyota Plant

It's official, that Toyota has selected a site near Tupelo, Mississippi for their next U.S. factory (Google News search here).

Thanks to Pete Abilla, he sent links to three NPR stories from this morning.

Mississippi Wins Battle for Toyota Plant

Tupelo Officials Worked Hard for Toyota Jobs

Arkansas City Spurned Twice By Toyota

Toyota has continued its trend of locating in the South, in non-union areas, and in a place where they can be the "big dog" of the area. Toyota likes being the primary employer where they can command the cream of the crop of area employees and seems like that will be the case in Mississippi. The Toyota plant will, however, be about three hours away from Nissan's Canton MS plant.

UK Hospitals Gemba Walk the U.S.

I was sent a nice "gemba report" essay from a UK lean healthcare consultant, Andrew Castle. Andrew consults for the UK National Health Service and came with a group to tour two American sites:

• Toyota Industrial Equipment (forktruck manufacturing in Indiana)
• Northwestern Memorial Hospital (in Chicago)
  

Download the full article here (pdf format)

Some highlights of their observations, brought back for a healthcare audience.

Toyota:

An interesting side note to TIE’s growth over the last decade is that post 9/11 the US economy suffered from an industrial recession. Demand for forklift trucks decreased by approximately 10% from September 2001 for the following 12 months. A large number of people were laid off and made redundant following 9/11 as demand for products decreased but Toyota decided not to lay off a single member of staff. They accepted that they needed 10% fewer staff (approximately 30 of the 300 strong manufacturing workforce in place at the time) to meet demand but rather than lay staff off they chose to second them internally from Manufacturing to a Service Improvement team.

For the 12 months following 9/11 these staff worked on projects that would improve efficiency once demand picked back up. The rational behind this strategy was that whilst customers were not going to buy new trucks following 9/11, eventually they would, and once they did they would have to make the trucks that were not bought during the year in which demand fell as well as the trucks that would normally have been bought that year.

One year after 9/11 staff were seconded back from Service Improvement to production, demand for trucks increased to levels greater than pre 9/11 due to customers ordering trucks that they should have bought during the recession as well as customers ordering trucks that were due for replacement and not one member of staff was laid off during this period.

TIE have seen a 70% reduction in staff turnover since 1990, from 30% to 9%, compared to a local level of 13%. There is a six month waiting list for staff to start and TIE no longer advertise for employees.

There is a PERFECT example of taking a long-term view in the face of economic trouble. Toyota could afford to keep employees on board after 9/11 and put them to productive use, kaizening their processes and preparing for the plan demand increase that would eventually come.

Northwestern Memorial Hospital:

From the design of the building to the internal environment in which care is provided NMH strives to provide the best patient experience from the patient’s perspective; recruit and retain the best people who share the organisation’s values and achieve results; and achieve exceptional financial performance. 9 quality improvement leaders work full time on multiple service improvement projects. Since 2002 NMH has undertaken 125 improvement projects resulting in a 57% reduction in potentially avoidable severe harm events and a greater than 4:1 annual financial benefit from improvement. There is an annual quality day where all improvement project teams present the status of their projects to 300 senior managers and clinicians. There is a board retreat for half a day per year. The focus of the retreat is on quality and safety. All potentially avoidable incidents are reviewed and actioned immediately or become the focus of future improvement projects.

There are lots of great details -- download the full report. Thanks again to Andrew for sharing this with the lean community.

Originally published in the Health Service Journal (http://www.hsj.co.uk/). More commentary can be found here.

A Leaner Message Delivered by UPS

For some context, here are my complaints about UPS ads from earlier today and from last year.

Thanks to the "create your own whiteboard" feature on the UPS website, I created this Lean Message. Check it out:

Click this link for an animated version (as long as UPS doesn't pull it for being "objectionable" content.

The "story board", Part 1:

Part 2:

And the Big Finish:

Much better than their messages pushing offshoring and overseas suppliers... expedited with overnight global shipping. Of course UPS should be trying to sell global shipping, that's the business they are in. The ads still bug me. I just hope corporate executives aren't having their sourcing decisions and supply chain strategies influenced by stuff like this.

You can make your own whiteboard ad and email it to me at markgbox-lean@yahoo.com by visiting ups.com/whiteboard.

The BBC on Lean Production

BBC NEWS | Business | The triumph of lean production

The BBC highlights lean practices and provides a stunning contrast between Toyota and Ford:

On the assembly line at Toyota's giant plant, Laura Wilshire is not happy.

There is something wrong with a seatbelt fitting on the Camry she is working on.

Laura pulls a cord, stopping the production line - and prompting her five fellow workers on trim line three to crowd round.

They soon see why it is not screwed in properly and fix the problem.

"I don't like to let something like that go," she says. "That's really important for people who buy our cars."

Workers at the Toyota plant in Georgetown, Kentucky, pull the cord 2,000 times a week - and their care is what makes Toyota one of the most reliable, and most desired, brands in the US.

In contrast, workers at Ford's brand-new truck plant in Dearborn, Michigan, pull the cord only twice a week - the legacy of generations of mistrust between shop-floor workers and managers.

There's a huge cultural difference between Toyota and Ford. Even with Ford's attempts at reclaiming the "Ford Production System," all of the lean design and lean documentation doesn't matter if you're not going to "manage lean" which includes letting workers pull the cord to fix quality problems.

The article doesn't delve deeper into Ford, but instead looks at GM's efforts to catch up to Toyota from a labor productivity standpoint. But it mentions nothing about quality or how GM's "andon" (not "andan" as the BBC spelled it) process works any better than Ford's. GM has had the chance to learn from Toyota at NUMMI, so you'd hope they would have a more robust line stop and quality improvement process. Do they?

The article doesn't draw a direct comparison to GM, Ford, and Chrysler building what they want (or what they can) and dumping it on dealers, but I will. Here's Toyota's approach:

Toyota also has a close relationship between the dealers who sell its cars and its plants.

The production run is adjusted at the Georgetown plant, and extra Saturday working is added, only when computerised orders from the dealer network show it is needed.

And individual buyers can alter what they want in their car - changing the paint colour or specifications - right on the production line, by notifying their dealers.

Let's not point out management practices as the differences between the "Detroit 3" and Toyota... let's blame healthcare and currency policy. Right. The differences between Toyota and the Detroit gang are so obvious. Having the better management system -- that's the key to Toyota's success.

The article ends with some added cynicism from our friend and future Podcast guest Jim Womack:

At a deeper level, the question is whether GM and Ford - the companies that perfected mass production -can fundamentally change their culture to the new lean production system.

"I hope they make it - but I am not optimistic they all will be able to," says James Womack, an expert who has advised many global companies, from Tesco to Boeing, on the advantages of lean production.

Mr Womack says it has to be something that is inculcated in all the company's workers, from the bosses to those on the factory floor.

"This is not Japanese companies vs American companies, it is smart Japanese companies vs smart American companies," he says.

"GM has caught up on assembly plants, but Toyota is still ahead on suppliers, product development and a problem-solving approach to issues.

"For too long, managers at US car companies were in denial about their problems."

Toyota to join Nissan in MS?

Toyota said to build plant in Mississippi - Feb. 27, 2007

Looks like Toyota's rumored U.S. expansion continues.

Toyota is under pressure to boost production in the region to avoid potential political fallout from a jump in the number of vehicles shipped from Japan to the United States. Last year, just half of the vehicles it sold in the United States were built in North America, compared with a rate of more than 70 percent for both Honda Motor Co. and Nissan Motor Co.

At the current rate of sales growth in North America, some analysts say Toyota would need to add capacity at a rate of one factory every year.

Thankfully, Toyota is expanding and adding jobs here in the U.S.

Somewhat unrelated, but here's an article that gives pretty good detail about what's in a 52-second job cycle at the Toyota Georgetown (TMMK) plant.

Many of the workers on the line will perform four different processes for two hours each during a typical eight-hour shift. Switching assignments every two hours helps workers battle monotony and expands the number of employees who understand a variety of tasks.

"It's almost mind-boggling to see how a car goes together," said Gary Scott, of Georgetown, a group leader who was overseeing the seat installation process one day not long ago. "That's what I like about these cars - these Camrys are tight," said Scott, a 15-year employee who was referring to the paper-thin tolerances that Toyota works with in building a Camry.

"When everything is going right, we build 536 quality vehicles (on his shift), nobody gets hurt and we all go home happy," said Scott, who studied civil and mine engineering in college before making Toyota a career.

What Can Brown Do? They Dumb It Down For Us

The UPS Whiteboard. What Can Brown Do For You?

These "whiteboard" ads with the guy with the long hair (Mark Fields would be proud!) drawing out logistics concepts on a whiteboard are pretty ubiquitous, especially during news shows and sporting events (the types of programming advertisers use to target executives).

Are the whiteboard ads meant to be friendly and not intimidating or do they have to dumb it down for the finance-driven executives?

Like the ad for China shipping, the man says:

"All right, China shipping... so you need to bring your product from China to the U.S. and you like the reliability of those big brown trucks. Problem is... truck don't float."

Really? Can't build a bride to Hawaii like they wanted to on Gilligan's Island? I don't think the UPS ads are going for humor... so do they really need to explain it on this level?

"But what if, that big brown truck were a big brown plane?.... Now it will get here in a hurry, early in the morning if you want."

I'm not expecting detailed analysis and discussion of supply chain logistics tradeoffs in a 30-second ad, but isn't this ad an indication of the bias towards "it's natural to build stuff in China, but how do you get it here?"

Great post over at Evolving Excellence on that topic, why is it inevitable (at least to Wall Street) that all manufacturers must go to China? Of course UPS makes a lot of money in the process, but does YOUR company?

I know Toyota still imports product to the U.S., but wouldn't it be great if some cash-rich lean proponent could run similar whiteboard ads explaining why lean and being close to your customer can sometimes beat just rushing to China?

I'm still looking for a way to give away that MP3 player pre-loaded with all of the LeanBlog Podcasts. If you can write a creative Lean "Whiteboard" script, send it to me or post it in the comments.

This UPS ad bugged me too. Same reasons.

Ford's Fields in Folicle Fantasy Land

Mullet or not, Fields' hair is talk of the auto industry

I know it's juvenile of me to point out the Mark Fields hockey hair and I was good about not mentioning it for a while (I made it past my promised 30 days). The "Jalopnik" blog also refers to his hair as a mullet. I'm not sure who started it first, but I scooped them on this one.

As is often the case, the "blogosphere" beat the "mainstream media" to the story.

Sunday's Detroit Free Press had an article about his hair. So I guess it's OK to talk about it. It's still juvenile, but we have to be able to laugh about something in the face of all of this auto industry decay.

Mark Fields gave up the corporate plane to fly home to Florida on the weekend.

But don’t expect him to cut his thick, wiry black hair — no matter how many people complain, tease or obsess about his so-called mullet.

That’s a hairstyle known for being short on top and longer in the back, and it was made popular in the 1970s and early 1980s. The often-ridiculed hairstyle is sometimes called hockey hair, a reference to the many players who still wear the style.

Fields said he doesn’t believe he has a mullet, but he prefers to wear his hair a little longer, even though it seems so out-of-step with the conservative culture and fashions in the auto industry.

“I don’t want to be too corporate,” he told the Free Press. “That’s part of my radical side.”

I would put a picture here, but please click on the Freep link because the picture there has a feature I can't offer -- "click to zoom." It's priceless.

I guess we've all collectively upset or puzzled his wife:

Don’t people in Detroit have better things to worry about?” Fields’ wife, Jane, a petite, tough-talking East Coat native, asked the Free Press in Las Vegas last month.

So the Financial Times actually beat us bloggers to it:

The first mention of Fields’ hair in a news article was in 1999, when it was announced Fields would lead Mazda.

The article ponders why we would care?

Such personal criticism or praise about the appearance of an automotive executive is highly unusual.

I'm no psycho-analyst, but I think the reason we all get so petty about minor things like hair is that we have so little control over the big things that matter, like boring car designs that don't sell, sourcing decisions, and plant closures... the total collapse of a great American car company.

Great Find on an Early Lean Hospital

Got Boondoggle?: The First Lean Hospital

Mike Wroblewski deserves a lot of credit for digging this up.... early attempt at a lean hospital in a surprising place and time (or maybe NOT surprising, once you know "the rest of the story.")

Check out his blog at the link above.

COMING MID 2008, A NEW BOOK ON LEAN HEALTHCARE - "Lean Hospitals: Improving Patient Safety, Quality, and Employee Satisfaction," by Mark Graban

Cost vs. Nimbleness at The Gap

Paul Pressler's Fall From The Gap:

Saw this in Business Week yesterday:

"As part of the supply chain revamping, Pressler also tinkered with the way the Gap brand produced clothing samples. These prototypes had long been made at studios in Manhattan's Garment District. But Pressler moved sample-making to Asia, where the company's many suppliers are located. With that change, designers had to create patterns, ship them to Asia, get the samples back, make changes, and ship them back to be remade. While making samples in Asia was cheaper than in New York, it delayed the process and 'made you less nimble,' says a former insider. Aggravating matters, the company instituted a new cost-cutting rule: No overnight shipping to Asia without high-level approval."

Talk about a road to frustration. Management makes a labor-cost driven decision (make samples in Asia, while designers are in New York). Then, to further aggravate the slowness and lack of response, put in a draconian ban on overnight shipping.

Is this a lean tale? Sure. Companies of all kinds need to look at more than unit labor cost. They need to look at overall cost and, more importantly, overall effectiveness. What good do "cheap samples" do when you're slow and can't get the right fashions into your stores for people to buy?

Compare them to the "lean apparel" examples that Evolving Excellence has documented.

There was another example that highlighted the tradeoffs between cost and effectiveness. At a purely financial level, it made sense for The Gap, Banana Republic, and Old Navy to all buy the same denim in a huge bulk purchase. But, each company is serving different markets (middle, high-end, and cheap), so none of the brands was happy with the material.

And with all that denim ordered in advance, there was less incentive for designers to keep their eyes open so they could jump on the next great style. Jeans made with material from the pooled purchases ended up largely falling flat, and the joint purchasing effort was abandoned.

So before anyone is going to beat up on manufacturers for making short-term decisions based on cost alone.... it happens everywhere. It's either human nature or it's nurtured in MBA programs, I'm not sure which.

More Lean Q&A

by Jamie Flinchbaugh, Lean Learning Center

I recently posted some Lean Q&A. These questions came from an Industry Week webcast that I did with sponsor Infor, and there were plenty more questions than time to answer. Here's the next installment of questions that I received.

If the dollars saved does not spark leadership to take lean steps to really start engaging people, what else would you suggest?

This is a question that would require a lot more context and specifics to answer, but I can try to answer how I would look at it. First, if there are true dollars savings and people are not getting behind, a direct inquiry as to why is important. There can be some valid reasons. For example, the dollars saved might be soft savings (that's doesn't make them not real) but the organizational situation, or possible culture, will only value hard savings (the budget is now lower). The second question or issue is around the topic of engagement. This is even more likely the issue. Many managers believe they are very supportive. They are 100 percent behind the lean efforts. The problem is that behind is still behind, but engaged likely means out in front. They might be very interested in what lean can do for them but not really know what they should do about it. One last thought is that dollars saved does not excite everyone even if they value it and even if they are measured by it. Still consider the emotional element. If people are leaving the office at 7 PM feeling they got nothing done, could lean help them leave at 5 PM feeling like they made a difference. Sometimes a vision like this is much more compelling and engaging than just saying we saved some money.

We have a minimal amount of experience in Lean. Therefore, we will have to get some suppport from the outside. Some will "help facilitate" over an extended period of time, othres will come in for 6 months and drive it (for a cost). What is the best type of consulting to use?

That is an important question, and one I feel a little biased and uncomfortable answer. Nonetheless, here's what I do believe. There is no recipe, no three-ring binder approach to lean. If someone brings you an approach and says "here is the best way to implement lean," please, run away. There is one right approach. The closest there is to a right approach is that there may be a right approach for you. Each company has different needs, different business conditions, different cultures and different capabilities, and your lean transformation strategy should reflect that. For example, a company near bankruptcy has different needs than a company making record profits. An international conglomerate has different needs than a family-owned tool distributor. Continuing down that line of thought, you also have to find a consultant that fits your needs. Do you need an army of people to hold your hand, or an advisor to give you occasional input and feedback. The personalities and styles of both the consultant and the company do matter. Know thyself, or know thy company, and find the right fit. Regardless of the right fit, I do believe a couple of things about consulting. First, they should transfer skills and knowledge. If they are continuing to execute the same tasks for you year after year without you learning and developing, they aren't doing their job, and neither are you. Also, a consultant has to be willing to walk away if they don't think you are willing to move in the right direction. If everything you ask or suggest the consultant agrees with, you are either brilliant and always right, or they aren't willing to tell you the truth. And last and perhaps most important, never, never abdicate your lean journey and company direction to the consultant. The consultant should only help. You must lead your own team, your own company. No one can do that for you.

Our company is struggling with how to measure our worker's continuous improvement activities. Is this something that should be measured, and if so, how would we measure it?

Know that you are not along - this is a common question and a challenge. Many people don't like my first answer, because it's not the answer they are looking for, but it's the right answer. The most important measurement is engagement. You have to engage and evaluate how people are thinking, working, engaging and improving. If you can't look your employees in the eyes and understanding their thinking. Now you can supplement that engagement with metrics, but it will only help, not replace, real engagement. If you are going to measure employee involvement in continuous improvement, never, never tie financial incentives to metrics of people behaviors. Measure things that indicate progress, either forward or backward. You can measure number of improvements, speed to closer, total dollars, percent of people participating, but any one of those can be misleading.

Should you quantify all lean upgrades in order to know what you accomplished or how well you are or are not doing?

One at a time, yes. When we talk about lean rules, one of those rules is improve through experimentation. That means even for a small improvement like changing a form or moving something, it starts with a hypothesis: "if I do this, I expect to get that." You then try it and find out if you got the result you expected.Two things happen when you do that. First, you find out if it was indeed an improvement. Second, you just tested your knowledge, which is how learning occurs. In case that sounds familiar, that is basically what PDCA, or Plan Do Check Act is all about. You can add improvements up if you want to or can, but if you improve through experimentation properly, you will know if you are making progress.

How can I succeed in a Lean implementation without upper management support?

First, recognize that few companies start with upper management support. Sometimes, but very rarely, it starts with the senior management. Slightly more often, someone in senior management gets the journey started. Much more often, someone else needs to get them there. If you want upper management support, then part of your job is to do whatever it takes to gain that support. That being said, you also can apply lean to your own job and your own sphere of influence, whether that is just you, a team, a department or a process. You have to deliver results anyway, why not use lean to do so. You will make things around you more effective. You might get upper management support because of those results. And hopefully you will also learn, which is all the reason any of us should need.

How to motivate people to implement Lean when we are cutting overtime by implementing Lean?

You can't, at least you can't motivate people when taking their money away. If you can replace that overtime pay with incentives tied to the profitability of the company, then you might have something, But if people take home less money, they will not be happy with the result. Some organizations hate overtime, but many seem to revel in it based on the increase in pay. If you have no room to change the incentive system, then you will have to accept their point of view, and motivation will not be part of it. The best thing you can do is move through the transition as fast as possible, let the dust settle, and rebuild from there.

If my company only focus on short term profitability, how do you apply lean? It's easy to apply lean tools but it's hard to change the culture in a short time.

I would say it's very hard to change the culture in a short time. But short term results and long term culture change do not have to be mutually exclusive. You need a long-term vision of the culture change you want. As you work on the problems and processes that are required to deliver those short-term results, do it in a way that builds the culture one step at a time. It's slow and steady but it works.

Support a Former Ford Employee's Education

I got an email last week, from Dan, a long-time Ford employee who took a buyout and is now working on a college degree. He's looking for a company (local to him in Sterling Heights, MI) where he can do some unpaid internship project work that will go toward his degree. Dan agreed to have me share his request -- you can email me via the link in the left column and I'll play go between between you and Dan.

Dan wrote:

In brief, I took the Ford Motor Educational Buyout in "2006" and am currently a full time Ferris State University student. In the near future, I will be requested to research and develop a thesis as my final requirement to receive my degree in Industrial Technology and Management.

Presently, I am looking for a company that would allow me to be part of a team involved in process improvements within their facilities or of a customer.

I am willing to work for no income or benefits in order to have the opportunity to accomplish my task.

After I asked a few questions, Dan replied:

Ferris State University administers the program at various satellite locations; mine in particular is Macomb Community College in Warren. At Ford Motor Co. I held an assortment of hourly positions in their Interior/Exterior Component Systems Plant in Utica, finalizing my stay there with a Hydraulic-Repair Journeyman position; all said and done I spent twenty-one years at the facility. As far as a "time table" is concerned, that answer is slightly based on the pace of the program and management's commitment, personally I would hope that it would be no longer than a quarter.

I certainly wish Dan best wishes for his education and career transition. I hope someone out there can help him out.

Carnival of Posts from the Lean Blogosphere

I'm down with the flu (and stuck out of town in a hotel room after an attempted early trip home was canceled due to weather) and not much in a good thinking mode.... so thanks to illness-inspired laziness and the desire to not duplicate the efforts of the other blogs, here is a good excuse to link to some good blog posts from the Lean Blogosphere:

• Jon Miller's "Gemba Pantarei" blog has a post about the "7 Habits of Toyota People"
  
  
• Peter Abilla's "Shumla" blog has a post about Toyota's code of conduct
  
  
• John Hunters "Curious Cat" blog has a post about an interview in Business Week with Toyota's CEO
  
  
• Ron Pereira's "Lean Six Sigma Academy" blog has a post (that's garnered a lot of comments), asking if the practice of "once a month cooking" for the family is "lean" or not.
  
  
• "Evolving Excellence" has an update on Home Depot and another recounting of their sad story.
  

While I'm recovering, check out these, and the other excellent blogs I've linked to in the left hand column. I'm excited that there's so much good stuff out there in the lean blogosphere.

Toyota and "Gung Ho"

Why Toyota Is Afraid Of Being Number One:

In this Business Week piece about Toyota's fear of a backlash against them, with their continued success, there was this tidbit I found interesting:

"That same year [as NUMMI opened], a Ron Howard comedy called Gung Ho appeared; it contrasted the American and Japanese work ethic at a car plant operated by an Asian company called Assan Motors. (Toyota later used the film as an example of how not to manage Americans.)"

Who knew?

Intel, Motion Develop Tablet PC for Nurses - WSJ.com

Intel, Motion Develop Tablet PC for Nurses - WSJ.com

More news stories via Google.

Is this a "siren song" of technology for healthcare? Executives and managers in any industry, it seems, believe in the promise of technology as the solution to problems.

At best, such as with this Intel-developed tablet PC designed "especially for RN's", it's only part of the solution, or at worst, it's a waste of money that could be used in other areas.

For any hospital considering this sort of purchase, I implore you:

1) Get input from your RN's
2) Plan out the processes in which the tablet will be used (Develop standard work)
3) Figure out if the tablets will actually be used
4) Make sure these things aren't going to drag more germs into the room

Intel, of Santa Clara, Calif., last year helped to establish a multicompany alliance called Continua to define medical-technology standards, and the company has set up a "digital health" group for its strategy to develop combinations of computer chips and other technologies for specific markets. With Motion, Intel deployed demographics researchers to study how nurses work, consulted with them and tested tablets at three hospitals, said Louis Burns, vice president of Intel's digital-health group.

Motion, a closely held tablet maker in Austin, Texas, already gets about half of its sales from the medical industry. It worked with a medical-software maker to ensure the new tablet can exchange information easily with hospitals' record-keeping systems, said Scott Eckert, Motion's chief executive.

I hope the focus was greater on making the laptops useful than the focus on making them "Sellable".

One regular chore for nurses is taking a patient's temperature, blood pressure and other vital signs. They often end up writing the data on scraps of paper, or even on their hands, before returning to a nurse's station to enter the data into a PC -- sometimes as much as two hours or more later.

"The accuracy of that data erodes over time -- they forget some of it," said Michael Blum, an associate professor of medicine who holds the title of chief medical informatics officer at the University of California at San Francisco, whose medical center hosted a news conference to discuss the new tablet yesterday. "Equally important is that the doctors don't have access to it right away."

Here is a clear process problem -- RN's are too busy and/or don't have standard work to make sure they can record patient information immediately. If they're so busy, today, that they're having to scribble data on their HANDS, are they going to have time to learn the new system and to actually use it?

As this PBS documentary showed, doctors have been incredibly resistant to using electronic medical record, electronic order input systems, or computers, in general, in some cases (hell, they're incredibly resistant to washing their hands properly). One difference is that the nurses are hospital employees (most of them) as opposed to MD's, who are generally independent contractors. It's easier to "tell RN's what to do," not that doing so is the preferred change management methods. If the technology truly makes the RN's jobs easier, they'll RUN to the technology.

I'd start first by asking "why" are they nurses too busy to immediately record patient data in existing systems. I'd also analyze the nurses's days to identify waste that can be eliminated (waste is often 60-70% of their time) AND ask the nurses how to improve their processes.

There are plenty of obstacles to deploying such tools, including hospital budget woes, said Marc Holland, research director at Health Industry Insights, a unit of research firm IDC. But the new tablet seems unusually attractive, he added, and comes as the Bush administration is pressing the medical industry to become more efficient.

Fancy laptops alone won't solve the hospital's problems. Lean is much cheaper to deploy and might actually solve the problem better.

Interview about Lean Software

InfoQ: InfoQ Interview: Mary and Tom Poppendieck on using Lean for Competitive Advantage

On the page above is the intro to a video interview with Mary and Tom Poppendieck on the topic of "lean software development". The page with the video can be accessed directly here. 38 minutes of interview, check it out.

The Shmula blog has the complete transcript if you click here.

Would Lean Work in Small MD Practices?

medinnovationblog: Systematic Innovation in U.S. Health Care: Toyota’s Lean Manufacturing Method and Its Application to Health Care

A post here from the "medinnovationblog" site. The first one, linked above, gives a pretty good overview of applications of the Toyota Production System as applied to healthcare.

That first post gives a good "state of the healthcare crisis" summary:

Science and process engineering had better work to reduce costs, or the U.S. health system may be headed for a cost meltdown. If current trends continue, health care as proportion of GDP will rise to 40%, by 2050. That would break our system of financing health through employers, pension funds, and Medicare/Medicaid.

Rather than saying the Canadian system is the model, this blogger talks about lean and Toyota, linking the Sunday NY Times piece on Toyota that we've discussed here.

In physican practices, you need some sort of organizational critical mass to make a Toyota-type philosophy work. True enough, which is why Toyota’s approach is being tested in groups with enough size to make it work.

I'm not sure why you need to be "big enough" to make TPS work in any setting. Sure, many of the best lean healthcare examples are in 300+ bed hospitals, but couldn't lean work in a small private practice office? You can reduce waste and improve flow in any setting, right? Continuous improvement works anywhere, right?

He continues:

Maybe not now, but in a generation or so when survival of small practices is at stake. The Toyota model works on the premise that all participants work together in teams, resources be spent on analyzing systems of care, traditional practice flow patterns by disrupted and changed, processes be standardized, defects be cut to zero, and statistical goals for improvement and safety be routinely met.

Will this approach work among individual “democratic” physicians who entered medicine to “be their own boss.” I have my doubts.

He doesn't really state his case as to why he has doubts. I'll have to ask him in the comments and see if he responds.

SPC and Lean

Got a question yesterday from Eric Christiansen, my guest for episode #18 of the LeanBlog Podcast.

He asked:

Can a company be considered a lean company if it does not use some method of statistical process control?

I toured a manufacturing plant in a non-US, non-Asia country. This place had a very nice flow system, things were in their proper place and clear markings were available to show people where to put tools and other items. And while most of their competitors are focused on mass production, these guys have built a flexible production system that does one-off or small batch jobs and a really good price.

But as I toured the facility, one question that I asked them was do they use any kind of statistical method to know if their processes are in control? Or how well their machines are performing? Or when it is time to do maintenance because variation of the product output is increasing? The response to the maintenance question was “When the noise changes on the machine, we know its time to do maintenance.”

I’ll be interested to see what your thoughts are on this.

My response follows (and I'm curious about your responses, click "Comments" to chime in):

I think you CAN be a "lean" company without SPC.... although it's dangerous to say who is "lean" or "not lean" as if it's a binary construct. SPC is a tool. I think if you have a continuous improvement philosophy of PDCA without SPC you are "more lean" (again, I hesitate to say that) than if you have SPC without the right mindset.

We used SPC, badly, at GM, because the managers wouldn't listen to the charts. If something was out of control, but in spec, you had to keep running. That was frustrating to the line workers (who cared more about quality than management at times) and it was frustrating to me. I'm sure you would say, in my example, they were keeping the SPC charts, but they weren't "doing statistical process control."

Listening to the machine or monitoring it by "gut feel" is a pretty common thing and I've heard that described as part of TPM methodologies, that you should be so intimately familiar with the machine that you know when it's going bad. But, that "gut feel" isn't very standardizable or transferable. Personally, I'd worry about relying on that the same way I'd use kanban instead of relying on a person who knows when to order by "gut feel."

Everything else you describe about the system sounds and smells like "lean," the methods at least. The philosophy is much harder to gauge.

Again, what do you think?

Another Sad Example of Gaming the System

Back to my original post about gaming the system, there are three ways people can respond to pressure to improve:

1. They can work to improve the system
2. They can distort the system
3. They can distort the data

I got an email from an old friend -- I'll keep his name, company, and industry confidential, but he said I could share this story. It's a major company with a long history, a company that should really know better, but they've lost their way, apparently.

"We have a position here called validation engineer. They are responsible for getting all the components of a program to 'pass' all of the required functional tests by a certain date set by program managers. They have no design input or ability to change it, a limited budget, and low part familiarity."

So the first thing that jumps out is the "job description" or purpose for that role. I'm sure it's not the official description... but you'd think someone responsible for testing (or inspecting quality) has the right and authority to either "pass" or "fail" an item. Their job shouldn't be to pass items -- or why have the validation job at all? Is it the role of a production inspector to pass everything? Of course not.

The fact that a program manager "has" to hit the date requires that they get designs that can pass the validation, not to pressure the validation process to be skewed or rendered worthless.

"Literally when we find a failure their response has been 'we can't report that, I need the part to pass or I'll be fired'. Needless to say there is high turnover rate and they are all hunting for jobs right now but the impact on every part of product development is affected."

There's the example of gaming the system... are people being pressured to fudge results or to cheat? Of course they are. Since employees aren't allowed to work with integrity, no wonder they get frustrated and want to go to a job where they can work with integrity. It doesn't rank high on the "respect for people" scale when you force them or pressure them to give up their integrity in exchange for a paycheck. If people find other job options, they'll take them. I really feel bad for the employees who are placed in this position.

My friend later admitted:

"They addendum is that I am frequently asked to lie. Often I have to make a judgment call. My integrity is the price that I pay, but I always try to remember that deception is only a short term gain. Someone may lose their job immediately but we'll may all be out of business if recalls are too high and we lose business. Or the other case, they go to another outside test lab who will give them a pass."

No wonder my buddy has been figuring out how to find a new job or a new industry, and he's been learning a lot about Lean (which only leads to more frustration with his non-Lean environment, although he's taking steps to make improvements).

Sad situation. Management is actively encouraging the distortion of the system and the distortion of the test results rather than working to improve the quality of the product designs. No wonder this company is struggling. They have to do better. When my friend gets a new job, maybe I can blast the company publicly, by name.

Call for Questions: Upcoming Womack Podcast

Lean Blog

Jim Womack has agreed to do another LeanBlog Podcast interview, in conjunction with the release of the updated The Machine That Changed the World.

We are tentatively doing the recording sometime next week, the week of Feb 28. If you have questions for Jim, related to the book, what we've learned since it was first published, what he now thinks of the book and its relevance today, etc., we want to hear from you. The best or most interesting question (judged by me) will win an MP3 player with all LeanBlog Podcast episodes pre-loaded and you'll also win a copy of the revised edition of "Machine."

You can email me, using the link in the left hand column of this page, or you can send a question via Skype voicemail. You can do this via a regular phone by calling (817) 776-LEAN (817-776-5326) or you can contact me through Skype via my id "mgraban". Please give your location and your first name only. Any questions (email or voicemail) might be used in the podcast. Please get me your questions by the 28th.

Here is a retrospective on the book by Jamie Flinchbaugh.

For earlier podcasts with Jim, visit the Podcast main page at www.leanpodcast.org.

An earlier text Q&A with Jim can be found here (all five parts, part 1 is here) and a second Q&A from a year ago.

GM Got Gamed

Following up on my post about my recent experience metrics and processes being distorted (and my less-than-perfect lean coaching efforts), I was thinking about to some first-hand experience I had at a GM engine plant, circa 1995. It's the most blatant example of someone intentionally distorting data that I've ever seen.

Our engine block line was designed at a throughput goal of 92 blocks per hour, if everything ran perfectly (but it hardly ever did, at least not for an entire 60 minute stretch). Our plant superintendent, Bob, (the #2 guy in the plant) decided that 60 pieces per hour was an acceptable number (partly based on productivity numbers that were attributed to Toyota). Anything below 60 and you’d have to explain why. Now, he wasn’t really the listening, problem solving type. He managed by fear, yelling, and intimidation. There was more yelling involved than listening or problem solving.

Anyway, at the end of the engine block line was a mechanical counter that recorded the hourly production counts. The UAW workers who unloaded blocks dutifully recorded the number every hour.

The numbers might typically look like (for you RSS readers, you might not see the image):

That's an average of 56.25 pieces per hour. Not quite up to Bob standards, although we exceeded the goal in 4 hours and came close to 92 in one hour.

At the end of the day, before our “4 o’clock meeting” where the plant salaried staff took its daily verbal beating from Bob, Scott, the production supervisor (technical title of “Team Coordinator” didn’t quite fit) would pick up the counts and do a little daily editing.

He’d take the numbers and turn them into, I kid thee not:

That's still an average of 56.25 per hour. But it's much more consistent, isn't it?

Bad ole’ Bob never questioned these numbers. I know it's hard to believe that he would believe those numbers, but when reviewing multiple departments, Scott's fudgery helped avoid too much attention that a really bad hour would bring upon him. Rather than asking "why don't we have more hours of 86 blocks?" the upper limit of expectations was set too low, at 60. I asked Scott once why he fudged the numbers each day, and his answer was:

"Bob wants 60 an hour, he gets 60 an hour."

Other departments got more than their share of the daily beatings (I had a bet with a co-worker if Bob would say “pathetic” or “miserable” first). Bob always had the same pronouncement for our problems: we weren’t trying hard enough. And apparently, more yelling from Bob was what we needed to motivate us. But that never worked.

“Not trying hard enough” fell into two categories: 1) urgency and 2) intensity. We didn’t have a sense of urgency. We didn’t have the proper intensity. Like a shorter imitation of Mike Ditka (with a signature bad toupee rather than a signature mustache), Bob would yell and scream and spit. Sometimes we got “we need urgent intensity” or “we need intense urgency” if things were really bad. All of the yelling and screaming, all of the fear, all of the fudging of the numbers got in the way of true process improvement and true problem solving.

Obviously, situations like this are part of the reason our plant manager eventually got moved out of the way for a new, NUMMI-trained plant manager. That started our road to recovery, as a plant. It was never a worker problem, it was a management problem. That's an important lesson of lean -- what's required is a change in management practices and management philosophy.

I'll leave it for another post to talk about that "4 o'clock meeting" and what its goals were supposed to be. The meeting was designed by some internal lean consultants we had, but was co-opted for non-lean management methods. Why weren't the lean consultants being listened to? Again, I'll save that for another post.

Illustration from igotzillustration.com

Lean Q&A

by Jamie Flinchbaugh, Lean Learning Center

A few of you may know that a couple weeks ago I did a webcast for Industry Week. For those of you attended, thank you for the great comments. As part of it, the sponsor, Infor, asked me to answer some of the questions that came in during the event that we didn't have time for. Here is the first batch, which I thought I would share with all of you. Most of the questions were good - too good. Many of them deserve a real answer, not a blog answer. They deserve dialogue and engagement, not a paragraph. Unfortunately, I am stuck with this medium for this purpose. Please share your comments below.

Q: How do you assure LEAN Thinking is being applied by leadership?

A: By leadership, I assume you mean the executive ranks. You can not "assure" that at the end of the day, as each person controls their own thoughts and actions. You can only encourage, promote, coach and drive. Here are a few thoughts. First, manage expectations. This in part may mean lowering yours, but too often we place an expectation on leadership that they live up to lean principles every minute of every day with no lapses. Even might Toyota would not sign up to that. These are human beings, and mistakes will happen - OFTEN. Expect that they learn, try, engage and learn some more, but while you should pursue perfection, do not make the mistake of expecting it. Second, if leadership is to apply lean thinking then they must learn true lean principles and not just lean tools. No executive will ever change bottom line performance by putting a 5S shadowbox around their stapler. But standardizing their information flow, believing and practicing waste elimination, directly observing work are things that they can practice in their own role. Next, reinforce the right behaviors by making it visible. Too often I see leaders change their way but no one really gets to see the change because the leader does not talk about it. Talk about it. Make sure people see it, and understanding it. It is not enough to just change; if people don't understand it, they will not know how to emulate it. Finally, start to measure it. I don't mean with a metric, but either through shadowing, coaches or even more formal reviews, begin to articulate the behavior changes and evaluate their success. In the end, the war for people's minds and hearts will probably have a few casualties along the way of people who cannot exhibit what is being asked of them, but you have to give them a shot first. Some might surprise you.

Q: How do you measure culture?

A: I think a better question is how do you evaluate culture. People tend to resort to measurement being the only tool of evaluati