It's NOT the Fault of GM's Workers

NPR : Reasons for GM Slide Go Beyond Work Force

Honestly, I'd expect more from liberal NPR and their headline. You'd expect NPR to be the friend of the UAW "working man" (or woman), but I don't appreciate how their headline is implying that GM's problems were the fault of normal workers, instead of management.

Japan's Toyota has overtaken United States rival General Motors in sales volume for the latest quarter, and is on pace to knock off GM as the world's biggest automaker.

There are lots of reasons for GM's decline, but industry analysts say assembly workers aren't to blame.

Of course workers aren't to blame. The difference between Toyota and GM is a difference in management systems, not a difference in workers. Look at the success of NUMMI, where Toyota is running a plant with the same workers GM was failing with, before 1983 (well, most of the 1983 workers are retired now, I'm sure). Toyota didn't hire EVERYONE back, but they were able to succeed with the UAW and its workforce.

GM was once no match for Toyota when it came to building cars fast. In 1998, it took GM workers an extra 10 hours to push a vehicle off the line. By 2005, GM had narrowed that gap to about an hour.

Is the implication here that GM workers were lazy before and now they're working harder? The "hours per vehicle metric is driven primarily by vehicle design and the design of the management system that runs the plants. Sure, you could also blame the inflexible work rules dreamed up by the UAW, but that's not the "workers" fault. If vehicles are designed to be more easily assembled, that would have a big impact on hours per vehicle. Even if you want to dump on GM workers, you'd have to agree, then, that they aren't working harder than they were in 1998. Lean practices would increase efficiency at the factory level, I'm sure that's a factor too.

Toyota Way author Jeff Liker pointed out:

"There would be evidence of what they learned from Toyota in every factory in the world," Liker said. "One of the more advanced ones is the Cadillac plant in Lansing (Mich.) where the quality and productivity is pretty close to Toyotas."

But it was too little, too late, he added.

GM copied some Toyota methods, but is that evidence that they copied the management system? Probably not. Hence, GM's troubles.

Indeed, the company has designed many vehicles that consumers just didn't want to buy. That damaged GM's image and cost thousands of workers their jobs.

"Some of the plants that have the reputation for being the best in terms of quality of the work force, teamwork, all the things that management asks, are the ones that were selected to be closed," Liker said.

To me, it's definitely not the workers' fault. Management designs vehicles and has responsibility for making sure these cars meet the needs of the workers. Having a super efficient factory that builds cars that don't sell isn't very Lean at all, even if the factory used Kanban and 5S. Lean isn't just a set of factory tools, it's an overall management system that includes product development and other aspects of the enterprise.

I think the article/audio story mostly gets in right, pointing out the systemic problems and management errors of GM. But, NPR should have titled their story "Reasons for GM Slide Aren't the Workforce." You won't get very far with Lean if you're dumping on or blaming your employees.

Lean Could Have Helped Hershey

New Haven Register - Bitter Ending

Thanks to Lean Blog reader Tom for sending this my way, sad story that it is.

Hershey's candy is moving a plant from Connecticut to Virginia:

The Hershey Co. will close its Peter Paul manufacturing plant here by the end of the year, putting about 200 employees out of work, the company confirmed Wednesday.
The 250,000-square-foot plant at 889 New Haven Road is 85 years old and the workers are non-union. Most of the jobs will move by the end of the year to a plant in Stuarts Draft, Va., where the candy will still be manufactured, said Hershey spokesman Kirk Saville.

On the surface, it's not strictly a move for lower labor costs, from CT to VA, but company officials said overall capacity utilization was very low, hence the need for consolidation. The company is, however, planning on moving work to Mexico and to outside contractors, hence the over capacity at existing U.S. plants, I guess.

The plant is the latest to succumb to offshore outsourcing, moving operations out of the United States in favor of cheaper locations, said David Cadden, a management professor at Quinnipiac University.

It's too little, too late, but the professor says Lean could have helped:

Hershey’s decision to leave is "profoundly disappointing" and, while it may have short-term financial rewards, could hurt the company in the long run, Cadden said. Hershey’s could reduce manufacturing costs at its U.S. sites if it used more cost-efficient, lean manufacturing techniques, he said.

To paraphrase the Almond Joy/Mounds commercial (youtube link), "Some times you feel like outsourcing, sometimes you don't." Well, mostly you do, I guess. Another company succumbs to the promise of cheap labor. Sad.

LeanBlog Contest: Visual Management (Win an iPod Nano!)

Sponsored by American-LEDgible, Inc.

It's time for another LeanBlog Contest! Update: Deadline is May 18

Submit your Visual Management stories and get a chance to win a Black 8 Gig Apple iPod Nano, a $249 value, courtesy of our sponsor American LED-gible, Inc. (www.ledgible.com). I wish I could keep it, it's an incredibly small, great looking device.

To enter, send an email (file attachments are OK especially if pictures are included) to the email address linked in the left hand column of the blog (email Mark) with the following (or bonus points for submitting an A3).

1) Brief Process Description (type of industry, etc.)

2) Problem Statement: What was the problem or type of waste encountered?

3) What visual management or visual control method did you use? How did this solve or prevent the problem? Why did you choose this solution?

4) What was the impact of visual management method?

The most creative example of visual management or the best written example will be named the winner and will receive the Nano. Entries don't have to demonstrate a technology-related visual control, such as andon boards or electronic signs.

The book The Toyota Way defines visual control as one of Toyota's key principles:

Use visual control so no problems are hidden.

Included in this principle, is the 5S Program - steps that are used to make all work spaces efficient and productive, help people share work stations, reduce time looking for needed tools and improve the work environment.

Entries are due by Friday, May 18 at 5 PM central daylight time. The winner and all entrants can remain confidential, but I reserve the right to publish any submitted story or picture here on the Lean Blog.

If you like, I will pre-load the Nano with all episodes of the LeanBlog Podcast, or I'll leave it as brand-new.

Thanks again to our sponsor, American LED-gible, a manufacturer of LED and electronic signs, andon lights, timers, counters, and other Visual Management products.

If you have any questions about the contest, email me using the left hand column link or leave a comment on this post.

I've been having some email trouble with the leanblog.org domain, so if you entered previously, please email me again using the link in the left hand column of this page.

LeanBlog Podcast #23 - Group Health Cooperative Lean Panel

Episode #23 of the LeanBlog Podcast features a panel of Lean leaders from the Group Health Cooperative, a consumer-governed, nonprofit health care system that coordinates care and coverage. Based in Seattle, Group Health and its subsidiary health carriers, Group Health Options, Inc. and KPS Health Plans, serve over 500,000 members in Washington and Idaho. GHC has been on a Lean journey, as documented on their "Daily Kaizen" blog. Joining us on the Podcast are three of their Lean Leaders:

• James Hereford, Executive Vice President, Strategic Services and Quality
• Dr. Ted Eyan, Medical Director of Health Informatics and Web Services
• Lee Fried, Manager of the Strategic Consulting team at Group Health

In this Podcast, they discuss how GHC got started with Lean, their early "point improvement" successes, and their transition to a more systemic approach to a Lean management system through their "model line" efforts.

MP3 File (Right Click to Save-As)

Show Notes and Approximate Time, Episode #23

• 1:15 James: Overview of the Group Health Cooperative (GHC)
• 2:00 Lee: How GHC got started on their Lean Journey in 2004, initial drivers
• 3:05 "RPIW" = Rapid Process Improvement Workshop (like a kaizen event)
• 3:30 Improved cost, quality, and delivery at the same time, in the lab, "wasn't believed possible in healthcare" and got senior management attention
• 3:55 Started with "point improvements"
• 4:15 Brought in some external consultants, education for the senior leadership team
• 4:30 Then moved from point improvements to large cross-departmental projects (e.g., health plan and delivery)
• 6:12 Looked at how to optimize the Electronic Medical Record system (involving IT and caregiver teams)
• 7:30 The model line, moving beyond point improvements and into cultural change --claims processing and customer service center (700 employees), HPA = Health Plan Administration
• 8:30 Had to make sure they weren't losing gains from earlier lean efforts -- started doing more to fully ingrain lean concepts into the management practices and culture
• 9:15 Three components to the "Model Line" 1) Standard work of the daily management system 2) Value Streams and RPIW's to "turn the organization on it's side," from functional organization to process organization and 3) hoshin kanri (policy deployment), building discipline around planning (goals and the means)
• 10:40 Ted: Have you had to adapt the lean management model to fit into a healthcare environment?
• 11:00 "Copy the thinking and the philosophy, not the tools".... "What's the tool you can use? Your Brain!"
• 11:30 Focused on providing the right care at the right time, rather than relying on technology (or relying on "tried and true" technology)
• 12:15 "Lean Thinkingblew my mind, everything had a corollary in medical care."
• 12:30 "Toyota puts a lot of care and compassion into building cars, and so do we in taking care of people."
• 12:48 "There things we don't want flexibility around" - certain medical situations that call for standard care
• 13:20 How did GHC try to get physicians on board and participating with Lean? "Patient at the center of care" is easy to get agreement with
• 14:00 "We want to take care of patients, and this helps you do it better... the system is more responsive."
• 14:42 James: Are there advantages to being an integrated delivery system? "Our opportunity is so much greater..."
• 16:30 Ted: "If it can't be done at Group Health, it can't be done anywhere."
• 16:50 Can GHC create more value through proactive or preventative health measures, ala TPM?
• 17:20 The goal is "lifelong health for our members... working with patients before they get sick."
• 17:45 James: What have the benefits and results of the Model Line area been?
• 18:35 ThedaCare and John Touissant showed great humbleness even with their success
• 19:00 Doing as many kaizen events as you can wasn't enough." Wanted to fundamentally change the leadership model, not the "all knowing and all doing" with the staff "checking their brain at the parking lot."
• 20:00 The VP over the HPA area fully embraced Lean and change himself20:45 Had a rigorous, step-by-step method of teaching the skills and doing daily practice. The biggest change was getting the middle managers and VP to change the way they interacted with supervisors, that was the foundation for the operational changes (workcells, etc.)
• 22:00 Lee: RPIW's changed the thinking of a lot of folks, but it didn't get high enough to change the behavior of the leaders
• 22:50 Changing core thinking before changing core processes has led to better sustainment
• 23:10 James: Where GHC hopes this goes... the Model Line needs to be a model to learn from, applied in other areas, forcing the organization to think more about value streams and less about traditional budgeting processes
• 24:00 GHC now has a place in GHC to see lean (as opposed to continued visits to Genie or Virginia Mason Medical Center)
• 27:00 What kind of feedback are you getting from employees about Lean? (lab example)"This is the most amazing experience I have ever had in all of my experience at Group Health"
• 29:00 Ted on helping doctors and professionals meeting their goals
• 30:00 Lee: it can be hardest on the middle managers, having to change their ways

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.

Click here for the main LeanBlog Podcast page with all previous episodes.

A Defect in My Morning Coffee Routine

I could have also titled this post "I screwed up!" or "Who Screwed Up? Me!" but we try not to point the finger of blame in the Lean mindset.... it's especially uncomfortable when you have to point it in the mirror.

I was trying to make a pot of coffee, same normal routine as usual. I got back out to the kitchen to pour my first cup and I noticed something was wrong. I hadn't pushed the filter basket all the way back in to its place above the coffee pot. Coffee had spilled out and all over the counter, leaving a mess and effectively ruining the pot of coffee (although the coffee that DID get into the pot was a surprisingly drinkable rich espresso type sludge). I won't claim I created "value" there.

The coffee pot was somewhat error proofed in that the pot has a "stop and serve" feature, a physical interlock that stops the flow of coffee when the pot and basket aren't engaged properly. But, with the basket out, water still flowed from the main reservoir and mixed with coffee grounds, flowing out over the basket edge onto the counter. The error proofing wasn't 100% sufficient (nor was it designed for that process defect, I'm sure).

Now looking back to prevention... is this an error I'm likely to make again? I don't know... I've made coffee hundreds of times on that maker and, if I made that mistake before, I don't remember it. Should I put up a large sign that says "Be Careful! Don't forget to snap the basket completely into place?" I'd argue no. Signs aren't effective error proofing and the world would be very visually cluttered if we to put up a sign for every possible thing that could go wrong (although lawyers might find that to be a good idea). That's often we react to problems in the workplace -- let's put up a warning sign!

I could make a "checklist" that I walk through every time I make coffee to make sure I don't miss a step. Airline pilots (thankfully) have checklists that they HAVE to go through every time, regardless of how experienced they are.

I'll skip the 5 whys analysis since you might be sick of reading about this by now. I think my final conclusion:

Error proofing should protect us from our worst days.

Most of us don't think it's going to be us who makes the mistake. But if the mistake is possible (not error proofed), then it's likely to happen to most of us or any of us.

Everyday Lean on TV in Denmark

From blog reader, Peter, in Denmark:

Hello again Mark.

Half a year ago I reported on a story in Denmark concerning Lean in the kindergarten.

Now I am bringing you new news!

The Danish television show "Rabatten," which translates into "The Discount," is dedicating a lot of next week's show to the idea of "Lean" and especially, since this is the idea of the show, how families can use the "powers" of Lean to improve efficiencies in their homes!

If you want I can report on it when it has been broadcast Thursday the 3rd of May.

"The Discount" is viewed by an average of around 650.000 people, which translates into about 13% of the population. It is a show generally concerned with how you can save money in your household, and also involves testing of various products.

On this link you can read (in Danish) the teaser for next week's show.

And here is the homepage for the show.
-------------------

Thanks Peter! Let us know what you see and maybe you can share some pictures or video from the show, somehow.

Clarifying Lean vs. Frugal

By Dan Markovitz

There's been some confusion over my recent post criticizing the Business Week article on Toyota's "frugality." I do not believe that Toyota is frugal (read: "cheap"). Rather, I believe that the company is simply focused on value.

The distinction I make is subtle, but I don't think it's trivial. Here's the way I look at it: frugality (or cheapness) makes cost-cutting the goal, rather than the means to the end -- which is to deliver the most value to the customer.

As I mentioned in my earlier post, if Toyota really wanted to cut indirect costs, they'd close down their dormitories instead of just turning off the lights. The dorms are not adding any value to you or me when we buy a car, except insofar as they help the company develop competent workers. And (in my mind, anyway) that's the road you'd take if you were just interested in cutting costs/being frugal.

Kirk Paluska, an instructor at the Lean Enterprise Institute, once pointed out that lean isn't a cost-savings strategy; it's a cost-avoidance strategy. That's a subtle distinction, too, but I think it gets to the heart of the difference between frugality and lean.

Avoiding costs is a strategy that places the customer and value front and center. Cutting costs puts the income statement front and center. And once you start doing that, you're on the road to layoffs, outsourcing, and all the other productivity-improving chimeras that so many companies chase.

A Lean Perspective on Employee Shortages

I heard a great comment on Monday from a hospital President.

He said, quite passionately, I might be paraphrasing slightly:

"We don't have a shortage of nurses and other workers. What we have is a shortage of good management systems, like Lean."

His point was that if hospitals, nationwide, could reduce wasted motion and wasted effort, that we'd have enough nurses. Nurses spend a very high percentage of their time on things not directly related to patient care. Imagine your assembly line shutting down because operators are leaving the line to go get their own parts and supplies. That happens all the time in hospitals, taking nurses away from patients and value added care because we don't properly support them with Lean processes.

I was reading Bob Emiliani's book "Real Lean" last night on the plane and there was a great related comment in there (again, might be paraphrasing):

If employees truly are our most important asset, why do we allow so much of their time to be consumed by wasteful activities?

L.A.M.E.: Thinking Lean is about Low Inventory

IndustryWeek : When Not To Go Lean

Here's another concept of Lean As Misguidedly Executed. I could nitpick the title of the IW piece, from page 51 of the May 2007 issue, for being misleading. For a publication that promotes Lean and always has a few articles about Lean, the headline writer didn't get it, I think.

A quick glance at the headline might make you think, "So Lean Isn't Always a Good Strategy?"

Better headlines for this column, which DOES make very good points, might be:

• "Lean isn't about low inventory"
• "Low inventory might cost you"
• "Losing sales is waste too"
  

The author quotes Professor Marshall Fisher, of Wharton, then adds his comment (in bold):

"If your product lifecycle is short and unpredictable but you have high margins, then overproduction may not necessarily be the most expensive planning mistake you can make." A far bigger mistake, he says, is to lose sales on a full-priced product that turns out to be more popular than you forecast. If you're producing consumer electronics, fashion apparel, books or DVDs, for instance, lean may not be the best way to go.

The author is the one bringing the word "lean" into the discussion, not Dr. Fisher. That is the mistake in the article. Lean is not equal to "zero inventories." Sure, inventory is a form of waste. Having excess inventory is a type of waste. I learned early in my lean career, from a Japanese sensei, that the first goal is to not shut the line down. "Then, low inventory."

Lean is more about total business effectiveness than only one particular metric. If the value of lost sales in a fast-changing or high-fashion industry is higher than the waste from excess and obsolete inventory, then keeping inventory too low might put you out of business.

This is a different dynamic than the auto industry. In 1998, I did a six-month internship at a Kodak division that made semiconductor chips for high-end digital cameras. Before I arrived, someone had the idea that Lean meant getting rid of the buffer inventory between the semiconductor fab and camera assembly. Because the fab (like any fab) had long lead times and highly variable quality yields, they couldn't keep from shutting down camera assembly. The chips were relatively inexpensive and the lack of inventory was keeping Kodak from selling $10,000+ digital cameras to photojournalists. Low inventory was killing them and hurt their business very severely.

My master's thesis (non-printable version linked here or I'll email it to you if you really want to read it) established a framework for determining the right inventory levels to avoid a pendulum swing in the other direction (such as "inventory solves everything.") Not too little inventory, not too much -- the right amount is needed. That's "Lean" to me. In the thesis, I describe how you can't take things like long lead time or variable quality as a given. You have to fix the "root causes" of the need to hold inventory. Inventory itself is a symptom.

Lean isn't just about any one tool (kanban or 5S) or any one goal (low inventory). Lean is a total business system and a management system. It's best to understand the concepts and philosophy rather than just blindly copying the goal of low inventory.

Do you "Embrace your Misses?"

Another great thought from David Mann this week was highlighting how a Lean culture will "embrace it's misses" rather than try to cover them up.

His example was in the context of a production line not making it's production goal for a 30-minute time frame. Do you make excuses for why it didn't happen or do you consider the "miss" an opportunity to fix a problem?

We had a similar discussion in the context of using "near misses" to drive process improvement. I posed the example of how a nurse might catch, at the last minute, the error that the wrong drug (or wrong dosage) was nearly administered to a patient. I asked, "Do you hide that error or do you embrace that and figure out how things could have gotten that far? Sure, you caught the error next time, but what if you're not so lucky the next time?" We need to fix the root cause problems that led to the error and the near miss so we can avoid future near misses or future negative outcomes.

An experienced healthcare person in the room pointed out, "Many nurses would look at that scenario and say 'see, the system worked, we caught the error."

We have to re-train ourselves to realize that a "process error" is anything that goes wrong and could have been prevented, not just an error that causes harm to somebody.

Darn Big Pieces on the Darn Big Loader

Big pieces of Boeing's 787 Dreamliner arrive | Seattle Times Newspaper

This is really Kevin Meyer's issue at Evolving Excellence, but I can't resist blogging about this myself.

Boeing is often hailed as a Lean company (or at least they have Lean factories), but here's an illustration what seems like a non-Lean supply chain. Here's a giant 787 wing being unloaded from the giant "Dreamlifter" supply chain transporter that Boeing had to invent (a modified 747) just to move wings from Point A (Italy) to Point B (refueling in Scotland) to Point C (delivery in Washington). I think this link to a custom Google Map will work.

The 42-foot-long frame carrying the tail pieces slid out of the Dreamlifter on a specially built 118-foot-long, 110-ton loading machine. During its development last year the loader was referred to inside Boeing as the "DBL Project," for Darn Big Loader.

The DBL's laser-guidance system lined up precisely with the holding fixtures that secure the 787 sections inside the Dreamlifter. It took 55 minutes, from the tail cracking open until the tail parts were completely out.

With floodlights illuminating the scene, the hold of the Dreamlifter seemed almost empty at first -- so small was the load compared to its capacity.

Laser guidance systems? Load was small compared to the plane? Holy Overprocessing, Batman? I'm sure a lot of engineering goes into this just to make sure the parts aren't damaged during transport, right?

Compare this to the 777 supply chain (I'm waiting at the airport to board a 777 right now):

For the 777, Boeing makes the horizontal tail from the same material in Frederickson, near Tacoma.

Can someone explain why Boeing is building these in Italy instead of Washington? Instead of right next door to the 787 assembly building? Toyota's new factory in San Antonio has plenty of on-site suppliers building parts, like seats, in a true just-in-time fashion an hour or two before being loaded into a car. Now I realize a horizontal tail is more complicated than a car seat, but still, it makes me wonder.

Eventually, believe it or not, the supply chain gets more complicated in the future:

It's expected that once the flow of 787 sections is running smoothly, the tail section will not fly directly to Everett but travel along with Grottaglie-built fuselage sections that must go to Charleston, S.C., for assembly there.

Every time I post about Boeing, I get a testy email from someone saying, "you don't know what you're talking about with aerospace." That may be true, but I think these are fair questions to raise. When I was at MIT, I saw Jim Womack speak, 1998 or so, about how he was fired by Boeing for complaining too much about their long disjointed supply chains (and that was in context of moving parts from Kansas!).

Who can explain the rationalization or the tradeoff that led to Boeing's supply chain design?

LEI Response to "Lean Killed Rover?"

Check out the comments below this earlier post to see an initial response from the Lean Enterprise Institute's Chet Marchwinski. He promises a lengthier response from Womack and Jones after they have had a chance to read the book that claimed lean is a "myth" and that there were flaws in the research behind "The Machine that Changed the World."

Lean and Green at Toyota San Antonio

MySA.com: Business:

Following up on the Lean and Green theme, from the new San Antonio Toyota plant:

"'Muda' is the Japanese term for waste. Toyota does not believe in muda, which is why San Antonio's plant is so clean and why very little trash ever leaves the plant or its suppliers for landfills.

Everything is recycled, from water in the paint shop to the leftover steel after sheets are stamped into parts. That helps the environment, of course, but it also saves costs. The savings add to Toyota's large cash reserves that the company uses for design, planning and marketing."

More Notes on the Business Week Article

Toyota: A Carmaker Wired to Win:

Dan Markovitz beat me to the punch, but I also wanted to comment on some things in the article:

The article says:

"Visit any Toyota plant in Japan, and it's easy to grin at the Orwellian factory banners emblazoned with exhortations such as 'good thinking means good products.'"

I saw signs and slogans when I toured NUMMI a while back and I wondered about the influence that Deming had on Toyota. Deming railed against slogans and signs, since they often caused resentment among workers. Signs like these are weird and Orwellian and are bound to cause frustration. Maybe the Toyota signs are OK because:

1. They focus on thinking (I don't recall a sign or a manager at GM, pre-Lean plant manager, telling employees to think more)
2. If Toyota management can back up the signs with consistent action and practice day to day, then the signs won't be as frustrating, right?

The Toyota Production System, or the ""Thinking Production System" does appear to be pretty consistent in its goal of developing good thinking and good problem solving skills. In my discussion with David Meier yesterday, he kept emphasizing how TPS is about good problem solving and good thinking more so than the typical "Lean tools" we know and use.

I have a question about this:

"...to learn the Toyota way of double- and-triple checking parts and processes for trouble and immediately signaling to superiors when things go wrong."

I understand that it's the Toyota Way to immediately signal (andon) when a problem occurs, but is it really the Toyota Way to double and triple inspect? I guess this is different than traditional "end of the line" inspection, where having multiple inspectors might be counterproductive (each person thinks the other will catch something and lets their guard down). Toyota inspection involves error proofing, checking your own work, and checking the work of the previous operation. I guess that adds up to two or three inspections in a way that's more constructive (and provides better process improvement feedback loops).

What are your thoughts?

Lean Is Not "Frugal." Lean Is "Value."

By Dan Markovitz

BusinessWeek online joined the rest of the media in noting that Toyota just passed GM as the global leader in auto sales this quarter. The article covers all the usual points, and to its credit, does add a few words about lean. But the author goes off-track when he states that,

Toyota workers value frugality—whether it's turning down the heat at company-owned dormitories during working hours back in Japan, or spending weeks jawboning with suppliers to figure out ways to redesign a key component and shave another 10% from production costs.

Clearly, the author is trying to address the issue of muda. But he misses the point: Toyota (and the employees) aren't trying to be "frugal." They're not trying to save money.

Rather, they're trying to eliminate the waste in their operations -- from the production line to the dorm rooms -- that the customer doesn't value. Hell, if Toyota really wanted to save money, they wouldn't have company dormitories at all. They'd let employees take care of their own housing.

From this perspective, "frugality" isn't the goal at all. Frugality is simply a by-product of the focus on customer value.

Toyota Tops GM in Sales

Toyota topples GM as global sales leader - USATODAY.com

It's been long expected, but the day is finally here: Toyota is now the global sales volume leader:

Toyota Motor sold more cars and trucks worldwide than General Motors in the first three months of 2007, marking the first time that Toyota has outsold GM.

Most auto analysts have predicted that Toyota will surpass GM this year as the world's largest automaker — a position the Detroit behemoth has held for 76 years. Toyota's global sales for the January-March quarter rose 9% to a record 2.35 million. GM reported last week that its global sales rose 3% to 2.26 million vehicles.

Does this help us in the Lean world? I'm not sure. Does it do anything more to validate the Lean/TPS approach? Not really. Does it validate Toyota's success? People already knew Toyota was successful and that TPS.

It *may* be helpful if the articles about Toyota's new #1 position emphasize, or at least mention, that Lean and the Toyota Production System are a major part of their success. I'm guessing that the articles might focus more on what GM has done wrong or the excuses that GM makes. Toyota long ago passed GM in profitability. That's really the measure that matters.

Here is a roundup of some articles on Toyota's new #1 sales position:

• NPR (audio and text)
• NPR analysis with Micheline Maynard, New York Times Detroit bureau chief
• MLive.com (GM says profitability is more important than sales volume)
• ABC News
• CNN/money.com
• NY Times
  

As a Lean practitioner, does this day matter to you or is it a "who cares?"moment?

Update: Great minds think alike, Kevin Meyer just said "who cares?" on Evolving Excellence

"Toyota Talent" out April 29

Amazon.com: Toyota Talent: Books: Jeffrey Liker,David Meier

This has been an exciting week for me. Monday, I met David Mann, author of Creating A Lean Culture, in person and had a chance to hear him speak and to speak with him at length. As I've mentioned before, his book is outstanding and has really been having a positive impact on folks in healthcare who are working to move from "Lean project" to "Lean culture."

Today, I was able to meet and talk with David Meier, another friend of the blog, sometimes poster, and co-author (with Jeff Liker) of The Toyota Way Fieldbook and the upcoming Toyota Talent. I was fortunate to read a preview copy of Toyota Talent and I'm sure it will be a very useful addition to the lean library. I'll try to post a formal review ASAP.

Both Davids were generous with their time and their thoughts, which I appreciate. I'd encourage you to check out their Podcasts (linked to their names above) and their books.

Lean, Green, and God

BeliefWatch: God Is Green - Newsweek Beliefs - MSNBC.com

This article struck me today, not exactly like a lightning bolt from the sky, but it struck me.

The Newsweek article talks about a growing movement among a number of churches, synagogues, and mosques to be more environmentally conscious and "green."

"Last year, Prestonwood Baptist Church, a conservative megachurch in Plano, Texas, enlisted the help of Energy Education, Inc. to help with its efficiency problem. Prestonwood, which caters to a Sunday crowd of 26,000, has four separate buildings and a million square feet of usable space. Its monthly utility bill was $250,000. "The Bible says, 'Let nothing be wasted'," explains Mike Buster, Prestonwood's executive pastor. "The Bible commands us to be good stewards of all of our resources. To be able to save money and use it for ministry and missions—I was very concerned with that." Seven months into the program—which consists of training staff to turn off lights and computers and rearranging program schedules to maximize efficient use of buildings—the church has saved nearly half a million dollars."

This is probably the first time religion has come up here on the Lean Blog. It's one of those topics you don't bring up at a polite dinner party right? When we think of waste reduction as a core concept in the Lean approach, that's something that can apply to everybody, even a church (or a building used by any faith).

Now the article isn't calling this a "Lean" initiative. But who knows if it was inspired locally at a church, synagogue, or mosque by someone who was exposed to Lean concepts at work? Or maybe because some Lean concepts can just seem like common sense. "Don't waste resources" - good words to go by if you call that "Lean" or not. Mom and Dad used to say "turn the lights off when you're not in the room."

My headline comes from a combination of things I've seen over time. Toyota has been linking Lean and the Toyota Production System to goals of environmental stewardship, "Lean and Green" some call it. Lean "zealots" often get branded with terms and phrases that invoke religion (not always in a positive way).

Anyway, it's interesting to me to see what might be a confluence of these worlds: Lean, environmental protection, and religion. I'm not a radical environmentalist, to say the least, nor am I trying to convert anyone to any particular religious faith. Anyone who knows me would probably say I'm more passionate about Lean. People in healthcare (hospitals are often faith-based), often refer to their work as a "calling." The same might be said about Lean??

L.A.M.E.: Thinking Lean is About Speed, not Quality

A blog reader, Tom, sent me a PDF of a column from the ASQ "Quality Progress" magazine, the April 2007 issue. The article is "Using Lean to Meet Quality Objectives," by Dale K. Gordon. The ASQ website has a link to the article here or you can download the PDF using this direct link.

I think the ideas in the article represent "L.A.M.E." (Lean as Misguidedly Executed) in the sense that the examples of "Lean" given don't seem very Lean to me at all. I always cringe when people talk about Lean being only about speed and efficiency or only being about cutting costs. Dale makes the case that Lean is about eliminating waste (it is) and that many companies choose "either defect reduction or lean manufacturing."

Dale says:

"Quality objectives and lean methodologies must work in tandem, not as discrete activities."

It's hard for me to imagine how a company would be truly working on Lean without focusing on quality and defects. It's possible if the company is more L.A.M.E. than Lean and they are looking only for quick payoffs such as headcount reduction.

It's hard to copy and paste from the PDF to here, so I'll reference the start of sentences...

"Lean improvements, or blitz kaizens performed in a vacuum..."

Of course it's bad to use Lean to only speed up the production of highly defective products. That's more L.A.M.E. than Lean. Creating a cellular production structure that relies on final inspection, instead of error proofing, doesn't sound very Lean either, but that's another kaizen event that Dale suffered through.

Anyway, this column is discouraging, if the American Society for Quality is sponsoring columns that say Lean and quality are different concepts, then I have to wonder about how much Quality is built into the ASQ thinking and publications. Is this an isolated case, an individual's author experiences with L.A.M.E., or is it indicative of the thinking at ASQ in general? What do you think?

Iacocca's Nine C's of Leadership

USATODAY.com

Former Chrysler chief Lee Iacocca has "failed" at retirement, he says. His latest project is a new book, Where Have All the Leaders Gone?. The book has made waves because of the political content (not the focus here), but he's also provided a list of leadership traits, something that I think is relevant to discuss here on the Lean Blog.

The "Nine C's of Leadership:

• Curiosity
• Listen to people outside the "Yes, sir" crowd. Read voraciously.
• Creative
• Go out on a limb. Leadership is all about managing change.
• Communicate
• A simple one. You should be talking to everybody, even your enemies.
• Character
• Having the guts to do the right thing. If you don't make it on character, the rest won't amount to much.
• Courage
• Courage in the 21st century doesn't mean posturing and bravado. Courage is a commitment to sit down at the negotiation table and talk. If you're a politician, courage means taking a position even when you know it will cost you votes.
• Conviction
• Fire in your belly. You've got to really want to get something done.
• Charisma
• The ability to inspire. People follow a leader because they trust him or her.
• Competent
• Surround yourself with people who know what they're doing. Be a problem solver.
• Common sense
• Your ability to reason.
  

I can see all of those being good traits for Lean leaders, as well. Be careful, maybe, with "be a problem solver." Lean leaders don't try to solve all of the problems themselves, they encourage and support their employees to solve problems themselves (when possible) and then stepping in with "solutions" only when necessary (such as cross-functional or value-stream level problems, for example). We don't need Lean leaders to be "heroes," fixing everything themselves. Then again, being a problem solver is usually better than accepting and tolerating a bad status quo.

2007 Lean Accounting Summit "Agenda Reveal"

GoToWebinar : Link for Webinar

Click on the link above for a free web seminar about the upcoming Lean Accounting summit, including two good friends of the blog, Norman and Jean:

Lean Accounting Summit organizers are hosting a free webinar in which the 2007 Summit agenda will be revealed... live! Why join us? You'll hear from Brian Maskell, Jean Cunningham, Mark DeLuzio, and Norman Bodek!

Mini Lean Carnival

Here is a mini "Lean Carnival" of some interesting blog posts I saw last week:

Here's a nice overview of the 5 Whys and Root Cause problem solving:
Shmula on asking "Why?" 5 times

Mike Wroblewski had an excellent picture of a "Kaizen Wall" in his blog post.

I've seen this method used at a previous company, but most of the pages were from "kaizen events." I think this method is MUCH more powerful when you are capturing "daily kaizen", or small improvements that come about through somebody's suggestion.

Taking quick action on the improvement and then documenting that improvement once it's been confirmed as helping (and standardized as part of the new process) is a valid improvement method. We don't have to rely on formal events. I've also started experimenting with this method at a hospital, to post our small improvements (things on the scale of moving a printer so that it didn't shake some nearby test instruments that had been on the same bench).

I don't have children, so I'm not really qualified to comment on Jon Miller's use of an A3 problem solving process to help get his kids to pick up their toys. His post prompted some discussion amongst some parents, mostly positive. Does this problem require something like an A3 method? Is this a good parallel to the workplace problem of employees not following standard work? I know people try to claim their workplace is like a family, do we want to treat our family like a workplace?

Productivity: Industry vs. Health Care

I don't know the source on the data, but I heard a hospital President today talking about his hospital's Lean journey. He said:

"Manufacturing productivity has increased 3% every year since 1980. In health care, we have LOST 2% productivity each year."

He spoke passionately about the need for Lean in health care, for the sake of quality, for taking care of patients, and for stemming the increases in health care costs.

As he talked about the need for more health systems to adopt lean, he concluded with:

"Our children will be paying for our wasteful methods [if Lean isn't adopted more widely."

I Stand Corrected

Are We Creating Problems By Design?: Beyond Blinking Lights and Acronyms

Mike Schaffner's "Beyond Blinking Lights and Acronyms" blog linked to my complaining about the lack of root cause problem solving during a tech support call. I proposed that the tech support department didn't care about fixing the root causes because that ensured some job security.

That probably wasn't the response that would have ranked highest on the "respect for people" scale.

Mike insightfully writes:

I don't agree with Graban's assumption. All the Tech Support people that I've ever met at many different companies have all been very dedicated and truly interested in helping their callers. I have yet to see any Tech Support people that wanted to perpetuate the need for calls just to protect their jobs. If there was ever reluctance on the part of the Tech Support folks to get a problem resolved I believe that it was due to a sense of futility.

Early on they've no doubt tried to get a situation, such as the one Graban encountered, truly fixed only to be stymied by lack of resources, prioritization processes and a cumbersome bureaucracy. After trying that a few times they learned that it was futile to try to fix the problem so they do the best they can to repeatedly help users as the problem occurs again and again.

Mike is right. I didn't mean to blame the individual tech support worker for "not caring." I'm sure it was frustrating for her to keep getting calls about the exact same systemic problem. I can understand her frustration in maybe trying to get it fixed, for real, the first time and then being "beaten down" into giving up.

I empathize with call center employees who are typically measured on strict quotas for call length or calls per hour metrics, metrics that don't allow them to do quality work the way they might otherwise want to.

Lean Killed Rover?

Driving on the wrong side of the road -- the myth of Japanese efficiency in car manufacturing

A new book is out attacking Lean. Or maybe the book is actually attacking "L.A.M.E.", or "Lean as Misguidedly Executed" at Rover. This is Rover, the car company that failed and went out of business in 2005 after earlier being taken over by BMW. This is not the Range Rover brand, that was purchased by Ford from Rover previously. Ford also then bought the Rover name and intellectual property after their failure. It sounds like the company had a number of long-standing marketing and quality problems in their attempts to compete with Jaguar, BMW, Mercedes, and the like.

The book, The Myth of Japanese Efficiency by Dan Coffey, says the "just-in-time" supply system at Rover destroyed its manufacturing flexibility, increased its production costs, and fueled hostility within its factories towards its marketing plans. Its publication will reopen the debate over the collapse of Rover just as car production resumes at its Longbridge factory under Chinese ownership.

The findings are based on the author’s extensive field research including independent and detailed participative research carried out within Rover Group itself.

"Lean" shouldn't decrease flexibility. Toyota plants are incredibly flexible, as the BBC also wrote about.

Lean shouldn't increase production costs. Toyota is a low cost producer, which leads to very high profits.

The researcher did "extensive" research within the Rover Group. Does that mean this book is helpful only for those within Rover? Or is there something transferable to those outside?

Without reading the book (it's $100, so it's not a high priority purchase for me), it's hard to see what conclusions the authors are drawing. Is it a problem with HOW Lean was implemented at Rover or does it highlight problems inherent to Lean?

I'd guess it's the former (HOW "lean" was implemented). Too many of us have had first hand experience with successful Lean implementations to want to blame Lean for Rover's problems. We also know that Lean Failures are far too common, even the most vocal Lean proponents (such as Jeff Liker) will admit that.

The book isn't just trying to point out what went wrong at Rover, they are trying to expose a "myth" of Lean production. It's hard to understand how somebody can take something very visible and call it a myth. Toyota is measurably more successful than the rest of the automakers, including the Detroit Three. Toyota does things measurably different and manages people in a different way. This is a "myth?"

I don't have a problem with people questioning Lean practices, but I do have a problem with people calling Lean a "myth." This isn't Bigfoot we're talking about, it's a proven management and process improvement methodology that has been very successful outside of Toyota and outside of automotive manufacturing (and outside of manufacturing!)

The book will force academics to review the findings of the 1989 Massachusetts Institute of Technology (MIT) survey of the global car industry, which gave birth in the first instance to the notion of ‘lean production’.

The MIT survey found Japanese plants enjoyed much higher labour productivity advantages than could be explained by investment in automation.

Dr Coffey shows the methodology for this revered research project was flawed both because of how the data was interpreted statistically and because it omitted overtime work in the index of labour used.

As a real-world Lean practitioner, I could honestly care less that "academics" might have to re-think Lean. The Lean cow is out of the barn, it's been proven in the real world.

I emailed Jim Womack and asked him about this book. Jim had heard of the book, but didn't know any details about the case it was making. I then asked Jim about the claim of omitting overtime data and I haven't heard back from him yet.

As Japanese imports made significant in-roads into Western markets in the 1970s and 1980s, this was more easily explained by finding a fictional manufacturing revolution.

This really makes me wonder if the researchers visited Toyota, to compare Rover and Toyota, or if they visited any sites of Lean success stories. This is not a "fictional" revolution. That sounds like the excuse-making talk of people who failed in their lean implementation and the researchers who parroted their claims.

The book has received praise from academic experts from across the world. Writing from the world-leading Stanford University in the US, Professor Sarah S. Lochlann Jain describes the book as "of exceedingly high calibre" and predicts it will make a "critical contribution to the literature on the automobile industry".

I'm not sure professor Jain knows about manufacturing or Lean. She's a cultural anthropology professor. Now, Jim Womack was a Political Scientist, but it's easy to argue he has made quite an effort to learn about manufacturing. I'm not sure if Professor Jain did anything other than read the "Myth" book.

The book's table of contents includes:

1. Introducing the Myth of Japanese Efficiency
2. Wide Selection / a Myth Encountered
3. Production Malapropisms: the BMW-Rover Group Controversy
4. Lean Production: the Dog That Did Not Bark
5. Back to the Future - the Reorganization of Work at Toyota
6. Rivalrous Asymmetries and the Japanese Myth
7. Rethinking Lean Thinking: Substance and Counterfeit
8. The Totalising Myth: Japanese Efficiency as a Cultural Fiction
   

Fair and balanced? If someone has $100 to throw around and wants to read this book, please report back to us.

Just as Bad in Canada

globeandmail.com: Private sector health care: Think quality, regulation

I don't think healthcare and quality is a "Private vs. Public" debate. As we'll inevitably have debate during the 2008 U.S. Presidential election, I think it's important to keep quality in mind (not just cost and access). Side note, electing a President sure is a "long lead time" process, we've already started the process here in early 2007.

In Canada, they have a single-payer government healthcare system. Canada is suffering from the same types of medical mistakes and patient deaths that are commonplace here in the U.S.

Canadian Institute for Health Information (CIHI) statistics show that as many as 24,000 people die each year from avoidable events like surgical errors, wrong medications and hospital-acquired infections.

These types of estimates are often questioned. The number thrown around for the U.S. is 98,000 avoidable patient deaths (Institute of Medicine's "To Err is Human" report). Assuming the Canada numbers are accurate, keep in mind that Canada's population is about 1/9th that of the U.S. So, either the per-capita avoidable death rate is worse or it's roughly the same scale.

Glossing over the details of "unknowable numbers," I think it's fair to assume that we have the same results from the very different systems in the U.S. and Canada. We shouldn't necessarily expect that a shift from one to the other would help, right?

The Canadian columnist I've linked to makes her case about standard work and quality:

A recent Auditor General's report estimated that one of every nine patients admitted to a Canadian hospital will become infected. Listening to hospital administrators doesn't exactly inspire hope. A televised response from the head of a Montreal hospital where patients died due to a particularly nasty C. difficile outbreak stated that he would "try harder" to get doctors and nurses to wash their hands between patients. And a B.C. regional health authority recently spent $130,000 on a campaign to "remind" staff about the importance of hand washing.

Try? Remind? If you were running an airline would you "try" to get the ground crew to properly service the aircraft, or "remind" the pilots to go through the final checklist just before they pushed the throttles forward? Of course not. You would require adherence to standardized safety procedures on a zero-tolerance basis.

The biggest difference is that pilots are employed by the airline, while doctors, in the U.S., are usually not employed by the hospital. I'm not sure if that's the case in Canada (does anyone know? please comment).

My question: Not that we want to lead with "firing people" as the first step, but has there ever been a case of a doctor getting fired or losing their privileges for bad hygiene?

David Mann had some good thoughts on standard work and hygiene recently.

Always Room For Improvement

By Andy Wagner:

I had an internal factory tour that reminded me of Mark's recent blog on the Not So Lean Factory Tour. The plant was not nearly the horror story Mark experienced, and in fact, it was one of best examples of lean that I've seen in my company. That said, based on some of the things expressed by this plant's leadership, I think there must be "12-steps" separating a true lean mindset from the oft present "LAME" mindset.

The first step, of course, is admitting that you have a problem, which the folks in the factory that Mark visited were not ready to do. The factory that I toured passed step one with flying colors, but their motivation shocked me. It took a near fatal accident performing routine maintenance on a machine to convince them to take lean seriously. The root cause analysis determined that the technician could not access the machine in a safe way due to the clutter packing the entire floor of the facility. Their first 5-S measures were dedicated to preventing this kind of serious safety problem by clearing out the extra carts, racks, toolboxes, and equipment and making the factory floor a safe place to be. As I said before, shocking, but thank goodness they were willing to commit to meaningful corrective action.

The second step: learning that continuous improvement must be continuous. They haven't got this one yet. The GM, professing to be a true convert to lean, told us all about their "5-year plan to lean the plant." I politely declined to ask the rhetorical question about what he intended to do when the 5 years are up. (By then, he'll be promoted to his next gig). In fairness, his 5-year plan represented prudent "hoshin kanri." The plant was organized functionally, so the initial plan was, over the course of 5-years, to move machines around into value stream oriented cells. No other machining plant that I've seen in my company has had the lean commitment or foresight to do this. Looking at the results two years into the process, I have to applaud it. Their inventory turns are approaching double what I've heard for similar facilities. Cycle time has had a similarly significant drop. Still, on the floor, I'm amazed at some of the clutter, the extra racks, the extra inventory. And the inventory turn numbers aren't very impressive compared to Danaher or Toyota numbers that I've read. I would hope they're willing to continuously raise expectations.

Accounting was another area where I was struck by some of the GM's comments. He was understandably oriented toward the financial numbers by which he is measured: direct labor productivity, keeping base hours up to reduce his labor rate. Unfortunately, as folks like Bill Waddell and Kevin Meyer continue to argue, none of these metrics drive you toward a lean and effective plant. By lean accounting standards, they're measuring the wrong things, and only through very diligent effort, able to justify doing the right things despite their incentives.

It was great to see a facility in my company doing as well as this one has, but at the same time, it mostly stoked my hunger to go farther. There's always room for improvement. That's step two.

Krazy Kwality Posters

I really dislike motivational posters, particularly those meant to inspire quality. I guess it comes from the early Deming training/indoctrination and having been around too many environments where Quality meant a poster that said "Quality is YOUR Responsibility." Posters are harmful when the point fingers at workers who don't have total control of a situation (such as those faced with using cheap parts bought by procurement) or when the posters send a different message (quality is important) than what non-lean management emphasizes (keep moving the metal and shut up).

The only posters that have value to me are the cynical "Demotivators" line from Despair Inc, including this gem about the value of motivational posters, that says:

"If a pretty poster and a cute saying are all it takes to motivate you, you probably have a very easy job. The kind robots will be doing soon."

Now the posters pictured here (click on them for a larger view) aren't meant to be ironic or funny, at least that's the appearance of it. They're all from a website that appears to sell legitimate safety supplies. Unfortunately, they've decided to add some "quality" posters to their site. Most are puzzling if not unintentionally hilarious. I stumbled across them looking for some bad motivational posters to use for facilitating a version of Deming's "Red Bead" exercise. To the left, Charlie Brown attempts to assemble a doll that hasn't gone through the Design for Manufacturing Process.



Stalin says "Get back to work, comrade!!!"

Really, is a poster like this supposed to help?









Good thing the Pharaoh finally came out to the desert floor to inspect their work. I wonder how many pyramid builders tried to "stop the line" but were whipped instead? Pharoah Stalin says "Get back to work!"










Is this almost an illustration of a stable, but incapable, process?











This is how Stalin punished workers for producing bad quality, apparently.

I wish I had something more profound to say to wrap this up, I think the posters pretty much tell the story themselves. Posters do not lead to quality. Does Toyota rely on posters like this? I doubt it.

Certification and Quality

Modern Healthcare Online (article available to subscribers only, March 12, 2007 Issue)

I think it's been true in the manufacturing world that quality certifications, such as ISO-9001, aren't necessarily predictors of world-class quality. I've seen it be far too easy for bad factories to get ISO certification. Companies play the game, they put together their binders, they coach their employees how to pass the certification, and their sole ISO focus is getting that certificate (as opposed to using the methodology to actually drive improvement).

The same dynamic is often true in healthcare, not surprisingly, maybe. Hospital labs have regular certification cycles with the same common dysfunctions as ISO.

Modern Healthcare magazine writes about the "Joint Commission" accreditation for hospitals and how some recent quality problems have occurred in accredited hospitals, including Walter Reed and West Texas Hospital (a specialty hospital where employees had to, on 15 occasions, call 911 to get patients moved to other hospitals for emergency care).

Dennis O'Leary, President of the Joint Commission says:

O’Leary defended the value of his organization’s accreditation, but acknowledged that the process has its limits. “Accreditation is not a warranty that any organization is perfect,” he said.

True. The burden isn't on any certification or accreditation organization. Quality is an ongoing process that is management's/administration's burden. As a customer/patient, don't take quality/safety for granted just because all of the right certification tickets have been punched.

We can't expect outside inspectors to catch every systemic process problem, as the article explains:

At Walter Reed, the problems may be linked to the accreditation process’ focus on clinical areas. Dean Samet, director of regulatory compliance services at consultancy Smith Seckman Reid and a former Joint Commission associate director, said it wouldn’t be uncommon for a building like the one affiliated with Walter Reed to not be included on the survey list. Whether any of the Army hospital’s staff mentioned the building’s condition during the overall accreditation survey is unclear—but also unlikely. “To be quite honest, the staff normally wouldn’t be airing their problem areas” to surveyors, Samet said.

Typically, Joint Commission surveyors focus first on the main clinical areas, such as inpatient and ambulatory-care settings, Samet said. “Time permitting, they may try to do a random sampling of some of the other areas,” he added. “But that’s only time permitting.”

Ticking off the checklist, Samet said that surveyors need to focus on emergency management, sentinel event alerts, compliance with the National Patient Safety Goals and, at the base level, the ever-changing Joint Commission standards. “That typically keeps surveyors pretty busy,” he said.

Of course employees aren't going to bring up problem areas. When the management focus is on "pass the inspection," speaking up in the name of solving a problem would probably only bring punishment down on yourself. Employees should be bringing those issues up to management first, ideally. And, ideally, management should be helping address those issues independent of any inspections/certifications.

Paul Keckley, executive director of the Deloitte Center for Health Solutions, Washington, noted that it’s generally accepted that Walter Reed’s problems are on its ambulatory side while the Joint Commission is more geared toward assessing acute care, but that the Joint Commission is probably getting “a spotlight it deserves” and that—at times—it “has been its own worst enemy.”

What these scandals illustrate is that “you can do all the right things to get accredited, yet there can be systemic problems in your organization,” Keckley said. “I think (the Joint Commission) made a couple changes that are significant in the past 18 months. That said, I still don’t think the Joint Commission is as significant a force in quality and safety as it should be.”

What are your experiences with certification and quality, in manufacturing or other industries? Do people just try to "pass the test" or use it for real improvement?

LeanBlog Power User Tip #1

In addition to my "Standard Work" for creating the blog, there are some good practices to share as a blog reader. Here's one.

If you're interested in following just a particular topic and having email updates sent to you, follow this process:

1. Go to a "label" specific page, such as http://www.leanblog.org/search/label/Healthcare
• Labels are found at the bottom of some posts and clicking on a label will bring up all posts that have that label
  
  
2. Use the Blogarithm service to "watch" the page (click on photo for larger view)
   
   
   
   
   
3. Blogarithm will email you updates whenever JUST the healthcare topic is updated, for example
   

You can also use Blogarithm to track the main page at www.leanblog.org, or use an RSS to subscribe.

Have any other "power user" tips to share?

Ford: Quality equal to Toyota

Detroit News Article

In terms of initial vehicle quality, Ford Motor Co. is in a statistical dead-heat for second place with Japan's Toyota Motor Corp. and Nissan Motor Co., according to a new study the Dearborn automaker plans to release today. Honda Motor Co. is the quality leader.

There are other quality measurements beyond initial quality:

In terms of initial vehicle quality, Ford Motor Co. is in a statistical dead-heat for second place with Japan's Toyota Motor Corp. and Nissan Motor Co., according to a new study the Dearborn automaker plans to release today. Honda Motor Co. is the quality leader.

It's nice to see Ford making quality improvements. As Deming might have asked, "By what methods?" Is the quality improvement a design effort (DFSS or Design For Six Sigma, maybe?) or a production quality effort, possibly driven by Lean methods?

As GM has complained about, it takes time for customer perception to catch up to reality.

And dealers say improved quality is helping bring customers back into their showrooms.

"We're not seeing the recalls after the launch of the vehicles like we used to," said Tim Mullahey of Mullahey Ford in Arroyo Grande, Calif. He said rampant recalls in the 1990s did immeasurable damage to Ford's brand image. Now, he and other dealers are touting Ford's recent quality improvements in their advertising. "The problem is really one of perception. We're trying to overcome the stereotypes."

Merger in the Lean World

DemandPoint

From their Press Release:

Pelion Systems, a market leader in Lean Manufacturing Operating Systems, and JCIT International, the pioneer of award-winning Demand Flow® Technology (DFT), have entered into an agreement to merge companies and create a new organization focused on enabling Demand Flow Fulfillment for customers. The combined entity will be known as DemandPoint. Terms of the deal were not disclosed.

DemandPoint leverages Pelion and JCIT's combined expertise in operational excellence and business process optimization driven by Lean and Flow principles. The objective of the combined company is to dominate the market for demand-driven fulfillment strategies that improve cash flow and working capital by streamlining the value chain and collapsing the order-to-cash cycle.

Together, Pelion and JCIT offer a proven methodology and technology framework for tying an organization's business model to its operating platform and linking all operational activities to customer demand. This involves not only manufacturing but all of the functional units involved in executing an order, including sales, marketing, procurement, distribution, logistics and finance.

Dave Gleditsch, featured in an earlier LeanBlog Podcast, remains with the combined company:

Dave Gleditsch, who drove several very successful Demand Flow implementations during a previous tenure at JCIT and architected a software platform based on Flow principles over the past six years as Chief Technology Officer for Pelion, will lead the company's Education arm as dean of the Demand Flow Institute

A New Sponsor: American LED-gible, Inc.

American LED-gible Products

I'd like to welcome American LED-gible (www.ledgible.com) as a sponsor on the Lean Blog.

About the company:

American LED-gible Incorporated has been in business since 1976 providing process control solutions for the workplace. We are a small, family owned and operated business. Manufacturing is done here in Columbus, Ohio.

I'm certainly happy to be promoting a company that is committed to American manufacturing. They told me many of their competitors are importing products, while they are remaining in Ohio. I asked American LED-gible if they indeed use their own products for supporting Lean production in their factory. Their response:

Yes, we use our products for different operations on the production floor.

• Timers for wash time, clean up, testing,etc.
• Production pace timers goal vs actual for pacing PC board fabrication/stuffing, wave soldering,etc.
• Light indicators for process complete indication,etc. (mainly qc/testing)
• LED alphanumeric boards for general data

As a Lean thinker, you will probably recognize the need for andon boards, takt time indicators, and other visual controls for a Lean factory (or any Lean environment, such as a hospital laboratory).

Look for their ad below in the left column and check out their products. Stay tuned for an exciting LeanBlog Contest. Thanks to American LED-gible's generous sponsorship, we'll be giving away a black 8 Gig iPod Nano (pre-loaded with all episodes of the LeanBlog Podcast, or a CD of them, your choice). Stay tuned for how to enter.

Click on the "Contest" link for some previous LeanBlog contests. This one will be another "submit a Lean story" type challenge.

Technology Is Key, Toyota Exec Says(?)

Chron.com - Houston Chronicle

The question mark was my addition to the headline. I wonder if this what the motivation behind this comment from Toyota's Jim Press was, saying "technology is key" or if he even said it at all.

"...a high-ranking Toyota executive said Tuesday that technology and innovation have the industry well-positioned for long-term growth."

I think the headline might have been a bit misleading, on the editor's part. Technology and innovation certainly are important for Toyota, looking at the Prius and manufacturing process innovations that have grown markets and reduced costs.

But to sum it up as "technology is key" sounds something more like a GM or Ford comment. Toyota normally talks about people and employees being key, how technology is something to support their people, not the primary driver. I doubt that's really changing, regardless of what the headline said here.

What do you think?

Lean Diaper Changing

Sean Michael's World: Lean Diaper Changing

This isn't from first-hand experience, believe me. Here's a post that linked to me from the blog that's tracking a baby who was born just two weeks ago. Dad is a Six Sigma black belt, but it sounds like he's getting into Lean and applying it to the baby.

I love how Dad has done his best to define "value" in the baby's terms:

Sean is our customer. What's valuable to him is a clean diaper change as fast as possible. As we organize the changing table and process, it should all be designed to deliver that clean diaper efficiently. Change Sean when he needs to be changed. Keep trying to do it better.

My first attempts were clumsy, at best, as I figured out the process. Undress, open diaper, cover Sean with a cloth, apply baby wipe, apply clean diaper, re-dress, calm screaming infant. It took a few tries to learn that:

• Sean really only complains when he is getting undressed. Try to minimize the amount of time that he is undressed, i.e. arrange all materials before undressing him
• Sometimes the cold air has an effect on him - cover him with a cloth to prevent an unpleasant accident.
• Those baby wipes are cold! Heat them up, will ya? (Best $23 we've spent so far)
• Get that diaper closed properly (one blow-out brought this error to my attention)

Without getting out the stopwatch, I think we're down to about 60 seconds for the whole process. Take that NASCAR pit crew (another excellent example of Lean).

A nice example of Everyday Lean! He's practicing "external setup" by having everything prepped (5S-ed even?) before undressing the baby.

Out of Step: What's Important to Standardize?

Ironically enough, the drummers in this photo are out of step. One is forward with the left foot, one is forward with the right. As a drummer and former marching band member (8 years in high school and college), it's embarrassing to find a stock image with the drummers out of step.

So what's my point? This came up the other day in a discussion about "what do we standardize?" As with many lean methods, a risk with "standard work" is that we start using the tool for the sake of using the tool. "Let's go standardize things!" might be the rallying cry without stepping back to think "why?"

I'd argue that we should focus first on standardizing work methods that impact safety, quality, on-time delivery, or cost. If we have something we can standard, we should ask first "should this be standardized?" and "what will the benefit be?" If the benefit of standardizing the location of tools on a surgical tray is a reduced risk of grabbing the wrong instrument, then that should be standardized (and it probably already is). You don't have to FORCE people to standardize when they see benefit to it.

Thinking back to the example of the UK Office 5S effort (corrected link 6:39 PM), was there benefit to standardizing the location of a stapler? I'd argue not, especially if it's not a shared workspace. There's probably much more important waste to be attacked first. Now, in a hospital lab, where a stapler is part of a shared work process that many people participate in, there might be value in marking the stapler location, so people aren't searching for it and delaying the processing of the lab paperwork.

I think it's a matter of context. We're not looking for excuses to NOT standardize. But, we're thinking about "what should we focus on first?" in our standardization efforts. The purpose of standardization is to reduce waste and to do a better job for the customer.

Back to the marching band analogy. In band, there are many things we standardize because it looks good visually in a parade or on the field:

• What foot we step with first (always the left)
• How big our steps are (22.5 inches if you're marching in traditional "8 to 5" style, 8 steps for every 5 yards, a method invented at my alma mater)
• How we turn, etc.

In the marching band context, it was VERY important that we all took that first step with the left foot and you always "hit a yard line" with your right foot. It probably didn't matter which foot went first, as long as it was standard.

In a non-marching band setting, whether in a factory or a hospital, will "standard work" go to that level of detail, telling employees which foot goes first? Of course not! It doesn't add any value in that context.

If you start standardizing things for the sake of standardizing (including 5S-ing for the sake of 5S-ing), you'll run the risk of looking silly and alienating your employees who will wonder why you aren't helping them go after the real waste in your system. Ask them what needs standardizing, as opposed to telling them (as an engineer or manager) what you think needs standardizing.

Quick Changeover for American Airlines Center

Juggling act sets up rink

Even though I'm still a pretty die hard Red Wings fan, I live in Stars country now. Don't ask me what I'll do if the Wings and Stars meet in the second round. I went to the Stars/Canucks game last night, which started at 8:30 PM central. I was surprised when, while putzing around the house Sunday, I saw the Spurs/Mavericks game on TV and realized it was also being played at the American Airlines Center. That left them only about 3.5 hours between the end of the NBA game and the start of the NHL game. Somebody had to hustle!

They showed a stop-action video of them taking down the basketball court and taking the cover pieces off of the hockey floor (I wish that video was online). This link shows a timeline for the conversion from hockey to basketball.

The article I linked to above had some details, including:

When the teams cleared the court, Waugh and a group of 60 went to work at precisely 5 p.m., peeling away 4x8 pieces of hardwood, taking down goalposts and removing spools of ABC TV cables in preparation for Game 3 of the Canucks-Stars playoff series.

"Normally our changeover is 40 people but we wanted more because it's a playoff game," Waugh said.

After the court was off, the ice deck was on with 15 minutes.

The crew finished at 6:28 p.m., making the total time of the job 1 hour 28 minutes -- in plenty of time for the 8:30 p.m. start.

"That's pretty good. Our fastest time last year was 1:55," Waugh said.

While we don't always want to "throw people at the problem," adding people CAN be an appropriate "quick changeover" strategy in any context. I'm not suggesting the Stars or the arena management are trying to be "Lean," but I'm trying to draw a parallel for the manufacturing world (or healthcare, for that matter).

60 people should be able to do the changeover work faster than 40, assuming you haven't reached the point where they are starting to get in each others' way. Taking the standard work for the floor/rink changeover (assuming there is so) and adding 50% more people should cut the time by dividing the work content into smaller pieces (assuming it can be divided evenly and can be done in parallel). There certainly would be a "bottleneck" or constraint step in the changeover process that would limit the changeover speed.

Other than adding people, what could you do to shorten the changeover time?

• "External Setup" -- do as many prep activities BEFORE the end of the NBA game as possible. Are all tools and equipment ready to go? You want to externalize setup activities so you don't waste time looking for things (or moving things unnecessarily) while the changeover is actually taking place (time during the changeover is called "internal setup."
  
  
• Identify the bottleneck step and speed it up, through some method
  
  
• Practice, practice, practice: Move up the learning curve through repetition and continuous improvement of the process (like a NASCAR pit crew) -- after each changeover, have the team debrief and discuss what went well and what didn't (and what to improve). I guess that's really the "PDCA" cycle at work.
  

Any other suggestions?

Is 88 minutes a "world class" time? It met customer expectations for last night (although I'm sure the ice WAS horrible).

Here is an article about the Pepsi Center (Denver) process for changeover. They always play hockey first when they have a "double header" out of concern for the quality of the ice. I guess Denver is more of a hockey town and Dallas is more of a basketball town (ignoring football, since it's April).

They have some standard work methods for putting the cover over their ice:

As they bring out the pieces of the cover, it looks like the conversion crew is working on a giant jigsaw puzzle. The crew, however, has a cheat sheet of sorts. The rounded pieces that cover the outer perimeter of the ice are numbered and stored in order. Once those are laid down, the rest of the pieces of the cover are the same size.

This video isn't exactly the same process, it's for an arena in Peoria, IL.

Dwight Bowen Podcast with Pascal Dennis

Lean Thinking Network | Competing Podcast » Interview with Pascal Dennis Part 1

Pascal Dennis interview Part 2 – Operations

Dwight Bowen, someone I consider a friend of the Lean Blog, has a two-part interview with Pascal Dennis, author of the book Getting the Right Things Done (my previous posts on the book).

Dwight is the President of the Lean Thinking Network in Pennsylvania, his main website is www.leanthinkingnetwork.com.

Dwight and I were both on the "Lean Roundtable" version of Ken Rayment's "Better Process" Podcast, back in September and earlier in April.

What Will You Do Differently Today?

By Dan Markovitz
Back in October, Lifehacker ran a lengthy article on "personal kaizen." The thrust of the piece is how we can improve our lives by adopting the kaizen approach of the TPS and applying it to our own work habits.

It's not worth nitpicking some of the author's misunderstanding of kaizen, and the confusion with other lean principles like error-proofing or eliminating waste. While he's certainly not ready to write a scholarly treatise on lean, he does touch on something very important: that kaizen can apply to every aspect of how we work, even the small, seemingly insignificant (or ancillary) aspects of our work habits.

There's a tendency to think of kaizen as a massive, stop-the-assembly-line "event" during which we make gigantic improvements in the company's operations. And certainly there's value to the kaizen blitz. But relying upon a "blitz" for improvement often means ignoring the value that the steady accretion of small changes can bring.

The author points out, for example, how he looked at his system for handling email and improved it so that he didn't lose urgent or critical emails:

You might introduce a folder flow. You're all email wizards by now, so this is just an example. You might have an inbox and an urgent box. You set up a filter so that all email marked urgent go into the urgent box, and all others sit in the inbox. You set aside five minutes every hour, right before you refill your coffee cup, to deal with the urgent items as quickly as possible-- you want that coffee, right? And twice, right before lunch and before you leave for the day, you clear out the inbox, reading and dealing with all items that weren't marked urgent. Easy and simple, with process improvements and thinking built in.

And here's another example of how he constantly fiddles with the way he stores information -- phone numbers, contact names, links to websites he finds valuable -- so as to improve his ability to find what he needs quickly:

A few months back, I started using GTDTiddlyWiki. It's packed with features, and I've found a number of them that I like very well-- really, it's just a canvas on which you can design your own process improvements and workflows. I store lots of data there. I back it up by sending it to my Gmail account. I'm continually tearing apart my system of hyperlinks and reconfiguring them in ways that make more sense, are simpler and easier. It took some time getting used to it, but that single, free HTML document ended up being my killer app, and I would miss it terribly. Now I use it every day, and using it is unconscious. I don't have to think about what I'm going to do with a phone number or a contact name. I don't need to wonder where I wrote that little idea. All that thinking is inbuilt.

All he was trying to do was make his life just a bit easier, and without realizing it, he hit on key elements of 5S, of waste, and of standard work.

Whether or not his system would work for you is irrelevant. What's important to note is his constant fiddling with his personal work system. He's attempting to make his job a little bit simpler, so that he can do his job a little bit more easily.

Have you examined how you work recently? Do you lose time looking for information -- or worse, actually lose the information itself? Do you start a task -- an email, a budget review, a press release -- and lose track of it behind six other windows on your computer -- and then, when you rediscover it, you realize that you forgot what you were going to write? Do you wake up at 2am remembering a phone call that you didn't make?

These are symptoms of problems that you can solve, with a little bit (okay, maybe a lot) of kaizen. Look at those annoyances and ask the Five Why's. Think about how you can improve your work habits to eliminate those problems. Just like problems on a production line, all these issues are simply opportunities to improve your work process and do your job better.

In a Fast Company article on Toyota, journalist Charles Fishman noted that a typical Toyota assembly line in the United States makes thousands of operational changes in the course of a single year. He adds,

that number is not just large, it's arresting, it's mind-boggling. How much have you changed your work routine in the past decade? Toyota's line employees change the way they work dozens of times a year.

And he's right, of course. Most of us handle memos, documents, phone calls, emails, meetings, interruptions -- all the forms in which information flows through us (and our office) -- the same way today as we did last month, last year, and three years ago. While we've been planning our upcoming kaizen blitz in the factory (or the hospital or the insurance office), we've forgotten to look at our own work habits to see what we could improve. And that's really the essence of kaizen.

"That's What We're Here For"

My main point here I think is "Tech Support should NOT be part of the normal process."

I needed to register for an internal company tech support website (for teleconference support) and was trying to log in to the website. I have a card here with the following info:

• Owner Name
• Owner Number
• Conference Code
• Leader PIN
  

To log in to the website, it asks for "Owner Name" and "Password." Since nothing I has says "Password" I tried the "Leader PIN." Didn't work. It says "If you are visiting here for the first time, click on forgot password." The "forgot password" screen wouldn't recognize me as a valid user, so it was time to call tech support.

Turns out, tech support had to give me a 4-digit "Web PIN" to be able to start the registration process. I went to another screen and created a "User Name" and "Password."

I got kicked back to the main screen, the place that says "Owner Name" wants you to enter the "User Name" or it doesn't work (these are two different things).

I said to the tech support rep, "You know, the website is very confusing. I'm good with computers and I couldn't figure it out because things are labeled wrong on screen and it seems every new user has to make a tech support call, which costs us all money."

The tech support rep was sort of irritated and said, "Well sir, that's what we're here for."

I told her, "It shouldn't be that way, I'm just trying to help, if you don't want to do anything to fix the website, then fine."

I can't imagine the tech support rep passing any of this along because, in a way, the poorly designed and poorly implemented website is job security for her and her co-workers. Fewer tech support calls probably means somebody loses their job.

It's too bad that organization can't have everyone on the same team in a way that improves quality (and reduces cost) for the company and the customers. How many people tolerate a bad process out of self-interest and/or fear? Management's job is to create an organization where people aren't paralyzed by fear, where they aren't punished for doing the right thing.

Thoughts on Driving a Prius

Car Keys Could Go the Way of Tail Fins - New York Times

So I've finally become a Toyota driver, driving an employer-provided Prius for over a month now. Answer to the first question I usually get, 42.9 MPG is what I'm getting (and that's mostly "around town" driving).

Second question, yes it's an ugly car. It's homely and odd shaped (for aerodynamics). But, it's also distinctive -- some of the features I find "ugly" can't have anything to do with aerodynamics (the tail lights). Is the design partly to be a rolling Toyota-awareness machine? It could be uglier.

Generally speaking, it's fine to drive. It's small, so I feel somewhat over matched on Texas roads, but it's peppy enough and is surprisingly OK to drive. Nothing to rave about, but not horrible.

Some of things that have jumped out at me early. First, was the imperfect delivery experience (my license plate frame problem) that I blogged about already.

Second is the process for starting the car. Starting a car is a somewhat standardized experience (with exceptions like Saab's quirky key location). With Prius, Toyota has changed pretty much everything about starting a car, which can be disorienting. I linked to the NY Times article about wireless key fobs -- my Prius does not have the "leave the keyfob in your pocket" feature. So here is the process for starting mine:

1) Insert keyfob into dash. The keyfob slot is strangely spring loaded. So, if you don't insert the keyfob far enough, it springs back and flies out of the slot. I've done this twice and, each time, the keyfob has flown and landed between the driver's seat and the center console, landing under the seat in a spot that's not so fun to reach. I'm not sure why it works this way, the springiness, and I haven't figured out how to "error proof" it other than to "be careful," which isn't effective error proofing.

2) Push the "Power" button. I don't really have a problem with this, but it's a somewhat awkward reach (I usually use my right hand, but I was taking the picture with my right hand). It got me wondering "what if I was left handed?" Not as irritating as #1 though, nor is it as puzzling as #3, below.




3) The picture shows the gear shift. Again, it's not the typical approach. Many people have asked (included a valet parking guy), "What does B mean?" It reminds me of the time Homer Simpson was buying a cheap Russian car and the salesman told him "Put it in H!". "B" is like a "low gear" mode, I was told, for driving down a mountain. For the life of me, I couldn't figure out what "B" would signify. It means "Brake" mode apparently, which operates like "low gear" but Prius only has one gear. Living in Dallas, I won't be coming across mountains.

The other thing that threw me off a bit (and I've gotten used to thankfully), is pushing "forward" (up) on the shifter for reverse and pulling "back" (down) for driving forward. Is this because "D" is usually down in the shifter after reverse? Maybe that's a dumb thing to worry about (and I'm sure an automotive engineer reading this can correct me). Update: This was questioned two years ago on another blog.

When you put the Prius in R, there are beeps to indicate that you're in reverse mode (like a large truck, I guess). But, the beeps aren't audible outside of the vehicle, where it would actually be helpful (since the Prius is pretty quiet when in battery-only mode, such as just starting out). It would be more helpful as an external beep (especially since many drivers turn off the beep, given this choice of websites that show you how).

My only other comment is that the driver's floor mat is wearing pretty quickly, pieces of fuzz are coming up and off of the carpeted mat. Doesn't seem like it was designed for much use.

Anyone else have comparable Prius experiences? Toyota might have had very good reasons for changing the car starting experience. But, at what point is it better to stay with an older, imperfect standard, as opposed to coming up with a new one? Does that conflict come up at all in your daily work?

The Lean Blog is now Fully on www.leanblog.org

I've made a major transition in the hosting of the blog, the "kanban.blogspot.com" name and pages are now automatically forwarded to "www.leanblog.org."

Any old pages or links now automatically forward to the proper www.leanblog.org page. For example, what used to be "http://kanban.blogspot.com/2005/05/what-is-lean.html" is now "http://www.leanblog.org/2005/05/what-is-lean.html".

One favor I would ask is that if you're a blog that has my site in your "Blog Roll," please update the URL to point to www.leanblog.org.

I apologize for any temporary glitches that might occur during the transition. If you get a "404" error, hit "reload", that has fixed the problem for me. I'm hoping that is just temporary.

While this might be confusing in the short term, I"m hoping it is ultimately less confusing in the long term. My branding will match the domain name that appears in everyone's browser address bar. Many organizations block the "blogspot.com" domain, so hopefully more people will be able to access the blog from corporate PC's (any "time wasting" that occurs is a Standard Work issue between you and your manager).

Update 11:30 am: www.leanblog.org is working, but leanblog.org (without the www) is not working currently.

Update 12:29 pm: it's now working, even without the "www." RSS feed is updated and should still be working. If you're an RSS reader, you shouldn't have to change a thing. Let me know if there are any problems.

Group Health Cooperative's Model Line

DailyKaizen » Where the coffee is free - The Model Line Revealed

Here is a preview of the "Model Line" area that Lee Fried, Dr. Ted Eytan, and James Hereford will be discussing in an upcoming LeanBlog Podcast.

The Group Health Cooperative is an organization that provides insurance AND treatment, which provides some interesting "extended value stream" opportunities. Their model line area is in a claims processing function with 700 employees. From their examples, you can tell they are really trying to use Lean in a significant operational manner, not just as a superficial exercise.

They are using hoshin planning and A3 reports, as well as a heijunka box to help manage and monitor workflow.

There are mother A3’s and baby A3’s on one wall. Lee shows me the current state and the future state. One wall is about successes. Another is about the competition, the voice of the customer, and “on the horizon.”

I am then walked over to claims processing, where there is a heijunka box on display. Lee asks me, “Ted, can you tell me if anyone is behind.” I can. I can tell that most of the team is not behind, and that some are at lunch, at a glance.

As their headline suggests.... and the coffee is free! I assume this is more important to folks in Seattle than in other locations?

I should be able to get the Podcast out in a week or two, stay tuned for updates.

Potential Downtime: Transitioning to www.leanblog.org

There have always been two ways of reaching the Lean Blog, either through http://kanban.blogspot.com or the easier-to-remember http://www.leanblog.org. The leanblog.org address has previously just forwarded to the kanban.blogspot.com site (which maybe is confusing for some first-time users).

Over the weekend, I'm going to attempt to transition the entire site to run off of the www.leanblog.org address. All of the previous links and pages on the site should automatically forward.

There might be some downtime over the weekend here. if you're a blog visitor who has typed "www.leanblog.org" into your browser. Wish me luck with the transition. Ideally, it should be pretty transparent to you, the blog reader.

Update 10:32 am, "leanblog.org" is still forwarding to kanban.blogspot.com now but "www.leanblog.org" is not. I'm still working on the full transition over to pages appearing as leanblog.org.

Update 10:54 am, it all appears to be working! Hooray for having a decent standard work document to follow.

Toyota's Convis to Retire

Press Named to Toyota Board - The Car Connection

Toyota's Gary Convis, a leader who I have admired greatly, is retiring in June:

Toyota also announced that Gary Convis will retire in June from his positions as a managing officer and chairman of Toyota Motor Manufacturing, Kentucky, Inc.

There is a quote from Convis that I often use in training sessions and presentations:

“You respect people, you listen to them, you work together. You don’t blame them. Maybe the process was not set up well, so it was easy to make a mistake.”

Hopefully he can do more to educate us about the Toyota leadership mindset after his retirement.

Click the "Convis" link below for more articles that feature him. Best wishes to Mr. Convis in his retirement.

An Important Application of Personal Kaizen

Comprehensive Drug & Alcohol Treatment Facility is First of its Kind in the State

Former classmate and blog reader Chris and I always used to joke about "PDCA-ing your life." Maybe it's not that funny, but we were at MIT.

The article I've linked to here is no laughing matter, the application of PDCA principles to help treat addiction:

The use of orthomolecular therapy and the inclusion of aftercare aren't the only features that distinguish Arche Wellness from other treatment facilities, however. They also utilize the Toyota Production System's philosophy of "Kaizen," or continuous improvement, to help achieve success. In other words, the program is an ongoing cycle of planning, implementing, refining and analyzing. Clients undergo repeated testing and therapeutic trials to fine-tune their treatment.

PDCA or PIRA, it's still the same approach. I'd be interested to learn more about how they learned about TPS or how they thought to apply it to addiction treatment.

Jim Press to be named Toyota Director

asahi.com : Toyota to name first foreign director

Congratulations to Jim Press:

Toyota Motor Corp., seeking to add an international flavor to its management, will appoint a foreign national to its board of directors for the first time, sources said Tuesday.

Japan's largest automaker will name James Press, the American president of Toyota's subsidiary in charge of North American operations, senior managing director, the sources said.

It harkens back to a year ago, when a couple of us (myself included) got into it with Bill Waddell about his characterization that Toyota was "racist" for having a board that was 100% Japanese. Bill isn't blogging actively anymore to be able to defend himself, but maybe he'll pop up and say something.

Confirmed today by the Detroit Free Press.

A Non-Lean Management Style

I know the WSJ is making a joke and satirizing it, but here's a classic example of non-Lean management to share. How would a "Lean Dog" involve the sheep? :-)

Lean & Six Sigma Traps to Avoid

Article Link

Thanks to Ron for sending this article my way. Check out his excellent blog post on the difference between being fast and "playing fast," tying the football idea to manufacturing (although I'm hoping my Wildcats can finally beat his Buckeyes again soon).

This article talks about failure modes for Lean and Six Sigma (check out my "Lean Failures" blog while you're at it, maybe).

Trap #2 is listed as: "A Few Hours of Training Is All Employees Need" and it goes on to talk about 3 to 5 day kaizen events, without mentioning that "Relying on Kaizen Events to become Lean" could also be listed as a "trap."

Today, I recorded a Podcast interview with a group of leaders from the Group Health Cooperative in Washington state, authors of the excellent Daily Kaizen blog. One point they made was that kaizen events ("rapid process improvement workshops") only got them so far. They had to move on to a more systemic approach to Lean as a management system. Stay tuned for that Podcast in the next few weeks.

Trap #4 is listed as "Housekeeping is for Sissies." Nice phrase, but I wish we could stop referring to 5S as a "housekeeping" initiative. 5S is a waste-elimination process, pure and simple. I do agree with this quoted comment:

"If you've set up your 5S program properly, you should be able to find a place on the floor where you can stand and just by looking you can tell if things are normal and going as planned," says Tompkins.

That's what 5S is about -- reducing waste and making abnormal conditions readily visible (thanks to Jamie Flinchbaugh for often making that point).

Nice Lean Healthcare Overview

Business Report - Toyota production system has the cure for the industry's ills

Much of the material in this summary, by a professor who teaches a Lean course, has been covered on this blog before, but it's a nice summary of some of well-known Lean Healthcare success stories.

LeanBlog Podcast #22 - Allan Wilson, "Factory Logic"

Episode #22 of the Podcast is a discussion with Allan Wilson, CEO of Factory Logic, a software company that was acquired by SAP late last year. Allan is now the VP of Lean Manufacturing Operations for SAP. We talk about the role of technology and software in a Lean implementation. In the interest of full disclosure, I worked for Factory Logic a few years back, including time under Allan's leadership, but I have no financial interest in the company or products.

MP3 File (Right Click to Save-As)

Show Notes and Approximate Time, Episode #22

• 0:20 Background and history on Factory Logic
• 2:00 Using software to help standardize processes in a Lean factory, including Johnson Controls, a key customer
• 5:20 Value proposition for the software on the factory floor (now known as SAP's XLPO product, or "Lean Planning and Operations")
• 6:00 CONWIP (constant work in process)
• 6:20 POLCA (not the dance!)
• 7:30 The SAP acqusition of Factory Logic, what will the impact be? 12,000 manufacturing companies use SAP
• 12:20 The XLPO/Factory Logic applications will still integrate to other ERP systems
• 13:00 What about the mindset of having a choice between Lean and technology, that many Lean folks are against technology/software. What about the Toyota Way principle of using technology "that supports your people and processes"?
• 16:30 XMII definition
• 19:00 Are Lean people becoming more accepting of technology?
• 22:00 What are some of the examples where a large company struggles to roll out Lean in a consistent way across plants?
• 22:30 BTR = Build to Replenishment
• 24:00 Building a consistent Lean model throughout your global company

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. Click here for the main LeanBlog Podcast page with all previous episodes.

Yay! Lean is Popular

IndustryWeek : Ranking Continuous Improvement Methods

According to a recent survey of 745 companies, 40.5% of them say they are using Lean as a continuous improvement strategy. The number is higher if you include "Lean Six Sigma," "Agile manufacturing," and "Toyota Production System" in the responses.

Is it safe to say that companies that try to adopt Lean because it's popular are more likely to do it in a superficial way or to give up on it sooner?

I don't think it's fair to judge the validity of a strategy based on how popular it is. Theory of Constraints is a completely valid and useful theory, but the fact that only 3% of companies say they use it.... what does that mean, other than there's less of a market for T.O.C. books and consulting?

Job Opportunity with the "Dell Lean Model"

Lean opportunities coming to Central Texas

I've been critical of folks who lump Dell into the "lean" world, since Dell hasn't really done much according to the Toyota model (previous posts on Dell). Dell developed its own model, the Dell Direct model, and it served them well during their boom in the 1990's. There's certainly something positive to be said for developing your own model for your own industry and your own company. That obviously worked well for a while.

However, Dell has hit (relatively) rocky times in this decade, in some part, I think, from moving away from the direct production model (with PC's) to a direct selling model (with PDA's, printers, TV's who are built by others). Dell has struggled through cycles of layoffs , outsourcing, and internal struggles that have, I would suspect, hampered their progress as a company.

It's interesting to now see that Dell *is* looking toward Toyota methods, as evidenced by the job posted over on the Message Board (link above). Maybe it' s a positive sign. Note: it's not an open job requisition, but they're looking for future candidates. Contact info for a Dell contact is posted over there on the board.

It will be interesting to see if Dell can merge Toyota methods and philosophies into their own very strong culture and operating model. Is Dell looking for outside experts to "make them Lean" or are they really looking to impact the way line managers and company leadership operate? A job like that has the potential to be very impactful, but it could also be a road to perpetual frustration.

I won't necessarily share all of the stories here, but when I worked for Dell (1999-2000), I was frustrated at the lack of Toyota Production System mindsets and approaches in the factories. Dell was growing so quickly, it was very much a "move the metal" mentality, similar to typical mass production mindsets. Sure, internal factory flow was very good, but there's so much more to Lean than "flow." But, that was a long time ago at this point, so I'm not the best commentator on Dell circa 2007.

Free Peeks into Lean Books

lean - Google Book Search

A friend just tipped me off to this Google feature, the ability to view limited pages from books, including a wide selection of Lean books. This list includes Jamie Flinchbaugh's "Hitchhiker's Guide to Lean."

It's a great way to sample a book before buying it online.

New Blogroll Addition

Patient Safety Blog - Telling Our Stories

For those interested in health care and patient safety, here's a blog about patient safety. Not "lean" focused per se, but provides many stories that emphasize why lean, root cause problem solving, and error proofing are so important in that setting.

Not such a "Lean" Plant Tour

Since I’ve been working exclusively in healthcare for almost two years, I haven’t been in too many factories lately. I was excited to get an invitation from the local Society of Manufacturing Engineers (SME) chapter to tour a local factory. The company was described as a family-owned, private company that was an example of lean practices. I hoped this would be a very positive story. The great lean case studies featured here on the blog seem more likely to come from smaller private companies rather than large global public firms. For reasons you’ll soon see, I’m keeping the name of the company private.

One trait I’m trying to further develop is my “respect for people” hat, namely in the context of “respect for managers.” I don’t think I’m a complete “boss hater,” as Jack Welch puts it, but I get very frustrated with management because, as Deming taught, they are primarily responsible for quality and responsible for “the system” in which we work. In that vein, I’ll say a few positive things about the company and our tour to start:

• The company makes a wide range of products, ranging from small commodity items to large, custom-engineered pieces. There is some engineering know-how that’s worthy of respect.
• The company has zero debt load and gave the impression of being very profitable for the multiple generations of family owners (the 2^nd generation was in their 70’s with the 3^rd generation waiting in the wings).
• The General Manager pointed out how their China factories were for China customers, as their larger, more complex products could not be shipped from China to the U.S. because of the resulting slow response time and high shipping costs. The company’s goal is to be “the last ____ maker standing” in the U.S., given the competition and pressures from lower labor cost countries. There was a real commitment to U.S. manufacturing that seemed genuine, something I admire and appreciate.

That said, the tour got started on a very dubious note. As our SME leader was introducing our host, he mentioned lean. The GM of the host company shook his head and said, “No…. a lot of what we do flies in the face of your lean stuff,” spoken with the tone of voice that is dismissive of “our” lean stuff, as if lean and economics don’t apply to everyone.

What are the innovative ideas that fly in the face of “that Lean stuff?” First, the GM said, “You see, WE consider inventory to be an asset!” as if they were the first company to rely on inventory not just as a financial asset on the books, but also as an operational strategy. They certain had plenty of assets on board, as 100k sq ft of the 400 sq ft were officially designated as “warehouse” (and this is not counting the outdoor metal storage and the piles of WIP that were everywhere in the “production” areas).

Inventory was everywhere and the company embraced its batch production strategy. The factory ran on a typical mid-market MRP/ERP system. From peeking at some shop orders, I saw a lot of MRP work orders with blank process times, which means they were running “infinite capacity” MRP planning, something that’s outdated even for the MRP world. I also saw plenty of orders that were beyond their delivery date and showed typical MRP production patterns of one short value-added operation followed by days or weeks of waiting time before the next scheduled operation.

Batch production was driven by their factory layout – it was straight out of the mass production playbook: a functionally driven layout with identical machines grouped in their own large departments of similar like-minded machines. Travel distances between operations were long, I’m sure, which only encouraged the batching mentality. At that point in the tour, I couldn’t muster up the energy to ask why they didn’t try forming a trial Lean production cell. Even with the MRP and the bad layout and the large batches, they could indeed get an order out “same day” if needed (which proves it IS possible). But, same days orders came either thanks to a lot of WIP or a vibrant “hero mentality.” The GM explained how they normally work two shifts, but they’ll work all night if necessary to get a hot order out for an important customer.

Putting the MRP system in (because of Y2K concerns) “damn near killed us” because it was running so slowly and they lost a lot of the functionality that was in their old custom system (a common complaint of MRP/ERP customers). They claimed the MRP system allowed them to “accurately cost out” the production and setup time. Maybe I was unlucky in peaking at work orders that had zero times, or the costing isn’t as accurate as they think.

Even with custom products, the GM bragged about their batch production, how they determined “optimal” run sizes based on their set up times, often producing a “year’s worth” of the product and then shipping it gradually in small quantities during the year. I didn’t get a chance to ask why they hadn’t tried reducing their setup times so that they could produce smaller batches.

Many types of waste were rampant, including operators watching machines (it wasn’t quite one man per machine, but it was close). I did see one machine running unattended, at least. I felt particularly bad for one operator who was loading successive parts of a batch after first carrying the heavy metal part about 20 feet from the WIP pallet to the machine. Why nobody was moving the pallet closer to the machine is anybody’s guess.

There were, of course, huge banners with the company logo proclaiming “Quality is a Way of Life” and “Do it RIGHT the First Time!” (maybe they are also proud to fly in the face of “that Deming stuff”). After walking through the giant warehouse, our next stop was the large “Inspection Department,” which makes you question why they need it if they were doing it right the first time, as the signs demanded. One of the engineers in our tour group asked about a popular quality method and the answer back was “What’s Six Sigma?”

I recall a large Safety banner hanging up for all to see, but also saw a machine running without guarding and another a vertical turning lathe with chips piled up so high around it that it was bound to be a safety problem or a quality problem, I wasn’t sure which, but it looked awful. The machines were old (which isn’t bad necessarily) but they were also oil colored – either through some master plan to keep them from looking dirty, or they were just covered in oil, as was the floor in many places. You really had to watch your step or you’d slip in oil or trip over a pallet holding WIP.

Anyway, I’m not trying to exaggerate it. The factory was a mess. It was a mess that management seemed quite content with. It really made me wonder, which of these was the case:

1. Their metal-cutting business is such an “unsexy” business that they can afford to be inefficient and still make money

Or

2. The place was doomed, it was just a matter of time before they would lose all of the business, short of the most custom and most lead-time sensitive products.

As we left, the tour guide thanked the GM for touring us around. I was thinking “thanks for taking us in the time machine.” A tour member asked the GM, “What’s the secret to your success?”

The answer: “Inventory.”

I emailed the SME tour organizer afterward (not wanting to be rude while on site at the tour, a main reason for just keeping my mouth shut) and asked about the disconnect in what was advertised as a “lean” company tour and the non-lean reality. The answer I got back started with “I guess it’s a matter of perspective. I was quite impressed with their logistics….” I don’t want to badmouth SME as they do a lot of good work and publishing related to Lean, but the sense I got from the average SME member on tour with us was that they were fascinated with the details of each individual machine, but they couldn’t see the waste around them. I’m glad the SME is at least trying to educate their members about Lean.

So even though I’ve completely badmouthed the nameless company, I really do appreciate them letting me come in and tour their operations. If anything, it was a reminder that not everybody values what Lean can bring to them. I just hope that the company is able to learn about Lean before it’s too late. Should I have spoken up and pushed Lean more? Would that have ultimately been more respectful than keeping my mouth shut for the most part?

"Open Wide and Say 'Lean'"

By Dean Bliss (bio below)

At the recent Shingo Prize conference, I was reminded of the power of Lean. Not just because of the award winners, but because of a humble dentist who practices in Jacksonville, Florida. And who practices Lean like few of us can.

His name is Sami Bahri, and he has a practice with 3 dentists. He heard about Lean, and thought it could help his practice, which was experiencing scheduling issues, repeat visits for treatment, and other inefficiencies that were affecting his patients and staff. He read up on Lean - not just the usual texts, but many others, over 20 books in all. He looked at the tools - again, not just the usual ones, but many of them, including kanban, level loading, one piece flow, even SMED. And his results were astonishing. Not just the numbers (82% capacity increase for the dentists, 57% fewer visits by patients for a full mouth treatment), but the adaptation of the tools - many more tools than I had seen applied outside a factory environment.

His presentation on stage included a demonstration of flow - he had two dentist's chairs set up on stage, just like in his practice, and he and his staff simulated the flow of patients and caregivers through the process. It was a show-stopping presentation. So much so, that when one of my friends from Productivity Press said that Sami wanted to meet me (I was one of the few healthcare people there), I hesitated, because I was afraid he might corner me on a specific Lean tool application that I may not have known as well as he did!

I learned a lot from Sami, and I was reminded yet again that the Lean most of us learned in the factory works anywhere. The tools can be adapted to anything. And the philosophy is the glue that holds it all together.

So when we hear from our co-workers or clients that "Lean is a factory thing" or "Lean doesn't apply to us", we can be reminded of Sami Bahri, the dentist who decided to open wide and say "Lean."

+++++++++++++++++++

Dean Bliss is the Director of Lean Improvements for St. Luke’s Hospital in Cedar Rapids, Iowa. Dean is responsible for leading the Lean management process at the hospital and affiliated organizations. He joined St. Luke’s in May, 2005, after a 25-year career at Rockwell Collins, an aerospace and communications electronics company.

In addition to his Lean knowledge, Dean gained experience at Rockwell Collins in areas including Finance, Human Resources, Information Technology, and Facilities management.

Dean has a BS degree in Business Administration from Iowa State University. He has spoken at numerous Lean conferences and seminars throughout the country.

UPS Reducing Driving Waste

ABC News: UPS Figures Out the 'Right Way' to Save Money, Time and Gas

"Efficiency is so much a part of the culture at UPS..." UPS has always been known as an Industrial Engineering driven company. Here's an example of reducing driving waste:

Listen to driver Bert Johnson describe his route in Gardena, Calif.

"We're gonna make a right turn onto 135th to Western. We'll make another right on Western down to 139th," Johnson says. And he goes on, "Right turn on 139th and go down to the end of the block and we'll make another right turn."

You getting the idea? UPS plots its delivery routes to make as many right turns as possible. In a world where half the driving choices are left turns, they avoid turning left.

And how much of the time are UPS trucks turning right? Tasha Hovland, an industrial engineering manager, said, "A guesstimate, I would probably say 90 percent. I mean we really, really we hate left turns at UPS."

Would I call this "lean"? Sure. At least partly -- the focus on standard work and on eliminating waste is strong, which is a very good start. I wonder how much employee input they get into continuous improvement. Is it all driven by engineers and VP's?

Is there a mechanism for employee suggestions (no, not a "suggestion system")? See Chuck Yorke's column on harnessing employee ideas for more on this topic.

You Still "Gotta Ask"

IndustryWeek : Where Is Your Company's Next Big Idea Coming From?

Chuck Yorke was co-author, along with our friend Norman Bodek, of the book All You Gotta Do Is Ask.

In an Industry Week column, Chuck continues to make the case for companies to encourage employees suggestions. Harnessing that power, instead of relying on managers or experts to come up with all of the answers, is a powerful force, as Chuck explains.

Video: Boeing's Moving Line

Here's an interesting video showing Boeing's 737 line, moving at a takt time pace of 2 inches per minute.



Any thoughts from those in the industry about the pro's and con's of the moving line? Can you be "Lean" without a moving line?

Will Lean Outperform Bureaucracy?

Worldandnation: Scandal sires bureaucracy

It's too bad that the Lean Six Sigma component of the response to the problems at Walter Reed has been lumped into the category of "bureaucracy."

There are no less than nine blue-ribbon committees, task forces and review groups investigating soldiers' medical care, some of them with overlapping missions.

"Every time I turn around there is a new committee," said William Bradshaw, national veterans service director for the Veterans of Foreign Wars. "That's just overkill. Everyone is piling on."

I can understand that all of the task forces, committees, and "blue ribbon" panels might be just political posturing or blaming exercises. But, Lean efforts should really be doing something to fix the problems, right?

The article says:

Lastly, there's a "Lean Six Sigma" review. Tiger Teams and 15-6 investigations are military jargon for internal investigations. Lean Six Sigma is a performance review used in the business world to improve speed and quality of service.

Done right, Lean should be more than just a review of the problems. It really should be focused on kaizen and improvement. I would bet that whatever improvements are driven by Lean and Six Sigma might well be claimed as success by any of the politically-driven investigations, eh?

Government, Soldiers, and Backlogs

Worldandnation: Backlog has veterans waiting for disability claims

Here is a sad case of bad flow, an imbalance in demand and capacity, and the impact it has on our country's injured and disabled soldiers.

Nearly 400,000 disability claims were pending at the VA as of February, including 135,741 that exceeded the VA's 160-day goal for processing them. The department takes six months, on average, to process a claim, and the waiting time for appeals averages nearly two years.

We can only guess what the "Value Added" time in that 160 days is. I'm sure it's a very short process with amazingly long "waiting time" and queues.

The only thing that can solve the backlog is increased capacity (either through improving productivity in processing claims or adding people).

Little's Law very much applies, where Cycle Time = WIP / Throughput

To reduce CT, you have to increase Throughput. With an expected increase of claims (from the deployments in Iraq and Afghanistan), Cycle Time and WIP will only get worse if the VA can't increase Throughput to 1) decrease the backlog and 2) meet new higher demand.

This strained system may grow more overburdened in years ahead as many of the troops deployed to Iraq and Afghanistan return from those wars, experts say.

Ronald R. Aument, VA deputy undersecretary for benefits, acknowledged that the department needs to do better, but he rejected the idea that the delays and denials are motivated by money concerns.

"It's not as though we're working on commission here," he said. "There is very much a shared passion in this organization in trying to do right by veterans."

It's probably either 1) lack of funding or 2) gross waste in the existing processes, not any lack of effort or lack of caring on the VA's part. Here's an opportunity where Lean, or dare I say, "Office Lean" can help immensely. Instead of pointing fingers, let's fix the process.

TX Paper Accuses Mulally of Insulting Salespeople

Star-Telegram.com | 04/06/2007 | America’s Great Automotive Stuntmen

Local car columnist Ed Wallace seems like a friendly curmudgeon. This week, he writes about Ford's CEO Allan Mulally and his adventures at Village Ford (back in Dearborn). Wallace rightfully takes on the "hero CEO" image that the Ford P.R. folks are apparently trying to create. That seems to go against the Lean and Toyota mindset, but Mulally has a tough enough job ahead without us nitpicking (and it's not even worth the bother to nitpick his paycheck, or Mark Fields').

From the Wallace column:

“Four cars (almost) in 40 minutes. That’s the Alan Mulally sales tally at Village Ford in Dearborn.” — Automotive News, March 28, 2007 “I’d say ‘Hi, I’m Alan. I’m from Ford. I’m just helping out today.’ I got so close to one family …”
— Alan Mulally, from the same article

Here we go again: PR campaigns being sold as real news, as the new head of the Ford Motor Company innocently and unintentionally manages to insult everyone who has ever tried to earn a living in the automobile industry by selling cars. The only humorous aspect to this story is that it ran in a respected automotive publication, the Automotive News, to which every new car dealer in this country probably subscribes.

It’s humorous because I doubt sincerely that any dealer, reading that Ford CEO Alan Mulally dropped by Village Ford in Dearborn for a mere 40 minutes and made three sales (and has another pending), did anything but roll his eyes and groan at that outrageous claim. Why? Because even at the best-run dealerships it often takes 10 minutes just to find the keys to the particular automobile that the customer is interested in purchasing.

The article also invites a pertinent question: Why, if Mr. Mulally can easily sell four cars in 40 minutes, didn’t he stay at the dealership all day earning new customers for Ford? After all, the owner of Village Ford probably would have appreciated the additional 72 more sales on that one day.

Wallace also takes a slap at Bill Ford:

Reading these stories reminded me of a Fortune magazine cover from many years ago, during Bill Ford’s ascendancy at his great-grandfather’s firm. It was a close-up of Ford sporting stylish sunglasses, under a title blaring, “Motown Cool.” One has to wonder what, exactly, is “cool” about nearly destroying one of America’s great automotive companies in less than half a decade.

At least Ford was only drawing a $1 salary. My thought is that we need fewer "hero CEO's" and more effort and focus on improving processes, improving quality, engaging employees (and dealers), and taking care of the customer.

Standardizing the Standards

Hospitals try to reduce wristband code risks

To put this in manufacturing terms, imagine how you might have to change your process if your product might get transferred to another factory for additional processes.

In recent years, hospitals have widely adopted color-coded wristbands as visual cues, reminding staffers to check for medication allergies, special risks and signed end-of-life document known as a do-not-resuscitate order.

But with no standard guides to designate specific meanings for each color, the wristbands designed to protect patients are actually increasing the risk of harm, safety experts say, endangering patients transferred between hospitals and confusing nurses and doctors who rotate among several hospitals where yellow might mean "do not resuscitate" in one and "restricted extremity for blood draw" in another.

I hope the health care industry can take action on this. Being aware of the risk is one thing, taking action is what's important. The article lists a few examples of states where industry groups are taking on this challenge, but there's really no excuse for this to not be worked on everywhere, including your community.

To address the problem, a number of hospitals around the country have formed groups to standardize color designations in their states and regions.

Here's yet another example of how it doesn't necessarily cost a lot of money to make a quality/safety improvement. Working on processes is inexpensive, compared to relying on high tech solutions. That's often true in manufacturing, as well as in health care

Remote Control Error Proofing

Here's another example of "Everyday Error Proofing' courtesy of the new cable box from my cable company (part of the federally mandated transition to digital-only service).

The manual for the remote says (not that I was reading it, but I just happened to notice):

"If the same button is pressed and held for 45 seconds, your remote control will turn itself off automatically.

This extends the battery life should the remote become lodged under or between heavy objects, for example sofa cushions."

There's an example of some thoughtful error proofing. That's much more effective than a big warning label that says, "BE CAREFUL, Do not get Remote stuck in Couch Cushions."

It's error proofed, and their manual explains "why," which is a nice touch. It's a nice Lean culture method to take the time to explain "why" rather than just telling somebody to do something or not to do something.

New 5S Store Offerings

There are some new offerings from our sponsor, The 5S Store (www.5sstore.com). I've ordered items from them and am happy to report that you get very personal service from folks at The 5S Store.

First, we now have a TPM (Total Production Management) category. This consists of gauge marking labels, torque seal, books, posters and more.

Secondly, we now provide vinyl tape for labs, workbenches and offices consisting of 1/4" and 1/2" widths in seven different colors.

Lastly, and most exciting of all is we have recently lowered our prices on our vinyl tape and eliminated minimum quantity requirements. All are in stock and ready to ship today!

I appreciate you, the Lean Blog readers, for supporting our sponsors.

My Stack of Books: Raw Material and WIP

I love books. I'd also love to have more time to read books, or finish books. People often ask me what I'm reading. Here's what I'm trying to read or am wanting to read:

"WIP" -- started, but haven't finished (doesn't mean I don't like the book)

• Getting the Right Things Done
• Leadership for Smooth Patient Flow
• Managing the Professional Services Firm
• Errors, Medicine, and the Law
  
• The Health Care Value Chain
• The Baptist Health Care Journey to Excellence

"Raw Material" -- books that are sitting here, but haven't started (in order I'd like to start them):

• Better: A Surgeon's Notes on Performance
  
• Evolving Excellence
• The Strategos Guide to Value Stream & Process Mapping
• The Gold Mine (sent to me for review)
  
• Value Acceleration (sent to me for review)
  
• Lean for Dummies

Ah, the waste of overproduction. My head tells me it is waste to buy books faster than I can read them, but I can't help it.

We're all busy and don't have enough time, especially with so many good lean books coming out on the market. Maybe we need a lean book summary service, along the lines of those business book summary clubs?

What are you reading, or waiting to read? What's in your book inventory that hasn't been converted to "finished goods"??

A note on the Strategos book. There's an endorsement quote from me on the back, I did look at an electronic preview copy, so I've sort of read it, I guess.

Seth Godin Got "Kanban" Wrong

Seth's Blog: In praise of a blank page

I don't expect "lean expertise" from marketing blogger Seth Godin (it's nice he often mentions lean concepts), but he got some details about lean wrong and he doesn't allow reader comments on his blog (sort of a one way conversation).

Seth wrote, and I wasn't exactly sure of his point (read his whole post for the context):

In Japanese car factories, this is called kanban. You trade production efficiencies for quality. If a part isn't perfect, the worker refuses to install it. And the entire assembly line stops. Detroit was horrified by this idea. Keeping the assembly line going is the holy grail. Guess what? The line doesn't get stopped very often. Things get better, fast.

Ah... he was already corrected by Ralph Bernstein (from Productivity Press) and Seth added that to his post. It's actually a two-way conversation with Seth if you email him.

Ralph's clarification (which is what I would have said here):

In your posting, In praise of a blank page, your use of the word kanban is incorrect. Kanban refers to a type of visual control that signals an upstream operation to deliver what is needed. (The Wikipedia description to which you linked touches on aspects of the concept, but doesn’t get it exactly right.)

What you probably meant was andon.

An andon is a device that calls attention to defects, equipment abnormalities and other problems, or reports the status and needs of a system by means of colored lights. Typically, when a worker on a line encounters a problem, he or she will pull a cord that lights up the andon board and stops the line.

Also, it’s a little misleading to say that in such a system, you trade production efficiencies for quality. It’s a lot more efficient to stop and eliminate a defect immediately than to repair a finished product (or dozens of finished products) containing the defect. But you are right about one thing: with this kind of system, things do get better fast.

At least Seth's blog believes in "kaizen." I don't mean to pick on him, I'm not always right myself and I admit that.

Thoughts on Handwashing from David Mann

Some good discussion was raised on my original post, thinking out loud about what lean management methods you should use to get clinical healthcare providers to wash their hands 100% of the time, in the name of patient safety.

Here are some thoughts from an email exchange with David Mann, author of the excellent book Creating A Lean Culture: Tools To Sustain Lean Conversions (used with his express permission). I was curious about his general model for solving the "how do I get compliance?" problem.

----------------

Mark,

Some thoughts based on a simple model of learning: knowledge, practice, feedback:

1. Are there visuals at the point of use (where handwashing occurs) based on, for example, time sample observations, that show percentage compliance versus the 100% goal? This feedback would be the equivalent of posting lean assessment scores or 6-S audit results.

1a. Is there something like a 6-S audit in which this practice is simply one of those explicitly expected and audited? If not, seems like it might be good to start.

2. Is there a method for reporting failures to comply. These could be anonymous (initially); the object is to provide feedback on daily or weekly (for example) performance which virtually all in the health care setting would agree (I’m assuming) is important.


3. Is knowledge of the situation widely disseminated? Are findings from consequences made visible, in incidence percentage (PPM?) and counts based on root cause analysis of the subject infections, plus those resulting in death? Are the data widely visible? Visuals raise the level of accountability and disseminate responsibility. Are there only a few with the data doing all the worrying? It wouldn’t be unusual if that were the case.


4. Is there the equivalent of a stand up meeting at some frequency where this subject and results (as from 1- 3, above) could be touched on? Counting on good habits to persist without reinforcement, measurement, and reminders isn’t a robust strategy. As you’ve said, hope isn’t a plan - unless you’re the chaplain!


5. Following a month or a quarter of implementing some or all of the above steps, consider converting step 2 from anonymous as to reporter and reported to the mode where the reported are identified by name and followed up by whatever authority with disciplinary action with the appropriate progressive steps. Or, begin random observation schedules by those in a position to initiate disciplinary action (progressively, of course) based on what they see.

In lean implementations, noncompliant individuals present themselves to be made examples of, part of their testing the system. The same will happen here, whether among staff or physicians. When it happens, it’s important to act. It’s often the case that the miscreant lets others know what happened: “You wouldn’t believe what they did to me!”, helping to spread the word. Organizations have discipline systems for good reason.

L.A.M.E.: Thinking Lean = "Zero Inventories"

When inventory is not waste - The Manufacturer.com

It's unfortunate that one of the early (1983) popular books about lean (or "just in time," as was the fashion of the day) was titled "Zero Inventories."

Many people who didn't read beyond the title, mistakenly thought lean meant getting rid of your inventory. I've seen this first hand, as my master's internship was spent at a division of a company that thought they had previously "gotten lean" and cut their finished goods inventory to the bone.

Problem was, the production process had hundreds of steps and process yield variation was very unpredictable (semiconductors) ... so they weren't meeting customer demand. It was brutal. They were the bottleneck for a high-tech end product that they couldn't sell enough of at the time. My job was to come up with a methodology for determining what inventory levels SHOULD be, given the lead times and variabilities involved (while using lean to try to drive down the variability, which would allow you to then reduce inventory).

One of my early lean mentors made the point very well. I'm paraphrasing his broken English, but he basically said:

"First flow, then low inventory. Shutting down line is not lean."

That's a lesson that has served me well. Variation shouldn't be a "forever" excuse to hold inventory, but you can just cut inventory without fixing the variation.

I was reminded of all of this reading the linked article, it gives this example:

"... their corporate anorexia may have made them look svelte but not necessarily beautiful in the eyes of customers. Take the example of the Industrial Controls Division of Moog, Inc., which found that, along with its many clear benefits, lean had also produced an embarrassing tendency to miss customer due dates. "

Here's another case where people might say "Lean nearly killed us," but it's more likely another case of "L.A.M.E." (or "Lean As Misguidedly Executed."). How is it "lean" to miss customer due dates? Sheesh.

The article goes on to describe how Moog utilized the services of Professor Mark Spearman, co-author of the wonderful textbook Factory Physics (yes it's worth the price!) and founder of the firm of the same name. Spearman is one of my favorite people in the manufacturing world (he was a professor of mine when I was an Industrial Engineering undergrad at Northwestern) and many of the invaluable lessons of my early manufacturing career are thanks to him.

Spearman's company and software tools allow you to determine "optimal" inventory levels that trade off service levels and inventory costs. I'm sure the tools do the job, but I also assume that Moog, Spearman, and company are not assuming that today's variation HAS to be that way forever. This is the same idea that you can't assume that today's long changeover times ALWAYS have to be that way (thus justifying large batch sizes). Reducing setup time allows you to reduce batch sizes. You don't just arbitrarily cut batch sizes (in many cases) the same way you don't (or shouldn't) arbitrarily cut inventory levels.

On the demand side, working with customers (or salespeople) to help level load sales will reduce demand variation, allowing you to reduce inventory. That's the "heijunka" principle at work.

On the supply side, using TPM tools, for example, will improve your production stability (reducing lead time variation), which will allow you to, again, cut inventory levels.

Just to be clear, I'm not calling Dr. Spearman "lame"!! Companies and managers who make arbitrary decisions without considering the consequences to their customers are L.A.M.E.

100% is the Only Goal

Ledger-Enquirer | 03/27/2007 | Campaign's goal is to reduce infections

To those who might have thought I overstated the situation with hand washing in hospitals, here's another article about maintaining proper hygiene among hospital staff and caregivers.

One particular risk is the bacteria Methicillin-resistant Staphylococcus aureus, or MRSA.

Susan Harp, M(ASCP), CIC, Columbus Regional infection control coordinator, says 40 to 60 percent of the population carries Staphylococcus in their nose.

"It lives there happily and many people can have staph and never have a day's problem," she explained.

The problem is that many of us carry this around and we're OK, but when it's passed to someone who is susceptible, it can be deadly.

Karen Williams director of infection control at Hughston Orthopedic Hospital likens a hospital to a Petri dish with bugs moving around in a rich culture. That can cause bacteria and infections to spread.

The problem of drug-resistant bacteria is blamed on overuse of antibiotics.... a form of "overprocessing" in the Lean terminology (the "waste of overprocessing," or doing more than is required to add value for the customer).

One "best practice" that helps stop the spread of MRSA -- basic hygiene, such as washing hands with soap or using alcohol-based cleaning gels.

The problem is getting caregivers to wash their hands. As I highlighted in my earlier essay, the lack of hand washing is a real problem. Although caregivers report higher numbers, hospitals that do direct observation often find that the compliance rate can be under 50%. Washing hands saves lives, pure and simple. But hospitals often lament, "how do we get people to wash their hands?"

Well, how does a factory get employees to follow safety practices, such as wearing safety glasses?

1. Leadership -- set an example, a visible example?
   
   
2. Explain Why -- employees should be reminded that proper safety measures are not optional and are not secondary to quality or speed.
   
   
3. Take Action -- you need to observe to see if "standard work" is being followed. Hope is not a strategy. There have to be consequences for people not following the standard work safety practices.

Ideally, we, as leaders, need to treat people as adults, trust them to do the right thing. But, if that's not happening... you have to fall back on your formal power... the power to discipline employees. This happens in good factories every day.... if someone's not wearing their glasses, they're reminded and probably threatened with punishment or discipline, if need be. Here's a case where "lean leadership" isn't "nice" -- you have to be tough when safety is involved. You can't just wait for someone to lose an eye before reacting and re-emphasizing safety glasses.

So why do hospitals find it so difficult to get compliance with hand washing standard work?

1. Doctors are usually not employees. There is a different dynamic involved. Hospital administrators don't hold the same kind of authority over doctors that a plant manager might have over a supervisor or an assembly worker. Hospitals rely on doctors to bring patients (and therefore revenue), so it's common for administration to not hold MD's accountable for following a standard process (whether it's washing hands or filling out post-op paperwork in a timely manner).
   
   
2. It's impossible to observe 100%. We can't possibly observe every MD every second of the day. I suppose the medical profession itself has to take this on, with colleagues pressuring or shaming their peers into handwashing compliance.
   
   
3. Patients are often afraid to speak up. Many patient safety experts are urging patients to speak up, to keep giant Purell bottles by their bedside, and to insist that your caregivers wash/clean their hands in front of you. If your MD or RN is offended, that's probably a bad sign.

In the article, they talk about using "secret observers" to look for compliance:

"You have to be consistent and conscientious," Harp said. She reports that at Columbus Regional they have secret surveyors, who watch for compliance.

"They look for opportunities when an employee should have washed, and then they see if they do," she explained.

But what when they see these opportunities? Are they collecting data or driving improvement? Is anyone being punished for NOT washing properly?

I can't believe we're even spending time discussing something like this. You'd think basic hygiene would be "a given."

One hospital mentioned in the article set a goal of "100%." That's a good start. Safety goals need to be in absolute terms. Factory safety goals need to be "zero injuries." Forget what people say is "impossible." Setting a goal other than perfect sends a horrible message that it's "OK" for a certain number of injuries or deaths. At least the hospital execs aren't setting goals of "75% handwashing compliance."

But setting the goal is just one part. Leadership and getting compliance to standard work is the ongoing challenge. Sad.

What advice would you give our healthcare leaders? Click "comments" to chime in.

Training Within Industry Article

IndustryWeek : TWI Promotes Quick Training, Standard Work

Here's an article about the Training Within Industry program, a key foundation of the Toyota Production System.

The article features Jim Huntzinger and mentions his upcoming TWI Summit. You can listen to my podcast with Jim about TWI here.

From the article:

Today in North America, a handful of companies have resurrected TWI, according to Huntzinger. One is Chittenango, N.Y.-based ESCO Turbine Technologies. The company attributes a 96% reduction in defects (over a two-year period) in one department to TWI. Also, training that used to take two months now takes two weeks.

Industry and Health Insurance

Heath Care - New York Times

Long, but interesting, piece in the Sunday Times about the history of how we got to the point of companies providing healthcare. No, and it's not an article calling for a single-payer system (nor am I advocating that).

One tidbit on how far we've come in healthcare:

The first calls to create what we now know as universal health care date back to the early 20th century. Before then, medical care was generally cheap because it was, for the most part, ineffective. As one scientist put it, “It was around 1910 or 1912 when it became possible to say that a random patient with a random disease consulting a random doctor stood better than a 50-50 chance of benefiting from the encounter.”

That's a pretty high process defect rate! Things have gotten much better, but we still have a long way to go with preventing healthcare delivery errors.

So how did we get the rise of industrial/company-provided healthcare?

And during World War II, when the government exempted fringe benefits from its strict controls on wages, employers started offering ever more generous health benefits in order to attract workers. Another government decision — to exempt group health insurance premiums from personal income taxes — made health insurance an even more attractive option for business to offer. This effectively made a dollar of insurance worth more than a dollar of income, giving companies an easy way to cement worker loyalty.

But as this developed in the auto industry:

former Chrysler C.E.O. Lee Iacocca was warning about health care’s impact back in the 1980s — the problem had magnified over the years. Uwe Reinhardt, a Princeton economist, has described the Big Three automakers as “a social insurance system that sells cars to finance itself.”

All of this is a huge distraction from taking care of the customer, I might suppose. Companies should be able to focus more on their direct "value added" activities. Every minute spent talking about or worrying about the rising cost of employee benefits is a minute not spent on taking care of customers or innovating/kaizening core business activities. It certainly provides a distracting excuse for the automakers, then and now. If we had a "level playing field" healthcare wise, what excuse would be used for the gap between Toyota and the Detroit Three?

Greatest Asset, My...

Circuit City's harsh layoffs give glimpse of a new world - Yahoo! News

First off, Circuit City is not a "Lean" company. So when people ask "is Lean always good for employees?," you can also ask "when is traditional management always good for employees?"

Case in point, Circuit City. The retailer is scraping the bottom of the cost-cutting barrel with their latest move to fire 3,400 of its highest-paid retail employees with the goal of hiring cheaper labor to replace them.

As the Yahoo piece points out:

Like many companies, Circuit City has a set of company values, which it conveniently lists on its website. First among them: "Our associates are our greatest assets."

Sure doesn't see like it. If you go into a Circuit City store (I won't be), and you run across grumbly disgruntled employees, you'll know why. I'm sure the ones who are left don't feel very valued and I'm guessing they don't feel very good about their employer.

Seems like Circuit City is in a "death spiral" race to the bottom -- lower wages, crappy service, the need to further cut wages....

The article asks some other great questions:

What kind of inducement is it for employees to work hard and excel if their reward might be a pink slip? And why would people want to shop at a store where the low premium on service is so loudly trumpeted?

How can management be so devoid of ideas that they can only think of wage cutting as an "improvement?"

NY Times article

Philadelphia call for a boycott

Baltimore Sun article

What are Lean retailers, like Britain's Tesco, doing? I'd doubt that they are relying on such "cost cutting" measures.

What should you do? You need to look at your value-adding processes -- how can you add more value for the customer and how can you take out waste in the process? The Lean approach would involve partnering with your employees, truly treating them like assets, and working with them to find ways to reduce costs and improve service and sales.

I'm sure their "leaders" are sharing the pain? Let's look at their compensation:

Philip J. Schoonover, CEO: Salary $975,000, total comp $8,520,000

Doing the math, if you have 3400 employees and find new employees making $3/hour less (my guesstimate), that adds up to $21,216,000 over the course of a year (40 hours and 52 weeks).

I'm having trouble finding the public comp numbers for other execs (the google search for the company's 2006 annual report leads to a dead link instead of a pdf). But it seems to reasonable to think the company could save as much money by cutting executive pay. But, then, we'd be punishing the wrong people, eh?

If you find the comp numbers for the rest of the top 5 executives, post it here, we'll see if adds up to $21M.

Actually, from the Baltimore Sun piece:

Circuit City said it let go of workers who were making 51 cents or more an hour above what the company had set as market wages.

So I think my goal of saving $3 an hour is probably wildly optimistic, then.

Challenges to "Respect for People"?

UAW, Toyota workers to talk

We often talk about Toyota and "respect for people" as one of their main pillars. I'm sure most of us paint a pretty idealistic picture of Toyota when we talk to others:

• Safety and Quality are priorities (The Toyota Way says the company "never" would prioritize production numbers over safety)
• Employees are listened to and respected, are involved in problem solving
• Toyota is non-union (in the U.S., with the exception of NUMMI) because they have paid and treated their employees fairly

Now the UAW challenges that -- and tries once again to get Georgetown (TMMK) represented by the union. Of course the UAW will try to paint a picture that it's an awful place to work (to meet their goal of unionization), so we have to take all of this with a grain of salt. We also have to take it with a grain of salt that Toyota is "perfect" --- they're not, they are human. Their managers are human, they won't ever live up to the Toyota Way principles 100% of the time.

A Toyota spokesman said:

"The UAW has been trying to organize this plant for over 20 years, so it's not surprising that they're continuing to make efforts in the area," Sieger said. "For 20 years, the majority of our team members have believed there is no need for third-party representation in our plant."

The UAW has made little headway in organizing workers at Toyota plants or any of the U.S.-based plants run by Nissan Motor Co., Honda Motor Co. or Hyundai Motor Co. Toyota has 14 manufacturing plants in North America, and the only UAW plant among them is a joint venture in California with General Motors Corp.

In 2001, Nissan workers in Smyrna, Tenn., rejected union representation with about two-thirds voting against the measure.

The union says:

"Where you have a company that's pushing hard -- and that is the heart of the Toyota system -- workers' concerns can get ignored in how things are managed," Shaiken said.

Toyota certainly pushes hard for improvement -- but is that necessarily bad for workers? Is Toyota pushing individuals harder than they can be pushed?

The Free Press had a story on the meeting:

John Sparks, an eight-year employee at the plant, said he was concerned about injured workers being branded as trouble makers and the increased use of temporary employees.

"No one can fake a surgery," he said. "Tools break down and so do people."

UAW representation doesn't mean the end to all problems. When I was at GM, the workers obviously had UAW representation and that didn't prevent the poor treatment that the old "mass production" management system brought, including bad management, abusive yelling and screaming, and inattention to quality.

I'd be curious to know the inside story on Toyota and the treatment of injured workers. The UAW claims that injured workers are fired and that temp workers aren't given the same respect and benefits of full time workers. I'd like to know what somebody without the obvious union organizing goal has to say about how Toyota treats their workers.

I don't mean for this to be a pro/anti-union debate, but I think it's healthy to examine the reality of the Toyota promise of "respect for people." I'm not expecting Toyota to be 100%, but how do they respond when someone acts outside of the "respect for people" realm?

Mark on the "Better Process" Podcast

PodcasterNews - Industry Report Mark and Dwight for a Lean Roundtable

I am appearing again on Ken Rayment's "Better Process" Podcast, the link is above.

In the podcast, Dwight Bowen (of the Lean Thinking Network) and I both discuss Lean and employee morale. Dwight also has a lean podcast, his most recent episode features Pascal Dennis, author of Getting The Right Things Done.

Workers, Supervisors, and Respect

The End of the Line as They Know It - New York Times

The link above is an article about "Detroit Three" employees taking voluntary buyouts. There are some insights into the working world of the plants these employees leave behind.

One thing about the title for this post: I hate the word "workers," as applied to just about anybody, when it implies "not thinking." When we refer to people as "workers," we often mean the Taylorist model where managers and engineers (or the educated) come up with plans and workers merely execute those plans. It comes back to a 35 year UAW veteran telling me once,

"Management told me to check by brain at the door."

The Toyota Way "respect for people" notion is supposed to work against this. I stood eye to eye with an outwardly tough UAW "worker" (heck, "worker" is in the name of the UAW), who seemed broken down and devalued since management never wanted to hear his thoughts. It was very sad.

In the intro to the NY Times piece, a slice of GM life:

Talk to Kenneth Doolittle about General Motors, where he once supervised a team of assembly line workers, and he readily speaks with pride about his job and the self-esteem it provided. “I loved all of it — the people, the work,” he says. “I was in a position finally where people listened to me when I spoke. I wasn’t just a Joe-Nobody. I contributed.”

Again, how sad that he was a "Joe Nobody" who wasn't listened to when he was just a "worker." Faced with the prospect of becoming just a "worker" again (a different job at a local plant), Mr. Doolittle took the buyout -- it sounds like it was a matter of dignity and respect for him.

Now if GM has been working on lean for such a long time, why are the production workers still treated like "nobodies?" Maybe this is why they aren't catching up to Toyota so quickly?

Mr. Doolittle, a stocky man with a narrow mustache, joined G.M. on the assembly line in Lansing in 1973 and rose to become a leader of one of the Japanese-style work teams that first became fashionable in the American auto industry in the 1980s.

These "work teams" were fashionable... and became just as unfashionable as managers and supervisors took control back. I'll write more about this some other time. In my archive of stuff, I have the signs and letters that talked about how my plant (circa 1995) was a "Deming Organization" based on teamwork and mutual respect. Ironically enough, the "Deming" approach had been reduced to meaningless signs and empty slogans. Not what Dr. Deming would have wanted.

Say "No" to Bad Drug Stores

The Blotter: ABC Report on Pharmacy Errors

I first stumbled across this 20/20 report when I saw a preview on the ABC investigative reports video podcast. Pharmacy errors are a major problem (see this story):

There are as many as 7,000 deaths annually in the United States from incorrect prescriptions, according to Carmen Catizone of the National Association of Boards of Pharmacy. He told The Washington Post that as many as 5 percent of the 3 billion prescriptions filled each year are incorrect.

In the ABC piece, they focus on Walgreens, although I'd suppose the conditions and processes are the same at other major chain pharmacies.

One former pharmacist was interviewed, talking about how he was fired for being too slow, the implication being that other employees rushed through their work to meet some sort of quotas and that he refused to work in a way that would have jeopardized patient/customer safety.

I think that leads us to a reminder about Lean and Standard Work. For one, nobody has accused Walgreens of using lean practices. The pressure that the former pharmacist described was probably an old Taylorist mass production approach of pressuring workers to work faster because management wanted better results.

With lean, Standard Work includes the steps in a process and the standard time required to do each step SAFETY and with high QUALITY. Sure, there might be variation in that time person to person. If someone is an extreme outlier, you would look at the Standard Work -- are they following it? In a lean setting, you don't pressure people to work faster "just because" and you don't pressure people to work faster than they are able to safely.

The story also highlights how many Pharmacy Technicians are 16 year olds without any sort of degree. I've never seen this in the hospital pharmacies I've worked with, the Pharmacy Techs are always trained, experienced adults.

A high school-aged pharmacy technician at a Walgreens in Lakeland, Fla., made a typing error and dispensed a dose of the blood thinner Coumadin that was 10 times what the doctor had prescribed.

She was in high school. Her prior job had been cleaning a movie theater and serving popcorn," said Karen Terry, a lawyer representing the patient's family.

The patient, Beth Hippely, suffered a massive stroke after taking the medicine she was incorrectly given, forcing her to stop chemotherapy for a treatable, stage II breast cancer. She died earlier this year.

That's a tragic story. There is some incredibly sad video of Ms. Hippely before she passed away. I don't think the problem would necessarily be a "young" employee, but isn't it likely Walgreens had a bad process with poor quality controls built in? The young tech dispensed the wrong dosage, but that happens a lot (unfortunately) at many pharmacies, which, to me, points to a systemic problem. Systemic problems are rarely solved completely by telling people to "be careful." Is a 16 year old less likely of "being careful?" Maybe, but there's a higher responsibility on Walgreens: the supervising pharmacist as well as the leaders who are responsible for creating a solid, lean, error proofed process.

More on Walgreens management's role:

The high school student who made the error with Beth Hippely testified she had watched a video and was taking classes in school to learn about the pharmacy job.

Testimony in the Hippely case also revealed that stock boys and photo shop workers were also pressed into service behind the pharmacy counter when the store became very busy.

"They know mis-fills and errors are bound to occur because they're giving huge responsibility and important responsibility to people that aren't trained to perform those duties," said Terry.

"This is an intentional, system drive for profits, for money. If it wasn't about that, they would hire more pharmacists," the lawyer said.

Or they would spend more money on training their pharmacy techs better. We can try to throw a nurse into jail for making ONE error, yet the executives who oversee failed systemic processes are left to collect huge paychecks. I think the focus on "oh how shocking, it's irresponsible teenagers filling your prescriptions!!!" is misplaced. The shocking things are the lack of training and lack of standard work.

The industry seems to want to cover up the problem (2nd ABC page). 46 out of 50 states have no requirement for reporting pharmacy errors, even those that are fatal.

While some fear there is an unreported epidemic of pharmacy errors, there are no reliable figures to gauge the scope of the problem. And that's the way the industry seems to like it.

"I don't think it should be publicized," said Mary Ann Wagner, the senior vice president of the National Association of Chain Drug Stores, in an interview to be broadcast Friday on "20/20."

She says the industry fears the public won't understand the difference between minor and major errors, and that the figures could be used to punish drug stores.

We won't understand?? Of course the figures should be used to punish drug stores. We, as consumers, should be able to choose a pharmacy based on their safety record. Customers should run away, in droves, from those pharmacies that refuse to do a better job with patient safety. Notice I said "refuse to." I don't think "can't" is the problem, I think it's a problem with "won't" fix.

One pharmacist who was deemed responsible for an error in another case:

The pharmacist who admitted responsibility for the error, William Zaeske, continues to work at Walgreens and is now a pharmacy manager at another store near the one where the prescription error happened.

This might actually be the right approach, in a way. Should the pharmacist be fired for something that happened under his watch that was a systemic problem that's occurring in other pharmacies? Again, what about management? Why aren't we outraged that a VP or CEO wasn't fired? I guess $21m lawsuits aren't waking up Walgreens.

Final thought, Walgreens says:

In a statement, Walgreens said, "We deeply regret the few errors that have occurred among the more than 500 million prescriptions we fill each year at our 5,600 pharmacies."

Instead of a sincere apology, we get a sales pitch from Walgreens about how big and popular they are. That's inappropriate. I guess they are saying that errors are inevitable because they're such a large company? That's an inappropriate attitude also. "Zero defects" really and truly needs to be the goal. We can't tolerate anything less, it's a matter of expectations. Put in error proofing methods and proper management oversight -- that's how you work toward zero defects. A "Six Sigma" level in that industry is going to kill people. That's why we need zero defects.

It says it has invested nearly $1 billion in "redundant pharmacy safety systems" and training over the last 10 years.

And I wonder how much of this $1B investment was in "siren song" technology instead of investing in people and process??

So what can you do?

• Insist on better oversight and reporting mechanisms for pharmacy errors
• Ask your pharmacist what THEY are doing to prevent errors from occurring
• DOUBLE CHECK each and every prescription you bring home to make sure you have the RIGHT PILL and the RIGHT DOSAGE

ABC Video Link #1 "Prescription Errors"

ABC Video Link #2 "What Your Pharmacist Doesn't Tell You."