Archive for August, 2010
A number of readers emailed me a link to this New York Times article: “U.S. Inaction Lets Look-Alike Tubes Kill Patients.” The headline emphasizes the lack of governmental oversight, but I’d rather talk about the poor system design that allows deadly errors to occur.
The article describes an error where food was mistakenly injected into her veins:
… the hospital mixed up the tubes. Instead of snaking a tube through Ms. Rodgers’s nose and into her stomach, the nurse instead coupled the liquid-food bag to a tube that entered a vein.
Putting such food directly into the bloodstream is like pouring concrete down a drain. Ms. Rodgers was soon in agony.
You might know of and already be a fan of Pascal Dennis (read more about him and listen to my recent podcast with him here). He has a new book out (The Remedy) and his firm, Lean Pathways, has published a cool set of “mental model pocket cards” (the first set of more to come).
Pascal and Lean Pathways have generously offered to give away a copy of The Remedy and the cards, both autographed by Pascal.
The term came from John Krafcik, who was a graduate student at MIT, working for Lean Enterprise Institute founder Jim Womack on the research for the book The Machine That Changed the World. See comment #5 where I added more detail about that.
Where is Krafcik today (pictured at left)?
Here is a nice little (under 2 minutes) news video from New Zealand talking about one hospital (in Auckland) and their implementation of the “Releasing Time to Care” program that was started in the British NHS. Other hospitals across New Zealand are doing this too, apparently
The story talks about how nurses were spending on 33% of their time with patients at the bedside. It’s such a systemic problem – the interruptions and waste – that the number is almost always between 30 and 33% in studies done around the world.
But it’s possible to double time at the bedside with this Lean-based program.
I’m currently in Minneapolis, where today is Day 2 of our Healthcare Value Leaders Network “Gemba Visit” to Park Nicollet (read more about these visits here). Dr. John Toussaint, author of the book On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry, is here with us as always (pictured at left during part of our visit to their “3p mockup area” used for space and process design work.
I’ll have more thoughts to share about the visit next week (including the value of learning and collaborating without copying), but I’ll link today to two recent interviews with John.
Here are a few events I’ll be a part of in the next few months, maybe I’ll see you there:
- Cindy Jimmerson’s “Big Sky” Lean Leadership Retreat, Sept 20-22
- Michigan Lean Consortium’s Lean Healthcare Event, Sept 28
- LEI “Key Concepts of Lean in Healthcare” Workshop, Oct 11-12
More details follow:
Many of you may know of Paul O’Neill for the dramatic employee safety improvements at aluminum maker Alcoa and you may know of him from his work in promoting healthcare improvement (he is the “bureaucrat” in “The Nun & the Bureaucrat” book about lean and systems thinking in healthcare). He also worked with Dr. Richard Shannon in the PRHI healthcare quality efforts (read my post from Monday about a separate interview with Dr. Shannon).
I didn’t realize that, during his time as Treasury Secretary, the time required to close the nation’s financial books was reduced from 5 MONTHS to 3 DAYS. You’ll learn that and more in this article: “In a Perfect World.”
By now, you may have read the news release and/or e-letter (scroll way down) from the Lean Enterprise Institute that announces founder and chairman James P. Womack is stepping down as CEO of LEI, to be replaced by longtime LEI senior advisor, and former Toyota manager, John Shook.
It’s an understatement to say that Jim has played an important role in helping share and promote lean thinking around the world – shifting from “lean production” to the lean enterprise and lean healthcare.
Today, I’m linking to a fantastic interview and discussion between two luminaries in the patient safety world – Dr. Robert Wachter (read his blog) and Dr. Richard Shannon (who is featured, among other places, in the “Good News: How Hospitals Heal Themselves” video and the companion book “The Nun & the Bureaucrat.“
A few thoughts while waiting for a Sunday flight… at least it’s a Sunday flight towards home.
One reason traditional organizations (and traditional leaders) struggle with Lean is because the mental models are different. The problem isn’t understanding tools; the problem occurs when people are forcing Lean methods into a traditional setting. What might work great in a Lean culture, might cause nothing but trouble in a traditional setting – all because of the mental models. When we implement a new method from another organization, we might do well to ask “What existing mental models is this going to conflict with? What might the side effects be?”
The WSJ has a long track record of not understanding Lean, as I’ve written about many times on my blog. There’s a major flare up at least once a year:
This time, I’m spoofing the overplayed GEICO commercials, where the gravely-voiced guy in the suit asks a series of funny rhetorical questions…
Updated: Here is a video version of my ad:
Mark’s note: I asked Dan to write a post about his upcoming class…
I’ll be teaching a class this fall at the Stanford University Continuing Studies Program on A3s — how to create them, how to review them, and how to coach others on them. The goal of the class is to help you learn to use PDCA thinking to improve performance.
The class will be held on Thursday evenings from 6:00pm to 7:50pm for five weeks, from September 23 to October 21. Each class will consist of a short lecture on the different parts of the A3, evaluation and critique of a sample A3, and then time to work on your own A3 with classmates.
I’ve had the chance recently to re-watch some of The Deming Library DVDs, thanks to my friends at CC-M Productions (found at www.managementwisdom.com). I’m watching some of the videos for the first time.
It’s always a joy for me to watch these videos, produced in the 1990s featuring interviews with Dr. W. Edwards Deming and clips of his seminars.
In one video, there was a point that I don’t recall from previous viewings. Dr. Deming was talking with Dr. Russell Ackoff about redesigning systems.
Dr. W. Edwards Deming always said we need to drive out fear from organizations, as point 8 of the 14 Points said:
“Drive out fear, so that everyone may work effectively for the company.”
Too many organizations, including hospitals, are driven by fear. This is counterproductive and harmful. You can’t implement Lean in a fear-based culture, as instilling fear in employees runs counter to the “Respect for People” principles. MSNBC and BusinessWeek bring us this article, “Ten signs you work in a fear-based workplace.“
Via Google Alerts, I try to regularly scan and see where hospitals are posting jobs related to Lean. I found (OK, Google found) one posting last week that I shared on my “Move to Healthcare” networking site (free registration required to view and participate fully). You can also see the posting here on hotjobs.
One frequent topic of discussion on MTH is how some hospitals are very open to hiring experienced lean and process improvement people from outside of healthcare, while others are insistent on only hiring within the industry. This one position, for a fairly deep “Lean Specialist” job at a hospital in Connecticut not only calls for “7 years of health care experience” yet also says “Lean experience is a plus.” No joke. Read that again.
I received an email from a reader that I’m sharing and commenting on with permission.
“Dear Mark: I am a lean coordinator for a manufacturing company and it was a real shock to see some of the waste during a recent hospital visit to see a dying family member. He was 92 years old and had a DNR in place. He was having trouble breathing and a Rapid Response Team was called into place. Now, again, he was dying, so my first thought was that this seemed unnecessary. But, as they were preparing to treat them, the waste and confusion was obvious.”
Props to KCOE for the spot-on parody video of Bruce Hamilton’s legendary Toast KAIZEN”: Introduction to Lean Principles DVD. Even if you just watch the first few minutes, it’s pretty priceless if you’re familiar with “Toast.”