Archive for August, 2010

How Can We Prevent This Medical Error?

How Can We Prevent This Medical Error?

I deleted all my photos
Creative Commons License photo credit: Stewart

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

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

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

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

Tweet to Win An Autographed Book and Mental Model Cards from Pascal Dennis!

Tweet to Win An Autographed Book and Mental Model Cards from Pascal Dennis!

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.

By August 30, 2010 3 Comments Read More →

Who Coined the Term “Lean”? And Where is He Today?

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

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

Where is Krafcik today (pictured at left)?

Releasing Time to Care (Lean Nursing) in New Zealand

Releasing Time to Care (Lean Nursing) in New Zealand

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.

By August 28, 2010 0 Comments Read More →
Recent Interviews with John Toussaint; “Gemba Visit” to Park Nicollet

Recent Interviews with John Toussaint; “Gemba Visit” to Park Nicollet

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

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

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

By August 27, 2010 0 Comments Read More →

Upcoming Public Lean Healthcare Events: Big Sky, Michigan, LEI

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

More details follow:

By August 26, 2010 1 Comments Read More →
Interview with Paul O’Neill; The Right Goals in Healthcare

Interview with Paul O’Neill; The Right Goals in Healthcare

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 August 25, 2010 6 Comments Read More →
John Shook to Replace Jim Womack as CEO of Lean Enterprise Institute

John Shook to Replace Jim Womack as CEO of Lean Enterprise Institute

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.

By August 24, 2010 5 Comments Read More →
Great Interview with Dr. Richard Shannon on Lean / Toyota Methods

Great Interview with Dr. Richard Shannon on Lean / Toyota Methods

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

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

Mental Models: Standardized Work and Performance Measures

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?”

Record of Annual WSJ JIT/Lean Blunders

Record of Annual WSJ JIT/Lean Blunders

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:


By August 20, 2010 8 Comments Read More →
Lean Parody Audio & Video: GEICO Commercial

Lean Parody Audio & Video: GEICO Commercial

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

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

Updated: Here is a video version of my ad:

By August 20, 2010 1 Comments Read More →

Dan Markovitz Teaching “A3” Course at Stanford this Fall

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

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

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

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

If You Had to Rebuild Your Workplace Tomorrow?

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 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.

By August 19, 2010 4 Comments Read More →
Top 10 Signs You’re In a Fear-Based Workplace

Top 10 Signs You’re In a Fear-Based Workplace

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.

Lean Experience “A Plus” for Lean Healthcare Job?

Lean Experience “A Plus” for Lean Healthcare Job?

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.

By August 17, 2010 5 Comments Read More →
Reader Question: Rapid Response Teams (Oops, We Don’t Have the Items)

Reader Question: Rapid Response Teams (Oops, We Don’t Have the Items)

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.”

By August 16, 2010 5 Comments Read More →

Weekend Fun: Beer Kaizen Parody Video

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.”

By August 14, 2010 9 Comments Read More →