Creating a Lean Family Practice

Creating a Lean Practice - April 2006 - Family Practice Management

I started a new client project yesterday, so I'm a bit swamped. I'm excited to be doing some work in a direct patient-care setting.

This linked article is a good one about the opportunities for Lean in a family practice type setting. I hope you find it interesting, regardless which side of the provider/patient relationship that you're on.

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Lean Overview Article in "The Hospitalist"

The Lean Hospital

The Hospitalist is a publication for physicians who practice "hospital medicine." I had a chance to be interviewed for what turned out to be a nice overview of "how can Lean help hospitalists and their patients?" article.

Unfortunately, it only looks like the first page is free (the rest requires a membership or subscription).

From the intro:

What does being lean entail?

"At its core, lean is a process-improvement methodology and management improvement system," says Mark Graban... Graban teaches the Toyota system to hospitals throughout the country. One of the system's most basic tenets is respect for the work force. Another is that it does not assign blame. Instead, Graban explains, "Lean engages the work force to improve the work they are involved in -- improving process and quality, and reducing delays for patients."

I don't think I got misquoted at all during the article and I think I helped shape what was a very positive look at how Lean is helping hospitals improve.

And the article mentions my book, which is a nice plus. Thanks to everyone who has downloaded the first chapter and for the nice feedback. People from all over the world are downloading the chapter, which is exciting for the Lean Healthcare movement.

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An MD/CEO In Indiana Believes in Lean

Doctor takes pulse of Lutheran Health | The Journal Gazette:

Here's an article about Dr. Mike Schatzlein, Chief executive officer for Lutheran Health Network and Dupont Hospital, in Indiana.

"Schatzlein believes “lean engineering” – like that employed by manufacturers to standardize processes – can help. Dupont Hospital has tripled the number of surgeries started on time in the past few months by standardizing certain pre-operation processes. That’s improved efficiency and reduced the likelihood of error, he said.

Schatzlein calls process improvement the “holy grail” – the only way you can get something out of nothing. But he doesn’t think any amount of process improvement will be enough to solve the overarching problem of containing cost while providing care to the nation’s uninsured.

“We can’t afford all the health care we want as a society,” Schatzlein said."

He's right, Lean is not a cure-all for any health system (be it in the U.S., Canada, or the U.K., each system having its own ills). But Lean is indeed a method that can improve both quality AND efficiency. More and more hospitals are learning this and it's continually reinforced through my experiences in hospitals.

Dr. Schatzlein sounds like the kind of humble leader who would fit with the Lean management philosophy:

Open-ended brainstorming is one of Schatzlein’s strengths, said Kirk Ray, CEO of St. Joseph Hospital, who considers Schatzlein a mentor. He’s not the typical guy just looking to fix things right away, Ray said.

“I think Mike is a very good listener.” The advice he does give is usually followed up with a “What do I know?” The undercutting humor “tends to put you at ease,” Ray said.

I am skeptical, though, about the use of rewards and incentives, as that goes against the notion that quality and performance are the result of a system, as Dr. Deming taught.

Goals for improvement, such as patient safety, will be gauged against widely accepted measures, like those used by Medicare & Medicaid Services to compare hospitals. After everyone understands the organizational goals, employees will get feedback on how they are doing and will be rewarded accordingly, whether with an award, money or a promotion.

The problem with incentives like this is that you're creating an extrinsic motivation for something that should be an intrinsic motivation -- providing safe care. Normal people (not the crazies who purposefully harm patients) don't want to hurt patients or co-workers.

Creating incentives creates too many opportunities for gaming the system or for outright luck to create "winners." Systems might reward those who might not have been performing differently than peers in other departments, but they ended up with better results through what Dr. Deming called a "lottery" of life. Incentive systems encourage people to game the system and they create fear of what happens if you don't hit your target (loss of a reward) -- robbing people of their intrinsic motivations.

I'm glad Schatzlein and his hospital are using Lean process improvement methods. The idealist in me would also want them to look at quality improvement methods that don't require rewards and incentives for doing the right thing.

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A Modern MD Who Makes House Calls

Jay Parkinson, MD. A doctor in Williamsburg, Brooklyn and Manhattan

HIStalk Interviews Jay Parkinson MD MPH, House Call Doctor

Posts will be pretty sparse and short the next few days, as I'll be in New York City through Sunday, busy with work and some vacation fun.

Saturday, I have the chance to meet and grab a cup of coffee with a doctor with a very interesting business model, as you can read about on his site or the interview linked above. He makes house calls, makes great use of the internet and new technologies, and requires that you pay up front (although you can submit for reimbursement through your insurance provider, if you have one). I'm really excited to chat with Dr. Parkinson about his practice and the overlap with Lean concepts and the idea of "Lean Solutions."

Keeping with the Womack and Jones principle of "don't waste the customer's time," Dr. Parkinson only makes house calls, which means you don't wait in a germ-filled office. He also does "e-visits" which means you can get answers or advice to certain types of problems without even having a face-to-face appointment. Cool stuff, hopefully we'll see more doctors adopting this sort of patient-focused, time-saving model. While his practice isn't strictly inspired by Lean, Dr. Parkinson had some exposure to kaizen events and Lean concepts in his formal medical education. We first got in contact because he had linked here to the Lean Blog from his blog.

He's agreed to do a Podcast with me sometime later, so if you have any questions, post them here or email me.

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Mindless Government Bureaucracy Puts a Halt to Hospital Checklists

A Lifesaving Checklist - New York Times

A number of you have emailed me, yes I'm aware of this horrible, ridiculous development that followed earlier reports of the success hospitals were having in reducing infections and improving patient care through "stupid checklists" (a form of Standardized Work) that aren't stupid at all. They're so simple, they're brilliant and they are saving lives, I mean WERE saving lives.

As Dr. Atul Gawande wrote about in the New York Times, a really misguided federal agency has shut the program down for some unbelievable reasons. You just have to read his column and then come back here.

Gawande pulls few punches in setting up the piece:

"In Bethesda, Md., in a squat building off a suburban parkway, sits a small federal agency called the Office for Human Research Protections. Its aim is to protect people. But lately you have to wonder."

I learned about this New Year's Eve and I tried to not let it ruin my holiday, nor did I want to start the blogging year on such a negative note. It must be incredibly frustrating for the people who have been working on this initiative -- to be making such great progress with a method that is repeatable and transferable to other hospitals and to forced to shut it down. Will the government pay for the care of patients who get infections as a result???

Maybe the fault in the Johns Hopkins program was that they purposefully set up this medical research structure of "we're using checklists for these patients and NOT using them for these... let's compare the results." That seems to be the tradition in medical research... it seems to be a bit different than the Lean notion of kaizen, don't you think? With kaizen, we would start with checklists in a small area, pilot to see the results, and then, given that it works, spread it to other areas as quickly as possible. Would the government see that any differently? I'd have to think you can't pilot changes in a small area first... but then again, if something works, why wait? To that end, why is the government not using its muscle to insist that EVERY hospital use the checklists method instead of slapping those who are, partly because it might make some doctors look bad?

Argh, there's more I want to write, but I need to step away from the keyboard and calm down again. This really worries me, the impact this might have on Lean methods and other process improvements that are going on in hospitals. I'd hate to think people would get scared and think it's safer or better to do nothing... the government doesn't seem to care if you do nothing to improve hand hygiene and prevent infections.

Gawande summarizes some of the history of healthcare quality improvement:

Scientific research regulations had previously exempted efforts to improve medical quality and public health — because they hadn’t been scientific. Now that the work is becoming more systematic (and effective), the authorities have stepped in. And they’re in danger of putting ethics bureaucracy in the way of actual ethical medical care. The agency should allow this research to continue unencumbered. If it won’t, then Congress will have to.

Ah the irony, as improvement becomes more "scientific," it somehow becomes more threatening to the feds. As I'm going through final editing of my book, this is really making me wonder about how "Standardized Work" and "kaizen" are really going to be implemented more widely in this industry. Maybe the hospitals who have done well so far should be lucky to have been "under the radar" if you will? Maybe we need less promotion of Lean and more action. What the bureaucrats don't know can't hurt them... but them taking action on stuff they know little about... that hurts patients.

Other blogs on this topic:

• Wachter's World
• Gemba Panta Rei
  
• To EHR is Human - Great headline, "Bureaucracy Kills!"
• Health Care Renewal
• Health Beat
• Health Care Organizational Ethics
  

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A Lean Hospital Story in Tennessee

Memphis Daily News - Le Bonheur's New Treatment-Speeding System Ups Productivity by 54 Percent - 12/11/2007

Here's a news story about a hospital I know people from, LeBonheur Children's Hospital in Memphis. I am have some examples of their in my upcoming book on "Lean Hospitals" (by "upcoming," I mean that I'm finishing up final touches on the manuscript and it should be available for sale later this year, check back here for more details.)

LeBonheur reconfigured their emergency department flow to reduce patient delays, finding that it also improved productivity for the physicians. One method they used was Standardized Work:

Because Le Bonheur is an academic hospital, there always will be inefficiencies because of teaching, he said, and there always will be complex cases, true life-or-death emergencies that demand the time of a lot of people. But the vast majority of cases can go through a defined treatment process.

What doctors once derided as "cookbook medicine" now is being embraced as "critical care paths," which quickly diagnose a patient and send him or her through a pre-determined course of procedures.

Sure, Standardized Work might might be applicable in every unique patient situation, but not every patient is a case worthy of the show "House." Making improvements to the "vast majority" of cases should free up more time to deal with really challenging or unique cases.

Exam rooms were also standardized, which reduces the amount of time employees spend searching for supplies and tools.

The hospital is also being smart and showing "respect for people" by committing to not use Lean improvements to drive layoffs.

One of Schlappy's rules up front is that nobody loses their job. Reductions in the lab, for example, came from attrition and retirement. It's simply inappropriate, he said, to ask people to work hard at eliminating their own jobs.

There are some unique dynamics with ED flow, as reducing delays might actually encourage more demand for care, instead of parents taking kids to primary care physicians.

But, the article says, and concludes with a quote from the chief MD of the ED

Parents are strongly urged to go to their regular providers for follow-up care, he said. Also, federal politicians are starting to scrutinize the nationwide problem of ER crowding and patient diversion. Hospitals have to tackle the problem or they'll face another load of regulations.

"At the federal level the only thing they can do is increase our regulations or decrease our funding," he said. "It's better if we figure this out ourselves."

That's a great point -- there are many things, in any industry, that we do NOT have control over... better to work on the things we do have control over, such as the design of our processes and Standardized Work!

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Checklists and Standardized Work in Patient Care

New Yorker - Dr. Atul Gawande

Here is an outstanding piece by one of my favorite medical writers, on the use of checklists (a form of Standardized Work) to improve healthcare quality.

How can "a stupid little checklist" have such an impact? Take a look at the article and see.

Within the first three months of the project, the infection rate in Michigan’s I.C.U.s decreased by sixty-six per cent. The typical I.C.U.—including the ones at Sinai-Grace Hospital—cut its quarterly infection rate to zero. Michigan’s infection rates fell so low that its average I.C.U. outperformed ninety per cent of I.C.U.s nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated hundred and seventy-five million dollars in costs and more than fifteen hundred lives. The successes have been sustained for almost four years—all because of a stupid little checklist.

Standardized Work and Lean (I'll call this article an example of "Lean" even though Gawande doesn't) are not glamorous. This isn't an exciting new drug or a flashy "gee whiz" technology. This is basic process management and kaizen 101... yet it's so effective. We need more of this in our hospitals...

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The Need for Clean Hospitals

Our Unsanitary Hospitals - WSJ.com

That's "Clean", not a typo of "Lean." Good column in the WSJ today by Betsy McCaughey, head of the Committee to Reduce Infection Deaths organization (link).

She asks why restaurants and meat packing plants get inspected more than our nation's operating rooms.

"Restaurants in New York are inspected, without prior notice, once a year. In Los Angeles, inspections are done three times a year, and restaurants must display their grade near the front door. After L.A. instituted this inspection system in 1998, the number of people sickened by food-borne illnesses fell 13%, according to the Journal of Environmental Health. Other cities are now following L.A.'s lead.

Why aren't hospitals held to the same rigorous standard? The consequences of inadequate hygiene are far deadlier in hospitals than in restaurants. The Centers for Disease Control and Prevention estimate that 2,500 people die each year after picking up a food-borne illness in a restaurant or prepared food store. Forty times that number -- 100,000 people -- die each year, according to the CDC, from infections contracted in health-care facilities."

What leads to infections? Some of it is a classic Lean "standardized work" issue:

These infections are caused largely by unclean hands, inadequately cleaned equipment and contaminated clothing that allow bacteria to spread from patient to patient. In a study released in April, Boston University researchers examining 49 operating rooms at four New England hospitals found that more than half the objects that should have been disinfected were overlooked by cleaners.

Why is this? Lack of training? Lack of clear standardized work? Lack of time to do their job properly?

She then writes:

"Hospitals used to routinely test surfaces for bacteria, but in 1970 the CDC and the American Hospital Association advised them to stop, saying testing was unnecessary. The CDC still adheres to that position despite a 32-fold increase in MRSA infections. CDC officials say that lab capacity should be reserved for tests on patients.

Testing surfaces is so simple and inexpensive that it's used routinely in the food industry. Is it more important to test for bacteria in meat processing plants than in operating rooms?"

If we have lab capacity issues (that testing is done in a hospital lab), there is another opportunity for Lean, to improve flow and to free up capacity. The healthcare industry has smart people and the tools to fix all of these problems, we just need the leadership and the attention to be paid to these issues. The public needs to start standing up and demanding better.

It's not just hospitals, either, it's doctor's offices, which get no inspection at all. McCaughey tells a story of a physician who was REUSING NEEDLES (yes, you read that right) with patients. Who in their right mind does that?

The New York State Department of Health called Dr. Finkelstein's reuse of syringes
a "correctable error," and is allowing him to continue to practice under observation.

I know I often write about not blaming people, but this is not an "error," it's a "violation," which involves choices that doctor is knowingly making. How can he not be held more accountable? The state "regulators" knew, in 2005, the doctor was doing this, but they wouldn't suspend his license. Yeah, the state sure is looking out for you in New York. (another article) It's mindboggling that we'll fire and punish people who make an inadvertant error, but we'll look the other way when a doctor is purposefully and intentionally doing something unsafe. They're having to test patients of his for Hep C and HIV because of his stupidity. Ok, enough of that tangent.

Anyway, the WSJ piece is a good article if you have access to check it out. Rupert Murdoch is most likely going to make the WSJ a free ad supported website in the future, rather than relying on paid subscriptions.

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Q&A With the Lean Dentist, Part 2

Here is a follow up to Part 1 of the recent Q&A I've facilitated with our friend, Dr. Bahri. Thanks to the blog reader (who works for a non-Dental, non-Medical company) who emailed me these questions. I always love hearing from my readers and Podcast listeners, thanks for writing.

1) What is a "flow manager"? I seem to remember in your podcast that he created a couple of "flow manager" positions. What exactly do these people do? I have thought about creating a "flow manager" position in my office who would primarily be responsible for "filling in the gaps" wherever they exist and helping to move things and update tracking reports, but I am getting pushback from people who think it would be more efficient for the workers in these respective areas to do the work themselves.

The “flow manager” position was created late in the process, when we already had flow in place. We needed to know where to go next after we were done treating a patient. The full title is “Patient Care Flow Manager”. The underlying meaning is to have a person focused on the non-stop care throughout the clinical part of the office. In a different environment her attention would be focused on the product, whatever it is, and making sure the work on that product is constantly advancing. These are her main functions in our practice:

• Secures JIT service for the next step through a “Service Kanban”
• Enters the line when needed
• Continually eliminates waste

I have no experience in creating the position of “Flow manager” before establishing Flow. I don’t see how it would work, but again, no idea is good or bad until we have tried it.

2) Training -- I suspect that Dr. Bahri was originally the one who came up with all the ideas. However, I also suspect that is no longer the case. How did he teach people to see things differently? Did he take them to an LEI training seminar, require them to read books, take them to visit other lean places? Or, was it simply a matter of Dr. Bahri leading the way and the rest of the team eventually learning from his example?

All training was made in-house. In fact, we have learned it together. It is true that, for the first years, I was doing all the research work, but I have always shared the relevant ideas with my staff. We put our heads together to figure out what the different principles meant for us. Principles like flow, level, pull, Kaizen, the different wastes etc. I believe in the one-piece flow principle for everything, including training. I have trained one person at a time, in one procedure at a time. Once it was successful and others asked to be trained in it we added them to the group (pull system in training). The idea of training everyone at the same time would be like applying “Batch Thinking” to the “Lean Thinking” implementation process.


3) Replication -- Are there any other dentists who have tried to replicate Dr. Bahri's methods? If yes, how has it gone? If no, why not?

I don’t know of anyone applying my methods. For a long time, up until lean people like Jerry Bussell, Jim Womack and John Shook told me that I was doing something special, I thought what I was doing was very normal. So I never prepared to share it with my colleagues. Today I have a little focus group trying to refine the message and make clear and appealing to the dental community.

Thanks again to Dr. Bahri for sharing his time and his responses with all of us. For more, click on the "Lean Dentist" link at the bottom of this post.

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My Visit with the Lean Dentist, Part 3

Click here for Part 1 and Part 2 of the series of posts about my visit to Dr. Sami Bahri, the "World's First Lean Dentist."

In Part 2, I talked about how the Lean "tool heads" might be disappointed, and we talked about aspects of a Lean Culture. But now, here's something for the "tool heads" -- yes, tools are important, but let's not put them first. Lean is a combination of tools, management system, and philosophy. Here are the tools I did see in place:

• U-shaped cells: sterilization areas are set up in U-shaped flows, where tools flow back to where they came from (as opposed to the old linear layout)
  
  
• Materials: inventory levels have been right-sized for each patient area, which bins that were created specifically for their use. Inventory layout appears to be pretty standardized across the stations. Inventory is pulled from a distributor using a re-order point system and a simple bar-code scanner (as opposed to kanban cards).
  
  
• Pull: I did see the famous "kanban cards" for pulling resources to the patient, whether it is a dentist or a hygenist. There were times I was talking with Dr. Bahri and there came the kanban card. He had lead time (as indicated on the card), so we could finish our thought and he didn't have to immediately run.
  
  
• Visual management: As you could see in the picture I posted the other day, each station has a simple "andon" card. Green means everything is OK and there are other colors to indicate what type of assistance might be needed. The kanban cards are also color coded to indicate who they are far (this is a recent kaizen improvement).
  
  
• Level loading: visual schedules are posted, an attempt is made to level load the cleanings throughout the day.
  

With the visual controls, one person who is monitoring those, among other duties, is the "Flow Manager," the position that Dr. Bahri described in the Podcast. The flow manager is a unique position. Their job is to manage the flow -- who is occupied with what, when will they be done, who is next, etc? Basically, the flow manager gets to tell Dr. Bahri (and others) where to go -- they just have to find him first!! That was made harder by him touring me around the office.

I asked the flow manager how she knows when to give the signal, to anticipate when things are done. In one example, she said that you can hear the hygenist flossing and that's one indicator, especially when they are working in a standardized sequence and you know how far along they are. "You can hear flossing?" I asked. "Sure, if you're close enough." The value of an open workspace and having a flow manager in "the gemba!"

It's very neat to see. I wish I could have spent time shadowing the flow manager for a while, time got short, there was so much to see and to talk about. The office definitely has opportunities for improvement. They recognize that, much the same way Toyota would. Dr. Bahri and his staff are very proud of what they have accomplished, but I would guess they wouldn't put themselves at a "Toyota level" of achievement.

To try to summarize, I was very impressed with the culture that was very strong in the areas that Jon Miller wrote about as leadership concepts of Toyota and Gary Convis:

• Total commitment. Definitely a strong commitment to improvement and to Lean, but not just Lean for Lean's sake. This commitment comes from the top (Dr. Bahri) but seems shared throughout the organization.
  

• Full commitment to the "customer-first" philosophy. They put the patient first.
  

• No artificial barriers between departments. I saw a lot of good teamwork and cooperation, the breaking down of barriers between "ront desk and dental assistants (making sure people have the proper training to help).

• Aggressively seek to solve problems. Strong problem solving and kaizen focus.

• Human development. Lean is about growing people, lots of time spend on development and improvement, it seems.

• Management must go to gemba. A dentist is unique -- Dr. Bahri is the CEO and he is also doing Value Added work at the gemba. That creates some unique leadership opportunities (and challenges, I'm sure).
  

You can also check out the Q&A's with Dr. Bahri, Part 1 and Part 2.

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Q&A With the Lean Dentist, Part 1

Thanks again to Dr. Sami Bahri for hosting me last week. You can read Part 1 and Part 2 of my visit report, stay tuned for Part 3 and for another Q&A. Thanks so much to Dr. Bahri for taking the time to respond to these questions:

Questions from Peter Abilla, of the Shmula blog (interesting link here about Amazon and Lean)

I'd love to learn more about the following:

1) Scheduling and Heijunka

The key point was not to track every single procedure in our business, but to stick to the 20% most frequent ones, (80/20 in frequency). We measured the takt time of those procedures. Then we spread them evenly over the schedule to create a scheduling template. The rest of the schedule was fitted around those core procedures and refined as we learned more about the next most frequent procedures.

2) Wait-Time: What is the doctor doing to reduce or eliminate this all-together?

This question is huge.

The main focus of lean management is reducing delivery (Mouth back to health) time by shortening the manufacturing (treatment) LEAD time.

As a consequence, any unnecessary time, waiting time included, is reduced through the shortening of lead time by pulling services, Just-in-time, one-patient flow etc.

If I had to pick the moments of tangible reductions in waiting time I would say:

• When we reduced setup time
• When we crossed the functional barrier between dentist and hygienist.
• When the front desk assistants accepted the practice of guiding the patients to their room as soon as they signed in.
• When we created the position of "patient care flow manager."

3) How does the doctor balance patient care, empathy, and listening against efficiency?

If you have a copy of “The Machine That Changed the World” look on page 93. It has a diagram showing that in lean, unlike batching, you don’t have to choose between quality, cost and productivity. They go hand in hand. In batch companies, quality goes down when productivity increases, and vice versa. In lean companies, both quality and productivity improve continuously.

If you judge that listening, empathy and patient care are value added, then they need to be accounted for in the appointment block.

In our case, the treatment appointment could be as long as four hours, which allows me to really focus on my patients need without being distracted by running back and forth to other patients. We are consolidating not only treatment, but also communication. Long appointment times give us plenty of time to discuss with our patients any relevant issues.

We seem to have good patient retention and tons of word-of-mouth referrals.

Thanks, Dr. Bahri. Stay tuned for more Q&A and more of my thoughts on my visit and what I saw.

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My Visit with the Lean Dentist, Part 2

Last Thursday, I had such an enjoyable visit to Dr. Sami Bahri's office. I was very impressed with the "Lean spirit" of Dr. Bahri and his employees. The culture there is pretty impressive.

Lean "toolheads," if you will, would possibly be disappointed. Is it a "Lean dental office?" they might ask, walking around looking for 5S and kanban cards. As an aside, here's a great paper by John Seddon, about that "toolhead" term and the dangers associated with being fixated on Lean tools. Dr. Bahri and the people in his office are NOT "toolheads" -- that's a good thing.

It's much more important to have a "Lean culture" and the Lean mindset in place, more so than the Lean tools. If you were to come in looking "have they 5s-ed everything?" you would be disappointed, and I think you'd be missing the point.

The office is focused on solving problems and preventing problems. Rather than implementing tools, I could tell the discussion is focused on making things better for the patient (reducing delays and inconvenience) and making work easier for the employees at all levels. That was impressive. I talked with many employees and they all talked about the same mindset, which was impressive. There is a drive to do things better. The employees (including Dr. Bahri) do not seem fixated on the press and the awards they have received.

"We're not perfect, but it's better than before. And we keep working at getting better."

That seemed to be the mantra, everyone seemed to make that same comment. Continuous improvement, involving all employees, and eliminating waste. They have a very advanced Lean culture, compared to almost any workplace I have seen or been a part of.

Talking to Dr. Bahri in his personal office, I saw many books that I also have on my bookshelves. We're both heavy readers. You would recognize many of the books, I'm sure. What is impressive to me is that Dr. Bahri (as you heard about in his Podcast) has gone to all of the original source texts -- Ohno, Shingo, Deming, and he has distilled it to what matters for his dental practice business. He didn't have anyone to copy, at least another dentist, so they had to figure it out for themselves.

"We start with the patient, not with the tools," a front-desk employee said.

I also saw the break room, which also doubles as the daily team meeting space. Just looking at the whiteboard, there's very neat evidence of the discussions that happen every day -- part training, part problem solving. It might be the only dentist office breakroom where the whiteboard has scribbles about:

• Process maps
• The types of waste
• The cost/price/profit equation (how price is set by the market, you increase profitability by reducing costs)
• Taguchi loss function

I saw examples of the Training Within Industry methodology, including a front desk assistant who showed me classic Job Breakdown Sheets that employees had been creating (and updating!). They focused on "what was important to document" rather than just documenting for the sake of documenting, which was nice to see.

Here's something that you can't teach, necessarily, and it's hard to copy -- you can tell Dr. Bahri cares about his employees very much. "Explaining why" is part of the culture, it's something they work at (although there's still room for improvement, which Dr. Bahri recognized when I pointed out a "warning" sign that didn't explain why). That's a key part of the "respect for people" principle.

Dr. Bahri and his office still have a lot of opportunities ahead, both in terms of implementing Lean methods and for their business, in general. The Lean improvements have freed up capacity that needs to be filled. So, if you know anyone who wants a new dentist in Jacksonville, Dr. Bahri's office can take them on. There is a strong commitment to making sure that freed up capacity won't translate into laid off employees.

In Part 3, I'll come back to the Lean tools that I saw in place and I'll also have some final comments about my visit.

You can also check out the Q&A's with Dr. Bahri, Part 1 and Part 2.

Thanks again to Dr. Bahri and his team for letting me spend time in their "gemba."

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My Visit with the Lean Dentist, Part 1

Here is a photo of me and Dr. Sami Bahri, the World's First Lean Dentist. I spent the afternoon at his office, observing their "gemba", talking with him and with his staff. What an incredible afternoon. I still need to absorb it all, but I will write about some highlights and what I saw.

If you zoom in on the photo, you can see some visual controls... a very manual (yet effective) "andon" system that indicates when somebody in a patient treatment area needs assistance. If you need a hint, it's the green cards.

That's good and all, but the Lean Dentist isn't about "Lean Tools." It's a story of Lean Culture and an amazing spirit amongst all of the employees. It was my privilege to be hosted by them today.

Additional Posts: Part 2 | Part 3 | Q&A with Dr. Bahri Part 1 | Part 2

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Visiting the Lean Dentist

I've been fortunate to be attending a healthcare related event in Jacksonville FL this week and I've had the chance to meet Dr. Sami Bahri, the "world's first Lean dentist," who lives and works here. You may remember him from our Podcast conversation that we shared.

Tomorrow afternoon, he is graciously letting me visit his office (no, I'm not getting my teeth cleaned). Dr. Bahri has agreed to let me write about my visit and what I see, so I will try to get that posted ASAP.

Let me know if any of you have specific questions for me to ask and I'll pass them along, maybe we will do a follow up Podcast.

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Your Dermatologist Might Not be FIFO

Patients get appointments for Botox faster than for moles: study

You might expect that a doctor's office either takes appointments in terms of:

• FIFO (first into the queue, first out -- first called, first seen) OR
  
• Triage priority (more serious or time critical cases first)

Here's an article with a study that suggests that some dermatologists are giving expedited priority to high-profit Botox customers over those who have concerns about potentially deadly skin cancer.

"The study was conducted last year by telephone with researchers posing as patients, contacting 898 dermatologists in 12 US cities.

In Boston, for example, the median wait for a Botox session was 13 days while it was nine weeks for an examination of a changing mole."

This was repeated in multiple cities and the study author said:

"It was possible doctors wanted to offer faster access for Botox treatments "because of higher relative payments for cosmetic services," the study said."

You might understand Dell choosing to build a huge order of expensive PC's first over a few smaller orders for a single $399 PC.... that's profit maximizing. But, as much as healthcare likes they say "they're different", this seems like once case where they are NOT different, and maybe they should be.

What do you think? I assume we have mostly patient perspectives here...

Profile of ThedaCare's CEO

John Toussaint, M.D. - Profile

From the University of Iowa alumni site, here's a nice Q&A with one of the leading advocates for Lean in healthcare, Dr. John Toussaint, CEO of ThedaCare, which is mentioned often here on the Lean Blog. Let's consider this a mental "palate cleanser," since he has such a positive attitude about improvement, leadership, and teamwork. You won't hear a lot of excuses from Dr. Toussaint.

From the Q&A:

Please describe your professional interests?

Presently I am doing a lot of work on quality improvement. Our organization of 5,300 employees is on a journey of continuous improvement. We are learning from Toyota how to create defect free care for our patients using the ThedaCare Improvement System.

Do you have an insight or philosophy that guides you in your professional work?

My philosophy is to improve something everyday. Our industry is stuck on compliance, not improvement. We are changing that at ThedaCare.

If you could change one thing about the practice or business of medicine, what would it be?

Stop the shame and blame and start working together as a team to improve the care we deliver.

What do you see as "the future" of medicine?

It is bright, but it will be about improvement not apprenticeship. Go spend a day at Toyota and you will see the future of healthcare.

Great lessons that can be applied anywhere.

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LeanBlog Podcast #29 -- Dr. Sami Bahri, "The World's First Lean Dentist"

LeanBlog Podcast #29 features a very special guest, Dr. Sami Bahri, "The World's First Lean Dentist." If you're thinking "what can I learn about lean from a Dentist?", please listen in. I think you’ll be amazed and will learn a ton. I’ve really enjoyed the two chances I’ve had to talk with Dr Bahri, including this podcast session and I’ve been very impressed with his approach to lean. He’s gone back to all of the source texts, including Shingo and Ohno and has really had to figure it out for himself, as opposed to following a cookbook approach. I particularly appreciate how he involves his employees and staff… it’s a great example we can all learn from.

If you have questions or comments for Dr. Bahri, he’s agreed to a follow on podcast. You can email me at leanpodcast@gmail.com or visit leanpodcast.org to leave a comment or read some linked articles about Dr. Bahri. His website can be found at http://www.firstleandentist.com/.

If you enjoy this podcast, I hope you'll check out the rest of the series by visiting the LeanBlog podcast main page.

MP3 File (Right Click to Save-As)

Keywords and Main Points, Episode #29

• Learning about Lean and figuring out, over time, how to apply it to a dental office.


• How Dr. Bahri is able to take care of patient needs all in a single visit (not coming back for separate follow on appointments).


• How Dr. Bahri has engaged his workforce, through Lean, to improve productivity, job satisfaction, and employee engagement.


• Lean as a never-ending journey toward perfection, an experimental process.
  
• Learn how Dr. Bahri's office creating an innovative "flow manager" position.

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.

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The First Lean Dentist

I recorded my Podcast interview with Dr. Sami Bahri, "The First Lean Dentist," last night. What a treat it has been to talk with Dr. Bahri. I can't wait to get this edited and released so you all can hear the discussion. Dr. Bahri is pretty humble, but I am so incredibly impressed with his Lean understanding -- the tools, the employee involvement, the management system, the drive for continuous improvement.

One example of what jumped out at me was his discussion of leadership and PDCA. I'm paraphrasing, but Dr. Bahri said he tells his employees "Don't trust me" when he has an idea. He doesn't want them implementing or changing something because he says so. He wants them experimenting to see if the idea works or not. Sometimes the ideas don't work, and that's OK. He is setting a great example of PDCA (Plan, Do, Check, Act) for his employees, so they will give their own suggestions and follow that same model.

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Video -- Lean in the UK National Health Service

The positive ER post of the day.... here's a nice video of a news story from the UK. The physician being interviewed does a good job of explaining Lean. "Accident and Emergency" is the UK term for "Emergency Room"

• Reducing wasted/unnecessary steps
  
• Better for the staff (more time on patient care)
• Better for the patient (more timely care that's safer)

The negative ER post of the day is found here.

I'm Writing A Book!

Last week, in calling for "guest bloggers," I hinted at a "special project" that will be keeping me busy over the next few months.

The tentative title is:

"Lean Hospitals: Improving Quality, Patient Safety and Employee Satisfaction"

It will be published by the well-known Productivity Press.

Wish me luck!

I won't disappear from the blog completely, but I'm going to try to force myself to spend a little less time on it.

The good news is that we'll have a lot of good guest bloggers and I hope that will lead to even better things for the Lean Blog in the long run.

As always, thanks for reading and supporting the Blog.

Update: It will be a while before the book will be done and before it will be published... no real ETA to share, but I'll continue to post here about my progress. It's my plan to have a public commitment here to get this thing done.

I also have a modest webpage for the book at www.leanhospitalsbook.com.

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