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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Mark on the "Better Process" Podcast

PodcasterNews - Better Process Podcast - Industry Report Mark Graban LeanHospitalsBook.com

OK, this is turning into a highly promotional week for my book, hope that's OK with everyone.

Here is another podcast interview, this time conducted by Ken Rayment. I've been interviewed by Ken before, and I also did a guest commentary about Lean healthcare last year. There are links to both of those here, on my book's webpage.


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Mark on the "Competing Podcast"

Lean Thinking Network | Competing Podcast » Archive » Competing Mark Graban

Thanks to Dwight Bowen for having me as a guest on his excellent podcast series. I chatted with Dwight about my book and the applications of Lean methods in healthcare and hospitals. Hope you enjoy the podcast.

Update on the book -- still targeted for late July, the book actually went to print a bit early. On time delivery!! (Knock on wood). I hope you also think the quality of the book is to high standards as well!



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A Powerful Message on Lean and Healthcare

Why I Work In Healthcare | DailyKaizen

Here's a great one to end the day on... Lee Fried has a powerful post over on the DailyKaizen blog. Some unfortunately heartache for him and his family, but an important reminder of why this stuff is so important (and why Lean is so powerful in helping).

Go to his site to read the whole post and the story behind it, but he's spot on about this (and everything he wrote, actually). Lee said:

I often find myself debating with people within my industry whether standard work can be applied to patient care. I often hear back that it does not apply because ”no two patients are the same” or “healthcare is far too complex for standard work” to work. This argument is frustrating and we need to find ways to put to rest. I am sure that every industry has heard the same exact argument about why standard processes can not be applied in their field. I was telling my neighbor about what happened and he confirmed that in his industry (aerospace) twenty years ago it was the same story. “Airplanes are far to complex to be built by standard processes.”

Yes, let's put the argument to rest. Lean *does* work in healthcare. Standardized Work is saving lives in many ways, including "checklists." We need more of this in healthcare and fewer obstacles.

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Surgical Checklists in the News!

WHO Proposes Checklist to Reduce Surgery Errors : NPR

A surgical revolution: checklist that could prevent thousands of deaths

Thanks to long-time readers Chet and Andrew for pointing out these similar stories, one from NPR in the U.S. and one from The Independent newspaper in the U.K. (front-page news!)

As a Lean thinker, I love the idea of checklists. They are the Lean concept of "standardized work" in a different wrapper. Standardized work helps ensure quality and consistency of processes - whether in a factory, an airplane cockpit, or a medical setting.

Checklists, when done properly, are written by the people who do the work (just as we would do with standardized work). This isn't about consultants, mangers, or a single expert dictating the process to others.

Checklists aren't intended to "turn people into robots." Checklists and standardized work are a foundation, they cover typical situations, but can't cover everything. When a truly unique situation comes up, people are expected to utilize their professional judgment - to use their brains. There's a Toyota expression that says standardized work allows you to avoid hundreds of little decisions so you can make the one major decision that matters.

Checklists aren't "carved in stone" practices that can never change. As new evidence or practices emerge, checklists and standardized work can be improved - that's the Lean concept of "kaizen."

All of these principles were seen back in the story of the cardiac surgeons at Geisinger Health System in Pennsylvania. The surgeons themselves credited the checklists and standardized process for elective bypass surgeries - before, during, and after. The surgeons were able to deviate from the standardized work IF they had a reason they could justify to their peers (not just "because I didn't want to follow it today"). They improved upon their standard over time... and outcomes for patients improved dramatically.

As I've also written about, the work of Dr. Peter Pronovost and Dr. Atul Gawande has proven that checklists are incredibly powerful - preventing infections another preventable patient harm. This probably should be a surprise to Lean thinkers.

So now the World Health Organization is looking to spread these simple, yet powerful, practices around the world.

From NPR:

Since the 1930s, airplane pilots have run through checklists before taking off. Now the World Health Organization wants surgeons all over the globe to use them, too.

Dr. E. Patchen Dellinger, a surgeon at the University of Washington Medical Center in Seattle, says people are surprised when he tells them about the project.

"One of the common reactions is, 'You mean you weren't doing that before? Good heavens!'" he says.

Yes, I can understand that reaction! For all of the medical and clinical brilliance in our hospitals, they often have a great deal of opportunity for operational improvements.

Of course there will be resistance to this - as with any change. Again, from NPR:

Gawande says there's been some resistance to the list. One London surgeon thought it was demeaning "Mickey Mouse stuff" until one day in the operating room.

"Right before the incision [the medical team] took a timeout," Gawande says, "and when it came to the nurse's turn to raise any concerns, the nurse asked: 'Are we really sure we have the right size knee replacement for this patient?'"

Turns out, they didn't — not anywhere in the hospital. That surgeon now swears by the surgical checklist.

The surgeon now sees the benefit of the checklists - to the patient and to themselves (avoiding a lawsuit -- although I don't know how the legal system treats that in the U.K., compared to here in the U.S.). We have to sell people on the benefits of checklists -- not just forcing the method on them and saying "here, do this." It's one of my truisms that "people don't like to be told what to do." That's true not only for doctors... but for practically any time of person or role.

From The Independent:

More than eight million operations were carried out in the UK last year, equivalent to one for every eight people in the population, and there were 129,000 reported incidents in which patients were put at risk, according to the National Patient Safety Agency.

An estimated 2,000 NHS patients die each year as a result of errors in treatment, and an inquiry by the National Audit Office in 2005 concluded that half of all incidents could have been avoided if staff had learnt the lessons of previous mistakes.

And more quotes from Gawande:

Atul Gawande, the US surgeon and columnist for the New Yorker who is leading the initiative for the World Health Organisation, said: "The complexity of medicine has increased to the point where no one person can ensure it is delivered reliably and accurately. We have been struggling for a tool that can help people reliably deliver safe care. The checklist is turning out to be as important to successful care as the stethoscope. I think you could make the case that it is the biggest innovation since the stethoscope."

...

Dr Gawande said: "At the start of the pilot in the eight hospitals, 64 per cent of patients missed at least one check. Putting in the checklist cut the failure rate by half and has reduced deaths and complications, though it is too early to put a figure on it. The remarkable thing was we couldn't tell the first world countries from the developing world countries. This has shown we can do something we have never seen before – improve the safety of surgery on a population basis."

I'm surprised that the error rate was only cut in half. Having the checklist is one thing -- we need a management system and culture that ensures that the checklist is used the right way. Zero errors needs to be the goal with checklists.

Worldwide, the WHO aims to have the checklist operating in 2,500 hospitals in the most populous countries (with 75 per cent of the world's population) by the end of next year.

If you're reading this and you're not a hospital employee or leader -- if you're a patient -- it's time to push your local community hospitals to implement this proven method. If not before YOUR surgery, then before the surgery of a neighbor or a loved one. As Pronovost said before, the only thing stopping us from spreading the use of checklists is a lack of desire to do so.

The method is cheap, it's relatively easy, and it works!

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Tom Peters on Healthcare

From Modern Healthcare, Tom Peters throws a few verbal bombs at the healthcare industry:

---

Quality gains needn’t be costly, Peters tells HFMA

Financial executives can do more to improve healthcare quality and it won’t cost more money to do so, said management guru Tom Peters, speaking at the Healthcare Financial Management Association’s yearly meeting.

In a keynote speech, Peters told attendees of the gathering that “despite our good work in some areas, like patient safety, we still haven’t reached up to the awful level.” The high number of hospital-caused drug errors and infections is a “disgrace,” Peters said.

Peters is absolutely right that better quality CAN cost less - and it should. Improving processes saves money -- Lean is one way to get there. I guess Peters has earned the right to throw rocks... is it helpful? In his talk, Peters said we need to train more in "people skills" not in numbers. To me, Lean definitely falls into the "people" side as opposed to being really mathematically rigorous like, say, Six Sigma.

Managing the right process will bring the right results -- that Lean truism certainly holds in healthcare. Managing processes means getting out there and seeing how work is done, working with and coaching people. I think the path to improvement can't rely exclusively on measurement, quotas, and incentives. You have to manage the people and the process. I'm hoping Peters would agree with that.

The HFMA website also has an interview with Peters.

Peters often speaks in terms that might remind you of Lean:

My revolution is a revolution of simplicity that gets us focused back on delivering health care and realizing that a lot of our operational problems that are involved with healthcare delivery itself are problems that can be fixed with some straightforward solutions. Just throwing money at these problems is not the answer.

You could think of Lean as a "revolution of simplicity" (he *is* good with turning a phrase). With Lean, we simplify procedures to get the waste out of people's day -- eliminating unnecessary steps and activities so people can focus on caring for patients. That's the brilliance of Lean -- not "working harder" or "being more careful." Lean solutions are straightforward - they seem like common sense, in hindsight -- but yet we're not always adopting these ideas on our own, without Lean training and coaching.

Part of his advice for CFO's:

I don’t want you to sign off on a $3.5 million investment to make patient safety things happen in your hospital. I do want you to sign off on 14 little experiments that go after bits and pieces of it where we can see what works and what doesn’t work.

That's also Lean thinking!! Great stuff from Peters...

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My Letter to the IE Magazine

I'm a proud member of the Institute of Industrial Engineers and their sub-organization the Society for Health Systems. I try to contribute to the cause with my "Everyday Lean" blog series that they host on their site. I wrote a "letter to editor" after reading something in their magazine recently...

I don't have the exact article I'm referring to from their March edition, but it was a short article (probably pulled from a wire service - a version of it can be found here) about hospitals using information systems and how that benefits patients. I think IE only published the first two paragraphs or so.

Anyway, after reading the article, I wrote a letter (in two separate graphic files, click for a larger view if needed):




I offered to write something (they edited that out of the letter and didn't respond to the offer). It would be nice to see an article in there about what Industrial Engineers are doing with Lean and process improvement activities. I'll have to follow up with one of their editors.

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Let the Process Experts Decide

Leading article: Infected by political calculation

This isn't a "Lean" story, per se, but it still caught my eye. Hospital-acquired infections are a major problem throughout the world. As this commentary from The Independent points out:

Britain has the worst record of hospital infections in Europe, and patient surveys reveal that superbugs have overtaken waiting times as their prime source of concern. The situation could not go unchallenged.

Fair enough -- it's a serious problem and it demands attention. The "solution" reminded me a of a recent rant from a specialist physician I saw back in the U.S. a month ago or so. He started complaining about all of the government interference in healthcare and he said "Every time there's legislation about medicine, they make it worse. They need to let doctors make the decisions, not the politicians."

To be a cynic, a politician's job is to get re-elected. Are they always making decisions that are right for the community or for patients? Back to the article, where the Prime Minister got involved:

But as so often with this administration, new rules have been accompanied with a heavy dose of politically-motivated and unhelpful meddling. Last September, Gordon Brown announced that the 1,500 NHS hospitals in England would be subjected to a "deep clean". It sounded good. This would involve clearing wards, washing walls and scrubbing behind radiators.

But there was a problem. There was no clinical evidence to suggest this was where effort ought to be directed. According to infection control experts, superbugs were being spread not by bacteria multiplying in neglected corners of wards, but by sloppy daily cleaning procedures and the failure of many medical staff to wash their hands properly. Yet the Prime Minister ploughed on anyway because the idea of a deep clean was deemed a way of communicating to the typical voter how seriously he was taking the problem of superbug infections. Most hospitals finished their deep clean three months ago and, as we can see from these latest figures, it has made very little difference to the standards of cleanliness in our wards.

Millions are being spent on efforts that "sound good" or "feel good" instead of doing what really works. Pretty lousy, huh? How do we get local hospitals to manage their "Standardized Work?" -- That's the challenge. It's not a great revelation that hand hygiene is critical. How do we get people to follow good daily processes (for hand hygiene and room/equipment cleaning) instead of taking big splashy efforts that might not make a difference. Did the politicians ASK hospitals, executives or physicians, how to solve this problem or did they mandate a "solution?" Sounds like they should have done more asking.

The column concluded:

This is a lesson on how little is achieved and how much is wasted when politicians put the chase for favourable headlines above expert advice. It is not only our hospitals that urgently need to clean up their act.

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Lean in a Liverpool Hospital

Follow Royal’s example on waiting lists, hospitals told - Liverpool Daily Post.co.uk

Nice story from here in the UK (where I am right now), about an NHS hospital in Liverpool reducing surgery patient backlogs and delays through Lean. From the article:

Surgeons, nurses, porters, managers, anaesthetists and admin staff got together to think of ways to shorten the patient journey for orthopaedic surgery at The Royal Liverpool Hospital.

This meant the number of planned operations taking place within 18 weeks of referral improved from 35% in April, 2007, to 88% in March, 2008. The number of patients waiting over 11 weeks for in-patient planned treatment fell from 261 to nine.

Theatre start times before 9am have been improved by 20%, and total cancellations have been reduced by 7%. Patient cancellations have been reduced by 30%.

The hospital has been working by the Lean method, which eliminates waste and improves efficiency.

Sounds like some nice teamwork and improvement. I'm nit picking on the reporter, but to give credit to the people at the hospital, the Lean method doesn't do anything. It's people using the Lean method, their drive, their leadership, and their creativity that eliminates waste and improves efficiency.

I'm hoping, in the future, I'll be able to publish or write about some of the work I'm doing over here.

I do have another publication coming out this summer, co-written by a colleague, about some Lean work at a hospital in Ontario, Canada. That will be in the Society of Manufacturing Engineers Lean Yearbook 2008. I also contributed a piece to the SME 2007 Yearbook, which can be ordered here. When the 2008 book is available, I'll post about it here.

So back to the main point... Lean really is universal -- across industries, across continents, and across cultures. It works! Or, I should say, the people make it work!

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LeanBlog Podcast #46 -- Dean Bliss, Lean Healthcare

Episode #46 is a chat with a good friend of the Lean Blog, Dean Bliss, a Lean Improvement Specialist with the Iowa Health System. Like myself, Dean made a transition in from manufacturing into health care a few years back, he'll share some of his experiences and recommendations for how to use Lean in a hospital and how to make that transition. He will also share some stories about how his hospital prioritized what problems to solve with the Lean methodology.

For earlier episodes, visit the main Podcast page, which includes information on how to subscribe via RSS or via Apple iTunes.

You can use the player (use the VCR-type controls) below to listen to a "streaming" version of the podcast (or click here for the streaming audio and RSS subscription). The streaming link is faster for one-time listening (hardly any delay to start listening). Or you can use the download link to put it on your iPod or other MP3 player.

MP3 File Right-Click to "Save As"

Enhanced AAC File

Episode #46 Key Words and Links:

• Lean in hospitals, making a transition from manufacturing into hospitals, how to get started with Lean in a hospital, what are the differences between working with people in these different settings?
  
• Iowa Healthcare Collaborative
• World Research Group event, June 25-26
• The 2nd Annual Summit on Deploying the Toyota Production System & Lean Healthcare in Hospitals

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.

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The President of Johns Hopkins Believes In Lean

Johns Hopkins Gazette | June 9, 2008

From the online newsletter of William R. Brody, president of The Johns Hopkins University. He writes:

First, a disclaimer: I don't own any stock in Toyota and am not going to get any discount on future purchases, even after writing this article.

On the other hand, I have been a shameless promoter of the automaker's manufacturing process, called Toyota Production System, which has become a widely copied (but rarely matched) method of continuously improving service. We have been using these methods very successfully at The Johns Hopkins Hospital to reduce medical errors and improve quality.

It's great when influential leaders see, understand, and value the power of Lean. That can only help further the spread of this powerful management system.

Johns Hopkins is the origin of Dr. Peter Pronovost's work on "checklists" -- the Lean concept of "standardized work" basically, in another name. It's not rocket science -- it's Lean process design and having a commitment to making sure a standard process is actually followed consistently.

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'Lean" (Toyota Production System) is Not Just for "Lean Times" (Bad Economy)

Grand Forks Herald | News in area business (scroll down)

From a North Dakota newspaper... see if you can spot the part of the article that irritated me:

"Training at Villa, Fair Meadow nursing homes

A $279,483 grant from the Minnesota Jobs Skills Partnership, matched by $456,000 from two participating providers, the Villa St. Vincent/Summit in Crookston and Fair Meadow Nursing Home in Fertile, Minn., in collaboration with Northland Community and Technical College, Thief River Falls, will make advanced lean healthcare training possible at both institutions.

The term “lean” applies to changes that need to be made in lean times.

The program will run for three years. NCTC will work with the two facilities to provide advanced, on-site lean courses on the fundamentals of lean health care, principles of continuous improvement and workplace organization. To help sustain a lean culture, a train-the-trainer course will be created for each facility. Continuing education credits will be awarded to trainees who successfully complete the training."

It's certainly not the part about money being spent to improve nursing home care. Nor did I mind anything in the third paragraph. You need a focus on a Lean culture, not just implementing tools. It needs to be a somewhat sustained effort to "make it stick" in the organization.

It's the middle paragraph... the last part:

"...need to be made in lean times."

Implementing Lean has nothing to do with "lean times" -- meaning either a bad economy or financial pressure to an organization. We also "need" Lean improvement (meaning quality improvement, safety improvement, employee morale improvement, and cost improvement) when times are GOOD. There's never a bad time to implement Lean in the sense of "lean times" or "good times."

The original The Machine That Changed the World definition of Lean had nothing to do about who was in "lean times." It was about Toyota's incredible advantage in quality, speed, cost, etc. True, you could say it was Toyota's (and Japan's) "lean times" after WWII that led to their creativity and development of the Toyota Production System. Have GM's "lean times" led to similar innovation?

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Using Lean Simulations to Spur Emergency Room Improvement

Institute for Healthcare Improvement: Getting Lean in the ED

Here is a story that includes examples of Lean improvements at Rockford Health System in Rockford, Illinois.

“The simulation embodied the difference between a classroom lecture and a psycho-motor experience,” explains Berg, whose ED is at Rockford Memorial Hospital, a Level 1 trauma center designated to lead health care disaster response in northern Illinois. Berg says the simulation helped him gain a better appreciation of team dynamics and “a better understanding of how to bring others on board.”

They were first exposed to Lean concepts through a simulation exercise conducted by the IHI. One improvement was the creation of an "Express Care" track (creating a separate "Value Stream" for patients with relatively simple cases):

At Rockford, the principle focus of change in the ED has been the Express Care unit for non-urgent problems such as wrist or ankle sprains or simple lacerations. Despite best intentions, says Jeff Berg, the four-bed unit was far too dependent on the main ED. “There was no dedicated waiting area, registration, or even staff. We drew everything from the main ED. The closest physician sat about 30 feet away.” The newly redesigned Express Care space has only three beds, but its own registration/discharge area, waiting room, and supply closet. There’s a nurse assigned exclusively to this unit and by June 2008 there will be a dedicated physician as well. During a one-week measurement period in February 2008, the redesigned Express Care unit produced shorter-than-usual waits for patients and no patients left without being seen, says Berg.

It's those results that matter -- reduced wait times for patients and they're no longer "bailing out" and leaving before receiving care. We have to hope the improvements have been sustained beyond the initial week.

There other "kaizen" improvements being made:

Smaller efficiencies have also been tried ― though not officially adopted ― in Express Care, such as getting rid of the bed pillows. “These patients don’t need them and it takes 30 seconds to change a pillowcase for the next patient,” says Berg, “so by eliminating pillows, every 30 patients or so, we could save 15 minutes, which is enough time to see an extra patient.” Another time-saver might come from the dispensing of medications, says Berg. “Instead of giving patients their first dose, along with their prescription we could just give them the prescription unless there’s an urgent need, for pain-killers for instance.” This would mean that, most of the time, the nurse wouldn’t have to fetch the medication or record the event in the patient chart.

The pillows -- that's a case where care should be taken to make sure patients really don't use them, that the efficiency isn't based on staff needs or a staff assumption. Maybe pillows are still available, if requested?

A few other kaizen examples given in the article, examples of Lean methods:

Visual aids such as neon-colored band-aids to show that a patient’s blood cultures have been drawn or paper flags that signal the arrival of test results;

Materials management, including centrally located supply closets for less commonly used supplies and pre-assembled equipment carts for frequently performed procedures so they can be stored near their point of use;

Standardization that leads to treatment guidelines for specific complaints (protocol checklists); and

Load-leveling or coordinating staff schedules to correspond with demand, and balancing workloads among nurses, technicians, and physicians to enhance flow.

A final thought. I think we can hope that hospitals and ED's are not just implementing Lean tools. Hopefully they are also learning about the Lean management system and behaviors for leaders and employees. How do you get all employees engaged in continuous improvement? How do you get all leaders to listen to their staff, making sure they are respected? That's the long-term improvement challenge (as well as being the opportunity).

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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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"Rounding" and "Gemba Walks"

StuderGroup - The Magic of Rounding

Here's a good article from Quint Studer about "rounding" -- something Lean folks might refer to as a "Gemba Walk." Studer's writing on leadership and management, although hardly referencing "Lean" or "Toyota," is pretty well aligned with the Lean management system.

His new book, Results That Last: Hardwiring Behaviors That Will Take Your Company to the Top, is inexplicably on sale for just $4.99 at amazon.com right now (I ordered a copy just now, since I haven't read this one yet). His earlier book, Hardwiring Excellence: Purpose, Worthwhile Work, Making a Difference was very inspirational and it's something I wrote about before and recommended even to manufacturing leaders to learn from. We could all apply his methods for "hardwiring" performance in ANY organization.

So back to the article on rounding. Some snippets:

As a leader, you want your employees to be happy, productive, and loyal. Indeed, it’s your job to create conditions that facilitate these qualities.

What a great start, very first sentence. How many managers blame the employees for having "poor morale"??

The good news, says Quint Studer, CEO of Studer Group, is that there is a proven way to stay on top of what your employees really want and need. It’s a concept from the health care arena called “rounding”—and it translates nicely to the world of business management.

“Rounding is what doctors in hospitals have traditionally done to check on patients,” says Studer... “The same idea can be used in business, with a CEO, VP, or department manager ‘making the rounds’ to check on the status of his or her employees. Rounding is all about gathering information in a structured way. It’s proactive, not reactive. It’s a way to get a handle on problems before they occur and also to reinforce positive and profitable behaviors. Best of all, it’s an efficient system that yields maximum ROI.”

Sounds just like a "Gemba Walk" doesn't it? This isn't about going around and just saying hi to everyone, it's "rounding with a purpose" (to use another phrase that Studer uses that I really like).

But is this time consuming? All managers are insanely busy with meetings and reports and email, right?

In a business setting, rounding involves leaders’ taking an hour a day to touch base with their employees, make a personal connection, find out what’s going well, and determine what improvements can be made. Quite simply, it’s a way to gather the information you need to do your job and do it well—in a timely and efficient manner.

One thing Studer advocates is focusing on the positive - what's working well? My understanding is that Toyota leaders always ask about problems first -- what are your top 3 problems? They ask about problems before focusing on anything good. Maybe Studer's approach is more palatable in a typical non-Toyota culture? Many people I've worked with cringe at the word "problem" -- seeing it as a far more negative word than I would myself.

Anyway, be sure to check out the article. Lots of great stuff in there. What do you think? Helpful to you in hospitals or in factories?

About the only nit I would pick is this point in Studer's 9 tips for Rounding:

6. When someone brings up a problem, assure him or her that you will do the best you can to get it resolved. Obviously, there will be circumstances you can't control. But people appreciate knowing that you will try. Sincere effort goes a long way.

Now "servant leadership" (which Toyota and Studer both advocate) is a wonderful thing. But the way Studer words it implies that any time an employee brings a problem to you, the leader, it's your job to fix it for the employee. The Lean approach encourages managers to push problem-solving and improvements to the employees themselves -- if they can.

The Lean leader only takes on problems that cannot be solved by the employees. You don't want to encourage over dependence on you, the leader, to always be the problem solver and the doer. There are certain complex problems or cross-functional problems that DO require a manager's involvement. My advice is that you have to be careful to not take on everything as a manager -- your time is limited... you're only one person. You can't fix it all.

But, you can using "rounding"!! Tell your employees you're borrowing a best practice from healthcare if they're tired of hearing about Toyota. :-)

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"Checklists" Innovator is One of Time's 100

Peter Pronovost - The 2008 TIME 100 - TIME

It's so nice to see someone like Dr. Peter Pronovost on the "most influential" list, even though he's out of place among the Miley Cyruses of the world (also on the list, ugh).

If you're regular Lean Blog reader, you know about Dr. Pronovost and his "checklists" -- a perfect adaptation of the Lean "standardized work" concept to medical settings.

TIME explains:

A critical-care researcher at Johns Hopkins University, Pronovost may have saved more lives than any laboratory scientist in the past decade by relying on a wonderfully simple tool: a checklist.

The checklists help dramatically reduce preventable patient infections and the practice spread beyond Johns Hopkins:

Michigan hospitals began implementing Pronovost's checklists in ICUs in 2003. Within three months, hospital-acquired infections at typical ICUs in the state dropped from 2.7 per 1,000 patients to zero. More than 1,500 lives were saved in the first 18 months.

The only burning question is why this method is spreading more quickly!!

California and Spain top a long list of places that soon hope to replicate Michigan's results. Pronovost says the checklist protocol could be rolled out nationwide within two years for less than $3 million.

Hat tip to the Wachter's World blog for pointing this out, read what Dr. Wachter has to say about Dr. Pronovost.

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Open Source Public Health Software through Lean Methods

Collaborative Software Initiative

The link above is a project that might be interesting to those of you working in "Lean Software"... or those who afraid of problems in our collective ability to track the spread of infectious diseases.

From their press release:

Collaborative Software Initiative (CSI), the company that brings like-minded organizations together to work on collaborative software at a fraction of the cost, today announced the release of the first open source, web-based infectious disease reporting and management system.

The system is being built with Lean methods:

When deployed, UT-NEDSS project will directly contribute to the prevention of sickness and death by effectively collecting, identifying, tracking and trending information gathered about infectious diseases and bioterrorism attacks. Additionally, this unique partnership is providing lessons for public health informatics on:

• Open source software best practices
• Lean Software Development practices
• Building an open source community for a public health product
• Contractual relations between public health entities and a commercial open source software company that support long-term product sustainability

I think we can all hope that systems like this can lead to better public health.

“We are excited by the promise that this collaborative approach offers to our state,” said Dr. Robert Rolfs, MD, State Epidemiologist, State of Utah Department of Health. “This system meets our needs by making it easy for our doctors and nurses across a variety of counties to better protect people’s health by detecting and preventing disease.”

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"Just In Time Patients??"

Medical Leave -- Offshore Medicine -- Fast Company

Interesting read here in the latest issue of Fast Company about a hospital in Thailand and one of the visionaries, Ruben Toral, who wants to globalize healthcare. The idea of patients flying halfway around the world for elective surgeries, taking advantage of lower labor rates, isn't exactly new.

"For someone such as Toral, the hypertrophied medical-industrial complex is just begging for a dose of disruptive innovation. He calls his vision the "Toyota-ization of health care," a metaphor so vast that it contains multiple readings, some fit for industry conferences and others he'll cop to only in confidence."

I'm not really sure what he means by that, Toyota-ization. Maybe one analogy is to compare the current American hospital industry to the Big Three automakers in the 1970's? Toyota, Honda, and others brought new competition to the market, bringing better quality AND lower costs. Much as the Big Three didn't believe you could have high quality and low cost (many thought Toyota was "dumping" products illegally below cost i the U.S.), you often have people in healthcare who don't believe you can have high quality and low cost.

There's often a mindset that healthcare is immune to "offshoring." Not that I'm advocating the practice of shipping people halfway around the world for medical care, but it will be interesting to see if this creates a crisis -- creating competition that creates more of a need for change. This can maybe spur improvements in quality AND cost in U.S. healthcare? These "medical tourism" hospitals are supposedly very clean and safe, run to very high standards.

"In order to ensure continuity of care," he goes on, "you'll never leave the system. What could be better than telling an American patient they're going overseas to an American-owned hospital? They're going to discover the same supply-chain advantages Toyota did when it created just-in-time manufacturing. We're going to have the same thing -- just-in-time patients. Hospitals are not going to spend any more money or any more time in the movement of that patient through the system than is necessary. They're going to get the patient in, get them on that global platform, and get them back. Now, how do they do that in a fast, efficient way where quality is kept, efficiency is gained, and prices don't go up? It's classic manufacturing and logistics."

The supply chain efficiency he describes sounds like local efficiency -- the idea of reducing waste reducing waste (eliminating patient flow time that is more "than is necessary"). But what about the supply chain at the global level? Toyota's approach is to be close to the customers. This approach, shipping customers halfway around the world, seems more like the notion of building product in China, shipping it halfway around the world. That's not necessarily Lean. Wouldn't it count as more movement than necessary, getting on a plane from Texas and flying to Thailand?

Toyota builds factories close to their customers (as evidenced by their North American expansion). Wouldn't a truly Lean medical model involve high quality care close to the customer, without waste or unnecessary time or expense? Flying everyone to Asia doesn't seem like a root cause solution to our problems with healthcare costs and quality.

It's interesting to think about, this global "patient chain." What would happen if the only care provided here in the U.S. were true emergency care? What if anything planned or non-emergent were being done in high-quality facilities in low-cost countries?

I'm not sure what it is, but I'm not sure it's "Lean" or something worth invoking the name of Toyota for, as Toral does. What do you think - about medical tourism, in general, or the somewhat shaky association to Toyota?

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Nursing Shortage Easing?

Slowdown's Side Effect: More Nurses - WSJ.com:

Not a Lean article, but a major issue for hospitals is a shortage of nurses. With the economy in its current condition, more nurses are returning to work. There's still a need for the reduction of wasted motion and wasted time in a nurse's workday... that's the Lean concept.

"Hospitals have also taken steps to keep older nurses in the work force by making their jobs easier, including replacing hand cranks used to lift beds with automated lift devices, bringing in lift teams so nurses don't strain themselves picking up patients, or putting supplies closer to patients' rooms to cut down on walking."

These are good practices, regardless of age. Lift assists are better ergonomically for nurses (preventing injury) and they can also help prevent patient falls. Reducing walking is good since that wasted time can be used in more productive ways (such as patient care).

Keeping supplies closer to rooms -- that goes against a previous trend toward centralized inventory cabinets (often automated) in a floor or unit. The advantages were all for materials management -- it was easier to restock and kept better control of inventory. But, optimizing materials management shouldn't be the primary goal. The nurses are providing "value added" care -- the job of the rest of the organization should be to support them in "making their jobs easier." There's a pretty direct parallel to a factory using material handlers to allow assembly operators to be more efficient.

You don't want assembly workers to stop, looking for parts. You don't want surgeons digging and searching for tools during a procedure (nurses or techs hand the instruments to the surgeon, an old idea that originally came from Frank Gilbreth). You also don't want nurses to be roaming around, searching for medications or supplies either. Systems and processes (and technology) need to support them in the way they do their jobs.

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The Power of Asking "Why?"

reportonbusiness.com: Asking 'why' again and again is harder than you think, but it works

It's kind of neat to see a column about the "5 whys" method in a general business publication (link above). The consultant and professor in the article gives proper credit to Toyota and Taiichi Ohno, but curiously calls it the "Japanese Manufacturing Technique" (as if that's a proper name). I've near heard that phrase... something he coined rather than just "Lean Manufacturing" or the "Toyota Production System?"

Anyway, the article gives a good example of a 5 Whys analysis from Ohno. In my experience, 5 Whys is hardly ever that neat and tidy (you can hit some dead ends or have multiple branches in the answers), but you can get some real breakthroughs.

Going through a 5 Whys exercise with a hospital group once, we asked "Why are hand hygiene practices not followed 100% of the time?" One real breakthrough was a comment "Our hands and arms are full when leaving a patient room sometimes." We asked why that was, and kept asking why -- turns out that carts were not always available, so the follow up would be a 5S initiative around proper storage locations for carts and having the discipline to keep them there. Instead of browbeating nurses for not washing, our job was to make it easier for them to do the right thing. We thought that was good problem solving -- or more effective than hanging more signs at least.

The linked article also talks about some of the downsides of asking why, especially if you're challenging technical experts or "lords," as he calls them. People can get defensive. You really have to watch your tone of voice when asking why. I've found it's better to ask "Why is it that...." instead of "Why do YOU..." because people take the latter as direct criticism.

Asking "why?" in private or 1x1 can also be less embarrassing than asking someone in front of a group. You always have to be aware of politics and sensitivity. Most of us aren't an Ohno, being comfortable yelling or screaming at someone.

What are your experiences with the 5 Whys, good or bad?

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