Process Firefighting

"process arsonist" - Google Search

I was talking with someone a few weeks back about the analogy of "fire fighting" in a workplace (something that applies in factories and hospitals... any workplace, basically). Typically problem solving involves just fixing the immediate problem. For example, if an item is missing (a part for assembly or a medication for a patient), the fire fighting approach stops when we "put the fire out" meaning we can now build our product or treat our patient.

Maybe this is a bad analogy, showing we don't know much about fire fighting (I would suspect). Does a fire crew all just leave once a fire is doused, or does somebody stay to investigate the root cause? Do they see what can be learned to prevent fires at other places? I bet they do. Can anyone shed some light on true "fire fighting?" Are we being unfair to fire fighters when we use this analogy in the workplace? If you know more about REAL fire fighting, please click on "comments" to share your thoughts.

The knock on workplace fire fighting is that we don't stop to analyze the root cause, nor do we focus on future prevention. When a part or medication is missing, do we (when we have a moment) stop and figure out WHY that happened (not WHO messed up)? Do we stop to improve the process so it can't happen again?

Thinking about medications that go missing in a nursing unit. we might ask questions like:

• Was there not a dedicated, well labeled location for that patient's medications?
• Is there not a standardized process for what to do with medications when they arrive from the pharmacy?
• If this was a stocked medication, does our standard inventory level need adjusting?
• Did the pharmacy have a slow delivery process? If so, what can be done to improve that process?

Depending on the particulars, there are MANY things that can be done after the medication has been found. Now, once the "fire" is out (we have the medication), we might have to first continue our value adding work (giving the medication to the patient). We might not have the luxury of immediately "stopping the line" to get a problem solving team together.

But, I bet later that day we would have some time to work on the process. We might identify a countermeasure to try, or we might better document the problem, setting it aside until a kaizen team can work on it, if it's a bigger problem. Simple fixes should be done immediately, but bigger fixes might have to wait. Such is life.

One other topic that came up was how some people LOVE fighting workplace fires. They get a rush from it. They're the hero. If we fix the process, maybe that person loses their chance to be a hero. Maybe they have less of incentive to be a part of the fix (of course, we have to let them find other ways to feel valuable, since fixing the process is important for the customer -- our patient).

Not participating in fixing root causes is one thing. The person I was talking to asked if some people purposefully create problems (or allow them to happen) so they can fix them. I asked, "that would be a process arsonist then, right?" I'd like to think that doesn't happen much in workplaces, yet alone hospitals.

I did a google search for the term "process arsonist" and surprisingly couldn't find any references. Did I coin a new term?? Have you ever seen a "process arsonist"??

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Fire Fighting vs. Root Cause Problem Solving

Lean Hospitals Book Newsletter Archive

Below is some of the text from edition #3 of the newsletter from my upcoming book "Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction." Click on the archive link above for previous issues or to sign up for future editions, including results from the online survey I conducted for the book.

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Hospitals are notorious for employing "workarounds" to respond to problems. For example, when supplies or medications are missing, the typical response is to run around, looking for what is needed. Once the missing item is found, the nurse might go back to their regular duties -- problem solved, right?

The workaround does nothing to prevent the problem from occurring again -- this ensures more wasted time and more potential problems in the future. It is not fair to blame individuals for this behavior, as workarounds and fire fighting are often encouraged by our organizational culture and reward systems.

In a Lean setting, we still "put the fire out," if you will. If a medication is missing, the first response is to make sure the patient has what they need -- get the med. But we then have to STOP and identify how to fix the process. Instead of blaming people or asking "who messed up?," we have to look at the process.

Two simple questions to ask:

1. How and why did this problem occur?
2. How can we prevent it from happening again?
   
   

For the first question, you might use the "5 Whys" method of continuing to ask why until you reach something that really is a "root cause" rather than being a symptom/result of a more fundamental problem.

With the second question, we focus on prevention. Use "error proofing" methods or ensure that a standardized process and method is in place.

This approach is all about the mind set. If you are a manager and employees come to you with a problem or complaint (or to report fire fighting), be sure to ask them about stopping to identify the root cause. Work together with them on preventative measures. Be sure to communicate changes with the rest of the team.

Many people complain, "That makes sense, but I don't have time for that." Have you gathered data on how much time is spent using workarounds and fighting with the current process? If you invest a bit of time on process improvement (even if it requires a few hours of overtime), you will likely find recurring time savings from improving the process instead of fighting the same fires over and over again.

One hospital pharmacy spent 11 hours a day processing medication that was returned from patient floors. Not all returns are the result of a process error, but many returns are the result of medications not being transferred to another unit along with the patient, for example. By dedicating some time to improving the process (delivering medications more frequently and working with nurses to prevent process errors), this time was significantly reduced. Those hours saved, time not spent processing returns, are saved each and every day.

As "fires" pop up during the day, there might not be time right then and there to stop and use the Lean problem solving approach. It can be useful to have a formal method of documenting problems that need solving as time allows. Sticky notes or note cards on a board can be a simple way of tracking these opportunities (don't hide the notes in a "suggestion box"). When slow times occur during the day, encourage team members to take a card off the board, spending some time on process improvement. Small improvements can often be made in a 20 or 30 minute window, as time allows. Almost all of us have some slack time in our day -- it's just often not identified or utilized properly.

Hospitals can break the cycle of fire fighting -- it requires dedication, some time investment, and continuous reinforcement from leadership until new habits are formed in the organization. When time is available in the day, are we chatting about "American Idol" or working on small process improvements (or "kaizen")?

Here is an outstanding article from Steve Spear and Mark Schmidhofer titled, "Ambiguity and Workarounds as Contributors to Medical Error."

Do you have examples of how you have struggled with breaking the fire fighting cycle? Have you been able to move toward root cause problem solving and prevention? Share your experiences on the message board or click comments to share your experiences here...

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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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Google-Funded eSolar project shows signs of Lean Thinking

By Jason Turgeon:

Google made headlines last year when it announced it that it was going to devote a significant chunk of cash to developing renewable energy that was cheaper than coal (the RE eSolar, a small startup that appears to be applying Lean principles to the thorny problem of how to bring the high costs of solar electricity down.)

First, a solar primer. There are two ways to make electricity with solar power. The high-tech way is through solar photovoltaic panels (aka solar PV). These are the panels that Google installed on the roof of its Mountain View campus, and although they turn solar energy directly into electric energy, they're still ridiculously expensive to produce. There's also some concern that the technology used to produce this "clean" power isn't necessarily so clean.

The second method of converting solar power to electricity is to concentrate the rays of the sun using mirrors. These mirrors usually focus on a central tower, which collects the heat and uses it to boil water, which turns a steam turbine to produce electricity. That's pretty much the way a coal-fired power plant works, only without the coal. And although this is cheaper and easier than solar PV, it's still not cost-competitive with coal.

Enter eSolar. The steps they've taken sure sound a lot like Lean. From an excellent article on Cleantech.com today, here are some key quotes:

"We can build these units smaller. This lets us build closer to cities. It lets us avoid some of the traditional roadblocks associated with large transmission projects," Robert Rogan, exec. VP of corporate development at eSolar, told Cleantech.com...."And we've got the ability to scale this very rapidly through
our existing manufacturing."

Hear any Lean concepts in this approach? This also crosses over into Bright Green environmental concepts, because shorter supply lines mean less waste and less infrastructure.

Google has said it believes it needs to get in the range of 1 to 3 cents per kilowatt hour for solar or other renewables to be competitive with coal....Rogan said his company has been very cost conscious. The company said its heliostat mirrors, designed to track the sun, were made to fit into shipping containers to keep transportation costs low, and are pre-assembled at the factory to minimize on-site labor.

More signs of Lean, although I'd like to see something in this about respect for people.

"Minimizing the shipping costs on the hardware is just one example of that very tightly cost-based approach to designing," said Rogan...."Our towers are very short. This, again, makes them very easy to assemble on site, faster to install, and ultimately much lower cost than building a 30-story skyscraper," he said. The company has also cut the amount of steel and concrete used in its systems by keeping the heliostats small and low to the ground, reducing their wind profile.

Again, a nice intersection of Lean and Bright Green. Besides the inherent "greenness" of a solar project, they've figured out how to do more with less.

"Another nice benefit of this pre-fab, modular, scalable approach is that we can incorporate, in the future, all varieties of storage." "Currently, we're not discussing our specific storage plans, except to say that we don't view it as being a barrier to entering the market," he said.

This somewhat resembles the flexible workspace approach of Lean. You can read a bit more about the company's lean approach here.

All in all, it's great to see Lean and Green integrated in such a fashion. Hopefully there will be a lot more of this kind of thing coming soon. Happy Earth Day, everyone!

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A Silly Example of Mandates and Threats Not Working

Cemetery full, mayor tells locals not to die - Yahoo! News

Maybe this mayor has consumed too much Bordeaux wine. But this story is a wonderfully comical illustration of how ineffective management mandates, targets, quotas, and the fear of punishment can actually be.

The mayor of a village in southwest France has threatened residents with severe punishment if they die, because there is no room left in the overcrowded cemetery to bury them.

In an ordinance posted in the council offices, Mayor Gerard Lalanne told the 260 residents of the village of Sarpourenx that "all persons not having a plot in the cemetery and wishing to be buried in Sarpourenx are forbidden from dying in the parish."

It added: "Offenders will be severely punished."

I doubt they attempted a "5 Whys" exercise that went like this (imagine an Inspector Clouseau accent -- the Peter Sellers one, not the lame Steve Martin one):

1. Why is zee cemetery full?
2. Because people are dying!!

Eh, sounds like zee root cause to me. Hmm.... let's drink more wine!!

Talk about NOT getting to a solvable root cause of the problem!!

And for any of you who are laughing at this or the mayor, he proactively responded:

"It may be a laughing matter for some, but not for me," he said.

Are any of our managers trying to manage the same way? Through mandates and threats? In the name of improving quality? Preventing errors or safety incidents?" Mandates, fear, and threats just lead to people hiding problems or being really creative in making things look good (rather than making real improvements). Have any examples to share?

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Why Do Patients Have to Do This?

The Informed Patient - WSJ.com

Good column in the WSJ today, as always, from Laura Landro. She writes about the need for patients to take an active role in their care and their own safety.

I'll try to keep with the Toyota philosophy of asking "why?" We could go through each of these in "the 5 Whys" problem solving method.

• Why do patients have to ask their surgeons if they are following proper surgical safety protocols?

• Related question, why do patients have to ask nurses and physicians if they have properly cleaned their hands?

The focus of my question is on the patients, why is it necessary to ask patients to take such an active role in the quality of care delivery, not "why is it important to properly clean your hands?"

Do we ever hear food safety advocates suggest, "You should ask your restaurant to confirm that the meat was cooked to the proper temperature"?? Are car buyers encouraged to nag Toyota or GM about whether the car is safe to drive off of the lot?

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My At-Home Medical Mistake

I'm a bit mad at myself for inflicting some preventable human error on myself last night. It's OK, I didn't harm myself, but let me tell the story.

I've been battling what's either severe allergies or a mild cold for three or four days. I've alternated a bit between the daytime and nighttime formulas of a major branded OTC cold/congestion pill. Last night, I was in bed and couldn't sleep, I was wired. I thought, uh-oh, got up to check and, sure enough, I had given myself non-drowsy daytime formula.

The upside is that I went out to the home office and got a lot of work done, but I'm dragging this morning.

What has me kicking myself... I didn't practice what I preach in the Lean methodology!!

I had a "near miss" the night before. I had made the exact same mistake the night before. I had caught the error right after popping the pills in my mouth, I spit them out and took the nighttime formula. I'm mad at myself for not fixing the root cause of the problem. I didn't move the daytime formula off the bathroom counter, making it harder to mistakenly grab the wrong on while getting ready for bed. I did what so many people do in healthcare, because of time pressures, fatigue, or because of just human fallibility. I didn't take the time to really prevent the problem from occurring again. Obviously, the stakes aren't very high in the case of OTC cold medicine.

I'm doubly human. 1) I took the wrong pill and 2) I didn't think to take preventative measures!!

That said, looking at the packaging of the two formulas, there's some room for confusion (again, the "severity" score for the FMEA calculation of the RPN would be low for this one). The outer box of the daytime formula used to be primarily yellow (somewhat indicating "day") and the nighttime formula used to be primarily blue (indicating "night"). But the packaging changed to be more consistent, and that color coding is less prominent in the corner of the box. The backs of the blister packs are all white, being basically identical, except for some small text.

There *was* some color coding of the pills themselves, which should have been a tip off. The daytime pills are white, the night time cold/head congestion pills are blue. But, the color coding is NOT consistent among different products in that brand family. The "sinus congestion/pain" formula is green for day, white for night, when they come in the dual-boxed pack that includes day and night formulas. Strangely, when you buy daytime "sinus congestion/pain" on its own (without night), the pill is a green/white caplet. Why would they manufacture two different forms of the same pill?" The "sinus congestion/pain SEVERE" formula has white pills for daytime.

Seems like an opportunity for some standardization. Or time for me to quit obsessing about it, time to get to work!

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Updated: How Often Must the Same Mistake Be Repeated?

Dennis Quaid's newborns reportedly harmed by medical mix-up - Los Angeles Times

(Updated 4:57 PM, again at 9:51 PM, see bottom of post)

If this story sounds familiar, it's because it is the exact same error as one that killed three babies in Indianapolis last year. This time, the error has harmed the twin babies of actor Dennis Quaid. The babies are reportedly in stable condition at L.A.'s Cedars-Sinai hospital and will hopefully pull through. My thoughts and prayers go out to the Quaid family.

"Dr. Michael L. Langberg, Cedars-Sinai's chief medical officer, confirmed in a statement late Tuesday that "as a result of a preventable error," three patients had their intravenous catheters flushed Sunday with a concentration of heparin 1,000 times higher than the normal protocol. Staff members used vials containing a concentration of 10,000 units per milliliter instead of similar vials containing a concentration of 10 units per milliliter."

This was truly a preventable error and something that should have never occurred. So what is the response? Do we ask "who did this?" or "why did this occur?" Those are two very different questions.

First off, let's give the hospital credit for their public response:

"Cedars-Sinai spokesman Elbaum said no employees had yet been disciplined because "our focus tonight is on quickly determining what needs to be done to make sure it doesn't happen again." For instance, all 1,800 nurses coming on duty beginning Tuesday night will be retrained on medication safety practices before they begin seeing patients. Other steps also will be taken."

It says "had yet been" disciplined, meaning I guess they are leaving that door open. Focusing on why it happened and making sure it doesn't happen again are good problem solving responses. With Lean, we first want to ask "why did this happen?" instead of "who screwed up?" The chief medical officer was quoted on the news as saying it was a "preventable error" but he also said that procedures and standards were not followed. That sounds like a precursor to throwing someone under the bus for not being careful.

In the Lean approach, management has a responsibility to ensure that "Standardized Work" is being followed. If the standardized work (or procedures) say that nurses are supposed to double-check the labels, how often does management spot check that the right process is being followed? A Toyota plant does not just assume that the work is being done properly, the managers and supervisors are constantly auditing and checking that procedures are being followed. They are not waiting for a defect or customer injury to occur first.

Blaming an individual might feel good, but who do we blame? The nurse who administered the wrong dose? In the Indianapolis case, the nurse never expected that an adult dose of heparin would be in a neonatal I.C.U. Do we blame the pharmacy technician who likely delivered the wrong dose to the unit? Do we blame the pharmacist who was supposed to confirm the medications that were being delivered? Do we blame the person who possibly put the wrong vial into to the wrong bin in the pharmacy? If the pharmacy technician scanned a bar code on the bin (and assumed that the medication also matched), do we blame them? Or do we blame the purchasing agent who buys different dose vials that look similar? Or do we blame the manufacturer of the heparin?

People were blamed in Indianapolis. But that didn't prevent the problem from happening in L.A.?

Cedars-Sinai is now taking reactive measures to train and raise awareness. Why was that not happening already? Does every single hospital have to make the same mistake before they take preventative measures? How about being proactive? How about we not rely on asking people to "be careful?"

In Indianapolis, they have "double checks" which is like a "double be careful."

"Nurses at Methodist didn't check the label and administered the wrong dosage. After the incident, the hospital required a minimum of two nurses to verify any dose of blood thinner used in the newborn and pediatric critical-care units, among other steps."

That's just another form of inspection. It doesn't prevent the root cause of the problem. We can't rely on people to be careful, especially when nurses often work 12 hour shifts. People get tired, we're human, we make errors. That's why the Lean philosophy of error proofing is so powerful. It recognizes that people make mistakes, so we design systems that make it less likely for errors to occur. And don't call it "dummy proofing." The nurses who make these mistakes aren't dummies. This might have been the only mistake they've made -- they were careful every other time, but here was one mixup that can have fatal consequences.

A professor of pharmacy in San Francisco was quoted as saying:

"This is not an unheard-of error," Kayser said.

It sure is. The FDA and Baxter issued a warning in February 2007. And we're going to keep hearing about it until every hospital takes proactive and preventative measures to keep this from happening. Reacting after an incident shouldn't be looked upon favorably.

Baxter's recommendation, for now, was to "be careful" basically:

Both products use blue as the primary background color on their labels, though in different shades.Baxter is looking for ways to vary the packaging to prevent future errors. In the meantime, it suggests that healthcare workers check their inventory to ensure no mix-up has occurred; notify staff of the problem; be sure not to rely solely on package color to identify a product; and always read the label and verify that the correct dose and product are being used.

Look at the packaging. Sure, they don't look identical, but imagine you're in a somewhat dark patient room at 3 a.m. Why isn't the stronger dose in a larger form factor bottle?? Or a different shape? Or maybe the adult dose bottle can have sharp jagged edges to poke the nurse to make sure they are being careful? We need error proofing devices, not "being careful."

If I ever have children, and they're in a hospital, I'm going to be a nervous wreck. My advice to others would be to have someone monitoring your child and their care 24 hours a day. You can't trust the system to protect them for you, unfortunately.

There is a surprisingly intelligent and informed comment on the E! Online website, discussing this problem (scroll down to the 4:27 comment). The comment actually comes from this blog posting, written by a nurse. Surprisingly, she primarily blames the nurses!

Yes, nurses in this day and age are very rushed to get everything done for their patients, and there is definitely not enough time in the day to get it all done. Nurses are overworked, underpaid, and stressed to the max. We are assigned to too many patients at times, creating unsafe situations for the very people we are here to help. But by skipping the very foundations of safety, we are putting each and every one of our patients at risk for medication errors, injury and potential death."

Can you really hold people solely accountable when they are overworked, stressed, or tired? I'm not saying people have zero responsibility, but merely blaming someone for firing a nurse won't prevent this from happening again. Training will help, at that hospital. But what about the others? I wish the media would go to the OTHER hospitals in L.A. and ask, "So what are YOU also doing to prevent this?"

Maybe this story will get the right kind of coverage since it's a celebrity's babies?

Update: This blog says the error was a result of a technician storing the drug in the wrong location.

Update: This site (lawyer alert) says that Methodist had made the same mistake five years before killing the three babies last year. The news article he links to says:

"The parents of one of the children overdosed five years ago were assured by the hospital that steps were being taken to ensure the mistake was not repeated, but those steps didn't stop it from happening again."

That's why being careful or even saying "we have procedures and policies" doesn't work. At some point, hospital leadership should be held accountable, not just individual workers.

The lawyer has it wrong when he says:

"Administering an adult dose of Heparin to an infant is the type of error that should only happen once in the history of a hospital."

No, it should never happen. Hospitals need to be proactive and NOT wait until a mistake is made. We need Lean and Toyota Production System methods to spread within health care.

Update (9:51 PM): This blogger (another lawyer!) reports that the celebrity site tmz.com is reporting:

We're told one dose was given on Sunday morning, another on Sunday evening.

We're told as many as thirteen patients at Cedars were mistakenly given the overdose of Heparin, but the effects are more critical because of the age and weight of the twins.

Wow, that is one hell of a systemic problem. It's not as simple as one nurse being careless one time if the Quaid twins were overdosed TWICE and it happened with other patients. Yikes, how is someone "not careful" that many times??

The lawyer then, predictably, goes on to rant that problems like this happen because hospitals aren't as afraid of being sued anymore, thanks to tort reform. Ah, the fear of lawsuits, the best path to quality! Not really. He also confuses the heparin dosing error with the "heparin and insulin confusion" error, which the FDA also gave a warning about and also happens all over the place.

Management's Job is to be Proactive

Running a hospital: Our Joint Commission Report

The headline is my modification of a Deming expression, that management's job is prediction. Statistical process control was one way of predicting future outcomes of a process (if you have a statistically stable process, you can predict that tomorrow will be like today). Management also has to be proactive in terms of anticipating potential quality or safety problems. That's one reason management must go to the "gemba" (or "actual place") and it's a reason why they must audit standard work and safety practices on a regular basis.

The blog I've linked to above is an interesting one, written by Paul Levy, the CEO of a major Boston Hospital (Beth Israel Deaconess Medical Center). He's very open in his discussion of hospital management issues, which is very admirable and unique. In the linked post, he writes about the hospital's recent "Joint Commission" inspection and links to the full report. Again, very admirable. I'm not sure if any other hospitals are doing this. Levy and BIDMC obviously mean well and want to improve their quality and their accountability to the public. Again, hooray for that.

Since many of you reading this are from the manufacturing world, I think the best parallel to the Joint Commission is to think about ISO9000, a quality "certification" of sorts that's been mocked in the Dilbert cartoon. The problem with ISO9000 is that getting certified is often NOT a predictor of good quality. That's not just me saying that, although my own personal experience bears that out. 'A factory can document poor processes and still get certified if they follow those processes and still have poor quality. Future LeanBlog Podcast guest John Seddon wrote a whole book debunking ISO9000.

The Joint Commission has its critics also, as this story about Mass General Hospital (also in Boston) shows. Inspectors found numerous quality and safety problems, yet the hospital was still going to have its certification renewed. Quality and procedural problems included:

"...staff neglecting to wash their hands before and after caring for patients; medical records lacking dates and times; and patients on pain medication for whom caregivers had not recorded whether their pain had improved.

Why beat up on MGH for a problem that plagues most hospitals (poor handwashing, something I've written about before and something David Mann commented on)? Ok, sorry, that was sarcasm. What does the Joint Commission prize guarantee to you, the patient? It's not a guarantee that caregivers are going to wash their hands!!! Maybe it's a certification that says they're trying hard or that they care, but that's not enough.

There's more criticism of the Joint Commission in the August 6 issue of "Modern Healthcare" magazine. John Toussaint, CEO of ThedaCare, a leading example of Lean healthcare, criticized them by saying:

"... the Joint Commission's hospital accreditation criteria falls short of what's needed to ensure safe, quality healthcare."

So back to BIDMC, what problems were found in their Joint Commission report?

Problems included:

• Doctors were not following standard work (my term, not theirs) and irregularly used the hospital's "medication reconciliation" system. That system helps avoid drug interaction and allergy problems. Levy said, "Over the coming weeks and months, we will make use of the system mandatory." You might think, why not now, this week, today? Why not before? I'm sure people at BIDMC knew the system wasn't be used, why wasn't this fixed? As Levy pointed out in the comments, it is a complication that physicians are not employees, but that's no excuse -- it's just an additional difficult leadership challenge, not being able to rely on "being the boss." Toyota's Gary Convis was always quoted as being taught you should "lead as if you have no authority." Maybe Convis can run a hospital now that he's retired from Toyota?
  
  
• "Code carts" in the patient units didn't have proper security for certain medication. "We are fixing this," Levy says. Again, did this require outside inspectors to discover? It seems reasonable that a hospital would consider drug security to be an important issue. Why was it not proactively addressed? Levy commented that they did have audits and "hold managers accountable," but that's not the same as actually fixing it, is it?
  
  
• In another safety problem, Levy reported, "...some gas canisters were not properly secured. This is a true public safety hazard. If an unsecured gas canister falls and the regulator breaks off, the heavy tube can be an uncontrolled projectile." To those of you working in factories -- how often is this unsafe condition allowed to exist? Hospital administrators and managers need to be in the "gemba" auditing for situations like that. Oh, and the gaps in the fire doors were too wide. Oops, they'll fix that too, now that it was pointed out. Levy said that it's hard to find a large factory that wouldn't have that problem. Really? If so, is that an excuse?
  

Levy says this:

"The upshot is this. We did very, very well. On average, the Joint Commission finds 10 or more requirements for improvement in their hospital surveys. We had eight. Our re-accreditation is secure. The areas in which they found us wanting were legitimate and proper, and it is our job to fix them. The good news is that we were not surprised. Most of the areas they pointed out were on our agenda to fix over the coming months as part of our continuous improvement efforts."

Being "on the agenda" is not the same is being fixed! I know that we can't magically fix all problems at the drop of a hat, but all organizations need to prioritize safety and quality issues, be proactive, and prioritize things. Is it complacency that thinks, "these things have been a problem for a long time, so we can take our time in fixing them?" Maybe it's a pat on the back to the employees to say "we did very, very well" but I'd rather see the Toyota mindset of striving for perfection and not being satisfied with passing marks from the Joint Commission.

I know I'm beating up on them, and I'm sure the hospital and its leadership have the best intentions. But, given the state of healthcare quality and safety, intentions aren't enough. We need improvement! Again, I do admire the hospital and Levy opening themselves open to criticism from yahoos like me.

I did submit a question to Levy on his blog (if you haven't figured that out already) and we had some discussion, you can read it yourself in his comments section or see Kevin's post about it on Evolving Excellence. I won't rehash it all here, but it's too bad that Paul started using the "tired excuse" (as another commenter said) that patients are complex. Of course they are, but let's discuss how to fix these problems faster rather than debating whose environment is more complicated. 600,000 unique patients don't require 600,000 unique processes to support their care. I'm not talking about standardizing how doctors diagnosis and cure. I'm talking about standardizing the truly repeatable support processes (lab, pharmacy, radiology, etc.). There aren't 600,000 femurs so different as to require 600,000 different ways to x-ray or MRI them.

Please do visit Paul's blog and read his full post and all of the comments. Thoughts?

Great Piece on Problem Solving

Elegant Solutions: Mind of the Innovator

Matthew May is the author of the book The Elegant Solution, a friend of this blog, and a blogger in his own right. He has a new "ChangeThis" manifesto called Mind of the Innovator: Taming the Traps of Traditional Thinking.

His piece gives some excellent examples of how we tend to jump to solutions without first properly defining and understanding the problem. He poses a fascinating challenge in the piece (read his piece for the "answer" and, more importantly, the powerful Toyota problem solving approach):

You own an upscale neo-luxury health club. As part of the membership perks, each of the 40 shower stalls is stocked with a bottle of very expensive, salon-only shampoo. The customers love it and rave about it. The front desk sells the bottles. Unfortunately, bottles disappear from the showers all the time. In fact, theft rate is 33%, presenting a costly situation. You’ve tried reminders, penalties, and incentives to try and reduce theft, but nothing so far has worked. You do not want to discontinue or alter the shampoo offering in any way—one bottle of the current brand per stall must not change. You want the problem solved within the guidelines:

• Theft must be 100% eliminated
• Any solution must be one of zero cost
• No burden on the patron

How do you prevent the theft of shampoo?

Let's Try a "5 Whys" Survey

Following up on the LEI survey that was released and discussed here, I've been talking with a few folks offline about what the "root causes" really are for Lean struggles. Instead of pointing at "who?" what would we find if we asked "Why?" And then asked "Why?" again. Let's utilize one of the Toyota Production System problem solving methodologies, the "5 Whys?"

So, an online survey is cheap and easy to set up. Let's give this a try. It's an experiment, in the spirit of PDCA. I'm not sure if this problem really lends itself to 5 Whys, because as blog reader Ralf pointed out, this is a complex business and organizational problem. It might not lend itself to an online survey, since I'm used to doing this in person and interactive.

Click Here to Take Survey

Those who take the survey and leave an email address (which will not be sold or distributed), we are going to do a few Lean giveways, including a donated copy of "Workplace Management", given by our friends at Gemba Research. I'll publish the results here and will email them out to those who leave an email address.

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"No fault, just an accident"

Explosions rock downtown Dallas | Latest News | WFAA.com

Working from home with this news on in the background, the massive gas cylinder explosions at a business near downtown Dallas, about 30 miles from my home.

What jumped out at me was the TV reporter probing "whose fault was this?" and the fire inspector/spokesman said:

"There's no fault, it's just an accident. We need to find out why this happened."

It's a horrible looking scene. A few burn victims, let's hope for their survival and recovery.

The spokesman was talking about some equipment failures/flaws that led to the chain reaction of explosions. It will be interesting to see if there is true root cause investigation (the Feds are headed in, for what that's worth) or if it eventually comes out that it was "somebody's fault."

It might be the fault of one person, but would you suppose this is more likely caused by something systemic and preventable? The video certainly was scary, the tanks flying through the air onto roads and over the freeway.

With Lean problem solving, we need to ask "why?" and not first look for "who?". Are fire investigators, by training, good root cause problem solvers? On the news, I'm hearing a lot of "why?" Why did this happen? Why are sites like this so close to downtown and major freeways? Many root causes are contributing to what could have been a much more lethal situation.

The Lean Toolbox: Where is the thinking cap?

By Bryan Lund:

For the full article, click here for a PDF file

The Lean toolbox is brimming with attractive tools and if you are like most Americans, you can’t wait to get your hands on one of those shiny new gadgets and show it off to the neighbors. The problem with tools is that we get wrapped up in what they look like, not in the purpose of having the tool in the first place. Following is an example of where using a “lean tool” has gone bad. In this case, the 5 Why tool was put to work, and nothing happened, but was on display for the neighbors. Let’s take a look at why good intentions went awry.

First, a quick glimpse of the picture: a group is in the middle of a kaizen event and someone says there is a chronic problem with a machine. A facilitator of the group says, “Let’s use the 5 Why tool to solve this problem”, which the group proceeded to do. Following is the line of questioning and answers provided during the 5 Why session:

Problem: The parts carrier doesn’t slide on the belt.

Why do the carriers not move along the belt?

The belt is caked with grime.

Why is there grime on the belt?

We are using silicone instead of light oil. Silicone builds up on the belt and attracts grime.

Why are we using silicone?

We need extra lubricant and silicone works for that. We normally wouldn’t use silicone.

Why do we need extra lubricant?

There is a problem when the machine tries to screw the assemblies together.

Why is there a problem with screwing the parts together?

There is a problem with the threads, but we can’t figure that out.

At this point, the group felt as if they had hit a dead end and threw the problem over the wall to engineering to solve. Fast forward 40 days.

This approach concerned me for several reasons. First, the group had a nice, stylish, flashy form created on the computer and dated 40 days prior to when we observed it on the machine. There was no status on the problem, and further discussion with the operators in the area yielded no other information. Another thing, the group literally stopped questioning at the fifth why. Problem solving sometimes requires multiples streams of questioning and certainly should never be limited to asking “why” only five times. Finally, it wasn’t clear how a physical feature on the subassembly was causing grime to build up on the belt, thereby causing the carriers to stop on the belt. At first glance, it may be obvious that, “since the parts don’t go together easily, we use more lubricant, which is transferred to the conveyor belt, causing grime to build up. This is basic 5S stuff!” Sadly, when we blindly using Lean tools we inadvertently reduce the credibility of a continuous improvement program.

For the full article, click here for a PDF file

About the author: Bryan Lund is a Lean Coordinator in the Global Lean Office for Energizer Battery Manufacturing. www.energizer.com. Bryan is also involved with the reintroduction of the WWII production improvement program, Training Within Industry, or, TWI. Many elements of TWI, notably Job Instruction Training, are fundamental to maintaining stability and improvements within the Toyota Production System. Learn more about TWI at our local SME #204 website: Training Within Industry

Lack of Error Proofing Kills 3 Babies

This is an incredibly sad, and completely preventable, situation. Three babies are dead, and three more injured, because the wrong drug was administered to them at an Indianapolis hospital.

Let's keep in mind, first, this quote from the World Health Organization:

“Human error is inevitable. We can never eliminate it. We can eliminate problems in the system that make it more likely to happen.”

This quote could easily come from Toyota leadership. This is why they error proof. You want to prevent good people from making mistakes. My point is to look at this situation by NOT pointing fingers of blame at an individual.

The situation and the news stories:

Initial story about the first two deaths from a local news station

CBN story, again after the first two deaths

"At the newborn intensive care unit of Methodist Hospital, the staff is blaming the newborn deaths on human error. Somehow the wrong dose of a blood-thinner medication, Heparin, was stocked in a hospital drug cabinet.

President and CEO of Methodist Hospital, Sam Odle, said, "They're both one-milliliter vials. One has 10,000 units of heparin, one has 10 units of heparin...so the nurses -- knowing they only carry one dose on the unit -- took the vial out and administered it to the patients."The mistake proved deadly.In all, six premature babies were given adult doses of the drug. Three babies are in stable condition. Another is in critical condition. Two babies died."

A lot of the initial response was focused on "a nurse made a mistake." Situations like this are far more systemic and wide spread than to think a single person and a single mistake led to this.

A nurse said:

"I have always been confident that the drug that I'm looking at is the drug that's in the drawer," said a nurse. "But, of course, it's still my responsibility to assure it's the right drug."

Since this was a CHILDREN's ICU, you would wonder why an adult-dose drug was ever there. The nurse is saying that it should NOT have been there. But still, a nurse did not read the label, she ASSUMED. That's just one mistake. A better process would be to ALWAYS double-check the drug name and dosage. The drug should have been labeled "Heplock" but it was actually "Heparin" that was loaded into the cabinet. Heparin has been in the news before when adults are killed because "Heparin" was confused with "Insulin" (same vial, clear liquid, etc.).

Looking at future PREVENTION, the CBN article says:

"Under new guidelines, the hospital staff will double-check drug labels and remove certain doses of the blood-thinning drug, heparin, from their unit."

Now the second part sounds like an error-proofing step.... but removing the drug that already shouldn't have been there is very reactive. How do you prevent the adult-dose drug from getting there? What process was responsible for that?

The Washington Post news story, after the third death has some more details:

"According to hospital officials' account, a pharmacy technician had loaded the cabinet with heparin, at 10,000 units per milliliter, instead of hep-lock, at 10 units per milliliter."

So we had one mistake, a tech from a different department loading the wrong drug. The nurses, far too trusting of the system, didn't double check the label and assumed, incorrectly, that they have the wrong drug -- partially lulled to sleep by the technology that you might expect to prevent this. There is a cabinet in the ICU that requires a nurse to enter their ID code and a patient code -- it prevents the wrong DRAWER from being opened. But, it doesn't address the issue of a pharmacy tech loading the wrong drug. How is that error-proofed?

Everyone is pointing fingers, some of it system related (how does the drug maker help make the packages more distinct, so Heparin and Heplock aren't confused?)

The mother, and we can't possibly have enough sympathy and empathy for her pain and suffering, she says:

"The nurses is what I'm blaming. They need to lose their licenses is what I am saying so it won't happen again to the other babies," Jeffers said.

I'm sorry, but that's not going to prevent other deaths. Everybody in the system, particularly the nurses, were probably trying their best. We need to improve the SYSTEM to prevent it from happening at Methodist and at other hospitals. Was this a one-time error?

"Methodist has acknowledged two other heparin mix-ups involving babies in 2001, and said both infants recovered."If this was an isolated incident I would say that it would be solely the responsibility of the person at the hospital," Lee said. "But this is not an isolated incident.""

The five nurses and pharmacy technician involved are on leave and receiving support and counseling, and are expected to return to work, Odle said.

I'm sure all of the hospital employees feel sick over what happened. I know I would. Hell, I read about this yesterday and I had basically a nightmare where I was working with a pharmacy and trying to get them to improve, mistakes were still being made and I was yelling at people (and I'm not normally a yeller). This kind of situation really bothers me and reinforces my mission to work in lean healthcare.

When I'm back to work at my client tomorrow, I'm going to talk with a pharmacy tech I know and get her perspectives on this, what procedures would be in place at their hospital to prevent this kind of situation.

People need to "be careful" but that isn't enough. As the quote up top says, people are human. Blaming "human error," as the hospital did doesn't mean "what individual screwed up?" It means, humans designed a fallible system. We need to try harder to design error-proofed systems, whether in healthcare, aviation, etc. In the current situation,d either in it takes MULTIPLE errors for a death to occur, but it still happens too often.

There are over 5,000 hospitals in the U.S. This kind of error could happen (and probably does) at any of them. My question is this --- what kind of network is in place to share situations like this? EVERY hospital in America (and the world) should be looking at their own processes today to prevent THIS problem. With the internet and modern communications, each hospital shouldn't be operating in a vacuum. One mistake ANYWHERE should be enough to drive change and process improvement EVERYWHERE. We don't need to make the mistake at each hospital before each hospital fixes the process.

Do we have any Intel readers who could share how "Copy Exact" communication among the fabs takes place? Sure, a network of 5,000 hospitals under different ownership is one thing compared to a smaller number of fabs all run by one company, but I'm sure lessons can be learned.

One lesson for me -- if I had a baby in the ICU (or any loved one in the hospital), I would be there and would monitor each and every drug that was ever administered. If a nurse is offended, so be it.