Tag: Problem Solving

3 Ways to React to Human Error

3 Ways to React to Human Error

What happens when a mistake is made in your organization? How do you react when an error occurs?

A lab specimen gets mislabeled. The wrong product is shipped to the wrong customer. A patient is injected with the wrong medication.

The Worst Root Cause Problem Solver in the Animal World Is… Who?

The Worst Root Cause Problem Solver in the Animal World Is… Who?

We all know the beaver is “the engineer of the animal kingdom.” That’s why MIT has a beaver as a mascot… it’s an engineer who likes to build things and is generally nocturnal, an apt description of MIT students.

Video: Toyota Helps Harbor-UCLA Medical Center and Their Eye Clinic

Video: Toyota Helps Harbor-UCLA Medical Center and Their Eye Clinic

California week on the blog continues after yesterday’s post about Lean at San Francisco General Hospital.

Today, I’m flying to Los Angeles to attend the 5th annual Lean Healthcare Transformation Summit. I will be, as usual, moderating the CEO panel and I will be, for the first time, moderating the Q&A session at the end of each keynote talk. Follow along on Twitter with hashtag #HCsummit14 and I’ll be blogging about things over these two days.

Kaizen Tip: Just Do Its and Root Causes

Kaizen Tip: Just Do Its and Root Causes

RootsIn the Kaizen process, we ask everybody to identify problems (or opportunities) and then to write down an idea that could potentially solve the problem (or at least solve it to some extent). 

What’s written down on the card (or submitted into KaiNexus software) is the starting point for discussion within a team and/or with a supervisor.

When coaching an organization on Kaizen recently, I got a really good question from a physician who had taken the excellent week-long Lean healthcare training at the University of Michigan. She said that, in the Lean training, they said you should never “jump to a solution” in the course of problem solving. She raises a good point.

Notes & My Short Talk from the #Lean Transformation Summit, #Lean14

Notes & My Short Talk from the #Lean Transformation Summit, #Lean14

lean geekIt’s been fun attending the annual Lean Transformation Summit (produced by LEI). Today is Day 2. I took some notes from Day 1 and Tom Ehrenfeld has been “live blogging” it a bit on the LEI site. Tom also took and posted a picture of me in my spiffy “Lean Geek” t-shirt.

LEI had a few experiments with this year’s Summit. One was the use of “open space technology” for a session yesterday afternoon where attendees self organized into discussion groups on these questions that were generated by the attendees.

The second experiment was a learning session that had four short ten-minute talks from different attendees who had submitted a proposal… including me.

Jumping to Solutions

Jumping to Solutions

We’ve all seen it. We’ve probably all done it.

What’s that?

Jumping to solutions.

I hope this illustration I created gives you a bit of pause… not just to laugh at others, but to reflect on this personally.

jumping to solutions_0

By February 25, 2014 4 Comments Read More →
The Truth About Data and PDSA/PDCA from a Toyota Publication

The Truth About Data and PDSA/PDCA from a Toyota Publication

Going down? (Azrieli Tower's staircases) Out there in the Lean and quality improvement communities, you sometimes hear some silly things. Sometimes, I want to attach the “Lean As Mistakenly Explained” (or L.A.M.E.) label to what’s said when it really seems off the mark from what Lean is really all about. Davis Balestracci, a columnist for Quality Digest, passed along something he heard from a “Lean guru” (whatever that means):

“In my opinion, any approach should also involve the use of data in some way, shape, or form. I once had a lean sensei (local “guru”?) vehemently make the point that lean does not involve data at all.”

What??

By February 20, 2014 5 Comments Read More →
The Power of Asking “What Do You Think?”

The Power of Asking “What Do You Think?”

Mark’s post: I’m still away on vacation, but happy to have some guest bloggers, including Chad Walters. Unlike his past posts, today’s not about Lean in sports… and I think you’ll enjoy it.

cw bw borderObviously one of the most important questions we ask in the field of continuous improvement is “Why?” and for very important reasons – we get answers for reasons decisions were made or we identify potential root causes the more we ask.

But from the perspective of respect for people, I also offer up “What do you think?” as another important question we should have in our arsenal of inquiries.

By November 1, 2013 4 Comments Read More →
From Vague to Passive to Active in Your Voice and Improvement Work

From Vague to Passive to Active in Your Voice and Improvement Work

GRAMMAR COP

While I’d be the first to admit that my writing is not perfect and I certainly need a copy editor for my books, I have a bit of a reputation as a “grammar cop” amongst co-workers in previous jobs. I even received a “mock awards” certificate from a team at Dell that said as much in 2000.

As I work coaching teams in various organizations on Kaizen and problem solving, I see a trend where people tend to want to use “passive voice” when describing problems or opportunities for improvement instead of using “active voice.” The difference isn’t just annoying from a grammatical standpoint, I think it interferes a bit with their improvement work.

By September 25, 2013 13 Comments Read More →
Don’t Let Looking at Data Blind You From Seeing Reality

Don’t Let Looking at Data Blind You From Seeing Reality

A couple of red traffic lights against a blue skyI recently read an article (a case study) about “Lean Six Sigma” in a publication. It’s not online, so I can’t link to it, nor do I really want to call them out by name.

I didn’t like the article, in part, because it used the old, tired (and wrong) idea that “Six Sigma is for quality” and that Lean is only about “faster and cheaper.”

Good gravy, how do people NOT realize that the Toyota Production System and Lean are about both flow AND quality? For direct evidence that Lean/TPS is about both,  see Toyota’s website on “jidoka” and “just in time.”) The article I read is, unfortunately, an example of L.A.M.E. or “Lean As Mistakenly Explained.”

The article talks about a scenario where a city government wants to reduce traffic accidents at one particular intersection. Since an accident is a “defect,” they called on the Six Sigma belts to gather data do a bunch of statistical analysis (assuming, it seems, that a quality problem must be the domain of Six Sigma). It took time and a bunch of meetings to plan for this formal exercise. It’s a “hard problem” that’s “hard to solve,” the author said.

By September 10, 2013 18 Comments Read More →
Weekend Fun: An Example of Poor Problem Solving

Weekend Fun: An Example of Poor Problem Solving

Here’s a funny ESPN commercial featuring golfer Rickie Fowler.

Fowler is pouring coffee, yet he makes some bad assumptions about which coffee is decaf and about the “milk” being bad (compounded by the joke that he’s supposedly color blind).

By August 30, 2013 7 Comments Read More →
Podcast #179 – Judy Worth & Tom Shuker, “Perfecting Patient Journeys”

Podcast #179 – Judy Worth & Tom Shuker, “Perfecting Patient Journeys”

MP3 File (run time 29:31)

perfectingMy guests for Podcast #179 are my friends Judy Worth and Tom Shuker, two of the co-authors of the book  Perfecting Patient Journeys, which was published earlier this year by the Lean Enterprise Institute. About the book: “Perfecting Patient Journeys  is a guide for leaders of healthcare organizations who want to implement lean thinking. Readers will learn how to identify and select a problem, define a project scope, and create a shared understanding of what’s occurring in the value stream. Readers will also learn to develop a shared vision of an improved future, and how to work together to make that vision a reality.”

We’ll talk about their book, what types of value streams and “extended value streams” are being worked on in healthcare (including “end-to-end” flows), breaking down silos, improving quality and cost as a result of taking time out of the value stream, and more.

For a link to this episode, refer people to  www.leanblog.org/179.

Other links and info:

Blame the Worker or the System – British Airways Engine Covers

Blame the Worker or the System – British Airways Engine Covers

IMG_4050I flew back safely from Finland on Saturday – or I should say British Airways and American Airlines flew me safety, including in the 747 pictured at left. 15 hours across three flights. It was a long day. But, I wasn’t really worried about my safety because of the great track record that the aviation industry has demonstrated (and taught to industries like healthcare).

That said, mistakes still happen. We’re all human. But, what does an industry do and how do they react when a mistake is made? Recent events with a British Airways flight are telling.

Lack of PDSA made JCP CEO SOL?

Lack of PDSA made JCP CEO SOL?

I love JC Penney's little eIt’s been interesting to follow the rise and fall of former Apple retailing executive Ron Johnson during his less-than-two-year stint as CEO at long-struggling retailer JC Penney. Johnson was often cited as the genius behind the generally outstanding Apple stores, but his approach didn’t translate well into trying to fix a dying company… and he was fired this week  (with a shockingly small severance package).

What went wrong? From a “Lean” perspective, some of the contributing factors might have been Johnson not understanding his JCP customers and a lack of “PDSA” when rolling out his “fixes.”

Error Proofing Against Drinking Bad Tap Water at #HIMSS13

Error Proofing Against Drinking Bad Tap Water at #HIMSS13

Here in New Orleans, there was a problem with the city water today and there’s a 24-hour “boil water” order in effect through tomorrow morning. We could play a good game of the 5 Whys:

  • Why can’t we drink the water? It’s potentially unsafe
  • Why? The water pressure dropped earlier this morning
  • Why? Because there was a power outage
  • Why? Because there was a small fire
  • Why? We don’t know (publicly… yet?)

There was a similar incident that affected the water in October and there was the famous Super Bowl outage. I hope the lights stay on for my HIMSS talk Monday morning!

Dilbert Challenges the Root Cause Problem Solving of His Boss

Dilbert Challenges the Root Cause Problem Solving of His Boss

Last Friday’s Dilbert touched on the important topic of problem solving and root cause analysis.

Stand up meetings, or huddles, are a great practice and they are pretty common in the Lean methodology. I saw a really impressive daily stand up meeting last week at a Texas hospital (more about that to come in a future blog post). The CEO was leading a daily review of the system’s “strategy deployment” metrics and improvement activities with the senior leadership team. Really inspiring leadership… and it’s part of a long-term, broad Lean transformation effort. It’s the complete opposite of Dilbert Land.

By February 20, 2013 2 Comments Read More →
Perfecting Patient Journeys and PDCA

Perfecting Patient Journeys and PDCA

Reminder: Please take my reader survey and enter to win some Lean prizes.

Perfecting Patient JourneysMy friends at LEI have a new book out by Judy Worth, Tom Shuker, and Beau Keyte: “Perfecting Patient Journeys.”  The book appears to focus on Lean problem solving processes, including value stream management… really important stuff.

Chapter 1 (PDF) has a good illustration of the PDCA cycle (although I, like Karen Martin, prefer to use the PDSA acronym). But, it’s the same thought process, as this diagram shows very well:

By January 31, 2013 0 Comments Read More →
Guest Post – Words Matter: Why I Prefer PDSA over PDCA

Guest Post – Words Matter: Why I Prefer PDSA over PDCA

Mark’s note — today’s guest post is by my  friend Karen Martin, my guest for Podcast #151 where we talked about her latest book The Outstanding Organization: Generate Business Results by Eliminating Chaos and Building the Foundation for Everyday Excellence Podcast #151   Karen Martin, The Outstanding Organization lean. Karen is the founder of Karen Martin & Associates and she is also the co-author of  The Kaizen Event Planner: Achieving Rapid Improvement in Office, Service, and Technical Environments Podcast #151   Karen Martin, The Outstanding Organization lean and Metrics-Based Process Mapping: Identifying and Eliminating Waste in Office and Service Processes

Think you know where PDCA (plan-do-check-act) came from? Think again. As I was writing my book, The Outstanding Organization, I dug into this powerful approach for problem solving and was surprised by what I learned.*

The two most influential voices for fact-based management in business have been Walter Shewhart, who is often referred to as the “father of statistical quality control,” and W. Edwards Deming, the “father of the Total Quality Management movement.”

By January 22, 2013 42 Comments Read More →