Here is LeanBlog Podcast #4, again featuring Dr. Jeffrey Liker,

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My guest for episode #4 of the Lean Blog Podcast is Dr. Jeffrey Liker, professor of Industrial and Operations Engineering at the University of Michigan. This is part two of our conversation, and the focus shifts to lean healthcare: value stream mapping at the University of Michigan Hospital, Toyota Memorial Hospital's own effort to apply TPS in Japan, and why the andon system's real value is getting problems to the surface, not hiding them. Even if you don't work in healthcare, I think there's a lot here for manufacturers too. The first part of his podcast can be found here.

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

LeanBlog Podcast #4 Show Notes and Approximate Timeline

• 1:28 Dr. Liker's comments on lean healthcare at the University of Michigan and their 5-day certificate program
• 2:03 Dr. Liker visited Toyota's own hospital last year and they are just starting to implement lean and the “Toyota Way” at “Toyota Memorial Hospital“
• 2:53 “Hospitals are often a complete mess, lack of organization.”
• 3:50 “A lot of a hospital is just a huge material flow system… and it's done really badly.”
• 5:08 Can also look at patient “value streams”
• 5:15 Can eliminate 80-90% of the waste (waiting) from a patient perspective
• 5:48 How the American Heart Association used the Toyota Product Development System
• 6:28 Why doctors are afraid that “standardized work” might stifle their actual work, “it's really about becoming a learning organization”
• 7:48 How healthcare professionals can be open to principles (lean principles) rather than being told what to do
• 9:33 Why Toyota has “mechanized the routine tasks” — to free people up for problem solving
• 10:48 Workarounds and problem solving in healthcare
• 13:03 How simple, visual tools helped
• 13:28 What kind of consulting or advising does Dr. Liker do for those who might want to contact him? Keynote speeches, conferences, leadership workshops and vision setting. His firm, Optiprise, does more detailed consulting work.
• 15:29 The Toyota Product Development System (with Jim Morgan) is a new book that came out a few months back. Currently working on a new book with David Meier (co-author of the Toyota Way Fieldbook), called Toyota Talent, about how Toyota develops their people. It is part of what will be a series of books. The book will come out next year.

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) 372-5682 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.

Lean Blog Podcast Episode 4: Dr. Jeffrey Liker, Part Two

Mark Graban: Hi, this is Mark Graban from the Lean Blog. Thanks for joining us today. This is the second part of my discussion with Dr. Jeffrey Liker. Last time we talked about how companies struggle with implementing the Toyota Production System. Dr. Liker commented that, at least among auto suppliers, well over ninety percent are talking about it, almost all of them have done something, but the number that have deeply implemented TPS is below two percent.

Today we're going to talk about lean healthcare, new applications of the Toyota Production System in hospital settings. Even if you don't work in healthcare, I hope this podcast will be of interest. I think manufacturers have the opportunity to learn about how hospitals are implementing the culture of TPS, not just the tools. And as somebody who works in healthcare, I hope this is something that's going to help the healthcare world and hospitals be more successful, relatively speaking, than the manufacturing world has been.

Lean Healthcare Work at the University of Michigan

Mark Graban: I want to change directions a little bit. This is an area I've been working in over the past year and have a lot of interest in: lean healthcare. I'm curious what your thoughts are on that. I've posted some articles on the blog about work the University of Michigan Hospital is doing. I was curious if you've been involved in advising them.

Jeff Liker: I've had some involvement, not heavily, but Dr. Billi, who's been leading that at the University of Michigan, he and I are co-directors of a lean healthcare five-day course at Michigan, a five-day certificate program. We've been teaching doctors from around the country, nurses, healthcare professionals of various kinds. Basically, what has become clear is that all the principles of the Toyota Production System apply very well in a hospital.

Toyota Memorial Hospital in Japan

Jeff Liker: I had the opportunity also to visit Toyota Hospital in Japan last summer, and they're in the process now of implementing the Toyota Production System within Toyota Hospital. They own it, and it's a public hospital.

Mark Graban: Yeah.

Jeff Liker: It's called Toyota Memorial Hospital. And believe it or not, with all the years of being part of Toyota, they never really were interested in implementing the Toyota Production System or Toyota methods. But they now have a new managing director and new head of the hospital who decided, “We're part of Toyota. We really have to learn the Toyota Way.”

There are lots of different things going on. At one level, there are tools like 5S and organization. In theory, you'd expect hospitals to be extremely well organized and antiseptic, everything in its place. But that's not the case. If you look behind closet doors–

Mark Graban: Oh, sure.

Jeff Liker: –you'll see it's a mess, a complete lack of organization. And then there are even simple things like kanban applied to the supply system. When I was in Japan, Toyota had reassigned two production control experts to the hospital. I was walking through the hospital, and these guys are giving me a tour, showing me all these kanban systems for all the materials moving through the building.

I asked, “How is it you came to be here?” And they said, “That's a good question. We were wondering that ourselves. One day we were told we were going to work at the hospital. We thought there was a mistake.” But they said, “Once we came here, we saw that a lot of the hospital is just a big material flow system. There's a huge amount of material that needs to flow through the hospital, and it's done really badly. We can use all the same concepts we use for material flow in a factory in a hospital, and they work just as well.”

Patient Value Streams and Where the Waste Goes

Jeff Liker: Another way of looking at it is in terms of value streams, patient value streams. Patients come in, they want to be served, they go through a whole series of processes, and then they come out the end and get sent home. From the patient's point of view, most of what they experience is waiting, waste, lost records, and misinformation.

A lot of the work at the University of Michigan Hospital has been to pick specific value streams, map those value streams using value stream mapping, just like in factories, and find there are incredible amounts of waste from the patient's point of view. Then they start reducing that waste using lean tools. They found they can easily cut the waste the patient experiences in half. Eventually we'll be getting up to cutting eighty or ninety percent of it.

For example, a patient who calls in with a problem in the sports medicine department used to wait weeks to get served. Now they're serving almost all of these patients within twenty-four hours. That sort of thing is becoming very common, and hospitals around the country are picking up on this.

When Lean Looks More Like Product Development: The American Heart Association

Jeff Liker: We also did work with the American Heart Association. You'd think, well, they're a healthcare organization, so the same lean manufacturing tools would apply. But their conclusion was, we're not really servicing patients. What we're doing is developing products. We're trying to get out information about heart disease, and we develop products to do that. They're training products, information products, internet-based products.

So they were looking more at the product development system as a model, and we did a product development system course for them. They found looking at themselves as a product development organization was more useful than looking at themselves as a manufacturing organization.

Mark Graban: Because I'm sure some manufacturers might struggle the same way if healthcare organizations are looking at Toyota and trying to copy specific tools. Nobody's suggesting putting an operating table on a moving line.

Jeff Liker: Oh, yeah. Well, they're doing more than that.

Misconceptions About Standardized Work in Healthcare

Jeff Liker: The doctors imagine that they're going to have standardized work and they're going to be told, reach for this at this second, reach for that at this second, following procedures like they're set in stone. And they see that the patient needs something different, but they're not allowed to do it because they have to follow the standardized procedure. So they have all these strange visions of what this is about.

What it's really about, again, is becoming a learning organization, understanding your processes so you can see where there's waste and how you can eliminate variability to better serve your customers. That's really what it's about. It's not about trying to make yourself look like an assembly line.

Why Healthcare Professionals Tend to Be Open to Lean Thinking

Mark Graban: The healthcare people I've worked with, I give them a lot of credit for being open-minded and not falling back on saying, “Well, we're different.” Even in the manufacturing world, people tend to say, “We're not auto assembly,” or, “We're not the auto industry.” They come up with so many excuses for why they're different. But it seems like the power of lean is that the principles and concepts, at the right level, can be applied just about anywhere.

Jeff Liker: Yeah, we've certainly seen that. One nice thing about healthcare is you have very highly educated professionals who are constantly learning, so they tend to be very open to it. If they feel that what you're trying to do is impose some recipe on them that doesn't fit, they're going to resist. But they tend to be very open to thinking in terms of principles, because that's what they're used to. Thinking in terms of tools and principles that need to be creatively applied to solve problems is something they do every day, so they're very open to that.

Mark Graban: We hear the complaint, “This isn't assembly line medicine.” I try to remind people that there's a pejorative version of that term, where people picture old, non-lean, problematic, poor-quality production lines. I always emphasize that it's not about turning this into a mindless, repetitive process. Not at all. But there are good lessons to learn from good lean assembly plants.

The Andon System and Surfacing Problems

Jeff Liker: Right. I think, as you're implying, people also oversimplify the assembly line. It's not a mechanical process where you turn it on and cars just crank off the end while everything runs smoothly like a big well-oiled machine. The assembly line is a bunch of people doing a bunch of pretty complicated tasks, seeing problems, needing to solve those problems, and collectively, through all these people, trying to build this thing together, solve problems, and coordinate their efforts. Then something comes out the end.

But to get really good quality, everybody has to be a problem solver. That's what Toyota has tried to do: mechanize the routine tasks to free up people to solve the problems, the deviations. There are always deviations. Assembly plants are extremely dynamic places, with problems going on everywhere.

One of the things that's good about the andon system is that you pull the cord, music comes on, lights go on, and that says, “I need help.” You surface the problem, and that's what Toyota wants. In a Toyota plant, there's music playing everywhere all the time, lights going on all the time. You'd think they must be the worst assembly plant in the world because of all the problems they have. The only difference between them and another plant is that they're calling attention to their problems.

Workarounds vs. Fixing the Root Cause

Mark Graban: And they're fixing them.

Jeff Liker: Fixing the root cause instead of just putting the fire out. So they're getting better every day, whereas the other plants that aren't calling attention to the problem aren't getting any better.

Mark Graban: That's the one message that seems to resonate really well. Steven Spear has written a lot about workarounds in healthcare, and you see that all the time: a problem pops up, a tube of blood is missing, and the default problem-solving process has always been, find the tube of blood. Once it's found, the problem's considered solved. Then something else comes up missing a couple of days later.

Learning those problem-solving approaches, starting to challenge, what if we never had a missing tube because we fixed the reasons they're getting lost? You see the light bulbs go off, and that change in people's thinking process seems to drive a lot more improvement than the things you might think of as more traditional lean tools, like 5S.

A Kaizen Example: The IV Catheter Process

Jeff Liker: Right. That process of calling attention to a problem and solving it is very powerful. At the University of Michigan Hospital, one of their model projects was an intravenous catheter, the kind you insert so you don't have to keep reinserting the IV line every day for the patient. You can easily insert it into this catheter that stays in place.

They mapped the process to see what happened from the time the doctor or nurse said, “We need this,” until it was actually inserted and ready to go. It could take days, and it was probably minutes of value-added work in that whole process. So they mapped it, put it on a big map on the wall: here's the current process. Then they asked for suggestions, and people put Post-it notes up. They got dozens of suggestions. Nurses came out of the woodwork to suggest improvements.

They came up with a future state and dramatically reduced the time it took. They developed carts that were well designed using 5S, developed a process for calling for it, and cut out a bunch of steps. But just the fact that they had the process visible on a wall, and then asked for suggestions, people loved making those suggestions. They got excited. They had the ideas and the knowledge, but they didn't have a vehicle to share that knowledge. Simple visual tools gave them that vehicle, made the process visible, and everybody said, “Oh yeah, that's been frustrating for years for me, and I'd love to come up with an idea for improving that.”

Consulting, Workshops, and Optiprise

Mark Graban: I'll make sure there are links to your books and information about you on the Lean Blog website. But if people wanted to contact you, or wanted help from you, what type of consulting or advising do you do personally, or through another organization?

Jeff Liker: Personally, I'm often asked to do keynote speeches and talk at conferences. Sometimes I do more of a workshop, where somebody will say, “We need a leadership workshop. We need a vision for what our company would look like if we were really following these principles of the Toyota Way. Can you help us by teaching us, then helping the management team develop a vision for our company?” I tend not to get so involved in the day-to-day tools and transformation work.

I'm also part owner of a company, Optiprise. Optiprise has a set of consultants who've been trained in lean, a number of whom used to work for Toyota. They go on the shop floor, do value stream mapping, put in pull systems, and step by step teach the plant what this is about, how to make it a system, and how to turn it into real problem solving. So I do both those kinds of things. I get regular emails just asking me to speak at this event or that event, sometimes a one-hour presentation, sometimes a whole day, sometimes a several-day workshop, as well as, “Is there a way you can help us on a consulting basis?” And then I rely on the people who work for me, who are more hands-on in their experience.

New and Upcoming Books

Mark Graban: One other question. I'm looking at my copy of The Toyota Way sitting here. Is there a follow-up coming? I know there's the Toyota Way Fieldbook that came out. Is there another book in the future?

Jeff Liker: The Toyota Product Development System actually came out about two months ago.

Mark Graban: Oh, okay.

Jeff Liker: That's through Productivity Press, with Jim Morgan. Jim Morgan was one of my PhD students.

Mark Graban: Mm-hmm.

Jeff Liker: So that's out now, you can see it on Amazon. Currently, what I'm working on with Dave Meier, who wrote the Toyota Way Fieldbook with me, we're finishing up a book called Toyota Talent, about how Toyota develops their people. What we're doing is writing a series of books that go into more depth on each piece we can learn more about, developing lean processes, developing people, problem solving. We're going to have whole books on each of those things.

The one we're working on now is the developing-people book, and it's due to the publisher by the end of September. It takes them about six months to get it out.

Mark Graban: So in the future, you might work on lean publishing to help them reduce their time to get books out.

Jeff Liker: Oh, they're terrible. I tried. I've given them unpaid, free advice that they mostly ignore.

Mark Graban: Well, I'm glad that hasn't discouraged you from writing more books.

Jeff Liker: Okay.

Mark Graban: I appreciate you joining us here on the podcast. I really do appreciate your time and your insights on the Toyota Production System.

Jeff Liker: Great. Enjoyed it. Bye-bye.

Coming Up Next

Mark Graban: I want to thank Dr. Liker again for being here on the Lean Blog Podcast. That's the second of a two-part discussion. Coming up in the next couple of weeks, we'll have podcast discussions with Jamie Flinchbaugh of the Lean Learning Center, and more discussions with Norman Bodek.