Episode #112 is a chat with Naida Grunden, the author of the outstanding book The Pittsburgh Way to Efficient Healthcare: Improving Patient Care Using Toyota Based Methods.
Here we talk about her experiences in Pittsburgh and her “small world” connection to Captain Chesley Sullenberger (a.k.a. “Sully”) and the connections between Lean, aviation safety, and checklists.
To point others to this episode, use this URL: www.leanblog.org/112.
In the podcast, Naida talks about three key components, via Capt. Sullenberger, of aviation safety that we would need in healthcare:
- A non-punitive national reporting system (the ASRS)
- Crew Resource Management (standardized work, checklists… in a less hierarchical environment)
- Culture change
I know the audio quality isn't great… so I've added a transcript below.
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Announcer: Welcome to the “Lean Blog” podcast. Visit our website at www.leanblog.org. Now, here's your host, Mark Graban.
Mark Graban: Hi, this is Mark Graban. Welcome to Episode 112 of the podcast for February 10, 2011. My guest today is Naida Grunden. She is the author of the book, “The Pittsburgh Way to Efficient Healthcare — Improving Patient Care using Toyota-Based Methods.”
Today, we're going to talk about her experiences with the Pittsburgh Regional Health Initiative and her small world connection to somebody who's very well-known in the aviation world. We're going to talk about connections between Lean, aviation safety, and checklists, and the common theme that this isn't just about the tool or the artifact, as Naida calls it, the checklist.
It's also primarily about culture change. This is the first of two podcasts that we're going to do in the next couple of weeks. You can go to leanblog.org/112 to post comments on this episode, or you can go to leanpodcast.org for all past episodes. Naida, I want to welcome you to the podcast. Thank you for taking time to talk to us today.
Naida Grunden: Well, thank you, Mark. It's great to be here.
Mark: If you could start maybe by introducing yourself to the listeners, talk a little bit about your background and talk about your book, I think that would be helpful.
Naida: Sure. I had the great good fortune 10 years ago, as a matter of fact, to have been hired by the Pittsburgh Regional Health Initiative, which was a very fledgling enterprise at that time, run through the Jewish Healthcare Foundation in Pittsburgh, where I lived.
At that time, we were still in the throes of trying to persuade people that using an industrial model would work at all in health care, that it even had a place. Well, the leader of our organization happened to be Paul O'Neill, who was the CEO of Alcoa. Subsequently, within a couple of weeks of my coming to work there, he became the Secretary of the Treasury.
Suddenly, interest really peaked among the hospitals across Pittsburgh, wanting to try this Toyota thing, whatever it was. The fact that it was offered through a neutral, nonprofit organization like PRHI allowed people to think, “Hey, this at least is non-competitive and something I want to try.” My job as the writer was to go from organization to organization and document, “Is this working? Is this Toyota business going to work in health care?”
For five years, I went from hospital to hospital, documenting and writing articles for the Pittsburgh Regional Health Initiative, the PRHI newsletter, and then was approached by Productivity Press in 2006…, “We think that you should consolidate the best of your stories here and create a book.”
I did, and that's called, “The Pittsburgh Way to Efficient Healthcare.” That book came out in late 2007, early 2008. It just compiles the stories, the actual, on the ground, what it looked like, the good, the bad, and the ugly of implementing Lean in these different hospitals across Pittsburgh.
Mark: Now, from that experience, can you share maybe one example of the good? Then since you mentioned ugly, it's always tempting to ask, what was ugly? Can you give maybe one example of each from what you documented?
Naida: Well, I would say probably the most significant thing, and I didn't know as I was documenting it that it would be so, you know that very often hospitals will invite you in to clean out their closets and fix up their rooms and everything peripheral to the actual health care process.
I think the most significant and interesting work that I was able to profile was the work of Dr. Richard Shannon at Allegheny General Hospital, when he reduced central-line infections over a period of 90 days to 0 in the two ICUs that he had jurisdiction over.
That was the first and I think still one of the best descriptions of using Lean in a clinical process to bring a real benefit to patients right now. That was a really great one.
Then some of the difficulties, one of the stories I wasn't able to get into the book, but I'll just highlight some of the difficulties in implementing Lean. I told a story about one of the receptionists at a mental health facility, who would go to work on Monday mornings and sit in her car.
She would weep because she knew she was going to have to deny people getting in to see a doctor right away, who were very sick. That was before the Lean improvement. They worked very hard to come up with a way to get some open access scheduling so that people who really needed an appointment could get right in. Some of those human stories, I think, are moving.
Mark: I cannot relate, not from a first-hand standpoint of sitting in the car and weeping. I've seen hospitals all over the country, and this is just a Pittsburgh problem of people that have gotten burned out and gotten frustrated from the waste and things that we can thankfully address with Lean. I'm sure you saw a lot of that, too, the improvements it helped address.
Naida: Absolutely. That was the really heartening thing. Occasionally, people would find it difficult, even though they knew the way we're currently doing things isn't working out very well. It's hard to let go of it. It's a very emotional thing to say, “Now we're going to do it differently.
“All of this wonderful workaround that I've gotten so good at, we're not going to need that particular skill anymore because they're making it easier for me.” There's some interesting aspects of it that I noted.
Mark: Moving ahead a little bit after, when you'd completed that book and amendments, I wanted to talk about what turned out to be a really small-world connection. As we were talking before, when your book came out, it allowed you to reconnect with some people, including somebody all of our listeners — not in just in the US, but around the world — would know.
Tell us that story about reconnecting with Sully .
Naida: It was very wonderful. When I wrote the book, and the book got out, I heard from people I hadn't heard from in a long time. My husband, Larry, is now retired, but he was an airline pilot with US Airways for decades. I heard from one of his colleagues.
The guy wrote to me through my web page, and he said, “Hey, look, I don't know if you remember me. I remember you from that union meeting that we attended together. I've flown with Larry.” It turned out this guy was one of these genius types. He has two master's degrees, one of them in Human Factors from Purdue.
The way that he came in touch, he said, “I see that you've written a book. A professor in Human Factors from San Jose State has sent me your book, and I realize I know you, and I've flown with Larry.” That was how we began the correspondence. This was in early 2008, right after the book came out. We corresponded all year long.
He kept saying, “I would like to start a business. There's such synergy between aviation safety and patient safety. We could learn together.” I kept emailing introductions to him to various people in the Lean movement, here and there, and folks that I knew over the years, having worked at the initiative.
Nobody wanted to talk to some pilot about safety because there are a lot of smart pilots that know a lot about safety. It's hard to describe the [laughs] gobsmacking surprise of January 15th, 2009. When I was watching CNN, I saw that the guy that landed that A320 on the Hudson River was none other than my correspondent, Sully Sullenberger.
It was wild. One of the first emails I sent him after that incident was, “Hey, Sully, in healthcare, they will listen to you now.”
Mark: He undoubtedly had a lot of demands on his time, but you were able to work with him. Maybe tell us a little bit about what you were able to do with him to help bridge aviation safety to patient safety, and to Lean.
Naida: What happened was, he contacted me a few months later and said some people in healthcare indeed had been asking him to speak. He doesn't forget his friends. He could've worked with anyone, and he asked if I would help him create this healthcare speech.
We'll put in some Lean elements and some elements of all the things, of course, that he knows about safety, framing it from the aviation standpoint. It was a real mental exercise for me to drop in healthcare examples, but reform it to use way-of-thinking in aviation safety. I learned a lot helping him write his speech.
Mark: From that speech and those connections, maybe tell us a little bit about the pieces that you think are complimentary. There's checklists. We've talked about a lot on my blog, and people have read Dr. Gawande's book. There's more to it than just the checklist itself with that methodology. Can you share your thoughts on that?
Naida: Sure. The three points that Sully makes in his speech…If you talk to any airline pilot, they'll let you know what the three elements of aviation safety are. Number one is a non-punitive national reporting system like the Aviation Safety Reporting System.
I know that creates a great deal of turmoil and heartburn because medicine has so many ad hoc and unconnected ways to report a problem. Aviation just has one, and anybody can report.
Mark: People in healthcare don't report the problem because it's not non-punitive, or it is punitive.
Naida: They don't report. They'll get punished. The idea behind healthcare is we're going to tally these mistakes and mete out punishment. For the last 30 years, the ASRS has as its guide that, “No, we're using this information. It's gathered not by the FAA, which is the police arm. It's gathered by NASA, which is a neutral organization that gathers the data and feeds it back.”
It creates patterns. It creates ways to learn from things. It informs their training, their checklists, and everything else. It's a super-important missing piece. I'm not sure how far we can get without a way to report and learn to see if we're even doing things better. That was number one with aviation.
The second thing is something all lean people will understand, and that is standardized work. What they call it is crew resource management, and they use that term to encompass standardized work, checklists and so forth, and the idea that the captain is no longer the cowboy or the god but that everybody on the crew shares responsibility for a successful outcome.
It's not just a matter, Mark, of getting, let's say, the nurse to speak up and not be afraid to speak up to say, “Gee, Doctor, I think such and so.” It's so much deeper than that. They are now expected to speak up. It's your responsibility to speak up if you see something that's out of the ordinary. This is a huge shift.
When my husband was first flying, he could remember actually carrying a little notebook in his breast pocket with all the different captains' preferences, so that's then. Calling a captain on something or requesting something or pointing something out could have resulted in termination.
That is the culture change that's happened in aviation. It's very sweeping and very incredible. Once you do that and you have this reporting mechanism, you then have the wherewithal to standardize processes.
The checklist, I think it's very encouraging to see the checklist being adopted in health care. The thing I think people need to stop and think about is what is a checklist? It's really not an artifact.
It's like lean in general. Lean is not a thing. It's a philosophy. A checklist is the same kind of thing. It summarizes the most critical, non-skippable steps. It's not a grocery list of procedures. It's not a to-do list.
It's only the most critical items. Everyone can agree on a standardized procedure, highlight those most critical items. It formalizes best practices. It encourages communication and leadership. It does all kinds of things. It encourages best behavior, best practices, and so forth.
People worry that it's going to make you a robot. You and I know, and all lean practitioners know that it's standardization that supports flexibility. You have to spend all your efforts on critical things, like landing on the Hudson, which medically, doctors and nurses have to land on the Hudson from time to time.
Having standardized procedures to fall back on frees up your mind to work on the critical thing in front of you.
Mark: I believe in hearing Sully recount the story, there was no checklist that they could pull out and say, “Here's how you land a plane on the Hudson River.”
There were a number of checklists that they did go through, how to restart the engines, a number of checklists that it seemed like they, Sully and his first officer, had to stitch together. That was their professional creativity and experience of knowing what checklist to go to.
Naida: That's true. As a result of the experience there, where the first officer was doing the restart, trying to restart, restart, restart this engine, which was toast…They could not restart this no matter how well he did that checklist or how perfectly he executed it or how quickly, all of which he did, that engine was not going to restart.
Now they're going back through that incident and saying, “Is there more we could have learned? Is there some signal that could have told that first officer right away give up on this checklist and go on to the next one?” Even the successful emergencies, they analyze and analyze and create more learning from it.
Mark: We can come back to the checklists here, but you'd mentioned that there were three points, first being non-punitive reporting, second being standardized work and CRM. What's the third point?
Naida: The third point has to do with culture change. If I can use the aviation example, although some people may consider it tired, but in 1977 there was the terrible disaster in Tenerife. Over 500 people were killed that day when two gigantic airplanes collided, ironically, on the ground.
As a result of that, they did a tremendous amount of learning. They discovered that so toxic was the culture in the cockpit of the KLM airplane, that it's quite apparent that the first officer knew something was wrong, and it's quite apparent that even the second officer suspected that there was an airplane on the runway.
They weren't sure that it wasn't there. Yet they spoke up once, they spoke up again, and the captain dismissed and dismissed them. There was no way for them to pull the Andon cord. There was no way for them to stop what was going on. They considered their way. They knew that if they were wrong, they'd be in trouble. If they were right, they could die.
Based on those observations about the feeling in the cockpit, the aviation industry did a lot of soul searching and said, “This has to change. We can't have the captain, god, cowboy anymore. We have to create a more cooperative environment in the cockpit.” That is when the culture change began in the cockpit.
It extends farther than that. Safety now must be seen as a core of business function. All managers have a stake in the safe requirements and outcomes of what happens. It's a costly thing to implement. Are we going to have safety be a core business function? Are we going to really put employees on the value side of the ledger? If we do those things, it's going to be expensive.
Then Sully calls the question, as many people have called the question, what's the cost of not implementing this?
Mark: You studied the culture that used to be there in aviation. It's interesting to see that a first officer would not speak up even though their life was on the line.
It's maybe a tired analogy. The difference between pilots and surgeons, highly skilled, highly trained, highly responsible and respected professionals, is that the pilots have skin in the game, if you will.
Mark: Surgeons walk away from surgical errors. Even with that life on the line here, your own life on the line that a culture could be so debilitating in preventing people to speak up is, I think, an interesting thing to think about when we consider the cultures in health care or other organizations.
Naida: That's right. The other thing people like to point out is that pilots have hundreds of lives in their hands at a time, and physicians have one at a time. Even so, this toxic culture had been allowed to develop.
I have to say, over the last 30 years, since the Tenerife disaster, aviation safety has improved. Your odds of dying in an airplane crash are minuscule compared to even what they were 30 years ago, which was quite small.
Improvement is possible. My hope is that we're able to figure out some way, some really legitimate way to have a non-gaming reporting system and real standardization and really making safety a core business function.
Mark: One other thing I'd be curious to hear your thoughts on, back to checklist and culture. I know you call it an artifact. You think of a factory, or a hospital even, that goes and just says, “We're going to take this artifact called 5S and use this tool.” Out of context, it maybe doesn't help or maybe causes different problems.
What would you surmise would happen or maybe know experiences where a hospital drafted a checklist or bought a checklist, and dropped it into place as a tool? What are some of the problems that might result if that doesn't fit with the culture and maybe the needed culture change?
Naida: It's not going to work. It simply won't work. It's just another thing, then. It's like you said, when it's dropped in out of context, it's not easy or instinctive to run a checklist.
One of the things, a doctor came up to my husband after one of my talks, and he said, “You mean to tell me that the minute you run into trouble, the first thing you do is you reach for a checklist?” My husband looked at him and said, “Yeah. That is the first thing we do.” That's not an instinctive thing to do when you're in trouble.
It has to be part of your training. It has to be so ingrained. If you drop in a checklist, the predictable thing is, what I've heard happens, where the doctors go, “I don't want to do this.” There's no culture where the surrounding people say, “Doctor, this is how we do things around here.” There's nothing to support it, and so it can't survive.
The other things is, as you know, we support what we create. If people have a hand in the creation of that checklist, it's far more likely to be done. Those kinds of activities are very congealed with me.
Mark: That was, I thought, a very strong point in Dr. Gawande's book — that people have to develop their own checklists. That is, I think, a perfect parallel to standardized work. You need to go back to the writings of Taiichi Ohno saying people who do the work need to develop their own standardized work.
Somehow I think in the US it's somehow gotten twisted into a point where an expert or a manager writes a standardized book and then throws it at people. It's natural to see why there would be discomfort with that.
Naida: Yeah, it's like, “Here you go. Here's your standardized work.” [laughs] That doesn't work.
Mark: A friend of mine here in Dallas was a pilot. He does training where they teach teams how to develop a checklist. He cringes when he knows that other hospitals might go and just buy a checklist to drop it in place.
It seems pretty intuitive why that wouldn't work, but it seems like people are tempted to take that shortcut, or they don't realize, to the points you're making here, why that's not going to work.
Naida: I think there is a tremendous opening, a tremendous opportunity between the world of aviation and the world of medicine.
I know people get tired of hearing it. They want to throw stones at it. “Airplanes aren't hospitals.” We heard it with, too, “cars aren't people,” but there really are ideas that can and should be flowing freely between these two disciplines because as Sully points out in his speech, pilots have paid for 30 years to develop these ideas, and they've paid with blood.
Mark: Wow. That's a powerful point. I guess it goes to show this isn't an overnight change. No culture change is going to happen immediately, right?
Mark: One other question that comes to mind — you talked about how Sully, before the landing on the Hudson, had talked about wanting to start a business. Has he indeed started that business? Is working with hospitals now?
Naida: He's delivered a number of healthcare addresses. As you can imagine, his life has taken such an unexpected turn. He is in demand in a lot of different ways, healthcare being but one. Of course, my fond hope is that he will end up devoting more and more time to healthcare, but right now, he's just a busy guy.
Mark: He's still flying, right?
Naida: No, he did retire. He went back on the line. He flew for a while, and then retired.
Mark: I'm sure that must have been reassuring to people who were boarding, or maybe it was a distraction, seeing, “Oh, wow, [laughs] …
Mark: …Sully is my captain today.” [laughs]
Naida: Yeah. Yeah. There were lots of skilled pilots. He is truly among the elite, but there are plenty of skilled people out there, and there's so much expertise that could be used.
Mark: Naida, I want to thank you for sharing, mostly, a little bit about your background and that great coincidence of running across Captain Sully, Captain Sullenberger a couple times in your life. I appreciate you being able to share some perspectives with us here on the podcast.
Naida: Thanks, Mark. It's been great to talk with you.
Mark: As a preview for people who are listening today, Naida and I are also going to have another podcast in the future. Maybe just give a quick preview about a trip that you're going to take to Cuba.
Naida: It actually involves another of my contacts from Pittsburgh. It's an organization called Global Links. Their mission, for the last 20 years, has been to offer equipment and supplies to countries in Latin America. They're now expanding that to offer Lean trainings so that they can get more out of the supplies that are being sent.
We've recently done some Lean training in Havana, and I have some interesting insights into that.
Mark: We'll have to leave that as a tease for a future episode. Sorry to do that to the listeners. Please do tune in and subscribe to the podcast feed through iTunes, or a few other ways if you go to leanpodcast.org, to be able to hear that next upcoming episode from Naida.
It was so nice talking to you, Naida. I'm glad you could join us.
Naida: Thanks, Mark.
Announcer: Thanks for listening. This has been the Lean Blog podcast. For Lean news and commentary updated daily, visit www.leanblog.org. If you have any questions or comments about this podcast, email Mark at leanpodcast@Gmail.com.
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