A Dutch Engineer Now Working in Lean Healthcare: Arnout Orelio


My guest for Episode #403 is Arnout Orelio, author of the book Lean Thinking for Emerging Healthcare Leaders: How to Develop Yourself and Implement Process Improvements.

Arnout is from the Netherlands, but we have crossed paths a number of times when he and many of his Dutch colleagues have come to the U.S. for events like the Lean Healthcare Transformation Summit, produced by Catalysis. His book, written in English, has a lot of great lessons for leaders and Lean practitioners in American healthcare and beyond. He has also written two books in Dutch.

Arnout and I have strikingly similar professional backgrounds and paths, which we discuss in the episode. We are both engineers who progressed from the automotive industry into healthcare. We talk about how he shifted into healthcare (in 2005, same year as me) and how this experience has reinforced that:

“Leadership is not a person, it's a process. Everyone can be a leader if you want to change something.”

We talk about the differences in the Dutch healthcare system, at a high level, and the similarities in how Lean can be applied. We also discuss topics near and dear to my heart:

  • Why Lean should keep employees (and patients) happy
  • Process Behavior Charts
  • Training Within Industry / Job Instruction
  • Eliminating overburden for healthcare staff (see the first bullet point)
  • The relevance of TWI to Covid vaccination

Here are his website and his publisher's websites, so please take a look.

The podcast is sponsored by Stiles Associates, now in their 30th year of business. They are the go-to Lean recruiting firm serving the manufacturing, private equity and healthcare industries. Learn more.

This podcast is part of the #LeanCommunicators network

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Video of the Episode

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Automated Transcript:

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Announcer (42s):
Welcome to the Lean Blog podcast. Visit our website www.leanblog.org. Now, here's your host, Mark Graban.

Mark Graban (53s):
Hi, it's Mark Graban. Welcome to episode 403 of the podcast. It's March 3rd, 2021. Joining us today is Arnout Orelio. He's coming to us from the Netherlands, and I think you're really going to enjoy our conversation about lean thinking and lean leadership for healthcare. You can find show notes and a link to his book and more by going to leanblog.org/403. Thanks for listening, and thanks again to our friends at Stiles Associates for sponsoring the podcast. Arnout Orelio. He has a background, very similar to my own and, and I I think we have a lot of shared experiences and perspectives.

Mark Graban (1m 39s):
His career has progressed like mine. He's evolved from engineer to manager to consultant. He started in the auto industry and has ended up working in healthcare. Is that a, a fair assessment of your background, Arnout?

Arnout Orelio (1m 53s):
Yeah, I would say, yeah, and I, I made a, like a site step to project management.

Mark Graban (2m 2s):
Okay. And part of the progression. And, and by the way, thank you for being here on the podcast. I got a little bit outta my standard work.

Arnout Orelio (2m 10s):
No worries. Thank you for having me.

Mark Graban (2m 12s):
Yeah, I'm, I'm really glad we could do this. And Arnout and I have crossed paths actually in person when I've had opportunities to go to the Netherlands for different healthcare events. And, and I forget, did you ever come to the US for any conferences where we've crossed paths or only in the,

Arnout Orelio (2m 29s):
Yes. There was a time when I organized study missions to the US and I visited quite some episodes of the Lean Healthcare Summits. Yeah. And I, I believe there was one where you were the, the master ceremonies, so, right. Yeah. Okay. So yeah,

Mark Graban (2m 51s):
So that might have been eight or nine years ago. So we've, we talked and crossed paths a lot over the past decade.

Arnout Orelio (2m 57s):
Yeah, we did

Mark Graban (2m 60s):
One other similarity. Arnout has also become an author, so two books. First off, written in Dutch, is that right?

Arnout Orelio (3m 8s):
Yeah. Correct. Yeah. The, the first one was published in 2019 in September. And then last year, 2020, I launched my second book in Dutch in June. And the translation of that book came out this September in 2020. Yeah, exactly that.

Mark Graban (3m 31s):
And for those watching, for those listening, you don't see me as the YouTube viewers will see holding up a copy of the book. I was able to buy it from amazon.com here in the States, and it is titled Lean Thinking for Emerging Leaders. And that's gonna be the main topic of conversation today. There's so much we could talk about. Let's talk about the book, and we will do podcasts again after this. How, how about that?

Arnout Orelio (3m 56s):
Yeah. Well, that would be awesome. Thank you. Yeah.

Mark Graban (3m 59s):
So congratulations on, on the book. And you know, before we, we, we dive in and talk about the book. Can you elaborate a little bit on some of your, your background and career path? I give the very quick summary of it.

Arnout Orelio (4m 13s):
Yes. So as you mentioned, I'm an engineer from background. I studied mechanical engineering and, but I've soon found out that I have not, not a strong passion for technology, which is strange maybe for an engineer, but I have a passion for people who try to understand and work with technology. So I started my masters in what, what's called innovation sciences currently. At the time it was called Technology and Society. It had all different kind of names, but the most important thing was what happens when people interact with technology.

Arnout Orelio (4m 59s):
And from there, I became a production management in the automotive industry in the time that we have one of the first companies that is a third party manufacturer for the automotive industry, which is quite rare in the world. And they were building Volvos and Mitsubishi in one on one line, which was at the time also very rare. So I was very lucky to be at this innovative point in the process. And there I found out that they found a way to increase performance of the factory fast without well overburdening the people.

Arnout Orelio (5m 51s):
So I felt that that to be very interesting. And I had the opportunity to work with an interim manager at the time, and he showed me maybe my first lean lesson, and that's that you need mirrors. He said, he said, you need to look in the mirror every day. And what he meant is he had all these graphs and he had people with their bicycle go into the factory to gather the data because there were no data on how many cars we made and how many were correct, and first time right passes, et cetera.

Arnout Orelio (6m 31s):
So he built a whole system and he called it his mirrors. So he said, I look in the mirror every day and see how, how am I doing? And I found that very intriguing, and that's a set of a huge improvement program because he was like, no one capable of knowing where they need, they needed their help or where the maintenance guys needed to go or whatever. So he used it to steer his company, but it was at a time still a company which was strongly hierarchical. And I'm not that good with the, the sense that you do what your boss says just because he says so, because I just came from university and I learned that you need to assess and you need to be methodical, but there's no time to be methodical when you need to build a car every minute.

Arnout Orelio (7m 33s):
So I soon found out that no science in tech time, at least not in that factory. So, and then I became a, a project manager, and I discovered that people can handle a lot of responsibility. So it was a very young company, and they taught me you have the responsibility you take. And that meant that the people who could take on a lot, and I was lucky to be somebody like that, they could grow because they get the largest projects, et cetera.

Arnout Orelio (8m 15s):
But to me, project management was more a trick than, than a profession. So it didn't challenge me enough. And then I saw an ad from an a lean consultancy firm, and all the words I heard, the buzz words I heard in school and in that automotive company were in that ad. And I thought, this is what I want. I want to be a consultant because then I never have a boss. I can talk with operators and with with the CEO just as partners. And that was the best decision I ever took in my career because I wanted to do it at the time, I thought, this is what I like.

Arnout Orelio (8m 59s):
So no career planning, just in the moment deciding this is what I need to do. And then I figured out that it had nothing to do with consultancy what they were doing, because consultants write reports and give presentations. And the only two thi two times I did that in my career as a consultant, these were the worst projects. So, so what we actually did is, and that's where I learned what actually management is, is we just went to the shop floor with the responsible person, the pro production manager, or maybe the CEO or whoever was hiring us to teach them this stuff.

Arnout Orelio (9m 46s):
And we went to the floor and we asked the operators, what are your problems? And they always knew. And if you asked, how do you think this problem occurs, why is it they always knew? And if you ask, how do you think we could solve it? They also knew. So we helped these leaders to see what their work was. And that's kind of interviewing the people on the floor, what are the real problems? What are the real causes, and how can we solve them? And then of course, the whole set of tools from Lean is helping you to give it some structure.

Arnout Orelio (10m 33s):
And I made a mistake at the time to think that Lean was all these tools, but the Yeah, yeah. But the more I, the more I did this work, the more I find out it had nothing to do with factories. I thought it was something it had to do with factories, but it had nothing to do with factories. And as soon as I figured that out, that it's like my engineering mind already knew, it's a system and it's a system design to help customers get what they want. And the system is not only the technical side, but it's these people that make the system alive. So if you can figure a way out to connect everybody, then you get, can have great results.

Arnout Orelio (11m 19s):
And because, well, I'm a father of three sons, so I always explain that that means that you visit the hospital from time to time. Yeah, yeah. Because they break their arm or they break their leg, or I

Mark Graban (11m 36s):
Don't know, not just when they're born, but other visits.

Arnout Orelio (11m 39s):
Yeah, yeah, yeah. Not only when they're born, but yeah, during, and what I, what I discovered, and it's always a bit difficult to say, but I felt terrible when I visited hospitals, especially when I developed this lean mindset and perspective. And I thought, how is it possible that in the world that we, we find it's so important because you're there, I'm there with my son and I'm feeling, I have, I've pain in my stomach and I have a headache, and I cannot figure out how long it's going to take.

Arnout Orelio (12m 24s):
Is there still time to go to the restroom? Are they going doing the right things to my son? Is he getting better? All those things. And it was for what I felt no system to assure and esp and to improve the quality of what they were doing. And then I decided together with some colleagues of that consultancy firm, we need to tell these people about, we called it world class performance at a time or lean or whatever you call it. So that became my mission. My mission became to spread this idea of that hospital is just like a factory, a system where the design of the system is determining the results.

Arnout Orelio (13m 16s):
So please let us not blame everybody, but let's figure out a way to improve the system. And then from, so this is now where 2005, I think for 2005, I start focusing on healthcare as a consultant. And I became a partner in that consultancy firm. And that went bankrupt in 2010. Hmm. Yeah. So I had only one business rela relationship that was with the bank at the time. But that, that was also good news because now I could truly focus on my mission to help healthcare improve.

Arnout Orelio (14m 4s):
And I also discovered that there's not many place knobs you can turn or buttons to push. I think I found out for me the most important place to start is with leadership, right? And leadership is not a person, it's a process. And I felt that everybody can be a leader as long as you want to change something. So I start to specialize in, okay, how can, how can I change the leadership mindset and behaviors of people?

Arnout Orelio (14m 46s):
So they start improving their process and their system such that by doing it, they continuously improve. And maybe this, this is what I, so these are, this awareness came when I started as a independent consultant and coach, I left the consultancy approach and I became more and more a coach because I felt it's my biggest gift to my customers is their self-reliance. If I can help them with something that they can use for the rest of their lives, then I would have the biggest impact.

Arnout Orelio (15m 32s):
And that's maybe also why this book is called, what it's called to make maybe the funnel go

Mark Graban (15m 41s):
Right into the book,

Arnout Orelio (15m 41s):
Right? Because it's called Lean Thinking for Emerging Healthcare Leaders.

Mark Graban (15m 46s):
Yes, exactly. Yeah.

Arnout Orelio (15m 48s):
So it's about the thinking, it's about the mindset that they can use for themselves to first become themselves better and then help their colleagues to become better, and therefore, thereby their processes and thereby taking care better care of patients. And it's called for emerging healthcare leaders because I feel that, and that was also the reason that the American publisher, Business Expert Press approached me. They figured that there's a gap in the market of education when it goes to healthcare professionals trying to lead.

Arnout Orelio (16m 32s):
There's not so much schools for them or training material, whatever. So they asked me, can you write something that is emerging leaders, so people who maybe were a doctor and now are a project leader or an innovator, or maybe a nurse who has become the department head, or how can we help them to get started with being a good leader right away? So I tried it to be, to keep it practical, and that's why I translated my second book and not my first, because the first book is called Making People Better, and the second book is called Making People Better in Practice.

Arnout Orelio (17m 17s):
So, so it would be the, the more tangible way to well, to improve yourself. So that's how my career ended up to be an author.

Mark Graban (17m 30s):
Yeah. I, I I just wanna jump in and say, I mean, there, there are so many parallels in our backgrounds. I also got into healthcare around 2005. I also left working for others in 2010. We had started working for myself. Slightly different circumstances, but, okay. The other thing, the other thing I was gonna say though, just to show, I think we, we think so much alike, Arnout, you don't see my notes, I didn't send you questions in advance, but everything that you've talked about there followed exactly the questions I was gonna ask. So how did you get involved into healthcare? What is an emerging leader? So you made it very easy for me.

Mark Graban (18m 12s):
I'm just sitting back and like,

Arnout Orelio (18m 13s):
Hey. Oh, you're welcome. I, I was just thinking how am I going to fit all this in this little time we have? Well, because well, it's always good to talk about yourself, so if you So please slow me down if you think that I'm maybe run over the edge a bit, but

Mark Graban (18m 33s):
No, it's okay. I mean, I'll, I'll, I'll help keep moving things along and hey, we'll, we'll do, we'll do other podcasts together and we can Okay, yeah. Take a deeper dive into some of these topics. So, stepping back a little bit though, I mean, you know, I've, I've had the opportunity to visit the Netherlands, oh, maybe even, maybe five times over the last 11 years. And I've visited a, a couple of, visited a couple different hospitals and have attended some conferences. And so I've always been, you know, quite impressed with the, the level of enthusiasm for lean across Dutch healthcare and, and for, you know, for the, the benefit of American listeners who don't know the differences across different European systems.

Mark Graban (19m 20s):
We don't cover them all, but the Dutch system is not what people might think of when, if they're familiar with the English, the, the NHS and

Arnout Orelio (19m 28s):
Nhs. No.

Mark Graban (19m 29s):
Can you, can you talk a little bit about how the Dutch healthcare system is structured? It's certainly not a single national organization.

Arnout Orelio (19m 37s):
No. So I, I will take it like 10,000 feet up, or, and so the system is that it's, well you would call it global payment, I guess so, but we try to work in some way to get some market work. So market would say that as a demand and supply, and that we arranged by we having this, like we have in Amer, we have insurance companies,

Mark Graban (20m 15s):

Arnout Orelio (20m 17s):
But these are not commercial, these are foundations.

Mark Graban (20m 21s):

Arnout Orelio (20m 22s):
Non-profit, so they're not allowed, they're not allowed to make a profit, but they, they, they receive payments from their, from their members or from from their patients. And each year you get the opportunity to select your healthcare insurance company. And the differences are that they may, they may be a bit cheaper, they may be don't, are not open to all hospitals or, so there's, there's little things that d differentiate them from each other. And then these insurance companies, they, they do the procurement of healthcare as representative for their patients.

Arnout Orelio (21m 13s):
So they make contracts with hospitals and with physical therapists and with whomever is there to provide curative care. So we have one system for the curative care, and the most important party in that system is our, is our family or primary physician, because they're the gatekeepers of the system, but they are also, I think they're very highly trained that it means that they can filter off most of the issues of their patients. So that means that we have, well, not too many, not too many patients are forwarded to the hospital.

Arnout Orelio (22m 1s):
And that's where we win a bit our costs because we save many people who have visited the hospital. So that, that would be the system. So I pay, as a, a patient, I pay a monthly fee to my insurance company, my insurance company procures makes a contract with the hospital, and then I can visit hospital and my bills are paid by the insurance company. Yeah. That's, that's the system in Well,

Mark Graban (22m 35s):
Well, and, and I think one other difference is that individuals buy insurance. It's not from a workplace benefit.

Arnout Orelio (22m 44s):
Yeah, exactly. No, we don't have a system where the, the employer is the buying parking. No, no. Individuals do. And we have, it's compulsory. So it's well obliged by law to have insurance. And the great thing about that is that it means also, and there is a, what's also very important is we have a, a base package. So each healthcare insurance company, they are obliged by law to purchase or procure or however you call it, a certain set of treatments to make sure that everything which is important and is, well, people cannot take the risk to not ensure it is there's the base package and it's all the same throughout the insurance companies.

Arnout Orelio (23m 58s):
And then there's additional things you can ensure, like your eyes, like glasses or contact lenses or facial therapy or things that are either not highly priced or are maybe for symptoms that are not too severe. So, so it would never happen that somebody is, I dunno, isn't allowed to go into the ER because they hit the bus.

Arnout Orelio (24m 39s):
Because it would, it could, it could, it's impossible for somebody like that to not be insured for those kind of treatments. I think that's also very important to know that, that that's the, to the high risk indications are all insured.

Mark Graban (25m 3s):
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Mark Graban (25m 46s):
Sure, sure. So thank you for setting that context. But you know, with the differences or similarities between, let's say the American system and the Dutch system, or the differences between the Dutch system and the NHS England, you know, I think the delivery of care ends up being very, very similar. So, you know, to that point, I mean, Arna, how would you describe, like what are the most talked about, most worked on motivations for lean in Dutch hospitals?

Arnout Orelio (26m 22s):
Yeah, that's interesting because the, well there, there's, well, there's two streams you could say. Because the interesting thing with things like Lean is they easily become the end in itself. So there's many people doing lean because their neighbors are doing lean, and we see that in healthcare there's a strong tendency to, to do what other people in healthcare do. So Lean is even getting a bit less attention because now we have value-based healthcare.

Arnout Orelio (27m 3s):
So I think that's, those

Mark Graban (27m 5s):
Ideas could be combined.

Arnout Orelio (27m 6s):
Yeah, yeah. Yes, of course. But that's only if you, that's the other stream. So there's one stream that's doing it because the neighbors are doing it and they, and they say, well, it's awesome, you need to do lean. But if you see what are the biggest issues why they should do lean, well then I think the biggest issue in the Netherlands currently as felt by the healthcare providers is staff shortages. And especially now during the Covid pandemic that's even more pro pronounced because it's, well, yeah, we have ICUs that have double their capacity to, to accommodate these covid patients.

Arnout Orelio (28m 1s):
And, but, and what's very popular in the Netherlands, if it, when it's about parts of the lean system, then it's, then it's that idea of continuous improvement and that that's something that people on the shop floor do. So there's many hospitals that have opened their, I dunno, their eyes for what nourish themselves can do to improve their work. Yeah. And, and of course that sounds like a good idea.

Arnout Orelio (28m 41s):
That's in itself, it's a good idea because they like it and it's better. But in my book, in my first book, I call this happy lean, and why do I call it that? Because the intention is to keep the people happy. Yeah. But it's not connected to the strategy of the hospital. So what you see is that it's, it has great effect on the atmosphere in the wards, for instance. And yes, things get better, but it comes with little to no change in mindset and le and behavior of management and senior leadership.

Arnout Orelio (29m 32s):
So there's another, so this is very motivating, but it's also a way to keep there by seeing it as a bottom up strategy, but keeping it at the bottom. That's what I, that's what I see often. So,

Mark Graban (29m 52s):
Yeah, I mean, I would say that's good, but it's not fully sufficient.

Arnout Orelio (29m 57s):
Exactly. Yes.

Mark Graban (29m 59s):
But I, I think that that happy lean, what you're describing reminds me of a, a mutual friend and teacher of ours who just passed recently, Norman Bodak, you know, he would call it quick and easy kaizen, just really, yeah, exactly. Really. Or Paul Acres who talks about, you know, two second lean fix, what bo that, that's a great start.

Arnout Orelio (30m 20s):
Yeah. But if you don't have a system around it to, to have it grow or, and the, the problem that I sometimes see is that if it's only making people happy and better working together, but it's, it doesn't go anywhere. So it's not often, not always goal-oriented. I mean, if you, what I see a lot is, and that's the, maybe a bit of the danger of this strategy is that if you, if you improve from the current situation away, I would say, I'm not sure if that is correctly English, but anyway, instead of two words ago, then the, the, the, well, the danger is that it goes in all directions.

Arnout Orelio (31m 22s):
And that in the end, we, the, the total performance didn't improve much. And that's what I, so it's a great start. But it's also difficult because if you have a, I don't know, do you know there's a, a model, it's the rollercoaster of emotions that you experience when you have loss. So when you change something

Mark Graban (31m 48s):
Yeah. The, the stages of grief or

Arnout Orelio (31m 51s):
Something. Yeah. Yes. So I, I came across somebody who changed it into the stages of emotions for change. And when you have changed it always start with enthusiasm. Yes, we're going to do something new. Awesome. So, and but many people forget that's the first stage. So as long as people are enthusiastic, you are probably not changing too much. So, and so if you asked what motivates people?

Arnout Orelio (32m 32s):
Well this energy of enthusiasm is, is used a lot to motivate people. And sometimes it's even the energy of the consultant or the coach that is used to create this energy. I've been used a lot to have people get energized, but that's not what needs to change because nurses and doctors alike, they're already motivated Yes. To change their work, but they need to know how and they need to be facilitated.

Arnout Orelio (33m 17s):
Or if they're not facilitated, well, maybe you should not be in the way at least, but it's very important, I have learned that you direct it maybe to make a small side step to my book. That's why the first, that's the, the, the first chapter is called give direction, right? So if you want these kind of changes, which are represented by lean management or whoever, whatever you call the new way of working, it's your job as a leader to, I call it give direction instead of, like Katie Anderson calls it set direction.

Arnout Orelio (34m 1s):
I say I, I took the word give because I feel that's more positive. And it says more that you are ser that you're a servant. It's, it's for you to give Yeah. Direction, but it's for you to give. So sometimes when I try to teach leaders that they should ask more questions, they're going to ask their their team members, well, what's the goal? Yeah. But if you ask your team member, what's the goal you are, if you don't watch out, you have 10 different, 10 different goals.

Arnout Orelio (34m 41s):
So no, it's not for you to ask them what's the goal? It's for you to give them direction, right? Yeah. To make clear why they are a team. Because they're only a team if you give them a goal. Yeah. If you don't give them a goal, you're not a team. Yeah. Good point. At least not in my definition. The definition I use in the book is a team is a group of people working together towards the same goal, and it's the goal that defines the team. Yeah. Like you would have in basketball where the goal is to have more points than the opponent, and you're not allowed to have more than five.

Arnout Orelio (35m 21s):
So you put five people in the, in the courts,

Mark Graban (35m 25s):
Well, you have the goal. And then there, there may be strategy. So you know, more and more basketball teams now would say the strategy is to take as many three point shots as you can. Yeah. And then it might be up to the players then to partly execute that strategy and figure out how to make that happen.

Arnout Orelio (35m 44s):
Yeah, exactly. Yeah,

Mark Graban (35m 45s):

Arnout Orelio (35m 46s):

Mark Graban (35m 48s):
So, you know, in the book, again, it's lean thinking for emerging healthcare leaders. There's a lot in there, you know, on, on lean mindsets and, and change management. And there's two other things I wanted to touch on from the book that some people might think of as tools, but I think also have a lot of mindset and involved and, and relate to strategy in the management system. So one of course, near and dear to my heart, which is not in most lean books, so thank you for, this is a brief discussion of process behavior charts, and thank you for including that and you know, for kindly mentioning measures of success. But the, the, the question I wanted to ask you, Arnout, is, you know, why, why do you think that's an important topic to expose people to?

Arnout Orelio (36m 35s):
Because it's all too easy, because I was one of the people who did that, that to go from wanting to become lean or the best or whatever, to start eliminating waste, because that's easy to explain and it's, it's logical to do. But then you forget two important other problems that Toyota was solving before they start eliminating waste. And the first is overburdened. So if you're overburdened, it's impossible to have a system giving you any results because it will be clocked.

Arnout Orelio (37m 26s):
And then if you have, if you reduce the overburden debt is needed so you can cope with variation. So, and I was taught, the first course that I got when I went into this automotive company, as I recall, was statistical osis control. And I, they had a matrix, and you should learn from the matrix that you need to have statistical stability to be able to pre-approve the process.

Arnout Orelio (38m 9s):
Right. So I thought I, although it's very hard and it's maybe more one of the more difficult subjects, I have to explain to my audience that before they go improve anything, they have to figure out whether what they're doing is stable or not. Yeah. And I thought, and maybe I cannot teach them all, but I need to put, and then that's the mindset thing. I have to teach them that overburden is first to be solved and then it needs to be stable.

Arnout Orelio (38m 55s):
And only when it's stable you can improve. And that has another very important effect because to stabilize or to figure out your, whether it's stable, you get confronted with whether you have standards and like TA already said, there can be, without standards, there can be no improvement. So teaching people that a problem is nothing more or less than where you wanna go and where you're now. And that where, and that the standard is nothing more than describing where you wanna go or what you want to happen or what you that Well, that motivated me to put this in.

Arnout Orelio (39m 45s):
And the great thing about it that because I had the maybe the courage to go into this topic, which is not self-evident, this became the thickest chapter because now I had ave Yeah, yeah. Because now I had a very good reason to teach about standardization. Whereas if you start standardization as a method on itself in healthcare, you get a lot of feedback, I would say, well,

Mark Graban (40m 16s):
It can cause problems again, like if, if you make, like you said earlier, we don't want, the goal is not pushing lean methods. The goal is improvement and Exactly. Excellence. And you don't want to push standard work without a problem.

Arnout Orelio (40m 28s):
Yeah. And we exactly. And we can only, the biggest problem for in healthcare to improve that there's very little problem awareness because they, the problems they are aware of are symptoms like staff shortages. So we have to teach them what the actual problems are before we do anything else. And that's why I figured it would be helpful to put the process, behavior charge.

Mark Graban (41m 2s):
Yeah. Well that's great. I'm glad you did. And the one other method you, there, there's a chapter here, it was chapter 11 on job instruction, case study, successful standardization through job instruction. And that draws on training within industry as you write about why, you know, why, why do you think that, I mean, you've already touched on it, but, you know, can, can you share a little bit about this, you know, this training within industry method, people might look and say, well, that was developed during the second World War. I said, well, old doesn't mean it's outdated. I think the fact that it's still being used today proves how helpful it is.

Arnout Orelio (41m 46s):
Exactly. Maybe with yoga, Yoga we do already for 5,000 years. So it must be good because otherwise we would've abandoned it already, or, or I dunno, the, in the beginning of the 19th, at the end of the 19th century, we, we did, we invented the car. So shouldn't we drive cars now because they were invented hundred years ago? No, no. So I, no, the, the, the power of the, the, the trading within industries is that had this, it has proven itself in the well World War ii and it, the most important thing is that the method didn't change.

Arnout Orelio (42m 38s):
So the method was so good.

Mark Graban (42m 40s):

Arnout Orelio (42m 41s):
That the only thing to be successful with training with industry is following the method. Yeah. So, well I rest my case almost

Mark Graban (42m 51s):

Arnout Orelio (42m 51s):
Yeah. But, and that has to do with the, I dunno the, the simplicity of it. And it's, it's very easy, it's very difficult for people who don't know what it is or didn't experience it to understand how powerful it is. But it takes very little to start believing in a method. I mean, in the book, I, I'm not sure, did I put a picture of myself in, I'm not sure. Well, in the book or in the case study, I'm explaining that part of the case study is that they trained me an engineer on a nursing task, which was to, to, I dunno, I had to use a scanner to measure the blood of a unborn child.

Arnout Orelio (43m 54s):
So if you, if I would explain, well they let me scan the blood of an unborn child, you would say they're nuts. But in 30 minutes I could do this task flawlessly. So that's, well that was all it took for me to, again, understand. Yes, this is so powerful. If you, if you take this medicine, you standardize the right way. You can Well you teach people things that they might take years to learn from experience.

Mark Graban (44m 38s):

Arnout Orelio (44m 39s):
And I think that, I think even if we could do only one thing for healthcare right now to help them with this pandemic, I would say training within industries, because the whole, if we take the whole structure from World War ii, they're, they're, they had a great, well challenge because, well, the men went to war, so we had to teach the women how to build arms. Right,

Mark Graban (45m 12s):
Exactly. Planes and munitions.

Arnout Orelio (45m 15s):
Yeah. Ammunition and tanks and whatever. So this method, well, we all know how the war ended. This was not because they, you had bad arms. No, the arms she used, they helped us to invade and conquer and take back Europe. So these women were trained within ye within months to do a task they were never trained for. And they did it extremely well. Yeah. So what if we would train healthcare people to do all their, their tasks that are related to this covid so we can have enough manpower to, well, to tend to all these patients.

Mark Graban (46m 12s):
Yeah. There, there's history where even during the second World War, there are nursing journal articles that were published just after the war, looking back at what had already been done training new healthcare professionals.

Arnout Orelio (46m 26s):

Mark Graban (46m 27s):
A lot of the women who then went into the factories created a need for backfilling and hiring in healthcare where they might have worked before. Yes. And you know, there are three episodes going back in the lean blog interviews series about T w I for people who want to hear more about this episode 1 96 with Jim Hunsinger, episode 2 0 2 with Patrick Grout, who's talking specifically about t w I in healthcare. And then episode three 14 with Skip Stewart and Brandon Brown, who are talking about the, the application there and further evidence of our aligned thought process.

Mark Graban (47m 11s):
Arnout, the follow-up question I was gonna ask you about T w I was related to Covid as you've already brought up, and, you know, having to figure out how to do mass covid vaccination. You know, I've, I've seen news reports, I've talked to one physician executive who's talking about the need to hire new people, or you've got medical students who maybe haven't given an injection before. And there, I think there is such an opportunity for t w I to train people quickly and effectively and consistently.

Arnout Orelio (47m 43s):
Yeah, exactly. Through

Mark Graban (47m 45s):

Arnout Orelio (47m 45s):
W Yeah, it is. Yeah, it is. And but what people in healthcare need to do is get rid of the ID that healthcare is so special that they have to figure it out all on their own

Mark Graban (48m 6s):
In terms of training methods and

Arnout Orelio (48m 8s):
Managements in terms of any method outside their own realm. I'm not saying that we should tell nurses how to te but how to train another nurse on how to put in an iv. There's a world's best method and it's not used. So I think that's, that would be such a huge opportunity

Mark Graban (48m 38s):

Arnout Orelio (48m 39s):
To bec especially because now we take so much time to figure things out that that young nurses, well they get over before they get to the point where they start understanding what the true work is. Yeah. In the Netherlands, there's double digit numbers of people who want to leave the the sector. That's a huge problem. And that's real, that's a huge problem. Whereas if we could help them get trained so they can do only what they need to do instead of figuring everything out and running around.

Arnout Orelio (49m 27s):
And I mean the, I did a, I was working in a public health organization just last year, 2020. And what I did is I helped some of the doctors there to figure out where their time went. So, and then I had to, I had them color their time and so green time was everything which was directly related to helping patients. And then yellow time was everything that is required by law or by their profession or whatever to make sure that we can tend to these patients.

Arnout Orelio (50m 11s):
And then you can think of stuff like things you need to do for privacy or maybe the electronic medical records, those kind of things. But also education, which is also necessary. You need to educate the doctors so they can help the patients. And then we had red time, that's everything, which is waste. Yeah. So waiting computers not working, I don't know, managing things. So the doctors were managing a lot of things, like when patients didn't show up, the doctor had to call the patients for a new appointment or whatever.

Arnout Orelio (50m 54s):
All the, so now for you, but your, your, although you were not in the project, you maybe too much of an insider, but now maybe you can tell me how much of their time was red and how much of the time was yellow and how much of the time was green

Mark Graban (51m 12s):
For the doctors?

Arnout Orelio (51m 14s):
For the doctors, yes.

Mark Graban (51m 15s):
I would guess only 30% of their time was green.

Arnout Orelio (51m 23s):
Yeah. If they were lucky, they had 25%.

Mark Graban (51m 26s):
Oh, okay. See, I almost said 25%, but I, you're right, my guess was a educated guest. Because I've seen studies that show in nursing that green time is very consistently 30 to 35%. Exactly. I've seen it through some of my own studies that I've done similarly with nurses. But yeah, I mean that's, that's so unfortunate. When, and, and that leads to frustration and burnout with the doctors and

Arnout Orelio (51m 53s):
The nurse. Yes. But it also tells you that there's no point in hiring more doctors.

Mark Graban (51m 59s):
Yeah. Well, let's make better use.

Arnout Orelio (52m 4s):
Yes. I mean, we could triple their productivity and they could still do stuff that wasn't for the patient. So,

Mark Graban (52m 14s):
And they wouldn't be overburdened.

Arnout Orelio (52m 16s):
No, exactly. Because that was the biggest problem. Because one of the problems was that they had a, they felt staff shortages. Yes, of course. Because you can, if you are only 25% of the time working for your patients, you can see only so many patients. Yeah. Yeah. So

Mark Graban (52m 37s):
Yes, there's a clear need and a clear benefit. And it just goes to show again how similar things are between an American hospital, a Canadian hospital, a Dutch hospital. Yeah,

Arnout Orelio (52m 47s):
Yeah. Yes. What I figured out is if you look to hospitals, they're the same everywhere around the world and everywhere the last 200 years. So they start, they're all siloed and everybody's very specialized in one particular task. So, so that's also maybe the problem. We don't know that there's another way,

Mark Graban (53m 18s):

Arnout Orelio (53m 21s):
So we think this is, yeah, this is it. We have done it always like this. And we are healthcare, so we do what's best for patients

Mark Graban (53m 30s):
Well, and we can help them really fulfill that promise.

Arnout Orelio (53m 35s):
Yeah. I guess, yeah, we could. So I hope that maybe some healthcare leaders are listening and they, they are willing to give it a try. I dunno, read my book or make an appointment. Call me. Because if I can help you in any way to see how much the opportunity is and how little time it can take to help your team be more productive, we need it more than ever, I would say.

Mark Graban (54m 8s):
I agree. I agree. So our guest today has been Arnout Orelio. The book is Lean Thinking for Emerging Healthcare Leaders in the us It's available through Amazon in Europe is, so if people wanna buy the Dutch version or the English version, where, where do you recommend people do that

Arnout Orelio (54m 28s):
In your Yeah, so the, it depends a bit on where you are, where you're at. So for the Dutch version of the book, you can go to either my website and that's called mention Beto marken.nl. So that's for people speak Dutch. They can figure that out. Yeah. Or they can buy it at the, the Dutch online stores for the English book. It's a little bit more complex. The easiest way, if you are anywhere in the world except for the Netherlands, then you can either go to Amazon or you can go to my publishers website.

Arnout Orelio (55m 20s):
They're called business expert press.com. And there you can buy a book, be from anywhere in the world, because they have all kind of publishing partners in the, in Southeast Asia, in, in the uk. And for people who are in the Netherlands and want to get the English book, they can either get it by sending me an email or they can go to any online store we have in the Netherlands, like ball or management book or, so. Okay. I guess that's, that's the, the details about how to get a book.

Arnout Orelio (56m 6s):

Mark Graban (56m 6s):
And then do you have a website in English?

Arnout Orelio (56m 9s):
Yes, I do. And that's where you can send, so it's called Lean thinking in healthcare.com. And on that website you can, well buy my book because it's directly linked to the publisher's website. You can subscribe to my blog. So then you're sure that anytime I provide new content, you will get it. And you can if you like. And if you need, I offer anybody in healthcare who is trying to change something, a free strategy call for 30 minutes.

Arnout Orelio (56m 52s):
And in that call, I will assure you that you will have figured out what you can do next. And that can be anything depending on the problem you or the issues you have. So it can be either in your personal development or it can be some process problem. Whatever you think is useful for you, just make an appointment and I try to help you.

Mark Graban (57m 19s):
All right. So again, that's lean thinking and healthcare.com. Our guest has been Arnout Orelio. Thank you so much, Arnout. Really enjoyed being able to talk with you. Let, let's do this again, maybe later this year if there's a, a different topic you want to take a deeper dive into. Let's, let's do that.

Arnout Orelio (57m 35s):
Yeah, sure. Thank you so much for the opportunity. Who knows? I'm trying to, my first Dutch book, I'm trying to translate it in English currently, so maybe I'm quick enough to present it in your, in your podcast somewhere later this year. If not, maybe we come with another topic. Keep in touch.

Mark Graban (57m 60s):
Okay. That would be great. Okay. Be well. Arnout. Yeah, you Thank you very much.

4 (58m 5s):

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Everyone likes to be viewed highly by their coworkers. Most people have pride in their work, and want to do well. Having strong job skills is one way to get those things.

    Unfortunately, Lean changes the skills you need to be good at your job.

    When your company becomes Lean, you don’t just have to do your own process well. You have to do process improvement well. You have to not only get better at your job; you have to make your job better.


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