Jody Crane, MD: Lean in Emergency Medicine and Hospitals; 3 Big Issues Causing Tough Times in Healthcare

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Joining us for Episode #468 of the Lean Blog Interviews Podcast is Jody Crane, M.D. He's the Chief Medical Officer for TeamHealth, and he was previously a guest for Episode 120.

As a proven leader, Dr. Jody Crane, M.D. is considered one of the leading experts in emergency department operations in the United States. Dr. Crane has taught and led healthcare and emergency department improvement efforts with hundreds of organizations in a wide variety of settings on six continents. In this role, he supports clinical quality and safety and performance improvement initiatives for all clinical service lines.

We're talking today because he's a keynote speaker at the upcoming Healthcare Systems Process Improvement conference, which is brought to us by the Society for Health Systems. I'm a member, and I'll be there at the event this year as usual, February 15 to 17 in Louisville, Kentucky. See Jody's full bio and more about his keynote talk.

His book, co-authored with Chuck Noon is The Definitive Guide to Emergency Department Operational Improvement: Employing Lean Principles with Current ED Best Practices to Create the “No Wait” Department.

Questions, Notes, and highlights:

  • First off, give us a bit of a preview of the core messages for your keynote talk…
  • It's a tough time in healthcare — three big issues
  • The impact of pay, culture, and working conditions?
  • Moral Injury vs. Burnout?
  • Fixing an imperfect system — broader value stream issues that aren't in our control?
  • Transitions between facilities and communication across shift handoffs – process improvement opportunities?
  • Helping people see improvement opportunity vs. “this is just the way it's meant to be”
  • Framing the problem as “not enough nurses” or “too much waste”?
  • The impact of Lean? The untapped potential of Lean?
  • Two questions for executives – Have you heard of Lean? Have you been part of a Kaizen Event?
  • Attrition — staffing based on actual workloads?

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

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Automated Transcript (Not Guaranteed to be Defect Free)

Announcer (1s):
Welcome to the Lean Blog Podcast. Visit our website www.leanblog.org. Now, here's your host, Mark Graban.

Mark Graban (13s):
Hi everybody. Mark Graban here. Welcome to episode 468 of the podcast for February 1st, 2023. Our guest today is Dr. Jody Crane. He's the Chief Medical Officer at TeamHealth. And we're talking today because he's one of the keynote speakers at the upcoming Healthcare Systems Process Improvement conference, which is brought to us by the Society for Health Systems. I'm a member of SHS. I'll be there at the event this year as I usually am. So you can look for a link in the show notes. You can still register. It's being held February 15th to 17th in Louisville, Kentucky. So as a proven leader, Dr. Crane's considered one of the leading experts in emergency department operations in the United States.

Mark Graban (54s):
Dr. Crane's taught and led healthcare and emergency department improvement efforts with hundreds of organizations in a wide variety of settings on six continents. In this role, he supports clinical quality and safety and performance improvement initiatives for all clinical service lines. So you can find his full bio, look for a link in the show notes, or you can go to lean blog.org/ 4 86. So, Jody, welcome back to the podcast. I, I can't believe it's been almost 12 years since episode one 20 when you joined us, but welcome back. How are you?

Dr. Jody Crane (1m 30s):
I'm doing great, Mark. How are you doing?

Mark Graban (1m 33s):
I'm doing, I'm doing real well. I I'm excited about the conference and, and, and hearing your keynote talk. And, you know, I thought we could maybe do a bit of a preview here today. Not to, to give away the whole, the whole story for those who are attending, but like, what, what's some of the core message of what you're gonna talk about to this conference audience?

Dr. Jody Crane (1m 54s):
Yeah, so first of all, Mark, thanks for inviting me and it's been too long, so we need to, you know, get, stay in touch more closely. But as you know, I've been pretty busy these days and I, you know, it, it's a tough time in healthcare these days. And really, I was gonna focus the, the, the talk on that. So what are the things that are impacting healthcare delivery today that maybe we didn't kind of even hear about or know about back in 2019, or one of the things that existed back then that are, that are exacerbated either by the pandemic or by fallout from the pandemic? Right. So, and you know, it's interesting because, you know, early on in my career, I faced a lot of challenges that, that all Eds are facing now.

Dr. Jody Crane (2m 42s):
So I faced, you know, nursing shortages, physician shortages, not enough beds, flow problems, and, and all of those things. And, you know, the way I dealt with it personally was I got my MBA and I, you know, met Chuck Noon who was at three degrees in industrial engineering. And I met Keith Litner who was, you know, 20 year history in manufacturing applying lean principles. And, and I realized that, you know, you can actually affect all of these things using lean principles and industrial engineering techniques. And I, I guess, you know, I was gonna kind of mention what I think the big three are these days and try to keep it a three.

Dr. Jody Crane (3m 23s):
Cuz there's, there's probably a hundred and, but, but they all kind of fall in some big categories. One is variation in demand in healthcare. You know, the pandemic has brought this like really unprecedented demand impact, right? So, you know, early on in the pandemic in the tr in the March, 2020, we saw our volumes drop 50% just in the emergency department. That's never happened in the history of emergency medicine. We saw entire, basically across the country, elective surgery stopped, right? That's never happened before. And, and so as we've kind of progressed through the pandemic, we've, we've, we're still dealing with those things, right?

Dr. Jody Crane (4m 5s):
We're, we're not even back to 2019, you know, we're down still 6% to 10% from 2019 volumes that we saw before. But, but you know, it's okay if you're on kind of a level rate, but, but what we're seeing is still significant variation day by day, week by week, month by month. And as you know, variation is, is really challenging from a performance improvement perspective. The, the, the other thing I think is really important is capacity, right? So, you know, we've got, we've got more challenging demand patterns than we've ever seen, and we've got really significant issues in capacity.

Dr. Jody Crane (4m 45s):
And that being nursing capacity, right? Physician capacity, pretty much everybody who works in a healthcare system, you know, especially if you were here before all of this started, they're pretty burnt out. And they, they, they've, the way they've always known healthcare, even when it wasn't great, now they're just seeing these challenges and they're saying, I'm, I'm just don't wanna work in healthcare anymore and if, if I stay in healthcare, you need to pay me more. And so, you know, we've seen that in nursing with $200 an hour rates for travelers in the last couple years. We've seen that on the physician side, 10% or so of people have basically left.

Dr. Jody Crane (5m 27s):
And, you know, maybe some of those were people who were kind of planning to retire earlier or planning to retire anyway, but maybe some of those are people who are just like, I can't take it anymore. Right? You know, but we're seeing it in radiology techs and lab techs and everything is just more challenging to staff in general, right? Those are two basic equations for, for queuing and for performance improvement and the key focus of, of lean, right? And then on top of of that, right, which is totally separate and unrelated, we've got these healthcare reimbursement issues, right? You've heard about the no surprises act, you've heard about Medicare payment cuts.

Dr. Jody Crane (6m 8s):
So, you know, we've got wages or workers kind of demanding more to work. We've got a shortage of workers, which is affecting the whole supply and demand curve. And then we've got this massive variation that really, really drives a really challenging staffing paradigm, right? Because one of the ways to, to deal with variation is to, to build in more surge capacity, right? That surge capacity costs money. So, so those are kind of three big issues. I'm gonna dive in really deeply in the H S B I conference and I, I think we gotta solve those moving forward.

Mark Graban (6m 44s):
Yeah. Well I look forward to hearing, you know, more during that talk of, you know, diagnosis and treatments, if you will, for all of that. You know, one follow-up question that comes to mind though, I mean, you know, there, there's a lot of emphasis on pay and that's important to people of course. Then there's also questions around working conditions and, and culture. And I'm, I'm, I'm curious your thoughts on what else beyond good pay do we, do organizations need to be providing, if people aren't quitting and leaving because of compensation issues, we know there are other causes of burnout. What, what, what are some of the prescriptions, if you will, to, to create a better working environment?

Dr. Jody Crane (7m 29s):
Yeah, and, and, and actually I would say people probably aren't leaving because of pay. They're just demanding higher wages because the work environment is so difficult, right? And I think, I think that's an important distinction and I'm glad you made it. What I'll say, and I'll, I'll, I'll actually, I'll actually paint this picture with, with maybe a snapshot of what we're dealing with in emergency medicine. So right now, on any given day, we've got more patients being cared for in the waiting room than ever before because, and, and it's a trickle down, right? We can't find enough nurses to staff the inpatient units. We close beds on the inpatient units that creates boarding in the emergency department that allows us no space to care for these really, really sick emergency patients.

Dr. Jody Crane (8m 15s):
So it, you know, one way to deal with that is to keep pushing care further and further out front. And, you know, as you know, kind of, I, I was kind of on the front end of that whole innovation and front end programs in the emergency department 20 years ago with, with the idea that if you just get, get people in process sooner after their arrival, and we get them, that's the best way to shorten their length of stay and get them back home with a satisfying, high quality experience that, that really does everything that lean tells you we need to do. The problem is, it's, it's really everything we talked about before. So the variation demand, the lack of people that are able to care for these patients has driven this waiting room medicine kind of to, to the brink even.

Dr. Jody Crane (9m 5s):
So there's hospitals that you walk into, you know, in the middle of the day and every single bed in the emergency department is taking up, taken up with borders and every single patient is seen in the waiting room. And so, so that, that whole concept of me as an emergency physician or as a nurse or as a, as a, as a, you know, phlebotomist or a, or an x-ray tech, having to go out and provide care for patients, a waiting room is very dissatisfying. And I think most people working in that system feel like they're not delivering the care that they could if the patient were in a quiet room and they had the, all the resources they needed.

Dr. Jody Crane (9m 48s):
So I think more, more than anything it's, it's, it's sort of this deterioration in the system and the capacity of the system and, and frankly, the resources that you need to feel like you're delivering high quality care is probably the primary driver of this burnout and this lack of satisfaction. I think if we fix that, then, then people will come back to the system and they will work in the system. A another element of it is the risk, and when I say risk, I mean, okay, I'm taking care of a patient in a very imperfect situation and I'm, I'm basically heroically working around all of the imperfections that currently exist, and I'm d I'm trying to deliver the best care I can for a patient, but, but things are gonna happen, right?

Dr. Jody Crane (10m 38s):
And so we don't even know, contextually we know that, that patients aren't getting the same care. They were nine, you know, in 2019. But what we don't know is what, what is gonna happen from a malpractice perspective, you know, that takes five years to kind of fully vet, you know, couple, two to three years to actually generate a lawsuit and then two to three years to, to gonna get through that lawsuit. We don't, you know, we don't know what impact the, the imperfect system we're working in today is gonna create down the road. But I can tell you a lot of physicians and other folks working in the system feel like they're putting their licenses at risk by working in these imperfect systems.

Dr. Jody Crane (11m 22s):
Yeah. So we need to, we need to change the way we support our, everybody who works in emergency departments and hospitals, the way they feel they're supported and, and do whatever we can to give 'em the resources they need to care for patients. Yeah.

Mark Graban (11m 37s):
So you, you mentioned burnout, and that's been a problem for a long time in healthcare. When, when you, you, you paint this picture of not just legal risk, but I'm sure what must be a really awful feeling of not being able to provide the right care to patients. There, there's a word that, it's not a new phrase, but I've been hearing it more and been trying to learn about it. I'm, I'm curious if you run across this phrase, moral injury that tries to describe the impact of not being able to provide the right care and, and, and what that means to, to clinicians. It seems like it goes, it's stronger or runs deeper than burnout.

Mark Graban (12m 18s):
What, what are you hearing or, or thinking about that?

Dr. Jody Crane (12m 21s):
Yeah, that term has come up over the last probably two to three years and, and it actually evolved literally out of the pandemic. And I, I think it's an accurate reflection of, of, of some of the challenges that we have. So early on in the pandemic, if you remember, we didn't even, we didn't even know what covid was, right? It, it, we had no idea if it was gonna kill us. So as, as healthcare providers, we were walking into this giant unknown and, and if you remember, we didn't even have a 90 fives, we didn't have any protection. The whole global kind of supply chain was, was shut down. And, and you know, I, I remember coming home from a shift and, you know, having to take off my clothes in the garage, just so cuz I didn't know what the potential impact to my family was.

Dr. Jody Crane (13m 14s):
And so, so there's this kind of running into the fire mentality, but it's running into the fire without a host right? Or without an X. And so that the whole concept of moral injury really is about sort of forcing one to face circumstances that are, are, are beyond that control or uncontrollable with, without even a hope of kind of doing their best. Right? And that's, that's how I characterize it. So, so prior to the pandemic, yeah, we had burnout, we had people that were working a lot, they were working too hard. They, you know, I, you know, early on in my career I told you, you know, I I had a challenge in my emergency department.

Dr. Jody Crane (13m 55s):
We overcame that challenge because it was overcomeable. But, but I'll tell you like there's this kinda that moral injury is, is what a lot of, of, and and I'm not just talking about physicians and in nurse practitioner PAs, but everybody working in the healthcare system kind of feels they're, they're kind of set up to fail walking into their shift. And it's just, it's just really, really challenging and it's hard to find that, that one or two people out there that are really pushing for you Yeah. Really trying to support you, you know, and it goes all the way up to the government. Yeah. Right.

Mark Graban (14m 34s):
Yeah. And yeah, I mean it's understandable where that would lead to all sorts of feelings, including resentment and like you said, those were serious. It's hard to even say, I mean, serious problems and, and situations that you, you wish nobody had had been put in. You know, you, you, Jody you mentioned, you know, imperfect systems and that includes, you know, ongoing imperfect systems around even in normal times the flow of supplies, you know, creating problems and, and, and, and challenges in some cases, you know, exacerbated by the pandemic and, and, and those lingering supply chain effects.

Mark Graban (15m 19s):
But, you know, when you talk about systems and, you know, you describe some of the symptoms as seen in the emergency department, but as you know, and as you write about and help people understand there, there are broader value stream issues in the lean language. Like what are, are there positive examples you've seen out there of, of organizations realizing, okay, we need, we need to look at the value stream, we don't need just more space in the emergency department, or more people like that might help in a temporary way, but how are, are there good examples of of of trying to help address the broader value stream?

Dr. Jody Crane (15m 58s):
Yeah, and you know, Mark, that's a heavily loaded question, right? Because, you know, if you think about the big picture in healthcare, right? There's so many inputs, right? You've got the elective surgery schedule, you've got the non-elective schedules schedule, you got inpatient demand, and then you've got all those outflows to post-acute care back to home and that sort of thing. And you know, it's really challenging because they're all interrelated, right? We know the relationship between the elective or schedule, for example, and inpatient crowding, the hospital crowding, right? We know that's closely tied to the OR schedule, right?

Dr. Jody Crane (16m 39s):
We know that it's difficult to get patients out of the hospital in inde post-acute facilities where that kind of, where that seamless transition hasn't been established, right? We know that, that some emergency departments get overcrowded and they're related to other things within the system. I'll tell you yes, I think it's solvable by, by engineering, right? And, and differences in the way we do things. And, and I, I guess I could give you a couple of of examples that are pandemic related, but, but I think really tangible in terms of like things that we could potentially do that we're, we're maybe not exploring right now.

Dr. Jody Crane (17m 24s):
And one would be the memorials down in, in south Florida when the Pan pandemic came around, we, we, at Team Health, we staff all of their inpatient hospital medicine programs and you know, they really acknowledged very early on that, that they're gonna hit, get hit pretty hard. If you remember, south Florida in particular was at least the epicenter of the, the entire global pandemic, at least twice and maybe three times. I'm not, I don't remember. But, but early on they said, we're gonna focus on these COVID patients and we're gonna put 'em all in the same unit and we're gonna kind of drive their care.

Dr. Jody Crane (18m 5s):
And, and they partnered with us and we kind of, we stepped up and we staffed every single covid patient that came through the door. And again, this is, this is early on, and we didn't, we had no idea where it was ultimately gonna go, but our hospitalist program ended up, you know, you know, one unit turned out wasn't enough, two units wasn't enough. We ended up opening six units over the course of several months and we had to kind of really float in about 20 extra hospitalists in weeks to, to kind of handle that demand. But the one thing, and and you could argue that whole patient population is like a value stream, right?

Dr. Jody Crane (18m 45s):
A pa it's a patient service family, right? So, so that allowed us to do some really innovative things. So one of, one of the things that, that the memorials do, and I love this, you know, if you think about all, you know, the pandemic and all of these patients brought a significant increase in cycle times of our clinicians, right? We had to don and doff, PPE, we had to do extra cleaning when a family member came in. We had to, you know, it was just very, very challenging to get through these encounters. And, and the memorials did one really simple thing. They put a, an iPad in the room, an iPad out of the room.

Dr. Jody Crane (19m 27s):
And so not only, so whenever a clinician needed to interact with the patient or their family, and it was a nonclinical thing where they didn't have to touch the patient or evaluate the patient, they would just come Zoom in on the, the iPad. We could have that face-to-face encounter without consuming PPE, but also without the challenges that, or the time that that was associated with getting the PPE on and off. And that's, that's one example of, of, of sort of an approach that was, I thought dramatically different in and saved a lot of time and saved a lot of supplies. And I think there's still a lot of opportunity for us to, to re-engineer things.

Dr. Jody Crane (20m 7s):
But if you think about the things that we talked about earlier, you know, we don't have enough nurses. We probably don't have enough clinicians out there. So, so really I think this, the whole kind of lean principles around eliminating waste, you know, improving flow, focusing, you know, all of that is really critical for the future.

Mark Graban (21m 48s):
So, so Jody, you, you know, you talk about this, this value stream, and I think you've touched on it, but maybe you can elaborate on, on the challenge where let's say the organization that has the emergency departments and the inpatient beds doesn't control the entire extended value stream, if you will. It goes across multiple organizations. Are there, you know, kind of particular lessons about trying to navigate working with other organizations or other budgets or, you know, things that you don't control as an organization?

Dr. Jody Crane (22m 24s):
Well, you know, Mark, that's a great question. Now, frankly, I think that's something we don't necessarily do great today in healthcare because, you know, the healthcare delivery systems relatively fragmented, right? So we have, we have, you know, outpatient urgent, urgent care, you know, companies, we've got hospital companies, we've got health systems and some are, you know, for-profits, some are not-for-profit, some are academic. And then we've got the whole post-acute system that's, that's relatively fragmented as well with some big players. So on the, on just sort of the care delivery system side, we've got lots of different, different players.

Dr. Jody Crane (23m 8s):
And then same thing on the physician services side. You know, there's, there's lots of groups out there that are trying to, trying to help deliver care. And so, so as a health system, you're trying to navigate all of that, right? Do I employ my physicians? Do I bring in an external company to provide services because they've got scale and they can help, you know, augment needs on a short term basis, like I talked about at the memorials, how do I partner or, or improve my relationship with long-term care? And then some of the things that we saw developed in the pandemic, especially te telehealth, telehealth and virtual care exploded, right?

Dr. Jody Crane (23m 51s):
It's coming back down now. But also this whole concept of caring for patients at home, right? Right. And so I guess I would kind of characterize that extended value stream, like we don't do it well right now, but I think that was one gonna be one of my really important messages in the HSPI conference is really about, instead of, you know, little tiny episodes of care, we need to kind of look at the patient across the continuum, right? We need to be able to address the patient wherever they are, either geographically or within their care episode. So one of the things we don't do really well right now, patient comes in the emergency department, they've got pneumonia, they get admitted to the hospital, maybe they've got some other medical problems that require a short stay in a rehab unit and then they get back home.

Dr. Jody Crane (24m 41s):
One thing we don't do well right now is, is like pay attention to those transitions. Cuz every time there's a transition, there's a risk that the patient, that information falls through the tr the cracks and the patient doesn't get the care that was intended for that transition. But also, you know, like, like in Toyota, you know, the early days of Toyota, you know, there's this famous story about how, you know, instead of, you know, buying up their suppliers, they, they developed this philosophy where I'm gonna share information with my suppliers. So like, you know, Michelin or the tires that they needed for their cars, instead of buying Michelin, they said, I'm just gonna give you information about the demand for cars so you can better plan your production lines so that we don't have this bullwhip effect going, going down the supply chain.

Dr. Jody Crane (25m 39s):
And, and I'd say that's, that's, that's probably one of the bigger opportunities that, that we have is to better communicate with our post key facilities, better kind of design care path pathways that actually end up in the home and, and then better articulate with the feeders so that the, the suppliers of patients like urgent care centers and that sort of thing, so that, so that the patient's care is integrated, right? So it's not like I went to an urgent care center, I got a bunch of labs there, and then they sent me to the er and the ER says, well, I don't trust all the labs that you got there. I'm gonna repeat all that stuff. And by the way, you didn't send me the x-ray and I can't look at the EKG. And that's all waste, right? Yeah. In the classic lean sense, right?

Mark Graban (26m 21s):
And, and there's also process opportunities, process improvement opportunities in those transitions that communication the handoffs, it's a little bit different situation, but you know, I've often had conversations about report nurse leaving to go home, new nurse coming in, they do that patient handoff and you know, if it's 12-hour shifts, that handoff is happening twice a day. There are a lot of problems that come with 12-hour shifts. And if we, if we were to have a conversation around having eight-hour shifts, the one objection is, well that means three handoffs a day and the handoffs are terrible. And things would be worse. Like, well wait a minute, why we can improve the handoffs. Like we know that, that that's doable and there's that difference, whether it's that or other situations of being like resigned to like, well, that's just how it is versus, hey, we can improve it.

Mark Graban (27m 13s):
So let me frame it as a question, whether it's to these transitions or, or something else. How do you help people work through seeing that this is actually a process improvement opportunity instead of it being doomed to be lousy forever?

Dr. Jody Crane (27m 28s):
Well, that's a w that's a great question, Mark. And I know you face this every day in your consulting world, and I, I would say, you know, obviously like in the, in the classic sense, you kind of seize on that burning platform, right? And I would say pre-pandemic, it was actually harder to engage people in the fact that we can't do things the way we're doing them anymore. I would say things are sufficiently broken such that it's relatively easy to engage people in. Perhaps there's a new way of doing things. One of the, the more recent challenges that I've experienced is everything's so tight, it's hard to get the people together in a kaizen event or even even a group of meetings because they're all so busy, you know, fighting the fires, right?

Dr. Jody Crane (28m 19s):
And so to me, the most challenging thing today is to get 'em to step outside of the fire to kind of look, you know, look at the process and how we're doing things to maybe prevent the fires from starting, right? Yes. So, so that having been said, I think early on in my kind of healthcare improvement journey, I, I, I think I looked at healthcare as, as people were generally entrenched in the way they do things as part of the nature of healthcare, right? We have to prove things are better and that takes years and years and years before we can actually do those things that are better. But I, but I found that as, as we kind of advanced this knowledge around performance improvement, I found it was easier and easy and years as the years went by, still, it's hard when you go into a relatively naive and naive, I mean, someone that hasn't, you know, traditionally been engaged in performance improvement.

Dr. Jody Crane (29m 15s):
Not like, you know, not insightful or anything like that, but it's, it's the, these naive locations, it's a little bit more difficult to get 'em on the bus, but when you do, boy, they, they get the bug, right? So, in short answer your question is, I think these days with all of the dysfunction, I think if we can get the people in the room, engage them in that future state design, I think, I think they'll go there because people are so frustrated.

Mark Graban (29m 46s):
You, you're, that's a, that's a great point about the motivation. If, you know, some of the, if people are, if it's easier to see the opportunity for improvement, that's great, but then there's the question of time and how do we make it happen? How do we redesign, how do we even find the time for relatively small tweaks? There's a catch-22, like you said, of staffing shortages there, you know, there's this traditional mindset of like, well, we need more people. But then you've touched on the other side of the equation of, well, we could reduce waste, we could help free up time and make, you know, help nurses be more effective and spend more of their time on patient care, which has all sorts of great benefits.

Mark Graban (30m 27s):
But there's that catch-22 of realizing we could free up time, but we don't have the time to do the work. That would help free up the time. Like, it can be really hard to get that, especially when people are exhausted and in burned out. There's, there's potential, but it's just, it's tough.

Dr. Jody Crane (30m 44s):
Yeah, no doubt.

Mark Graban (30m 47s):
So one other thing I wanted to touch on before we wrap up here is, you know, you, you, your, your book came out, I know it was before 2010, it was probably that year or the year before.

Dr. Jody Crane (30m 58s):
I think the, the first version came out, I think 2011, but you might have seen a, a snapshot earlier than that, is my guess. But, but I think it was 2011, but correct me if I'm wrong, could have been 2009 all blurs together.

Mark Graban (31m 15s):
All right, well, I I apologize for not having those dates clear in my head either. So the podcast was June, 2011, so, okay, I think the book probably had just come out, but, you know, in this time your work and, and the work of others, and there's, there's been a lot of books including my own and books by other people. There's more exposure to lean concepts and there's this high level question of, and want, you know, your assessment than maybe either generally speaking or looking for pockets where you see the impact of lean versus what we might call the untapped potential for lean. It's not like healthcare has been quote unquote, and I hate this phrase leaned out because that means all kinds of, there's

Dr. Jody Crane (31m 57s):
No awful thing, awful thing is

Mark Graban (31m 60s):
That yeah. That, that has all kinds of admittedly awful connotations, which I don't use the phrase and I shouldn't have used it there, but you know, it's not like lean has been adopted and all the problems were solved and, and, and hooray, you know, I see lots of pockets of excellence and there's still, it, it's frustrating sometimes to see the potential that's untapped. How, how do you see things?

Dr. Jody Crane (32m 22s):
Yeah, I'm, I'm right there with you. You know, I would say every health system that, that I encounter, you know, day in and day out has a performance improvement team that is working hard to improve processes. You know, I I would say the, the complete penetration of Lean within organizations is pretty rare to see, but you see these pockets of improvement where lean principles were applied. I will say, you know, with, with my work in our MBA program and kind of going out in the field and, you know, giving talks for ASAP and that sort of thing, one of the things I do a lot is I have people raise their hands.

Dr. Jody Crane (33m 3s):
I say, who is, who has ever heard of Lean in the Room? And, and I say, who has ever heard of queuing theory in the, in the room? And I say, who has ever read the book The Goal? You know? And when I do that, and, and back in the day, call it early 2000s, you know, it was like five or 10% of the room had heard of Lean and like 1% had heard of queuing theory and you know, some people had read the goal, but it was only because they had been through some sort of business curriculum or something like that. But I'll tell you, like, you know, around 2010 or so, I, I almost stopped asking about Lean cuz everybody had heard about it. And frankly I think that that tells me that if you've heard about it, probably you generally agree with the principles, right?

Dr. Jody Crane (33m 48s):
Eliminating waste, putting the patient first, focusing on flow and re kind of continuous improvement as a means to, to, to engage the entire system in moving forward. Right? I I would say I stopped asking about Lean, I'd say, I'd say queuing theory and some, some other ones kind of, they've, they've come a long way in terms of people hearing about them, but really applying them on the ground probably still has a ways to go. I, I'd say just if anybody thinks that we've fixed healthcare or we've saturated healthcare with, with lean principles or any performance improvement principles, DMAIC or whatever, I would kind of challenge that because right.

Dr. Jody Crane (34m 39s):
You know, we're not anywhere near the airline industry in terms of prevention of defects and we're not, we're not, we haven't sufficiently improved the care delivery models so that, so that it's highly reliable, right? In terms of delivering high quality care in a system that's sustainable to work in from the people that do the work, right? So to me, if that's the kind of the goal or the gold standard is best care for patients, sustainable from, from people who work in the system at a cost that's affordable for the, the entire globe in a way that's satisfying.

Dr. Jody Crane (35m 20s):
I don't think we're there yet. So I think we got a long way to guess. There's tons of opportunity in my opinion. Yeah.

Mark Graban (35m 26s):
And even the organizations where they've made the most progress, so let's say in a single organization, even in a single site hospital, still exists, you know, in some places. Yeah. The ones that have made the most progress are the first to say we're nowhere close we a as we've made progress, now we see more problems and they think those problems are solvable and, you know, so yeah, I mean clearly at a broader American health system standpoint, I don't think there's anyone, yeah, they're, if I throw out that hypothesis that somebody holds, it's probably a bad hypothesis that anybody holds the hypothesis that it's all been fixed. But lemme bring it back to one other question maybe cuz when you talk about asking who's heard of Lean Over time, I agree with you, the number of hands going up would, would go up over time, but then the the follow up question I've learned that I have to ask is, well, what have you heard about Lean, or sometimes it's what are people assuming about Lean?

Mark Graban (36m 28s):
So in some, and I think this is, this holds lean back, there are organizations that will slap the lean label on a bunch of cost cutting exercises. And we probably agree that's not really, that's not what right, what Lean is. I remember one organization in particular having some of those first conversations with staff members and somebody spoke up and you thought, like they said their, their spouse was in a manufacturing company that had done lean and there were a ton of layoffs. You hate to hear about that because that, that's not really a Toyota-based way of going about lean. So, you know, unfortunately sometimes I think you have to check those assumptions and sort of dig in of like, have you heard, have they heard accurate information about lean or have they experienced things that we would wish the Leann word was never associated with?

Mark Graban (37m 17s):
I'm curious thoughts or experiences there?

Dr. Jody Crane (37m 20s):
Yeah, good point. And I, and I will say my always next follow on is, you know, how many of you have done a Kaizen event and how many of you all have, have sort of done value stream mapping and map the future state? And and I usually start a dialogue there and yeah, I think, I think you're right. There's varied responses, right? And I'll I'll tell you like, if, if you've ever been one of those in one of those lean, you know, kaizen events or, or lean programs that's, that's eventually led to cuts or, or the soft cuts, which is we're not hiring anymore kind of, and we're gonna let attrition kinda level the workforce, you quickly learn that the lean's like not something I wanna be a part of.

Dr. Jody Crane (38m 7s):
But if you, if you're kind of in a, a lean program that's done right, where you're focusing on the patient, you're redesigning the, the care pathways so that they're, they really work for the people working in the system and they ultimately drive better care, then I think those people kind of get the itch point. These systems that have adopted it like UPMC or others, you know, it's, it's an endless pursuit of continuous improvement because the very act of reaching a future state begets the next future state, right?

Dr. Jody Crane (38m 47s):
Yeah. So it somewhat becomes addictive.

Mark Graban (38m 50s):
Hmm. Yeah, yeah, that's that's very true. There's these positive dynamics and, and even starting with baby steps, like it's, it's great to see when people start realizing they can actually change things, they can actually make things better and they can participate in that. And you know, that participation, you know, when you ask that question of, well, who's been in a Kaizen event? John Toussaint as a physician and CEO you know, who was actually participating in Kaizen events himself, he's, he's tried to spread the word to other healthcare CEOs. I I, I'm, I'd be curious how many ever took him up on it. My my wife is in a manufacturing company where the CEO does participate in Kaizen events and it's just this different, and he is done so for a very long time.

Mark Graban (39m 35s):
So it's just this different level of participation and learning and, you know, when the CEO is involved and understanding and realizing that they're, they're driving the culture instead of just a bunch of projects happening, that's, that's even more powerful when you see that. But I, I wish we would see it more often in healthcare.

Dr. Jody Crane (39m 55s):
Yep. Agreed.

Mark Graban (39m 58s):
And then, you know, when you talk about attrition, maybe you know, one other thing to to, to look at here, if, if, if you were really taking waste out of the work and realizing we don't need as many people then redeploying people, or like you said, taking advantage of a, of attrition and not backfilling, that's less traumatic than layoffs would be. But I think you kind of point to the challenge of, if it's happening in the other direction of we're gonna just choose to not hire replacements, now you've got fewer people doing the same work. And as an industrial engineer, like your co-author Chuck Noon, I, you know, I think I always fall back on like the staffing levels need to be based on the work, right?

Mark Graban (40m 42s):
Not on the budgets. And you know, I think that's where we still have huge opportunity for, you know, lean thinking were to become more widespread, some of these industrial engineering practices like queuing theory and that understanding and, you know, this idea of we're gonna study the work, we're gonna look and, and see how many people do we need to do the right work the right way, you know, I think it would be better for the patients and it would, it would, it would create less of that burnout and moral injury. But I still see budgets and benchmarks being used more than the study of the actual work. I feel like I'm being gloomy about this, but I think it's part of the, it's part of the current state. Yeah.

Dr. Jody Crane (41m 18s):
I'll, I'll, I'll offer kind of some insight here because I do think, you know, an example would be left without being seen. Rates in emergency departments are higher than they've ever been. And, and that's a function of, of a probably not having the resources that you need to perform within the system that currently exists, right? So if you were able to redesign that system to make the system better for the res resources that exist today, you're gonna see more patients, it's gonna be more satisfying for you as a nurse at the bedside to care for those patients. And more patients are gonna come subsequently, you're actually gonna need more nurses.

Dr. Jody Crane (41m 60s):
But from the system perspective, you've rooted out waste. So you're gonna see more patients per nurse hour on, on any given day, that nurse is gonna be more satisfied with the care that they're delivering and you're gonna grow your bottom line because you're growing revenue, but not having to add as many resources as you, as you would've over time. I will tell you that like there, there, people know when you're cutting, however you're cutting, right? Because they show up and they've got five beds instead of four, or they've got six beds instead of five. So you can't hide that cutting mentality, especially when it's done to them and they're not part of the redesign that enables them to be more effective in the care system that they're working in.

Dr. Jody Crane (42m 49s):
So I, I would say that, you know, it, it, it is, it is challenging to kind of see this from the clinician or the healthcare provider's eyes, but one thing that I, I'm a hundred percent sure of when you engage them in the solution, you always have a much better outcome.

Mark Graban (43m 11s):
Well, that's very true. And so, you know, Jody, thank you for sharing your thoughts and perspectives with us. Thank you. I'm, I'm excited that you're gonna be there at the Health Systems Process Improvement conference coming up real soon. People can still sign up if they're able to go February 15th to 17th in Louisville. Again, look for a link in the show notes for more information about that. And, you know, I appreciate that you'll be there as a physician, you know, talking to a room full of a lot of engineers, not, not wholly engineers, but it is based on the Institute for Industrial and Systems Engineers. So your, your clinical perspective, your leadership perspective, your improvement perspective is gonna, I'm excited you're gonna be a part of it.

Mark Graban (43m 54s):
So thank you in advance for that Jodi, and thank you for coming back on the podcast.

Dr. Jody Crane (43m 58s):
Yeah, Mark, looking forward to seeing you in, in Louisville and just, just, you know, I'm a closet engineer, right? So love engineering was in engineering in college prior to switching over to pre-med. I was in right aerospace engineering, but listened to a couple buddies of mine and said, Hey, you know, you should go into healthcare. And I've never regretted that decision, but I think it's enabled me to, to practice my love, which is fixing things and, and re-engineering things while also make things better for patients and clinicians. So thanks for having me on the, on the podcast and look forward to seeing you soon..

Dr. Jody Crane (44m 38s):
Thanks again. Take care, Mark. Great seeing you.

Announcer (44m 41s):
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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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.

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