Interview with Arnout Orelio on Lean Thinking in Healthcare: The Netherlands and Beyond

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Joining us for Episode #479 of the Lean Blog Interviews Podcast is Arnout Orelio, a returning guest (from Episode 403 in 2021). He has been working with Lean management since 1995, the last 15 years as a trainer, coach, and consultant in healthcare. 

He is the owner of The Lean Mentor, where he helps people who want to (learn to) improve healthcare. Arnout focuses on teaching lean leadership, as an author, speaker, and mentor, bringing top performance and high levels of productivity within everyone's reach. His mission is to make “more time for better health care.”

His first book was Lean Thinking for Emerging Healthcare Leaders and, today, we're discussing his brand new book, Lean Thinking in Healthcare.

Questions, Notes, and Highlights:

  • How do you summarize your 25 years of learning how to improve?
  • Creating more time for better healthcare?
  • Problem and productivity as dirty words?
  • Similarities between Dutch and US health systems / payers?
  • What's the general state of healthcare in the Netherlands right now?
  • It's hard to manage the work when you don't understand the work
  • From the cover — 4 things… do they represent “True North” to you? At your hospital? 
  • Right care, right place, right time for the right patient
  • Zero Waste – resource efficiency vs flow efficiency?
  • How to engage everybody in improvement, every day? Fixing or redesigning the system vs. improving the system?
  • Learn to change small systems first
  • Cycle of continuous misery?
  • Not just what are we moving from, but also what are we moving to?
  • What does it mean to “learn from the best” in your experience? The best hospitals? The best organizations?
  • Two problems with learning from others?

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 at www.leanblog.org. Now, here's your host, Mark Graban.

Mark Graban (12s):
Hi, it's Mark Graban here Welcome to episode 479 of the podcast. It's July 5th, 2023. Joining us today is a returning guest, Arnout Orelio. We're gonna be talking about his brand new, recently released, available now book titled Lean Thinking in Healthcare. So for a link to Arnout's website and more, look for links in the show notes, or you can go to leanblog.org/479. As always, Thanks for listening. Well, hi everybody. Welcome back to the podcast. We're joined today by a returning guest, Arnout Orelio. He's been, he was a guest in episode 403 back in 2021.

Mark Graban (53s):
He's been working with Lean Management since 1995. That's, that's when I started. There's a lot of parallels to our stories if you want to go back and listen to that episode 403. But he's worked for the last 15 years as a trainer, coach, and consultant in healthcare. He is the owner of his firm, The Lean Mentor, and he helps people who want to learn how to improve healthcare. So his first book was titled Lean Thinking for Emerging Healthcare Leaders, and he has a new book coming out titled Lean Thinking in Healthcare. So we're gonna be talking about that today. Arnout, thank you for coming back on the podcast. How, are you?

Arnout Orelio (1m 32s):
Yeah, I'm fine. Thank you Thank you so much for having me back. It's always good to have conversations with colleagues, especially because since our paths are so similar without us being aware of it for a long time. So yeah, Thank you so much for having me back.

Mark Graban (1m 53s):
Yeah. Well, it's great to talk to you again. Arnout's website is Leanthinkinginhealthcare.com, and I'll put links in the show notes to the past episode and, and the books and You know, again, Congratulations on, on, on the books. So that's gonna be sort of, I think part of what, how we structure the conversation here today. You know, Arnout, you introduced yourself and, and, and told your story last time, but You know, with, with the book, you talk about learning how to improve and how would you summarize without telling your whole career story, like learning how to improve, learning how to learn how to improve Like. what, tell us about that part of your journey.

Arnout Orelio (2m 33s):
Yeah, so as an engineer, I think I got this intrinsic drive to make things better. So, I. As a perfectionist, I had a tendency to think that, to think that things needed to be better. So maybe that accelerated things a bit. And then when I started my career in automotive industry, I was almost confronted as a manager with the fact that performance improvement was your daily work, but maybe not how we think about it currently.

Arnout Orelio (3m 18s):
It was the performance needed to be what they said it needed to be. And if it wasn't, then you had some kind of conflict and the conflict would be around maybe the, your line has stopped and then your boss wants it to run and the operator wants their her problem to be solved and to be recognized for the problem. So I learned early about improvement, that it has a lot to do with how we treat people and how we perceive problems. Recently I got a post on LinkedIn where somebody replied with, yeah, you shouldn't use the word problem.

Arnout Orelio (4m 2s):
Yeah, I saw that. Cause that has a, yeah, that has a negative connotation. And So, I was, I was taught early on that that is, it's maybe better not to have problems when you are in a, an organization where hierarchy is the method. And what I mean by that is that when your boss is telling you what to do, because he's the boss, and that's the way to go about improvement or at least getting things back on track. Well, I perceive that as well didn't work for me.

Arnout Orelio (4m 45s):
So, and later on, I, I became a Lean consultant, and then I was handed a completely the opposite, almost way of going about solving problems. and that was because what we did as consultants had nothing really to do with Consultee. We went to the shop floor, to the mostly factories, and we were starting conversations with operators about what do you think the problems are and what do you think caused them and what do you think we might do about them? And then I figured out, wow, these people know the answer to these questions.

Arnout Orelio (5m 29s):
So leadership, instead of the using the hierarchy, you can better use the hierarchy of competence. and that means that you best start your problem solving with the people who are doing the work and know the problems best. So that was my, that was the first like a transition I made. And then after that, the more I did it, the more I find out this is not just a method or a way to solve problems, it's, there's a system behind it. And the system consists of a set of principles. And if you use them in, in like in concert, I don't know if you can say that in English, but then, then you get these wonderful results while making everybody happy.

Arnout Orelio (6m 23s):
So all stakeholders are recognized for their needs, like the customers are recognized for their needs, and the, and your management is recognized for what they need. And operators as well as maybe suppliers or even owners of companies, they're, they're all in it equally. And when I found that out, of course it was a small step to finding out. It had nothing to do with factories, although I was trained in a factory and all the books I read and all the methods I learned, like TPM and Lean, et cetera, came from factories.

Arnout Orelio (7m 3s):
It had to do with people who wanted to do things for other people. and that made, brought me to the part of going into the office, which is a completely different environment. And their problem solving is even more difficult because in the office there is no system for performance. So like in the factory, we always knew what the quality was, how many products we made, et cetera. But when I came in HR or in even in finance, what, what was their process and, and and, and what are their measures, right?

Arnout Orelio (7m 45s):
What are they measuring? Yeah, what are they measuring on? What do, how do we know they're, they're doing the right things, et cetera. So we developed as all kind of tools to visualize problems in an office setting. And then of course, like most people will experience, there's enormous amounts of waste in the office way more than in factories. And this is because in factories, at least you can see when there's waste, you can see piles of stuff where you can see a bin with rejected products. But in the office there's no way of knowing whether it's excellent or not, and whether it's productive or not.

Arnout Orelio (8m 34s):
And from the office, it became easier to maybe help organizations who had nothing to do with, with production, or at least not in the factory sense of the word. And because I, at the time, I had I visited the hospital from time to time, So I got this personal experience of hospitals, And I knew about a system to improve problems. And then I found that these hospitals, it looked like they didn't have that system, but it appeared that they had a lot of problems, at least in my eyes, And, I think that's, that's when I took the next step in process improvement, like focusing on a sector where I felt the need is high.

Arnout Orelio (9m 29s):
There's maybe a lack of awareness of the fact that these problems are there and that they can be solved. So, I, I was compelled maybe even to change my career focus. And from that time, I, I made it my mission to build what I called at the time world-class healthcare. And yeah, so, so that's so improvement became from doing things to solve problems in a factory, being my philosophy of how I think we should go about making the world better.

Arnout Orelio (10m 14s):
Yeah. And in my case, hospitals or healthcare institutions. Yeah,

Mark Graban (10m 19s):
I mean in, in hospitals in a lot of ways you can see the waste very clearly, the way you might see waste in a factory, you can see patients literally waiting for care. You can see the physical motion of the people doing work and, and the waste that's driving You know wasted motion that delays patient care and leads to the extra waiting time. And then like in an office setting, a lot of the waste in healthcare then is somewhat hidden because of it's, it's more administrative in nature. I was wondering if you, you could tell us a little bit more about that and You know helping people see the waste and then the leap.

Mark Graban (11m 2s):
Sometimes people, people can see the waste, but they think the problem isn't solvable. Like how Yeah.

Arnout Orelio (11m 7s):
Actually did, how do you help through that? Yeah, that's, I recognize both. So as a patient or following the patients, it's easy to see waste, but that doesn't mean that the caretakers know how to see waste because their eyes are not on the patient flow, their eyes are doing their work and because they're forced to do their individual work, extremely efficient. And whether that's truly efficient or not, we can talk about that later. But so that there's a lot of, I think you could call that resource focus and resource efficiency.

Arnout Orelio (11m 51s):
So we need as, as least amount of doctors and nurses to do the job as we can, can get away with sometimes maybe even. And, but what we forget are, at least what I see is that if you would make a detailed analysis of what a nurse or a physician is doing throughout the day and detailed, I mean, let's say every five minutes, my, I found that if you would then categorize that work in three buckets and one bucket is doing work that is actually needed to help patients, that could be work that is necessary under current conditions.

Arnout Orelio (12m 40s):
That's may, maybe it's you need to do it by law or maybe the health insurance company requires you to do some registration or, or all those kind of things. And then there's a bucket waste. And waste means that you are walking about or you are searching for things or maybe you have to correct something because it didn't go well the first time. And then it's interestingly, I found that it's one third, one third, one third. Yeah. Yeah. So that means that, so my, my mission could be, I think that for healthcare we could say we can double productivity without hiring anybody and

Mark Graban (13m 29s):
Without working twice as hard and

Arnout Orelio (13m 31s):
That without working twice as hard. Yes, exactly. So, because if you would cut the necessary, but the necessary on the current conditions, but not adding value time in half and you would cut waste in half, then still you have time to do those things. Because I don't think we help anybody to say that it need to be perfect, because there's always waste and there's always things to do because the legislators wants us to, I mean, I have an, I have a business of my own. I need to tell the IRS about my value added tax, et cetera.

Arnout Orelio (14m 12s):
So yes, it's always like that, but it need doesn't need to be as much as it is currently. So within these silos of so-called resource efficiency, there is still, we can still do twice as much with way less energy because what people often why nurses and doctors have to work so hard is because this administrative work and this wasteful work, your body knows when he does that. So it's way more frustrating. It costs way more energy if you're, if you're working with a patient and you do what you love, this will give you energy.

Arnout Orelio (14m 57s):
So it'll be very way more easier if you could do that all day instead of filling in forms, et cetera. Yeah,

Mark Graban (15m 5s):
Well that, that, there's a phrase for those who are just listening to the audio podcast. They won't see the video. There's a, a flip chart behind ar no, and there's a phrase there that seems to encapsulate what you're talking about there. And an important goal for healthcare, more time for better healthcare. You know, we, we look at that theme, releasing Time to care, I think was a, a pro the name of a program in, in the N N H S England at one point. There's another similar program transforming Care at the Bedside. But You know, I think that phrase releasing time to care more time for better healthcare, that's a very important goal.

Mark Graban (15m 48s):
It's a very positive framing. And You know, I'm thinking back to the history. I think this goes back at least 15 years ago. I think that program in N h S England was initially called the productive ward. And the people in the ward felt insulted and let You know it's not a matter of blaming the ward for being unproductive. They're doing the best they can. They're working too hard. So I, I think a phrase like releasing time to care You know. It's, that's, that's

Arnout Orelio (16m 15s):
A better question. Better word. Yes. Yes. It's interesting that the, the number one, one most important goal for healthcare increasing productivity is one that has so much negative connotation because that it was very difficult to talk about productivity. Whereas if you would call productivity is, to me, it's just the amount of value added work you do compared to the resources you put in. So, but because productivity is for so long measured by how much time do you work, people think, yeah, I work all day.

Arnout Orelio (17m 2s):
And I work overtime, So I can't be more productive. Sure. Right. And that's, yeah, that's a difficult thing to do.

Mark Graban (17m 11s):
Yeah. And there's a, there's a lesson going back to ta chio You know motion does not equal value or being You know.

Arnout Orelio (17m 17s):
Exactly. Yeah.

Mark Graban (17m 18s):
And, and, and people conflate the two. And yeah, I mean these are dirty words you mentioned earlier, problem and productivity because You know there, there's, there's quite often a lot of blaming and shaming associated with those words, where in some cultures, like a Toyota culture, the word problem is pretty neutral. Like the problem exists, it's Yeah. Pointing to a wrench, it exists. Let's yeah, let's do something about it. Yeah, exactly. Cause we, we don't have the, the same emotional stress that's created.

Arnout Orelio (17m 50s):
Yeah, yeah. They might even think that's a positive word because no problem is a problem is what said. Right. And I think that's true. If you, if You know what your problems are, How are you going to improve. So, but then that can only be true if you get the help you need to actually solve the problem. Cause otherwise you could just get frustrated. I mean, sometimes we do these exercises to have people see the waste in their department and sometimes they make very long lists, and that's not necessarily what makes them happy. Because some people like me, they, they, I can't unsee it.

Arnout Orelio (18m 37s):
So once I saw it, then I, yeah, I keep, it'll be on my focus. So yeah. And what's interesting about more time for better healthcare is also that there's a lot of research, at least in the Netherlands, I'm not sure if it's international research, but it could be that if a family physician or general practitioner would spend 15 minutes with a patient instead of 10, it saves a huge amount of people need sending be sent to the hospital because then you can get a true amnesia and a good true diagnosis of what's going on with this person, what's his context, what's happening at home?

Arnout Orelio (19m 24s):
And then that normally is enough to find out what can be done without look having a, an a specialist look at it. Right.

Mark Graban (19m 39s):
Yes. I mean that, that sounds like another example of the difference between resource efficiency and system effectiveness

Arnout Orelio (19m 46s):
Or system, exactly. Yeah.

Mark Graban (19m 48s):
Efficiency. The American system is so disjointed, it's difficult to think syste systemically. That might be easier in some other settings, but You know, it's a bit of a recap. Not to You know, dive into this too much, but my, my understanding of the Dutch system is that it's more similar to the US system than it would be to the N H S England system that you have private insurers that are nonprofit and private Yeah. Healthcare delivery organizations. Is that a fair summary? Yeah.

Arnout Orelio (20m 20s):
Yeah. But we haven't, so, so what's what's similar is we use the health insurance companies as the payers, and then we have the patients who pay a premium to the healthcare insurance organization and they make contracts with hospitals. And then these hospitals, they report how much care they're providing and then they get paid at least. So that's how it should work. So we, but these health insurance are all nonprofits. So we don't have health insurance who represent a business,

Mark Graban (21m 3s):
Right. People

Arnout Orelio (21m 5s):
Get insurance. In some cases

Mark Graban (21m 7s):
People get insurance independently as opposed to being an employer of benefits, right?

Arnout Orelio (21m 11s):
Yes. It's a, it's a, it's a private and you are, and everybody has insurance. In the Netherlands, you are even obliged by law to have an insurance, to have health insurance. And then there, there's, there's a basic package which is defined by the government. And they say, okay, these treatments and these kind of help is compensated. And the, and you can have additional packages if you want to have extra, but these are by choice.

Arnout Orelio (21m 55s):
So what, so the good part of, and what what, but what is very different in the Netherlands is we have a very solid first line we call it. So the family physicians or the, the general practitioners, these are at no cost. So anybody can go anywhere. They don't have to pay a, a contribution of some kind. And I think that it's about 95% of the curative care is done by these family physicians.

Arnout Orelio (22m 39s):
And only in 5% of the cases people are cases sent to the hospital. So this is where, where our system is fairly cheap or low lower cost than particularly the United States. Yeah.

Mark Graban (22m 54s):
And then is there a capacity shortage at some point? Or is, is the system designed in a way where more physicians are encouraged to become general practitioners or, or primary care So, you can go get that care without waiting a long time for appointments?

Arnout Orelio (23m 10s):
No, no, no. The, so the, the, the problem is that this, these health insurers, they make contracts with all care providers and they try to squeeze all of them. So, and this is where it's, the system is going wrong because the health insurance companies are saying they, they select on quality and cost, but because they are health insurance, they can't judge quality. So what they do is they make all these rules and all these regulation, all this administration, so all this bureaucracy, so care providers can prove that they, they do the right things, that the, their, their invoices are legitimate, et cetera.

Arnout Orelio (23m 60s):
But if you ask somebody who's doing the work to be accountable for that work, to somebody who doesn't understand the work, that means that it's all built on distrust. and that means that the bureaucracy is always increasing because it's never enough. There's always a reason why they think it's not good enough, or we are not sure, or So I think this is the, the, this is the biggest problem. And then, and then we have like what, what we tend to call staff shortages.

Arnout Orelio (24m 41s):
So we have a lot of, it's very difficult to find enough nurses, especially, and in some disciplines it goes for doctors, like family physicians, but yeah, hiring extra when they're not there. Yeah. That's very difficult. So that costs a lot of money. And what we also see is that because the general vision is we have staff shortages, everybody is solving that problem. And my, I always tend to say staff shortages are not a problem.

Arnout Orelio (25m 24s):
They are a solution disguised as a problem

Mark Graban (25m 26s):
Or it's a symptom of

Arnout Orelio (25m 29s):
Yeah, yeah. But cause cause the, the, because the solution is more stuff.

Mark Graban (25m 35s):
Yeah. And for those who are just listening, ar no, did the finger quotes around quote unquote staff storages, right? I

Arnout Orelio (25m 42s):
Mean, so yeah. And, and because it's, it's actually, so they, they feel like they do not have enough staff, and then they shout to their managers, we need more nurses, et cetera. And then there's all these vacancies. So people start to believing, oh, there's so many vacancies, we can't fill them. We have stop shortages. But there's nobody who says, okay, why do you think you have not enough nurses? And because that question would say, well, I, I working my ass off and I'm so busy and this patient didn't get her treatment.

Arnout Orelio (26m 24s):
and that one is, and we have this waiting list, et cetera, so that we can reframe the problem to, we can't treat, give all patients what they need. If we would frame the problem as we can't give all the patients what we, what they need, then you do two things. First, you, it's about what they need. So, you have to understand, is everything you're doing, is it actually what they need? Or are you doing things that they don't need that today we had a, a very interesting article in the newspaper about a hospital that's having patients and, and family members of elderly people discuss whether they want a hip operation, because all elderly people, they have a lot, a lot of times they fall, and when they fall, they tend to break their hip.

Arnout Orelio (27m 23s):
But if they're old, it's, it appears that many of them, when you ask them, they have very different priorities than being mobile again, because often it's not possible anymore. So they don't want pain and they want a high quality of life. So from, they went from 1% to 13 or percent of the people avoiding an operation and just taking palliative care. So, and that, so that would be, so do what they need and compare the work we do to what patients need.

Arnout Orelio (28m 4s):
And, and then we have, we can comp and we have the focus on this, on helping patients. So the primary task is to have enough capacity to do what patients need. And then we can ask, okay, where does our capacity go? And then we come back to this circle with this three parts, like a pie, where we spend only one third of our time on what patients need. And then we know, oh, we don't have staff shortages. The problem is we ha the, or the cause of us not doing what patients need is we let them do the wrong things.

Arnout Orelio (28m 50s):
If we would have them just do what patients need and nothing else. We have enough patients and enough surgeons and enough physicians. Yeah. So,

Mark Graban (29m 5s):
So You know Arne, you talk about the need for productivity improvement and, and, and that You know that relates to cost and efficiency and other factors. You know, on, on the cover of your book, Lean Thinking and Healthcare, there's, there's four phrases that seem to maybe represent true north. So let, let me ask that as a question. Do these things represent true north to you or the hospital you were working with? Those, those words and phrases are safe, compassionate, zero waste, no struggle. Is that, is that your true north?

Arnout Orelio (29m 37s):
Yes. And of course it's a summary because what would be in the middle of that is it would comprise the right care at the right time, at the right place for the right patient. But that's, that's the content of the work. And what I see in healthcare is that there's an unbelievable passion and scientific curiosity and every, all the energy in healthcare, if it comes to doctors and nurses, it's about the content of the work. But we do all these things around them, or they have all these processes and systems around them that fail them on the other aspects.

Arnout Orelio (30m 25s):
So that's why I selected these few four words because I think well safe, you can't go around it. If it's not safe, then you might want, don't wanna do it at all. And then compassionate, because compassionate means that you're willing to take action to actually help somebody. I had a great, I dunno, it was a graphic this week on LinkedIn by somebody who made a difference of ping sympathy, empathy, and compassion. And then it was in gradations to how much you care about the other person and how much you are willing to help them or take action to help them.

Arnout Orelio (31m 9s):
So that's where the compassion comes from. And the thing with thing with the word compassion is you can maybe put the word, if you take away the word calm, then you get passionate. Right? And, I think that's, that's what you want from your nurses and physicians and for everybody around them that they're passionate about the work they do about the patients. And what people tend to forget is that passion comes from, of course, from the, I think it was the, the bearing of the cross of Jesus.

Arnout Orelio (31m 51s):
And it has to do with being willing to suffer to get to your goal. So when somebody says he's passionate about this, about, about something they often mean, or especially when coaches on LinkedIn say it, they often mean, I, I like this work. But passion is not about liking the work, it's about willing to suffer to get to your end goal. If you want to, if you want to see passion, go watch cycling. Hmm. I don't know if you ever watched the Tour de France or something. Just a little bit. Yeah. But these, these people there six hours on their bike so that at the end they can be one second faster than anybody else.

Arnout Orelio (32m 39s):
Yeah. So it has not, and maybe they like cycling, but I'm sure you don't like it if you're six week and six hours on your bike on an average of 40 kilometers an hour. So that's, that's also what I have in my head. and that's, and that is because when you analyze, maybe to take a step back to where we started with improvement, the Japanese have this word kaizen You know it says very well. Yeah. Since the name of your company Connexus is inspired from it, I guess it

Mark Graban (33m 13s):
Is partly.

Arnout Orelio (33m 14s):
Yeah. So, and if you look at the characters of Kai and Zen, you see a whip Mm. Somebody whip and you see an altar with a sheep

Mark Graban (33m 29s):
And it's whipping yourself, not whipping.

Arnout Orelio (33m 32s):
Yeah. It's whipping yourself. So it means that means that continuous improvement means self-discipline and sacrifice. So, so, and then, so it's not just the true north, but it is also the emotions and the, the human endeavor. We need to get to that point. That's where I think then the book is about. So that, so the, on the, on the front of the book, it says these four things, which where we want to end up, we want it to be safe, we wanted to be compassionate, we want zero waste, and we want no struggle.

Arnout Orelio (34m 13s):
But to get there, we need, well we need this engine of willingness to suffer to make it better for other people. And this is where maybe that's why Lean is so difficult. I guess

Mark Graban (34m 30s):
I I can see two sides of that, of You know one, I mean sure. You know the need to put the effort into improvement is, is important. And there's bound to be struggle in our attempts to improve. But when you think of You, know the passion that healthcare providers have, what word would we use? We, we could say it's a calling that they have a mission that they, they start their career with enthusiasm, but then they have, then they end up suffering too much because of the waste, because of some of the different dynamics. People get worn down or burned out or, or, or worse, And, I, And, I think that's a big part of what we need to try to help fix in, in, in he healthcare.

Mark Graban (35m 13s):
And then that leads to staff shortages. When people say, I can't take it anymore, and they

Arnout Orelio (35m 18s):
Yeah. They

Mark Graban (35m 20s):
Quit or You know, I think we need to figure out how to break some of those cycles and and, and engage people in trying to help fix that.

Arnout Orelio (35m 30s):
Yeah, exactly. I mean they have, it's, it's hard enough to help fragile people and to sometimes fail. I mean, and, and nothing, nothing you can do about it. I mean, people die and people get hurt in ways that we can no longer fix them. So yeah, I think that's, that's fair to say. So we need to have them use this passion for their patients and not to work through the mud that we put on them. Right.

Mark Graban (36m 11s):
And You know, I think there's, maybe we can talk a little bit more about You know, one element of Kaizen is engaging everybody in improvement every day. And I know that's something you focus on in, in the book You know. I think one thing that makes it difficult to translate some of this from Toyota, and not the language, but just from one environment to another, is I think a lot of the context of Kaizen is built on top of a well-designed system like Toyota. People will talk about the obligation of leaders to create a system in which people can succeed. Dr. Deming would talk about the role of Executives in owning the system.

Mark Graban (36m 53s):
And I You know, I think sometimes You know I Well, well sure. The ideal is to engage everyone in improvement. I think sometimes I, I see or hear Executives think that all they have to do is empower the frontline staff and like, well, they could be there, they can tweak the existing system and there can be benefit to that. But when and how do you say we need to really redesign the system and that that has to involve more than the frontline staff?

Arnout Orelio (37m 23s):
So, you were asking me about this. Yeah. How, when should we go about changing the system instead of modeling on the shop floor to maybe increase it a bit, a little bit? Well, I would say as an engineer, when I first met the healthcare system, I was already thinking we should change the system. The, the current system is perfectly designed for the current results. And that's why I, with this engineering mindset, I made the introduction a chapter of the, of the book is about what I see in the current system that's keeping us from actually improving healthcare.

Arnout Orelio (38m 17s):
and that has to do with the silos. We already talked about it a bit that, that everybody is doing his or her work within his or her department and discipline. And because we science, we did science and improvement processes all to increase the content of the work. But we did hardly nothing to change the system that is supporting that work. So, I would say we need to completely redesign healthcare.

Arnout Orelio (38m 58s):
Where the most important thing is that we look at the needs of the patients and we look at what type of processes and models we need to help them and stop putting all those models in one system, which we currently have because the, the way we get paid is the same all throughout. Whereas the way we provide care could be very different. There's a great book about it, it's called the Innovator's Prescription by Clay Christensen.

Arnout Orelio (39m 40s):
and he made some points about the difference between diagnosis and standardized treatments and maybe treatments for illnesses we don't know much about or what, what to do with chronically ill, should we have them keep coming to the hospital or is it maybe better that we have some system that they can have at home? Those kind of things. So at the system level, I think there's a, there's a lot to be done, but the problem is you can only do that if you understand how to change systems. And for this, you need to learn to change small systems first.

Arnout Orelio (40m 22s):
So if we could help people on a smaller scale, learn how to change in a multidisciplinary way and teach leaders how to manage multidisciplinary cooperation and improvement, then this will give us the skills and the competencies and maybe the way of thinking we need to solve ever larger problems. Yeah.

Mark Graban (40m 51s):
Yeah. I mean like get there, there's that human tendency to want to jump to solutions and we can learn on a small scale maybe how that doesn't work. But there are at a larger system level again that, that tho those efforts to jump to solutions. If, if we don't may fully understand the problem. I mean, You know the, the US for You know decades has thrown around this phrase healthcare reform and that means different things to different people. Are there efforts to try to redesign the system in the Netherlands or or Belgium that you're aware of? Is that, is that kind of a Yes. A political question of well, how do we reform the system?

Arnout Orelio (41m 33s):
Yes. For a large part it's a political, the interesting thing is, it's not necessarily a political question, but it's made political. So what I, what what we see in healthcare is that people are doing each other's work. Like I told you that the, that the health insurers are trying to define and manage quality of healthcare where they don't know much about how to treat patients. And the same goes the other way around in the sense that if there's problems in healthcare, like staff shortages, everybody is looking up to the min minister of healthcare.

Arnout Orelio (42m 13s):
And the problem is sometimes the, he even listens and then he starts to devise solutions for the problems that people say are his fault. And this is where the problem is, people are thinking about who's responsible, And, I, they mean who, whose fault is this? And they start telling him, you need to fix this because it's all terrible. And then he fixes it with solutions that don't work. And then we get, so we get this cycle, I call it the, the circle of continuous misery. It's in my book as well Yeah. As part of this introductory chapter.

Arnout Orelio (42m 54s):
And so, but it shouldn't be, the problem is, and the other problem is we don't really look at the current condition to understand it. Right. We look at it as just to judge it as horrible, but not to understand it. So, and as long as we don't understand what we are now doing and why that is not working or why it is working, in some instances, like I told you about the general practitioners in the Netherlands, which is work working quite fine. So and so we need these people, they make all kind of, I dunno you call it, he could also treaties.

Arnout Orelio (43m 44s):
They, they make a long reports and they say, okay, for the next year we agree that this will, that we will do this, but it's all works. It says like, we need to cooperate more and we, et cetera, et cetera, et cetera. But there's no system or id How, so the the best thing for them is to have all everybody in the system just join to understand the current condition with the aim of just giving patients what they need. And if they want to say with the least amount of cost that that will be, if you just give them what they need and nothing else, that will be the lowest cost version of your system.

Arnout Orelio (44m 31s):
But then they have to agree that it's that they're all in it together and that they need a plan that's understood from all perspectives. Because these health insurance companies, yes, they have a, they have the obligation to pay the least amount of money for my care because that's why I pay him the premium. So And I want the premium to be low. So, so we ask things from people and when they do what they're, where they're asked to, to do, then they're blamed for it. Yeah. So yeah, that's not helping. I'm not sure it is the same in the us that's,

Mark Graban (45m 13s):
Yeah. Yeah. I mean I think there's, there's something consistent in, in the human condition there of reacting to symptoms, jumping to solutions, expecting other people to solve it. You know, you're, you, you make me think of really helpful idea that You know Toyota people like Pascal Dennis have taught me You know the difference between what they would call a big vague concern and a well-defined problem statement. So, you used a phrase or we could just say something like, You know, a big vague concern would be something like You know the pa our healthcare, our healthcare system sucks. Okay, well how specifically, how do we define that and, and how do we define a measurable gap?

Mark Graban (45m 59s):
Or it could be You know, everybody hates working here and they're all leaving. Okay. That, that's a big vague concern. We need to define the problem. We need to understand causes, we need to understand more detail of the current condition as, as, as you're describing. And You know, I know as, as, as you teach others. So You know that that discipline, problem solving process, even at a smaller scale yet alone, a bigger scale that takes more time. But I think that's the only chance we have to actually be effective. It seems faster to jump to a solution and jump into action. And then if it's not effective, well then we're either right back where we started or we've made things worse.

Arnout Orelio (46m 38s):
Yes. And there's another thing which I almost forgot because I'm so used to it, which Lean thinkers are, or companies like Toyota are, that we need to start to understand the direction. That's why on the front of my book is this true note, because we often forget about it. And if you don't have a true note, then you automatically get some vague problem statement. Whereas if You know that it's need to be a gap between something where you want to be or need to be and what you currently have, then you will start seeing and then the clutter will disappear as well.

Arnout Orelio (47m 22s):
Because I I see in the Netherlands and, and some examples I saw elsewhere that we tend in healthcare and maybe it's human, the human condition as well as like you said, but we, we improve away from something. So we try to improve away from the current situation, which we don't like. But if everybody is moving away in a different direction, then the, then we, the, the, the status quo remains, right?

Mark Graban (47m 56s):
Or what. So we, we, we need to understand what we, what we're moving to, what's the ideal That's, that's an important part of the problem solving process. Define the ideal state, right?

Arnout Orelio (48m 6s):
Yeah, exactly. Yes. And I think that we should learn to start there.

Mark Graban (48m 11s):
Hmm.

Arnout Orelio (48m 13s):
So yeah,

Mark Graban (48m 14s):
That's, that's, that's a great point. Not just what are we moving from, but what are we moving to?

Arnout Orelio (48m 20s):
Yeah.

Mark Graban (48m 22s):
So that's, yeah. So one, one other thing I wanted to ask you, and, and again, we're joined by Arnout Orelio, his new book is Lean Thinking. And in Healthcare, You know we, we've talked about the need to look at our work to understand the current state and, and, and, and to make things better. You know you, you also talk about and write about learning from the best. So where, what's, what's the right role for that? Does that mean learning from the best hospitals or the best whatever?

Arnout Orelio (48m 54s):
Well, learning from the best, luckily it's not, the first chapter is chapter 10, I think. So it's somewhere at the end of the book. And that's because learning from other people, I think in healthcare they really try to, and they like to, but it has two problems that first of all, they, they tend to start learning from other people by brainstorm or by visiting somebody before they understand their own situation and their own problem. And they haven't yet decided where they wanna go.

Arnout Orelio (49m 34s):
and that means that if you then go look at somebody else, you automatically will refute like almost everything you see because it won't work where you are at for all kind of reasons. So they're jumping to solutions without being aware of it. They're jumping to the solutions of the other person. And then of course, even if they like them, it's very difficult to implement them because they have no connection to their cur their own problems. Right?

Mark Graban (50m 7s):
They're trying to copy lot.

Arnout Orelio (50m 9s):
Yeah. And then the other thing is they tend to go learn from the content of the work. So they go to learn from other, let's say I'm a surgeon, I'm going to learn from other surgeons. I mean, surgeons go to surgeon conferences, which narrows down the amount of possible solutions. Extremely, because then somebody who has the same job as you has already need to have the same problem, which they assume they do. And then if he solved it, I can solve it as well. And if somebody is not a surgeon, maybe he solved it, but it can't be for me because he's not a surgeon.

Arnout Orelio (50m 54s):
So if you learn, I feel that if you learn from the best, it's then learn from people who know how to solve problems or how to lead because that's universal. So it's way more be, it's way better to invest in yeah. What you call meta skills, new ways to solve your problems. And or if you can't find a good solution, I mean, if you understand your problem, then ask yourself who solved this problem already?

Arnout Orelio (51m 36s):
And then be blind for what kind of work they do. I mean, if you want to know how to safely change some information at the other end of the world, and then it will be automatically the same at this end of the world without everybody, anybody can have access, go to a bank. So if you want to design ehr, ask banks how they make sure that your privacy and your bank account are guaranteed, despite the fact that you go to Singapore to get cash out of the machine.

Arnout Orelio (52m 19s):
I mean that that I think that it was already in the nineties or maybe the end of the eighties that we were, we were able to do this automatically world around. And in healthcare we're still, I think we have, last year we, we eliminated the fax machines from hospital. So Wow. Congratulations, that's so, yeah. So, so learning from the best, preferably learn from their ability to solve problems and from their leadership. And the best way to learn is don't go to another hospital.

Arnout Orelio (53m 2s):
Because the problem with that is that you see all their solutions and you understand them. I, I, I used to organize study missions to the US actually, and we went to Seattle and with I think about 40 people from healthcare and the, especially the physicians, they went on the tour because we were going to visit hospitals like at Virginia Mason. But where, where they learned the most was at Boeing because they didn't have that frame of reverence. So there were completely, it's like going on a holiday.

Arnout Orelio (53m 45s):
If you go to new country, you can't be otherwise other than open to all the new experiences because you, you don't have a reference. So they learned at Boeing that maybe building an airplane in 10 days and then have the client fly it themselves from your factory to the other side of the world, while you have put 300,000 different pieces together to get this playing, this might be actually also quite complex. And if they can standardize their processes and they, they are able to manage quality and they are able to do it in a safe way and make, make the plane flow Yeah.

Arnout Orelio (54m 34s):
Then why can't the hospital? Yeah. So that, that's where they learned the most. Yeah. So I in a sense from the best, in the best in doing this extremely logistically complex process. Yeah.

Mark Graban (54m 51s):
Well, thank you for, for sharing that Arnout You know, thought provoking and, and really insightful. So we wanna thank you for being here again today. Our, our guest has been Arnout Orelio, his website. And, and again, there will be links in the show notes here, Lean thinking in healthcare.com and the new book, Lean Thinking in Healthcare, Congratulations on getting that, getting that published and released. It's very exciting. So

Arnout Orelio (55m 16s):
Thank you. I hope it

Mark Graban (55m 18s):
People will check it out. And I, hope it's well received. And needless to say, for those who are listening, the the, the book is in English. So,

Arnout Orelio (55m 26s):
So, and if you by accident are Dutch speaking, the book is in Dutch as well, because I originally wrote it in Dutch And I, translate it myself, So

Mark Graban (55m 37s):
I, hope people again, hope people will go check it out. So Arnout, thank you. It's great to talk to you again and let's, let's do this again sometime.

Arnout Orelio (55m 44s):
Yeah. Thank you so much

Announcer (55m 46s):
Thanks for listening. This has been the leanblog 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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