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My guest for Episode #417 of the Lean Blog Interviews Podcast is John W. Kenagy, MD, MPA, ScD, FACS, of his firm Kenagy & Associates based in Washington state.
John is the author of the book Designed to Adapt: Leading Healthcare in Challenging Times.
Dr. John Kenagy knows healthcare as a physician, executive, academic researcher and advisor. In addition to his clinical experience as a vascular surgeon, he has been Chief of Surgery, Chief of Staff and Regional Vice President for Business Development in a not-for-profit healthcare system. But, his most meaningful experience was becoming a patient, as we'll hear about today.
Searching for new answers, he became a Visiting Scholar at Harvard Business School. His research included developing disruptive innovation healthcare strategy with Harvard Professor Clayton Christensen and translating to healthcare the drivers of success in resilient, highly adaptive companies like Toyota, Intel and Apple.
Dr. Kenagy is hosting a webinar in the KaiNexus Continuous Improvement webinar series on June 15th. Please join us for that by registering here.
Topics, questions, and links related to today's episode include:
- What's your Lean / Toyota Production System “origin story”?
- What he learned after falling out of a tree in 1982
- What he learned from Clayton Christensen, Kent Bowen & Steve Spear at HBS
- “Toyota enables people to succeed & makes learning part of that success”
- 4 Rules in Use – the essence of TPS
- Spear: Decoding the DNA of the Toyota Production System
- The rules applied in HC? What did you learn?
- Learned also from Amy Edmondson at HBS
- Learned from Toyota's Mr. Oba
- “Education can get in the way of learning”
- Learned at a smaller TMMK supplier, not at Georgetown, only 120 employees
- What is “adaptive design”? Origins of that phrase?
- Why avoid the word “Lean”?
- Being adaptive in dealing with pandemic challenges — what are the characteristics of their success?
- Leadership Kata — 5 principles
- 1) Clear, meaningful objective (hearts & minds)
- 2) always start small, simple, safe, and fast
- 3) use relevant (timely, role specific, actionable) info and simple rules, rapid feedback on effects on your action
- 4) improvements made by teams involving people doing the work
- 5) replicate and scale, success trust and optimism … never stop
- What do you mean by “virtuoso leadership”?
The podcast is sponsored by Stiles Associates, now in their 30th year of business. They are the go-to Lean recruiting firm serving the manufacturing, private equity, and healthcare industries. Learn more.
This podcast is part of the #LeanCommunicators network.
You can listen to the audio or watch the video, below. I hope you enjoy it like I did.
Video of the Episode:
Automated Transcript (Not Guaranteed to be Defect Free)
Hi, it's Mark Graban. Welcome to episode 418 of the podcast. It's June 16th, 2021. We've got two guests today joining us from Munson Healthcare in Northern Michigan. They are Caleb Foss and Butch Bowlby. Today we've got this great combination of the continuous improvement manager and a pharmacy director. They're going to be talking about lean and continuous improvement at Munson, what it means for them to have a management system or an operating system, and how they've focused on culture change and safety. We're also going to have a long conversation about setting up mass vaccination clinics and how they got that set up for employees in just six days. So I think it's a really fascinating story that they tell. You can find show notes, links, a transcript, and more at leanblog.org/418.
We're joined by Caleb Foss. He is the continuous improvement or CI department manager, and we're also joined by Butch Bowlby. He is the System Director of Pharmacy. So Caleb, Butch, thank you for joining us. How are you?
Great, thanks, Mark. Thanks for having us. Look forward to having great discussion with you today.
So I'm going to ask you to, you know, each, we'll learn a little more about your backgrounds individually. But could one of you tell us a little bit more first about Munson Healthcare as an organization?
Yeah. Munson Healthcare is a system of nine hospitals in northern Michigan. We serve about 30 counties, approximately 450,000 residents. We have over 70 medical specialties. We have over 700 licensed beds in our system. Also, we have an opportunity to serve our long-term care patient population of over 260 beds, with over a thousand physicians, and approximately 8,500 employees. So we have the opportunity to really serve our communities in a way that as a collection of system hospitals.
Well, thanks. So, you know, I'd like to ask guests, if you will, like, what's your lean origin story? Or, you know, what are your roots personally of continuous improvement? How did you get exposed to this? Why does it resonate with you? Caleb, maybe we'll have you go first on that.
Sure. Roots for me started back in manufacturing where I had an opportunity to work on some exhaust gas temperature sensor lines with a company called Stone Ridge in Lexington, Ohio. And really got some exposure to mechanical engineers working on the deployment side of Lean. From there, I really had an opportunity to connect with my uncle as a Lean Six Sigma black belt, and really just started to get further interest in lean concepts in general.
And then from there I had an opportunity at Florida Hospital to really go through their particular green belt training led by Charlie Morrison. And from there really escalated to process improvement consultant in Amita Health in the Chicago land market, and now at Munson Healthcare, where we've really had an opportunity to our lean journey over the last five years. So really looking forward to the journey ahead for Munson Healthcare. And really what Lean is to me is really about respect for people. And if we can ensure that we are showing respect to others, we can move all along together in a much more succinct way.
Yeah. And that principle of respect for people and the actions that come with it, that to me, that's part of what's very transferable from manufacturing into healthcare as we're going to hear from Butch soon. Butch has had a career in healthcare and we will maybe get to explore some of those connections of what's transferable. But Caleb, one follow up question for you is like, what was that spark? What was that moment that led you to go from manufacturing into healthcare?
It really is about the people, you know, in manufacturing, it's about the widget. And here in healthcare it's really about taking care of the patient, taking care of people and working alongside those caregivers who are taking care of people at a time where they really don't want to be in the hospital, but we're here to serve them. And so they're at their worst sometimes. And so that respect for humanness, that's really the spark to connect with people in a different way, to assist in a way that, you know, I'm nonclinical, but however we have an opportunity to impact the frontline and the patient at the bedside through continuous improvement.
Yeah. And I think part of what's transferable, even in an environment where we're making widgets, taking care of the people in the factory leads to better performance for customers and all around for the organization. But I guess, you know, it is just coming back to that question real quickly, like, had you been seeking out opportunities in healthcare? Did a recruiter find you? I'm just always curious like what personally for you, Caleb helped get you into a slightly different, well into a different career direction in a different industry?
Yeah, well, you know, I had an opportunity, my aunt has been a nurse for several, several years and she really has a knack for trying to take care of individuals. So I had an opportunity really kind of fell in the lap as far as it really started healthcare as a PRN front desk registrar. And really had an opportunity to start connecting with patients at that level, specifically in medical and radiation oncology. And so you learn a lot about patients and their needs and be able to support them in a really difficult time. So that opportunity really just presented in myself at Florida Hospital and I really had the opportunity to accelerate my career in healthcare.
Well good. I'm glad you had that opportunity, Caleb. So let's turn over to Butch Bowlby here again. He is the system director of pharmacy. Butch, tell us a little bit about your background professionally, and then at what point did you get introduced to lean practices?
Sure. So I'm a pharmacist by trade. I also have a master's degree in healthcare administration. And I'm kind of unique maybe as a system pharmacy director. And then I spent about half my career in business development, kind of operations finance with retail health, and then the other half in hospitals. I had a clinical position when I was younger and I've been in administration for a couple health systems towards the back end of my career.
As far as lean training goes, for me, it's been on the job. The health systems that I work for employed Lean Principles. In addition, my work in business development, lean was part of that as well. I will say I've got a crash course this last year working almost on a daily basis with Caleb over the pandemic and in particular with our vaccine program up here in northern Michigan.
So for me, it's been very, very interesting and when I think of lean there are a lot of applications within pharmacy, quite frankly. I think first and foremost about patient outcomes and patient safety. But then we look at inventory management. I run a significant drug budget. It's one of the highest line items in any hospital. You know, we're constantly thinking about waste. So the lean principles in my day-to-day are certainly applicable.
And I love how you point out that collaboration that I've seen be so powerful in healthcare. I'm an engineer, non-clinician, partnering up with clinicians, whether it's a pharmacist or a lab director who is a medical technologist or nurses or physicians, what have you. It's those combination of perspectives when we've got aligned goals and focus on the people and the patient that leads to great things.
It is interesting to me at Munson that with this dedicated continuous improvement department, it's a resource I haven't really had a lot of access to. Like I said, it was more on an informal basis. So, you know, I view Caleb and that department has just a tremendous resource, and I certainly advocate for my team to utilize that resource as frequently as I can. And they can. It's been a tremendous help for us.
It helps you, I'm sure, Caleb and your team when there's pull for your services and help, right?
Oh, yeah. You know, that's one of the things we're here to try to make good things happen for other people as well. And so the biggest thing here is that pull. How do we respond as a CI team? What are your needs? How can we be here to serve you? Our leaders are our customers and we try to do what we can to serve what their needs are each and every day.
So we'll have a chance to take a deeper dive into some of the work that you've done around vaccination, but to help sort of paint the picture of the history and some of the foundations of this at Munson. How would you describe, Caleb, the approach that taken there at Munson? Has it evolved in any way over time?
Yeah. In Munson Healthcare, over the last probably 20, 25 years, we've only had some form of lean. Our previous vice president was an industrial engineer by trade and so she brought those concepts into our health system. That performance services or continuous improvement has always been kind of at the forefront here. However, you know, we made a concerted effort about five years ago to really talk about transformation and transformation in regards to starting with model learning areas with our central billing office, surgery and our ED, starting with rapid improvement events and then really working through with ThedaCare and Catalysis to pull in a lean management system and then really have an opportunity to then make it ours. We leverage the experts and those who came before us to really learn from them and really then apply to how does that make that ours in Munson Healthcare.
From there, we really had an opportunity to build the Munson Healthcare Alignment Framework. And that Munson Healthcare Alignment Framework really helped us align as an organization and we're still aligning, however, of our align to our purpose of we improve lives, looking at our operational True North metrics, ensuring that we have our strategic vision and goals. And then really the biggest piece here of how we're accomplishing lean in Munson Healthcare is our operating system. And our operating system really consisted of six core systems of goal setting, alignment, visual management, problem solving, standard work, and our people systems of follow up and accountability and individual and team development. And so that's how we're going to accomplish our outer aspects of our alignment framework. So that's our journey till this date. And so we're still working through that evolution. As we know, transformation definitely takes time and we're having fun doing it.
Yeah. And it'll continue to evolve as you learn more, get new experiences, get input from others, and maybe develop some new practices on your own.
Yes, very much so.
Yeah. So, Caleb, looking back at this longer journey here, how would you describe some of the benefits of the results that you've seen at Munson Healthcare? Let's say there are people, I mean, I think a lot of people listening to this podcast already agree that Lean is helpful and applicable in healthcare. Or maybe they wouldn't be listening otherwise. But let's say you had the opportunity to talk to somebody who's still considering the application of Lean in Healthcare and they ask, okay, well, why should we do this? You've talked about some of the general goals. Are there any specific benefits or results that you can quantify and point to?
Yeah, I think the biggest thing for me is we are trying to look at cultural indicators and the cultural indicators. What I mean by that is regards to how are our leadership teams and our frontline teams behaving, if you will. And the things that we're hearing are, you know, what problem are we trying to solve? Is that addressing root cause? What metrics are you tracking to ensure that your countermeasures are effective? This way of language is really been a benefit. And we're starting to see that. We're seeing increased quality, increased safety, increased outcomes that are positive for our patients. This is what it's all about.
And so I think the benefit of that is that we all are now speaking or starting to speak a common language. And that's what that operating system is trying to and intended to do. So that when we talk about goal setting alignment, leaders know what that means. Or we talk about problem solving, we know we're going to talk about at its the highest level plan to study and adjust. And we're going to dive into an A3 when necessary. You know, we talk about our SBAR–situation, background, assessments and recommendations. That's a way we communicate. So that language has really been key and that's been happening at all levels of the organization. And so those I think are some of the big cultural and benefits to our community and our leadership team and their development.
You know, it sounds like all of that is a really helpful foundation in a way that's gonna flow through to different metrics. And I appreciate you've both brought up patient safety as a primary goal and I think keeping that at the forefront is really important. Other organizations that you may have seen or heard about, I think sometimes put too much focus on cost and efficiency when I think, again, some of the lessons coming from manufacturing are keeping a primary focus on safety and quality and flow. And if we do those things, cost will follow. So has that become more of the discussion with leaders at different levels?
I would say yes. I mean, the looking at quality and safety, it's not only just about the patient, but also keeping our healthcare team safe. And so what are we doing to ensure safety for our teams? What are we doing not only just physical safety, but psychological safety, being able to speak up, being able to increase the number of what our system of voice reporting. So ensuring that we're understanding what are our near misses, how can we learn from the defects, how can we ensure that we can prevent these errors that do happen in healthcare. I mean, it's the reality of it all. And so the better reporting that we have, the more that we know, the better that we can understand what problems are out there that our front lines are facing. And then how do we as leaders help remove those barriers that they're facing each and every day to ensure safety for them and the ones that they're taking care of.
And Butch within the pharmacy realm, does discussion of Lean or this idea of an operating system within Munson Healthcare, does that change any of the metrics that you're tracking, or is it just intended to help drive improvement in things you're already measuring?
You know, I think it does change the metrics and I kind of think of it as an evolution, and I've seen it in healthcare, we're using, Caleb mentioned language. I mean, my department is using language that really wasn't utilized years ago, quite frankly, we're constantly talking about standard work and alignment, and then again, in healthcare, this focus on transparency, patient outcomes and patient safety. Honestly, it's very exciting. And you know, I have dedicated people focus on nothing but patient safety that necessarily wasn't the case 10 years ago. And it really isn't the case everywhere across the country. So to me, what's interesting is the evolution in healthcare and the lean applications. There again, there's language utilized in my department, lean language that really wasn't the case 10 years ago.
And I think some of that language as you referenced Caleb, that I think is really important is around psychological safety. And I'll point listeners back to episode 356. From January of last year, I had an opportunity to talk with Professor Amy Edmondson from Harvard Business School, who's written many articles, and she has a book called The Fearless Organization. And, you know, healthcare was one of the areas where she really did a lot of her research. The idea that organizations that had a higher number of reported errors were actually safer, right? So it's not, you know, it sounds like a conundrum, but it's not that they had more errors, they were just being more honest, or they created a safer environment. I don't mean to imply somebody who doesn't speak up as being dishonest. Like that's a cultural organizational dynamic if people are afraid to speak up. So I'm just curious if you have anything else that you would want to add around that theme of the importance of psychological safety.
Well, I think it's, you know, I go back to another principle leading with humility and our leadership team is growing in that. I mean, 'cause you know, again, all growth requires vulnerability. So how are we putting ourselves out there to open, I don't know, everything. And so it's, and that's okay. And so we can collectively use our team's knowledge to help solve problems. Another aspect of our operating system is the improvement huddle. And so how are we also giving the frontline a voice to that so they can speak up to safety, they can speak up to quality, they can speak up to operational performance issues. So it's not, uh, it's, we have avenues for frontline to speak up and we're really working hard to encourage that.
So let's shift direction a little bit and talk about some of the more recent work related to setting up mass vaccination clinics and sites. And that's all evolved and changed quite a lot over the last couple of months. Caleb, maybe you can start here. If you can talk about the challenge you were given and some of this initial vaccination setup. And Butch, I know you'll have perspectives on that, and I'd really like to hear more about the partnership as you had described it, Butch. But Caleb, maybe I'll have you go first.
Yeah. We knew vaccines were coming, but we didn't know what it was. I don't think anybody in the country knew what this was going to look like. And so in our organization, there were pockets of individuals working on the right stuff. What are we going to do about labor? What are we going to do about sites? What are we going do? And you know, I got the call Friday, I think it was December 11th, and it was like a three o'clock. We had an all leader meeting and it was like, all right, here's, you have pretty much within five minutes I was given the charge, the project manager and CM to help pull everybody together. And that was just, you know, that first step. It was like, all right, how do we accomplish this? The first questions was, who do I need to involve right away? And so right away we got everyone together and we had a plan and approach to set up mass VAX clinics for our employees within six days. Um, so that was kind of the task.
Um, and then that involved with setting up working alongside Bonnie Kruszka, VP of Ambulatory and CNO services, a call center. So we had that call center established and set up working with IT and corporate communications and messaging. And the task was very large, obviously. So from that perspective, we had a call center established and set up within three days, email communication and compass communication was on our main venues in our organization to communicate to team members and opened up a call center. It was a beautiful sound to hear all those calls coming in, ensuring that everything was working at 8:00 AM when we opened up those doors. And so from that perspective, we had to figure out staffing. We had to figure out standard work and processes and what systems are we gonna use? How are we gonna track measurements? What's our flow? How many individuals can we pull through a clinic at one time? Time studies and overarching goals that we had set of creating an equitable and safe deployment of vaccine administration across Munson Healthcare in northern Michigan with zero harm and zero waste and administration of our vaccine with 90% of our allocation within seven days. I mean, we really had goals that we aligned to, and you'll still hear that today. And you know, Butch can speak to this about breaking that of around zero waste and the conflict we had with zero waste versus zero harm. And so overall, I mean that was the initial task is to really take the lead from the state's direction of where we need to start vaccinations and then apply that project management and continuous improvement mindset with a core team that we had set up.
So Butch, what would you add to that? I'm curious to hear more about this idea of zero waste versus zero harm. What was some of the dynamic or the trade off there?
Yeah, I would love to talk about that. One thing I do wanna comment, Caleb mentioned the different pockets working on this prior to pulling everybody together under Caleb's leadership. But I was one of those pockets, and as this started to transition early December, I just started to realize along with some of my peers around the state, the enormity of what we were facing. I don't think people generally grasped it initially. But the zero harm, zero waste tenant was kind of what drove everything. But in addition, we kind of told each other vaccine drives everything, and that was another pretty big tenant for us. And that was so true from a pharmacy perspective. I mean, even before the vaccine was shipped, we started to hear we could potentially be getting Pfizer vaccine. And I think most people are familiar with the storage requirements, these ultra freezers. I mean, these didn't exist in northern Michigan, other than a few small ones and labs for specimens. So trying to figure out, are we going to get Pfizer? Do I need freezers? Everybody in the country's trying to order these things. So right away the challenges really started. I didn't want to be the health system that couldn't get the vaccine because we didn't have a freezer. It sounds pretty simple, but there was a lot going on there.
I think as it evolved, we didn't necessarily know what we would be getting. Are we getting Moderna? Are we getting Pfizer? How much are we getting at that time, the state of Michigan just kind of auto allocated. So how do you plan for that when you don't necessarily know what you're getting? Initially we talk about patient safety a lot. We had made a decision organizationally that we were going to segregate the vaccine that we would get. So a particular hospital would only get Pfizer and a particular hospital only get Moderna. And we just felt that these vaccines were different enough that we really tried to segregate them that way. But that created a lot of logistic problems 'cause the states weren't necessarily sending to those locations what we had designed them for. Accounting was a big issue. You heard a lot about five doses per vial for Pfizer versus six doses. Again, that sounds simple, but there's issues with that, that variability. My main concern was second dose obligations to patients for pulling six doses out of these vials for first dose clinics. And then we can't do that for second doses. We're going to be short vaccine for people. So there was a lot of logistics really involved in that.
Reporting to the state, the state continually, up until recently, accounted for Pfizer vaccine, five doses per vial. Yet when we were administering, we were getting six. So my math never really added up when I was trying to report to the state or administration. We experienced some pretty significant changes in shipments, for example, for three weeks, four weeks, we stopped getting Pfizer just based on availability. So again, all that work that we put in place with these mass fax clinics kind of had to be adjusted a little bit. Deployment of people was a big one. You know, we didn't get extra people to stand up mass fax clinics, from the logistics portion to vaccine prep administration, all that. And then another big one that's interesting for Northern Michigan was weather, because we were doing this in the middle of winter on the shores of Lake Michigan. So the challenge list was pretty significant. Looking back and taking a couple notes prior to this, I had to chuckle about some of the conversations that we had to have. There was a lot to overcome there.
There's a lot of detail and I've heard time and time again what you were saying, Caleb? Getting six days notice, getting one week's notice of, okay, you gotta be up and running high volume. Go figure it out. And the challenges and the conundrum of, you've gotta schedule people for appointments, but you also don't know how much vaccine is coming. That's not really compatible. It's not ideal. But you know, everyone did the best they can and then improve. What I love hearing is the stories of improvement that followed the initial setup. We do our best to design what we think is a good process that's gonna work well. But then we learn, we identify things, we move forward. So like, for example, Butch, you talk about this decision of this hospital's gonna be Pfizer only, this hospital's gonna be Moderna only. I could see where in some ways that would simplify things at each site. It would simplify as people come back for their second dose, you don't have the risk of showing up on the wrong day or, well, I need a Moderna second shot and you're doing Pfizer second shots today. But then what I heard you saying was the state was all shipping vaccine. Did you end up having to do some sort of reshipping within the Munson healthcare system then?
We certainly did. I mean, we weren't necessarily getting the quantity shipped to locations that they needed to fulfill those appointments. And we certainly didn't want to kind of cap appointments if we didn't have to. So there are a significant amount of shipping across Munson. And again, you think about that Pfizer vaccine, then once we pull it out of an ultra freezer, we've got a limited window to be able to utilize that. And our big tenant was zero waste. So we worked very, very hard not to waste a dose. Um, so yeah, there was a lot of logistics involved in it, which is really out of the normal work for pharmacy. We do some of that, but not to the extent that this pandemic called for.
So back to the freezers for a second. How did that end up working out, that scramble to come up with the ultra cold freezers?
Yeah. We bought eight freezers. In fact, I got a couple for sale, but we did have the capability of using Pfizer at all our sites. But again, we tried to sequester that to the best we could. Now we started to partner with some physician practices, and that's a pretty big evolution in the Munson vaccine program. So, for example, there's a privately owned large practice in northern Michigan. We allowed them to utilize one of these freezers that we weren't using, so they could ramp up and stuff like that. So we really took a regional approach by eight ultra deep freezers.
Yeah. Well, and then a lot of this has been evolving, maybe just as the medical community learns more and they have more time to study this. I mean, you may have seen, it was just in the news I saw last night that the FDA now says it's okay to store the Pfizer vaccine at normal refrigerator temperatures for up to a month instead of, what was it before, hours or a day or it says previously it could be stored for up to five days. So I guess this'll help a lot.
Absolutely. You know, and we think about it, we've got a pediatric population that's gonna be able to utilize Pfizer vaccine. So this is gonna make the logistics that much easier in the vaccine, that much more accessible.
So, and that may be very helpful. You know, maybe, we'll come back and talk about other elements of the mass vac process design, but I know a lot of parts of the country, the larger mass vaccination sites are being shut down and there's more of an effort to do more distributed vaccination, find people where they are, pharmacies, doctors' offices, community outreach in different ways. How is that evolving now with your communities?
I'll go ahead and start. So one of the core pieces of why we feel we were successful was we established a vaccine steering team and that steering team was led initially by our senior hr officer and our chief medical officer, and now is transitioned to our Chief Safety and Quality officer and Joe Santangelo and Dr. Christine Nefcy and Sue Peters. And so from that perspective, we also collaborated with our local health departments. And so the collaboration, there was a community approach. We ensured that we were all on the same page. We were all on consistency of what we were working towards sharing knowledge and transferring that knowledge to our clinics. And so as we evolved from mass vax clinics from employees to our community, Butch can speak to this as well, but we were all doing mass facts. And so we noticed that there were some levels of thresholds that we were all doing the same thing. So how can we transition our mass vax to help support the health departments and then what is Munson Healthcare gonna do differently? And so what we were doing differently was try to get into and work through getting into our physician network practices, both our own and our independent through our PHO and our NPOs, and really start collaboration with our patient panels and our primary care offices. And so that was really the next evolution of where we transitioned. While mass effects clinics were still happen with the health departments, we were also working into getting into our provider clinics and still do that today.
Butch do you have have anything to add about kind of that evolution? How does that change your role or as a pharmacy, what are your perspectives on that?
Yeah. You know, Caleb mentioned, I mean, we would've nightly meetings and the health departments were represented, but that duplication effort was really apparent a few weeks into the health departments really setting up robust mass vax clinics. So our move to the physician practices, I think was pretty unique, at least in the state of Michigan. Um, and it added just another avenue of vaccination for our region. It did create a lot of, again, logistical challenges for my department in particular. We went from a couple transfers across hospitals to facilitate vaccine at a mass VAX clinic to 30 to sometimes 45 transfers to the hospitals and then out to physician practices. Caleb touched on that development of standard work. I think that was really, really critical in the rollout. You know, we were able to provide standard work to these practices. Now practices give vaccines on a daily basis, but there's a lot of unique aspects to this COVID vaccine that they weren't familiar with. So that creation of standard work I thought was critical. But we've done tremendous work. I think we've been 18 weeks into our practices and our private practices and our own practices giving vaccinations. So we were probably ahead of the curve on that. And the thing that's interesting to me on that is that we've kind of got the next evolution in place because these practices are gonna have to have some form of COVID vaccine. So all that work is already in place and they're up and running on it. So we can just scale it down to the need at this point.
So maybe we can go back and I'd be curious to talk through some of the detail of trying to shoot for zero waste. If you can talk about some of the dynamics and the standard work that helped make sure once the vaccine has been thawed, that it gets used and doesn't go to waste. And then the dynamic of, let's say the day of vaccination as it's being drawn up into syringes and vials are being, when you're breaking the seal, I guess, or you're diluting that vial if it's the Pfizer. What were some of the things that you did from a standard work perspective to make sure you didn't have to throw away vaccine?
I think one of the things was kind of creating a schedule that was organized and knowing everybody. So we knew a particular vaccine and what their schedule. Then also doing some footwork later in the day to make some phone calls to people, to have folks on retainer, if you will. So if we end up with four doses, we wanted to have a number of people that we could call that they could come in and get a vaccine. And that didn't always work, but our staff oftentimes would be there one, two hours into the evening. Everybody really treated this vaccination as a… and I'm not aware of really any wasted doses because we couldn't get it into an arm early on. And I thought that was telltale of the dedication of our staff at these clinics that they went ahead and did that.
We ran into some issues with weather. I know we lost one dose because it froze on the way out to the vaccination. But those things were very, very minimum. And for the number of doses we've given, we still have very little waste within our system. But to answer the question about zero harm and zero waste, we had to transition over the last month to basically accept some collateral damage. So the state of Michigan gave a pretty clear message that we no longer wanted to turn people away if they wanted to get a vaccine. So we may have to sacrifice a couple doses to get somebody that wants the vaccination and get them that shot right at that time. And our staff, we really had to do a lot of teaching with them to let them know that at this point, along this evolution, we're okay in a little bit of waste. We have to accept that.
So yeah, that goal, yeah, there would be harm possibly then in delaying the dose is what you're talking about there. That makes sense.
We ran into that discussion a little bit too with, for example, with trying to figure out how to take care of some homebound patients that were brought to our awareness. You know, if we only have three and we have Pfizer with six doses. What's the decision there? So there's sometimes some conflict between zero harm and zero waste.
Yeah, I think the connection point, so one of the concepts that we leveraged was a standard shift huddle across our clinics. And so we knew what's the operations, who was working, which position, what was our goals for the day. And so that collaboration. So there might have been, you know, upwards in the Max Fax, almost 80 people sometimes working those clinics. And so the communication was a really core concept there and a standard that we shared across all of our Max Fax sites, which we ended up standing up about seven of those and making sure that there was that consistent communication and coordination of those vaccines. We also then would collaborate with the health departments on who could we call? We were very good at adhering to the state recommendations on who we should be vaccinating. And that was sometimes of a challenge. We were trying to get to first responders, we were trying to get to teachers. And then trying to find those onesie twosies at the end of the night was very difficult for our regional community health leaders. And really went above and beyond what they needed to do to accomplish and make sure that we didn't waste and that we were vaccinating individuals the best we could. So there was a lot of firefighting heroic efforts there, but that was really, I think, necessary to the vaccine administration process at this time or at that time.
And I imagine when you've got things that pop up and the need for firefighting is there, having a structure of huddles, having a foundation of psychological safety that helps people bring up these issues in a way that allows you to, if you can find a root cause and have things work more smoothly the next day, right?
Yeah, very much so. That was the learning. So if we needed to, we had a less escalation structure to be able to call our decision makers and our vaccine steering committee to be able to say, Hey, this is what we're facing. What can we do? Can we rally signal swarm and solve around this problem? Um, and then from there we would take that cascade. We would have twice a day also connection point huddles with our leaders that would pull information to us to be able to say, all right, here's where we're at. Here's what we need. How can you help us? And so we were that liaison to them to ensure that they had responses. And our time to decision from a response of a highlight of an issue was, I think pretty was, was pretty good. Um, so that, you know, we had that real time, so we didn't end up harming or wasting.
Um, one other thing I thought maybe we could chat about for a couple of minutes here, a different dimension to zero harm is seeing reports in the news, rare but non-zero occurrences in different countries of two types of errors of one, patients being injected mistakenly with saline only 'cause know the Pfizer vaccine, it comes in a vial, it gets diluted with an amount of saline, and then you're supposed to drop, like you said, five or if you can get six doses out. And then there's been a different error, a different failure mode where this happened, I think at least reportedly, most recently in Italy, where a patient was injected with an entire undiluted vial of Pfizer vaccines. So they got the equivalent of five doses. And, you know, unfortunately these articles, it's the headlines and the article, you see the blame language front and center of what I would describe as systemic problems if it's happening in all these different health systems, if it's happening more than once by different people. To me, that screams systemic issue, that nurses are accustomed to drawing up an entire vial. That there are different habits or the articles talk about people being fatigued or distracted. I'm like, well, that comes back to Caleb, what you brought up earlier, this idea of respect for humanity, of realizing whether we like it or not, people get distracted. We get fatigued. How do we design a good process that makes a, you know, either of those errors impossible. So I'm curious if you have thoughts or if your standard work addressed, you know, how do you minimize that risk of confusion of, has this been diluted or not yet? How do we make sure someone's actually drawing up from the diluted vaccine vial instead of drawing up from a saline vial? Was there standard work or error proofing that you had in place for that?
I can tell you, we did have multiple people, professions, but primarily pharmacists, working on the kind of the preparation of the vaccines, if you will, in a segregated area following standard work. So really for them it's kind of what they've been trained to do on a day-to-day basis. We use a lot of pharmacy technicians that essentially sterile compound for a living. So by following standard work, using professionals that this is really in their scope of day-to-day. In addition, in that segregated kind of quiet area, if you will, depending on where the vaccination clinic was at, I think really helped to to mitigate any potential errors.
Another piece was around scheduling. So we tried to minimize the amount of time that individuals work. So we tried to limit the amount of hours that they worked. So it was either two or four hour shifts and then, but that also leads to an opportunity of handoffs. So what does that look like? So ensuring that we have an onsite leader that is there to welcome and ensure that we know who they need to go to. You try to use visual management of our jackets of like, here's the leader, here's where this particular person is. Here's station one, station two, station three. And ensuring that if you did have an issue specifically in the cold too, we would try to only allow individuals to be out there for 30 minutes to and allow them come back in warmth so they can make sure that their fingers and get warm again to administer these vaccines. So we try to really deploy and really, again, I think it goes back to that respect to people of ensuring that we're taking care of them so they can take care of others.
So, yeah, I mean, what what you both described there, having a separate area helps prevent, minimize, or eliminate distraction. The shorter shifts help eliminate fatigue. So that's great to hear. You know, the vaccine sites that I had the chance to visit generally had what I would call as an engineer, maybe this is a little bit manufacturing language, a sub-assembly area where vaccines, syringes were being pre-filled and then delivered to the point of vaccination. Um, you could call it a feeder line or a feeder cell. And it seems like you could have good standardized work that's structured where if you have a handoff and think of a flow of somebody is maybe doing nothing but diluting the vials and then somebody is doing nothing but drawing from a diluted vial that you might eliminate some of the risk of confusion of like, what's the state of this vial or something being in the wrong place. And um, there's been debate within some other health systems where the nurses are drawing up their own syringes and like, for one, that that seems to be slower of the how many vaccines they can do per hour. And it also seems like it introduces more risk of distraction or falling out of process. So I've talked to some other health systems where they've had a lot of robust debate where the nurses were insistent that they drop their own vaccines and there were others lobbying that we should really have pharmacy or specialized area. Like what I saw at a site here in Texas that was jointly set up and run by the city of Frisco and Toyota, they were really heavily utilizing EMS. And so they had tables where you had EMS staff doing nothing but diluting and filling and prepping the syringes so then they could be delivered, ready to use. So, it's just interesting to hear how different organizations have sometimes had slightly different process designs to accomplish the same thing. More of a statement than a question. Sorry about that.
No, that's fine. But no, and you know, again, we had to make some adjustments, you know, down to ensuring that we had a small styrofoam cooler that we would make sure we had an, we had a plan, a process for how many we would draw up and then transport those outside because we try to have that consistency and temperature even if we were only walking maybe 50 yards. And to, to again, help build into that process of consistency and also safe handling of the vaccine, et cetera.
You know, and even something as simple as like a lot number that needs to be recorded using the same lot number at a clinic versus using multiple lot numbers just creates that potential for confusion and error. And it sounds pretty simple, but it could really slow a process down if if we didn't kind of pay attention to those types of things.
So maybe one last thing we can cover here is some of the continued evolution and the shifts that you've seen. So you described earlier, the vaccine just arrived. You didn't have the ability to order what you wanted or needed. And then we were in a situation of not having enough vaccine vaccine supply being the bottleneck. And now that has shifted. I was wondering if you could talk about those two shifts and any impact that that's had on your process.
You know, I could jump in because it's really, that's a very relevant question right now. And we've talked a lot about Munson's collaboration with our health departments in northern Michigan, and you know that that relationship is really paying benefits for what you're speaking to. Now we're running into situations where the health departments and Munson, we've got more vaccine than we're probably going to use in the foreseeable future. And we're looking at potential expiration dates for a lot of the vaccine that was shipped relatively recently. So we're looking at July where some of this is gonna start to expire. So now we're working closely across the health departments and within Munson to kind of create a tracking tool on that. So we are allowed to order directly from the state, but in our weekly meetings that we have with the health departments, we first talk about who's got what. And I'm kind of a gatekeeper of that at this point with regards to vaccine that we are gonna try to use regionally. So before we order from the state, we're gonna try to use what we have up here again to prevent zero waste. So there's different pockets of needs around the region and we're just gonna try to push and pull that vaccine to where it's needed to prevent any issues with expiration dates.
And so you're now, I mean, this is a more traditional pharmacy process where you place an order like you would for any other medication, right.
Exactly right. Um, you know, and it, we're only in in the state of Michigan two weeks into that at this point. So it's kind of relatively new for everybody and we're figuring it out as is the state. Now I'm hearing relatively soon that we'll be ordering directly from the manufacturers. That isn't in place yet in the state of Michigan, but I think the state's gonna try to get out of the vaccine distribution game at some point here relatively soon.
Sure. And that's two weeks ago, as of May 20th, that's the date we're recording this. Um, so Caleb, I, do you have some thoughts on kind of the shift of what Munson healthcare, what the community is doing? Now that there is in a lot of cases more vaccine than supply, than there are patients showing up, what are some of the other things being done to try to help address that bottleneck? The new bottleneck, if you will.
One of the things is really addressing vaccine hesitancy. And so our leadership team and our chief medical officer are really focused and our corporate communications team are really focused on helping the community understand and address the hesitancy that we're seeing out there. Our health departments are working to even schedule and send out surveys, what's going on, getting a pulse of the community. So we'll be hoping to receive some of that information this coming week from them and really trying to collaboratively address hesitancy. And then we heard this morning on a call in regards to the specific patient, new patient population that we're finding is that the allergy, the, so they're allergic to some elements of that. So how do we have real time vaccinations with those who go to an allergist to ensure that they can get vaccinated right then and there based off of the results from the testing. And so I think that those are some of the core things and then also working collaboratively. One of the things we're trying to establish here is is a basically a mobile vaccine clinic. And so most of our health departments are starting to do that, and we're starting to allow that for Munson Healthcare. We're starting to just do pop-up. We're just starting to get out to community events. We're really just trying to promote the availability, leveraging vaccine finders, making sure that we're promoting those opportunities to get vaccinated. So a lot of focus on vaccine hesitancy. And then these the patient populations that are now in a opportunity for us to to serve in a different way.
Well it's it's such important work they've been doing in general over time here related to continuous improvement in healthcare and even more meaningful I think during this era of COVID and a vaccination and helping get us on a path, a path out of this. So again, we've been joined today from Munson Healthcare, our two guests, Caleb Foss and Butch Bowlby. As we wrap up here, maybe I'll turn it over to each of you if you've got either just a final thought that you would want to share or a reflection on, maybe what you expect to happen with Lean at Munson Healthcare in the future. If either of those or something that you might wanna touch on to wrap up.
Yeah, I think in general, our focus over the next 12 to 18 months is on two particular systems, and that's goal setting, alignment, follow up, and accountability. Coming out of COVID-19 has been the focus of obviously every health system. And so what are we doing as an organization to respond to the change? How are we gonna change differently as an organization? You know, we have a lot of pent up demand, if you will, for projects that are trying to compete for our overall system resources. And so the biggest thing that we're trying to do is align and prioritize. And how are we filtering that down to our corporate services and other departments to make sure that we are have an opportunity to execute towards those goals as an organization. Other comment that I would make is that just reflect, I think that the biggest thing for us is we try to reflect, we try to continuously improve each and every day. Uh, there's an opportunity for improvement in every occasion. And I just thank you, Mark, for the opportunity to have the discussion alongside you today.
Yeah. Well, Caleb, thank you so much for taking time away from that work to share about the work. I really appreciate hearing the perspectives and what you've been doing there. Butch, do you have kinda a final thought to share.
You know, I do, and I, you know, one, just maybe a quick story. We pulled a number of recently retired pharmacists, kind of outta retirement to help with the with the vaccination process. And one of these individuals, Mike Tyberg, is a long time infectious disease kind of icon up here, if you will. And he's still involved in the process. In fact, I took my 15-year-old son in a couple days ago to the health department and Mike Tyberg is there giving shots and he and I talked a little bit about it as we seem to be winding down, but really re reflected that as a healthcare professional, the opportunity to work and really touch your community is a once in a lifetime opportunity. And you know, Mike's a guy that, you know, been doing this for a lot of years and really felt that, and I do as well. And I try to share that with everybody that we work with around here, that when this is all said and done, I really think we're gonna feel good about what we did for the public. And then, you know, just kind of as a follow up to my future here, I'm looking forward to working with Caleb and his organization to kind of get back to what is hopefully a post pandemic world and utilize those resources. Like I said, I'm new here, looking forward to creating a robust pharmacy program for Munson. And looking forward to the future here.
That's a great note to end it on. We are looking forward to the future and everything that, you know, a more, getting back to getting back to normal and the normal challenges. There are always challenges and lean and continuous improvement can help us address those. So Caleb and Butch, thank you again, thank you so much for sharing your perspectives and experiences. I think it's really, really interesting and hopefully really inspiring to others as well.
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