Book Review: On the Mend

While I am not a Lean Healthcare professional per say I am a Lean professional that has worked in various aspects of healthcare.  My experience varies from the patient floor, to the ER and OR, to long term care, to psychiatric ward and a few things in between.  Most of my family are healthcare professionals of some kind and I have been on both sides of care.  So when I had the opportunity to review On the Mend I jumped on it.

On the Mend, authored John Toussaint, MD and Roger A Gerard, PhD, is about the seven year Lean healthcare journey of the author's medical system Thedacare.  After some false starts with trying to improve clinical performance they went outside healthcare for an improvement strategy.  They studied the manufacturing industry and found Lean.  The Lean principles they learned had to be adapted to healthcare.

The first part of the book is about defining the principles that make up the lean healthcare process.  In summary they are:

The principles are presented with real life medical examples from the authors' Lean journey.  This creates a compelling reason to adapt these principles.   For instance, they relate the loss of time in healthcare to the loss of muscle, loss of brain, or even loss of life.

Focus on patients and design care around them.

Identify value for patient and get rid of everything else (waste).

Minimize time to treatment and through its course.

Continuous improvement of work practices every day in every area.

The second half of the book focuses on people aspect of Lean healthcare.  John and Roger introduce the leadership skills needed in a lean environment, how to engage Doctors in the process, how to create the problem solver culture, and how to develop future lean healthcare leaders.  The examples in this section are more personal in nature as you might expect. I particularly liked Roger's "communities of practice" where he describes the five stages of change: initiation, reality, resistance, compromise, and integration.

The book ends with a nine step action plan for starting lean initiatives in healthcare.  Based on the authors experience they recommend:

1. Identify the crisis.  What is the platform for change?
2. Create a Lean promotion office.  Critical for planning and managing change.
3. Find change agents.  They will help lean take root in your organization.
4. Map your value streams.  Understand the true patient experience.
5. Engage senior leaders early in strategy deployment.  Improvements must be focused on what is important.
6. Acquire and disperse knowledge broadly.  Learning and applying knowledge is necessary for everyone.
7. Teach a man to fish (or, become a mentor).   You need to create the leaders you want.
8. Involve suppliers in Lean.  Invite them to join in improvements and develop partnerships.
9. Restructure your organization into product families.  Design value from patients' perspective.

They conclude with this advice: Don't let anything stop you.  Trust the improvement process.

The real-life examples of patients' experiences with the Lean system make the book particularly compelling.  The book has plan that can be used to guide other healthcare organizations to sustainable improvement. They further prove this can be done without compromising the patient care; on the contrary it is improved.

The book is short, non-technical, and can easily be read in one day.  However, due to the subtle attention to detail you will find yourself re-reading it to truly get the most out of it. 

I definitely recommend this book to healthcare professionals and those practitioners associated with either the quality or upper management functions.

Lean Quote: Get it Right or Can't Get it Wrong

On Fridays I will post a Lean related Quote. Throughout our lifetimes many people touch our lives and leave us with words of wisdom. These can both be a source of new learning and also a point to pause and reflect upon lessons we have learned. Within Lean active learning is an important aspect on this journey because without learning we can not improve.

"Amateurs work until they get it right. Professionals work until they can't get it wrong." ~Author Unknown

This quote resounds of Lean Thinking.  One of the premises of Lean is to make it right the first time.  The truth is people make mistakes.

 In Lean organizations, mistakes are seen as opportunities to improve.  There is no blame game if something goes wrong.  People are not rewarded for how few mistakes they make, but on how well they improve the process when mistakes have occured.  Management bears the responsibility for creating effective systems that prevent mistakes.

To do this we need to understand the circumstances that led to the error.  The answer may be to evaluate standard work, make sure no steps are omitted, or to poka yoke (mistake proof) the process.  Don't make the mistake of believing every error requires a "device" to prevent recurrence.

The goal needs to be about making the work easier by thinking about the process as Taiichi Ohno says:

“Why not make the work easier and more interesting so that people do not have to sweat? The Toyota style is not to create results by working hard. It is a system that says there is no limit to people’s creativity. People don’t go to Toyota to ‘work’ they go there to ‘think’.”

Lean professionals continually work to prevent the opportunity for errors since quality is of utmost value to the customer.

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New Feature: Daily Lean Tips

For my Facebook fans you have probably already seen this. But for those of you that are not connected to A Lean Journey on Facebook or Twitter I started a new feature which I call Lean Tips.  It is meant to be advice, things I learned from experience, and some knowledge tidbits about Lean to help you along your journey.

Click this link for A Lean Journey's Facebook Page Notes Feed.

Here are the first 15 tips from the Facebook page:

Lean Tip #1 - 3 Knock Rule
Use the "3 Knock" rule if any team member deviates from the meeting agenda to improve meeting productivity. This is when a person politely knocks on the table to provide an audio indicator that the speaker is going off track of the agenda topic being discussed.

Lean Tip #2 - Stay Organized

Staying organized will save you time and money and allow you to focus on your tasks effectively thus increasing your personal productivity. Is Disorganization Holding You Back?

Lean Tip #3 - Use Checklists

Use checklists. Make and use checklists of daily tasks. This saves you time in two ways: you will work more efficiently with a checklist in front of you, and you will spend less time trying to remember what still needs to be done. Expert Advice for Getting Things Done

Lean Tip #4 - To Do List Tonight So You Can Start Tomorrow Productively

Write up tomorrow's to-do's before you leave the office today. I find that I can hit the ground running when I get into work the next day if I have a plan for the most important to-dos for day. Expert Advice for Getting Things Done

Lean Tip #5 - Overproduction: Too much, too early often leads to too little, too late
Overproduction is producing more, sooner or faster than is required by the next process. Ohno considered overproduction to be the most grievous form waste because it generates and hides other wastes, such as inventories, defects, and excess transport. 'Too much, too early' often leads to 'too little, too late' because of the cumulative nature of time.

Lean Tip #6 - Use informational measures not motivational measures.

Informational measures help you to decide what to do. But targets (motivational measures) are often associated with rewards, punishments and motivation. Targets thereby almost invariably encourage deviant behavior. Motivational measures frequently result in cheating, but informational measures can assist improvement.

Lean Tip #7 - Measure the Process, not the Person
Deming spoke about the 94/6 rule - 94% of problems can be traced to the process, but only 6% to the person. But often it is the person that is measured, not the process. Start with the assumption that it is the process that is broken and most times you will be right.

Lean Tip #8 - 3 Simple Questions all Managers Should Learn to Ask
All management should learn to ask these three simple questions: 1) What is the process? 2) How can you tell it is working? 3) What are you doing to improve it (if it is working)? Nothing sustains itself, certainly not Lean manufacturing or Lean management. So, establish and stick to a routine including regular visits to the Gemba, check the status of visual controls, follow-up on daily accountability assignments, and ask the three simple questions everywhere. Lean management is, as much as anything, a way of thinking. Three Simple Questions All Managers Should Ask

Lean Tip #9 - Learn to create a "Self" visual system in your workplace so you can "See".
The goal in Visual Factory is to create a "status at a glance" in the workplace. This refers to an operating environment where anyone can enter the workplace and: See the current situation (Self-explaining) See the work process (Self-ordering) See if you are ahead, behind or on schedule (Self-regulating) and See when there is an abnormality (Self-improving) You Won't Get Lean, Until You Get Visual

Lean Tip #10 - Standardize: All work shall be highly specified as to content, sequence, timing, and outcome
Lean Rule in Use #1: All work shall be highly specified as to content, sequence, timing, and outcome.
Ask these questions of your process: Is the work being performed to the written procedure? Is the outcome of the work known to be good when it's complete? Can the worker spot a problem and ask for help if one is found? If you can't answer "yes" with satisfaction then you need to focus on standard work.

Lean Tip #11 - Binary Communication: Direct, unambiguous customer-supplier communication
Lean Rule in Use #2 - Binary Communication Every customer-supplier connection must be direct, and there must be an unambiguous yes-or-no way to send requests and receive responses.
Ask these questions of your process: Is there a clear signal of when to produce/provide a product or service (and when not to) and in what quantity? Do the workers have a clear method to signal for help? Does the worker clearly know when help has been received? If you answer no then you need to revisit your visual management and signals.

Lean Tip #12 - The pathway for every product or service must be simple and direct

Lean Rule in Use #3: Simple and Direct Flow The pathway for every product and service must be simple and direct.
Ask these questions of your process: Do products and services follow one simple, direct flow path? Does a request for a product or service move directly from the requestor to the provider? If you answer no then you may want to try to Value Stream Map your process with the aim of reducing those wastes preventing flow.

Lean Tip #13: Continuous improvement must be done with the scientific method (PDCA)
Lean Rule in Use #4: Continuous Improvement Any improvement must be made in accordance with the scientific method, under the guidance of a teacher, at the lowest possible level in the organization.
Ask these questions of your process: Can the workers recognize problems and opportunities for improvement by themselves? Do they measure their own performance? Is there a structured method for problem solving that can be utilized by everyone in the organization? Do leaders teach scientific problem solving and coach the teams to develop their skills? This is truly the power behind sustaining Lean. If you have difficulty answering these questions with a resounding yes then sustaining is going to be difficult. Focus on the process and the people if you want to be successful.

Lean Tip #14 - Go and see for yourself and thoroughly understand the situation.

Solve problems by going to the source and seeing the problem personally. Always speak based on facts you have personally observed. A dramatic example of this is the Ohno circle.  Tachii Ohno the father of the Toyota Production System is known for his practice of painting a circle of the plant floor and having managers stand in that circle for hours at a time and to report back their observations.

Lean Tip #15 - The Operator is Your Most Important Resource
The Lean philosophy is that the operator, not the machine, is the most important asset. The machine serves the person, not the other way around. It is disrespectful to the individual to waste his or her value by waiting for the machine to complete its cycle. The Standardized Work Combination Table is used to gain an understanding of the man/machine relationship and to effectively utilize the human asset.

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The Emotion™ Roadmap: A Proactive Change Management Tool

In the last few months I have had the pleasure to get to know Shingo Prize Winning author Mark Hamel.  As it turns out Mark and I share a number of things in common like living near each other, working for the same past employer, members of the same fraternity (and that of Jamie Flinchbaugh), and of course a passion for Lean and blogging.  I have been reading Mark's award wining book Kaizen Event Fieldbook.  I will have a review of the book at a later date but wanted to share some thoughts on transformational leadership and the emotional scope of change.

Change is difficult and Kaizen events which are the necessary action of transforming an organization are no different. It is effective leadership which drives effective enterprises and effective transformation.  Mark says Lean transformational leadership encompasses four areas:

Technical scope (the hard "what")

Transformation leaders (the "who")

Emotional scope (the soft "what")

Transformational leadership model (the "how")

Change management is most effective when the approach recognizes the feelings of those who will be impacted by the change.

"To be successful in implementing change in a company requires leaders who recognize the emotional impact significant change creates among organizational members and who understand how to minimize resistance to change."

The role of emotions and how the Lean leader can react to problems are an important consideration for any change. Mark suggests the use of a proactive tool he created called the Emotion Roadmap™. This four branch model is applied by a set of questions based on four abilities:

	Abilities	Questions
Identify	Current feelings.  What is the situation and what are the current feelings.	Who are the key people involved? How is each key person feeling?
Use	Ideal feelings.  What feelings will most likely facilitate a successful outcome?	What feelings would be ideal for each key person?
Understand	Gaps.  Are the current feelings the ones you want or is there a gap between them and the ideal feelings?	Why are people feeling the way they do? How can we create the feelings we want?
Manage	Gap Closure.  Select a plan from the possible alternatives.  Execute the plan and modify as necessary.	What are we able to do? What are we willing to do to change the current feelings?

Every group, organization, and situation is different.  Leaders and followers in organizations naturally form emotional responses to proposed changes.  However, the Emotion Roadmap as part of the transformational leadership can be used as a guide to maximize the opportunity for successful change.  As you implement Lean and the necessary Kaizen or improvement events it is important to pay attention to the emotions involved.

If you enjoyed this compilation on the emotional side of Lean transformations then I would encourage you to consider reading Mark Hamel's Shingo Prize Winning Book, Kaizen Event Fieldbook. It is a practical reference guide for lean leaders and implementers leading a transformation in any industry.

Effective Information Visualization

With today's technology we are swimming in data.  But this data can be useless if we are not able to react to it.  Information needs to be displayed in an easy to interpret manner.  In a previous post I talked about the visualization techniques of Matthias Shapiro in terms of current events.  Now he walks us through the visualization techniques that can be used to figure out what a data set is trying to tell us.



When you are in the Gemba look at your visual information boards and consider the techniques in this video to see if your visualization is effective.  Ask the employees in the area what story the information tells.  If you get the answer you are looking for then it is effective.  If not change the way the inormation is displayed.

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Lean Quote: The Impossible is Untried

On Fridays I will post a Lean related Quote. Throughout our lifetimes many people touch our lives and leave us with words of wisdom. These can both be a source of new learning and also a point to pause and reflect upon lessons we have learned. Within Lean active learning is an important aspect on this journey because without learning we can not improve.

Feel free to share some of your favorites here as well.

"The impossible is often the untried." ~Jim Goodwin

Here is a short inspirational video to illustrate the point of this quote:

My Simple Advice:
Nothing is impossible.  If you never tried it then you would never know if it worked.  Every failure teaches you something if you are willing to learn from your mistakes. Those saying it can not be done should not interrupt those trying it.  Artificial roadblocks are wasteful and counterproductive. Keep trying.  Keep learning.

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Book Review: Clinical 5S for Healthcare

I recently had the opportunity to review the latest publication by ENNA called “Clinical 5S for Healthcare.” This book is authored by Akio Takahara, a leading expert on Lean Healthcare and 5S for the medical field.

The book opens by explaining one of the critical challenges that face hospitals is the chronic occurrence of accidents. Medical accidents are strongly related to the overall workplace environment of the hospital and misunderstandings by humans. The author defines “human error” as follows:

“Human error is essentially a human malfunction that occurs in the process of understanding, decision-making, and carrying out an action. Humans continue to suffer from such failures no matter how much attention is given to trying to not make any mistakes.”

Clinical 5S is the foundation for promoting medical safety and improving operational effectiveness. Implementing 5S allows you to:

Reduce human errors
Prevent patient accidents
Eliminate the waste of searching
Better utilize available work space
Increase patient and colleague satisfaction

The first half of the book explains the true meaning of, and practical methodologies for, 5S implementation. There are several chapters on the procedures and key points to implement 5S in a healthcare setting. Visual management is highlighted in the section on standardize as an effective way to maintain the previous S’s. I certainly agree with this assessment. Four important aspects of visual management are:

“Visualization” allows you to see the condition of work
“Clarification” helps us draw appropriate judgments
“Marking” allows us to identify items
“Sharing Rules” creates a sharing environment

The author claims that the rationale for failing to sustain can be classified by these four causes:

No rules to follow – Manager’s responsibility
Rules not understood – Frontline leader’s responsibility
Unreasonable rules – Manager’s responsibility
Unwillingness to follow rules – Your responsibility

I believe there is more to sustaining than rules but the author is right by saying sustaining is everyone’s responsibility. In my experience people will commit themselves when the reward to do it is greater than that of departing from it.

The second half of the book illustrates a series of case studies of actual 5S implementations that have taken place at Takeda General Hospital under Mr. Takahara’s direction. The best part of this section is the lessons learned from the experience of implementing 5S.

The book has nearly 100 illustrations and photos to help you understand Clinical 5S. However I found a number of the photographs to be hard to see in the black and white format. There are also a several templates in the back of the book used at Takeda General Hospital.

Clinical 5S provides a great introduction and overview of implementing 5S. Unfortunately, it misses the opportunity to present a comprehensive system of maintaining 5S after the initial year. Commitment doesn’t happen on its own. You must create the conditions to make sustaining possible. This generally includes: awareness, enough time, structured activities, management support, rewards and recognition, and employee excitement and satisfaction.

The element of continuously improvement seems to be lost in sustaining 5S. The process of sustaining is in part a review of the ideal state and the current state. This gap in the two states provides for more improvement. It is from this improvement that we convert from reactionary thinking to preventative thinking. Given the premise of the book is to use 5S as a philosophy to reduce errors it would have been beneficial to make this link.

Ultimately, I enjoyed this book and found it to be a practical guide to implementing 5S. Clinical 5S is obviously written for healthcare but certainly could apply to similar institutions. This book is a good place to start for healthcare professionals looking to reduce errors by making their workplace less susceptible to causing mistakes and confusion.