Guest Post: How Does Your Hospital Give Excellent Service?

For today's guest post I am happy to have my friend Brian Buck talk about Lean in Healthcare. Brian is an internal Lean consultant at a hospital in Washington State. He blogs at http://improvewithme.com and can be found on Twitter as http://twitter.com/brianbuck.


A frequent driver for Lean in hospitals is to improve clinical outcomes to make diagnoses and treatments safer and more predictable which drives down costs for all stakeholders. For hospitals to be competitive, they must also improve their service as well. Providing great medical care is not enough if the service is poor or inconsistent.

I recently spoke with an executive at the Lean Healthcare Transformation Summit who captured the typical patient experience fairly well. She said “Going to a hospital is like visiting a foreign country for patients and their families. Everybody speaks a different language. They can’t find their way around. They do not know anybody. The only thing that is recognizable is eating and going to the bathroom. With the food, we usually offer two choices that they would never pick on their own and then dictate what time they are to eat it. For the bathroom, we do not allow them to lock the door when they use it.”

There are some outstanding people who work in hospitals that provide great service and display a genuine care for the patients. The problem is this level of service is not consistent. A culture needs to be in place to ensure everybody in the hospital has an awareness of what the customer is experiencing so they can help them. Capacity needs to be created to ensure people are not overburdened which can negatively impact service.

A couple of years ago, a family member went to a local hospital and had service that was unacceptable to him. He frequently encountered nurses who either did not answer basic questions or took a very long time to respond. Doctors did not appear to talk to each other because of inconsistent messaging about the plan of care. Some people said he would be discharged on one day while others said it would be on a different day. He was already scared due to the medical condition, but the lack of service completely frustrated him and his wife. When he left after four days, his medical condition was taken care of but the service he received made him vow to never return there again.

Hospitals that pursue improvement to both clinical excellence and service excellence will attract more patients and retain those that need to return for other services. These kinds of improvements are critical for hospitals to survive.

Guest Lean Quote: Root Causes Should Make Solutions Clear

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.

This weeks Lean Quote is brought to you by my friend and fellow blogger Christian Paulsen. Christian helps companies optimize performance. He is a Lean – TPM facilitator and adds value to organizations by driving continuous process improvements and bottom line cost savings. Christian is a Consultant who brings 20 years of manufacturing leadership experience and Lean Manufacturing expertise. He authors Lean Leadership and is a regular contributor to the Consumer Goods blog.

"Determination of root causes should provide a clear and obvious understanding of the necessary solutions." — Jeffrey Liker and David Meier, The Toyota Way Field book

Proper analysis of an issue’s root causes could be the most crucial part of the problem solving process.

While this seems like an obvious statement, leaders and their teams fail to dig deep enough to find the root cause all too often. Others fail to follow-up on the countermeasures. These failures have consequences:

• Failure to identify root causes can lead to superficial solutions or Band-Aides that don’t work very long.  
• Erroneous root causes lead to ineffective ideas that don’t impact the issue at hand. 

Failure to follow-up on your countermeasures can lead to several issues as well. The countermeasures may not be working as intended or there could be unintended negative consequences. You could also be missing out on an opportunity to further improve your process if you don’t follow through in the spirit of Deming’s PDCA.

Finding the true root causes of an issue allows your team to identify true countermeasures that are in their control and are positively effective. Teams that are capable of identifying the true root causes of and issue are normally able to identify effective countermeasures for that issue.

Guest Post: It’s Better Than Stuffing Your Ears With Wax

I am pleased to present a guest post by Daniel Markovitz. Dan is president of TimeBack Management, a consulting firm specializing in the application of lean concepts to individual and group work.

He is a faculty member at the Lean Enterprise Institute and teaches at the Stanford University Continuing Studies Program. He also teaches a class on A3 thinking at the Ohio State University’s Fisher School of Business.

He is the author of the forthcoming book, A Factory of One, to be published by Productivity Press in late 2011.

You can reach him at dan@timebackmanagement.com or via Twitter @timeback.
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According to Greek legend, Odysseus plugged his sailors’ ears with wax and tied himself to the mast of his ship so that he could listen to the song of the Sirens. Sometimes I think we need a similarly drastic approach to email (and attention) management. However, given that you’d have a hard time explaining to the HR department and OSHA why you’re asking your staff to shove beeswax in their ears, I thought you’d appreciate what I’ve done.

Within the lean community, Tim McMahon, Jon Miller, and I have been publicly exploring ways in which we can use a kanban to help us make our knowledge work visible and better manage its flow. (Jon’s posts are here, Tim’s are here, and mine are here.) Recently, I deployed my kanban as armor against the dreaded incursion of reflexive email use. Tim and I have both preached long and loud about the evils of squandering your day processing email. But I, at least, sometimes have feet of clay, and end up spending more time in my inbox than is healthy.

The question is, could I make a visual cue to keep me from grazing at the email trough? This is what I came up with:

In this picture of my kanban, all of my work-related tasks are written on pink post-it notes. Nothing special there.

However, you’ll notice three yellow post-it notes in the “To Do” section of the kanban. These are my “email production” signals. There are only three of them, meaning that I can only go into my email inbox to read or write new messages three times during the day. There are no time constraints: I can use these kanban cards anytime during the day, and I can spend as much time as is reasonable processing mail. But I only get three cracks at it.

Although it may seem like a waste of motion, when I’m ready to go into mail, I move a post-it into the “Doing” column, and when I’m done, I move it into the “Done” column. That reduces the number of email kanban cards in the “To Do” section, which is a powerful visual signal about the limits I’m placing on email use.

This technique has been very effective in keeping me focused on key tasks and projects. It’s also easier than tying myself to a mast or putting wax in my colleagues’ ears.

Guest Post: Lean Sales and Marketing – Not without a new Toolset!

Joe Dager, owner of Business901 specializes in bringing the continuous improvement process to the sales and marketing arena. Joe has owned and operated companies involved in retail, manufacturing and professional services that include several turnarounds and growth companies. He has authored the books The Lean Marketing House, Marketing with A3 and Marketing with PDCA.


Think of all the changes and improvements in the manufacturing world in the last 20 years. We manufacture off floors cleaner than many tables that we eat off. You open a box, turn a key, or press a button and it works. Even the batteries are included! Most products manuals and operating instructions are never used. In fact, we seldom include them anymore. Our machines are so smart that they are completely intuitive to work for the entire population. Products have come a long way! More specifically quality has been an amazing success story and manufacturers have led the way.

What about sales and marketing? Is your sales and marketing that much better? Has it advanced at the same rate of improvement that your manufacturing has? Why not?

What are some of the improvement methods? In the marketplace, this is some of the good “marketing” ideas:

1. A recent blog headline summed said, Use Value-Added Sales to Boost Your Profit Margin. The blog post recommended extended warranties or guarantees, free shipping, consulting and more. I don’t know where value –added came into this. They are all delayed costs in my mind. I can go on but I felt the advice was like telling someone not to pay cash but put on your credit card. That way you don't have to pay for it, NOW!
2. Accelerate innovation and broaden our product line. We add more features and more products but seldom does that add or equate to more benefits that a customer wants. 
3. Create better websites, SEO, Social Media and send out more e-mails. There are so many things that we can do on the web that you need a marketing technologist, nice word for a geek to keep up. Many manufacturers are still struggling using the internet and more specifically social media in any other way besides a more sophisticated and sometime animated tool to deliver the old same marketing material, just in a little greener way. 

So I go back to my original question, do you think sales and marketing has improved at the same rate as manufacturing? If not, why not?

Most of us start our quality processes through the tool set of the methodology. I know that everyone likes to talk about Lean Culture and that tools are secondary and they are. But how many of us did not start there? The reason that sales and marketing has never become “Lean” is that they lack the proper tool set. I know the traditionalist Lean people will roll over with the comments forthcoming but bear with me.

With few exceptions, every time Lean is introduced to sales and marketing, it was through Value Stream Mapping with the sole purpose of removing waste in the process. Salespeople had every right to scream and ignore the conversation because all they were ever told to do was gather data. Than they were told what that data meant and as a result what they should stop doing. This resulted in neither an increase in sales nor an increase in value added time with the customer.

The toolset that is available is the one that has evolved from the Lean Software World of Agile and the world of Design Thinking. These worlds developed entirely from a different Lean format than the one found in U.S. manufacturing which is based on removing non-value added activities and waste. Lean Sales and Marketing needs to be based on customer value and PDCA (from a knowledge building platform). The funny thing is that both worlds of thought still reference the Toyota Production System and Lean Thinking by Womack and Jones as their basic guides.

The reason, I believe that these worlds are still so disconnected is how they think about customer value. Customer value cannot be an internal control point. It must be determined at the point of consumption. Only customer’s (customer defined as the user of the product) determine value and the non-customer when addressing markets. The funny thing is that Agile and Design Thinkers understand that value is not derived till the product is put into use and their efforts are not realized till that point. It puts an entirely different slant on looking at Lean and looking at the customer. Look at how the tools of Lean need to be presented to Sales and Marketing:

1. Don’t think Value Stream Mapping think Journey Mapping
2. Don’t think Future State think Concept Development
3. Don’t think Build and Deliver think Prototype and Test
4. Don’t think Product Benefits think Value in Use

If you want to bring sales and marketing into a continuous improvement mindset, change the tool set.

Related Posts:

The Role of PDCA in a Lean Sales and Marketing Cycle

Asking the right questions about Lean?

Where is the path in Continuous Improvement for Sales and Marketing?

Why does sales and marketing operate to a different quality standard?

Guest Post: Second Try at My Personal Kanban

Today I am pleased to share a guest post from my friend Matt Wrye who blogs at Beyond Lean. With Matt's 10+ years of lean implementation and problem solving experience, he is able to draw on his successes and failures to tackle new challenges by presenting fresh perspectives and results-driven solutions. Through his exposure to multiple business operation facets in divergent industries that include aluminum, electronics, auto, HVAC, and consumer goods, he is able to provide real-life lean solutions to everyday business challenges.
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His cornerstone belief is that all levels of the business unit should be educated on lean thinking and principles. To this point, Matt diligently challenges his own lean knowledge while working with all business levels ranging from human resources, accounting and the manufacturing floor to senior managers, executives and presidents. By adhering to this continuous learning philosophy, Matt is able to focus his lean efforts to provide continuous improvement.

Matt has a Bachelor of Science degree from Purdue University in Industrial Engineering. Among his other accomplishments, he is a certified Shainin Red X Journeyman and is certified in Statistical analysis and Kepner-Tregoe problem solving methodology. He is proud to have played a large and significant role in starting the Smith County Lean Consortium in Tyler, TX.
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As I look for ways to improve, I am inspired by other lean thinkers and bloggers. I see what they are trying and look to how that might work for me. I try and experiment with things in order to make my job easier and to feel more in control and organized. 

I decided to start a series that will be based on what I have tried in order to make my work better. It may be small or large things and most likely it was an inspiration I got from someone else. I hope that by passing along what I have learned that it may inspire others the way others have inspired me.

About three months ago, I posted a blog about my first attempt at a personal kanban. It was not successful at all. With some encouragement from fellow blogger Tim McMahon, I reflected more on why it didn't work and then learned more about how to apply personal kanban. "Personal Kanban" by Jim Benson and Tonianne Barry was a helpful resource for me.

At the end of my previous post, I talked about digitizing my kanban board. I almost fell prey to a common error.....looking for a technology solution when a process has not even been established. I was tempted by the dark side, but resisted. A digital format may be what I need in the future but first I must establish a process that works.

The second try at a personal kanban board has been very successful. Here is a picture of my board. It isn't very clear, but I think it will help with the discussion.

My value stream is Ready (my queue of work), Doing (what I am working on), Pen (items I have worked on but waiting for input), and Done. I have set my max for Doing and Pen at 3 items. I move items for Ready to Doing after I have moved all items from Doing to Done or Pen. This prevents one thing from sitting in the Doing column for a long time because I move the other two items and avoid the third.

Down in the bottom right-hand corner I have a color key. The color of the Post-It notes is related to a specific area of work.

Also, I have blog posts that I do weekly. It doesn't matter what day the posts are written but I would like to write 3 a week. It would get monotonous if I used Post-Its for writing three blog posts every week. Instead of using Post-Its, I put up three check boxes. I put a check after in th box after I finish a blog post. The section below it is a place I can put an idea for a blog post. When I want to write a post, I can grab one of the ideas from that section.
The board has helped me keep track of my work and made it visual to my boss all that I have going on. It has helped my boss understand where I am spending most of my time.

One of the keys is to choose the correct work chunk to put on a Post-It. Too small of a item is a quick to-do. An example of something too small would be to send an email or make a call. Too big of a chunk and nothing will ever move. XYZ Project would be too big. There is a middle ground. Breaking the XYZ Project into smaller chunks has helped me. Create charter for project. Study the current state of the process. Update action item list. These are examples of the middle ground that I have found.

I hope this helps others looking at trying a personal kanban. It isn't easy, but when it works it feels good and keeps the work flowing. Now I get to go check a box for blog posts!



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Vacation Brings A Collection of Exceptional Guest Posts

Over the next several days I will be on vacation taking some much needed time with my family.  Every year for the last 14 years we head to New Hampshire for several days to take in the NASCAR race.  It is a great time for sun, fun, camping, and high speed action.

I have been fortunate to arrange a great cast of guest bloggers while I am taking some time off.  Here is a quick preview of what is in store for you next week:

On Tuesday, Matt Wrye from Beyond Lean shares the next improvement of his personal kanban system.  This time he adds in weekly repetitive tasks into his board. 

Then on Wednesday, Joe Dager from Business901 talks about how the Lean tools used in manufacturing need to be presented in a different way when applying Lean thinking in sales and marketing. 

Thursday, Dan Markovitz from TimeBack Management shares a personal kanban system with a unique countermeasure for dealing with email throughout the day.  His solution aims to keep him as productive as possible.

On Friday, Christian Paulsen from Lean Leadership provides the Friday Lean Quote covering the important topic of root cause analysis.

On Monday, Brian Buck from Improve With Me writes about excellence in healthcare with the patients experience as the means to judge the quality of service.

Then on Tuesday, Christian Paulsen is back to elaborate on Deming's Plan-Do-Check-Act cycle from the root cause analysis discussion.

I will be back soon but not before learning a little about quick changeover from the NASCAR pit crews like that from this post last year - Lean in the Fast Lane.

“The winner ain't the one with the fastest car its the one who refuses to lose” - Dale Earnhardt, #3  - Lean Quote, June 25, 2010: Desire


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Lean Quote: Curiosity is More Valuable Than Skill

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.

"Our number-one value isn't in any of the skills we have. It's that we're essentially curious." — Jim Coudal

One of the most important benefits of being a curious person is that you will become very open-minded towards new ideas, interests and adventures. Being curious helps you to approach challenging tasks or problematic situations in a positive, curious way rather than steadily visualizing the associated fears towards a task.

By being curious, you will be:

• More open minded
• Increasing your awareness of the world around you
• Enhancing your chances of new experiences
• Learning new things
• Building your confidence
• Improving your job performance

So how can you be more curious?  The following 5 tips are a good place to start:

Question relentlessly. A sure way to dig deeper beneath the surface is asking questions: What is that? Why is it made that way? When was it made? Who invented it? Where does it come from? How does it work? What, why, when, who, where, and how are the best friends of curious people. Questions keep your mind engaged.

Keep an open mind. Be open to learn, unlearn, and relearn. Some things you know and believe might be wrong, and you should be prepared to accept this possibility and change your mind.
This is essential if you are to have a curious mind.

Don’t take things as granted. If you just accept the world as it is without trying to dig deeper, you will certainly lose curiosity. Never take things as granted. Try to dig deeper beneath the surface of what is around you.

Read books, blogs, etc. Reading new things is another way to feed your curiosity and develop it. Reading is a great way to continue learning as much as you can. You might like to focus on just one thing but you should be open to as many different topics and things as possible when it comes to reading. This can help you build your curiosity even further. 

Be enthusiastic! Enthusiasm will allow you to be by far more interested in a certain topic than without it. You can become enthusiastic by associating fun and joy with the tasks you have to perform, rather than expecting them to be a waste of time or irrelevant for you. 



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