“Jaded Julie, if you were going technical mountain or rock climbing out in the Rockies or down at Devil’s Lake, this is the advice that I would give you: ‘Climb on good rock, with good equipment, and with good people.’”
“That sounds like excellent advice, Curmudge, but why are you giving it and what does it have to do with health care?”
“If you are climbing, I want you to be protected against misfortunes that might befall you (no pun intended) that are no fault of your own. The same should hold true for health care. If I am experiencing anything from a simple injection to major surgery, I want it done according to an evidence-based protocol, and by a person who is well trained, has done the procedure hundreds of times, and is not distracted by the hospital surroundings or problems at home.”
“I’ve got it, Curmudge. It’s our job to protect our patients against errors just like it’s the climbing guide’s job to protect his clients against falls. In health care we’ve got to do it right the first time every time; in climbing the first false step may be a long way down.”
“We’ve already laid the foundation for our discussion and talked about the importance of having a culture that allows one to report errors safely. It’s time now to consider some specific threats to patient safety.”
“This ought to be old stuff to most everyone working in patient care. Is there really any value in our taking time to talk about this?”
“Consider this, Julie. Would you prefer to be cared for by someone who is completely up to date on safe practices or one who reads this blog and says, ‘I didn’t know about that.’? We want to get inside the head of anybody who is even the slightest bit uninformed.”
“Okay, Curmudge, let’s do it. Where do we start?”
“Let’s begin with AHRQ’s 20 Tips to Help Prevent Medical Errors (1). A medical error is when something planned as a part of medical care doesn’t work out, or when the wrong plan was used in the first place. Errors can involve medicines, surgery, diagnosis, equipment, or lab reports. Sometimes errors can occur when doctors and their patients have problems communicating. LucidMED (2) is an example of new technology that can reduce communication problems. The 20 tips cover such things as medicines, hospital stays, surgery, and other topics. AHRQ (Agency for Healthcare Research and Quality) says that the single best way a patient can help to prevent errors is to be an active member of his/her health care team.”
“That sounds like something that everyone should read. All that is required is a computer connected to the Web.”
“Here are some other topics that patients as well as caregivers should have in mind:
· Accurate patient identification
· Labeling and administration of medications
· Reconciled medications across the continuum of care
· Effective communication among caregivers
· Reduced health care-associated infections
· Reduced risks of patient injury from falls.”
“I presume that we’ll talk more about some of these in the coming weeks. But Curmudge, how can you, a retired chemist, hope to tell anyone in health care about patient safety?”
“It’s pretty simple, Julie. I read, write, and tell other people where to find the information. As long as I have your help, it’s an easy job even for a curmudgeon.”
Affinity’s Kaizen Curmudgeon
(1)http://www.ahrq.gov/consumer/20tips.htm
(2)http://www.lucidmed.com
Tuesday, December 30, 2008
Thursday, December 18, 2008
Holiday Greetings from Curmudge and Jaded Julie
“Julie, last year you really dumped on me when I wished our readers a Merry Christmas. I thought it was safe to use that greeting in any hospital with a name like St. Elizabeth, St. Mary’s, or St. Whatever.”
“Nope, Curmudge. These days one must be politically correct everywhere. So how are we going to handle our greetings in a way that is, as you would say it, innocuous?”
“Let’s try this. Major holidays, as celebrated by most religions, heritages, and ethnic groups, have several elements in common. Things like religious observances, festive meals, days off work, and family gatherings. Let’s consider family gatherings and focus our concerns and best wishes on those people who can’t attend. For those folks, any holiday must be a real bummer.”
“Great idea, Curmudge. People like nurses in the patient care units, physicians in the ED, and flight crews on airplanes.”
“My presumption is that the nurses and others will simply defer their family celebration until their shift is over. That may be an inconvenience, but the problem shouldn’t be insurmountable. Things will be much sadder for those who can’t just wait a few hours until their schedule allows them to be home.”
“Of course. Hospital inpatients and members of the military who are deployed in far-away lands. At least the patients will probably have family visits, and the service people will call home. It is certainly worse for the people on the streets who are homeless or whose home doesn’t want them. Also among the homeless are the survivors of earthquakes and civil wars. Then there are those whose physical or emotional state prevents their even remembering what home was, but it is unlikely that they will even be aware that a holiday is occurring.”
“That’s quite a list, Julie. What is celebratory to most people ranges from an inconvenience to abject misery for others.”
“What can we do, Curmudge? You initiated this topic; I hope you have some ideas.”
“Your mission Julie, if you choose to accept it, is to bring a bit of light to the dark side of the human condition. It’s hard to make much of an impact as an individual, although the Good Samaritan gained quite a reputation for his efforts. There are lots of charities—religious or secular and from local to international—who would love to have your financial support or service as a volunteer. Political correctness prevents my making a specific recommendation.”
“Good thought, Curmudge. I’ll put serving as a volunteer in my New Years resolutions. Maybe my efforts will help someone get home for his or her special holiday. If they can’t get home, perhaps they can feel more at home wherever they are.”
“You’ve got it, Julie. You’ve got the real Christmas…oops, holiday spirit.”
“Happy Holidays, Curmudge.”
“Merry Christmas, Julie.”
Affinity’s Kaizen Curmudgeon
“Nope, Curmudge. These days one must be politically correct everywhere. So how are we going to handle our greetings in a way that is, as you would say it, innocuous?”
“Let’s try this. Major holidays, as celebrated by most religions, heritages, and ethnic groups, have several elements in common. Things like religious observances, festive meals, days off work, and family gatherings. Let’s consider family gatherings and focus our concerns and best wishes on those people who can’t attend. For those folks, any holiday must be a real bummer.”
“Great idea, Curmudge. People like nurses in the patient care units, physicians in the ED, and flight crews on airplanes.”
“My presumption is that the nurses and others will simply defer their family celebration until their shift is over. That may be an inconvenience, but the problem shouldn’t be insurmountable. Things will be much sadder for those who can’t just wait a few hours until their schedule allows them to be home.”
“Of course. Hospital inpatients and members of the military who are deployed in far-away lands. At least the patients will probably have family visits, and the service people will call home. It is certainly worse for the people on the streets who are homeless or whose home doesn’t want them. Also among the homeless are the survivors of earthquakes and civil wars. Then there are those whose physical or emotional state prevents their even remembering what home was, but it is unlikely that they will even be aware that a holiday is occurring.”
“That’s quite a list, Julie. What is celebratory to most people ranges from an inconvenience to abject misery for others.”
“What can we do, Curmudge? You initiated this topic; I hope you have some ideas.”
“Your mission Julie, if you choose to accept it, is to bring a bit of light to the dark side of the human condition. It’s hard to make much of an impact as an individual, although the Good Samaritan gained quite a reputation for his efforts. There are lots of charities—religious or secular and from local to international—who would love to have your financial support or service as a volunteer. Political correctness prevents my making a specific recommendation.”
“Good thought, Curmudge. I’ll put serving as a volunteer in my New Years resolutions. Maybe my efforts will help someone get home for his or her special holiday. If they can’t get home, perhaps they can feel more at home wherever they are.”
“You’ve got it, Julie. You’ve got the real Christmas…oops, holiday spirit.”
“Happy Holidays, Curmudge.”
“Merry Christmas, Julie.”
Affinity’s Kaizen Curmudgeon
Thursday, December 11, 2008
Patient Safety Requires a Reporting Culture
“Let’s see, Curmudge, there’s a Lean Culture, a Safety Culture, a Just Culture, a Learning Culture, and even a culture we don’t want, a Punitive Culture. We’ve got more cultures than a microbiology lab.”
“Think of the Learning Culture as supporting the other cultures, Jaded Julie. All of the other ‘good’ cultures require us to learn continually how to make our activities safer and more effective and efficient. We must ‘routinely capture data on processes to discover how work really happens.’ This practice forms the basis of a ‘learning infrastructure that makes continual learning part of business as usual.’ (1) Without a Reporting Culture, the Learning Culture can’t function, and the other cultures are in jeopardy.”
“And in a hospital we need blame-free reporting so we can find and correct systemic problems—if that’s what they are—before they turn into something more serious.”
“Good point, Julie, and it’s well known in industry. Heinrich’s Law on Safety says that for every 330 industrial accidents, one may be serious. (2) Heinrich said that to avoid that one serious event, the minor and no-damage accidents should be reduced. Mark Graban teaches the same lesson using the Alcoa safety pyramid, in which there are 30,000 unsafe behaviors per 3,000 first-aid accidents or near misses for each fatality. (3) One cannot obtain these data or conduct an effective safety program without the organization’s having a reporting culture.”
“Golly, Curmudge, is this another instance—like Lean—where health care is lagging industry in finding better ways to do what needs to be done?”
“Regrettably true, Julie, but I think we are finally getting our act together. The University of Nebraska Medical Center has collected a lot of information, all on the same website, about engineering a reporting culture, a just culture, a flexible culture, and a learning culture. (4) Their PowerPoint presentation on Reporting Systems as the Foundation of Patient Safety Programs is especially informative. In it they quote Dr. Lucian Leape’s list of characteristics of successful reporting systems:
Nonpunitive
Confidential
Independent
Expert analysis
Timely
Systems-oriented
Responsive”
“Those headings look valuable. I’ll bet there’s good information behind them.”
“There is, Julie, but you’ll have to go to the web to read it. Remember that this is a blog and not a textbook.”
“Curmudge, I don’t want to wreck your day by bailing out now, so I’d better ask if there is any more info about a reporting culture that we need to mention.”
“One very import thing, and it’s from our friends at IHI. It’s an example of a non-punitive reporting policy from Wentworth-Douglass Hospital in Dover, New Hampshire (5) The document looks like an excellent model that captures much of what we have discussed about a just culture.”
“I can’t wait to read it. See you soon.”
Affinity’s Kaizen Curmudgeon
(1)http://www.ncbi.nlm.nih.gov/pubmed/18681298
(2) Imai, M. Gemba Kaizen. p. 274, McGraw-Hill 1997.
(3) Graban, M. Lean Hospitals. p. 133, CRC Press 2008.
(4)http://www.unmc.edu/rural/patient-safety/tools/Inventory.htm
(5)http://ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/Non-Punitive+Reporting+Policy+Wentworth+Douglass.htm
“Think of the Learning Culture as supporting the other cultures, Jaded Julie. All of the other ‘good’ cultures require us to learn continually how to make our activities safer and more effective and efficient. We must ‘routinely capture data on processes to discover how work really happens.’ This practice forms the basis of a ‘learning infrastructure that makes continual learning part of business as usual.’ (1) Without a Reporting Culture, the Learning Culture can’t function, and the other cultures are in jeopardy.”
“And in a hospital we need blame-free reporting so we can find and correct systemic problems—if that’s what they are—before they turn into something more serious.”
“Good point, Julie, and it’s well known in industry. Heinrich’s Law on Safety says that for every 330 industrial accidents, one may be serious. (2) Heinrich said that to avoid that one serious event, the minor and no-damage accidents should be reduced. Mark Graban teaches the same lesson using the Alcoa safety pyramid, in which there are 30,000 unsafe behaviors per 3,000 first-aid accidents or near misses for each fatality. (3) One cannot obtain these data or conduct an effective safety program without the organization’s having a reporting culture.”
“Golly, Curmudge, is this another instance—like Lean—where health care is lagging industry in finding better ways to do what needs to be done?”
“Regrettably true, Julie, but I think we are finally getting our act together. The University of Nebraska Medical Center has collected a lot of information, all on the same website, about engineering a reporting culture, a just culture, a flexible culture, and a learning culture. (4) Their PowerPoint presentation on Reporting Systems as the Foundation of Patient Safety Programs is especially informative. In it they quote Dr. Lucian Leape’s list of characteristics of successful reporting systems:
Nonpunitive
Confidential
Independent
Expert analysis
Timely
Systems-oriented
Responsive”
“Those headings look valuable. I’ll bet there’s good information behind them.”
“There is, Julie, but you’ll have to go to the web to read it. Remember that this is a blog and not a textbook.”
“Curmudge, I don’t want to wreck your day by bailing out now, so I’d better ask if there is any more info about a reporting culture that we need to mention.”
“One very import thing, and it’s from our friends at IHI. It’s an example of a non-punitive reporting policy from Wentworth-Douglass Hospital in Dover, New Hampshire (5) The document looks like an excellent model that captures much of what we have discussed about a just culture.”
“I can’t wait to read it. See you soon.”
Affinity’s Kaizen Curmudgeon
(1)http://www.ncbi.nlm.nih.gov/pubmed/18681298
(2) Imai, M. Gemba Kaizen. p. 274, McGraw-Hill 1997.
(3) Graban, M. Lean Hospitals. p. 133, CRC Press 2008.
(4)http://www.unmc.edu/rural/patient-safety/tools/Inventory.htm
(5)http://ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/Non-Punitive+Reporting+Policy+Wentworth+Douglass.htm
Thursday, December 4, 2008
Implementing a Culture of Safety
“Curmudge, I have the feeling that we’ve been here before.”
“We have, Jaded Julie. Same church but a different pew. We spent much of April and May of 2008 talking about change leadership. Our goal then was changing from an existing culture to a Lean culture. Now we want to change from a punitive culture to a just culture. Each type of change requires many of the same tools, starting with the dedicated and active support of the organization’s top management. As we said back in April, he or she should follow the guidance provided in John Kotter’s book, Change Leadership. Although one element of Kotter’s ‘Eight-Stage Process of Creating Major Change’ is to establish a sense of urgency, one shouldn’t wait for a sentinel event to initiate the change.”
“I just read Leanne Huminski’s ‘Eight Steps to Creating a Culture of Safety.’(1) Let’s list them and see how similar they are to Kotter’s. Note that the order of Huminski’s list has been changed to fit Kotter’s order.”
Huminski, 2008
· Develop a sense of urgency
· Involve leaders in the process
· Develop a vision
· Communicate the change vision
· Engage and empower the staff
· Realize it can’t happen overnight
· Test new ideas before full rollout
· Be alert for sabotage and workarounds
Kotter, 1996
· Establish a sense of urgency
· Create a guiding coalition
· Develop a vision and strategy
· Communicate the change vision
· Empower broad-based action
· Generate short-term wins
· Consolidate gains and produce more change
· Anchor new approaches in the culture
“It’s pretty clear, Julie, that Kotter’s recommendations apply to implementing all
sorts of changes, including a culture of safety. However, one must realize that if
an organization doesn’t develop a reporting culture, their culture of safety will never get off the ground.”
“Curmudge, two weeks ago you said that the ‘blame game,’ or hiding one’s errors, is the natural thing to do. I guess that means that reporting errors is unnatural. It should be evident to any mom that instilling a reporting culture is not too different from toilet training. People have to learn that doing the right thing often requires doing something that is not natural, just like when they were little kids. Remember? We discussed this back on May 8, 2008.”
“Of course I do. Error reporting is intimidating to employees just like the big porcelain toilet may be scary to a child. In both cases, they are fearful of being flushed.”
“I’ve got the solution, Curmudge. It’s trust. If the child trusts her mommy when she says that everything is okay, the problem should go away. And when employees trust their employer and their colleagues, error reporting should become less unnatural. Of course, mothers have a better reputation for trustworthiness than organizations.”
“That’s right, Julie. A reporting culture requires that trust exist among and between the organization’s people from the very top all the way to gemba. People must be able to trust that they will be treated fairly if they report an error. We’ll talk more about this next time. I trust you’ll be here.”
“I might bring the kids. They’ll learn how they help Mom teach about change.”
Affinity’s Kaizen Curmudgeon
(1)http://blog.hin.com/?p=391
“We have, Jaded Julie. Same church but a different pew. We spent much of April and May of 2008 talking about change leadership. Our goal then was changing from an existing culture to a Lean culture. Now we want to change from a punitive culture to a just culture. Each type of change requires many of the same tools, starting with the dedicated and active support of the organization’s top management. As we said back in April, he or she should follow the guidance provided in John Kotter’s book, Change Leadership. Although one element of Kotter’s ‘Eight-Stage Process of Creating Major Change’ is to establish a sense of urgency, one shouldn’t wait for a sentinel event to initiate the change.”
“I just read Leanne Huminski’s ‘Eight Steps to Creating a Culture of Safety.’(1) Let’s list them and see how similar they are to Kotter’s. Note that the order of Huminski’s list has been changed to fit Kotter’s order.”
Huminski, 2008
· Develop a sense of urgency
· Involve leaders in the process
· Develop a vision
· Communicate the change vision
· Engage and empower the staff
· Realize it can’t happen overnight
· Test new ideas before full rollout
· Be alert for sabotage and workarounds
Kotter, 1996
· Establish a sense of urgency
· Create a guiding coalition
· Develop a vision and strategy
· Communicate the change vision
· Empower broad-based action
· Generate short-term wins
· Consolidate gains and produce more change
· Anchor new approaches in the culture
“It’s pretty clear, Julie, that Kotter’s recommendations apply to implementing all
sorts of changes, including a culture of safety. However, one must realize that if
an organization doesn’t develop a reporting culture, their culture of safety will never get off the ground.”
“Curmudge, two weeks ago you said that the ‘blame game,’ or hiding one’s errors, is the natural thing to do. I guess that means that reporting errors is unnatural. It should be evident to any mom that instilling a reporting culture is not too different from toilet training. People have to learn that doing the right thing often requires doing something that is not natural, just like when they were little kids. Remember? We discussed this back on May 8, 2008.”
“Of course I do. Error reporting is intimidating to employees just like the big porcelain toilet may be scary to a child. In both cases, they are fearful of being flushed.”
“I’ve got the solution, Curmudge. It’s trust. If the child trusts her mommy when she says that everything is okay, the problem should go away. And when employees trust their employer and their colleagues, error reporting should become less unnatural. Of course, mothers have a better reputation for trustworthiness than organizations.”
“That’s right, Julie. A reporting culture requires that trust exist among and between the organization’s people from the very top all the way to gemba. People must be able to trust that they will be treated fairly if they report an error. We’ll talk more about this next time. I trust you’ll be here.”
“I might bring the kids. They’ll learn how they help Mom teach about change.”
Affinity’s Kaizen Curmudgeon
(1)http://blog.hin.com/?p=391
Friday, November 28, 2008
A Just Culture
“Curmudge, when one thinks about a ‘just culture’ as the opposite of a punitive culture, its meaning is pretty obvious; but I know that there’s a lot more that you intend to say about it.”
“That’s for sure, Jaded Julie. The ‘just culture’ approach to patient safety is so important that even screaming from the top of the parking ramp, ‘Read what I write!’ is not sufficient. We both must shout in unison, ‘Read what I write about!’ That means that this blog will only scratch the surface, and that one should read the publications referenced below.”
“Sounds like fun, Curmudge. I’d wear my high school cheerleading uniform, but it probably wouldn’t fit. Anyway, after we have finished screaming, maybe you can give me a more complete definition of ‘just culture’? And while you are at it, you might also tell me what this has to do with Lean.”
“As you know, Julie, a Lean culture is one in which we continuously learn to do our work better. In a just culture, we learn to do things more safely. Both are learning cultures. That is this blog’s raison d’être.”
“(’Raisin debt?’ Oh well, sometimes the Old Guy talks funny. I guess it’s a justification for the blog’s existence.) So what is a ‘just culture’?”
“A just culture is one ‘that is supportive of system safety by facilitating open communication within the organization, while working with a system of accountability that supports safe behavior choices among staff.’(1) In health care, this boils down to being able to safely report errors and near misses so that their root cause can be discovered and the system improved to avoid the error’s recurrence. But there is more to it than that; a culture that is free of blame is not necessarily a culture that is free of responsibility. We’ll talk more about that in a moment.”
“Here’s another question. Sometimes I see ‘Just Culture’ capitalized, and it’s not in a title. Is that different from ‘just culture’?”
“Good catch, Julie. The Just Culture Community was formed by representatives from high-risk industries like aviation and health care to control the hazards of human and organizational error. Their website, http://www.justculture.org, is moderated by the firm, Outcome Engineering. The site is an extremely valuable resource.”
“As I understand it, Just Culture classifies errors and the organization’s response to them in terms of personal responsibility. They use a tool called the Just Culture Algorithm.” (2)
“Now aren’t you glad, Julie, that we explained algorithms on October 23? In this algorithm, error-producing behaviors are classified as Human Error, At-Risk Behavior, and Reckless Behavior. Human Error reflects the fact that no one is perfect and that some errors are truly inadvertent. The appropriate organizational response is to console the person and to manage the system to minimize the risk that human errors will harm the patient.”
“I’ll bet that the other classifications are more serious. Right?”
“Right. At-Risk Behavior is unintentional risk-taking, such as taking a shortcut to get necessary work done on time. The organization needs to establish whether the employee had a good faith but mistaken belief that the violation was insignificant or justified. If so, the employee should be coached and the incentives for at-risk behavior removed.”
“And finally we get to a situation where punishment may be justified.”
“That’s called Reckless Behavior. In this case, the employee consciously disregarded a known substantial and unjustified risk. So if an investigation has established that there has been reckless behavior, punishment can occur in a just culture.”
“Well, it’s a relief to learn that there is a system out there in which the organization’s response is not totally dependent on how serious the error was.”
“There is a similar but less complex algorithm available from IHI; it’s called the Decision Tree for Determining Culpability of Unsafe Acts.(3) A critical element of this algorithm is the substitution test: ‘Would three other individuals with similar experience and in a similar situation and environment act in the same manner as the person being evaluated?’ It should be very helpful to an organization working toward a non-punitive approach to errors and patient safety.”
“Curmudge, I’ve had enough ‘raisin debt’ for one day. Will we continue the discussion next week?”
“We sure will, Julie. And bring your French dictionary.”
Affinity’s Kaizen Curmudgeon
(1)http://www.jutculture.org/faq.aspx
(2)http://www.mocps.org/resources/Marx%20Presentation%20Handouts%201.JC%201Day%20Training%20Slides%20PrintV2.pdf
(3)http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/Decision+Tree+for+Unsafe+Acts+Culpability.htm
“That’s for sure, Jaded Julie. The ‘just culture’ approach to patient safety is so important that even screaming from the top of the parking ramp, ‘Read what I write!’ is not sufficient. We both must shout in unison, ‘Read what I write about!’ That means that this blog will only scratch the surface, and that one should read the publications referenced below.”
“Sounds like fun, Curmudge. I’d wear my high school cheerleading uniform, but it probably wouldn’t fit. Anyway, after we have finished screaming, maybe you can give me a more complete definition of ‘just culture’? And while you are at it, you might also tell me what this has to do with Lean.”
“As you know, Julie, a Lean culture is one in which we continuously learn to do our work better. In a just culture, we learn to do things more safely. Both are learning cultures. That is this blog’s raison d’être.”
“(’Raisin debt?’ Oh well, sometimes the Old Guy talks funny. I guess it’s a justification for the blog’s existence.) So what is a ‘just culture’?”
“A just culture is one ‘that is supportive of system safety by facilitating open communication within the organization, while working with a system of accountability that supports safe behavior choices among staff.’(1) In health care, this boils down to being able to safely report errors and near misses so that their root cause can be discovered and the system improved to avoid the error’s recurrence. But there is more to it than that; a culture that is free of blame is not necessarily a culture that is free of responsibility. We’ll talk more about that in a moment.”
“Here’s another question. Sometimes I see ‘Just Culture’ capitalized, and it’s not in a title. Is that different from ‘just culture’?”
“Good catch, Julie. The Just Culture Community was formed by representatives from high-risk industries like aviation and health care to control the hazards of human and organizational error. Their website, http://www.justculture.org, is moderated by the firm, Outcome Engineering. The site is an extremely valuable resource.”
“As I understand it, Just Culture classifies errors and the organization’s response to them in terms of personal responsibility. They use a tool called the Just Culture Algorithm.” (2)
“Now aren’t you glad, Julie, that we explained algorithms on October 23? In this algorithm, error-producing behaviors are classified as Human Error, At-Risk Behavior, and Reckless Behavior. Human Error reflects the fact that no one is perfect and that some errors are truly inadvertent. The appropriate organizational response is to console the person and to manage the system to minimize the risk that human errors will harm the patient.”
“I’ll bet that the other classifications are more serious. Right?”
“Right. At-Risk Behavior is unintentional risk-taking, such as taking a shortcut to get necessary work done on time. The organization needs to establish whether the employee had a good faith but mistaken belief that the violation was insignificant or justified. If so, the employee should be coached and the incentives for at-risk behavior removed.”
“And finally we get to a situation where punishment may be justified.”
“That’s called Reckless Behavior. In this case, the employee consciously disregarded a known substantial and unjustified risk. So if an investigation has established that there has been reckless behavior, punishment can occur in a just culture.”
“Well, it’s a relief to learn that there is a system out there in which the organization’s response is not totally dependent on how serious the error was.”
“There is a similar but less complex algorithm available from IHI; it’s called the Decision Tree for Determining Culpability of Unsafe Acts.(3) A critical element of this algorithm is the substitution test: ‘Would three other individuals with similar experience and in a similar situation and environment act in the same manner as the person being evaluated?’ It should be very helpful to an organization working toward a non-punitive approach to errors and patient safety.”
“Curmudge, I’ve had enough ‘raisin debt’ for one day. Will we continue the discussion next week?”
“We sure will, Julie. And bring your French dictionary.”
Affinity’s Kaizen Curmudgeon
(1)http://www.jutculture.org/faq.aspx
(2)http://www.mocps.org/resources/Marx%20Presentation%20Handouts%201.JC%201Day%20Training%20Slides%20PrintV2.pdf
(3)http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/Decision+Tree+for+Unsafe+Acts+Culpability.htm
Thursday, November 20, 2008
Clashing Cultures in Patient Safety: the "Blame Game" vs. the "Just Culture"
“Jaded Julie, you look very stylish in your coveralls, hard hat, safety glasses, and steel-toed shoes. What’s the event?”
“Well, Curmudge, you said that we were going to lay a foundation, so I felt that I should wear the appropriate personal protective equipment.”
“The foundation will be for our discussion of patient safety, Julie, and our computer shouldn’t be much of a hazard. But I’m delighted that your heart is in the right place. Let’s begin with a quotation from Dr. Lucian Leape, a well known guru of patient safety, ‘The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.’(1) He seems to be saying that in a punitive culture, organizations try to punish people into not making mistakes.“(2)
“I presume that Dr. Leape is referring to the so-called ‘blame game’ in which every adverse event is considered a personal failure and triggers the ‘name, blame, and shame’ response. In that sort of atmosphere, it’s not surprising that people will hide any error that can be hidden. They’re not going to look for the root cause of the error, and it will probably happen again with a possibly more serious outcome.”
“Regrettably, Julie, in our society the ‘blame game’ seems like the natural thing to do. Professionals aren’t supposed to make mistakes, and it is assumed that when a mistake is made it’s because the person wasn’t good enough. Even the person making the mistake often feels that way. Our legal system compounds the problem with the threat of civil penalties (from malpractice suits) and in rare cases criminal penalties as well. It’s not surprising that if somebody makes a mistake, we either cover it up, refuse to admit it, or punish the person instead of asking, ’What gave rise to that mistake?’”(3)
“Curmudge, I have read that IHI uses a technique called the Global Trigger Tool to count mistakes. It’s used because only about 10 to 20 percent of errors are ever reported. Can you tell me more about it?”
“The Global Trigger Tool (4) uses retrospective reviews of randomly selected patient charts to locate and count adverse events (AEs). An AE is an injury or harm related to the delivery of care; it does not have to be the result of an error. A ‘near miss’ does not count because it, by definition, does not cause harm. Lists of ‘triggers’ are provided to serve as clues that an adverse event, from the viewpoint of the patient, has occurred.”
“This doesn’t sound much like Lean, Curmudge. Do you have an inexpert opinion?”
“You’re right as usual, Julie. Use of the trigger tool does not require a change of culture, identification of root cause, and use of the Deming cycle to develop countermeasures. Because it identifies AEs after the fact, there is no such thing as ‘stop the line.’ However, it does provide useful metrics to indicate if changes being made are improving the safety of care processes.”
“Okay, Curmudge. We have the metric, so how can we make the changes in patient care processes that it is going to measure?”
“The most effective change—yet the most difficult to achieve—is to abandon the punitive culture, i.e., the ‘blame game,’ and adopt the ‘just culture.’ We’ll start talking about that next week. I hope you’ll be here, Julie.”
“With bells on, Curmudge. I guess I won’t need the hard hat.”
Affinity’s Kaizen Curmudgeon
(1)http://www.mocps.org/resources/Marx%20Presentation%20Handouts%201.JC%201Day%20Training%20Slides%20PrintV2.pdf
(2)http://justculture.org Summer Edition, 2007
(3)http://www.webmm.ahrq.gov/perspectives.aspx November 2006. Conversation with Donald A. Norman
(4)http://ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/IHIGlobalTriggerToolforMeasuringAEs.htm
“Well, Curmudge, you said that we were going to lay a foundation, so I felt that I should wear the appropriate personal protective equipment.”
“The foundation will be for our discussion of patient safety, Julie, and our computer shouldn’t be much of a hazard. But I’m delighted that your heart is in the right place. Let’s begin with a quotation from Dr. Lucian Leape, a well known guru of patient safety, ‘The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.’(1) He seems to be saying that in a punitive culture, organizations try to punish people into not making mistakes.“(2)
“I presume that Dr. Leape is referring to the so-called ‘blame game’ in which every adverse event is considered a personal failure and triggers the ‘name, blame, and shame’ response. In that sort of atmosphere, it’s not surprising that people will hide any error that can be hidden. They’re not going to look for the root cause of the error, and it will probably happen again with a possibly more serious outcome.”
“Regrettably, Julie, in our society the ‘blame game’ seems like the natural thing to do. Professionals aren’t supposed to make mistakes, and it is assumed that when a mistake is made it’s because the person wasn’t good enough. Even the person making the mistake often feels that way. Our legal system compounds the problem with the threat of civil penalties (from malpractice suits) and in rare cases criminal penalties as well. It’s not surprising that if somebody makes a mistake, we either cover it up, refuse to admit it, or punish the person instead of asking, ’What gave rise to that mistake?’”(3)
“Curmudge, I have read that IHI uses a technique called the Global Trigger Tool to count mistakes. It’s used because only about 10 to 20 percent of errors are ever reported. Can you tell me more about it?”
“The Global Trigger Tool (4) uses retrospective reviews of randomly selected patient charts to locate and count adverse events (AEs). An AE is an injury or harm related to the delivery of care; it does not have to be the result of an error. A ‘near miss’ does not count because it, by definition, does not cause harm. Lists of ‘triggers’ are provided to serve as clues that an adverse event, from the viewpoint of the patient, has occurred.”
“This doesn’t sound much like Lean, Curmudge. Do you have an inexpert opinion?”
“You’re right as usual, Julie. Use of the trigger tool does not require a change of culture, identification of root cause, and use of the Deming cycle to develop countermeasures. Because it identifies AEs after the fact, there is no such thing as ‘stop the line.’ However, it does provide useful metrics to indicate if changes being made are improving the safety of care processes.”
“Okay, Curmudge. We have the metric, so how can we make the changes in patient care processes that it is going to measure?”
“The most effective change—yet the most difficult to achieve—is to abandon the punitive culture, i.e., the ‘blame game,’ and adopt the ‘just culture.’ We’ll start talking about that next week. I hope you’ll be here, Julie.”
“With bells on, Curmudge. I guess I won’t need the hard hat.”
Affinity’s Kaizen Curmudgeon
(1)http://www.mocps.org/resources/Marx%20Presentation%20Handouts%201.JC%201Day%20Training%20Slides%20PrintV2.pdf
(2)http://justculture.org Summer Edition, 2007
(3)http://www.webmm.ahrq.gov/perspectives.aspx November 2006. Conversation with Donald A. Norman
(4)http://ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/IHIGlobalTriggerToolforMeasuringAEs.htm
Thursday, November 13, 2008
Resources for Learning about Patient Safety
“Hey, Curmudge, where should I go to do a quick study on patient safety?”
“Right here.”
“No, no. If I couldn’t wait until we finished our discussions on the topic, where should I go?”
“As you know Jaded Julie, you can always start with Google; but you can save a few clicks by starting at http://www.ihi.org/IHI/Topics/PatientSafety/. You can peel the Institute for Healthcare Improvement website like an onion to dive more and more deeply into your topic of choice.”
“I suspect that there are other sites that you monitor, Curmudge.”
“Here are two more: (1) Morbidity and Mortality Rounds on the Web (http://www.webmm.ahrq.gov). Topics on this site are not nearly as ominous as they sound. Perspectives on Safety provides two full-text articles per month. (2) Patient Safety Network (http://psnet.ahrq.gov). One may access this site directly, via webmm, or as a free e-mail newsletter. The site’s archives may be browsed by safety target, approach to improving safety, error types, clinical area, target audience, and setting of care. One may also view their Patient Safety Classics, a collection of the most influential, frequently cited articles, books, and resources on patient safety.”
“And in addition…”
“In addition, I recommend that you play detective and follow leads on the net that look interesting. Don’t ignore the health care blogs that—unlike this one—are written by hands-on practitioners. There’s a ton of information out there.”
“Back to IHI, Curmudge. What’s on their Patient Safety menu? Is there a specialty of the house, or as you would say, a plat du jour?”
“We’ll talk about some examples later, Julie. It’s critical for you to know that all of the topics covered by IHI—not just Patient Safety—pertain to health care quality, and quality in health care is virtually synonymous with patient safety. So when you explore the IHI site, don’t limit yourself to Patient Safety. For example, last week we talked about standard work and reliability, and IHI was our principal resource.”
“So now can we discuss specific threats to patient safety?”
“Not so fast, Julie. This is a big topic, and there’s a lot of groundwork that we must do first. So wear your coveralls next week and be ready to build the foundation for our further discussions.”
Affinity’s Kaizen Curmudgeon
“Right here.”
“No, no. If I couldn’t wait until we finished our discussions on the topic, where should I go?”
“As you know Jaded Julie, you can always start with Google; but you can save a few clicks by starting at http://www.ihi.org/IHI/Topics/PatientSafety/. You can peel the Institute for Healthcare Improvement website like an onion to dive more and more deeply into your topic of choice.”
“I suspect that there are other sites that you monitor, Curmudge.”
“Here are two more: (1) Morbidity and Mortality Rounds on the Web (http://www.webmm.ahrq.gov). Topics on this site are not nearly as ominous as they sound. Perspectives on Safety provides two full-text articles per month. (2) Patient Safety Network (http://psnet.ahrq.gov). One may access this site directly, via webmm, or as a free e-mail newsletter. The site’s archives may be browsed by safety target, approach to improving safety, error types, clinical area, target audience, and setting of care. One may also view their Patient Safety Classics, a collection of the most influential, frequently cited articles, books, and resources on patient safety.”
“And in addition…”
“In addition, I recommend that you play detective and follow leads on the net that look interesting. Don’t ignore the health care blogs that—unlike this one—are written by hands-on practitioners. There’s a ton of information out there.”
“Back to IHI, Curmudge. What’s on their Patient Safety menu? Is there a specialty of the house, or as you would say, a plat du jour?”
“We’ll talk about some examples later, Julie. It’s critical for you to know that all of the topics covered by IHI—not just Patient Safety—pertain to health care quality, and quality in health care is virtually synonymous with patient safety. So when you explore the IHI site, don’t limit yourself to Patient Safety. For example, last week we talked about standard work and reliability, and IHI was our principal resource.”
“So now can we discuss specific threats to patient safety?”
“Not so fast, Julie. This is a big topic, and there’s a lot of groundwork that we must do first. So wear your coveralls next week and be ready to build the foundation for our further discussions.”
Affinity’s Kaizen Curmudgeon
Thursday, November 6, 2008
Reliability and Patient Safety
”Curmudge, if you could foresee that you would be run over by a giant turtle while you are jogging tonight, what words of wisdom about patient safety would you gasp with your final breath?”
“Turtle? Don’t you mean Beetle? There may still be a few that haven’t rusted away.”
“No, I really mean turtle. I know how slowly you jog. So, Speedy, what would be your final words?”
“Well, if you must know: ‘We must be serious about patient safety and do the right thing right the first time every time. That requires know-how, systems designed for safety, and a safety culture exhibited by everyone involved.’”
“Okay, Curmudge, let’s assume you survived your 22-minute mile unscathed and can discuss patient safety at your leisure. What’s our first topic?”
“Let’s start with the need to address patient safety. Regrettably, the story about Stan that I related last week is not a once-in-100-years event. Most patients approach a medical procedure with confidence in achieving a favorable outcome. An informed patient will approach the same procedure with trepidation. ‘In health care delivery, a defect—an error, omission, or other failure to accomplish an intended action—occurs, on average, 10 to 20 percent of the time, compared to 0.0001 percent of the time for airlines and nuclear power plants.’(1) It is evident that health care has a reliability problem.”
“Hey, that’s pretty scary, Curmudge. But how about this: The 100 thousand deaths per year in hospitals purported to result from medical errors would be equivalent to the lives lost in four jumbo jet crashes per week.(2) Maybe I should give those numbers to my hypochondriac mother-in-law. She’s afraid to fly, but she thinks a hospital is just like a hotel with room service providing all the meals.”
“Julie, the Institute for Healthcare Improvement (IHI) has developed a framework for improved reliability based on industrial principles of standardization.(3) It begins with protocols of care that are evidence based and widely agreed upon. As IHI says, ‘Standardization is crucial to improvement, because that’s what promotes reliability.’”
“I see now, Curmudge, why we talked about standard work a few weeks ago.”
“The IHI framework employs a three-tiered strategy:
· Prevent failure using guidelines, checklists, and other techniques for best-practice treatment of specific conditions.
· Identify and mitigate failure by using standing orders for best-practice treatments, warnings when an undesirable event is approaching, and independent double-checking of required actions.
· Redesign for success after root cause analysis of persistent failure reveals a flaw in the system design.”
“I presume that IHI’s ‘bundles’ that we discussed two weeks ago were a product of this effort. So we know the importance of standardization; what else must a hospital do to keep its patients safe?”
“Let’s continue this next week, Julie. We’ve got lots to talk about, so you’d better ask your husband to fix supper for the kids.”
“Sure…and supper will be potato chips and toasted Pop-Tarts.”
Affinity’s Kaizen Curmudgeon
(1)http://www.ihi.org/IHI/Topics/Reliability/ReliabilityGeneral/ImprovementStories/WhenGoodEnoughIsntGoodEnoughTheCaseforReliability.htm
(2)Karl, R.C., Staying Safe: Simple tools for safe surgery. Bulletin of the American College of Surgeons 92 (4):16-22 (April, 2007).
(3)http://www.ihi.org/IHI/Results/WhitePapers/ImprovingtheReliabilityofHealthCare.htm
“Turtle? Don’t you mean Beetle? There may still be a few that haven’t rusted away.”
“No, I really mean turtle. I know how slowly you jog. So, Speedy, what would be your final words?”
“Well, if you must know: ‘We must be serious about patient safety and do the right thing right the first time every time. That requires know-how, systems designed for safety, and a safety culture exhibited by everyone involved.’”
“Okay, Curmudge, let’s assume you survived your 22-minute mile unscathed and can discuss patient safety at your leisure. What’s our first topic?”
“Let’s start with the need to address patient safety. Regrettably, the story about Stan that I related last week is not a once-in-100-years event. Most patients approach a medical procedure with confidence in achieving a favorable outcome. An informed patient will approach the same procedure with trepidation. ‘In health care delivery, a defect—an error, omission, or other failure to accomplish an intended action—occurs, on average, 10 to 20 percent of the time, compared to 0.0001 percent of the time for airlines and nuclear power plants.’(1) It is evident that health care has a reliability problem.”
“Hey, that’s pretty scary, Curmudge. But how about this: The 100 thousand deaths per year in hospitals purported to result from medical errors would be equivalent to the lives lost in four jumbo jet crashes per week.(2) Maybe I should give those numbers to my hypochondriac mother-in-law. She’s afraid to fly, but she thinks a hospital is just like a hotel with room service providing all the meals.”
“Julie, the Institute for Healthcare Improvement (IHI) has developed a framework for improved reliability based on industrial principles of standardization.(3) It begins with protocols of care that are evidence based and widely agreed upon. As IHI says, ‘Standardization is crucial to improvement, because that’s what promotes reliability.’”
“I see now, Curmudge, why we talked about standard work a few weeks ago.”
“The IHI framework employs a three-tiered strategy:
· Prevent failure using guidelines, checklists, and other techniques for best-practice treatment of specific conditions.
· Identify and mitigate failure by using standing orders for best-practice treatments, warnings when an undesirable event is approaching, and independent double-checking of required actions.
· Redesign for success after root cause analysis of persistent failure reveals a flaw in the system design.”
“I presume that IHI’s ‘bundles’ that we discussed two weeks ago were a product of this effort. So we know the importance of standardization; what else must a hospital do to keep its patients safe?”
“Let’s continue this next week, Julie. We’ve got lots to talk about, so you’d better ask your husband to fix supper for the kids.”
“Sure…and supper will be potato chips and toasted Pop-Tarts.”
Affinity’s Kaizen Curmudgeon
(1)http://www.ihi.org/IHI/Topics/Reliability/ReliabilityGeneral/ImprovementStories/WhenGoodEnoughIsntGoodEnoughTheCaseforReliability.htm
(2)Karl, R.C., Staying Safe: Simple tools for safe surgery. Bulletin of the American College of Surgeons 92 (4):16-22 (April, 2007).
(3)http://www.ihi.org/IHI/Results/WhitePapers/ImprovingtheReliabilityofHealthCare.htm
Thursday, October 30, 2008
Stan's Story
“Who is this Stan fellow, Curmudge?”
“He is one of the reasons that we are going to talk about patient safety, Jaded Julie. Another reason is that we have recently been discussing standard work, and improved patient safety is one of the main benefits of standard work in a hospital.”
“I’m listening, Curmudge. Tell me about Stan.”
“Shortly after his retirement, Stan, a very close friend from my college days, suffered a stroke. While he was recovering in the hospital, he sustained a tragic fall that injured his brain much more than the stroke had. Stan, always a gentle giant, now cannot speak a coherent sentence. Although he is cared for by his devoted wife, this is not the way Stan planned to spend his ‘golden years.’
Here are some of the details as provided by Stan’s wife: Stan experienced a severe stroke early one evening a few years ago, and his wife rushed him to the hospital a few minutes away. She anticipated that Stan would be treated with thrombolytics within the ‘golden three hours.’ (However, I never did learn whether the stroke was ischemic or hemorrhagic.) Stan was first seen by a physician in the ED two hours after they had arrived; he apparently did nothing. At 2:00 a.m., a cardiologist appeared, and he pronounced that it was ‘too late’ for treatment with t-PA (or whatever). So Stan was admitted to the ICU.
While in the ICU, Stan fell and crushed the bones around one of his eyes. The eyeball was out of the socket, and 15 stitches were required to close the cut. After performing the necessary repairs, the physician checked the sight in Stan’s eye by holding up three fingers and asking Stan to count them. At that point, Stan was in no condition to count anything.
When Stan’s wife left the hospital the night of his fall, the rails of the bed were up and an alarm was in place. Stan’s condition would have prevented his lowering the rail by himself, and the alarm should have alerted the nurse had he done so. Yet the nurse in the ICU said that the rail was down when Stan fell (of course it was, but who lowered it?). Stan was her only patient. And so the risk management and legal issues began. Ultimately, Stan and his wife had to accept what they considered a very inadequate settlement from the hospital.
The final outcome is as I described at the beginning of our conversation. Stan’s wife is his constant caregiver. Stan recognizes me but not the names or anything about many of our close college friends. He can say ‘hello’ and ‘good-by,’ but his long sentences are quite incomprehensible. We try to see Stan and his wife whenever we visit the far away city where they live, but reminiscing about our college days is pretty difficult.”
“Curmudge, that is so sad. And it appears to have been preventable. I guess that explains why you are a patient safety zealot.”
“Julie, everyone should be a patient safety zealot, but it’s inevitable when tragedy strikes close to home.”
Affinity’s Kaizen Curmudgeon
“He is one of the reasons that we are going to talk about patient safety, Jaded Julie. Another reason is that we have recently been discussing standard work, and improved patient safety is one of the main benefits of standard work in a hospital.”
“I’m listening, Curmudge. Tell me about Stan.”
“Shortly after his retirement, Stan, a very close friend from my college days, suffered a stroke. While he was recovering in the hospital, he sustained a tragic fall that injured his brain much more than the stroke had. Stan, always a gentle giant, now cannot speak a coherent sentence. Although he is cared for by his devoted wife, this is not the way Stan planned to spend his ‘golden years.’
Here are some of the details as provided by Stan’s wife: Stan experienced a severe stroke early one evening a few years ago, and his wife rushed him to the hospital a few minutes away. She anticipated that Stan would be treated with thrombolytics within the ‘golden three hours.’ (However, I never did learn whether the stroke was ischemic or hemorrhagic.) Stan was first seen by a physician in the ED two hours after they had arrived; he apparently did nothing. At 2:00 a.m., a cardiologist appeared, and he pronounced that it was ‘too late’ for treatment with t-PA (or whatever). So Stan was admitted to the ICU.
While in the ICU, Stan fell and crushed the bones around one of his eyes. The eyeball was out of the socket, and 15 stitches were required to close the cut. After performing the necessary repairs, the physician checked the sight in Stan’s eye by holding up three fingers and asking Stan to count them. At that point, Stan was in no condition to count anything.
When Stan’s wife left the hospital the night of his fall, the rails of the bed were up and an alarm was in place. Stan’s condition would have prevented his lowering the rail by himself, and the alarm should have alerted the nurse had he done so. Yet the nurse in the ICU said that the rail was down when Stan fell (of course it was, but who lowered it?). Stan was her only patient. And so the risk management and legal issues began. Ultimately, Stan and his wife had to accept what they considered a very inadequate settlement from the hospital.
The final outcome is as I described at the beginning of our conversation. Stan’s wife is his constant caregiver. Stan recognizes me but not the names or anything about many of our close college friends. He can say ‘hello’ and ‘good-by,’ but his long sentences are quite incomprehensible. We try to see Stan and his wife whenever we visit the far away city where they live, but reminiscing about our college days is pretty difficult.”
“Curmudge, that is so sad. And it appears to have been preventable. I guess that explains why you are a patient safety zealot.”
“Julie, everyone should be a patient safety zealot, but it’s inevitable when tragedy strikes close to home.”
Affinity’s Kaizen Curmudgeon
Thursday, October 23, 2008
Documents and Standards
“Curmudge, if we define a standard loosely as something in writing that tells ‘how to do it,’ most hospitals have an overabundance of standards. (I could have said ‘plethora,’ but that would have been too sophisticated for me.—JJ)"
“That’s for sure, Jaded Julie. Those documents serve a useful purpose, but many don’t meet all of the criteria we have been discussing (established, documented, implemented, and maintained). Perhaps we can call these quasi standards. Things like guidelines, job aides, operating instructions for medical devices and instruments, and all sorts of different lists. Also, there are de facto standards such as evidence-based procedures, policies and procedures to demonstrate JCAHO compliance, algorithms, and bundles.”
“Whoa, Curmudge! I know you wrote about this stuff before I came on board, but I need some help understanding algorithms and bundles.”
“No problem, Julie. An algorithm is a step-by-step protocol, often in the form of a decision tree. Using a series of questions, it guides you to do the right thing based on the patient’s symptoms, test results, and responses. The questions are usually ‘yes/no’; a ‘yes’ answer sends you out one branch, and a ‘no’ sends you in a different direction.”
“And what about bundles?”
“The Institute for Healthcare Improvement (IHI) has been a strong proponent of bundles for several specific processes. A bundle consists of ‘a small, straightforward set of practices—generally three to five—that, when performed collectively and reliably, have been proven to improve patient outcomes.’* Each practice in the bundle is evidence-based, but they all must be used in order to achieve the bundle’s improved outcome. Bundles have been used to minimize central line blood stream infections and ventilator-associated pneumonia and to treat severe sepsis.”
“That’s a ‘bundle’ of information, Curmudge. So all of these kinds of documents can be made into standards?”
“Sometimes it’s just a matter of adding the ‘boilerplate’ (dates, authors, approvals, etc.) necessary to meet the hospital’s formatting requirements. In other cases, long policies and procedures must be broken up to make them user- and learner-friendly. For some institutions, the biggest challenge will be putting all of their standards in a searchable database.”
“This sounds like a lot of work, Curmudge. Where is the gain?”
“There’s no free lunch, Julie. We apply Lean to nursing to reduce waste, ambiguity, and workarounds, and to increase efficiency and patient safety. These require standard work and documentation. We are depending on the gains’ outweighing the work that went into developing the standards.”
“Curmudge, do you recall the nurses in Hôpital Nord 92 in France that we discussed a few weeks ago?”
“Of course I do. They prepared—and complied with—lists of the essential steps in several of their basic nursing processes. The authors of the paper considered it to be a major accomplishment.”
“Do you know, Curmudge, whether in France they have an accrediting body like our Joint Commission? If they don’t, the nurses in Nord 92 might have been starting at square one with their documentation.”
“I haven’t the foggiest, Julie, but I think I know what you are getting at. Because of regulatory requirements here in the U.S., we have documentation virtually ‘coming out of the woodwork.’ In France they may need to create documents, while our greatest need in the U.S. is to manage effectively the documentation that we already have.”
“So how are these documents to be managed?...Wait, Curmudge! I have the answer. The leaders teach the folks in gemba about Lean principles and guide them in the use of Lean tools. Like your favorite Peter Drucker quote, ‘It’s all about the people.’”
“Julie, I think you’ve got it.”
Affinity’s Kaizen Curmudgeon
*http://ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/WhatIsaBundle.htm
“That’s for sure, Jaded Julie. Those documents serve a useful purpose, but many don’t meet all of the criteria we have been discussing (established, documented, implemented, and maintained). Perhaps we can call these quasi standards. Things like guidelines, job aides, operating instructions for medical devices and instruments, and all sorts of different lists. Also, there are de facto standards such as evidence-based procedures, policies and procedures to demonstrate JCAHO compliance, algorithms, and bundles.”
“Whoa, Curmudge! I know you wrote about this stuff before I came on board, but I need some help understanding algorithms and bundles.”
“No problem, Julie. An algorithm is a step-by-step protocol, often in the form of a decision tree. Using a series of questions, it guides you to do the right thing based on the patient’s symptoms, test results, and responses. The questions are usually ‘yes/no’; a ‘yes’ answer sends you out one branch, and a ‘no’ sends you in a different direction.”
“And what about bundles?”
“The Institute for Healthcare Improvement (IHI) has been a strong proponent of bundles for several specific processes. A bundle consists of ‘a small, straightforward set of practices—generally three to five—that, when performed collectively and reliably, have been proven to improve patient outcomes.’* Each practice in the bundle is evidence-based, but they all must be used in order to achieve the bundle’s improved outcome. Bundles have been used to minimize central line blood stream infections and ventilator-associated pneumonia and to treat severe sepsis.”
“That’s a ‘bundle’ of information, Curmudge. So all of these kinds of documents can be made into standards?”
“Sometimes it’s just a matter of adding the ‘boilerplate’ (dates, authors, approvals, etc.) necessary to meet the hospital’s formatting requirements. In other cases, long policies and procedures must be broken up to make them user- and learner-friendly. For some institutions, the biggest challenge will be putting all of their standards in a searchable database.”
“This sounds like a lot of work, Curmudge. Where is the gain?”
“There’s no free lunch, Julie. We apply Lean to nursing to reduce waste, ambiguity, and workarounds, and to increase efficiency and patient safety. These require standard work and documentation. We are depending on the gains’ outweighing the work that went into developing the standards.”
“Curmudge, do you recall the nurses in Hôpital Nord 92 in France that we discussed a few weeks ago?”
“Of course I do. They prepared—and complied with—lists of the essential steps in several of their basic nursing processes. The authors of the paper considered it to be a major accomplishment.”
“Do you know, Curmudge, whether in France they have an accrediting body like our Joint Commission? If they don’t, the nurses in Nord 92 might have been starting at square one with their documentation.”
“I haven’t the foggiest, Julie, but I think I know what you are getting at. Because of regulatory requirements here in the U.S., we have documentation virtually ‘coming out of the woodwork.’ In France they may need to create documents, while our greatest need in the U.S. is to manage effectively the documentation that we already have.”
“So how are these documents to be managed?...Wait, Curmudge! I have the answer. The leaders teach the folks in gemba about Lean principles and guide them in the use of Lean tools. Like your favorite Peter Drucker quote, ‘It’s all about the people.’”
“Julie, I think you’ve got it.”
Affinity’s Kaizen Curmudgeon
*http://ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/WhatIsaBundle.htm
Thursday, October 16, 2008
More Work on Standard Work
“Curmudge, at the end of our conversation a week ago, my mind had become boggled by the magnitude of the whole standardization issue. To help me get my head on straight, please tell me where we are ‘at’ and why we are here.”
“Jaded Julie, Masaaki Imai has answered your ‘why are we here?’ question most clearly in his book, Gemba Kaizen: ‘Where there is no standard, there can be no improvement.’ If Generic General Hospital wants to improve—and especially to develop a Lean culture—they must have standards.”
“Now I recall where we stopped last time. We were talking about the requirements of documented procedures for standard work. We had discussed established and documented and were ready to tackle implemented, or as specified by JCAHO, accessible to nursing staff. These are the requirements for implemented: ‘All pertinent staff must be made aware of the procedure, trained in its use, and then use it. Training, proof of competency, and use of the procedure must be documented in appropriate records.’”
“The documentation requirements are pretty onerous; but if I were to be the subject of a procedure, I would want the nurse to be trained and able to demonstrate her competence. Another aspect of implemented is that standard work needs to be managed to assure compliance with the standard. However, as Mark Graban suggests in Lean Hospitals, the manager who observes a deviation should always ask ‘why?’ There may be a perfectly valid reason for the deviation, and it might lead to an improvement in the method. Another way to gain compliance with a standard method is for it to have been written by the people who use it. Compliance is undoubtedly proportional to one’s sense of ownership.”
“Curmudge, are you ready for the fourth requirement, maintained? This means that the procedure must be approved, reviewed on a defined schedule, and promptly revised when improvements are developed.”
“JCAHO requires review every three years, but that’s a long time for people to wait to learn about an improvement. If it’s difficult to create a standard and gain its approval, it’s probably going to be difficult to revise it. The hospital’s organization should facilitate rapid revision. One certainly doesn’t want a procedure to be done by a method that differs from an out-of-date standard, especially in front of an auditor. People should remember the old laboratory rule, ‘say (write) what you do, and do what you say.’”
“Curmudge, I surely hope that the people in Generic General Hospital know they don’t have to write all of their standards from scratch. They can adopt their standard work from lots of existing sources.”
“And that, Julie, is what we are going to talk about next week.”
Affinity’s Kaizen Curmudgeon
“Jaded Julie, Masaaki Imai has answered your ‘why are we here?’ question most clearly in his book, Gemba Kaizen: ‘Where there is no standard, there can be no improvement.’ If Generic General Hospital wants to improve—and especially to develop a Lean culture—they must have standards.”
“Now I recall where we stopped last time. We were talking about the requirements of documented procedures for standard work. We had discussed established and documented and were ready to tackle implemented, or as specified by JCAHO, accessible to nursing staff. These are the requirements for implemented: ‘All pertinent staff must be made aware of the procedure, trained in its use, and then use it. Training, proof of competency, and use of the procedure must be documented in appropriate records.’”
“The documentation requirements are pretty onerous; but if I were to be the subject of a procedure, I would want the nurse to be trained and able to demonstrate her competence. Another aspect of implemented is that standard work needs to be managed to assure compliance with the standard. However, as Mark Graban suggests in Lean Hospitals, the manager who observes a deviation should always ask ‘why?’ There may be a perfectly valid reason for the deviation, and it might lead to an improvement in the method. Another way to gain compliance with a standard method is for it to have been written by the people who use it. Compliance is undoubtedly proportional to one’s sense of ownership.”
“Curmudge, are you ready for the fourth requirement, maintained? This means that the procedure must be approved, reviewed on a defined schedule, and promptly revised when improvements are developed.”
“JCAHO requires review every three years, but that’s a long time for people to wait to learn about an improvement. If it’s difficult to create a standard and gain its approval, it’s probably going to be difficult to revise it. The hospital’s organization should facilitate rapid revision. One certainly doesn’t want a procedure to be done by a method that differs from an out-of-date standard, especially in front of an auditor. People should remember the old laboratory rule, ‘say (write) what you do, and do what you say.’”
“Curmudge, I surely hope that the people in Generic General Hospital know they don’t have to write all of their standards from scratch. They can adopt their standard work from lots of existing sources.”
“And that, Julie, is what we are going to talk about next week.”
Affinity’s Kaizen Curmudgeon
Thursday, October 9, 2008
Let's get to work on Standard Work.
“Curmudge, we’ve spent the past couple of weeks talking about problems that hospitals might have with non-standard work and how Lean should be the best source of countermeasures. Despite the fact that you don’t know diddly about running a hospital, is there any more guidance that we might share with the folks at Generic General?”
“At best, Jaded Julie, we might speculate on some of GenGen’s needs, but ways to satisfy those needs must be determined locally. That will require the combined insight of people from top management all the way down to gemba. To guide our thinking about the documented procedures necessary for standard work, let’s adopt ISO 9001’s definition: ‘…the procedure is established, documented, implemented, and maintained.’”
“I mentioned those criteria a couple of weeks ago, but we blew right by them. As I recall, Curmudge, you wrote about these two years ago, before you had my expert guidance.”
“Ah…right, Julie. In addition, here’s a requirement from JCAHO Standard NR.3.10 which should capture the attention of hospital people more firmly than ISO: ‘All nursing policies, procedures, and standards are defined, documented, and accessible to the nursing staff in written or electronic format.’ Notice how JCAHO’s wording correlates with ISO’s ‘established, documented, and implemented.’”
“Okay, now that we have done our homework, how are we going to apply this stuff to Generic General Hospital?”
“In my opinion, GenGen’s first need is to agree on the existence of a problem. Of course, this will require deliberation by a team representing management, information systems, the library, and all of the hospital’s affected gembas. If they can’t develop a consensus or path forward, they might as well break for lunch. My hope is that they will recognize that the issue of standard work and documentation is critical, especially if they have many of the problems that we discussed a couple of weeks ago. Then they should try to discern the most meaningful improvements that can be made before everybody in the room reaches retirement age.”
“If someone knows how another hospital solved these problems, GenGen just needs to steal and adapt the solution. But assuming there’s not a solution out there worth stealing, let’s go on to the first of the criteria of a procedure, established or defined. In health care this means that for every activity that is critical to a patient’s care and treatment, there must be a defined and accepted way of performing that activity. I presume, Curmudge, that you have thought about this one between naps.”
“Again, a representative team will be required. Because some procedures are so elementary and others are virtually all professional judgment, deciding what procedures should be standardized will not be easy. In addition, the team (or ad hoc sub-teams) will need to identify those steps that impact quality, outcome, and safety and as a result must be highly specified. Of course, the decision to simply adopt an evidence-based standard should be straightforward.”
“I presume, Curmudge, that administering an enema would be a good example of an elementary procedure. Most nurses learn that right out of Perry and Potter’s Clinical Nursing Skills & Techniques.”
“As long as they minimize patient discomfort, I don’t care where they learn it.”
“The next criterion is documented; that’s not going to be a slam-dunk either.”
“That’s for sure, Julie. But remember, GenGen has most likely had JCAHO surveys and found compliant with Standard NR.3.10, so they must have a documentation system acceptable to JCAHO. Generic General will undoubtedly try to use as much of their current documentation system as possible.”
“Curmudge, the problems in creating a unified system from a wide variety of documents in different media from all over the hospital seem mind-boggling.”
“I agree, Julie. The beauty of blogging is that when one’s mind becomes boggled, one can just log off the computer and continue the discussion next week. So that’s what we’ll do.”
Affinity’s Kaizen Curmudgeon
“At best, Jaded Julie, we might speculate on some of GenGen’s needs, but ways to satisfy those needs must be determined locally. That will require the combined insight of people from top management all the way down to gemba. To guide our thinking about the documented procedures necessary for standard work, let’s adopt ISO 9001’s definition: ‘…the procedure is established, documented, implemented, and maintained.’”
“I mentioned those criteria a couple of weeks ago, but we blew right by them. As I recall, Curmudge, you wrote about these two years ago, before you had my expert guidance.”
“Ah…right, Julie. In addition, here’s a requirement from JCAHO Standard NR.3.10 which should capture the attention of hospital people more firmly than ISO: ‘All nursing policies, procedures, and standards are defined, documented, and accessible to the nursing staff in written or electronic format.’ Notice how JCAHO’s wording correlates with ISO’s ‘established, documented, and implemented.’”
“Okay, now that we have done our homework, how are we going to apply this stuff to Generic General Hospital?”
“In my opinion, GenGen’s first need is to agree on the existence of a problem. Of course, this will require deliberation by a team representing management, information systems, the library, and all of the hospital’s affected gembas. If they can’t develop a consensus or path forward, they might as well break for lunch. My hope is that they will recognize that the issue of standard work and documentation is critical, especially if they have many of the problems that we discussed a couple of weeks ago. Then they should try to discern the most meaningful improvements that can be made before everybody in the room reaches retirement age.”
“If someone knows how another hospital solved these problems, GenGen just needs to steal and adapt the solution. But assuming there’s not a solution out there worth stealing, let’s go on to the first of the criteria of a procedure, established or defined. In health care this means that for every activity that is critical to a patient’s care and treatment, there must be a defined and accepted way of performing that activity. I presume, Curmudge, that you have thought about this one between naps.”
“Again, a representative team will be required. Because some procedures are so elementary and others are virtually all professional judgment, deciding what procedures should be standardized will not be easy. In addition, the team (or ad hoc sub-teams) will need to identify those steps that impact quality, outcome, and safety and as a result must be highly specified. Of course, the decision to simply adopt an evidence-based standard should be straightforward.”
“I presume, Curmudge, that administering an enema would be a good example of an elementary procedure. Most nurses learn that right out of Perry and Potter’s Clinical Nursing Skills & Techniques.”
“As long as they minimize patient discomfort, I don’t care where they learn it.”
“The next criterion is documented; that’s not going to be a slam-dunk either.”
“That’s for sure, Julie. But remember, GenGen has most likely had JCAHO surveys and found compliant with Standard NR.3.10, so they must have a documentation system acceptable to JCAHO. Generic General will undoubtedly try to use as much of their current documentation system as possible.”
“Curmudge, the problems in creating a unified system from a wide variety of documents in different media from all over the hospital seem mind-boggling.”
“I agree, Julie. The beauty of blogging is that when one’s mind becomes boggled, one can just log off the computer and continue the discussion next week. So that’s what we’ll do.”
Affinity’s Kaizen Curmudgeon
Thursday, October 2, 2008
Standard Work--Countermeasures
“So, Curmudge, after our discussion of obstacles last week, what solutions… countermeasures…did you come up with?”
“Lean.”
“Lean? That’s all? Just Lean? No details?”
“Details are above my pay grade.”
“Curmudge, everything is above your pay grade. You don’t even have a pay grade.”
“True, Jaded Julie. But I still think that’s a great default answer for a volunteer. So back to the problem at hand. Ultimately the folks at Generic General Hospital will need to develop a Lean culture, which as we know, includes continuous improvement of their processes. To improve a process it must be standardized, and to be standardized it must be documented.”
“I’ve got it, Curmudge. A Lean culture is the countermeasure for non-standardized work and documentation problems. So how do they acquire the Lean culture?”
“Julie, people can learn a Lean culture—and any other culture for that matter—by doing it until it is hardwired.”
“Of course, just as we have been discussing for the past year.”
“So GenGen needs to hire a sensei; train their Lean Team, their leaders, and the people in gemba; and get going on kaizen events. Their efforts will be prioritized according to corporate goals and strategies as developed via hoshin kanri planning. As hoshins are completed, leaders will realize that further progress is being held back by the lack of standard work and documentation. Hopefully, management will elevate standard work and documentation to the top of the priority list and develop organizational frameworks to support them. This should mitigate the obstacles we discussed last week.”
“Mark Graban suggests that the Lean technical tools will allow us to turn Lean philosophy and concepts into action. Might the reverse also be true? Could the repeated use of Lean tools help instill Lean philosophy and concepts in the people?”
“It may be defying the law of gravity, Julie, but perhaps Lean can pull itself up by the bootstraps. If that’s possible for an inanimate object like a computer, it should be feasible for a living concept like Lean.”
Affinity’s Kaizen Curmudgeon
“Lean.”
“Lean? That’s all? Just Lean? No details?”
“Details are above my pay grade.”
“Curmudge, everything is above your pay grade. You don’t even have a pay grade.”
“True, Jaded Julie. But I still think that’s a great default answer for a volunteer. So back to the problem at hand. Ultimately the folks at Generic General Hospital will need to develop a Lean culture, which as we know, includes continuous improvement of their processes. To improve a process it must be standardized, and to be standardized it must be documented.”
“I’ve got it, Curmudge. A Lean culture is the countermeasure for non-standardized work and documentation problems. So how do they acquire the Lean culture?”
“Julie, people can learn a Lean culture—and any other culture for that matter—by doing it until it is hardwired.”
“Of course, just as we have been discussing for the past year.”
“So GenGen needs to hire a sensei; train their Lean Team, their leaders, and the people in gemba; and get going on kaizen events. Their efforts will be prioritized according to corporate goals and strategies as developed via hoshin kanri planning. As hoshins are completed, leaders will realize that further progress is being held back by the lack of standard work and documentation. Hopefully, management will elevate standard work and documentation to the top of the priority list and develop organizational frameworks to support them. This should mitigate the obstacles we discussed last week.”
“Mark Graban suggests that the Lean technical tools will allow us to turn Lean philosophy and concepts into action. Might the reverse also be true? Could the repeated use of Lean tools help instill Lean philosophy and concepts in the people?”
“It may be defying the law of gravity, Julie, but perhaps Lean can pull itself up by the bootstraps. If that’s possible for an inanimate object like a computer, it should be feasible for a living concept like Lean.”
Affinity’s Kaizen Curmudgeon
Thursday, September 25, 2008
Standard Work—Obstacles and (A Few) Solutions
“Solutions to problems in standard work? Curmudge, you must be dreaming.”
“Solutions are ultimate goals that we’re unlikely to attain anytime soon, Jaded Julie; ‘countermeasures’ is a more realistic term. And as for dreaming, the Book of Acts says that’s what I’m supposed to be doing. ’Your young men shall see visions, and your old men shall dream dreams.’”
“Okay Old Man, wake up and tell me about standard work.”
“My off-the-top-of-my-head definition of standard work is ‘everybody doing the same work does it the same way.’ The ‘same way’ is, of course, the best way we know to do that job. The ‘way’ is described in a simple-as-possible document, readily available to all doing the job, which can be promptly revised when a better ‘way’ is found. However, I admit that my statement about everybody doing the same work the same way is probably too rigid for nurses in a hospital.”
“I agree, Curmudge. I’ve been reading your copy of Mark Graban’s Lean Hospitals, and he favors the term standardized rather than standard. Standardized implies that only those actions that impact quality, outcome, and patient safety need to be highly specified; adherence to other details in a procedure may be more flexible. Graban also regards standardized work to include consideration of what tasks are done by which people.”
“Another issue for nurses is professional judgment. There may be instances when a nurse might decide to overrule a standard and invoke her professional judgment in order to achieve a better outcome. And a related problem is that no one, especially a professional, likes to be told what to do. We should minimize that and help everyone gain a sense of ownership by having the people who do the work write—or at least approve—the standard.”
“Could this be a path forward, Curmudge? Just have the folks in gemba develop standards that are established, documented, implemented, and maintained, as you wrote a couple of years ago.”
“That’s the right idea, Julie, but doing it is not as easy as writing it. A hospital is a veritable black hole for efforts at standardization. As Graban states, ‘Trying to standardize all of our methods would seem like an overwhelming challenge.’ Let’s begin at the beginning and think about some of the obstacles to standardization that probably exist in most hospitals. Then, hopefully, we can devise ways by which they can be overcome.”
“Are we going to discuss our hospital, Curmudge?”
“I can’t, Julie. If I tried, I’d get at least half of the facts wrong. There are thousands of hospitals in the U.S. They range from those with Magnet status for nurses down to some that are a hazard to patients and a dead end for employees. Let’s pick one in the middle and call it Generic General or GenGen for short. In your long career you’ve probably worked in a place like GenGen and have seen a variety of standard work and documentation situations.”
“That’s for sure. My GenGen had more silos than the whole state of Wisconsin, and each one had its own methods and documents.”
“That sounds pretty tough for pool nurses who worked in several units.”
“Right. And some units’ methods were electronic—on a server somewhere—while others used hard copies in big loose-leaf notebooks. And believe it or not, some units depended on sticky notes and nurses with long memories.”
“It sounds as if ambiguity could have been rampant at Generic General. How did they train new nurses?”
“GenGen had dedicated mentors, but a lot of what they taught was by word-of-mouth. I believe you call those ‘oral traditions’.”
“’Oral traditions’ aren’t good, Julie, unless you are an aboriginal tribe somewhere in the jungle.”
“Finally, Curmudge, Generic General had a totally top-down organization. No one seemed to have thought about a nurse using professional judgment, although they probably did anyway. New procedures were written by someone in an office, and it was hard for nurses to change things. If they did, only nurses in their own unit found out about it. There was no way for others in the hospital to learn about the improvements that were made.”
“There’s no question, Julie, that any hospital resembling Generic General has a bedpan full of problems.”
“So what solutions…er, countermeasures…do you propose?”
“None, Julie. I haven’t thought of them yet. You’ll have to wait until next week.”
“Next week! Curmudge, you’ll have to conjure up some visions in a hurry, unless of course you plan to spend the week dreaming.”
“Don’t worry. They will be visions; they keep me young.”
Affinity’s Kaizen Curmudgeon
“Solutions are ultimate goals that we’re unlikely to attain anytime soon, Jaded Julie; ‘countermeasures’ is a more realistic term. And as for dreaming, the Book of Acts says that’s what I’m supposed to be doing. ’Your young men shall see visions, and your old men shall dream dreams.’”
“Okay Old Man, wake up and tell me about standard work.”
“My off-the-top-of-my-head definition of standard work is ‘everybody doing the same work does it the same way.’ The ‘same way’ is, of course, the best way we know to do that job. The ‘way’ is described in a simple-as-possible document, readily available to all doing the job, which can be promptly revised when a better ‘way’ is found. However, I admit that my statement about everybody doing the same work the same way is probably too rigid for nurses in a hospital.”
“I agree, Curmudge. I’ve been reading your copy of Mark Graban’s Lean Hospitals, and he favors the term standardized rather than standard. Standardized implies that only those actions that impact quality, outcome, and patient safety need to be highly specified; adherence to other details in a procedure may be more flexible. Graban also regards standardized work to include consideration of what tasks are done by which people.”
“Another issue for nurses is professional judgment. There may be instances when a nurse might decide to overrule a standard and invoke her professional judgment in order to achieve a better outcome. And a related problem is that no one, especially a professional, likes to be told what to do. We should minimize that and help everyone gain a sense of ownership by having the people who do the work write—or at least approve—the standard.”
“Could this be a path forward, Curmudge? Just have the folks in gemba develop standards that are established, documented, implemented, and maintained, as you wrote a couple of years ago.”
“That’s the right idea, Julie, but doing it is not as easy as writing it. A hospital is a veritable black hole for efforts at standardization. As Graban states, ‘Trying to standardize all of our methods would seem like an overwhelming challenge.’ Let’s begin at the beginning and think about some of the obstacles to standardization that probably exist in most hospitals. Then, hopefully, we can devise ways by which they can be overcome.”
“Are we going to discuss our hospital, Curmudge?”
“I can’t, Julie. If I tried, I’d get at least half of the facts wrong. There are thousands of hospitals in the U.S. They range from those with Magnet status for nurses down to some that are a hazard to patients and a dead end for employees. Let’s pick one in the middle and call it Generic General or GenGen for short. In your long career you’ve probably worked in a place like GenGen and have seen a variety of standard work and documentation situations.”
“That’s for sure. My GenGen had more silos than the whole state of Wisconsin, and each one had its own methods and documents.”
“That sounds pretty tough for pool nurses who worked in several units.”
“Right. And some units’ methods were electronic—on a server somewhere—while others used hard copies in big loose-leaf notebooks. And believe it or not, some units depended on sticky notes and nurses with long memories.”
“It sounds as if ambiguity could have been rampant at Generic General. How did they train new nurses?”
“GenGen had dedicated mentors, but a lot of what they taught was by word-of-mouth. I believe you call those ‘oral traditions’.”
“’Oral traditions’ aren’t good, Julie, unless you are an aboriginal tribe somewhere in the jungle.”
“Finally, Curmudge, Generic General had a totally top-down organization. No one seemed to have thought about a nurse using professional judgment, although they probably did anyway. New procedures were written by someone in an office, and it was hard for nurses to change things. If they did, only nurses in their own unit found out about it. There was no way for others in the hospital to learn about the improvements that were made.”
“There’s no question, Julie, that any hospital resembling Generic General has a bedpan full of problems.”
“So what solutions…er, countermeasures…do you propose?”
“None, Julie. I haven’t thought of them yet. You’ll have to wait until next week.”
“Next week! Curmudge, you’ll have to conjure up some visions in a hurry, unless of course you plan to spend the week dreaming.”
“Don’t worry. They will be visions; they keep me young.”
Affinity’s Kaizen Curmudgeon
Friday, September 19, 2008
More Problem Solving
“I liked A3 Problem Solving, Curmudge, but it was a bit of a stretch to envision all of that information on an 11- by 17-inch piece of paper. Are we going to cover all of the problem-solving techniques used in Lean in that much detail? My brain is filled up.”
“No way, Jaded Julie. I recall several years ago when President Ronald Reagan said, ‘If I have to learn any more names, I’m going to forget some that I already know.’ I don’t want you to forget the really important stuff that we have already covered. Besides, one can google most of the common problem-solving tools and find good discussions of them in Wikipedia. We’ll discuss only those topics that are the most important, the most fun to write about, and those that don’t require us to squeeze a lot of figures into the blog.”
“Okay, Curmudge, but why shouldn’t everyone ignore the blog and just google everything?”
“Hey, you’re pretty negative today. The answer is that Curmudgeon gives readers an old guy, a feisty nurse, your couch-potato husband, and health care examples. If no one were to read Curmudgeon, we’d be unemployed.”
“You’re already unemployed, Curmudge. So what other than idle chit-chat are we going to do today?”
“Let’s begin by listing some of the common problem-solving tools and how they might be used. We most likely won’t devote further blog space to these:
Bar chart—A chart with rectangular bars of lengths proportional to the value that they represent. Used to summarize attribute (categorical or discrete) data. Improves the data’s visual impact.
Histogram—A bar chart showing the frequency distribution of quantitative values with the values, not time, on the x-axis. A common example is the number of students (y-axis) who achieved test scores within certain intervals [e.g., 61-70, 71-80, 81-90, 91-100] (x-axis). This is the basis for the familiar academic practice of ‘grading on a curve.’
Pareto chart—A special type of bar chart where the values being plotted are arranged in descending order. Use this for displaying the probable reasons for an unfavorable outcome, such as poor patient satisfaction scores. Tackle the reason with the tallest bar first.
Fishbone (Ishikawa or cause-and-effect) diagram—A diagram that shows the possible causes of a certain event. Use this to visualize the many possible factors contributing to a problem. Data are often organized into six categories: material, assessment, people, method, equipment, and environment.
Scatter diagram—A graph of pairs of numerical data, with one variable on each axis, to look for a relationship between them. Data grouped closely about a line suggest that the variables are related. Of course, this does not prove that the relationship is cause-and-effect.
Run chart—A line graph showing values (y-axis) plotted against time (x-axis). Can be used for most any data collected in time-order sequence.
Control chart—A run chart with control limits to differentiate between common cause variation and special cause variation (signifying a problem). Seeks to determine if a sequence of data can be used to predict the future. Sometimes used to look back in time to demonstrate compliance with a standard.”
“Curmudge, I’m not really turned on by variables and axes. But if I really need to use some of these tools, is there someplace on our intranet where an Affinity employee can go for more information?”
“Sure thing, Julie. From the home page, click on the Affinity Learning Center, then Lean, Lean Tools, and finally Problem Solving. In addition, templates for many of the tools are in the right bucket (margin). Finally, there was a course presented at Affinity ten years ago called Sailin’ Thru Statistics; many Affinity veterans should have a copy of the course notebook that you might borrow.”
“It looks to me as if the techniques you listed are more for finding problems than for solving them.”
“You’re right, Julie, but identifying the problem is pretty important. That’s the reason we introduced The Five Whys and root cause analysis last January. As Albert Einstein said, ‘The formulation of a problem is often more essential than its solution.’”
“Thanks for the info, Curmudge. So what are we going to talk about next week?”
“Next week I hope we can talk about standard work.”
“You hope! Don’t you know for sure?”
“Julie, a senior citizen can never say ‘for sure’ when looking into the future. That’s why I have to pre-pay when I order a three-minute egg.”
Affinity’s Kaizen Curmudgeon
Thursday, September 11, 2008
A3 Problem Solving
“As I see it, Curmudge, an A3 report is an excellent tool for today’s workers in gemba to use in problem solving. It’s concise and thus consistent with modern reading habits, and it’s visual, which should help people who grew up in front of a TV set. Is that how you grew up?”
“Not quite, Jaded Julie. My first TV-watching experience was when I was a teenager. I was tossed out of a bar while trying to watch the World Series (1950?) on the only TV set in town. But I am fairly good at visualizing. One had to be in order to ‘watch’ The Lone Ranger on the radio.”
“You promised last week that we’d probe more deeply into A3 problem solving. Shall we do it?”
“Without delay. A3 problem solving acquired its name from the use of an A3 report for its planning and communication. As we learned, the medium of the A3 report is a single sheet of A3 (11 by 17-inch) paper. The report flows from top to bottom on the left-hand side of the paper, then top to bottom on the right side.”
“Because Blogger software doesn’t seem to like sketches, Curmudge, it looks as if you are going to have to use 1000 words in place of one picture. Our goal of achieving simplicity is defeated before we even start.”
“Unfortunately true, Julie. But perhaps we can reach our objective of piquing someone’s interest in A3 reports enough to steer them toward the work of Cindy Jimmerson that we’ll reference below. So let’s proceed. At the top left of the A3 sheet is the Issue Statement, usually as seen through the eyes of the patient. Below that is the Background, which helps us understand why the issue is important.”
“My kids would like the next part, a sketch of the Current Condition. We draw storm clouds for problems and icons for people like in value stream mapping. I guess that’s why we studied VSM a couple of weeks ago.”
“Right, Julie. But we must draw with a pencil so it’s easy to erase and make changes. The value of the sketch is that it inspires everyone’s thinking—the members of the team as well as the person with the pencil in his/her hand. We need to remember to KISS visually.”
“That might be considered suggestive spoken by most anyone else, but not by you, Curmudge.”
“At the bottom of the left half of the A3 is the Problem Analysis. We want to identify the problems signified by the sketch’s storm clouds and use the 5 Whys to find their root cause. What is learned here will help determine whether we have discovered too many problems for a single A3.”
“We are back to sketching again at the top of the right side of the A3. Here we want to show the Target Condition. This will be a graphic—again drawn with a pencil—that shows the process with problems, workarounds, and re-work eliminated. As Jimmerson states, this will illustrate ‘a new way to work that is closer to ideal.’ See, Curmudge, I’ve been reading the stuff that you recommend.”
“Countermeasures are listed in the next step down the page. These are the changes needed to get from the current condition to the target condition. One might call these ‘solutions’ if they produced the ideal result. But ‘countermeasures’ are more consistent with the Lean concept of achieving incremental improvements. Then comes the Implementation Plan, or how we are going to make the countermeasures occur. Sometimes the activities are shown in a matrix describing who, what, when, and the anticipated outcome.”
“I remember, Curmudge. We talked about a matrix a year ago—on September 25, 2007.”
“We’re almost finished, Julie. Costs and Benefits are estimated so we can list what the countermeasures might cost and the savings that should accrue. If a time saving is multiplied by a charge rate and hours per year, the dollars saved could be eye-catching. If a Test can be devised that will quantify the improvements, it should be noted here. Then comes the Follow Up in which the test results are shown and a path forward is proposed. Finally, way up in the top right corner, is the Title Information. This is just boilerplate showing the title of the A3 report, to whom it is directed, the author(s), and the date. So, Julie, do you now understand an A3 report and A3 Problem Solving?”
“No, of course not. You said it yourself, ‘A blog is not a teaching medium. It should simply arouse the reader’s interest.’ And there’s one more problem with a blog.”
“Oh, what?”
“Although the A3 is great, the blog isn’t visual enough. Remember, Curmudge, my generation grew up in front of a TV set.”
Affinity’s Kaizen Curmudgeon
P.S.—Cindy Jimmerson’s workshops as well as her book, reVIEW, are excellent. See also an older, all-text report, A3 Reports: Tools for Process Improvement and Organizational Transformation, by Durward K. Sobek, and Cindy Jimmerson, found at http://leanhealthcarewest.com/a3_problemsolving.html.
“Not quite, Jaded Julie. My first TV-watching experience was when I was a teenager. I was tossed out of a bar while trying to watch the World Series (1950?) on the only TV set in town. But I am fairly good at visualizing. One had to be in order to ‘watch’ The Lone Ranger on the radio.”
“You promised last week that we’d probe more deeply into A3 problem solving. Shall we do it?”
“Without delay. A3 problem solving acquired its name from the use of an A3 report for its planning and communication. As we learned, the medium of the A3 report is a single sheet of A3 (11 by 17-inch) paper. The report flows from top to bottom on the left-hand side of the paper, then top to bottom on the right side.”
“Because Blogger software doesn’t seem to like sketches, Curmudge, it looks as if you are going to have to use 1000 words in place of one picture. Our goal of achieving simplicity is defeated before we even start.”
“Unfortunately true, Julie. But perhaps we can reach our objective of piquing someone’s interest in A3 reports enough to steer them toward the work of Cindy Jimmerson that we’ll reference below. So let’s proceed. At the top left of the A3 sheet is the Issue Statement, usually as seen through the eyes of the patient. Below that is the Background, which helps us understand why the issue is important.”
“My kids would like the next part, a sketch of the Current Condition. We draw storm clouds for problems and icons for people like in value stream mapping. I guess that’s why we studied VSM a couple of weeks ago.”
“Right, Julie. But we must draw with a pencil so it’s easy to erase and make changes. The value of the sketch is that it inspires everyone’s thinking—the members of the team as well as the person with the pencil in his/her hand. We need to remember to KISS visually.”
“That might be considered suggestive spoken by most anyone else, but not by you, Curmudge.”
“At the bottom of the left half of the A3 is the Problem Analysis. We want to identify the problems signified by the sketch’s storm clouds and use the 5 Whys to find their root cause. What is learned here will help determine whether we have discovered too many problems for a single A3.”
“We are back to sketching again at the top of the right side of the A3. Here we want to show the Target Condition. This will be a graphic—again drawn with a pencil—that shows the process with problems, workarounds, and re-work eliminated. As Jimmerson states, this will illustrate ‘a new way to work that is closer to ideal.’ See, Curmudge, I’ve been reading the stuff that you recommend.”
“Countermeasures are listed in the next step down the page. These are the changes needed to get from the current condition to the target condition. One might call these ‘solutions’ if they produced the ideal result. But ‘countermeasures’ are more consistent with the Lean concept of achieving incremental improvements. Then comes the Implementation Plan, or how we are going to make the countermeasures occur. Sometimes the activities are shown in a matrix describing who, what, when, and the anticipated outcome.”
“I remember, Curmudge. We talked about a matrix a year ago—on September 25, 2007.”
“We’re almost finished, Julie. Costs and Benefits are estimated so we can list what the countermeasures might cost and the savings that should accrue. If a time saving is multiplied by a charge rate and hours per year, the dollars saved could be eye-catching. If a Test can be devised that will quantify the improvements, it should be noted here. Then comes the Follow Up in which the test results are shown and a path forward is proposed. Finally, way up in the top right corner, is the Title Information. This is just boilerplate showing the title of the A3 report, to whom it is directed, the author(s), and the date. So, Julie, do you now understand an A3 report and A3 Problem Solving?”
“No, of course not. You said it yourself, ‘A blog is not a teaching medium. It should simply arouse the reader’s interest.’ And there’s one more problem with a blog.”
“Oh, what?”
“Although the A3 is great, the blog isn’t visual enough. Remember, Curmudge, my generation grew up in front of a TV set.”
Affinity’s Kaizen Curmudgeon
P.S.—Cindy Jimmerson’s workshops as well as her book, reVIEW, are excellent. See also an older, all-text report, A3 Reports: Tools for Process Improvement and Organizational Transformation, by Durward K. Sobek, and Cindy Jimmerson, found at http://leanhealthcarewest.com/a3_problemsolving.html.
Thursday, September 4, 2008
The A3 Report
“Curmudge, conventional wisdom says that people don’t read anymore.”
“I hope it’s not that bad, Jaded Julie, but I agree that people are very selective about what they read. They rarely read deeply enough to become well informed or to broaden their education. Mrs. Curmudgeon reads the comics and checks up on our friends in the obituaries.”
“If it’s not on the TV or in the sports pages, my husband never sees it. Information is filtered, spun, and condensed into 30-second sound bites. These days, a Renaissance man (or woman) is someone who takes the time to look up something in Google. Come to think of it, that sounds like you, Curmudge. But why are we talking about this? What do people’s reading habits have to do with Lean?”
“Julie, as Lean proponents we must be effective communicators. Our Lean communications must fit the attention span of a 21st century person, and the best way to do that is to use A3 reports.”
“At this point I feel obligated to ask, ‘What is an A3 report?’”
“Thank you for asking; I knew you would. Physically, an A3 report is an 11-inch by 17-inch sheet of paper viewed with its long axis horizontal. The term, A3, refers to paper of the designated size, which would be about 30 cm X 42 cm outside of the U.S. An A3 report—all on one sheet of paper—is most commonly used in a process called ‘A3 Problem Solving’ in which the report depicts the problem, what is known about it, and how it might be solved. Key elements of the process and of the report include:
· Issue
· Background and current condition
· Problem analysis
· Target condition
· Countermeasures
· Implementation plan, including cost/benefit analysis
· Test of implementation plan
· Follow-up”
“You mean that the whole caboodle is on a single sheet of paper, right up there for everyone to see? That’s visual communication to the max. Who but the Japanese could have thought of that? I assume, Curmudge, that like much of Lean this A3 stuff originated with the Toyota Motor Corporation.”
“That’s where the application of A3 reports in problem solving began. However, most of us don’t realize that the principal concept and greatest attribute of an A3 report, simplicity, is much older than Toyota. A 14th century Franciscan friar, William of Ockham, stated that ‘entities should not be multiplied beyond necessity.’ This statement, meaning that one should cut away all that is not necessary, became known as ‘Ockham’s razor.’ (We credit Group 8020’s blog for the history lesson.)”
“I’ve got it, Curmudge! The modern translation of Ockham’s razor is KISS (keep it simple, Stupid). Something simple, like an A3 report, is the best way to communicate with 21st century readers who won’t read long documents.”
“Your perspicacity continues to amaze me. Now that we have laid the groundwork, in our next conversation we’ll probe more deeply into A3 Problem Solving.”
“I look forward to it, Curmudge, but remember to KISS.”
Affinity’s Kaizen Curmudgeon
“I hope it’s not that bad, Jaded Julie, but I agree that people are very selective about what they read. They rarely read deeply enough to become well informed or to broaden their education. Mrs. Curmudgeon reads the comics and checks up on our friends in the obituaries.”
“If it’s not on the TV or in the sports pages, my husband never sees it. Information is filtered, spun, and condensed into 30-second sound bites. These days, a Renaissance man (or woman) is someone who takes the time to look up something in Google. Come to think of it, that sounds like you, Curmudge. But why are we talking about this? What do people’s reading habits have to do with Lean?”
“Julie, as Lean proponents we must be effective communicators. Our Lean communications must fit the attention span of a 21st century person, and the best way to do that is to use A3 reports.”
“At this point I feel obligated to ask, ‘What is an A3 report?’”
“Thank you for asking; I knew you would. Physically, an A3 report is an 11-inch by 17-inch sheet of paper viewed with its long axis horizontal. The term, A3, refers to paper of the designated size, which would be about 30 cm X 42 cm outside of the U.S. An A3 report—all on one sheet of paper—is most commonly used in a process called ‘A3 Problem Solving’ in which the report depicts the problem, what is known about it, and how it might be solved. Key elements of the process and of the report include:
· Issue
· Background and current condition
· Problem analysis
· Target condition
· Countermeasures
· Implementation plan, including cost/benefit analysis
· Test of implementation plan
· Follow-up”
“You mean that the whole caboodle is on a single sheet of paper, right up there for everyone to see? That’s visual communication to the max. Who but the Japanese could have thought of that? I assume, Curmudge, that like much of Lean this A3 stuff originated with the Toyota Motor Corporation.”
“That’s where the application of A3 reports in problem solving began. However, most of us don’t realize that the principal concept and greatest attribute of an A3 report, simplicity, is much older than Toyota. A 14th century Franciscan friar, William of Ockham, stated that ‘entities should not be multiplied beyond necessity.’ This statement, meaning that one should cut away all that is not necessary, became known as ‘Ockham’s razor.’ (We credit Group 8020’s blog for the history lesson.)”
“I’ve got it, Curmudge! The modern translation of Ockham’s razor is KISS (keep it simple, Stupid). Something simple, like an A3 report, is the best way to communicate with 21st century readers who won’t read long documents.”
“Your perspicacity continues to amaze me. Now that we have laid the groundwork, in our next conversation we’ll probe more deeply into A3 Problem Solving.”
“I look forward to it, Curmudge, but remember to KISS.”
Affinity’s Kaizen Curmudgeon
Wednesday, August 27, 2008
A value stream map without pictures?
“Okay, Curmudge, how are you going to do it? No one can teach value stream mapping without pictures.”
“You’re right as usual, Jaded Julie. It would be like trying to teach chemistry without a blackboard, or a whiteboard, or these days without a ‘smart board.’ So I won’t try to teach value stream mapping; I’ll just introduce the concept. Anyone with a bit of imagination should be able to handle that.”
“Oh, I should be able to do that all right. I once imagined that my husband would become a millionaire, but then reality set in.”
“Remember reading about the nurses in Nord 92? They said they didn’t utilize mapping, but I’ll bet they were able to clearly envision their processes. So sit back and try to conceptualize what I describe. But don’t close your eyes or you’ll fall asleep as we senior citizens do.”
“G’night, Curmudge.”
“Up and at ‘em, Julie! Let’s start by imagining a simple flow chart…just a few rectangles connected by lines or arrows. A value stream map (VSM) is a sketch of a process showing procedures in the boxes with intervals between procedures shown by the connecting lines. It differs from a flow chart by showing times for value-added activities (what the customer is willing to pay for) and non-value-added activities (when nothing constructive is happening, from the customer’s view). Think of an appointment with a physician. Your time spent with the nurse and the doctor should be value-added, but any waiting time is non-value-added. Unless you have been on vacation all summer, you should recognize the waiting time as waste or muda.”
“Me! Vacation? Curmudge, you are the one who has been on vacation.”
“How can you tell, Julie? As a retired person, I am on vacation 24/7…or at least that’s what some people think. So back to VSM. A process for study is identified, a team is formed to study the process, and they create the current state value stream map. This reveals the sources of waste in the process. The team then brainstorms ways to improve the process and reduce waste using special symbols for people and activities, storm clouds for problems, and ‘Kaizen bursts’ (stars) for ideas. A future state value stream map depicts the product of their efforts, and it serves as a blueprint for the action plan to upgrade the process.”
“The ‘VSM Game’ sounds like something my kids would like to play. So the team fixes the process and they live happily ever after, right?”
“No, Julie. The future state value stream map becomes the new current state value stream map, and that will help the team discern where even further improvements can be made. Remember, this is Lean, where the people in gemba continually strive to make incremental reductions in process waste.”
“Incremental. That means making little improvements but never reaching perfection.”
“Practically speaking, Julie, that’s true. However, a word that might better fit your definition is ‘asymptotic.’ But don’t worry; that’s a word that you don’t have to remember.”
“Consider it forgotten, Curmudge.”
Affinity’s Kaizen Curmudgeon
P.S.—“Julie, if you want to learn about value stream mapping, go to Lean in the Affinity Learning Center on the Affinity intranet. See also Mike Rother and John Shook’s book Learning to See, published by The Lean Enterprise Institute. The book’s title is very appropriate, because that’s what VSM teaches us. Another excellent resource is the section on Value Stream Mapping in Cindy Jimmerson’s reVIEW, second edition. And most recently, Mark Graban has a chapter that covers VSM in his new book, Lean Hospitals.”
“You’re right as usual, Jaded Julie. It would be like trying to teach chemistry without a blackboard, or a whiteboard, or these days without a ‘smart board.’ So I won’t try to teach value stream mapping; I’ll just introduce the concept. Anyone with a bit of imagination should be able to handle that.”
“Oh, I should be able to do that all right. I once imagined that my husband would become a millionaire, but then reality set in.”
“Remember reading about the nurses in Nord 92? They said they didn’t utilize mapping, but I’ll bet they were able to clearly envision their processes. So sit back and try to conceptualize what I describe. But don’t close your eyes or you’ll fall asleep as we senior citizens do.”
“G’night, Curmudge.”
“Up and at ‘em, Julie! Let’s start by imagining a simple flow chart…just a few rectangles connected by lines or arrows. A value stream map (VSM) is a sketch of a process showing procedures in the boxes with intervals between procedures shown by the connecting lines. It differs from a flow chart by showing times for value-added activities (what the customer is willing to pay for) and non-value-added activities (when nothing constructive is happening, from the customer’s view). Think of an appointment with a physician. Your time spent with the nurse and the doctor should be value-added, but any waiting time is non-value-added. Unless you have been on vacation all summer, you should recognize the waiting time as waste or muda.”
“Me! Vacation? Curmudge, you are the one who has been on vacation.”
“How can you tell, Julie? As a retired person, I am on vacation 24/7…or at least that’s what some people think. So back to VSM. A process for study is identified, a team is formed to study the process, and they create the current state value stream map. This reveals the sources of waste in the process. The team then brainstorms ways to improve the process and reduce waste using special symbols for people and activities, storm clouds for problems, and ‘Kaizen bursts’ (stars) for ideas. A future state value stream map depicts the product of their efforts, and it serves as a blueprint for the action plan to upgrade the process.”
“The ‘VSM Game’ sounds like something my kids would like to play. So the team fixes the process and they live happily ever after, right?”
“No, Julie. The future state value stream map becomes the new current state value stream map, and that will help the team discern where even further improvements can be made. Remember, this is Lean, where the people in gemba continually strive to make incremental reductions in process waste.”
“Incremental. That means making little improvements but never reaching perfection.”
“Practically speaking, Julie, that’s true. However, a word that might better fit your definition is ‘asymptotic.’ But don’t worry; that’s a word that you don’t have to remember.”
“Consider it forgotten, Curmudge.”
Affinity’s Kaizen Curmudgeon
P.S.—“Julie, if you want to learn about value stream mapping, go to Lean in the Affinity Learning Center on the Affinity intranet. See also Mike Rother and John Shook’s book Learning to See, published by The Lean Enterprise Institute. The book’s title is very appropriate, because that’s what VSM teaches us. Another excellent resource is the section on Value Stream Mapping in Cindy Jimmerson’s reVIEW, second edition. And most recently, Mark Graban has a chapter that covers VSM in his new book, Lean Hospitals.”
Future State VSM--Triage in the ED
P.P.S.—“Look up, Julie, I’ve got one—a VSM picture. Janice found it for us.”
“That’s not much of a VSM; it doesn’t even show value-added and non-value-added times.”
“Hey, beggars can’t be choosers. Besides, this is a future state VSM. On these, times are only hoped-for estimates.”
“Now you’ll have to revise the title, Curmudge. It’s no longer ‘without pictures.’”
“Not a chance, Julie. We’d need to rewrite the first half page, and I don’t want to delete your dream about your husband becoming a millionaire. Mrs. Curmudgeon once had the same dream about me."
Thursday, August 21, 2008
Problem Solving Then and Now
“Curmudge, were you involved in problem solving in your earlier life?”
“Lives, Jaded Julie. I had several of them. I was a chemist, and problem solving was what scientists and engineers did. If we weren’t fairly good at it, the men became mill workers and the women home economics teachers.”
“Tell me how you solved problems back in the last century. It sounds as if it were the exclusive purview (purview; did I say that?) of professionals.”
“Like management in those days, problem solving was essentially a seat-of-the-pants endeavor. For problems requiring research, we followed a sequence sort of like this: Define the problem. Learn what was already known by studying the literature, sometimes in a foreign language. Plan the investigation, and then do it. We didn’t know Plan, Do, Check, Act, although we probably did it intuitively. Dr. Deming may have still been in Japan.”
“That sounds difficult, Curmudge, especially the foreign language part. It’s pretty evident why the Toyota Production System had to be developed if they wanted everyone to become a problem solver. On January 25 and 31 we talked about some general aspects of the TPS; perhaps it’s time to tackle the specifics.”
“I agree, Julie. To sum up the two approaches to problem solving, let’s call the old way ‘seat-of-the-pants for scientists and engineers’ and the new way ‘organized common sense, i.e., Lean tools, for the people in gemba.’ The beauty of Lean tools is that everyone can use them.”
“My brain is in gear. When do we start?”
“We already did. On January 18 we used The Five Why’s to identify the root cause of a problem. More recently, on July 10, we introduced 5S, and on August 14 we talked about The Eight Wastes of Health Care. Although the Eight Wastes is not really a tool, it helps guide our thinking. Recall once again, however, that in a blog we can only introduce a concept. Taking a workshop, studying a dedicated text, or working with an experienced person will be necessary before one can rigorously apply a Lean tool.”
“Curmudge, I believe you once said that one of the principles of a Lean transformation is continuous improvement of processes. If we are going to solve problems in processes, we’d better understand the difference between a process and a procedure.”
“Okay, here it is, courtesy of an international standard (ISO 9000) and a seminar at SEH by Lucia Berte on 10/12/06. A process is a sequence of activities involving more than one person (usually) across a span of time. A process description defines who does what in the proper sequence (when). Typically, a process involves several procedures. Thus, the process description, outline, or flow chart is the tie that binds the procedures into a coordinated effort to achieve the desired outcome. A procedure tells how to do something. It is a set of instructions that describe the stepwise actions taken to complete an activity identified in a process. It usually involves just one person. Here is a simple example: Getting up and going to work is a process; brushing one’s teeth is a procedure.”
“The definitions sound reasonable to me, Curmudge. I think the term, ‘procedure,’ is overworked. It is too often used to refer to processes as well as procedures, and we throw in surgical procedures for good measure. Is it really important for us to differentiate between processes and procedures?”
“If people become too absorbed in performing their own procedures, they are apt to acquire a ‘silo’ mentality. In a Lean transformation we need to remove the boundaries between silos and think about how we are going to move patients through processes efficiently.”
“Curmudge, for an old chemist, you’ve covered a lot of ground in two pages. I noticed that you mentioned using a flow chart to describe a process. Does that mean that we’ll talk about value stream mapping sometime soon?”
“Of course, Julie. You can depend on me to be here. After 40 years of getting up and going to work, I’ve hardwired the process.”
Affinity’s Kaizen Curmudgeon
“Lives, Jaded Julie. I had several of them. I was a chemist, and problem solving was what scientists and engineers did. If we weren’t fairly good at it, the men became mill workers and the women home economics teachers.”
“Tell me how you solved problems back in the last century. It sounds as if it were the exclusive purview (purview; did I say that?) of professionals.”
“Like management in those days, problem solving was essentially a seat-of-the-pants endeavor. For problems requiring research, we followed a sequence sort of like this: Define the problem. Learn what was already known by studying the literature, sometimes in a foreign language. Plan the investigation, and then do it. We didn’t know Plan, Do, Check, Act, although we probably did it intuitively. Dr. Deming may have still been in Japan.”
“That sounds difficult, Curmudge, especially the foreign language part. It’s pretty evident why the Toyota Production System had to be developed if they wanted everyone to become a problem solver. On January 25 and 31 we talked about some general aspects of the TPS; perhaps it’s time to tackle the specifics.”
“I agree, Julie. To sum up the two approaches to problem solving, let’s call the old way ‘seat-of-the-pants for scientists and engineers’ and the new way ‘organized common sense, i.e., Lean tools, for the people in gemba.’ The beauty of Lean tools is that everyone can use them.”
“My brain is in gear. When do we start?”
“We already did. On January 18 we used The Five Why’s to identify the root cause of a problem. More recently, on July 10, we introduced 5S, and on August 14 we talked about The Eight Wastes of Health Care. Although the Eight Wastes is not really a tool, it helps guide our thinking. Recall once again, however, that in a blog we can only introduce a concept. Taking a workshop, studying a dedicated text, or working with an experienced person will be necessary before one can rigorously apply a Lean tool.”
“Curmudge, I believe you once said that one of the principles of a Lean transformation is continuous improvement of processes. If we are going to solve problems in processes, we’d better understand the difference between a process and a procedure.”
“Okay, here it is, courtesy of an international standard (ISO 9000) and a seminar at SEH by Lucia Berte on 10/12/06. A process is a sequence of activities involving more than one person (usually) across a span of time. A process description defines who does what in the proper sequence (when). Typically, a process involves several procedures. Thus, the process description, outline, or flow chart is the tie that binds the procedures into a coordinated effort to achieve the desired outcome. A procedure tells how to do something. It is a set of instructions that describe the stepwise actions taken to complete an activity identified in a process. It usually involves just one person. Here is a simple example: Getting up and going to work is a process; brushing one’s teeth is a procedure.”
“The definitions sound reasonable to me, Curmudge. I think the term, ‘procedure,’ is overworked. It is too often used to refer to processes as well as procedures, and we throw in surgical procedures for good measure. Is it really important for us to differentiate between processes and procedures?”
“If people become too absorbed in performing their own procedures, they are apt to acquire a ‘silo’ mentality. In a Lean transformation we need to remove the boundaries between silos and think about how we are going to move patients through processes efficiently.”
“Curmudge, for an old chemist, you’ve covered a lot of ground in two pages. I noticed that you mentioned using a flow chart to describe a process. Does that mean that we’ll talk about value stream mapping sometime soon?”
“Of course, Julie. You can depend on me to be here. After 40 years of getting up and going to work, I’ve hardwired the process.”
Affinity’s Kaizen Curmudgeon
Thursday, August 14, 2008
The Eight Wastes of Health Care
“Jaded Julie, I’ve forgotten something.”
“Of course you have, Curmudge. You’ve spent the past 40 years forgetting most everything you learned in the preceding 20.”
“You are probably right, Julie, but more to the point, we haven’t said much about Lean tools. Several months ago we decided to focus on the Lean culture, and that’s what we have done. Things like the Toyota Way pyramid, leadership, The Flywheel.”
“I recall learning about The Eight Wastes of Health Care. That’s not a tool, but it’s a Lean fundamental that everyone must know. When did we discuss that?”
“It was back in the winter of ’07, Julie. Before my transformation into the Kaizen Curmudgeon. The list was published on the Affinity intranet but not in a blog. Why don’t I name a type of waste, and you can provide some health care examples? Then the blog readers won’t feel neglected.”
“Okay, let’s do it.”
“Waiting:”
“To be seen in the ED
To be admitted to the hospital from the ED
For testing, treatment, or discharge
For laboratory test results”
“Motion:”
“Searching for meds, charts, supplies, patients
Handling paperwork”
“Transportation:”
“Moving patients for testing or treatment
Moving specimens”
“Defects:”
“Wrong patient or procedure
Medication error or omission
Missing information”
“Processing:”
“Unnecessary testing (defensive medicine)
Excessive paperwork”
“Inventory:”
“Pharmacy stock and lab supplies
Paperwork in process”
“Overproduction:”
“Any testing or treatments done at the convenience of the institution rather than the patient”
“Underutilization of Human Resources:”
“Lack of involvement and participation of all members of the workforce”
“Good job, Julie. Did I ever tell you that the Japanese word for waste is muda?”
“You just did, and I am forever in your debt. How did I ever live this past year without knowing that? I must admit that as Japanese words go, muda isn’t too tough. At least it’s easier than genchi genbutsu. By the way, Curmudge, what does genchi genbutsu mean?”
“You know me, Julie; I forgot. We’d better look it up in Liker’s The Toyota Way.”
Affinity’s Kaizen Curmudgeon
Tuesday, July 29, 2008
More Lean Lessons from Hôpital Nord 92
“So, Curmudge, what more are we going to learn from Hôpital Nord 92?”
“Jaded Julie, I hope we’ll learn more about safety and efficiency in nursing.”
“By the way, Curmudge, how does one say 92 in French?”
“Quatre-vingt-douze. It means four twenties twelve. Why do you ask?”
“Well, their math is okay, but it’s sure not a very efficient way to say ninety-two. Can the French really teach us anything about efficiency?”
“You’re in luck, Julie. Ballé and Régnier cite an American author, Steven Spear. Dr. Spear contends that ambiguity and workarounds contribute to medical errors*. They are also undeniable sources of inefficiency. Think of what must be known for any process to occur: who (patient as well as caregiver)? what? when? where? why? how? Ambiguity in answering any of these questions leads to inefficiency and time wasting. If root causes of problems in a process or procedure are not resolved, workarounds must be developed each time it is performed.”
“I can certainly see that ambiguity can lead to inefficiency, but in what ways might it compromise patient safety?”
“Answering the ‘how?’ question is one of the most critical. Here’s what people tend to do when they are uncertain about how to do something (from a seminar at SEH by Lucia Berte):
· They ask someone.
· They look it up (if the document is easy to interpret and not too long).
· They make it up.
· They might not do it. (In Nord 92, the nurses sometimes skipped steps in procedures.)”
“Wow, Curmudge, the last two options are kind of scary. I can understand how they might lead to errors. So how did the nurses at Nord 92 respond to Dr. Spear’s teachings, especially his urging that patient care practices be highly specified, i.e., standardized?”
“Because checklists had been developed in order to achieve the basic stability that we discussed last week, the nurses were familiar with the concept. They were, as might be expected, protective of their autonomy and reluctant to use checklists on themselves. So the effort started on a small scale with a checklist on basic patient care. Early checklists likely avoided topics that might be considered efforts to standardize nursing judgment. Later, however, the program grew to standardize more technical aspects of patient care.”
“It sounds as if the folks at Nord 92 jumped headlong into the Toyota Production System.”
“They did, Julie. And they used some other Lean techniques that we’ll cover in later discussions. Remember that they accomplished all of this using teams of nurses guided by their managers. If these changes had been dictated by management, they would have been accepted about as fast as if they had been written in German (or maybe in English).”
“The French have taught us a valuable lesson. After basic stability is achieved, standard work can be applied to patient care. Say, Curmudge, do you have any other examples of French efficiency?”
“Sure. Est-ce que at the beginning of a sentence means that the sentence will be a question. You don’t have to wait for the question mark at the end.”
“Well, that’s not as efficient as the inverted question mark (¿) in Spanish.”
“Good observation, but did you ever hear anyone speak an inverted question mark?”
“Hey! That’s pretty quick for an old guy. See you after your trip, Curmudge?”
“Of course, Julie.”
Affinity’s Kaizen Curmudgeon
*http://www.annals.org/cgi/reprint/142/8/627.pdf
P.S.—“Check this out, Julie. It’s a timely blog posting that provides strong support for standardized processes in patient care.” http://www.dailykaizen.org/archives/564
“Jaded Julie, I hope we’ll learn more about safety and efficiency in nursing.”
“By the way, Curmudge, how does one say 92 in French?”
“Quatre-vingt-douze. It means four twenties twelve. Why do you ask?”
“Well, their math is okay, but it’s sure not a very efficient way to say ninety-two. Can the French really teach us anything about efficiency?”
“You’re in luck, Julie. Ballé and Régnier cite an American author, Steven Spear. Dr. Spear contends that ambiguity and workarounds contribute to medical errors*. They are also undeniable sources of inefficiency. Think of what must be known for any process to occur: who (patient as well as caregiver)? what? when? where? why? how? Ambiguity in answering any of these questions leads to inefficiency and time wasting. If root causes of problems in a process or procedure are not resolved, workarounds must be developed each time it is performed.”
“I can certainly see that ambiguity can lead to inefficiency, but in what ways might it compromise patient safety?”
“Answering the ‘how?’ question is one of the most critical. Here’s what people tend to do when they are uncertain about how to do something (from a seminar at SEH by Lucia Berte):
· They ask someone.
· They look it up (if the document is easy to interpret and not too long).
· They make it up.
· They might not do it. (In Nord 92, the nurses sometimes skipped steps in procedures.)”
“Wow, Curmudge, the last two options are kind of scary. I can understand how they might lead to errors. So how did the nurses at Nord 92 respond to Dr. Spear’s teachings, especially his urging that patient care practices be highly specified, i.e., standardized?”
“Because checklists had been developed in order to achieve the basic stability that we discussed last week, the nurses were familiar with the concept. They were, as might be expected, protective of their autonomy and reluctant to use checklists on themselves. So the effort started on a small scale with a checklist on basic patient care. Early checklists likely avoided topics that might be considered efforts to standardize nursing judgment. Later, however, the program grew to standardize more technical aspects of patient care.”
“It sounds as if the folks at Nord 92 jumped headlong into the Toyota Production System.”
“They did, Julie. And they used some other Lean techniques that we’ll cover in later discussions. Remember that they accomplished all of this using teams of nurses guided by their managers. If these changes had been dictated by management, they would have been accepted about as fast as if they had been written in German (or maybe in English).”
“The French have taught us a valuable lesson. After basic stability is achieved, standard work can be applied to patient care. Say, Curmudge, do you have any other examples of French efficiency?”
“Sure. Est-ce que at the beginning of a sentence means that the sentence will be a question. You don’t have to wait for the question mark at the end.”
“Well, that’s not as efficient as the inverted question mark (¿) in Spanish.”
“Good observation, but did you ever hear anyone speak an inverted question mark?”
“Hey! That’s pretty quick for an old guy. See you after your trip, Curmudge?”
“Of course, Julie.”
Affinity’s Kaizen Curmudgeon
*http://www.annals.org/cgi/reprint/142/8/627.pdf
P.S.—“Check this out, Julie. It’s a timely blog posting that provides strong support for standardized processes in patient care.” http://www.dailykaizen.org/archives/564
Thursday, July 24, 2008
Lean in a French Hospital
“Have you ever been in a French hospital, Curmudge?”
“No, Jaded Julie, but we came very close. Mrs. Curmudgeon contracted food poisoning in Paris several years ago. We stayed in the hotel because my wife was too sick to move—except frequently to the bathroom. I went to the local pharmacy, and the pharmacist provided something that seemed to be effective. Perhaps pharmacists there can dispense without a prescription more powerful stuff than here. Although my wife felt like dying, she eventually got better.”
“It sounds as if the French have become more helpful to Americans than in years past.”
”I suppose so. You can depend on the French; they are always there when they need us.”
“Curmudge, did you say that right? Considering the source, I guess you did. So anyway, tell me about the paper you found—the one about a hospital in France.”
“I was googling ‘Lean in nursing’ and encountered the paper, Lean as a Learning System in a Hospital Ward. I’ll give you the URL*, but Word refuses to open the file. Perhaps it has the same French bug that my wife had. At least it can be accessed via Google.”
“Please proceed, Professor. We’ve already used a half page.”
“The staff at the hospital, Hôpital Nord 92, used Lean tools, especially 5S, and encountered what the authors call the ‘pillowcase syndrome’. If one squeezes at one end, it bulges elsewhere. When they made an isolated improvement, it shifted the burden to another element in the system. The authors, Ballé and Régnier, attributed their lack of meaningful progress to the lack of basic stability in their unit. Although the ‘basic stability’ problem has been described by Smalley in the manufacturing context**, it can be translated into health care.”
“Okay, Curmudge. I think at this point you want me to ask, ‘How can one achieve basic stability in a patient care unit?’”
“The folks at Park Nicollet Health Services in Minneapolis provide some inspiration in their listing of the ‘7 Flows of Medicine’***. These are factors that they consider in designing changes in processes or delivery of services:
· Flow of patients
· Flow of providers
· Flow of medications
· Flow of supplies
· Flow of information
· Flow of equipment
· Flow of instruments and processes”
“I think I get it, Curmudge. The better one can control these flows, the greater the unit’s basic stability. Did the nurses at Nord 92 improve any of their flows, perhaps without even knowing of Park Nicollet’s list?”
“Yes, they really made significant progress toward basic stability. They initiated a ‘clear corridor’ policy so that wheelchairs and trolleys (carts) were properly located and not scattered all over. Materials handling and storage were studied and improved. They adopted a ‘supermarket’ (first in, first out) policy for storage areas. A clear benefit of these changes was that anything out of date or out of place would stand out. Success in these projects convinced the nurses that there might be value in achieving basic stability in nursing care itself. At the end of the paper, the nurses were developing checklists and devising what we would call ‘standard work’ for some of their processes and procedures.”
“That’s great, Curmudge. I understand that we’ll talk more about Nord 92 in our next conversation. By the way, did your wife ever return to Paris?”
“Never. And she refuses to eat foie gras.”
Affinity’s Kaizen Curmudgeon
*http://lean.enst.fr/wiki/pub/Lean/LesPublications/HospitalLearning.pdf
**http://www.superfactory.com/articles/Smalley_Basic_Stability.htm
***http://www.msp-ifma.org/0702prgnotes5S3PLeanCaseStudyDSpiegle.ppt
“No, Jaded Julie, but we came very close. Mrs. Curmudgeon contracted food poisoning in Paris several years ago. We stayed in the hotel because my wife was too sick to move—except frequently to the bathroom. I went to the local pharmacy, and the pharmacist provided something that seemed to be effective. Perhaps pharmacists there can dispense without a prescription more powerful stuff than here. Although my wife felt like dying, she eventually got better.”
“It sounds as if the French have become more helpful to Americans than in years past.”
”I suppose so. You can depend on the French; they are always there when they need us.”
“Curmudge, did you say that right? Considering the source, I guess you did. So anyway, tell me about the paper you found—the one about a hospital in France.”
“I was googling ‘Lean in nursing’ and encountered the paper, Lean as a Learning System in a Hospital Ward. I’ll give you the URL*, but Word refuses to open the file. Perhaps it has the same French bug that my wife had. At least it can be accessed via Google.”
“Please proceed, Professor. We’ve already used a half page.”
“The staff at the hospital, Hôpital Nord 92, used Lean tools, especially 5S, and encountered what the authors call the ‘pillowcase syndrome’. If one squeezes at one end, it bulges elsewhere. When they made an isolated improvement, it shifted the burden to another element in the system. The authors, Ballé and Régnier, attributed their lack of meaningful progress to the lack of basic stability in their unit. Although the ‘basic stability’ problem has been described by Smalley in the manufacturing context**, it can be translated into health care.”
“Okay, Curmudge. I think at this point you want me to ask, ‘How can one achieve basic stability in a patient care unit?’”
“The folks at Park Nicollet Health Services in Minneapolis provide some inspiration in their listing of the ‘7 Flows of Medicine’***. These are factors that they consider in designing changes in processes or delivery of services:
· Flow of patients
· Flow of providers
· Flow of medications
· Flow of supplies
· Flow of information
· Flow of equipment
· Flow of instruments and processes”
“I think I get it, Curmudge. The better one can control these flows, the greater the unit’s basic stability. Did the nurses at Nord 92 improve any of their flows, perhaps without even knowing of Park Nicollet’s list?”
“Yes, they really made significant progress toward basic stability. They initiated a ‘clear corridor’ policy so that wheelchairs and trolleys (carts) were properly located and not scattered all over. Materials handling and storage were studied and improved. They adopted a ‘supermarket’ (first in, first out) policy for storage areas. A clear benefit of these changes was that anything out of date or out of place would stand out. Success in these projects convinced the nurses that there might be value in achieving basic stability in nursing care itself. At the end of the paper, the nurses were developing checklists and devising what we would call ‘standard work’ for some of their processes and procedures.”
“That’s great, Curmudge. I understand that we’ll talk more about Nord 92 in our next conversation. By the way, did your wife ever return to Paris?”
“Never. And she refuses to eat foie gras.”
Affinity’s Kaizen Curmudgeon
*http://lean.enst.fr/wiki/pub/Lean/LesPublications/HospitalLearning.pdf
**http://www.superfactory.com/articles/Smalley_Basic_Stability.htm
***http://www.msp-ifma.org/0702prgnotes5S3PLeanCaseStudyDSpiegle.ppt
Thursday, July 17, 2008
Let's talk more about nursing.
“Turn up your hearing aid, Curmudge. I’m going to teach you more about nursing, and I don’t want you to miss anything.”
“Don’t you offer a senior discount, Jaded Julie, that will allow me to not hear 10% of your words? Well anyway, I recall from our discussion two weeks ago that when you were a new nurse you considered your profession a calling and your daily work a mission. Apparently your feelings have become tempered by the realities of experience. Tell me more.”
“Curmudge, hospital nursing is the ultimate ‘in-the-middle’ occupation. Despite being licensed professionals, we have an almost infinite number of bosses—each patient that we care for, his or her physician and the physician’s PA, and the hospital administration. Of course the heart of the job is to meet the needs of the patients:
· to experience minimal pain and discomfort,
· to receive the best possible treatment and care,
· to be kept safe from errors, infections, or falls,
· and, in general, to be delighted with their stay at an Affinity hospital.
While doing the above, we try to meet our own needs for professional and personal fulfillment. Nursing is always demanding and sometimes frustrating.”
“That’s an imposing list, Julie. Indeed, nurses are special people. When I meet a nurse in the stairway, I feel like saying, ‘Thank you.’ But as Lean zealots, you and I feel that in all of the above there are processes that contain waste and efforts that add no value from the patients’ or physicians’ perspective. With less waste, nursing would be more rewarding. Getting rid of this waste will be a big job. How will we do it?”
“You know better than that, Curmudge. It’s not going to be we; it’s going to be they, the nurses working in teams to 5S their areas and take waste out of their processes. Nurses excel in working on teams; think of how well they do in the OR or the ED when a trauma patient rolls in.”
“On the other hand, Lean practiced by nurses will be somewhat different from Lean in manufacturing. In manufacturing the workers gain a measure of participative management. But despite having many bosses, hospital nurses already enjoy significant professional autonomy. Their autonomy may be reduced by Lean when processes become more standardized and efficient.”
“Let’s put off autonomy and nursing practice issues for awhile, Curmudge. We need to score some early wins in areas that are not controversial. I believe you quality guys call that ‘picking the low-hanging fruit’. For example, if we train people in 5S and immediately put them to work using it, they will gain a feeling of accomplishment and be able to see the evidence of their good work. There aren’t many storage areas in the hospital that couldn’t profit from a good 5S’ing.”
“Not so fast, Julie. Before we do lots of rapid improvement events, or what my colleagues call ‘drive-by kaizens,’ we need to understand the ‘big picture’. As someone said, ‘Before the bus leaves, it must have a destination.’ Recall our discussions about hoshin kanri planning back in September and October of 2007. Then on January 18 we mentioned Pascal Dennis’s emphasis on strategy deployment to focus Lean tools on business needs. It’s important for people with discretionary time, as we discussed on 10/12/07, to work on hoshins and the projects that support them.”
“That’s not me, Curmudge. As a staff nurse, virtually all of my time is what you Lean folks call ready-to-serve. Is there some sort of big picture that guides the Lean efforts that I can squeeze into my ready-to-serve time?”
“I think so, Julie. I found a very insightful article that we’ll talk about next time. Although the paper is from France, it is written in English.”
“If it weren’t, Curmudge, you would find me taking ‘French leave’ from our discussion.”
“Au revoir, Julie.”
Affinity’s Kaizen Curmudgeon
“Don’t you offer a senior discount, Jaded Julie, that will allow me to not hear 10% of your words? Well anyway, I recall from our discussion two weeks ago that when you were a new nurse you considered your profession a calling and your daily work a mission. Apparently your feelings have become tempered by the realities of experience. Tell me more.”
“Curmudge, hospital nursing is the ultimate ‘in-the-middle’ occupation. Despite being licensed professionals, we have an almost infinite number of bosses—each patient that we care for, his or her physician and the physician’s PA, and the hospital administration. Of course the heart of the job is to meet the needs of the patients:
· to experience minimal pain and discomfort,
· to receive the best possible treatment and care,
· to be kept safe from errors, infections, or falls,
· and, in general, to be delighted with their stay at an Affinity hospital.
While doing the above, we try to meet our own needs for professional and personal fulfillment. Nursing is always demanding and sometimes frustrating.”
“That’s an imposing list, Julie. Indeed, nurses are special people. When I meet a nurse in the stairway, I feel like saying, ‘Thank you.’ But as Lean zealots, you and I feel that in all of the above there are processes that contain waste and efforts that add no value from the patients’ or physicians’ perspective. With less waste, nursing would be more rewarding. Getting rid of this waste will be a big job. How will we do it?”
“You know better than that, Curmudge. It’s not going to be we; it’s going to be they, the nurses working in teams to 5S their areas and take waste out of their processes. Nurses excel in working on teams; think of how well they do in the OR or the ED when a trauma patient rolls in.”
“On the other hand, Lean practiced by nurses will be somewhat different from Lean in manufacturing. In manufacturing the workers gain a measure of participative management. But despite having many bosses, hospital nurses already enjoy significant professional autonomy. Their autonomy may be reduced by Lean when processes become more standardized and efficient.”
“Let’s put off autonomy and nursing practice issues for awhile, Curmudge. We need to score some early wins in areas that are not controversial. I believe you quality guys call that ‘picking the low-hanging fruit’. For example, if we train people in 5S and immediately put them to work using it, they will gain a feeling of accomplishment and be able to see the evidence of their good work. There aren’t many storage areas in the hospital that couldn’t profit from a good 5S’ing.”
“Not so fast, Julie. Before we do lots of rapid improvement events, or what my colleagues call ‘drive-by kaizens,’ we need to understand the ‘big picture’. As someone said, ‘Before the bus leaves, it must have a destination.’ Recall our discussions about hoshin kanri planning back in September and October of 2007. Then on January 18 we mentioned Pascal Dennis’s emphasis on strategy deployment to focus Lean tools on business needs. It’s important for people with discretionary time, as we discussed on 10/12/07, to work on hoshins and the projects that support them.”
“That’s not me, Curmudge. As a staff nurse, virtually all of my time is what you Lean folks call ready-to-serve. Is there some sort of big picture that guides the Lean efforts that I can squeeze into my ready-to-serve time?”
“I think so, Julie. I found a very insightful article that we’ll talk about next time. Although the paper is from France, it is written in English.”
“If it weren’t, Curmudge, you would find me taking ‘French leave’ from our discussion.”
“Au revoir, Julie.”
Affinity’s Kaizen Curmudgeon
Thursday, July 10, 2008
Some people don't know about 5S.
“Curmudge, I’ve been reading your mind again.”
“Well if anybody can, it’s you, Jaded Julie.”
“If we are going to continue talking about nursing and Lean, at some point you’ll mention 5S. Some people don’t even know what 5S is.”
“Gosh, I must have forgotten to introduce it. But 5S is such a household word around Affinity, how could anyone be unacquainted with it?”
“It’s certainly not a household word in my household. Whenever I try to explain 5S to my husband, he gets up off the couch and leaves the room on the second S.”
“I sympathize; that happens in our house, too. So anyway, 5S is most easily understood when we envision its ultimate result: a place for everything, and everything in its place. 5S is needed because people—in fact, all of nature—exhibit a tendency toward disorder. The scientific term for this is entropy.”
“Hey, Curmudge! Please, no thermodynamics.”
“Okay, especially for you, we’ll name the scientific term Ross, my 20-month old grandson. Every night after Ross goes to bed, his dad puts all of his toys back in the toy box. By the end of the next day, the toys are scattered all over the house again. Why? Because Ross has been doing what comes naturally.”
“I get it. People in the hospital are a bit like Ross, and they have a tendency to put stuff down without returning it to its proper place. We use 5S to reverse the resulting disorder, and it can be applied to storage and supply areas, to desks, and virtually anywhere. So what, specifically, does ‘5S’ mean?”
“Like most of Lean, 5S is based on Japanese words—in this case, five of them. There are several English translations; here is one set:
· Sort. Keep what is needed, and get rid of what is not needed or almost never used.
· Straighten/Simplify/Set in order. A place for everything, and everything in its place.
· Scrub/Shine/Sweep. In health care, cleanliness is essential.
· Standardize. Make the organization of a room or drawer identical with that of all other rooms or drawers used for the same purpose. Also, make the first 3 S’s a standard.
· Sustain. Develop the self-discipline to make the first four S’s a habit and part of the organization’s culture.”
“The concepts are not so tough, Curmudge, but making it happen could be a challenge.”
“5S’ing a room or an area is usually a team event. Fortunately, the Kaizen Promotion Office has prepared a 5S Resource Guide that should help one organize a 5S activity.”
“It seems, Curmudge, that several aspects of Lean are not truly natural and have to be taught. Recall our discussion on May 8 about Leadership and Character.”
“Many people here at Affinity will need to learn 5S, which is somewhat unnatural, just as Ross has yet to encounter toilet training and putting away his toys.”
“It shouldn’t be a problem here, Curmudge. Our colleagues have all passed potty training, so 5S should be a slam-dunk.”
Affinity’s Kaizen Curmudgeon
“Well if anybody can, it’s you, Jaded Julie.”
“If we are going to continue talking about nursing and Lean, at some point you’ll mention 5S. Some people don’t even know what 5S is.”
“Gosh, I must have forgotten to introduce it. But 5S is such a household word around Affinity, how could anyone be unacquainted with it?”
“It’s certainly not a household word in my household. Whenever I try to explain 5S to my husband, he gets up off the couch and leaves the room on the second S.”
“I sympathize; that happens in our house, too. So anyway, 5S is most easily understood when we envision its ultimate result: a place for everything, and everything in its place. 5S is needed because people—in fact, all of nature—exhibit a tendency toward disorder. The scientific term for this is entropy.”
“Hey, Curmudge! Please, no thermodynamics.”
“Okay, especially for you, we’ll name the scientific term Ross, my 20-month old grandson. Every night after Ross goes to bed, his dad puts all of his toys back in the toy box. By the end of the next day, the toys are scattered all over the house again. Why? Because Ross has been doing what comes naturally.”
“I get it. People in the hospital are a bit like Ross, and they have a tendency to put stuff down without returning it to its proper place. We use 5S to reverse the resulting disorder, and it can be applied to storage and supply areas, to desks, and virtually anywhere. So what, specifically, does ‘5S’ mean?”
“Like most of Lean, 5S is based on Japanese words—in this case, five of them. There are several English translations; here is one set:
· Sort. Keep what is needed, and get rid of what is not needed or almost never used.
· Straighten/Simplify/Set in order. A place for everything, and everything in its place.
· Scrub/Shine/Sweep. In health care, cleanliness is essential.
· Standardize. Make the organization of a room or drawer identical with that of all other rooms or drawers used for the same purpose. Also, make the first 3 S’s a standard.
· Sustain. Develop the self-discipline to make the first four S’s a habit and part of the organization’s culture.”
“The concepts are not so tough, Curmudge, but making it happen could be a challenge.”
“5S’ing a room or an area is usually a team event. Fortunately, the Kaizen Promotion Office has prepared a 5S Resource Guide that should help one organize a 5S activity.”
“It seems, Curmudge, that several aspects of Lean are not truly natural and have to be taught. Recall our discussion on May 8 about Leadership and Character.”
“Many people here at Affinity will need to learn 5S, which is somewhat unnatural, just as Ross has yet to encounter toilet training and putting away his toys.”
“It shouldn’t be a problem here, Curmudge. Our colleagues have all passed potty training, so 5S should be a slam-dunk.”
Affinity’s Kaizen Curmudgeon
Thursday, July 3, 2008
Let's talk about nursing.
“Let’s talk about nurses and nursing, Jaded Julie. Nurses are my favorite people. This will be a giant leap from our recent discussions about difficult employees.”
“The last time we talked about nursing was back on December 3, 2007, when I told you about the nursing process. I thought you had forgotten all about us.”
“Me? Forget? Although I did sort of overlook my 50th wedding anniversary a few weeks ago.”
“Congratulations, Curmudge.”
“On my anniversary?”
“No. On surviving the forgetting of your anniversary.”
“Not a problem. To make up for it I sent my wife to Ireland, the land of her ancestors. So what do you want to teach me about nursing? As a nurse, you’ll have to provide the expertise for our discussion.”
“Naturally, Curmudge. If we had to depend on your nursing knowledge, our story would end right here. But more to the point, why am I going to teach you about nursing? I’ll bet that you are going to bend our conversation so that it relates to Lean. I’ll have to admit that applying Lean to nursing is likely to be quite different from implementing it in manufacturing.”
“You’ve got the right idea, Julie, as usual. Let’s start by characterizing the actors (usually actresses) in our scenario. Nurses clearly have some endearing as well as compelling professional qualities.”
“Of course we do. Let me count the ways. We are technically proficient, dedicated, compassionate, capable of hard work, sufficiently versatile to move into management or education, and charming in every way.”
“Hey, where did you get that ‘charming’ stuff, Julie? That wasn’t on my list.”
“Of course it wasn’t. I added it to describe me, Jaded Julie.”
“Well, if we are going to describe you, we’d better add feisty to the list. But that doesn‘t apply to all nurses. Is there anything else you’d like to add?”
“Back when I was starting out, I viewed my profession as a ‘calling’ and every day’s work a ‘mission.’ Hopefully most new nurses feel that way. However, as time passed my view of my profession hasn’t changed, but I’m not as starry-eyed about my daily work. I’ve seen too much waste and inefficiency. I guess I’ve just become jaded.”
“It’s interesting that you should choose that word, Julie. I sensed that you felt that way when we first met over a year ago. It may be the result of having to do too many ‘workarounds.’ I understand that nurses are the world’s best ‘workarounders’.”
“You’ve got that right, Curmudge. When I need something to care for a patient and the item isn’t where it’s supposed to be, I have to hunt for it. If I can’t find it, I devise a substitute or take a shortcut. These are all ‘workarounds,’ and shortcuts by some nurses might even compromise patient safety. Running down the hall to search for an urgently needed item may be good exercise for me, but it’s also one reason why older nurses migrate away from direct patient care.”
“If I were the patient, I’d prefer a workaround than having to do without something essential, but I surely don’t want to be the subject of an unsafe shortcut. It sounds to me as if the processes and procedures used by nurses would be ideal candidates for a Lean cultural transformation. If you did that, you could reduce your waste and inefficiency and minimize your workarounds.”
“You did it, Curmudge! Just as I expected, you sneaked Lean into our conversation. You are as predictable as you are forgetful.”
“Maybe so, Julie, but I didn’t forget that Lean is the reason for this blog’s existence. You might say that I worked our conversation around to Lean.”
“And my further prediction is that we are going to continue our discussion about Lean in nursing. Right?”
“Right, Nurse Charming.”
Affinity’s Kaizen Curmudgeon
“The last time we talked about nursing was back on December 3, 2007, when I told you about the nursing process. I thought you had forgotten all about us.”
“Me? Forget? Although I did sort of overlook my 50th wedding anniversary a few weeks ago.”
“Congratulations, Curmudge.”
“On my anniversary?”
“No. On surviving the forgetting of your anniversary.”
“Not a problem. To make up for it I sent my wife to Ireland, the land of her ancestors. So what do you want to teach me about nursing? As a nurse, you’ll have to provide the expertise for our discussion.”
“Naturally, Curmudge. If we had to depend on your nursing knowledge, our story would end right here. But more to the point, why am I going to teach you about nursing? I’ll bet that you are going to bend our conversation so that it relates to Lean. I’ll have to admit that applying Lean to nursing is likely to be quite different from implementing it in manufacturing.”
“You’ve got the right idea, Julie, as usual. Let’s start by characterizing the actors (usually actresses) in our scenario. Nurses clearly have some endearing as well as compelling professional qualities.”
“Of course we do. Let me count the ways. We are technically proficient, dedicated, compassionate, capable of hard work, sufficiently versatile to move into management or education, and charming in every way.”
“Hey, where did you get that ‘charming’ stuff, Julie? That wasn’t on my list.”
“Of course it wasn’t. I added it to describe me, Jaded Julie.”
“Well, if we are going to describe you, we’d better add feisty to the list. But that doesn‘t apply to all nurses. Is there anything else you’d like to add?”
“Back when I was starting out, I viewed my profession as a ‘calling’ and every day’s work a ‘mission.’ Hopefully most new nurses feel that way. However, as time passed my view of my profession hasn’t changed, but I’m not as starry-eyed about my daily work. I’ve seen too much waste and inefficiency. I guess I’ve just become jaded.”
“It’s interesting that you should choose that word, Julie. I sensed that you felt that way when we first met over a year ago. It may be the result of having to do too many ‘workarounds.’ I understand that nurses are the world’s best ‘workarounders’.”
“You’ve got that right, Curmudge. When I need something to care for a patient and the item isn’t where it’s supposed to be, I have to hunt for it. If I can’t find it, I devise a substitute or take a shortcut. These are all ‘workarounds,’ and shortcuts by some nurses might even compromise patient safety. Running down the hall to search for an urgently needed item may be good exercise for me, but it’s also one reason why older nurses migrate away from direct patient care.”
“If I were the patient, I’d prefer a workaround than having to do without something essential, but I surely don’t want to be the subject of an unsafe shortcut. It sounds to me as if the processes and procedures used by nurses would be ideal candidates for a Lean cultural transformation. If you did that, you could reduce your waste and inefficiency and minimize your workarounds.”
“You did it, Curmudge! Just as I expected, you sneaked Lean into our conversation. You are as predictable as you are forgetful.”
“Maybe so, Julie, but I didn’t forget that Lean is the reason for this blog’s existence. You might say that I worked our conversation around to Lean.”
“And my further prediction is that we are going to continue our discussion about Lean in nursing. Right?”
“Right, Nurse Charming.”
Affinity’s Kaizen Curmudgeon
Thursday, June 26, 2008
More about Difficult People
“Our discussion last time about your experience with difficult people was pretty depressing, Curmudge. Yet I expect that some businesses have even worse employees than you had.”
“That’s for sure, Jaded Julie. And sometimes the problem people aren’t your subordinates; they can be your colleagues and even your boss.”
“I shudder at the thought. What can I do?”
“You’re not alone, Julie. Get help from the experts in HR as I did, and keep your boss informed, unless she is the bad actor. There’s also a ton of books out there detailing how others approached their ‘people’ problems. Bell and Smith present their advice in a very short book*, and Solomon provides guidance on dealing with bosses, colleagues, and subordinates**. Here’s how each of these books categorizes difficult people:
· Bell and Smith: (1) the voice crying in the wilderness, (2) the backstabber, (3) the yes, but (4) the politician, (5) the busybody, (6) the short fuse, (7) the liar, (8) the blamer, (9) the bitter recluse, and (10) the silent martyr.
· Solomon: (1) hostile/angry, (2) pushy/presumptuous, (3) deceitful/underhanded, (4) shrewd/manipulative, (5) rude/abrasive, (6) egotistical/self-centered, (7) procrastinating/vacillating, (8) rigid/obstinate, (9) tight-lipped/taciturn, and (10) complaining/critical.”
“Wow, Curmudge! I didn’t know there could be so many types of painful people. I’ll really have to do my homework if I recognize any of these folks. Fortunately, there aren’t many of these types in the hospital, unless they are on the other side of the door in Behavioral Health.”
“In a Lean culture, I would consider the people listed by the authors as team-destroying or team-endangering. I hope that in the hospital the problems you’ll be faced with are less serious. Perhaps we can call them second-order difficult people. Here are some of the deficiencies that might be found among hospital staff: reluctance to help others, poor communication, absence of empathy, chronically late for work, resistance to change, poor technique, and carelessness. I’m sure you can make your own list that is much longer. Of course when patient safety is a concern—as in poor technique and carelessness—the problem is much more serious than second order.”
“So how do we tackle second-order problems, Curmudge? You taught me that reluctance to address a performance or behavioral issue is a failure in servant leadership.”
“It certainly is. Al Stubblefield (we mentioned his book on March 6) said, ‘You’ll never change what you tolerate.’ Quint Studer, whose book we referenced on January 14, recommended that a hospital—with employee participation—develop a set of standards of behavior. Stubblefield’s book has a partial example. Prospective employees must sign this as part of their application. Employees who cannot improve their attitude or performance in a way that meets the commitment that they signed may be asked to leave the organization. Of course before that point is reached, you should try to guide them toward doing better.”
“It sounds reasonable, Curmudge, but not especially easy. Do either of the authors have specific suggestions on how to proceed?”
“Here’s what Studer proposes we do in a meeting with a low performer:
· Do not start the meeting on a positive note.
· Describe the behavior you have seen.
· Evaluate how you feel about that behavior.
· Show how the work must be done (this may occur after the meeting).
· Make certain that the employee knows the consequences of continued poor performance.”
“It’s as you said a few weeks ago, Curmudge. ‘A servant leader can be just as demanding of her direct reports as anyone else.’ Sounds a lot like tough love.”
“That’s true, Julie. You’ve learned a lot, but I hope that you’ll never need to use it.”
“Oh, I’ll use it all right. I’m going to go home and write a set of standards of behavior for my husband. He’ll have to fix dinner for the kids when I work the p.m. shift, take me out for dinner once a week, watch only one football game per weekend, will not practice his bagpipes when I’m working the night shift and trying to sleep during the day, …”
Affinity’s Kaizen Curmudgeon
* Bell, A.H. and Smith, D.M. Winning With Difficult People. Barron’s, 1991.
** Solomon, M. Working With Difficult People. Prentice Hall, 1990. (Both books available in the Appleton Public Library.)
“That’s for sure, Jaded Julie. And sometimes the problem people aren’t your subordinates; they can be your colleagues and even your boss.”
“I shudder at the thought. What can I do?”
“You’re not alone, Julie. Get help from the experts in HR as I did, and keep your boss informed, unless she is the bad actor. There’s also a ton of books out there detailing how others approached their ‘people’ problems. Bell and Smith present their advice in a very short book*, and Solomon provides guidance on dealing with bosses, colleagues, and subordinates**. Here’s how each of these books categorizes difficult people:
· Bell and Smith: (1) the voice crying in the wilderness, (2) the backstabber, (3) the yes, but (4) the politician, (5) the busybody, (6) the short fuse, (7) the liar, (8) the blamer, (9) the bitter recluse, and (10) the silent martyr.
· Solomon: (1) hostile/angry, (2) pushy/presumptuous, (3) deceitful/underhanded, (4) shrewd/manipulative, (5) rude/abrasive, (6) egotistical/self-centered, (7) procrastinating/vacillating, (8) rigid/obstinate, (9) tight-lipped/taciturn, and (10) complaining/critical.”
“Wow, Curmudge! I didn’t know there could be so many types of painful people. I’ll really have to do my homework if I recognize any of these folks. Fortunately, there aren’t many of these types in the hospital, unless they are on the other side of the door in Behavioral Health.”
“In a Lean culture, I would consider the people listed by the authors as team-destroying or team-endangering. I hope that in the hospital the problems you’ll be faced with are less serious. Perhaps we can call them second-order difficult people. Here are some of the deficiencies that might be found among hospital staff: reluctance to help others, poor communication, absence of empathy, chronically late for work, resistance to change, poor technique, and carelessness. I’m sure you can make your own list that is much longer. Of course when patient safety is a concern—as in poor technique and carelessness—the problem is much more serious than second order.”
“So how do we tackle second-order problems, Curmudge? You taught me that reluctance to address a performance or behavioral issue is a failure in servant leadership.”
“It certainly is. Al Stubblefield (we mentioned his book on March 6) said, ‘You’ll never change what you tolerate.’ Quint Studer, whose book we referenced on January 14, recommended that a hospital—with employee participation—develop a set of standards of behavior. Stubblefield’s book has a partial example. Prospective employees must sign this as part of their application. Employees who cannot improve their attitude or performance in a way that meets the commitment that they signed may be asked to leave the organization. Of course before that point is reached, you should try to guide them toward doing better.”
“It sounds reasonable, Curmudge, but not especially easy. Do either of the authors have specific suggestions on how to proceed?”
“Here’s what Studer proposes we do in a meeting with a low performer:
· Do not start the meeting on a positive note.
· Describe the behavior you have seen.
· Evaluate how you feel about that behavior.
· Show how the work must be done (this may occur after the meeting).
· Make certain that the employee knows the consequences of continued poor performance.”
“It’s as you said a few weeks ago, Curmudge. ‘A servant leader can be just as demanding of her direct reports as anyone else.’ Sounds a lot like tough love.”
“That’s true, Julie. You’ve learned a lot, but I hope that you’ll never need to use it.”
“Oh, I’ll use it all right. I’m going to go home and write a set of standards of behavior for my husband. He’ll have to fix dinner for the kids when I work the p.m. shift, take me out for dinner once a week, watch only one football game per weekend, will not practice his bagpipes when I’m working the night shift and trying to sleep during the day, …”
Affinity’s Kaizen Curmudgeon
* Bell, A.H. and Smith, D.M. Winning With Difficult People. Barron’s, 1991.
** Solomon, M. Working With Difficult People. Prentice Hall, 1990. (Both books available in the Appleton Public Library.)
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