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

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.

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