“Bon anniversaire, Jaded Julie.”
“Last year you sang ‘Happy Birthday’ in Italian, so this year it must be French. Happy birthday to you also, Curmudge. The first Kaizen Curmudgeon posting was on May 23, 2007, so we’ve selected that as the blog’s birthday. Our fictional names were conceived somewhat before that, weren’t they? Like most facts, it has probably escaped from your memory; but if it hasn’t, please tell me where my name came from.”
“In Lean terms, Jaded Julie, your name was simply the result of an ‘aha moment’ when I was comparing Lean with other programs back on February 15, 2007. I would like to think of it as a stroke of genius, but realistically, it was just an incidental inspiration.”
“Are real—not fictional—people conceived as the result of an ‘aha moment,’ Curmudge?”
“The process is more complicated than that, but sometimes it’s not given any more forethought than I did.”
“Since we don’t have any birthday cake to share with our readers, is there anything we can give people to make their having clicked on our URL worthwhile?”
“There always is, Julie. Back on October 29, 2009 (101 Curmudgeons) we told our readers the dates where they could find our discussions of the topics covered in our first 100 postings. Let’s continue from that point up to the present date:
Medical Home—November-December 2009
Volunteering—January 7, 2010
Communications—January 22 & 28, 2010
Lean in Construction—February 2010
5S and Kanban—March 4 & 11, 2010
Culture of Elegance—March 25, 2010
Mistakes—April 1 & 8, 2010
‘Invisible’ People—April 15 & 22, 2010
Checklists—April 29, 2010
Hospitals in Appleton—May 13, 2010
Medical Home Teamwork—May 20, 2010”
“Hey, Curmudge, don’t forget Curmudgeon’s Wastebasket that we started back on January 10. As I understand it, that’s for Kaizen Curmudgeon drafts that were ‘deep-six’ed’ as well as controversial topics that you just found interesting.”
“That’s it, Julie. But postings will be irregular. When Kaizen Curmudgeon requires lots of time, nothing will go into the Wastebasket. And speaking of time, I’m going to take some time off. As they say in the theater, Kaizen Curmudgeon will be ‘dark’ next week.”
“You’ve earned it, Curmudge. But at your age, don’t forget to turn the lights back on when you return.”
Affinity’s Kaizen Curmudgeon
Friday, May 28, 2010
Thursday, May 20, 2010
Teamwork--It's the People
“Curmudge, you promised to resume our discussion of the medical home. We spent most of October and November of 2009 on this topic, but it came to an abrupt halt when everyone in the clinics became involved with treating folks with H1N1 flu. Most of what we wrote came from the literature, but we couldn’t complete our study by describing how it was working out at Affinity.”
“That’s it, Jaded Julie. Now the team members at our pilot site at Koeller Street have time to talk with me, so we’ll pick up the medical home story where we left off.”
“You’re assuming our readers remember what they read seven months ago? If they can do that, they’ve got better memories than you have.”
“Doesn’t everyone? Well if they need a one-stop refresher, they can go back to our posting of November 19, 2009.”
“So compared with what we read in late November, how is the medical home team at Koeller Street doing?”
“Stated most simply, Julie, ‘they’re doing it.’ That’s the story, and it’s time for my morning nap. So if you’ll excuse me…”
“Wait, Curmudge! You can’t just drift off without telling me how they are doing whatever they are doing. You once told me about how you became a teamwork zealot many years ago when you worked in industry. The teamwork exhibited at Koeller Street must have delighted you. What have they done to make that happen?”
“It’s the people, Jaded Julie. They have the right people. There are lots of books written about teamwork; but if you don’t have the right people on the team, applying the principles in the books will be an uphill struggle.”
“Okay, amateur psychologist, after just a one-hour meeting, how did you conclude that these were the right people?”
“After over 40 years attending meetings like ours—on both sides of the table—it was evident to me that the team got along well together and that they seemed to accept my presence. I didn’t see any eye-rolling (what’s this nut-cake doing here?) or squinting (when will he leave?). The team had been assembled from within and outside of Affinity. In addition to their professional qualifications, team members were ‘hand-selected’ who were congenial, communicative, and interested in cross-training. One member indicated that her position with the team was ‘the best job she has had in 14 years.’ On an earlier occasion another team member stated, ‘I have come from many a broken home (presumably an inefficient conventional medical office)—I now could never settle for anything less than a medical home.’”
“Those certainly are impressive testimonials. So what did the group do to make their team a medical home? ‘You can’t tell the players without a scorecard,’ so perhaps you can start by telling me the number of people at each position.”
“The team is what one would expect in a medical home: one physician, two nurse practitioners, one RN specialist, four health care associates (five people with two sharing a position), four patient service representatives, and one social worker who serves as a behavioral health provider and case coordinator. The makeup and functions of medical home teams might be different at other sites depending on the patient panel size and demographics. Duties of these people are generally as described in our posting back on November 12, 2009.”
“There are no surprises there. So, Curmudge, where does the teamwork come in?”
“The physician and nurse practitioners work collaboratively; this keeps any one of them from being overloaded and provides more prompt personalized care for the patients. In Lean we call this load leveling. The nurses (health care associates) work as a team, with no nurse assigned exclusively to a provider. In addition, on a daily rotating basis, one nurse sits with the patient service reps to handle calls from patients who need to speak with a nurse. She is called the ‘nurse of the day’ (NOD), and she provides patients a single, familiar voice on the phone for calls and call-backs during the day.”
“I know, Curmudge, that cross-training is one of your hot-button topics. The team does that in a big way.”
“They certainly do, Julie. The patient service reps learn from the health care associates so that they can room patients and take vitals in addition to scheduling and record-keeping. When people are interested in career development, this is a way for them to ‘be all they can be.’ In health care language, this is called ‘encouraging people to work up to the full scope of their licensure and potential.’”
“So what is today’s bottom line, Curmudge?”
“The medical home concept is a model for primary patient care; it is not a template supplying every detail. The team members at Koeller Street are working together to develop the detailed workflows that work best for their team. Continuous improvement—the heart of Lean—is the heart of their medical home.”
Affinity’s Kaizen Curmudgeon
“That’s it, Jaded Julie. Now the team members at our pilot site at Koeller Street have time to talk with me, so we’ll pick up the medical home story where we left off.”
“You’re assuming our readers remember what they read seven months ago? If they can do that, they’ve got better memories than you have.”
“Doesn’t everyone? Well if they need a one-stop refresher, they can go back to our posting of November 19, 2009.”
“So compared with what we read in late November, how is the medical home team at Koeller Street doing?”
“Stated most simply, Julie, ‘they’re doing it.’ That’s the story, and it’s time for my morning nap. So if you’ll excuse me…”
“Wait, Curmudge! You can’t just drift off without telling me how they are doing whatever they are doing. You once told me about how you became a teamwork zealot many years ago when you worked in industry. The teamwork exhibited at Koeller Street must have delighted you. What have they done to make that happen?”
“It’s the people, Jaded Julie. They have the right people. There are lots of books written about teamwork; but if you don’t have the right people on the team, applying the principles in the books will be an uphill struggle.”
“Okay, amateur psychologist, after just a one-hour meeting, how did you conclude that these were the right people?”
“After over 40 years attending meetings like ours—on both sides of the table—it was evident to me that the team got along well together and that they seemed to accept my presence. I didn’t see any eye-rolling (what’s this nut-cake doing here?) or squinting (when will he leave?). The team had been assembled from within and outside of Affinity. In addition to their professional qualifications, team members were ‘hand-selected’ who were congenial, communicative, and interested in cross-training. One member indicated that her position with the team was ‘the best job she has had in 14 years.’ On an earlier occasion another team member stated, ‘I have come from many a broken home (presumably an inefficient conventional medical office)—I now could never settle for anything less than a medical home.’”
“Those certainly are impressive testimonials. So what did the group do to make their team a medical home? ‘You can’t tell the players without a scorecard,’ so perhaps you can start by telling me the number of people at each position.”
“The team is what one would expect in a medical home: one physician, two nurse practitioners, one RN specialist, four health care associates (five people with two sharing a position), four patient service representatives, and one social worker who serves as a behavioral health provider and case coordinator. The makeup and functions of medical home teams might be different at other sites depending on the patient panel size and demographics. Duties of these people are generally as described in our posting back on November 12, 2009.”
“There are no surprises there. So, Curmudge, where does the teamwork come in?”
“The physician and nurse practitioners work collaboratively; this keeps any one of them from being overloaded and provides more prompt personalized care for the patients. In Lean we call this load leveling. The nurses (health care associates) work as a team, with no nurse assigned exclusively to a provider. In addition, on a daily rotating basis, one nurse sits with the patient service reps to handle calls from patients who need to speak with a nurse. She is called the ‘nurse of the day’ (NOD), and she provides patients a single, familiar voice on the phone for calls and call-backs during the day.”
“I know, Curmudge, that cross-training is one of your hot-button topics. The team does that in a big way.”
“They certainly do, Julie. The patient service reps learn from the health care associates so that they can room patients and take vitals in addition to scheduling and record-keeping. When people are interested in career development, this is a way for them to ‘be all they can be.’ In health care language, this is called ‘encouraging people to work up to the full scope of their licensure and potential.’”
“So what is today’s bottom line, Curmudge?”
“The medical home concept is a model for primary patient care; it is not a template supplying every detail. The team members at Koeller Street are working together to develop the detailed workflows that work best for their team. Continuous improvement—the heart of Lean—is the heart of their medical home.”
Affinity’s Kaizen Curmudgeon
Thursday, May 13, 2010
Twice Blessed
“Curmudge, it’s frustrating. We’re working our heads off spreading the Lean culture throughout Affinity, but the hospital on the other side of town seems to get most of the publicity. If one reads the health care blogs, especially Mark Graban’s LeanBlog, you’d think our competition is the only hospital in Appleton.”
“As I mentioned in our last discussion, Jaded Julie, competition between hospitals is a bit different than between manufacturers. For readers who are not local, let’s begin with some geography and history.”
“Go ahead, Old Guy, but I suspect you’ll take the scenic route in answering my concerns.”
“The Fox River flows from west to east, dividing Appleton into the North Side and the South Side. Over 100 years ago this distinction was fairly critical because the North Side was populated mainly by Protestants and the South Side by Catholics. It is said that on Sundays, the teetotaling Methodists sat on the north bank watching the Catholics on the south bank drink beer. Of course, that’s where the brewery was located.”
“So when our Founding Sisters arrived over 100 years ago, they established St. Elizabeth Hospital amid the Catholic population on the South Side.”
“That’s it, Julie. As time passed, the North Side folks grew tired of driving through the Flats and crossing the narrow, low-level bridges (Oneida St., Lawe St., and John St.) to get to St. E’s. By 1958 the Appleton business leaders had raised enough money to open Appleton Memorial Hospital on the North Side. Of course by then, everyone lived everywhere; and cultural differences between North Side and South Side were no longer meaningful. As they say, the rest is history.”
“But it’s not the rest, Curmudge. What about Lean?”
“Well, we became Affinity, and they became ThedaCare. They began their Lean journey a couple of years before we did. As Civil War General Nathan Bedford Forrest advised, ‘git thar fust with the most,’ and ThedaCare did. The Lean movement in health care needed early success stories, and they were provided by Virginia Mason Medical Center and ThedaCare.”
“If that is our history, where are we now?”
“As I understand it, we both have dynamic Lean efforts and excellent equipment and facilities. At Affinity we are seeking an advantage in quality of service through Personalized Care.”
“So what, Curmudge, is the ‘twice-blessed’ stuff in the title of today’s discussion?”
“Over the years, many people in Appleton have been patients of specialists and primary care physicians who later became affiliated with Affinity or ThedaCare. If we are still seeing them, we might end up in either of the two Appleton hospitals. Both should provide excellent care, so we are indeed twice blessed.”
“I don’t advocate getting sick anywhere; but if it’s going to occur, Appleton is not a bad place for it to happen.”
“Julie, as I described on April 23, 2009, it’s surely better here than in Prague, Czech Republic.”
Affinity’s Kaizen Curmudgeon
“As I mentioned in our last discussion, Jaded Julie, competition between hospitals is a bit different than between manufacturers. For readers who are not local, let’s begin with some geography and history.”
“Go ahead, Old Guy, but I suspect you’ll take the scenic route in answering my concerns.”
“The Fox River flows from west to east, dividing Appleton into the North Side and the South Side. Over 100 years ago this distinction was fairly critical because the North Side was populated mainly by Protestants and the South Side by Catholics. It is said that on Sundays, the teetotaling Methodists sat on the north bank watching the Catholics on the south bank drink beer. Of course, that’s where the brewery was located.”
“So when our Founding Sisters arrived over 100 years ago, they established St. Elizabeth Hospital amid the Catholic population on the South Side.”
“That’s it, Julie. As time passed, the North Side folks grew tired of driving through the Flats and crossing the narrow, low-level bridges (Oneida St., Lawe St., and John St.) to get to St. E’s. By 1958 the Appleton business leaders had raised enough money to open Appleton Memorial Hospital on the North Side. Of course by then, everyone lived everywhere; and cultural differences between North Side and South Side were no longer meaningful. As they say, the rest is history.”
“But it’s not the rest, Curmudge. What about Lean?”
“Well, we became Affinity, and they became ThedaCare. They began their Lean journey a couple of years before we did. As Civil War General Nathan Bedford Forrest advised, ‘git thar fust with the most,’ and ThedaCare did. The Lean movement in health care needed early success stories, and they were provided by Virginia Mason Medical Center and ThedaCare.”
“If that is our history, where are we now?”
“As I understand it, we both have dynamic Lean efforts and excellent equipment and facilities. At Affinity we are seeking an advantage in quality of service through Personalized Care.”
“So what, Curmudge, is the ‘twice-blessed’ stuff in the title of today’s discussion?”
“Over the years, many people in Appleton have been patients of specialists and primary care physicians who later became affiliated with Affinity or ThedaCare. If we are still seeing them, we might end up in either of the two Appleton hospitals. Both should provide excellent care, so we are indeed twice blessed.”
“I don’t advocate getting sick anywhere; but if it’s going to occur, Appleton is not a bad place for it to happen.”
“Julie, as I described on April 23, 2009, it’s surely better here than in Prague, Czech Republic.”
Affinity’s Kaizen Curmudgeon
Thursday, May 6, 2010
The Sensei is Concerned
“Curmudge, you look worried.”
“Perhaps, Jaded Julie, I’m just reflecting Jim Womack’s concerns about the future of Lean. If a person of his stature in the Lean movement is wondering what lies ahead, the rest of us should also.”
“Okay, Mr. Prognosticator, what do you and Womack see coming at us?”
“Womack reminds us that the process improvement programs of the past, like Total Quality Management, have emerged as waves that crested and then declined. Might this happen to Lean, and if it does, why? Then he answers himself by asserting that while we have been improving our core (production) processes, we have not similarly improved the management processes. He implies that an organization’s persistence in using traditional management will be Lean’s downfall.”
“I shudder at the thought. So what countermeasures does Womack propose?”
“He suggests that senior managers be engaged as a team to evaluate the current state of the organization’s management system. They need to consider how to identify the most important problems, how to evaluate proposals originating in gemba, how to implement standardized work and management, and how to create the current and next generations of lean managers.”
“Womack’s comments were for everybody. How do they apply to health care?”
“Actually, Julie, in this blog we addressed some of Womack’s issues long ago. We talked about hoshin kanri to prioritize problems (September-October 2007), and the development of manager/leaders and servant leaders (from May 8 through June 5, 2008). Although neither hoshin kanri nor servant leadership is an integral part of Lean, they both are essential adjuncts. And in addition, we talked about things an organization must do to prevent Lean’s early demise (October 29, 2007).”
“Curmudge, I recall your mentioning something about the differences in the nature of competition between manufacturers and hospitals.”
“Confidentiality is a critical issue with manufacturers of similar products. When husband and wife work for competing companies, there is great concern that company-confidential information might get mentioned in ‘pillow talk.’ It seems to be different in health care. In metropolitan areas with several hospitals in close proximity, the interchange of employees is common. Although the hospitals compete for patients, they do so by openly advertising their advances in service and how the advances were achieved.”
“So what does this have to do with the longevity of Lean programs in health care?”
“The folks in Hospital A know that if they allow their Lean efforts to lag and their waste and inefficiency to increase, it will inevitably be recognized in the community. As a result, Hospital B will become dominant in attracting providers as well as patients. Self-preservation will be a powerful motivator for Hospital A to maintain their Lean culture.”
“I suspect what you are saying, Curmudge, is that of necessity Lean will evolve and grow in health care; and even if its name is changed, the reincarnation will contain the best features of Lean.”
Affinity’s Kaizen Curmudgeon
“Perhaps, Jaded Julie, I’m just reflecting Jim Womack’s concerns about the future of Lean. If a person of his stature in the Lean movement is wondering what lies ahead, the rest of us should also.”
“Okay, Mr. Prognosticator, what do you and Womack see coming at us?”
“Womack reminds us that the process improvement programs of the past, like Total Quality Management, have emerged as waves that crested and then declined. Might this happen to Lean, and if it does, why? Then he answers himself by asserting that while we have been improving our core (production) processes, we have not similarly improved the management processes. He implies that an organization’s persistence in using traditional management will be Lean’s downfall.”
“I shudder at the thought. So what countermeasures does Womack propose?”
“He suggests that senior managers be engaged as a team to evaluate the current state of the organization’s management system. They need to consider how to identify the most important problems, how to evaluate proposals originating in gemba, how to implement standardized work and management, and how to create the current and next generations of lean managers.”
“Womack’s comments were for everybody. How do they apply to health care?”
“Actually, Julie, in this blog we addressed some of Womack’s issues long ago. We talked about hoshin kanri to prioritize problems (September-October 2007), and the development of manager/leaders and servant leaders (from May 8 through June 5, 2008). Although neither hoshin kanri nor servant leadership is an integral part of Lean, they both are essential adjuncts. And in addition, we talked about things an organization must do to prevent Lean’s early demise (October 29, 2007).”
“Curmudge, I recall your mentioning something about the differences in the nature of competition between manufacturers and hospitals.”
“Confidentiality is a critical issue with manufacturers of similar products. When husband and wife work for competing companies, there is great concern that company-confidential information might get mentioned in ‘pillow talk.’ It seems to be different in health care. In metropolitan areas with several hospitals in close proximity, the interchange of employees is common. Although the hospitals compete for patients, they do so by openly advertising their advances in service and how the advances were achieved.”
“So what does this have to do with the longevity of Lean programs in health care?”
“The folks in Hospital A know that if they allow their Lean efforts to lag and their waste and inefficiency to increase, it will inevitably be recognized in the community. As a result, Hospital B will become dominant in attracting providers as well as patients. Self-preservation will be a powerful motivator for Hospital A to maintain their Lean culture.”
“I suspect what you are saying, Curmudge, is that of necessity Lean will evolve and grow in health care; and even if its name is changed, the reincarnation will contain the best features of Lean.”
Affinity’s Kaizen Curmudgeon
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