Thursday, February 25, 2010

Lean Lessons from Long Ago

“Jaded Julie, one of the beauties of Lean is that it provides a framework—a philosophy and organization—for management techniques that have been used since long before Lean was invented.”

“Well, Old Guy, if anyone can teach a history lesson, it’s you. I presume that you’ll be telling us about things you have observed since the middle of the last century.”

“Let’s start with some very un-Lean statements that were burned into my memory. From a world-class chemist speaking about his technician: ‘She’s just a pair of hands.’ Today, one would expect him to help her become the best that she can be.”

“Of course, Curmudge, that assumes that she was capable of being something better than ‘a pair of hands.’”

“Here’s another one. A very proficient technician (not in my group) was speaking of the value of doing excellent work vs. just doing enough to get by: ‘The pay’s the same.’ Whether or not that represented his true feelings, I hope no one else heard him. In fact, in that organization ‘just getting by’ was quite rare.”

“So far, Curmudge, you have made the workplace of yesteryear sound like a haven for mediocrity. You must also have encountered some examples of excellence.”

“I have, and here is one. The scene was a pulp and paper mill in the middle of a small town. The main street ran right next to the mill’s bleach plant. I was in a meeting in our lab building a couple of hundred yards up the hill from the mill when the bleach plant blew up. We felt the shock wave as our windows rattled. Although no one was injured by the blast, anyone walking past the bleach plant would have experienced instantaneous incontinence.”

“Hey, you’re supposed to be providing examples of excellence. That doesn’t sound very good to me.”

“The story’s not over. Mill personnel reacted like real professionals (the mill even had its own fire department). The mill manager assured the town mayor that there was no need to evacuate. The next day, mill management and technical and operating personnel were hard at work performing root cause analysis. They presumably found the cause and made the necessary repairs (rebuilding part of the bleach plant and its bulged-out exterior wall). It must have truly been the root cause, because in 20 years the bleach plant has never experienced another explosion.”

“Managers must know what’s going on in their mill. Did they ever go to gemba?”

“The people that I worked with never heard of ‘gemba,’ but they certainly went there. The manager of a small mill walked through the mill as his first duty every morning. He knew and talked with everybody. Although he wasn’t a very pleasant person to work with, he certainly kept his finger on the pulse of the mill.”

“What about big facilities? They are too big to walk through every day.”

“Usually big mills have the traditional ‘morning meeting’ involving the manager and department heads who report on their respective areas. It’s essential that someone go to gemba on a regular basis, and the department heads did.”

“It’s time for true confessions, Curmudge. Were you ever directly involved in any of these events? If it was something bad, you’ve probably forgotten.”

“Late in my career I worked part time in a small lab with a rather imperious president. Most often, when he went into the lab it was to chew someone out. I decided to walk through the lab’s several rooms every day to say ‘good morning.’ Apparently the technicians valued my visits; one said she’d miss them after she resigned. I guess that everyone needs to feel appreciated even if it’s by an old greybeard who had absolutely no authority.”

Affinity’s Kaizen Curmudgeon


Check out the latest posting in Curmudge and Jaded Julie’s personal blog, Curmudgeon’s Wastebasket.

Thursday, February 18, 2010

Heart, Lung & Vascular Center: From Current State to Future State

“It looks as if we are back to classical Lean, Curmudge. No more sophisticated mattresses.”

Matrices, Jaded Julie. Despite using the wrong word, you have the right idea. The team made a current state map of a patient’s route through pulmonary testing and treatment. They estimated value added and non-value added times and the patient’s walking distance. In addition, they used a spaghetti diagram to depict the walking required of various types of patients.”

“When showing a current state, a spaghetti diagram really hits you in the eye. If you want to impress someone with the need for improvement, that diagram ought to do the job. It’s too bad that we can’t show one in the blog.”

“Our space is too narrow, Julie. The value of the maps and diagrams was to inspire the team to think of opportunities to improve patient privacy, travel distance, and wait time as well as staff productivity and waiting. So the next logical step was to go to gemba—the pulmonary area—and measure the actual times of patients as they passed through each step in their appointments.”

“Another cool move, Curmudge. As I understand it, staff members recorded times on a time study template based on a current state map. This was attached to the charge sheet that accompanied each patient that visited the department in a typical week. The template made the time study irresistibly easy for the staff.”

“It gets even more cool, Julie. For every timed step in the patient visits, statistical software was used to plot frequency (i.e., number of patients within a given time interval) vs. time. The times studied in this manner included the total visit overall, patient wait time, registration, nurse rooming and vitals, provider exam and treatment, nurse follow-up, and scheduling the next appointment. Studies of provider times suggested that long appointments should rarely be needed. Providers should be able to see more patients in a week and log more relative value units (RVUs).”

“I see tears in your eyes, Curmudge. Is that because back when you were doing statistics there wasn’t Minitab software to do the hard work?”

“Good observation, Julie. Not only was there no Minitab, there was no computer. All I had was a slide rule and a pencil, paper, and ruler to draw histograms. Now, in addition to Minitab, teams use an electronic whiteboard and modeling and simulation software to test possible configurations of their future space. It’s like building the building, trying it on for size and efficiency, and then tearing it down and trying it again—all in the computer.”

“Curmudge, the elegance of this process boggles my mind as much as it does yours. So what was the result of this effort?”

“The insights gained by the team served as the basis of the new construction. The biggest innovation was that providers come to the patient instead of patients’ moving from place to place. To increase efficiency, each computer in the department has an electronic map of the area. It shows the progress of a patient, rooms that are vacant or in use, who is doing what, and signals when a scheduler is needed to plan the patient’s next appointment. This system serves as a workflow, and it significantly increases staff efficiency.”

“And so, Senescent Storyteller, your tale is told and everyone lived happily ever after.”

“That’s essentially true, Julie, but remember that the Lean story never ends because perfection is never achieved. This process will be repeated for each remodeling and construction project. A team will listen to the voices of their customers, prioritize customer inputs, select and perform measurements of their current state, analyze their data, and model and select their most efficient future state. It’s a great development, but as Lean suggests of any process, it will eventually be improved.”

Affinity’s Kaizen Curmudgeon


Check out the latest posting in Curmudge and Jaded Julie’s personal blog, Curmudgeon’s Wastebasket.

Thursday, February 11, 2010

From Customer Ideas to Project Choices

“I’m confident, Jaded Julie, that you know this old saying, ‘There are only two things in this life that you have to do. You have to die and you have to…”

“…pay taxes.’ Everybody knows that one, Curmudge. So why wreck a nice day by talking about taxes?”

“Because, Ms. Know-It-All, the old saw is wrong. Some people exist out in the boonies, live off the land, and don’t pay taxes. The correct saying is, ‘You have to die, and you have to make choices’ (1).”

“That makes sense, Well-Read Relic, but what does it have to do with the patient experience and building an addition onto the hospital?”

“Pretty simple, Julie. In our last discussion, the teams began with 860 patient ideas and made judicious choices of common themes and big ideas. Next was deciding where to apply these learnings, and the logical choice was the construction project at the top of the list, the Heart, Lung, and Vascular Center.”

“If this blog is about Lean in health care—and it is—you’ll soon tell me about the advanced Lean techniques used in designing the new construction.”

“I sure will, but first we need to define ‘the team.’ Because we were planning Heart/Lung Center construction, the team represented H/L staff, the architectural firm, and a facilitator from the Kaizen Promotion Office. The facilitator’s tasks were critical because he had to teach the advanced Lean techniques to the staff and guide them in their use.”

“I understand, Curmudge, that the team used matrices as the advanced Lean methods to aid their choices (2). Back on September 25, 2007 you described a matrix using a calendar as a simple example.”

“This time, Julie, our discussion will be even less technical. First the team used the customer needs—most of which are the criteria of our Personalized Care—to create a matrix of critical-to-quality factors (CTQs). CTQs are measureable characteristics of service that are, in the eyes of the patients, critical to the quality of care that they receive. So up to this point, the team had identified what the patients want and the relative importance of things that can be measured to determine if the patients’ needs are being met.”

“That’s pretty cool, Curmudge. The team’s judgments were based on quantifiable measures rather than on seat-of-the-pants choices.”

“Next the team used another technique (a Pugh matrix, but you can forget the name, Julie) to select projects and measurements that should have the greatest impact on meeting patient needs. The results pointed the team toward educated decisions regarding projects needed to guide the architect’s final design. In-room scheduling, clinic communication, and exam room layout were among the potential projects that received the highest rankings. We’ll talk about those projects next time.”

“It’s certainly reassuring to learn that there can be science behind making decisions. Do you suppose, Curmudge, that using a Pugh matrix might have helped me in choosing a husband? If I had, I might not have selected a couch potato.”

Affinity’s Kaizen Curmudgeon

(1) Hunter, James C. The Servant (Crown Business, 1998)
(2) Hess, M. Quick, quality decision-making using Six Sigma tools. http://www.isixsigma.com/library/content/c041108a.asp

Check out the latest posting in Curmudge and Jaded Julie’s personal blog, Curmudgeon’s Wastebasket.

Thursday, February 4, 2010

The First Step in New Health Care Construction: The Voice of the Patient

“Jaded Julie, what’s the first thing we should consider in planning new additions to the hospital campus?”

“”I’m delighted that you asked, Curmudge. The first thing we should design is a sumptuous nurses’ lounge.”

“Get serious! You know that’s not correct. But being the forgiving guy that I am, I’ll give you a second chance at the question.”

“You know me, Curmudge. When given the opportunity, I swing for the fences. I guess the traditional way to design new additions to the hospital is to hire an experienced architect, tell him what you want, and hope for the best. If the new facility has deficiencies, you spend the rest of your career doing kaizen events to correct them.”

“If you did that these days, the ‘rest of your career’ might be very short. Now we ‘do it right the first time’ whether it’s building a hospital or running a test in the lab. So how do we learn what we want so we can tell the architect?”

“I’ve got it, Curmudge; I finally have the answer. The first step is to listen to the voice of the customer—in this case, the patient.”

“Good job, Julie, and it only took you half a page. Teams representing each of the departments to be involved in new construction were assembled for the purpose of assessing the experiences of patients coming into our present facilities. Patient interviews helped us understand our present shortcomings and what the patients would like to experience in the future. It’s quite amazing that the patients came up with 860 ideas.”

“Do you mean that we have been doing 860 things wrong?”

“Not necessarily, but there were 860 items to consider. Each team gathered the ideas collected by its members into groups based on the ideas’ similarity. Numbers of groups ranged from 5 for the Inpatient Surgery team to 18 for Outpatient Testing. Some themes, such as privacy, patient safety, and communications, appeared repeatedly in the groups from several teams. The big ideas on how to make things better were then put on a high-level process map of the patient experience. Parts of the map include Understanding (why the patient decides to come to Affinity), Entry (arrival, wayfinding, and registration), Assessment (identifying patient status and needs), Treatment, and Transition (follow-up and ongoing care).”

“Voice of the customer. Process Map. Hey, Curmudge, this is sounding more and more like Lean.”


“That’s because it is Lean, Julie. If we use Lean in building design, we’ll have fewer irritants—like nurse workarounds—that require Lean events later on. And in addition, what was learned in the Patient Experience study sounds more and more like the attributes of our brand promise, Personalized Care.”

“It certainly seems as if we are on the right track. I presume our discussion of Lean in building design will be continued next time. By the way, Curmudge, in your long and misspent life you must have had a few experiences as a patient.”

“Those are things I want to forget. Almost exactly 51 years ago I was a patient for two days. As a result, my advice to a patient then was, ‘Leave your dignity at home.’ Thank God things are much better now, and with Personalized Care they’re improving every day.”

“Amen, Curmudge, amen.”

Affinity’s Kaizen Curmudgeon

Check out the latest posting in Curmudge and Jaded Julie’s personal blog, Curmudgeon’s Wastebasket.