Thursday, March 25, 2010

A Culture of Elegance

“Curmudge, we recently discussed examples of poor organizational cultures in Curmudgeon’s Wastebasket. Judging from today’s title, we must be at the opposite end of the cultural scale.”

“We are, Jaded Julie, and we’d better begin by defining elegance in the context of our discussion. It’s more than dressing and behaving properly—as the Italians call it, la bella figura. To me, elegance is being a little bit better than excellent in every respect. It’s the perception that we want to impart to patients whenever they walk into one of our hospitals or clinics. It’s fully deployed personalized care that gives a patient the feeling that the right things will be done right the first time every time. I’ve never been to the Mayo Clinic, but I suspect that they have it.”

“That sounds great, Curmudge. You’ve actually experienced this?”

“Let’s start with a classical example, the cathedrals of Europe. The elegance of their construction and decoration suggests that, to a degree, they were a labor of love (plus a lot of hard work by generations of laborers and artisans).”

“The next time you go, I’d like to tag along. Do you suppose Mrs. Curmudgeon might object?”

“There are examples of elegance a lot closer to home. Let’s step back in time about 30 years. When a new person joined the organization where I was working, he or she soon realized, ‘Here I am in an organization known across the world for its high quality. I’m going to do my personal best—or even better—to achieve that standard.’ And they proceeded to meet or exceed their own expectations.”

“You must have had a powerful corporate training program.”

“There was nothing formal. It was individual-to-individual and often peer-to-peer. Although it is hard to explain, it was undoubtedly aided by the organization’s collegial atmosphere. Everyone from the front office to the person who washed dishes in the corner of the basement was respected for the quality of their work. Back in the days when all incoming calls came into the switchboard our operator was able to greet many of the callers by recognizing the sound of their voice. She listened carefully, remembered, and performed with élan.”

“Wow, that was elegant service beyond anyone’s expectations. There’s more?”

“Before personal computers were common, most outgoing documents were typed in the secretarial pool. The woman in charge knew that the documents were the face of our organization, so she demanded perfection. Style (from our Style Manual), spelling, punctuation—when the documents went out the door, they were elegant. Forty years later, the women that she trained and the people for whom they typed are still perfectionists.”

“I guess that explains, Curmudge, why you go ballistic when you see a typo. Are you aware of examples of elegance in health care?”

“Here’s another personal example. When I had surgery on my ear, the surgeon insisted on grafting skin from behind my ear to cover the surgical site. I mentioned that no one cares what an old man’s ear looks like. He said that he did and that he didn’t want any of his patients going around with a scarred-up ear. In this case, elegance was the physician’s personal requirement that reflected his pride in his workmanship.”

“Gosh, Curmudge, I suspect the surgeon’s feeling is pretty widespread in health care. I wish everyone felt that way.”

“Okay, here’s a lesson for everyone and it’s one with which I fully agree. It’s from a 1950’s Constitution (Rule of Life) of Religious Women who ministered in Catholic schools and hospitals throughout the world. It’s called The Perfection of Our Ordinary Actions. ‘The perfection of the…soul depends not so much on performing extraordinary actions as on performing extraordinarily well the ordinary exercises of every day.’ ‘…do each work as if it were the only one (you) had to do.’ The sisters might not agree with my choice of words, but everyone’s adherence to that passage is exactly what is needed to create an elegant organization.”

“Right on! That’s something we should all hardwire. So, Curmudge, what’s the bottom line? What do we take home from today’s discussion?”

“I hope you recall, Julie, our discussion of personal brands a year ago, on
March 18, 2009. We said that the corporate brand of an organization is the aggregate of the personal brands of its employees. When elegance in performance has become a major part of everyone’s personal brand, elegance will join personalized care as a hallmark of our organization.”

“Curmudge, if we’re not there already, I hope we get there soon.”

Affinity’s Kaizen Curmudgeon

Thursday, March 18, 2010

What do you say after, “Lean is based on the Toyota Production System”?

“Curmudge, it’s pretty hard to say that you are a ‘chip off the old block’ when your father has just been accused of poor behavior.”

“It’s almost that bad, Jaded Julie, when one considers Lean’s familial tie to the TPS. Historically, when we explained Lean by referring to Toyota, the listener knew immediately that Lean had something to do with high quality. Now, with Toyota’s recalls and sudden acceleration issues, the listener thinks about quality problems.”

“So how does one avoid mentioning Toyota?”

“Just focus on Lean. It has been used successfully in the U.S. in manufacturing and health care for several years. Talk about respect for people, reduction of waste, and no-layoff policy (using the employer’s approved wording). Until Toyota’s quality problems are resolved, it might be prudent not to emphasize its role in the origin of our culture.”

“But, Curmudge, what if the questioner already knows about the connection between Lean and Toyota?”

“I guess we have to explain things as best we can. Every culture—and religion—has backsliders, and some people say that’s what happened at Toyota. Of course, it’s pretty unusual for the originator of the culture to be an apostate.”

“(Apostate? Knowing Curmudge, that’s got to be just a fancy word for ‘backslider.’) Have any experts with intimate knowledge of Toyota addressed this situation? It would be really helpful to be able to answer an inquisitor by sharing the insights of recognized Lean authorities.”

John Shook’s Lean management column provides several valuable discussions with acknowledged leaders in the Lean fraternity. The comments by Robert Cole were quite critical of Toyota. In 1998 the president of Toyota challenged his managers to double their global market share by 2010. Although it was not his intent, the Toyota president ‘underestimated the way his directive got transmuted as it traveled through the organization. Toyota managers became so busy pressing their suppliers to increase capacity that they became less interested in listening to supplier concerns about what such rapid capacity expansion might do to quality.’”

“In simple terms, Curmudge, it seems as if the Toyota managers strayed from their traditional quality focus and lost their way. Did Professor Cole propose an explanation for this behavior?”

“He did, Julie, and it’s a valuable lesson for all of us. ‘The focus (at Toyota) on hyper-growth led to a growing divergence between its culture and its incentive system. Under these conditions, culture always loses.’”

“I suspect that most everyone attributes Toyota’s situation to some aspect of their rapid growth.”

“Right, Julie, but
Jeff Liker is a bit more forgiving. ‘I think this (dilution of the Toyota Way) was inevitable as the company globalized, lost most of the original generation, and took on hundreds of thousands of outside people.’ ‘I am not so sure that Toyota lost its way as much as they have been struggling to grow up.’”

“What about Japanese experts? Did any of them weigh in with a different view?”

“Professor
Takahiro Fujimoto spoke of the ‘Demons of Complexity.’ ‘The governments of developed countries have imposed strict regulations governing safety, emissions, fuel consumption, and so on. Meanwhile, the requirements of customers have also grown more stringent.’ ‘(The vehicles) contain software with more than 10 million lines of code.’ ‘If there is one primary reason for the crisis, it is that this overwhelming complexity exceeded Toyota’s organizational capability.’”

“At least from the technical standpoint, John Shook provided an encouraging
word. ‘If any company can get to the bottom of an issue like this, a problem like this, it’s Toyota.’ So, Curmudge, what might be the fate of Toyota here in the United States?”

“Japanese executives doing
hansei (reflection) before a congressional committee or in a U.S. courtroom probably won’t cut it. In short, I suspect that Toyota is in a peck of legal trouble that might ultimately spill over into the whole auto industry. The paradigm (prevailing view) of highway safety might shift from asking, ‘What did the driver do wrong?’ to ‘What did the car manufacturer do wrong?’ At least for the moment, we would do well to forget that the TPS was the progenitor of our Lean culture. So after our discussion, Jaded Julie, do you know the real origin of Lean at Affinity?”

“I certainly do. Gary invented it.”

Affinity’s Kaizen Curmudgeon

Thursday, March 11, 2010

Kanban

“Jaded Julie, in my earliest recollection of shopping at the local store (there were no supermarkets then), the clerk wrote the price of each item on a paper bag and manually added up the sum. He then bagged the groceries and my mother paid the bill in cash (how else?). Subsequently, the clerk used a manual adding machine and then a manual cash register (with a hand crank and bell). The store’s inventory control was ‘by guess and by gosh.’”

“Does anyone know how to manually sum a column of numbers these days, Curmudge? I wonder if they teach it in grade school. Now the bar codes on all the items are scanned into a computer. The only manual operation is bagging the groceries, and you are the only person I know who consistently pays in cash.”

“You can bet that the computer records each item purchased and uses the information for inventory control. This keeps the store from experiencing ‘stock-outs,’ although they often intentionally drop a particular brand that might not be selling well. Mrs. Curmudgeon considers that disgusting.”

“So what does all this have to do with health care?”

“One might consider a hospital to be like a big supermarket with many separate inventories and check-out counters. If each stored item had a bar code that was scanned when it was used, the hospital’s inventory could be managed just like the supermarket’s. However, Julie, the nurses and staff would regard scanning each item as extra work, and they would prefer a simple process over one that is complex.”

“But what we have now is simple, especially if the storage area has been 5S’d and everything is in its place.”

“At this point inventory control is haphazard. If a department is out of a critical item (which could be tragic), their next order is apt to be larger to avoid the stock-out. And when the larger order arrives, it might overwhelm the storage area. Another problem is that to avoid being impacted by a stock-out, people will hide their own supply (a phantom inventory) of critical items.”

“I guess what is needed is an inventory management system that is simple and effective.”

“And that, Jaded Julie, is kanban. It’s a Japanese word meaning ‘card’ or ‘signal,’ and that’s what it is and does. It is a card or other object that signals when new inventory needs to be ordered and how much to order. Its effect is to ensure that ‘needed supplies are in the right place, at the right quantity, at the right time, and to ensure the availability of material with the lowest required inventory levels’ (1). Oh, and by the way, I’m sorry that you had to learn a new Japanese word; at least it’s an easy one.”

“Curmudge, if it helps us avoid stock-outs, I’d be willing to learn a new word even if it were in Arabic or Czech. Besides, the word kanban is quite specific. If we just used the English word ‘card,’ it might be confused with business card, playing card, note card, postcard, and more. So tell me how this kanban system works.”

“We’ll start with a system that is up and running, like the one for office supplies on the other side of my office (but this same system could be used for everything from prosthetic joints to boxes of 4” x 4” gauze pads). The kanban card for 1-inch wide rolls of masking tape is a pink 4” x 8” card that shows the stock number of the tape and indicates that the maximum shelf quantity is 3 rolls, that tape should be reordered when one roll remains on the shelf, and that 2 rolls should be reordered at that time. For ultimate simplicity, the kanban card protrudes from the stack of tape rolls one up from the bottom of the stack. When a person takes the last roll of tape on top of the card, she knows that it is time to reorder.”

“I presume, Curmudge, that she gives the card to the person in the group who orders supplies. When the new rolls of tape arrive, they and the kanban card are put back on the shelf. What could be simpler? However, setting up the system and knowing how much to order and how much to have in reserve requires someone with experience and judgment.”

“Right, Julie. One would need to know the demand for an item and its variability as well as how long it typically takes for the replacement order to arrive. When starting up the system for critical items, one might have an extra-large reserve supply to ensure against stock-outs.”

“This might be one feature of Lean that I could take home. My couch potato husband would rebel against 5S’ing our kitchen cupboard and refrigerator, but I bet he’d love a kanban system so he wouldn’t run out of potato chips and beer.”

Affinity’s Kaizen Curmudgeon

(1) Graban, Mark. Lean Hospitals p.109. (Productivity Press, 2009)


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

Thursday, March 4, 2010

Packrattery, Chaos and their Countermeasure, 5S

“Jaded Julie, did you know that there are two kinds of people?”

“I know, Curmudge, that there are lots of two kinds’s—male and female, right-handed and left-handed, Democrats and Republicans, and many more.”

“The two kinds that I was thinking of are savers and thrower-outers. And among the savers are two subgroups, the packrats who never throw anything out and those disorganized people who never put anything back where it belongs.”

“It seems to me, Curmudge, that the two kinds of savers aren’t really very different. When a packrat acquires too much ‘stuff,’ his storage area becomes chaotic. And when a disorganized person can’t find something, she orders more than she needs; and her chaos begins to look like packrattery.”

“I trust you know the Lean tools used to mitigate this problem, 5S and kanban. We talked about 5S back on July 10, 2008.”

“Of course I recall. 5S stands for Save, Store, Stockpile, Stash, and Sequester.”

“Julie! You know that 5S in Lean language means Sort, Straighten/Set in order, Sweep/Scrub, Standardize, and Sustain.”

“I know, Curmudge. I was just making sure that you hadn’t dozed off. So if I may play the skeptic, why would someone devote the time and effort to 5S something?”

“In patient care—especially places like the ED and OR—when something is urgently needed for treating a patient, it must be available right now. There isn’t time to run around the department searching. For that matter, people shouldn’t have to search for things in any department.”

“In addition to being more efficient, an area that has been 5S’d looks better.”

“That’s for sure, Julie. How would you feel if you were a patient or a visitor in a hospital where Fibber McGee’s closet was behind every door? It would look as if the hospital couldn’t get its act together, including the care of its patients. The horrible impression would overshadow all of our talk about personalized care.”

“(I have no idea what this Fibber McGee stuff is, but knowing the Old Guy, it must be from old-time radio.) Since 5S is a Lean tool, the process must start with Plan from the Plan, Do, Check, Act cycle. Maybe we should call the process P5S.”

“Don’t confuse things, Julie. Because all processes begin with planning, let’s consider the ‘P’ to be silent, like the ‘P’ in pneumonia. After that, everything starts with ‘S’, and it’s all spelled out in Implementing 5S and Kanban in Lean Projects available from the Kaizen Promotion Office.”

“You know, Curmudge, the first three S’s are pretty straightforward. One can have everything in order and looking great, and you can walk away with a feeling of accomplishment. But then, as you taught me in 2008, disorder sets back in and the place gets messy again. I guess that’s why we have the last two S’s, Standardize and Sustain.”

“Exactly. These two S’s occur after the 5S project and are more like management than kaizen. An owner is assigned to the area, a checklist is developed, and monthly audits are scheduled. Before-and-after photos and posted audit results serve as visual management. Staff members not involved in the project should be trained in the culture that specifies ‘a place for everything and everything in its place.’ Management will require accountability for maintaining the gains that were achieved.”

“Curmudge, I presume that there’s been a lot of 5S’ing going on around here since the concept was introduced.”

“There sure has. Here are just a few examples from the St. E’s campus: the hospital pharmacy, 4 West as part of its conversion from subcritical to oncology, Behavioral Health in 1531 S. Madison, and the Kaizen Promotion Office. I’ve probably forgotten several others, but for a senior citizen, that’s allowed.”


“You mentioned kanban earlier, Curmudge? You sounded as if 5S and kanban go together like peanut butter and jelly.”


“They do, Julie, and we’ll talk about that soon.”

Affinity’s Kaizen Curmudgeon

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