“Most people speak of Lean training, Curmudge, but we have education in our title. Is there a real difference between the terms, or are you just being curmudgeonly in your old age?”
“Me? Curmudgeonly? I’ve read that education is for people and training is for dogs. We do have some poodles as hospital volunteers to cheer up our patients, but none has signed up for a Lean course.”
“So other than the hominid vs. canine situation, what are the differences between education and training?”
“In my opinion, Jaded Julie, education tries to answer the questions, who, what, where, and especially why, and training teaches us how. Although a dog sometimes cocks his head in presumed wonderment, I’ve never heard one ask ‘why?’ Lean learning contains both education and training. Education involves leaning the Lean culture and principles, and training teaches us how to apply the Lean tools.”
“Despite your semantic nit-picking, Curmudge, training is used more than education in health care; so let’s consider training to include ’why’ as well as ‘how.’ I trust your ossified brain can handle that.”
“No problem, so let’s get on with our topic. Attendees at the initial Lean instruction at Affinity, the Lean Health Care Tool Kit, came from two populations: (1) top management, directors, and some managers, and (2) Lean facilitators-in-training recently selected to staff the incipient Kaizen Promotion Office (KPO). Those in the management group had been told that Lean represented Affinity’s future, and they attended the initial training to prepare them for service in Affinity’s guiding coalition for change. Two weeks of comprehensive Lean training might have been excessive for this group, but it was essential that they receive training at the outset of Affinity’s Lean journey.”
“In contrast with the management folks, the first crop of Lean facilitators needed the comprehensive training to prepare them to spread Lean to the far corners of Affinity. They would require a command of Lean principles and culture, Lean tools and examples of their use, and—as you would say, Curmudge—the whole geschäft. Like you once advised, ‘they should always know more than they teach.’”
“This training ran for two weeks, contained a lot of PowerPoints, and had an open-book exam at the end of each topic. Presenters were from WCM (World Class Manufacturing) and were affiliated with the Milwaukee School of Engineering. Participants received several books (Liker, Dennis, Kotter, Rubrich & Watson) that are now considered Lean classics. Those two weeks were undoubtedly a busy period for course participants. For the KPO people, a one-week course on being a facilitator was presented later.”
“That sounds pretty intense, Curmudge, but the KPO staff taking the course knew that their future at Affinity depended on their ability to apply what they learned. Everyone appreciates that a mid-career course correction can’t be taken lightly. Learning is not very easy when one has to sit and watch PowerPoints fly by, but they did it.”
“For the record, Julie, the two-week course ran through 2007 and attracted 151 participants. For any adult learner, the gain from a course must be worth the time required. Two weeks is a pretty big time demand for busy people, so the KPO decided to shorten the course to one week for 2008. Participation by mid-level management is key to a Lean transformation, and the KPO felt that a one-week course would be attractive to managers and provide them with an adequate introduction to Lean.”
“How did the one-week course differ from the two-week course?”
“Topics were not covered as extensively, and there were no exams. The PowerPoints were from WCM, but the course presenters were from our Kaizen Promotion Office. The shorter duration of this course and the lack of out-of-class assignments made it easier for the middle-management participants to keep their fingers on the pulse of work in their regular jobs. In 2008 and 2009 the one-week course had 58 participants.”
“And then in 2010 the one-week course was subdivided into three one-day classes. These include one on Lean principles (Lean Overview), and two on tools (A3 Problem Solving and 5S and Kanban). I presume we’ll discuss the rationale behind these changes, Old Guy?”
“We will, but not today. It’s time for lunch followed by my afternoon nap.”
Affinity’s Kaizen Curmudgeon
Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.
Friday, November 26, 2010
Thursday, November 18, 2010
The Old Scout's Funeral
“A few weeks ago I attended the funeral of a former assistant scoutmaster of the troop to which our sons belonged. It seemed as if about half of the attendees were either former scouts or parents of scouts.”
“I assume, Curmudge, that you were there to show your respect for the deceased.”
“If it were only respect for the deceased, Jaded Julie, we should have visited him while he was alive. It was more than that. I believe it was respect for what he stood for and for what Scouting—with the involvement of all of us—had done for our sons many years ago.”
“That sounds pretty important; and since we are talking about it here, it must have something to do with Lean.”
“Although Scouting and Lean occur at different points in a person’s life, i.e., they are not contemporaneous, they are quite complementary. Here are some Lean (and Scouting) examples: Respect for people (Do a good turn daily. Help other people at all times. A Scout is trustworthy.). Continuous improvement (advancement from Tenderfoot to Eagle Scout). Leadership (Patrol Leader, Senior Patrol Leader, and leading a team in the scout’s Eagle project).”
“Let’s talk about that ‘not contemporaneous’ thing, Curmudge. A lot of time can pass between Scouting in adolescence and when an adult assumes a leadership role in industry, the military, or a hospital. What keeps the lessons of Scouting from being lost in the interim?”
“They need to become hardwired, Julie. That comes from repetition, dedication, and advancement, and that’s why Eagle Scouts are valued in any organization. I know of a young man who enlisted in the Marines and because of his Eagle rank was promoted almost immediately.”
“Scouting sounds like a unique opportunity for boys, Curmudge, but these days being unique is not always considered a virtue.”
“The Venturing program of the Boy Scouts includes young women aged 13-21. Many cultural mores similar to those of Scouting are taught in other organizations ranging from Girl Scouts to kindergarten to Sunday school. Even in service clubs for adults, like Rotary International. It certainly appears, however, that Scouting is more fun. Here’s an interesting observation: ‘Scouting's genuinely egalitarian goals and instincts are more important now than they've ever been. It's one of the only things that kids do that's genuinely cooperative, not competitive.’ (1)”
“It would appear that former Scouts and members of many other groups will have a head start in learning Lean.”
“You’re right, Julie. They already have a humanizing background and should readily understand Lean principles and culture. Next they’ll need to hone their leadership skills and learn to use Lean tools and procedures. Ultimately, these people would be ‘early adopters’ and perhaps members of the organization’s guiding coalition. If you found these people in a Lean Overview class you were teaching, you’d feel glad all over.”
“I certaily would. But what if people had become corrupted by working in a command-and-control, dog-eat-dog environment?”
“They would need to start Lean training at square one. If they couldn’t adapt to a Lean culture, it might be better if they ‘got off the bus.’”
“Although over 30 years have passed, Curmudge, you seem to be as enthusiastic about Scouting as you are about Lean. What did you do in Scouting that was so great?”
“Camping with the troop in the north woods and running the Pestigo River rapids in open canoes. Developing the required coordination between father (paddling in the stern) and son (paddling in the bow) builds a bond that lasts a lifetime.”
Affinity’s Kaizen Curmudgeon
(1) Applebome, Peter (2003). Scout's Honor: A Father's Unlikely Foray Into the Woods. http://en.wikipedia.org/wiki/Boy_Scouts_of_America
Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.
“I assume, Curmudge, that you were there to show your respect for the deceased.”
“If it were only respect for the deceased, Jaded Julie, we should have visited him while he was alive. It was more than that. I believe it was respect for what he stood for and for what Scouting—with the involvement of all of us—had done for our sons many years ago.”
“That sounds pretty important; and since we are talking about it here, it must have something to do with Lean.”
“Although Scouting and Lean occur at different points in a person’s life, i.e., they are not contemporaneous, they are quite complementary. Here are some Lean (and Scouting) examples: Respect for people (Do a good turn daily. Help other people at all times. A Scout is trustworthy.). Continuous improvement (advancement from Tenderfoot to Eagle Scout). Leadership (Patrol Leader, Senior Patrol Leader, and leading a team in the scout’s Eagle project).”
“Let’s talk about that ‘not contemporaneous’ thing, Curmudge. A lot of time can pass between Scouting in adolescence and when an adult assumes a leadership role in industry, the military, or a hospital. What keeps the lessons of Scouting from being lost in the interim?”
“They need to become hardwired, Julie. That comes from repetition, dedication, and advancement, and that’s why Eagle Scouts are valued in any organization. I know of a young man who enlisted in the Marines and because of his Eagle rank was promoted almost immediately.”
“Scouting sounds like a unique opportunity for boys, Curmudge, but these days being unique is not always considered a virtue.”
“The Venturing program of the Boy Scouts includes young women aged 13-21. Many cultural mores similar to those of Scouting are taught in other organizations ranging from Girl Scouts to kindergarten to Sunday school. Even in service clubs for adults, like Rotary International. It certainly appears, however, that Scouting is more fun. Here’s an interesting observation: ‘Scouting's genuinely egalitarian goals and instincts are more important now than they've ever been. It's one of the only things that kids do that's genuinely cooperative, not competitive.’ (1)”
“It would appear that former Scouts and members of many other groups will have a head start in learning Lean.”
“You’re right, Julie. They already have a humanizing background and should readily understand Lean principles and culture. Next they’ll need to hone their leadership skills and learn to use Lean tools and procedures. Ultimately, these people would be ‘early adopters’ and perhaps members of the organization’s guiding coalition. If you found these people in a Lean Overview class you were teaching, you’d feel glad all over.”
“I certaily would. But what if people had become corrupted by working in a command-and-control, dog-eat-dog environment?”
“They would need to start Lean training at square one. If they couldn’t adapt to a Lean culture, it might be better if they ‘got off the bus.’”
“Although over 30 years have passed, Curmudge, you seem to be as enthusiastic about Scouting as you are about Lean. What did you do in Scouting that was so great?”
“Camping with the troop in the north woods and running the Pestigo River rapids in open canoes. Developing the required coordination between father (paddling in the stern) and son (paddling in the bow) builds a bond that lasts a lifetime.”
Affinity’s Kaizen Curmudgeon
(1) Applebome, Peter (2003). Scout's Honor: A Father's Unlikely Foray Into the Woods. http://en.wikipedia.org/wiki/Boy_Scouts_of_America
Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.
Thursday, November 4, 2010
Superbugs
“Jaded Julie, a couple of weeks ago Mrs. Curmudgeon had some minor surgery, and I was really concerned.”
“Why should you be concerned, Curmudge? It was performed by an experienced surgeon, in a hospital that you respect, and the three little incisions were less than an inch long.”
“Perhaps I’m just an old worry-wart, but I was concerned that my wife might contract a nosocomial infection. I read a lot about infections a couple of years ago, and we talked about them on January 29 and February 5, 2009. It’s still a hot topic in the literature, and I read some newer stuff last month. When it comes to nosocomial infections, one may be either concerned or clueless; there’s no middle ground.”
“Despite your advanced age, Curmudge, you are rarely clueless. That makes me concerned as well. So what did you read that put the pepper in your Metamucil?”
“Dr. David Shlaes, MD, PhD has spent his career in the development of antibiotics, and he recently published a book, Antibiotics-the Perfect Storm. The book’s price as around $150, so I’ve had to be satisfied with reading his blog by the same name.”
“So what is the good doctor’s thesis, Curmudge? It must be mighty serious if he calls it a perfect storm.”
“Despite the appearance of new drug-resistant bacteria almost every day, the major pharmaceutical companies in the U.S. are abandoning the development of new antibiotics. If this continues, we’ll soon be as defenseless against these new ‘superbugs’ as we were against their predecessors 100 years ago.”
“I now appreciate your concern. But why are the drug companies getting away from antibiotics?”
“It’s a matter of economics, Julie. When a new drug is developed for a chronic illness, a patient might take it (buy it) for the rest of his life. Contrast that against a new antibiotic; the patient will take it for perhaps two weeks or until the infection is cured. With the latter scenario it’s very hard for the company to sell enough of the drug at a reasonable price to recoup its multi-million dollar development cost.”
“As I understand it, Curmudge, clinical trials are an essential and expensive part of new drug development. We talked about trials just a few weeks ago, on September 30. They are required to prove the drug’s safety and effectiveness.”
“The drug people call that efficacy, Julie. Recruiting participants for the traditional clinical trial of an antibiotic is especially difficult. People with a potentially deadly infection would be reluctant to join a trial in which they had only a 50% probability of receiving the medication. Those in the control group might die before the trial’s conclusion.”
“So what’s the answer? Or to use a term you brought from industry, what’s the path forward?”
“Approaches to this problem involve definitions of safety and efficacy, trial design, ethics, and controversy. Any one of these puts their discussion beyond the scope of this blog. I invite you to read Dr. Shlaes’ blog, or if your rich uncle just died, his book. If you need some grisly statistics to catalyze your concern, consider these from the Centers for Disease Control: ‘As many as 90,000 people die in the nation’s hospitals every year from bacterial infections. About 70,000 of these deaths are from drug-resistant bacteria—well above the 58,000 U.S. soldiers who died during the Vietnam War era.’”
“Okay, Curmudge, you’ve really got my attention.”
“Here’s another statistic that I’ve been thinking about in recent weeks: ‘Of all the complications that occur in the 30 days after surgery, such as infection and blood clots, almost half will surface after the patient leaves the hospital.’(1) That’s why I scrubbed my hands thoroughly before I changed the dressings on Mrs. Curmudgeon’s incisions.”
Affinity’s Kaizen Curmudgeon
(1) Landro, L. Patient, Heal Thyself. Wall Street Journal, October 26, 2010.
“Why should you be concerned, Curmudge? It was performed by an experienced surgeon, in a hospital that you respect, and the three little incisions were less than an inch long.”
“Perhaps I’m just an old worry-wart, but I was concerned that my wife might contract a nosocomial infection. I read a lot about infections a couple of years ago, and we talked about them on January 29 and February 5, 2009. It’s still a hot topic in the literature, and I read some newer stuff last month. When it comes to nosocomial infections, one may be either concerned or clueless; there’s no middle ground.”
“Despite your advanced age, Curmudge, you are rarely clueless. That makes me concerned as well. So what did you read that put the pepper in your Metamucil?”
“Dr. David Shlaes, MD, PhD has spent his career in the development of antibiotics, and he recently published a book, Antibiotics-the Perfect Storm. The book’s price as around $150, so I’ve had to be satisfied with reading his blog by the same name.”
“So what is the good doctor’s thesis, Curmudge? It must be mighty serious if he calls it a perfect storm.”
“Despite the appearance of new drug-resistant bacteria almost every day, the major pharmaceutical companies in the U.S. are abandoning the development of new antibiotics. If this continues, we’ll soon be as defenseless against these new ‘superbugs’ as we were against their predecessors 100 years ago.”
“I now appreciate your concern. But why are the drug companies getting away from antibiotics?”
“It’s a matter of economics, Julie. When a new drug is developed for a chronic illness, a patient might take it (buy it) for the rest of his life. Contrast that against a new antibiotic; the patient will take it for perhaps two weeks or until the infection is cured. With the latter scenario it’s very hard for the company to sell enough of the drug at a reasonable price to recoup its multi-million dollar development cost.”
“As I understand it, Curmudge, clinical trials are an essential and expensive part of new drug development. We talked about trials just a few weeks ago, on September 30. They are required to prove the drug’s safety and effectiveness.”
“The drug people call that efficacy, Julie. Recruiting participants for the traditional clinical trial of an antibiotic is especially difficult. People with a potentially deadly infection would be reluctant to join a trial in which they had only a 50% probability of receiving the medication. Those in the control group might die before the trial’s conclusion.”
“So what’s the answer? Or to use a term you brought from industry, what’s the path forward?”
“Approaches to this problem involve definitions of safety and efficacy, trial design, ethics, and controversy. Any one of these puts their discussion beyond the scope of this blog. I invite you to read Dr. Shlaes’ blog, or if your rich uncle just died, his book. If you need some grisly statistics to catalyze your concern, consider these from the Centers for Disease Control: ‘As many as 90,000 people die in the nation’s hospitals every year from bacterial infections. About 70,000 of these deaths are from drug-resistant bacteria—well above the 58,000 U.S. soldiers who died during the Vietnam War era.’”
“Okay, Curmudge, you’ve really got my attention.”
“Here’s another statistic that I’ve been thinking about in recent weeks: ‘Of all the complications that occur in the 30 days after surgery, such as infection and blood clots, almost half will surface after the patient leaves the hospital.’(1) That’s why I scrubbed my hands thoroughly before I changed the dressings on Mrs. Curmudgeon’s incisions.”
Affinity’s Kaizen Curmudgeon
(1) Landro, L. Patient, Heal Thyself. Wall Street Journal, October 26, 2010.
Wednesday, November 3, 2010
The Robot
“Wow, Jaded Julie! That da Vinci robot is the greatest thing to hit the OR since anesthesia.”
“No way, Curmudge, am I going to let a robot operate on me. It might run amok and start ripping out my innards.”
“This isn’t ‘Star Wars,’ Julie; this is the ultimate in modern surgery. The robot simply mimics the movements of the surgeon’s hands and fingers. In a demonstration, I sat at the console and remotely maneuvered pumpkin seeds around inside a jack-o-lantern. Except for the fact that I don’t know anything about anatomy, even I could be a surgeon.”
“I shudder at the thought. As I understand it, the robot is an enhancement to laparoscopic surgery, which I already considered a great innovation. However, I’ve been both amazed and somewhat apprehensive at major surgery performed through three little incisions.”
“Before we reassure and further astonish you, let’s set the stage. The patient has at least three small incisions, one for the camera and two for the robotic probes. The surgeon sits at the console, puts his hands on the controls, and views the inside of the patient (‘the field’) through a binocular scope. What the surgeon sees is also projected on a monitor above the patient so the nurse can follow the action and anticipate the surgeon’s need for different probes.”
“Hey, Curmudge, this is getting interesting. I can appreciate why you got a kick out of ‘operating’ on a pumpkin.”
“There are two features of the robotic probes that provide the da Vinci’s great advance over conventional laparoscopy. At the end of the probe is a ‘wrist’ that can rotate and allow the probe to reach areas that are inaccessible to a conventional probe. The other enhancement is the da Vinci’s ability to shrink the surgeon’s motions by a factor of 5, i.e., when the surgeon moves 1 cm, the probe moves 2 mm. This permits delicate work that would be impossible with a conventional laparoscopic probe or extremely difficult with gloved fingers in open surgery.”
“I’m sold, Curmudge. Buy me one for Christmas with your Social Security check, or more realistically, donate your check to the hospital foundation. But seriously, what kinds of operations can be performed with the robot?”
“Most things that are currently done with conventional laparoscopy: hysterectomies, radical prostatectomies, cholecystectomies, nephrectomies, and several others. I suspect that all of these can be done better and safer with the da Vinci robot. And following surgery, the patient has less pain and can go home sooner.”
“For a surgeon, training in any new technique has to be a serious undertaking. That is undoubtedly true with learning to use the robot.”
“Julie, I believe they start by observing, and then they practice on pigs. Initial surgery on human patients is closely observed by experienced surgeons. That’s facilitated by the monitor above the patient that we described earlier.”
“Considering your enthusiasm, Curmudge, I assume that you will volunteer for robotic surgery as soon as possible.”
“My last major surgery was 51 years ago, Julie. I’m quite willing to wait another 51 years for the next.”
Affinity’s Kaizen Curmudgeon
“No way, Curmudge, am I going to let a robot operate on me. It might run amok and start ripping out my innards.”
“This isn’t ‘Star Wars,’ Julie; this is the ultimate in modern surgery. The robot simply mimics the movements of the surgeon’s hands and fingers. In a demonstration, I sat at the console and remotely maneuvered pumpkin seeds around inside a jack-o-lantern. Except for the fact that I don’t know anything about anatomy, even I could be a surgeon.”
“I shudder at the thought. As I understand it, the robot is an enhancement to laparoscopic surgery, which I already considered a great innovation. However, I’ve been both amazed and somewhat apprehensive at major surgery performed through three little incisions.”
“Before we reassure and further astonish you, let’s set the stage. The patient has at least three small incisions, one for the camera and two for the robotic probes. The surgeon sits at the console, puts his hands on the controls, and views the inside of the patient (‘the field’) through a binocular scope. What the surgeon sees is also projected on a monitor above the patient so the nurse can follow the action and anticipate the surgeon’s need for different probes.”
“Hey, Curmudge, this is getting interesting. I can appreciate why you got a kick out of ‘operating’ on a pumpkin.”
“There are two features of the robotic probes that provide the da Vinci’s great advance over conventional laparoscopy. At the end of the probe is a ‘wrist’ that can rotate and allow the probe to reach areas that are inaccessible to a conventional probe. The other enhancement is the da Vinci’s ability to shrink the surgeon’s motions by a factor of 5, i.e., when the surgeon moves 1 cm, the probe moves 2 mm. This permits delicate work that would be impossible with a conventional laparoscopic probe or extremely difficult with gloved fingers in open surgery.”
“I’m sold, Curmudge. Buy me one for Christmas with your Social Security check, or more realistically, donate your check to the hospital foundation. But seriously, what kinds of operations can be performed with the robot?”
“Most things that are currently done with conventional laparoscopy: hysterectomies, radical prostatectomies, cholecystectomies, nephrectomies, and several others. I suspect that all of these can be done better and safer with the da Vinci robot. And following surgery, the patient has less pain and can go home sooner.”
“For a surgeon, training in any new technique has to be a serious undertaking. That is undoubtedly true with learning to use the robot.”
“Julie, I believe they start by observing, and then they practice on pigs. Initial surgery on human patients is closely observed by experienced surgeons. That’s facilitated by the monitor above the patient that we described earlier.”
“Considering your enthusiasm, Curmudge, I assume that you will volunteer for robotic surgery as soon as possible.”
“My last major surgery was 51 years ago, Julie. I’m quite willing to wait another 51 years for the next.”
Affinity’s Kaizen Curmudgeon
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