“It used to be said, Julie, that the only things certain in life are death and taxes, but that’s wrong. Some people don’t pay taxes. The correct statement is, ‘the only things certain are death and choices.’ " (1)
“At the time many choices are made, people tend not to appreciate their significance. For example, one’s choice of a job and its location affect the environment in which one’s children will grow up. For that matter, one’s choice of a mate impacts the very existence of one’s children.”
“Fortunately, a lot of these are two-party choices. In the distant past Mrs. Curmudgeon vetoed some of my job location choices with two words, ‘too rural.’ In many cases, if one fully comprehended the future impacts of a choice he had to make today, he would be paralyzed with indecision.”
“Curmudge, we have been reading a book about choices; it is James C. Hunter’s The Servant (2). It’s not about the kinds of choices described above. It’s about moral choices and the fact that it is up to us to make them.”
“You’re right, Julie. If I were to list the five best books that I have read in the past ten years, it would be on the list.”
“I’m not sure that you have read five books in the past ten years. But no matter how you count, it’s a great book. Without its intent being obvious, it introduces the principles of servant leadership in the form of an allegory involving six people meeting for a week with a teacher at a retreat center.”
“Perhaps we should explain why our title is Choices and not Servant Leadership. In his epilogue, Hunter includes this quote, ‘it is of no profit to have learned well if you neglect to do well.’ It is our thesis that to gain value, one must choose to put to use what he has learned. If one puts down this book and says, ‘Ho hum, that was interesting,’ he is both insensitive and foolish.”
“But Curmudge, we’ve addressed servant leadership in several Kaizen Curmudgeon postings. There were three in May 2008 and two last November, on 11/11/11 and 11/03/11. Do we need more?”
“We certainly do, for two reasons. Hunter’s 2004 book (3) was sort of a textbook, but The Servant grabs your heart and mind. The second reason is that we need to hardwire Hunter’s eight essentials of good character: patience, kindness, humility, respect, selflessness, forgiveness, honesty, and commitment.”
“Well, at least the words aren’t in Japanese. My guess is that today we’ll pick off the high points that haven’t already been addressed, and as before, quoted material will be from Hunter’s book.”
“Fortunately, Julie, all of Hunter’s words are in English, and the first one we’ll mention is paradigm. Paradigms are the psychological maps we use to navigate our way through life. ‘The outside world enters our life through the filters of our paradigm.’ You can bet that the paradigm of the traditional command-and-control manager is different from that of the servant leader.”
“I’ve got it, Curmudge. In order to improve, the traditional boss who wants to become a leader has to change his paradigm; and Hunter’s teachings describe how he can do it. For starters, the leader has to identify and meet the legitimate needs of his people, and that is what serving is all about. In case you wondered, legitimate needs are those listed, in order, in Maslow’s hierarchy: food, water, shelter; safety and security; belonging and love; self-esteem; self-actualization. Self-actualization is being all you can be. Sound familiar?”
“Let’s pick love off Maslow’s list and use it in a leadership sense. This is the agapé-type love as used in the Bible. It is the ‘love of deliberate choice rooted in behavior toward others without regard to their due.’ Agapé love and leadership are synonymous, and the properties of agapé love are that same list of Hunter’s eight essentials of good character. Are you surprised, Julie?”
“I am not; please remember that I read the book. Note also how well that list correlates with the list of characteristics that people look for in a good manager: ‘honest & trustworthy, good role model, caring, committed, good listener, held people accountable, treated people with respect, gave people encouragement, positive & enthusiastic attitude, and appreciated people.’ When we think more about that list, we realize that ‘love is not how you feel toward others but how you behave toward others.’ “
“One item on the list represents an almost universal weakness—being a good listener. ‘Active listening requires a disciplined effort to silence all our internal conversations while we are attempting to listen to another human being.’ We should attempt to see and feel things as the speaker sees and feels them, and to empathize—be fully present—with the speaker.”
“I guess, Curmudge, that requires you to do more than just turn up your hearing aid.”
“Another common oversight is neglecting to give praise to people. People need to be appreciated. Your praise should be specific and sincere. Catch people doing something right. I think I’m better at it now than I was 40 years ago, but it doesn’t mean much coming from a volunteer.”
“In the past we have managed to bring several postings on servant leadership to a logical conclusion, Curmudge, but what is the real bottom line? What should we shout from the top of the parking ramp?”
“Becoming a true leader is a choice. Servant leadership is not inborn; it must be learned and then practiced. As we have said before with different wording, ‘we are more likely to act ourselves into a feeling than to feel ourselves into action.’ (4) So here’s what to shout: ‘Servant leadership. Just do it.’ “
Affinity's Kaizen Curmudgeon
(1) Soren Kierkegaard
(2) Hunter, James C., The Servant (Crown Business, 1998)
(3) Hunter, James C. The World’s Most Powerful Leadership Principle (Crown Business, 2004)
(4) Jerome Brunner
Note: This year’s holiday story from Curmudge and Julie may be accessed elsewhere.
Thursday, December 15, 2011
Tuesday, November 22, 2011
The Most Recent Kaizen Curmudgeon Postings
On December 22, 2010 the Kaizen Curmudgeon blog celebrated its 150th posting by listing the titles and posting dates and supplying links to the 50 most recent postings. Provided below is the same information for each posting since December 29, 2010. This is in celebration of the “almost 200th” posting.
Kaizen Curmudgeon Blog Title—Date Posted
Stan’s Story Redux—12/29/10
Autonomy—1/06/11
Autonomy 2—1/27/11
What shall we do with you?—2/02/11
The Middle Years—2/09/11
Way to go!—2/17/11
Way to go! 2—2/24/11
Complacency—3/03/11
Complacency 2—3/10/11
Kaikaku, a countermeasure for “We’ve always done it that way.”—3/18/11
I’ve always done it that way.—3/24/11
The Crystal Ball—Prologue—4/07/11
The Crystal Ball 1—4/15/11
The Old Men’s Table—4/18/11
The Crystal Ball 2—4/27/11
The Crystal Ball 3—5/05/11
The Crystal Ball 4—5/12/11
The Crystal Ball 5—5/19/11
Happy Fourth Birthday—5/20/11
The Crystal Ball 6—5/31/11
The Crystal Ball 7—6/03/11
The Crystal Ball 8—6/13/11
The Laboratory—6/30/11
The Laboratory 2—7/07/11
The Laboratory 3—7/14/11
The Laboratory 4—7/21/11
The Laboratory 5—7/28/11
Conventional Wisdom—8/08/11
Hardwiring—8/12/11
Hardwiring 2—8/18/11
Sepsis—8/26/11
Sepsis 2—9/07/11
Sepsis 3—9/15/11
The Bad, Good Medication—9/23/11
Series Contents—9/29/11 This contains subtitles or keywords for individual postings in series posted between April 1, 2010 and September 15, 2011.
How Things Happen—10/06/11
The Need for Lean Leadership—Entropy—10/13/11
Lean Leadership 2—10/20/11
Lean Leadership 3—10/28/11
Lean Leadership 4—Servant Leadership—11/03/11
Lean Leadership 5—Links Between Lean Leadership and Servant Leadership—11/11/11
Affinity’s Kaizen Curmudgeon
Kaizen Curmudgeon Blog Title—Date Posted
Stan’s Story Redux—12/29/10
Autonomy—1/06/11
Autonomy 2—1/27/11
What shall we do with you?—2/02/11
The Middle Years—2/09/11
Way to go!—2/17/11
Way to go! 2—2/24/11
Complacency—3/03/11
Complacency 2—3/10/11
Kaikaku, a countermeasure for “We’ve always done it that way.”—3/18/11
I’ve always done it that way.—3/24/11
The Crystal Ball—Prologue—4/07/11
The Crystal Ball 1—4/15/11
The Old Men’s Table—4/18/11
The Crystal Ball 2—4/27/11
The Crystal Ball 3—5/05/11
The Crystal Ball 4—5/12/11
The Crystal Ball 5—5/19/11
Happy Fourth Birthday—5/20/11
The Crystal Ball 6—5/31/11
The Crystal Ball 7—6/03/11
The Crystal Ball 8—6/13/11
The Laboratory—6/30/11
The Laboratory 2—7/07/11
The Laboratory 3—7/14/11
The Laboratory 4—7/21/11
The Laboratory 5—7/28/11
Conventional Wisdom—8/08/11
Hardwiring—8/12/11
Hardwiring 2—8/18/11
Sepsis—8/26/11
Sepsis 2—9/07/11
Sepsis 3—9/15/11
The Bad, Good Medication—9/23/11
Series Contents—9/29/11 This contains subtitles or keywords for individual postings in series posted between April 1, 2010 and September 15, 2011.
How Things Happen—10/06/11
The Need for Lean Leadership—Entropy—10/13/11
Lean Leadership 2—10/20/11
Lean Leadership 3—10/28/11
Lean Leadership 4—Servant Leadership—11/03/11
Lean Leadership 5—Links Between Lean Leadership and Servant Leadership—11/11/11
Affinity’s Kaizen Curmudgeon
Friday, November 11, 2011
Lean Leadership 5
Links Between Lean Leadership and Servant Leadership
“I trust, Jaded Julie, that you are still willing to play the role of a front-line leader in a generic hospital?”
“No sweat, Curmudge. That’s as easy for me as it is for you to play the role of a cantankerous old codger. I believe last time we promised to describe how servant leadership can be tied with Lean leadership. To me, the most obvious connection would be through the Lean principle of respect for people.”
“Good observation. In manufacturing the Lean manager respects the knowledge and ability of the workers to solve—with coaching—the problems that arise in their process. This should be easier in a hospital, where most of the people in gemba are professionals. In your role, Julie, achieving mutual respect might be the most important element of respect for people. In your unit the ‘people will not care what you know until they know that you care, and they won’t believe the message until they believe the messenger (1).’ “
“I agree, Curmudge. As Hunter has said, ‘Management is what we do; leadership is who we are. Simply knowing how to do the job well has little to do with developing the skills necessary to inspire others to do the job well.’ “
“In our lesson on becoming a servant leader back on May 22, 2008, we mentioned the need to get feedback from one’s direct reports. In doing so, you might tell your people about servant leadership and your efforts to become one. Hopefully they will acquire a stake in your success.”
“Accountability is essential in Lean management, and it’s an important part of servant leadership. Of course, it should not be a problem if people are motivated. ‘Motivation is people moved to action because they want to act. We cannot change anyone; the best we can do is influence their future choices.’ “
“It’s clear to me, that while a servant leader will help his/her people be the best they can be, he will strongly influence them to do so. Here is what Hunter’s book says about accountability: ‘It is immoral not to fire those who can’t do the job. Think about the bad messages we send about our lack of commitment to excellence and our failure to do the right thing.’ ‘The biggest gap in leadership skills is failing to confront people with problems and situations as they arise and to hold them accountable.’ I’ve seen that at all levels, Julie, and I confess to not having acted promptly in at least one case. But that was before Hunter wrote his books.”
“I think I’ve got it, Curmudge. A servant leader is a person of high character who is willing to use ‘tough love’ to help his/her direct reports to be the best they can be. Now here’s a tough problem for you. What about the employee with family responsibilities who simply wants to work her shift and go home as soon as possible? She has little interest in ‘being all she can be.’ ”
“Let’s not overlook the possibility that she might already ‘be all she can be.’ If she really wants to leave promptly, she might be your strongest ally in improving the unit’s efficiently. People in health care usually believe on the day they are hired that what they are doing is important, that it serves a purpose, and adds value to the world. Perhaps between then and now something has caused her to become de-motivated. Your training as a servant leader should help you differentiate between a person with legitimate needs and one who is truly a detriment to the organization. Thus servant leadership doesn’t provide silver bullets; it develops the character to make difficult decisions.”
“Lean is based on continuous improvement, and Lean leadership—supported by servant leadership—is the way we make the improvements happen. Leaders are made, not born, and they don’t leap from the cradle as servant leaders. Becoming a servant leader, like Lean, requires continuous improvement.”
“That’s it, Julie. While one can read books on Lean and servant leadership, one can only accomplish the desired goals of each by continuous efforts in the workplace.”
“Well senescent senior, that’s a lot to learn. But if you can, anybody can.”
Affinity’s Kaizen Curmudgeon
(1) Hunter, James C. The World’s Most Powerful Leadership Principle (Crown Business, 2004)
P.S.—Back on May 22, 2008 we talked about how one might become a servant leader. Anyone who wasn’t reading our blog back then can click on the link and learn about Hardwiring What We Have Learned.
“I trust, Jaded Julie, that you are still willing to play the role of a front-line leader in a generic hospital?”
“No sweat, Curmudge. That’s as easy for me as it is for you to play the role of a cantankerous old codger. I believe last time we promised to describe how servant leadership can be tied with Lean leadership. To me, the most obvious connection would be through the Lean principle of respect for people.”
“Good observation. In manufacturing the Lean manager respects the knowledge and ability of the workers to solve—with coaching—the problems that arise in their process. This should be easier in a hospital, where most of the people in gemba are professionals. In your role, Julie, achieving mutual respect might be the most important element of respect for people. In your unit the ‘people will not care what you know until they know that you care, and they won’t believe the message until they believe the messenger (1).’ “
“I agree, Curmudge. As Hunter has said, ‘Management is what we do; leadership is who we are. Simply knowing how to do the job well has little to do with developing the skills necessary to inspire others to do the job well.’ “
“In our lesson on becoming a servant leader back on May 22, 2008, we mentioned the need to get feedback from one’s direct reports. In doing so, you might tell your people about servant leadership and your efforts to become one. Hopefully they will acquire a stake in your success.”
“Accountability is essential in Lean management, and it’s an important part of servant leadership. Of course, it should not be a problem if people are motivated. ‘Motivation is people moved to action because they want to act. We cannot change anyone; the best we can do is influence their future choices.’ “
“It’s clear to me, that while a servant leader will help his/her people be the best they can be, he will strongly influence them to do so. Here is what Hunter’s book says about accountability: ‘It is immoral not to fire those who can’t do the job. Think about the bad messages we send about our lack of commitment to excellence and our failure to do the right thing.’ ‘The biggest gap in leadership skills is failing to confront people with problems and situations as they arise and to hold them accountable.’ I’ve seen that at all levels, Julie, and I confess to not having acted promptly in at least one case. But that was before Hunter wrote his books.”
“I think I’ve got it, Curmudge. A servant leader is a person of high character who is willing to use ‘tough love’ to help his/her direct reports to be the best they can be. Now here’s a tough problem for you. What about the employee with family responsibilities who simply wants to work her shift and go home as soon as possible? She has little interest in ‘being all she can be.’ ”
“Let’s not overlook the possibility that she might already ‘be all she can be.’ If she really wants to leave promptly, she might be your strongest ally in improving the unit’s efficiently. People in health care usually believe on the day they are hired that what they are doing is important, that it serves a purpose, and adds value to the world. Perhaps between then and now something has caused her to become de-motivated. Your training as a servant leader should help you differentiate between a person with legitimate needs and one who is truly a detriment to the organization. Thus servant leadership doesn’t provide silver bullets; it develops the character to make difficult decisions.”
“Lean is based on continuous improvement, and Lean leadership—supported by servant leadership—is the way we make the improvements happen. Leaders are made, not born, and they don’t leap from the cradle as servant leaders. Becoming a servant leader, like Lean, requires continuous improvement.”
“That’s it, Julie. While one can read books on Lean and servant leadership, one can only accomplish the desired goals of each by continuous efforts in the workplace.”
“Well senescent senior, that’s a lot to learn. But if you can, anybody can.”
Affinity’s Kaizen Curmudgeon
(1) Hunter, James C. The World’s Most Powerful Leadership Principle (Crown Business, 2004)
P.S.—Back on May 22, 2008 we talked about how one might become a servant leader. Anyone who wasn’t reading our blog back then can click on the link and learn about Hardwiring What We Have Learned.
Thursday, November 3, 2011
Lean Leadership 4--Servant Leadership
“Jaded Julie, even though you couldn’t stay for the whole orchestra concert, did you enjoy what you heard?”
"It was great, and as you advised, I listened intently. The first violins all played the same melody, but sometimes the woodwinds or the brass played something different. But it fit together beautifully.”
“That was a countermelody. If the whole orchestra had played exactly the same notes, it might have sounded like a grade-school band. You have observed that when something extra is added to a simple theme, the combined effect is enhanced.”
“I’ve got it, Curmudge. But what does this have to do with Lean? If there’s no connection, this posting will end up in the wastebasket.”
“I used countermelody, Julie, as a metaphor for servant leadership. If you can combine servant leadership with Lean leadership, your performance as a Lean leader will be greatly improved.”
“We talked about servant leadership over three years ago, on May 8, 2008 and also on May 15 and 22. I agree that it’s time for a refresher.”
“Let’s skip the history of servant leadership and get right to today’s lesson. Most of what we will share with readers is found in books by James C. Hunter (1, 2). In fact, much of this posting will simply be quotations from Hunter’s second book. We’ll also reference the statements of authorities that Hunter quoted.”
“Curmudge, I understand that Lean and servant leadership are complementary, but how do they differ?”
“Pretty simple. Lean is organizational; servant leadership is personal. Lean is the organizational culture that we are trying to develop. Servant leadership describes the character that should be a part of a truly successful leader. If all of the managers in an organization were servant leaders, pulling off a Lean transformation should be a slam-dunk.”
“We know intuitively what character means, but how does Hunter define it in the servant leadership context?”
“ ‘Character is our moral maturity and commitment to doing the right thing regardless of personal costs. Character involves the will to respond to stimuli according to values and principles rather than to appetites, urges, whims, or impulses.’ Here are some of the essentials of good character: patience, kindness, humility, respect, selflessness, forgiveness, honesty, and commitment.“
“Presumably, these are also essentials of leadership. Here are some things that others have said about character and leadership: ‘Ninety-nine percent of leadership failures are failures of character (3).’ ‘Leadership is character in action (4).’ ‘There are no weak platoons—only weak leaders (5).’ “
“Julie, we must have said this back in 2008, but it’s worth repeating: Leadership is ‘the skills of influencing people to enthusiastically work toward goals identified as being for the common good, with character that inspires confidence.’ “
“Okay, we’ve tied leadership to character, but how does ‘servant’ enter the picture?”
“Here it is at the most basic level: ‘If you choose to lead, you must serve (6).’ It’s simpler if you consider The Law of the Harvest; you reap what you sow. ‘You sow service and sacrifice; you extend yourself for others and seek their greatest good; you will build influence with them.’ “
“But in the world of commerce and even health care, the word ‘servant’ sounds a bit wimpish.”
“Don’t confuse a servant leader with being a total ‘Mr. Nice Guy,’ Julie. Here’s what Hunter says: ‘The servant leader does not abdicate responsibility to define the mission, set rules governing behavior, set standards, or define accountability. Then the leader helps people meet their legitimate needs so they can become the best they are capable of becoming and effectively accomplish the mission.’ Note that Hunter said ‘needs’ and not ‘wants.’ He illustrates that in this way: ‘If you get your people what they need, they will get you everything that you need. Our leadership will be defined not by what we accomplish but by what we get accomplished through others.’ “
“Old Guy, it looks as if we’ve presented some of the most important elements of servant leadership. I trust that next time we’ll relate servant leadership more closely with Lean leadership.”
Affinity’s Kaizen Curmudgeon
(1) Hunter, James C. The Servant (Crown Business, 1998)
(2) Hunter, James C. The World’s Most Powerful Leadership Principle (Crown Business, 2004)
(3) Schwarzkopf, Norman
(4) Bennis, Warren
(5) Creech, William
(6) Book of Matthew (paraphrased)
"It was great, and as you advised, I listened intently. The first violins all played the same melody, but sometimes the woodwinds or the brass played something different. But it fit together beautifully.”
“That was a countermelody. If the whole orchestra had played exactly the same notes, it might have sounded like a grade-school band. You have observed that when something extra is added to a simple theme, the combined effect is enhanced.”
“I’ve got it, Curmudge. But what does this have to do with Lean? If there’s no connection, this posting will end up in the wastebasket.”
“I used countermelody, Julie, as a metaphor for servant leadership. If you can combine servant leadership with Lean leadership, your performance as a Lean leader will be greatly improved.”
“We talked about servant leadership over three years ago, on May 8, 2008 and also on May 15 and 22. I agree that it’s time for a refresher.”
“Let’s skip the history of servant leadership and get right to today’s lesson. Most of what we will share with readers is found in books by James C. Hunter (1, 2). In fact, much of this posting will simply be quotations from Hunter’s second book. We’ll also reference the statements of authorities that Hunter quoted.”
“Curmudge, I understand that Lean and servant leadership are complementary, but how do they differ?”
“Pretty simple. Lean is organizational; servant leadership is personal. Lean is the organizational culture that we are trying to develop. Servant leadership describes the character that should be a part of a truly successful leader. If all of the managers in an organization were servant leaders, pulling off a Lean transformation should be a slam-dunk.”
“We know intuitively what character means, but how does Hunter define it in the servant leadership context?”
“ ‘Character is our moral maturity and commitment to doing the right thing regardless of personal costs. Character involves the will to respond to stimuli according to values and principles rather than to appetites, urges, whims, or impulses.’ Here are some of the essentials of good character: patience, kindness, humility, respect, selflessness, forgiveness, honesty, and commitment.“
“Presumably, these are also essentials of leadership. Here are some things that others have said about character and leadership: ‘Ninety-nine percent of leadership failures are failures of character (3).’ ‘Leadership is character in action (4).’ ‘There are no weak platoons—only weak leaders (5).’ “
“Julie, we must have said this back in 2008, but it’s worth repeating: Leadership is ‘the skills of influencing people to enthusiastically work toward goals identified as being for the common good, with character that inspires confidence.’ “
“Okay, we’ve tied leadership to character, but how does ‘servant’ enter the picture?”
“Here it is at the most basic level: ‘If you choose to lead, you must serve (6).’ It’s simpler if you consider The Law of the Harvest; you reap what you sow. ‘You sow service and sacrifice; you extend yourself for others and seek their greatest good; you will build influence with them.’ “
“But in the world of commerce and even health care, the word ‘servant’ sounds a bit wimpish.”
“Don’t confuse a servant leader with being a total ‘Mr. Nice Guy,’ Julie. Here’s what Hunter says: ‘The servant leader does not abdicate responsibility to define the mission, set rules governing behavior, set standards, or define accountability. Then the leader helps people meet their legitimate needs so they can become the best they are capable of becoming and effectively accomplish the mission.’ Note that Hunter said ‘needs’ and not ‘wants.’ He illustrates that in this way: ‘If you get your people what they need, they will get you everything that you need. Our leadership will be defined not by what we accomplish but by what we get accomplished through others.’ “
“Old Guy, it looks as if we’ve presented some of the most important elements of servant leadership. I trust that next time we’ll relate servant leadership more closely with Lean leadership.”
Affinity’s Kaizen Curmudgeon
(1) Hunter, James C. The Servant (Crown Business, 1998)
(2) Hunter, James C. The World’s Most Powerful Leadership Principle (Crown Business, 2004)
(3) Schwarzkopf, Norman
(4) Bennis, Warren
(5) Creech, William
(6) Book of Matthew (paraphrased)
Friday, October 28, 2011
Lean Leadership 3
“Continuing with our music analogy, Jaded Julie, what is the first thing that happens after you have arrived at a concert venue?”
“I go to the ladies’ room and ‘powder my nose,’ as my mother would say.”
“But right after that you would receive a program for tonight’s orchestra concert.”
“Right, Curmudge. I’ll need that to learn what’s going to be played and who will play it. Say, that reminds me of the visual controls—the dashboard or process status board—that we are developing for the unit back at the hospital. That makes our organization, efforts, and accomplishments transparent to our team as well as to passers-by.”
“I’m delighted that you are thinking about work, Julie, but you must not be enjoying the concert. So what goes on the board? I presume that it is updated at the beginning of each shift.”
“These are my thoughts, Curmudge. I will need to collect input from above and below me in the organization. Presumably this would include hospital-wide and unit measures of performance. Unit data would include census, patients (room numbers) of concern or likely to need special care, and anticipated discharges. Safety issues and the status of process improvement efforts should be included. Of course, it shouldn’t become so crowded that one can’t see the forest for the trees.”
“Good, Julie. Now that the dashboard is designed, let’s think about standard work for you, a front-line leader in a nursing unit. You might not have thought about it, but you closely resemble front-line leaders at Toyota. They have developed hands-on proficiency at all of the operations performed by their team. With all of your experience, you have developed comparable proficiency in nursing. Congratulations, you are a supernurse.”
“I won’t be a supernurse in this position very long if I don’t develop some leadership standard work. Each day (or shift) will start with a report from my predecessor and a tour of the unit to collect data to update the dashboard. This will be followed by a brief stand-up huddle in front of the dashboard with the nurses in the unit; of course, this can’t occur until they have taken report from their counterparts on the preceding shift. We’ll welcome any ‘float’ nurses and assure that they will be brought up to speed on our standard work. The focus of this short meeting will be the current data on the dashboard, especially that pertaining to current improvement projects.”
“At that point, I’d be ready for a coffee break, but I know that you don’t have time. It’s time to get out in gemba and see that the agreed-upon standard work is being followed. If the work had not been standardized, you wouldn’t be able to detect deviations. When you see a deviation, ask ‘why?’; it might represent a new idea to improve the process. Be alert for ‘workarounds’ and ‘treasure hunts;’ they are clear signals of problems to be addressed and corrected. As a supernurse, you will be the unit’s fount of knowledge and master of techniques. If a patient is a ‘hard stick,’ you’ll be able to insert an IV catheter on the first try. And even when special talents are not required, you can provide an extra pair of hands to fill in where needed.”
“Thus far, except for the dashboard much of my job doesn’t sound too different from what it was before Lean.”
“But now your front-line leader’s job has become standard work. Your tasks are very similar (standardized) to those of other leaders in other comparable units. Through your joint efforts, you have learned what works best and adopted it as standard work. All of you are coaching your teams in standard work, continuous improvement, problem solving, and respect for one another. This requires that you possess personal discipline and can impart—through coaching—discipline to each of your direct reports.”
“Before we leave Lean at my level of leadership, we must not forget my daily or weekly meetings with my supervisor or manager. Her standard work is to assess my accountability for providing the Lean leadership that we have been discussing. She fully understands the value of gemba walks and agrees that ‘the currency of leadership is presence.’ If I appear unenthusiastic about Lean, she will remind me that, ‘it is easier to act your way into a new way of thinking than to think your way into a new way of acting.’ That translates into, ‘just do it,’ or ‘try it and you’ll like it.’ “
“Our readings (1,2) have suggested that regular daily or weekly meetings of leaders and their staffs going at least three levels up the chain of leadership are essential in maintaining the momentum of a Lean transition. Remember Masaaki Imai’s admonition, ‘Kaizen is everyday improvement, everybody improvement, everywhere improvement.’ Remember also that Lean, like the flywheel we discussed back on March 26, 2008, resembles a bearing with lots of friction; it requires constant pushing. That puts a lot of responsibility for Lean’s success on the shoulders of middle managers who must adopt Lean leadership.”
“There’s a bundle of stuff that we front-line and middle managers have to know and do on a daily basis, Curmudge. Can you summarize from our reading?”
“From Kenney (1):
• ‘Know the status of daily work.
• Know if planned work is completed on time.
• Understand both upstream and downstream impact.
• Know that standard work is being followed.
• Know when to take action and what action to take.’
From Mann (2):
• ‘Assessment based on data captured on visual controls.
• Assignment for corrective action and/or improvement.
• Accountability for having completed the previous day’s assignments.’ "
“All of that sounds pretty intuitive, Curmudge. As I’ve said before, ‘Lean is just organized common sense.’ Lean leadership is powerful because it enforces daily accountability. And if people do this every day for months or years, they will forget what they would slide back into if they had any inclination to back-slide.”
“By the way, Julie, whatever happened to that concert that you were attending?”
“I got so wrapped up in thinking and talking about Lean that I was asked to leave.”
Affinity’s Kaizen Curmudgeon
(1) Kenney, Charles Transforming Health Care (CRC Press, 2011)
(2) Mann, David Creating a Lean Culture (CRC Press, 2010)
“I go to the ladies’ room and ‘powder my nose,’ as my mother would say.”
“But right after that you would receive a program for tonight’s orchestra concert.”
“Right, Curmudge. I’ll need that to learn what’s going to be played and who will play it. Say, that reminds me of the visual controls—the dashboard or process status board—that we are developing for the unit back at the hospital. That makes our organization, efforts, and accomplishments transparent to our team as well as to passers-by.”
“I’m delighted that you are thinking about work, Julie, but you must not be enjoying the concert. So what goes on the board? I presume that it is updated at the beginning of each shift.”
“These are my thoughts, Curmudge. I will need to collect input from above and below me in the organization. Presumably this would include hospital-wide and unit measures of performance. Unit data would include census, patients (room numbers) of concern or likely to need special care, and anticipated discharges. Safety issues and the status of process improvement efforts should be included. Of course, it shouldn’t become so crowded that one can’t see the forest for the trees.”
“Good, Julie. Now that the dashboard is designed, let’s think about standard work for you, a front-line leader in a nursing unit. You might not have thought about it, but you closely resemble front-line leaders at Toyota. They have developed hands-on proficiency at all of the operations performed by their team. With all of your experience, you have developed comparable proficiency in nursing. Congratulations, you are a supernurse.”
“I won’t be a supernurse in this position very long if I don’t develop some leadership standard work. Each day (or shift) will start with a report from my predecessor and a tour of the unit to collect data to update the dashboard. This will be followed by a brief stand-up huddle in front of the dashboard with the nurses in the unit; of course, this can’t occur until they have taken report from their counterparts on the preceding shift. We’ll welcome any ‘float’ nurses and assure that they will be brought up to speed on our standard work. The focus of this short meeting will be the current data on the dashboard, especially that pertaining to current improvement projects.”
“At that point, I’d be ready for a coffee break, but I know that you don’t have time. It’s time to get out in gemba and see that the agreed-upon standard work is being followed. If the work had not been standardized, you wouldn’t be able to detect deviations. When you see a deviation, ask ‘why?’; it might represent a new idea to improve the process. Be alert for ‘workarounds’ and ‘treasure hunts;’ they are clear signals of problems to be addressed and corrected. As a supernurse, you will be the unit’s fount of knowledge and master of techniques. If a patient is a ‘hard stick,’ you’ll be able to insert an IV catheter on the first try. And even when special talents are not required, you can provide an extra pair of hands to fill in where needed.”
“Thus far, except for the dashboard much of my job doesn’t sound too different from what it was before Lean.”
“But now your front-line leader’s job has become standard work. Your tasks are very similar (standardized) to those of other leaders in other comparable units. Through your joint efforts, you have learned what works best and adopted it as standard work. All of you are coaching your teams in standard work, continuous improvement, problem solving, and respect for one another. This requires that you possess personal discipline and can impart—through coaching—discipline to each of your direct reports.”
“Before we leave Lean at my level of leadership, we must not forget my daily or weekly meetings with my supervisor or manager. Her standard work is to assess my accountability for providing the Lean leadership that we have been discussing. She fully understands the value of gemba walks and agrees that ‘the currency of leadership is presence.’ If I appear unenthusiastic about Lean, she will remind me that, ‘it is easier to act your way into a new way of thinking than to think your way into a new way of acting.’ That translates into, ‘just do it,’ or ‘try it and you’ll like it.’ “
“Our readings (1,2) have suggested that regular daily or weekly meetings of leaders and their staffs going at least three levels up the chain of leadership are essential in maintaining the momentum of a Lean transition. Remember Masaaki Imai’s admonition, ‘Kaizen is everyday improvement, everybody improvement, everywhere improvement.’ Remember also that Lean, like the flywheel we discussed back on March 26, 2008, resembles a bearing with lots of friction; it requires constant pushing. That puts a lot of responsibility for Lean’s success on the shoulders of middle managers who must adopt Lean leadership.”
“There’s a bundle of stuff that we front-line and middle managers have to know and do on a daily basis, Curmudge. Can you summarize from our reading?”
“From Kenney (1):
• ‘Know the status of daily work.
• Know if planned work is completed on time.
• Understand both upstream and downstream impact.
• Know that standard work is being followed.
• Know when to take action and what action to take.’
From Mann (2):
• ‘Assessment based on data captured on visual controls.
• Assignment for corrective action and/or improvement.
• Accountability for having completed the previous day’s assignments.’ "
“All of that sounds pretty intuitive, Curmudge. As I’ve said before, ‘Lean is just organized common sense.’ Lean leadership is powerful because it enforces daily accountability. And if people do this every day for months or years, they will forget what they would slide back into if they had any inclination to back-slide.”
“By the way, Julie, whatever happened to that concert that you were attending?”
“I got so wrapped up in thinking and talking about Lean that I was asked to leave.”
Affinity’s Kaizen Curmudgeon
(1) Kenney, Charles Transforming Health Care (CRC Press, 2011)
(2) Mann, David Creating a Lean Culture (CRC Press, 2010)
Thursday, October 20, 2011
Lean Leadership 2
“I suspect that all of us start each workday with standard work. I turn off the alarm clock and jump out of bed. Shave, do stretching exercises, and bring in the Wall Street Journal from the driveway. Eat breakfast, get dressed, and drive to work. Except for weekends, every day is essentially the same.”
“That was when you were working, Curmudge. Now that you are retired, you get out of bed more slowly and take time to read the front and editorial pages of the Journal. Everything else is pretty much the same as before.”
“My point, Jaded Julie, is that everyone knows about standard work, but each person has his/her own routine. That’s okay at home but not at work. Correcting this problem—facilitating the development of a unit’s standard work—is one of the most important tasks of a front-line supervisor. That’s the role I’d like you to play, Julie—a charge nurse or coordinator in a nursing unit of a generic hospital.”
“At least it’s better than my last role—a terminal patient in an ICU. If the nurses and techs haven’t taken a Lean Overview course, there’s a lot that I’ll have to teach. Kaizen events, value-stream mapping, A3 problem solving, 5S, PDCA, and more.”
“What the team members learn should stick with them, because they’ll be putting it to use right away. Remember that the standard processes will be developed by and owned by the team. A standard won’t fly if it is imposed from above.”
“Can you give me some ideas of things the team might achieve, Curmudge?”
“For inspiration, read about what other Lean hospitals have accomplished (1). Note that in every case their focus has been on enhancing the patient experience. Here are some of the things done at Virginia Mason Medical Center: made ‘taking report’ at shift change more efficient, reduced nurses’ time required for paperwork, instituted medical emergency teams, changed hourly rounding so that nurses would anticipate patient needs, and involved other departments in studies of systems to reduce the hospital’s ‘silo’ culture.”
“Those all sound good to me. They are excellent examples of Lean as it should be practiced in gemba. If I, as a front-line supervisor, could lead my team to accomplishments like those, you’d deem me an unqualified success.”
“You’ve made good progress, Julie, but there’s more. At this point in your fictional Lean leadership journey you are not doing what is needed to make those process changes endure. The problem is that some people in management—I hope not you—tend to leave standard work at the breakfast table. They arrive at work, check the day’s schedule for meetings, sometimes say a brief ‘good morning’ to the team members, and begin to fight the day’s most serious fire. They are attempting to manage a Lean team, but they aren’t practicing Lean themselves.”
“I’ve got it, Curmudge. Without Lean leadership, members of the team start drifting away from standard work and return to doing things ‘the way I’ve always done it.’ As we learned last week at Granddad’s farm, entropy is at work.”
“It’s also like a choir, where everyone might be singing a solo if it weren’t for each member reading from the same score…”
“…and an orchestra where we hear a bunch of toots and bleeps until the conductor taps his music stand with his baton.”
“Please note, Julie, that in both organizations the conductor can’t stop directing, walk away, and expect that the good music will continue. So next week we’ll return and play the next movement of the Lean Leadership Symphony.”
“I hope it won’t turn out to be a dirge. Bravo, Curmudge!”
“Brava, Julie.”
Affinity’s Kaizen Curmudgeon
(1) Kenney, Charles Transforming Health Care. (CRC Press, 2011)
“That was when you were working, Curmudge. Now that you are retired, you get out of bed more slowly and take time to read the front and editorial pages of the Journal. Everything else is pretty much the same as before.”
“My point, Jaded Julie, is that everyone knows about standard work, but each person has his/her own routine. That’s okay at home but not at work. Correcting this problem—facilitating the development of a unit’s standard work—is one of the most important tasks of a front-line supervisor. That’s the role I’d like you to play, Julie—a charge nurse or coordinator in a nursing unit of a generic hospital.”
“At least it’s better than my last role—a terminal patient in an ICU. If the nurses and techs haven’t taken a Lean Overview course, there’s a lot that I’ll have to teach. Kaizen events, value-stream mapping, A3 problem solving, 5S, PDCA, and more.”
“What the team members learn should stick with them, because they’ll be putting it to use right away. Remember that the standard processes will be developed by and owned by the team. A standard won’t fly if it is imposed from above.”
“Can you give me some ideas of things the team might achieve, Curmudge?”
“For inspiration, read about what other Lean hospitals have accomplished (1). Note that in every case their focus has been on enhancing the patient experience. Here are some of the things done at Virginia Mason Medical Center: made ‘taking report’ at shift change more efficient, reduced nurses’ time required for paperwork, instituted medical emergency teams, changed hourly rounding so that nurses would anticipate patient needs, and involved other departments in studies of systems to reduce the hospital’s ‘silo’ culture.”
“Those all sound good to me. They are excellent examples of Lean as it should be practiced in gemba. If I, as a front-line supervisor, could lead my team to accomplishments like those, you’d deem me an unqualified success.”
“You’ve made good progress, Julie, but there’s more. At this point in your fictional Lean leadership journey you are not doing what is needed to make those process changes endure. The problem is that some people in management—I hope not you—tend to leave standard work at the breakfast table. They arrive at work, check the day’s schedule for meetings, sometimes say a brief ‘good morning’ to the team members, and begin to fight the day’s most serious fire. They are attempting to manage a Lean team, but they aren’t practicing Lean themselves.”
“I’ve got it, Curmudge. Without Lean leadership, members of the team start drifting away from standard work and return to doing things ‘the way I’ve always done it.’ As we learned last week at Granddad’s farm, entropy is at work.”
“It’s also like a choir, where everyone might be singing a solo if it weren’t for each member reading from the same score…”
“…and an orchestra where we hear a bunch of toots and bleeps until the conductor taps his music stand with his baton.”
“Please note, Julie, that in both organizations the conductor can’t stop directing, walk away, and expect that the good music will continue. So next week we’ll return and play the next movement of the Lean Leadership Symphony.”
“I hope it won’t turn out to be a dirge. Bravo, Curmudge!”
“Brava, Julie.”
Affinity’s Kaizen Curmudgeon
(1) Kenney, Charles Transforming Health Care. (CRC Press, 2011)
Thursday, October 13, 2011
The Need for Lean Leadership--Entropy
“Curmudge, did I understand you to say that many organizations are stymied in their Lean journey because they haven’t developed a Lean management system to go along with Lean implemented in their workplace?”
“That’s what the literature says, Jaded Julie. People in gemba have learned to use Lean tools, like standard work; but without ongoing reinforcement by Lean leadership, they tend to slip back into their old, nonstandard ways of doing things. Then the Lean journey sputters to a halt.”
“That’s a sad commentary on human nature. But you have said that this tendency toward disorganization is quite natural, applies to everything—not just people—and that it is described by a thermodynamic term called entropy. Without an external input of energy, disorganization—entropy—tends to increase.”
“You’ve got it, Julie, and I can assure you that the objects in my example never studied thermodynamics. When I was a child back in the early 1940’s I used to visit my grandfather’s farm in the hills of southwestern Virginia. Granddad’s sons, my uncles, were away in the war, so he was running the farm with the help of my step-grandmother and their dog, Shep. When it was time to milk the cows, Granddad would send Shep up the ‘holler’ (hollow, a narrow valley) to collect the widely scattered cows and herd them back to the barn. Because Shep was part Border Collie, this was a very natural task.”
“I’m listening, Curmudge. This will undoubtedly turn out to be one of your homespun tales ending with a lesson.”
“So we’ll continue, Jaded Julie. The cows went into the barn and into their familiar stalls (in those days we didn’t have stanchions). Grandfather milked each cow by hand. I tried to help but got little milk; I did get a solid whack on the head by the cow’s tail. Upon finishing, we opened the barn door and the gate to the pasture, and the cows filed out and up into the hills.”
“I suspect that we are just about to learn something about entropy, the topic of today’s conversation.”
“The cows might have stood shoulder-to-shoulder and marched in rank up the holler like a cavalry charge consuming the grass in a wide swath. They didn’t, of course. Each cow went its own way—some on one hill and some on another—so they were scattered all over the place for Shep to find them when milking time came around again.”
“I’ve got it, Curmudge. The cows’ random distribution demonstrated entropy, the natural tendency toward increased randomness. That’s similar to the story you told once before about your grandson. Although his toys were put away neatly in the toy box each evening, they were scattered all over the house by the end of the next day.”
“When winter came to Granddad’s farm, he kept the cows in the barn. It was a lot of work carrying in feed and hauling out manure, but he didn’t want a cow breaking a leg slipping on an icy rock on a steep hill. However, if the barn door and the pasture gate had been left open and if Shep had been busy trying futilely to herd the chickens, the cows would have wandered out of the barn, up the holler, and again become scattered randomly up in the hills.”
“I’ve got it again, Curmudge. When the cows were not being carefully managed, they backslid into their old habit of wandering randomly. Their actions again demonstrate the tendency of entropy—randomness—to increase.”
“Here’s another example of increasing randomness. If one puts a cube of ice—a well-ordered structure—into a glass of Scotch, the ice will spontaneously melt into less-ordered liquid water. Of course, the full explanation is rather complicated.”
“Good example, Curmudge, but not if you like to drink your Scotch neat. So are we going to carry this lesson over to Lean, where we’ll discuss workers and managers instead of cows and Border Collies?”
“Nurse Julie, you can bet your white cap (if you have one) on that.”
Affinity’s Kaizen Curmudgeon
“That’s what the literature says, Jaded Julie. People in gemba have learned to use Lean tools, like standard work; but without ongoing reinforcement by Lean leadership, they tend to slip back into their old, nonstandard ways of doing things. Then the Lean journey sputters to a halt.”
“That’s a sad commentary on human nature. But you have said that this tendency toward disorganization is quite natural, applies to everything—not just people—and that it is described by a thermodynamic term called entropy. Without an external input of energy, disorganization—entropy—tends to increase.”
“You’ve got it, Julie, and I can assure you that the objects in my example never studied thermodynamics. When I was a child back in the early 1940’s I used to visit my grandfather’s farm in the hills of southwestern Virginia. Granddad’s sons, my uncles, were away in the war, so he was running the farm with the help of my step-grandmother and their dog, Shep. When it was time to milk the cows, Granddad would send Shep up the ‘holler’ (hollow, a narrow valley) to collect the widely scattered cows and herd them back to the barn. Because Shep was part Border Collie, this was a very natural task.”
“I’m listening, Curmudge. This will undoubtedly turn out to be one of your homespun tales ending with a lesson.”
“So we’ll continue, Jaded Julie. The cows went into the barn and into their familiar stalls (in those days we didn’t have stanchions). Grandfather milked each cow by hand. I tried to help but got little milk; I did get a solid whack on the head by the cow’s tail. Upon finishing, we opened the barn door and the gate to the pasture, and the cows filed out and up into the hills.”
“I suspect that we are just about to learn something about entropy, the topic of today’s conversation.”
“The cows might have stood shoulder-to-shoulder and marched in rank up the holler like a cavalry charge consuming the grass in a wide swath. They didn’t, of course. Each cow went its own way—some on one hill and some on another—so they were scattered all over the place for Shep to find them when milking time came around again.”
“I’ve got it, Curmudge. The cows’ random distribution demonstrated entropy, the natural tendency toward increased randomness. That’s similar to the story you told once before about your grandson. Although his toys were put away neatly in the toy box each evening, they were scattered all over the house by the end of the next day.”
“When winter came to Granddad’s farm, he kept the cows in the barn. It was a lot of work carrying in feed and hauling out manure, but he didn’t want a cow breaking a leg slipping on an icy rock on a steep hill. However, if the barn door and the pasture gate had been left open and if Shep had been busy trying futilely to herd the chickens, the cows would have wandered out of the barn, up the holler, and again become scattered randomly up in the hills.”
“I’ve got it again, Curmudge. When the cows were not being carefully managed, they backslid into their old habit of wandering randomly. Their actions again demonstrate the tendency of entropy—randomness—to increase.”
“Here’s another example of increasing randomness. If one puts a cube of ice—a well-ordered structure—into a glass of Scotch, the ice will spontaneously melt into less-ordered liquid water. Of course, the full explanation is rather complicated.”
“Good example, Curmudge, but not if you like to drink your Scotch neat. So are we going to carry this lesson over to Lean, where we’ll discuss workers and managers instead of cows and Border Collies?”
“Nurse Julie, you can bet your white cap (if you have one) on that.”
Affinity’s Kaizen Curmudgeon
Thursday, October 6, 2011
How Things Happen
The Medicare Summary Notice and Provider Reimbursement
“Curmudge, don’t you think a better title would be How Things Work?”
“Not really, Jaded Julie. Saying that something works implies a favorable judgment regarding the performance of the subject, and I don’t think that we are qualified to do that.”
“But doesn‘t a ‘happening’ suggest a natural occurrence, like a tornado or a snowstorm? Isn’t provider reimbursement completely anthropogenic?”
“It is indeed man-made, Julie, but instead of semantics, let’s tackle our subject.”
“How did you get onto this topic, anyway?”
“A friend asked me to explain some of the numbers on her Medicare Summary Notice, which is sort of like an insurance company’s Explanation of Benefits. If you wonder why we are limiting this discussion to Medicare, it’s because most of my friends are my contemporaries and all of my contemporaries are either on Medicare or deceased.”
“Let’s get with it, Curmudge. I believe we must start by learning some abbreviations.”
“RVUs (Relative Value Units) are used to determine how much medical providers should be paid. Components of RVUs include physician work (time, skill, training), practice expense, and malpractice insurance expense. They are adjusted by a factor that reflects the different costs of practicing medicine across the country and are then multiplied by a dollars-per-RVU conversion factor.”
“I know the next one; that’s the CPT (Current Procedure Terminology) code. There is a CPT code for each medical, surgical, and diagnostic service, and each CPT has an associated RVU. That’s the origin of the ‘Medicare-Approved’ values next to each CPT code on your Medicare Summary Notice. The RVUs have a lot of bearing on provider compensation, Curmudge. Are they handed down on stone tablets?”
“They might as well be. They are determined in meetings of a committee representing all medical specialties. I have read of these meetings described as the proverbial ‘smoke-filled room’ but without smoke.”
“And finally we have ICD (International Classification of Diseases), a system of diagnosis codes. This is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases, as maintained by the World Health Organization (WHO). We are now using Revision 9 (ICD-9), but Revision 10 (ICD-10) must be employed by October 1, 2013. The new code set contains more codes than ICD-9, including many for very specific occurrences.”
“Do you suppose that they have one for getting crushed in a buffalo stampede in Buffalo, New York?”
“It’s interesting, Curmudge, that Medicare will reject a provider’s claim if the procedure code is not appropriate for the diagnosis code. For example, an x-ray of the wrist will be rejected if the patient is diagnosed with glaucoma. It is certainly critical for a provider to have proficient back-office support.”
“So back to the Medicare Summary Notice, the most common one (Part B) showing claims from individual providers. You may note that the ‘Medicare-Approved’ amount may be a lot less than the ‘Amount Charged’ (by the provider). Don’t worry; you’re usually not responsible for the difference. The next column is ‘Medicare Paid Provider’. It is typically 80% of the ‘Medicare-Approved’ amount. The remaining 20%, in the ‘You May Be Billed’ column, is the total that you plus your secondary (medi-gap) insurance are expected to pay. On occasion, my final out-of-pocket cost has been around 1% of the amount charged. Mrs. Curmudgeon’s hospital bill was $4,000, but I ended up paying only $40. Actually, I thought she was worth more than that.”
“Curmudge, despite all of the RVUs, codes, and correction factors, it just sounds as if providers are paid on a piecework basis. Did you ever have a job in which you were paid for piecework?”
“I did that back in the 1940’s when I was a child. It was called berry pickin’. We kids would stand on a designated corner, and a farmer would come by to pick us up and take us to his berry field. I would select a row that appeared to have lots of berries (I think they were strawberries), grab a basket, and fill it as fast as I could. Then another basket and then another. It was hard stoop-labor, and we were paid only a few pennies per basket. To this day, whenever I buy berries my back hurts.”
“Do you see any parallels between your experience and provider compensation?”
“Well, I suppose choosing a medical specialty might relate to selecting a row with lots of berries. (Some day we’ll cogitate a bit on why docs select specialties.) And my filling lots of boxes of berries might correlate with a provider’s racking up a lot of RVUs.”
“Pretty interesting, Curmudge. I hope your friend who inspired this topic wasn’t looking for a short answer.”
Affinity’s Kaizen Curmudgeon
“Curmudge, don’t you think a better title would be How Things Work?”
“Not really, Jaded Julie. Saying that something works implies a favorable judgment regarding the performance of the subject, and I don’t think that we are qualified to do that.”
“But doesn‘t a ‘happening’ suggest a natural occurrence, like a tornado or a snowstorm? Isn’t provider reimbursement completely anthropogenic?”
“It is indeed man-made, Julie, but instead of semantics, let’s tackle our subject.”
“How did you get onto this topic, anyway?”
“A friend asked me to explain some of the numbers on her Medicare Summary Notice, which is sort of like an insurance company’s Explanation of Benefits. If you wonder why we are limiting this discussion to Medicare, it’s because most of my friends are my contemporaries and all of my contemporaries are either on Medicare or deceased.”
“Let’s get with it, Curmudge. I believe we must start by learning some abbreviations.”
“RVUs (Relative Value Units) are used to determine how much medical providers should be paid. Components of RVUs include physician work (time, skill, training), practice expense, and malpractice insurance expense. They are adjusted by a factor that reflects the different costs of practicing medicine across the country and are then multiplied by a dollars-per-RVU conversion factor.”
“I know the next one; that’s the CPT (Current Procedure Terminology) code. There is a CPT code for each medical, surgical, and diagnostic service, and each CPT has an associated RVU. That’s the origin of the ‘Medicare-Approved’ values next to each CPT code on your Medicare Summary Notice. The RVUs have a lot of bearing on provider compensation, Curmudge. Are they handed down on stone tablets?”
“They might as well be. They are determined in meetings of a committee representing all medical specialties. I have read of these meetings described as the proverbial ‘smoke-filled room’ but without smoke.”
“And finally we have ICD (International Classification of Diseases), a system of diagnosis codes. This is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases, as maintained by the World Health Organization (WHO). We are now using Revision 9 (ICD-9), but Revision 10 (ICD-10) must be employed by October 1, 2013. The new code set contains more codes than ICD-9, including many for very specific occurrences.”
“Do you suppose that they have one for getting crushed in a buffalo stampede in Buffalo, New York?”
“It’s interesting, Curmudge, that Medicare will reject a provider’s claim if the procedure code is not appropriate for the diagnosis code. For example, an x-ray of the wrist will be rejected if the patient is diagnosed with glaucoma. It is certainly critical for a provider to have proficient back-office support.”
“So back to the Medicare Summary Notice, the most common one (Part B) showing claims from individual providers. You may note that the ‘Medicare-Approved’ amount may be a lot less than the ‘Amount Charged’ (by the provider). Don’t worry; you’re usually not responsible for the difference. The next column is ‘Medicare Paid Provider’. It is typically 80% of the ‘Medicare-Approved’ amount. The remaining 20%, in the ‘You May Be Billed’ column, is the total that you plus your secondary (medi-gap) insurance are expected to pay. On occasion, my final out-of-pocket cost has been around 1% of the amount charged. Mrs. Curmudgeon’s hospital bill was $4,000, but I ended up paying only $40. Actually, I thought she was worth more than that.”
“Curmudge, despite all of the RVUs, codes, and correction factors, it just sounds as if providers are paid on a piecework basis. Did you ever have a job in which you were paid for piecework?”
“I did that back in the 1940’s when I was a child. It was called berry pickin’. We kids would stand on a designated corner, and a farmer would come by to pick us up and take us to his berry field. I would select a row that appeared to have lots of berries (I think they were strawberries), grab a basket, and fill it as fast as I could. Then another basket and then another. It was hard stoop-labor, and we were paid only a few pennies per basket. To this day, whenever I buy berries my back hurts.”
“Do you see any parallels between your experience and provider compensation?”
“Well, I suppose choosing a medical specialty might relate to selecting a row with lots of berries. (Some day we’ll cogitate a bit on why docs select specialties.) And my filling lots of boxes of berries might correlate with a provider’s racking up a lot of RVUs.”
“Pretty interesting, Curmudge. I hope your friend who inspired this topic wasn’t looking for a short answer.”
Affinity’s Kaizen Curmudgeon
Thursday, September 29, 2011
Series Contents
“Curmudge, you messed up.”
“Jaded Julie, what do you mean, I messed up? Everything we do is a joint effort. You must mean that we messed up, but what did we do or not do?”
“Back in 2009 we had 12 postings on Patient Safety. Each posting had an extended title so the reader would know in which posting to look for information on medications or infections or falls or whatever. Later we posted series (three or more postings) on Mistakes, Amazing Devices, Evidence-Based Medicine, The Crystal Ball, The Laboratory, and Sepsis without extended titles. Unless he/she had an excellent memory (which you don’t have), the reader would have to search for a particular topic within a series by trial-and-error.”
“You’re right as usual, Julie. Let’s create extended titles or keywords for the postings within those series. That will help me when I want to insert a link back to an earlier posting. As you know, I forget what’s in an article the day after it is posted.”
“You conjure up the subtitles, Curmudge, and I’ll type.”
April 1, 2010: Mistakes—mnemonics, sleep deprivation
April 8, 2010: Mistakes 2—standard work, checklists, ‘Isabel’
July 22, 2010: Mistakes 3—necessary fallibility, see February 19, 2009
Aug. 5, 2010: Amazing Devices—AutoAnalyzer, pulse oximeter
Aug. 12, 2010: Amazing Devices 2—Library resources, PDA Road Map; Information at Your Fingertips;, August 6, 2009
Sept. 2, 2010: Amazing Devices 3—The Wireless Future of Medicine
Sept. 9, 2010: Amazing Devices 4—ultrasound, electronic stethoscope
Sept. 23, 2010: Evidence-Based Medicine—URLs for reviews
Sept. 30, 2010: Evidence-Based Medicine 2—review articles, clinical trials
Oct. 14, 2010: Evidence-Based Medicine 3—evaluating the literature
Oct. 14, 2010: Evidence-Based Medicine 4—“Will it help my patient?”
Oct. 21, 2010: Evidence-Based Medicine 5—getting a second opinion
April 7, 2011: The Crystal Ball—prologue
April 15, 2011: The Crystal Ball 1—need for Lean
April 27, 2011: The Crystal Ball 2—specialized consultancies, IHI
May 5, 2011: The Crystal Ball 3—Sg2
May 12, 2011: The Crystal Ball 4—The Innovator’s Prescription by Clayton Christensen, disruptive innovation
May 19, 2011: The Crystal Ball 5—intuitive & precision medicine, NPs displacing docs displacing other docs, pharmacogenomics
May 31, 2011: The Crystal Ball 6—‘solution shops’ & value-added processes; straightforward and difficult diagnoses
June 3, 2011: The Crystal Ball 7—chronic diseases, integrated fixed-fee providers
June 13, 2011: The Crystal Ball 8—two health care philosophies; HSAs plus high-deductible insurance
June 30, 2011: The Laboratory—phlebotomist, specimen processing, blood bank
July 7, 2011: The Laboratory 2—CBCs, chemistry, troponins (heart attack), hemoglobin A1C (diabetes), microbiology
July 14, 2011: The Laboratory 3—identification of bacteria
July 21, 2011: The Laboratory 4—pathology, histology, cytology
July 28, 2011: The Laboratory 5—quality control, workload, turnaround, education requirements
Aug. 26, 2011: Sepsis—introduction, pathogenesis
Sept. 7, 2011: Sepsis 2—diagnosis, management
Sept. 15, 2011: Sepsis 3—resuscitation bundles, MMC data
“Julie, these should be helpful for our readers and also for me. Let’s do this the next time we write three or more postings on the same general topic.”
“I’ll remind you, Curmudge. If I don’t, you’ll forget.”
Affinity’s Kaizen Curmudgeon
“Jaded Julie, what do you mean, I messed up? Everything we do is a joint effort. You must mean that we messed up, but what did we do or not do?”
“Back in 2009 we had 12 postings on Patient Safety. Each posting had an extended title so the reader would know in which posting to look for information on medications or infections or falls or whatever. Later we posted series (three or more postings) on Mistakes, Amazing Devices, Evidence-Based Medicine, The Crystal Ball, The Laboratory, and Sepsis without extended titles. Unless he/she had an excellent memory (which you don’t have), the reader would have to search for a particular topic within a series by trial-and-error.”
“You’re right as usual, Julie. Let’s create extended titles or keywords for the postings within those series. That will help me when I want to insert a link back to an earlier posting. As you know, I forget what’s in an article the day after it is posted.”
“You conjure up the subtitles, Curmudge, and I’ll type.”
April 1, 2010: Mistakes—mnemonics, sleep deprivation
April 8, 2010: Mistakes 2—standard work, checklists, ‘Isabel’
July 22, 2010: Mistakes 3—necessary fallibility, see February 19, 2009
Aug. 5, 2010: Amazing Devices—AutoAnalyzer, pulse oximeter
Aug. 12, 2010: Amazing Devices 2—Library resources, PDA Road Map; Information at Your Fingertips;, August 6, 2009
Sept. 2, 2010: Amazing Devices 3—The Wireless Future of Medicine
Sept. 9, 2010: Amazing Devices 4—ultrasound, electronic stethoscope
Sept. 23, 2010: Evidence-Based Medicine—URLs for reviews
Sept. 30, 2010: Evidence-Based Medicine 2—review articles, clinical trials
Oct. 14, 2010: Evidence-Based Medicine 3—evaluating the literature
Oct. 14, 2010: Evidence-Based Medicine 4—“Will it help my patient?”
Oct. 21, 2010: Evidence-Based Medicine 5—getting a second opinion
April 7, 2011: The Crystal Ball—prologue
April 15, 2011: The Crystal Ball 1—need for Lean
April 27, 2011: The Crystal Ball 2—specialized consultancies, IHI
May 5, 2011: The Crystal Ball 3—Sg2
May 12, 2011: The Crystal Ball 4—The Innovator’s Prescription by Clayton Christensen, disruptive innovation
May 19, 2011: The Crystal Ball 5—intuitive & precision medicine, NPs displacing docs displacing other docs, pharmacogenomics
May 31, 2011: The Crystal Ball 6—‘solution shops’ & value-added processes; straightforward and difficult diagnoses
June 3, 2011: The Crystal Ball 7—chronic diseases, integrated fixed-fee providers
June 13, 2011: The Crystal Ball 8—two health care philosophies; HSAs plus high-deductible insurance
June 30, 2011: The Laboratory—phlebotomist, specimen processing, blood bank
July 7, 2011: The Laboratory 2—CBCs, chemistry, troponins (heart attack), hemoglobin A1C (diabetes), microbiology
July 14, 2011: The Laboratory 3—identification of bacteria
July 21, 2011: The Laboratory 4—pathology, histology, cytology
July 28, 2011: The Laboratory 5—quality control, workload, turnaround, education requirements
Aug. 26, 2011: Sepsis—introduction, pathogenesis
Sept. 7, 2011: Sepsis 2—diagnosis, management
Sept. 15, 2011: Sepsis 3—resuscitation bundles, MMC data
“Julie, these should be helpful for our readers and also for me. Let’s do this the next time we write three or more postings on the same general topic.”
“I’ll remind you, Curmudge. If I don’t, you’ll forget.”
Affinity’s Kaizen Curmudgeon
Friday, September 23, 2011
The Bad, Good Medication
“A long time ago, in my UW-Madison years, I used to share the ride home from campus with my neighbor, Bernie, a physician in the Division of Clinical Oncology. One day we were stopped at a traffic light and Bernie glanced at a passing pedestrian and said, ‘See that guy with the moon face. I’ll bet he’s on steroids.’ ‘If you say so, Bernie,’ and we continued on home.”
“That must have been your introduction to corticosteroid medications, Curmudge. Have you ever experienced them first hand?”
“Right hand as well as left hand, Jaded Julie. Tendonitis in several of my fingers was treated with cortisone injections. The pain was exquisite as the doc probed around with the needle inside each finger trying to locate the tendon. But I never had to take prednisone, the common oral corticosteroid that is the topic for today’s discussion.”
“Pray tell, O Unpredictable Oracle, why your brain decided to focus on prednisone, of all things.”
“Prednisone has been around since the 1950’s, and it is prescribed for a wide variety of conditions. Patients who are anywhere north of clueless probably have heard that there is something about prednisone that they won’t like, but they might not recall what it is. We are going to tell those patients what is in store for them by sharing what I have observed in the past year.”
“In my training I learned that cortisone is produced in the body’s adrenal glands, and its synthetic form is prednisone. It was originally hailed as a wonder drug for its effect on patients with rheumatoid arthritis, and it is used for other autoimmune diseases like multiple sclerosis and lupus. A valuable property of corticosteroids is their ability to prevent release of substances in the body that cause inflammation; that explains the injections into the tendons of your fingers. Other treated conditions include inflammatory bowel disease, some lung diseases, severe allergies, and asthma.”
“Because of its amazing versatility, prednisone is sometimes prescribed when nothing else seems to work…sort of a medication of last resort or a forlorn hope.”
“Forlorn hope? What is that?”
“It’s like a ‘Hail Mary’ pass, Julie, only an ‘incomplete’ has much greater significance for the patient.”
“Except for the ‘forlorn hope,’ everything we’ve said about prednisone sounds pretty good. What about side effects?”
“The package insert with most medications describes a lot of side effects that rarely occur. With prednisone, many of the side effects almost always occur, especially if the med is taken for many weeks or months. Most patients seem to gain weight around the middle and acquire the ‘moon face’ that my neighbor, Bernie, observed. You know how female patients feel about that. A patient with the beginnings of cataracts will find that they bloom dramatically and soon require surgery.”
“I’ve read, Curmudge, that mood changes are common and that prednisone tablets have been referred to as ‘nasty pills.’ Other threats are osteoporosis, increased susceptibility to infections, general malaise, and shaky handwriting. Prednisone even has side effects if one suddenly stops taking it. The body’s own corticosteroid factory goes on standby in the presence of an external source of the chemical, and it takes awhile for it to resume production.”
“I observed a patient entering a physician’s waiting room who had apparently been on prednisone long term for a lung condition. She was grotesquely obese, in a wheelchair, and clutching an oxygen cylinder with a plastic tube leading up to the cannula in her nostrils. I heard another patient whisper with fierce resolve, ‘I don’t want to ever be like that.’ Little did she realize that death was the only sure way to avoid that fate. Can’t you envision a patient’s final words before expiring, ‘At least I won’t have to take any more prednisone.’?”
"Yuk! What a morose ending. Can’t you think of a brighter way to conclude today’s discussion?”
“I can, Jaded Julie. It’s called ‘precision medicine.’ As we quoted Clayton Christensen in The Crystal Ball 5, it is ‘the provision of care for diseases that can be precisely diagnosed, whose causes are understood, and which consequently can be treated with rules-based therapies that are predictably effective.’ If society doesn’t stifle creativity, our grandchildren won’t have to be treated with medications that have as many side effects as benefits.”
“Halleluiah amen, Curmudge!”
Affinity’s Kaizen Curmudgeon
“That must have been your introduction to corticosteroid medications, Curmudge. Have you ever experienced them first hand?”
“Right hand as well as left hand, Jaded Julie. Tendonitis in several of my fingers was treated with cortisone injections. The pain was exquisite as the doc probed around with the needle inside each finger trying to locate the tendon. But I never had to take prednisone, the common oral corticosteroid that is the topic for today’s discussion.”
“Pray tell, O Unpredictable Oracle, why your brain decided to focus on prednisone, of all things.”
“Prednisone has been around since the 1950’s, and it is prescribed for a wide variety of conditions. Patients who are anywhere north of clueless probably have heard that there is something about prednisone that they won’t like, but they might not recall what it is. We are going to tell those patients what is in store for them by sharing what I have observed in the past year.”
“In my training I learned that cortisone is produced in the body’s adrenal glands, and its synthetic form is prednisone. It was originally hailed as a wonder drug for its effect on patients with rheumatoid arthritis, and it is used for other autoimmune diseases like multiple sclerosis and lupus. A valuable property of corticosteroids is their ability to prevent release of substances in the body that cause inflammation; that explains the injections into the tendons of your fingers. Other treated conditions include inflammatory bowel disease, some lung diseases, severe allergies, and asthma.”
“Because of its amazing versatility, prednisone is sometimes prescribed when nothing else seems to work…sort of a medication of last resort or a forlorn hope.”
“Forlorn hope? What is that?”
“It’s like a ‘Hail Mary’ pass, Julie, only an ‘incomplete’ has much greater significance for the patient.”
“Except for the ‘forlorn hope,’ everything we’ve said about prednisone sounds pretty good. What about side effects?”
“The package insert with most medications describes a lot of side effects that rarely occur. With prednisone, many of the side effects almost always occur, especially if the med is taken for many weeks or months. Most patients seem to gain weight around the middle and acquire the ‘moon face’ that my neighbor, Bernie, observed. You know how female patients feel about that. A patient with the beginnings of cataracts will find that they bloom dramatically and soon require surgery.”
“I’ve read, Curmudge, that mood changes are common and that prednisone tablets have been referred to as ‘nasty pills.’ Other threats are osteoporosis, increased susceptibility to infections, general malaise, and shaky handwriting. Prednisone even has side effects if one suddenly stops taking it. The body’s own corticosteroid factory goes on standby in the presence of an external source of the chemical, and it takes awhile for it to resume production.”
“I observed a patient entering a physician’s waiting room who had apparently been on prednisone long term for a lung condition. She was grotesquely obese, in a wheelchair, and clutching an oxygen cylinder with a plastic tube leading up to the cannula in her nostrils. I heard another patient whisper with fierce resolve, ‘I don’t want to ever be like that.’ Little did she realize that death was the only sure way to avoid that fate. Can’t you envision a patient’s final words before expiring, ‘At least I won’t have to take any more prednisone.’?”
"Yuk! What a morose ending. Can’t you think of a brighter way to conclude today’s discussion?”
“I can, Jaded Julie. It’s called ‘precision medicine.’ As we quoted Clayton Christensen in The Crystal Ball 5, it is ‘the provision of care for diseases that can be precisely diagnosed, whose causes are understood, and which consequently can be treated with rules-based therapies that are predictably effective.’ If society doesn’t stifle creativity, our grandchildren won’t have to be treated with medications that have as many side effects as benefits.”
“Halleluiah amen, Curmudge!”
Affinity’s Kaizen Curmudgeon
Thursday, September 15, 2011
Sepsis 3
“Jaded Julie, I’ve read so many articles on sepsis in the past few weeks that my head is spinning.”
“I know you are confused most of the time, Curmudge, but do you have chills, a fever, or are you hyperventilating? Here, let me check your blood pressure.”
“No, Julie. I don’t have sepsis. It’s just that the articles are generally similar, and as a layperson, I wouldn’t understand subtle differences if I saw them. So from now on, I’m not going to sweat the details. I’ll leave them to the physicians and nurses. Our focus today will be on Affinity’s experience with sepsis, including diagnosis and management.”
“But we’ve already discussed diagnosis. Is there anything special that we do?”
“There is, Julie, and it’s a mannequin called iStan. iStan is the smartest dummy in town because he can be programmed to portray a vast array of symptoms of a host of diseases. For example, iStan’s software comes with a sepsis simulation scenario.”
“Well at least if he exhibits oliguria, there won’t be much of a puddle to clean up.”
“iStan is a new addition to our staff and has been used thus far for orientation of new hires. His use will grow as people get more familiar with his operation. I’m looking forward to being impressed whenever I can arrange a demonstration.”
“So what else is new, Curmudge? The links to Affinity documents in Sepsis 2 suggest that our hospitals are doing the right things in sepsis diagnosis and management.”
“There’s more to be told, Julie, but I promise…no clinical details. We have been using IHI’s Surviving Sepsis Guidelines since 2005 and the IHI Sepsis 6-Hour Resuscitation Bundle. These have been translated into pre-printed order sets, the Severe Sepsis Screening Tool and the Severe Sepsis Septic Shock Order Set: 6-Hour Resuscitation Bundle. If you read any of these, they would look pretty familiar.”
“And that’s the Lean standard work you were talking about. The value of these is that for severe sepsis and septic shock, one can’t afford to overlook any of the critical steps.”
“The ICU’s also use spreadsheets to track their compliance with each step in the resuscitation and management bundles for each patient.”
“Our procedures sound impressive, Curmudge. Are we saving lives?”
“I have some data from Mercy Medical Center, Julie. In 2004 the nation-wide mortality rate for sepsis was 28.6% (215,000 deaths). For MMC, the sepsis mortality rate was 11% in 2005-2006 and 6-7% in 2009. MMC treated 22 patients for sepsis from January 2011 through early August.”
“What might one do to avoid becoming a sepsis patient?”
“Avoid sepsis by avoiding infections. You and I talked about avoiding infections back on January 29, 2009. Although that posting was about nosocomial infections, one should also practice good hygiene at home. Teach your children about washing their hands and not neglecting a cut or scrape. If because of joint or other prior surgery you are directed to take a prophylactic med before having dental work, do it.”
“The mortality rate from sepsis in U.S. hospitals is worrisome enough. It’s undoubtedly higher in hospitals in the Third World.”
“One who travels to undeveloped countries should certainly have air-evacuation coverage in their trip insurance. If you contract sepsis in one of those strange-sounding places, your life may depend upon being airlifted out ASAP.”
“I understand that you found a valuable lesson in your reading last night. (Hey, Curmudge, get a life.)”
“The Smiths took their ill 7-year old son to the ED. Aside from nausea and a heart rate of 148, his vitals were normal. While he was at the ED his heart rate decreased and he was able to receive fluids. The Smiths wanted to leave, although results from the complete blood count were not yet back from the lab. The doctor, believing the child had a urinary tract infection, discharged the patient and told his parents that he should be better in 24 hours but to return if he is not.”
“I see impending trouble. What happened?”
“Within the next few hours, the child developed severe sepsis. He survived but suffered organ damage. The lesson: Stay with your sick child; lose a night’s sleep if necessary. If his condition deteriorates, don’t delay in returning to the ED. Incidentally, this scenario can occur with other illnesses such as appendicitis.”
“Actually Curmudge, that’s one of the perennial concerns of ER docs…that a patient will come in with a condition not well enough developed for a definitive diagnosis. Then the condition intensifies and clobbers the patient within 24 hours after he is sent home. So, Student of Medieval History, do you have a final perspective on sepsis?”
“Back in 1348 when the Black Death ravaged Europe, about three-fourths of the population of Great Britain died. The survivors were possibly not exposed to the sick people or the fleas carrying the disease, or perhaps they possessed a natural immunity. One of the three forms of the medieval plague was septicemic plague (the others were bubonic and pneumonic); its symptoms were similar to modern severe sepsis. In the 14th century, the mortality rate from septicemic plague was 99-100%. Patients sometimes died the same day they contracted the disease. The lesson: Sepsis was—and still is—a deadly condition.”
Affinity’s Kaizen Curmudgeon
“I know you are confused most of the time, Curmudge, but do you have chills, a fever, or are you hyperventilating? Here, let me check your blood pressure.”
“No, Julie. I don’t have sepsis. It’s just that the articles are generally similar, and as a layperson, I wouldn’t understand subtle differences if I saw them. So from now on, I’m not going to sweat the details. I’ll leave them to the physicians and nurses. Our focus today will be on Affinity’s experience with sepsis, including diagnosis and management.”
“But we’ve already discussed diagnosis. Is there anything special that we do?”
“There is, Julie, and it’s a mannequin called iStan. iStan is the smartest dummy in town because he can be programmed to portray a vast array of symptoms of a host of diseases. For example, iStan’s software comes with a sepsis simulation scenario.”
“Well at least if he exhibits oliguria, there won’t be much of a puddle to clean up.”
“iStan is a new addition to our staff and has been used thus far for orientation of new hires. His use will grow as people get more familiar with his operation. I’m looking forward to being impressed whenever I can arrange a demonstration.”
“So what else is new, Curmudge? The links to Affinity documents in Sepsis 2 suggest that our hospitals are doing the right things in sepsis diagnosis and management.”
“There’s more to be told, Julie, but I promise…no clinical details. We have been using IHI’s Surviving Sepsis Guidelines since 2005 and the IHI Sepsis 6-Hour Resuscitation Bundle. These have been translated into pre-printed order sets, the Severe Sepsis Screening Tool and the Severe Sepsis Septic Shock Order Set: 6-Hour Resuscitation Bundle. If you read any of these, they would look pretty familiar.”
“And that’s the Lean standard work you were talking about. The value of these is that for severe sepsis and septic shock, one can’t afford to overlook any of the critical steps.”
“The ICU’s also use spreadsheets to track their compliance with each step in the resuscitation and management bundles for each patient.”
“Our procedures sound impressive, Curmudge. Are we saving lives?”
“I have some data from Mercy Medical Center, Julie. In 2004 the nation-wide mortality rate for sepsis was 28.6% (215,000 deaths). For MMC, the sepsis mortality rate was 11% in 2005-2006 and 6-7% in 2009. MMC treated 22 patients for sepsis from January 2011 through early August.”
“What might one do to avoid becoming a sepsis patient?”
“Avoid sepsis by avoiding infections. You and I talked about avoiding infections back on January 29, 2009. Although that posting was about nosocomial infections, one should also practice good hygiene at home. Teach your children about washing their hands and not neglecting a cut or scrape. If because of joint or other prior surgery you are directed to take a prophylactic med before having dental work, do it.”
“The mortality rate from sepsis in U.S. hospitals is worrisome enough. It’s undoubtedly higher in hospitals in the Third World.”
“One who travels to undeveloped countries should certainly have air-evacuation coverage in their trip insurance. If you contract sepsis in one of those strange-sounding places, your life may depend upon being airlifted out ASAP.”
“I understand that you found a valuable lesson in your reading last night. (Hey, Curmudge, get a life.)”
“The Smiths took their ill 7-year old son to the ED. Aside from nausea and a heart rate of 148, his vitals were normal. While he was at the ED his heart rate decreased and he was able to receive fluids. The Smiths wanted to leave, although results from the complete blood count were not yet back from the lab. The doctor, believing the child had a urinary tract infection, discharged the patient and told his parents that he should be better in 24 hours but to return if he is not.”
“I see impending trouble. What happened?”
“Within the next few hours, the child developed severe sepsis. He survived but suffered organ damage. The lesson: Stay with your sick child; lose a night’s sleep if necessary. If his condition deteriorates, don’t delay in returning to the ED. Incidentally, this scenario can occur with other illnesses such as appendicitis.”
“Actually Curmudge, that’s one of the perennial concerns of ER docs…that a patient will come in with a condition not well enough developed for a definitive diagnosis. Then the condition intensifies and clobbers the patient within 24 hours after he is sent home. So, Student of Medieval History, do you have a final perspective on sepsis?”
“Back in 1348 when the Black Death ravaged Europe, about three-fourths of the population of Great Britain died. The survivors were possibly not exposed to the sick people or the fleas carrying the disease, or perhaps they possessed a natural immunity. One of the three forms of the medieval plague was septicemic plague (the others were bubonic and pneumonic); its symptoms were similar to modern severe sepsis. In the 14th century, the mortality rate from septicemic plague was 99-100%. Patients sometimes died the same day they contracted the disease. The lesson: Sepsis was—and still is—a deadly condition.”
Affinity’s Kaizen Curmudgeon
Wednesday, September 7, 2011
Sepsis 2
“Hey Curmudge, it was fun last week doing our folksy introduction to sepsis laced with ten-dollar words, but why so much technical stuff?”
“It’s hard to express the complexity of the human body without a few big words, which, you may have noticed, were all defined in the text. I also felt that any terms as hard to learn as those deserved to be spread around. By the way, I haven’t been holding my breath as you recommended last week. I’ve been reading about how health care handles sepsis. May I share?”
“You may, as long as you haven’t been reading a medicinal biochemistry text.”
“Articles on sepsis often start with its diagnosis. In reality, when a patient arrives in an ED, the ED doc’s first question isn’t, ‘Does this person have sepsis?’ His first mental query must be, ‘What’s wrong with this person?’ Then a lot of things happen almost simultaneously. The doc tries to alleviate the patient’s distress (she wouldn’t be in the ED if she didn’t have distress), performs a history and physical, and begins tests and interventions indicated by the history and physical.”
“Of course, several things can help the doc avoid starting at square one. If someone is accompanying the patient, they can help with the history. If the patient can’t communicate, that person would be essential. Similar information might also come along with the patient if she is sent from a skilled nursing facility. In addition, they should know if the patient has a fever and perhaps an infection and what organ is affected. In that case, the physician would order a blood culture before starting a broad-spectrum antibiotic.”
“In the physical—and possibly in triage—the first indication of sepsis will likely be signs of an infection, hypotension, a systolic BP of less than 90 or mean arterial pressure (MAP) less than 65. This tells the provider that time is of the essence, not only because of the crowded ED waiting room but because the patient’s life may be in the balance. All of the actions below should be taken within one hour of the patient’s arrival at the ED. IV access is established, and a fluid challenge and vasopressors (to raise blood pressure) would be ordered. An arterial line to measure consistent and accurate blood pressure and a central venous catheter to deliver IV fluids and vasopressors to the larger veins of the body should be placed immediately.”
“Now that sepsis is suspected, Curmudge, the next task is to learn how bad it might be. Here’s a useful algorithm:
1. SIRS (Systemic Inflammatory Response Syndrome): Temperature >100.4F (38C) or <96.8F (36C), heart rate >90, respiratory rate >20, WBC >12,000 or <4,000. Patient already found to be hypotensive.
2. Sepsis: SIRS plus source of infection.
3. Severe sepsis: Sepsis plus organ dysfunction.
4. Septic shock: Persistent hypotension and organ dysfunction despite aggressive fluid resuscitation.
If sepsis isn’t found, seek an alternative diagnosis. If sepsis is found, admit the patient to the hospital—the ICU for those with severe sepsis or septic shock—ASAP.”
“Transferring the patient to the ICU and to the care of intensivists and critical care nurses will bring the hospital’s best resources to bear on her condition. In general, these are the kinds of therapies that will be used:
1. Increase perfusion to organs and tissues by increasing blood pressure with fluid resuscitation and through the use of vasopressor medications (examples are norepinephrine and dopamine).
2. Treat the underlying infection through use of antibiotic therapy or surgery.
3. Provide oxygen and treat respiratory distress (if present).”
“Here are some (there are more) specific things to be done at Affinity hospitals (and elsewhere) for the sepsis patient. They should occur within the first six hours, and are called Early Goal-Directed Therapy.
1. Draw labs for blood cultures and obtain specimens from other sources for identification of infection. Serum lactate levels are an indicator of oxygen deficits (Curmudge, I put this in because I knew you’d be interested in the biochemistry).
2. Perfusion: If mean arterial pressure is <65, give sufficient IV fluids to assist in raising blood pressure. Start norepinephrine or dopamine to keep systolic BP >90 and mean arterial pressure >65. When fluid challenge therapy is not effective, implement Critical Care Nursing Considerations.
3. Oxygenation: Keep oxygen saturation >90%. Mechanical ventilation if needed.”
“Julie, putting the patient on a ventilator is certain to impress the patient’s relatives of the seriousness of her situation. The only patients that I’ve seen on a ventilator were at death’s door."
“Remember, Curmudge, that not all sepsis patients come in through the ED. Some are inpatients who have taken a turn for the worse. Nurses in the medical/surgical units are taught to watch for these observable symptoms in their routine rounding on the patients under their care:
1. Chills, shaking, low body temperature, or fever.
2. Rapid breathing (hyperventilation), lightheadedness, rapid heart beat.
3. Decreased urine output (oliguria).
4. Confusion or delirium.
5. Warm skin or skin rash.
These should trigger the nurse’s concern about SIRS. She should immediately initiate quantitative measures, like BP and temperature, and should contact the physician. More specific quantitative indicators of sepsis, used to augment routine bedside assessment, are listed in Affinity’s Cellular Perfusion Assessment Parameters.”
“Next week, Julie, let’s focus on Affinity’s experience with sepsis. We’ll point out how our care of sepsis patients exemplifies standard work, which is essential in implementing a Lean culture.”
“Lean, Curmudge! I was afraid that you’d forgotten about Lean.”
Affinity’s Kaizen Curmudgeon
“It’s hard to express the complexity of the human body without a few big words, which, you may have noticed, were all defined in the text. I also felt that any terms as hard to learn as those deserved to be spread around. By the way, I haven’t been holding my breath as you recommended last week. I’ve been reading about how health care handles sepsis. May I share?”
“You may, as long as you haven’t been reading a medicinal biochemistry text.”
“Articles on sepsis often start with its diagnosis. In reality, when a patient arrives in an ED, the ED doc’s first question isn’t, ‘Does this person have sepsis?’ His first mental query must be, ‘What’s wrong with this person?’ Then a lot of things happen almost simultaneously. The doc tries to alleviate the patient’s distress (she wouldn’t be in the ED if she didn’t have distress), performs a history and physical, and begins tests and interventions indicated by the history and physical.”
“Of course, several things can help the doc avoid starting at square one. If someone is accompanying the patient, they can help with the history. If the patient can’t communicate, that person would be essential. Similar information might also come along with the patient if she is sent from a skilled nursing facility. In addition, they should know if the patient has a fever and perhaps an infection and what organ is affected. In that case, the physician would order a blood culture before starting a broad-spectrum antibiotic.”
“In the physical—and possibly in triage—the first indication of sepsis will likely be signs of an infection, hypotension, a systolic BP of less than 90 or mean arterial pressure (MAP) less than 65. This tells the provider that time is of the essence, not only because of the crowded ED waiting room but because the patient’s life may be in the balance. All of the actions below should be taken within one hour of the patient’s arrival at the ED. IV access is established, and a fluid challenge and vasopressors (to raise blood pressure) would be ordered. An arterial line to measure consistent and accurate blood pressure and a central venous catheter to deliver IV fluids and vasopressors to the larger veins of the body should be placed immediately.”
“Now that sepsis is suspected, Curmudge, the next task is to learn how bad it might be. Here’s a useful algorithm:
1. SIRS (Systemic Inflammatory Response Syndrome): Temperature >100.4F (38C) or <96.8F (36C), heart rate >90, respiratory rate >20, WBC >12,000 or <4,000. Patient already found to be hypotensive.
2. Sepsis: SIRS plus source of infection.
3. Severe sepsis: Sepsis plus organ dysfunction.
4. Septic shock: Persistent hypotension and organ dysfunction despite aggressive fluid resuscitation.
If sepsis isn’t found, seek an alternative diagnosis. If sepsis is found, admit the patient to the hospital—the ICU for those with severe sepsis or septic shock—ASAP.”
“Transferring the patient to the ICU and to the care of intensivists and critical care nurses will bring the hospital’s best resources to bear on her condition. In general, these are the kinds of therapies that will be used:
1. Increase perfusion to organs and tissues by increasing blood pressure with fluid resuscitation and through the use of vasopressor medications (examples are norepinephrine and dopamine).
2. Treat the underlying infection through use of antibiotic therapy or surgery.
3. Provide oxygen and treat respiratory distress (if present).”
“Here are some (there are more) specific things to be done at Affinity hospitals (and elsewhere) for the sepsis patient. They should occur within the first six hours, and are called Early Goal-Directed Therapy.
1. Draw labs for blood cultures and obtain specimens from other sources for identification of infection. Serum lactate levels are an indicator of oxygen deficits (Curmudge, I put this in because I knew you’d be interested in the biochemistry).
2. Perfusion: If mean arterial pressure is <65, give sufficient IV fluids to assist in raising blood pressure. Start norepinephrine or dopamine to keep systolic BP >90 and mean arterial pressure >65. When fluid challenge therapy is not effective, implement Critical Care Nursing Considerations.
3. Oxygenation: Keep oxygen saturation >90%. Mechanical ventilation if needed.”
“Julie, putting the patient on a ventilator is certain to impress the patient’s relatives of the seriousness of her situation. The only patients that I’ve seen on a ventilator were at death’s door."
“Remember, Curmudge, that not all sepsis patients come in through the ED. Some are inpatients who have taken a turn for the worse. Nurses in the medical/surgical units are taught to watch for these observable symptoms in their routine rounding on the patients under their care:
1. Chills, shaking, low body temperature, or fever.
2. Rapid breathing (hyperventilation), lightheadedness, rapid heart beat.
3. Decreased urine output (oliguria).
4. Confusion or delirium.
5. Warm skin or skin rash.
These should trigger the nurse’s concern about SIRS. She should immediately initiate quantitative measures, like BP and temperature, and should contact the physician. More specific quantitative indicators of sepsis, used to augment routine bedside assessment, are listed in Affinity’s Cellular Perfusion Assessment Parameters.”
“Next week, Julie, let’s focus on Affinity’s experience with sepsis. We’ll point out how our care of sepsis patients exemplifies standard work, which is essential in implementing a Lean culture.”
“Lean, Curmudge! I was afraid that you’d forgotten about Lean.”
Affinity’s Kaizen Curmudgeon
Friday, August 26, 2011
Sepsis
“You know, Curmudge, the human body is quite amazing.”
“I agree, Jaded Julie, but it’s not always amazingly good. The body I know best seems to be getting older and slower, and the body I loved most shut itself down rather suddenly a few months ago. Perhaps I need more explanation of this ‘amazing’ stuff.”
“Okay. As an example, let’s use the condition called sepsis. Were you aware that only one out of three Americans has ever heard the word ‘sepsis’ and that it is the tenth most common cause of death? In sepsis bad things occur because of actions taken by parts of the body to protect themselves.”
“Julie, if you are inspired by the same sepsis I’ve been reading about, you have a mighty morbid sense of amazement. But as a compulsive learner, if there’s more that I need to know, let’s get on with it. Tell me about sepsis.”
“Well Curmudge, old codgers like you might recognize the term, ‘blood poisoning,’ but that’s an inadequate description. Sepsis is not an infection in of itself; it’s a systemic (whole-body) response to infection or injury. Specifically, bacteria, a fungus, or a virus overwhelm the bloodstream. This is called septicemia.”
“So far so good (or bad), Nurse-Educator, but where do these bad guys come from?”
“Lots of places: the bowel (peritonitis), the kidneys (pyelonephritis), the lining of the brain (meningitis), the lungs (bacterial pneumonia), the skin (cellulitis). In hospitalized patients, common sites of infection include IV lines, surgical wounds and drains, and bedsores.”
“Thus far, everything I’ve heard is bad. Where does the ‘amazing’ stuff occur?”
“Let’s start simple. When the body incurs an insult—from a minor injury to the entry of bacteria and bacterial toxins into the bloodstream—the immune system is activated. Cells of the endothelium—the lining of blood vessels—respond by initiating the inflammation process. This involves dilation of blood vessels and consequent leakage. The cells—seeking to maintain internal equilibrium (homeostasis)—try to reestablish control through the process called coagulation, the formation of blood clots. They are an interlacing fibrous network of a substance called fibrin.”
“Hooray for blood clots. That’s why I grew a beard…so I wouldn’t have to worry about cutting myself shaving.”
“Don’t speak too soon, Curmudge. There’s a lot more biochemistry going on. The body views blood clots as an abnormality, so it cranks up the process of fibrinolysis to get rid of them. Sort of like when a bruise loses its purple coloration. Tissue plasminogen activating factor (t-PA) forms plasmin, the workhorse of fibrinolysis.”
“Hey Julie, I know about t-PA. That’s what they give victims of an ischemic stroke, the type of stroke often caused by a blood clot.”
“Unfortunately in sepsis, inflammation and coagulation overpower fibrinolysis, and the sepsis victim has microvascular thrombosis, i.e., blood clots in his capillaries.”
“I can see now that when that happens throughout the body, the patient is in deep trouble. As you said originally, the human body is amazing; each of these processes is essential. But problems arise when one process becomes dominant and forces homeostasis out of balance. It is just too much of a good thing. So what happens to a body when it is full of little blood clots?”
“It would seem as if the body is trying to self-destruct. Back during inflammation, when the blood vessels are dilating, the body senses that blood pressure is dropping. It’s time to set priorities, so vasoconstrictors are released to constrict blood vessels and elevate blood pressure in order to maintain blood flow to the vital organs, the heart and brain. Of course, that shunts blood away from the ‘non-vital’ organs such as lungs, kidneys, gastrointestinal tract, and skin.”
“Obviously Julie, the patient, who has a whole-body outlook, takes a dim view of the so-called ‘non-vital’ organs’ losing their blood supply and shutting down. It’s evident that without major assistance from skilled health care, the patient will expire.”
“I hate to leave the patient in such a precarious situation, but we won’t talk about the role of health care in sepsis until next week. Until then, Curmudge, please hold your breath.”
Affinity’s Kaizen Curmudgeon
“I agree, Jaded Julie, but it’s not always amazingly good. The body I know best seems to be getting older and slower, and the body I loved most shut itself down rather suddenly a few months ago. Perhaps I need more explanation of this ‘amazing’ stuff.”
“Okay. As an example, let’s use the condition called sepsis. Were you aware that only one out of three Americans has ever heard the word ‘sepsis’ and that it is the tenth most common cause of death? In sepsis bad things occur because of actions taken by parts of the body to protect themselves.”
“Julie, if you are inspired by the same sepsis I’ve been reading about, you have a mighty morbid sense of amazement. But as a compulsive learner, if there’s more that I need to know, let’s get on with it. Tell me about sepsis.”
“Well Curmudge, old codgers like you might recognize the term, ‘blood poisoning,’ but that’s an inadequate description. Sepsis is not an infection in of itself; it’s a systemic (whole-body) response to infection or injury. Specifically, bacteria, a fungus, or a virus overwhelm the bloodstream. This is called septicemia.”
“So far so good (or bad), Nurse-Educator, but where do these bad guys come from?”
“Lots of places: the bowel (peritonitis), the kidneys (pyelonephritis), the lining of the brain (meningitis), the lungs (bacterial pneumonia), the skin (cellulitis). In hospitalized patients, common sites of infection include IV lines, surgical wounds and drains, and bedsores.”
“Thus far, everything I’ve heard is bad. Where does the ‘amazing’ stuff occur?”
“Let’s start simple. When the body incurs an insult—from a minor injury to the entry of bacteria and bacterial toxins into the bloodstream—the immune system is activated. Cells of the endothelium—the lining of blood vessels—respond by initiating the inflammation process. This involves dilation of blood vessels and consequent leakage. The cells—seeking to maintain internal equilibrium (homeostasis)—try to reestablish control through the process called coagulation, the formation of blood clots. They are an interlacing fibrous network of a substance called fibrin.”
“Hooray for blood clots. That’s why I grew a beard…so I wouldn’t have to worry about cutting myself shaving.”
“Don’t speak too soon, Curmudge. There’s a lot more biochemistry going on. The body views blood clots as an abnormality, so it cranks up the process of fibrinolysis to get rid of them. Sort of like when a bruise loses its purple coloration. Tissue plasminogen activating factor (t-PA) forms plasmin, the workhorse of fibrinolysis.”
“Hey Julie, I know about t-PA. That’s what they give victims of an ischemic stroke, the type of stroke often caused by a blood clot.”
“Unfortunately in sepsis, inflammation and coagulation overpower fibrinolysis, and the sepsis victim has microvascular thrombosis, i.e., blood clots in his capillaries.”
“I can see now that when that happens throughout the body, the patient is in deep trouble. As you said originally, the human body is amazing; each of these processes is essential. But problems arise when one process becomes dominant and forces homeostasis out of balance. It is just too much of a good thing. So what happens to a body when it is full of little blood clots?”
“It would seem as if the body is trying to self-destruct. Back during inflammation, when the blood vessels are dilating, the body senses that blood pressure is dropping. It’s time to set priorities, so vasoconstrictors are released to constrict blood vessels and elevate blood pressure in order to maintain blood flow to the vital organs, the heart and brain. Of course, that shunts blood away from the ‘non-vital’ organs such as lungs, kidneys, gastrointestinal tract, and skin.”
“Obviously Julie, the patient, who has a whole-body outlook, takes a dim view of the so-called ‘non-vital’ organs’ losing their blood supply and shutting down. It’s evident that without major assistance from skilled health care, the patient will expire.”
“I hate to leave the patient in such a precarious situation, but we won’t talk about the role of health care in sepsis until next week. Until then, Curmudge, please hold your breath.”
Affinity’s Kaizen Curmudgeon
Thursday, August 18, 2011
Hardwiring 2
“Curmudge, in our last conversation about hardwiring you said you would tell me how to hardwire Lean.”
“If I said that, Jaded Julie, I spoke too soon. Lately I’ve been thinking a lot about learning and hardwiring. May I share my cogitations with you?”
“Sure, as long as ‘cogitations’ aren’t something you’ve been drinking or smoking.”
“Back on May 8, 2008 we talked about how leadership often requires doing things which are not truly natural. The things that a young baby does that are natural are cry, nurse, and soil its diapers. As life progresses most of our actions have been taught to us until they become hardwired. You might think that brushing your teeth in the morning is natural, but in fact it was hardwired into your brain by your mother’s repeated insistence and reinforcement. We might feel that driving on the right side of the street is natural, but don’t try it in Great Britain.”
“I’ve got it, Curmudge. Hardwiring requires repetition, reinforcement, and sometimes intense study until it feels natural. If any element is most important, it’s repetition. That’s why my mother took me to religious services every week. We hardwire our morals and the elements of our character, and a society hardwires its mores.”
“So if repetition and reinforcement are essential for hardwiring, how much of it can we achieve in a one-week kaizen event or a one-day Lean Overview class?”
“I’m afraid not very much, and I’ll bet that was the conclusion that popped out of your cogitations. At least an event is usually a hands-on and brains-on activity for the participants. I’ll also bet that we won’t recommend subjecting the students to increasing amounts of ‘death by PowerPoint.’ “
“Excellent perception, Julie. How about this? Although we have the participants’ bodies for only the single day or week of the event, perhaps we could stretch their experience with pre-work and post-work. The pre-work could put their minds in learning mode, and whatever was done after the event would serve as reinforcement.”
“The event should include videos, games, discussions, and team activities. Perhaps even a pop quiz on the preliminary reading. If the event itself is memorable, perhaps more of the subject material will be retained. Of course, if any of the students is like you, Curmudge, we’ll need to keep him/her awake.”
“Although we’d like participants to retain details of the Lean tools used in the event, our most important goal is to hardwire the principles of the Lean culture.”
“Perhaps, Curmudge, we should shout them from the top level of the parking ramp at St. E’s. ‘Show respect for people.’ ‘Eliminate waste.’ ‘Use standard work.’ ‘Promote continuous improvement.’ We could do it every day at noon, just like a town crier.”
“I’d prefer to stay in out of the weather and just write a blog like Kaizen Curmudgeon. Every week we send a reprint of an earlier posting to each graduate of the Lean Overview course. But in the absence of organized reinforcement, you have to do it on your own. For example, there are blogs from many sources that one should follow to get a regular Lean ‘fix.’ Examples are http://dailykaizen.org/, http://leanhealthcareexchange.com/, and http://www.leanblog.org/ (although that author seems to feel that there is only one health care organization in town). While the blogs tend to be repetitive (and sometimes self-serving), they present Lean fundamentals from many different perspectives.”
“I think I know your bottom line on hardwiring, Curmudge, but I’d prefer to hear it in your trite, but umforgettable, manner.”
“A man on the street in New York City asked a passer-by how to get to Carnegie Hall. The passer-by’s answer was, ‘practice…practice.’ “
Affinity’s Kaizen Curmudgeon
“If I said that, Jaded Julie, I spoke too soon. Lately I’ve been thinking a lot about learning and hardwiring. May I share my cogitations with you?”
“Sure, as long as ‘cogitations’ aren’t something you’ve been drinking or smoking.”
“Back on May 8, 2008 we talked about how leadership often requires doing things which are not truly natural. The things that a young baby does that are natural are cry, nurse, and soil its diapers. As life progresses most of our actions have been taught to us until they become hardwired. You might think that brushing your teeth in the morning is natural, but in fact it was hardwired into your brain by your mother’s repeated insistence and reinforcement. We might feel that driving on the right side of the street is natural, but don’t try it in Great Britain.”
“I’ve got it, Curmudge. Hardwiring requires repetition, reinforcement, and sometimes intense study until it feels natural. If any element is most important, it’s repetition. That’s why my mother took me to religious services every week. We hardwire our morals and the elements of our character, and a society hardwires its mores.”
“So if repetition and reinforcement are essential for hardwiring, how much of it can we achieve in a one-week kaizen event or a one-day Lean Overview class?”
“I’m afraid not very much, and I’ll bet that was the conclusion that popped out of your cogitations. At least an event is usually a hands-on and brains-on activity for the participants. I’ll also bet that we won’t recommend subjecting the students to increasing amounts of ‘death by PowerPoint.’ “
“Excellent perception, Julie. How about this? Although we have the participants’ bodies for only the single day or week of the event, perhaps we could stretch their experience with pre-work and post-work. The pre-work could put their minds in learning mode, and whatever was done after the event would serve as reinforcement.”
“The event should include videos, games, discussions, and team activities. Perhaps even a pop quiz on the preliminary reading. If the event itself is memorable, perhaps more of the subject material will be retained. Of course, if any of the students is like you, Curmudge, we’ll need to keep him/her awake.”
“Although we’d like participants to retain details of the Lean tools used in the event, our most important goal is to hardwire the principles of the Lean culture.”
“Perhaps, Curmudge, we should shout them from the top level of the parking ramp at St. E’s. ‘Show respect for people.’ ‘Eliminate waste.’ ‘Use standard work.’ ‘Promote continuous improvement.’ We could do it every day at noon, just like a town crier.”
“I’d prefer to stay in out of the weather and just write a blog like Kaizen Curmudgeon. Every week we send a reprint of an earlier posting to each graduate of the Lean Overview course. But in the absence of organized reinforcement, you have to do it on your own. For example, there are blogs from many sources that one should follow to get a regular Lean ‘fix.’ Examples are http://dailykaizen.org/, http://leanhealthcareexchange.com/, and http://www.leanblog.org/ (although that author seems to feel that there is only one health care organization in town). While the blogs tend to be repetitive (and sometimes self-serving), they present Lean fundamentals from many different perspectives.”
“I think I know your bottom line on hardwiring, Curmudge, but I’d prefer to hear it in your trite, but umforgettable, manner.”
“A man on the street in New York City asked a passer-by how to get to Carnegie Hall. The passer-by’s answer was, ‘practice…practice.’ “
Affinity’s Kaizen Curmudgeon
Friday, August 12, 2011
Hardwiring
“Curmudge, when a fact or concept is ‘hardwired,’ does that mean that it will never be forgotten?”
“To me, Jaded Julie, the term ‘hardwired’ (which most of us learned from the writings of Quint Studer) is not an absolute. Without reinforcement, most of the professional stuff we learned years ago will eventually slip away. However, it’s interesting that sometimes personal experiences will stick with us forever. An example is when my older playmates kicked me out of the sandbox because I was only four years old.”
“I must admit that during the years we have worked together I’ve become impressed by the leakiness of your memory. Is it true that you tell your educated friends that their advanced degrees expired after 40 years?”
“Although I’m just kidding, for most people the concept is probably correct. Exceptions would be some professors and physicians who teach or use their professional knowledge on a daily basis. They support my contention that reinforcement is essential.”
“If as you say mental ‘wiring’ comes in varying degrees of hardness, you must know some convincing examples.”
“At the extreme end of hardness are the connections between the mind and fingers of the professional musician. These people are able to see a multitude of notes on a score and translate them into actions of their fingers (and sometimes feet) at a frequency of several per second. It takes years of practice to develop those connections; and if they stop practicing, they lose their performer’s ‘edge.’ But they never totally forget basic fingering.”
“Do we see some of this in the practice of medicine, Curmudge?”
“We know that it takes years of residency to train a specialist, but the Army is finding that their special skills begin to erode after about four months of deployment away from their specialty. (1) Thus it’s a bit of a surprise when an OB/GYN volunteers to serve a year in a battalion aid station.”
“What about the other end of the ‘forgettable’ scale? We all recall from our formal education years that information in which we had little interest was pretty transitory.”
“Julie, my retention of some courses—especially those that were required—is zilch. In fact, I suspect that when I walked out of the final exam, my brain dumped the whole course content right there in the hallway.”
“I hate to disturb your reverie, Curmudge, but how can we apply these insights to Lean training?”
“Our goal, Julie, is to impart a Lean mindset to everyone and to help them retain and use what they have learned. It’s pretty lofty, but it is expressed well in this quote from Masaaki Imai (in the 6/22/11 posting of leanblog.com), ‘engage everybody in improvement every day, everywhere in the organization.’ We’ll talk later about how to do that.”
Affinity’s Kaizen Curmudgeon
(1) Deering, S. H., et al. Am. J. Surgery vol. 201 (May 2011)
Note: We last wrote about hardwiring three years ago (May 22, 2008). The current posting is consistent with our belief that some repetition of principles is necessary to reinforce knowledge.
“To me, Jaded Julie, the term ‘hardwired’ (which most of us learned from the writings of Quint Studer) is not an absolute. Without reinforcement, most of the professional stuff we learned years ago will eventually slip away. However, it’s interesting that sometimes personal experiences will stick with us forever. An example is when my older playmates kicked me out of the sandbox because I was only four years old.”
“I must admit that during the years we have worked together I’ve become impressed by the leakiness of your memory. Is it true that you tell your educated friends that their advanced degrees expired after 40 years?”
“Although I’m just kidding, for most people the concept is probably correct. Exceptions would be some professors and physicians who teach or use their professional knowledge on a daily basis. They support my contention that reinforcement is essential.”
“If as you say mental ‘wiring’ comes in varying degrees of hardness, you must know some convincing examples.”
“At the extreme end of hardness are the connections between the mind and fingers of the professional musician. These people are able to see a multitude of notes on a score and translate them into actions of their fingers (and sometimes feet) at a frequency of several per second. It takes years of practice to develop those connections; and if they stop practicing, they lose their performer’s ‘edge.’ But they never totally forget basic fingering.”
“Do we see some of this in the practice of medicine, Curmudge?”
“We know that it takes years of residency to train a specialist, but the Army is finding that their special skills begin to erode after about four months of deployment away from their specialty. (1) Thus it’s a bit of a surprise when an OB/GYN volunteers to serve a year in a battalion aid station.”
“What about the other end of the ‘forgettable’ scale? We all recall from our formal education years that information in which we had little interest was pretty transitory.”
“Julie, my retention of some courses—especially those that were required—is zilch. In fact, I suspect that when I walked out of the final exam, my brain dumped the whole course content right there in the hallway.”
“I hate to disturb your reverie, Curmudge, but how can we apply these insights to Lean training?”
“Our goal, Julie, is to impart a Lean mindset to everyone and to help them retain and use what they have learned. It’s pretty lofty, but it is expressed well in this quote from Masaaki Imai (in the 6/22/11 posting of leanblog.com), ‘engage everybody in improvement every day, everywhere in the organization.’ We’ll talk later about how to do that.”
Affinity’s Kaizen Curmudgeon
(1) Deering, S. H., et al. Am. J. Surgery vol. 201 (May 2011)
Note: We last wrote about hardwiring three years ago (May 22, 2008). The current posting is consistent with our belief that some repetition of principles is necessary to reinforce knowledge.
Monday, August 8, 2011
Conventional Wisdom
“Curmudge, if we’re going to talk about conventional wisdom, I hope you will define it for me.”
“O course, Jaded Julie. In my view, conventional wisdom is the generally accepted knowledge about a topic at a given point in time. For example, in medieval times, the accepted way to treat an open wound was to pack it in goat dung. And until the time of Galileo, most everyone believed that the sun went around the earth once per day.”
“Wow! I’m sure glad things had changed by the time I was a child and skinned my knee.”
“Conventional wisdom can do two things; it can stagnate and become unassailable dogma, or it can evolve with the growth of knowledge. Although new knowledge in medicine seems to be slow in its adoption, we’ve seen amazing advances in our lifetime. I remain intrigued by the oft-quoted medical school professor who told entering students, ‘About half of what we teach you here will eventually be proven to be incorrect, but we don’t know which half.’ “
“What about that ‘unassailable dogma’ stuff, Curmudge? How does that come about?”
“It is easy to scare people but hard to ‘unscare’ them. When something frightens people, it is very difficult to change their view. A pertinent example is radiation. Some people fear radiation whether it’s the small amount used in medical imaging or the massive amounts confined in nuclear power plants.”
“Confess, Curmudge. Are you making this up, or do you actually know something about radiation?”
“The latter, Doubting Julie. I spent most of the summer of 1970 studying it in Oak Ridge, Tennessee. Of course, during the intervening 41 years I’ve forgotten most of what I learned. And to make matters worse, the international pooh bahs changed the names of the units of measurement. So I guess the most truthful answer to your question is that I read a lot.”
“So what did you read that catalyzed your concern about radiation and conventional wisdom?”
“Well, years ago we learned that any amount of radiation—no matter how little—had the potential of causing cancer. A plot of cancer occurrence vs. exposure, based on high levels of exposure, could be extrapolated to the origin, i.e., there was no threshold below which there was no effect. This was called the ‘linear no-threshold theory’ (LNT). It was the conventional wisdom then, and over time it became dogma and even the basis of laws and regulations. Additionally, it justified the anxiety of those who were extremely fearful of all radiation.”
“Does your reading suggest, Curmudge, that the LNT theory no longer represents the consensus regarding radiation exposure?”
“That is certainly implied in several review articles published during the past ten years. Here is a typical conclusion, ‘Based on a review of epidemiological and other data for exposure to low radiation doses and dose rates, it was found that the LNT model fails badly.’ (Vaiserman) Other authors have discussed protective effects from low radiation doses, ‘Irradiated cells protect themselves (a) by immediate defense, repair, and damage removal mechanisms and (b) by delayed and temporary protection also against renewed DNA damage, irrespective of its causes—that is, through adaptive responses.’ (Tubiana, et al.)”
“But Curmudge, there have been articles in the recent scientific and popular literature suggesting that the growing use of diagnostic computed tomography (CT) scans might increase the incidence of cancer. (Brenner & Hall, Landro) It sounds as if conventional wisdom is up for grabs.”
“It seems to be. Others have said: ‘There is no credible evidence to support the contention that current routine usage of CT scans in clinical settings in the United States will cause future cancers. Rather, the available data indicate that occasional exposure to diagnostic x-rays could possibly reduce the risk of future cancers among irradiated adults.’ (Scott et al.)”
“How do we resolve issues like this, Curmudge?”
“As you know, Jaded Julie, we’re not qualified to address that question. However, there is one more bit of older conventional wisdom that we should consider even though it contains regulations based on the LNT theory. It’s called ALARA, the acronym for As Low As Reasonably Achievable. Although the regulations might change, the concept is common sense: don’t expose anyone—patients, workers, or yourself—to more radiation than is absolutely essential. In the case of CT scans, one should be especially protective of children and pregnant women.”
“In your work long ago and for more recent diagnostic purposes you have been exposed to a variety of kinds of low-level radiation. Do those exposures leave you concerned?”
“I have always respected radiation and tried to minimize my exposures. However, for old geezers like me who won’t be around long enough to experience long-term effects—good or bad—from low-level radiation, this literature is just interesting to read and share.”
Affinity’s Kaizen Curmudgeon
Literature Cited
Vaiserman, A.M. Radiation Hormesis: Historical perspective and implications for low-dose cancer risk assessment. Dose-Response 8:172-191 (2010). http://pubget.com/paper/20585444
Tubiana, M., et al. The linear no-threshold relationship is inconsistent with radiation biologic and experimental data. Radiology 251(1):13-22 (April 2009). http://radiology.rsna.org/content/251/1/13.full.pdf
Brenner, D.J. and Hall, E.J. Computed tomography—an increasing source of radiation exposure. N. Engl. J. Med. 357: 2277-2284 (2007). http://www.nejm.org/doi/full/10.1056/NEJMra072149
Landro, Laura. Radiation risks prompt push to curb CT scans. Wall St. J. (March 2, 2010)
Scott, B.R., et al. CT scans may reduce rather than increase the risk of cancer. J. Am. Physicians & Surgeons 13(1):8-11 (Spring 2008). http://www.jpands.org/vol13no1/scott.pdf
“O course, Jaded Julie. In my view, conventional wisdom is the generally accepted knowledge about a topic at a given point in time. For example, in medieval times, the accepted way to treat an open wound was to pack it in goat dung. And until the time of Galileo, most everyone believed that the sun went around the earth once per day.”
“Wow! I’m sure glad things had changed by the time I was a child and skinned my knee.”
“Conventional wisdom can do two things; it can stagnate and become unassailable dogma, or it can evolve with the growth of knowledge. Although new knowledge in medicine seems to be slow in its adoption, we’ve seen amazing advances in our lifetime. I remain intrigued by the oft-quoted medical school professor who told entering students, ‘About half of what we teach you here will eventually be proven to be incorrect, but we don’t know which half.’ “
“What about that ‘unassailable dogma’ stuff, Curmudge? How does that come about?”
“It is easy to scare people but hard to ‘unscare’ them. When something frightens people, it is very difficult to change their view. A pertinent example is radiation. Some people fear radiation whether it’s the small amount used in medical imaging or the massive amounts confined in nuclear power plants.”
“Confess, Curmudge. Are you making this up, or do you actually know something about radiation?”
“The latter, Doubting Julie. I spent most of the summer of 1970 studying it in Oak Ridge, Tennessee. Of course, during the intervening 41 years I’ve forgotten most of what I learned. And to make matters worse, the international pooh bahs changed the names of the units of measurement. So I guess the most truthful answer to your question is that I read a lot.”
“So what did you read that catalyzed your concern about radiation and conventional wisdom?”
“Well, years ago we learned that any amount of radiation—no matter how little—had the potential of causing cancer. A plot of cancer occurrence vs. exposure, based on high levels of exposure, could be extrapolated to the origin, i.e., there was no threshold below which there was no effect. This was called the ‘linear no-threshold theory’ (LNT). It was the conventional wisdom then, and over time it became dogma and even the basis of laws and regulations. Additionally, it justified the anxiety of those who were extremely fearful of all radiation.”
“Does your reading suggest, Curmudge, that the LNT theory no longer represents the consensus regarding radiation exposure?”
“That is certainly implied in several review articles published during the past ten years. Here is a typical conclusion, ‘Based on a review of epidemiological and other data for exposure to low radiation doses and dose rates, it was found that the LNT model fails badly.’ (Vaiserman) Other authors have discussed protective effects from low radiation doses, ‘Irradiated cells protect themselves (a) by immediate defense, repair, and damage removal mechanisms and (b) by delayed and temporary protection also against renewed DNA damage, irrespective of its causes—that is, through adaptive responses.’ (Tubiana, et al.)”
“But Curmudge, there have been articles in the recent scientific and popular literature suggesting that the growing use of diagnostic computed tomography (CT) scans might increase the incidence of cancer. (Brenner & Hall, Landro) It sounds as if conventional wisdom is up for grabs.”
“It seems to be. Others have said: ‘There is no credible evidence to support the contention that current routine usage of CT scans in clinical settings in the United States will cause future cancers. Rather, the available data indicate that occasional exposure to diagnostic x-rays could possibly reduce the risk of future cancers among irradiated adults.’ (Scott et al.)”
“How do we resolve issues like this, Curmudge?”
“As you know, Jaded Julie, we’re not qualified to address that question. However, there is one more bit of older conventional wisdom that we should consider even though it contains regulations based on the LNT theory. It’s called ALARA, the acronym for As Low As Reasonably Achievable. Although the regulations might change, the concept is common sense: don’t expose anyone—patients, workers, or yourself—to more radiation than is absolutely essential. In the case of CT scans, one should be especially protective of children and pregnant women.”
“In your work long ago and for more recent diagnostic purposes you have been exposed to a variety of kinds of low-level radiation. Do those exposures leave you concerned?”
“I have always respected radiation and tried to minimize my exposures. However, for old geezers like me who won’t be around long enough to experience long-term effects—good or bad—from low-level radiation, this literature is just interesting to read and share.”
Affinity’s Kaizen Curmudgeon
Literature Cited
Vaiserman, A.M. Radiation Hormesis: Historical perspective and implications for low-dose cancer risk assessment. Dose-Response 8:172-191 (2010). http://pubget.com/paper/20585444
Tubiana, M., et al. The linear no-threshold relationship is inconsistent with radiation biologic and experimental data. Radiology 251(1):13-22 (April 2009). http://radiology.rsna.org/content/251/1/13.full.pdf
Brenner, D.J. and Hall, E.J. Computed tomography—an increasing source of radiation exposure. N. Engl. J. Med. 357: 2277-2284 (2007). http://www.nejm.org/doi/full/10.1056/NEJMra072149
Landro, Laura. Radiation risks prompt push to curb CT scans. Wall St. J. (March 2, 2010)
Scott, B.R., et al. CT scans may reduce rather than increase the risk of cancer. J. Am. Physicians & Surgeons 13(1):8-11 (Spring 2008). http://www.jpands.org/vol13no1/scott.pdf
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