“As I see it, Curmudge, an A3 report is an excellent tool for today’s workers in gemba to use in problem solving. It’s concise and thus consistent with modern reading habits, and it’s visual, which should help people who grew up in front of a TV set. Is that how you grew up?”
“Not quite, Jaded Julie. My first TV-watching experience was when I was a teenager. I was tossed out of a bar while trying to watch the World Series (1950?) on the only TV set in town. But I am fairly good at visualizing. One had to be in order to ‘watch’ The Lone Ranger on the radio.”
“You promised last week that we’d probe more deeply into A3 problem solving. Shall we do it?”
“Without delay. A3 problem solving acquired its name from the use of an A3 report for its planning and communication. As we learned, the medium of the A3 report is a single sheet of A3 (11 by 17-inch) paper. The report flows from top to bottom on the left-hand side of the paper, then top to bottom on the right side.”
“Because Blogger software doesn’t seem to like sketches, Curmudge, it looks as if you are going to have to use 1000 words in place of one picture. Our goal of achieving simplicity is defeated before we even start.”
“Unfortunately true, Julie. But perhaps we can reach our objective of piquing someone’s interest in A3 reports enough to steer them toward the work of Cindy Jimmerson that we’ll reference below. So let’s proceed. At the top left of the A3 sheet is the Issue Statement, usually as seen through the eyes of the patient. Below that is the Background, which helps us understand why the issue is important.”
“My kids would like the next part, a sketch of the Current Condition. We draw storm clouds for problems and icons for people like in value stream mapping. I guess that’s why we studied VSM a couple of weeks ago.”
“Right, Julie. But we must draw with a pencil so it’s easy to erase and make changes. The value of the sketch is that it inspires everyone’s thinking—the members of the team as well as the person with the pencil in his/her hand. We need to remember to KISS visually.”
“That might be considered suggestive spoken by most anyone else, but not by you, Curmudge.”
“At the bottom of the left half of the A3 is the Problem Analysis. We want to identify the problems signified by the sketch’s storm clouds and use the 5 Whys to find their root cause. What is learned here will help determine whether we have discovered too many problems for a single A3.”
“We are back to sketching again at the top of the right side of the A3. Here we want to show the Target Condition. This will be a graphic—again drawn with a pencil—that shows the process with problems, workarounds, and re-work eliminated. As Jimmerson states, this will illustrate ‘a new way to work that is closer to ideal.’ See, Curmudge, I’ve been reading the stuff that you recommend.”
“Countermeasures are listed in the next step down the page. These are the changes needed to get from the current condition to the target condition. One might call these ‘solutions’ if they produced the ideal result. But ‘countermeasures’ are more consistent with the Lean concept of achieving incremental improvements. Then comes the Implementation Plan, or how we are going to make the countermeasures occur. Sometimes the activities are shown in a matrix describing who, what, when, and the anticipated outcome.”
“I remember, Curmudge. We talked about a matrix a year ago—on September 25, 2007.”
“We’re almost finished, Julie. Costs and Benefits are estimated so we can list what the countermeasures might cost and the savings that should accrue. If a time saving is multiplied by a charge rate and hours per year, the dollars saved could be eye-catching. If a Test can be devised that will quantify the improvements, it should be noted here. Then comes the Follow Up in which the test results are shown and a path forward is proposed. Finally, way up in the top right corner, is the Title Information. This is just boilerplate showing the title of the A3 report, to whom it is directed, the author(s), and the date. So, Julie, do you now understand an A3 report and A3 Problem Solving?”
“No, of course not. You said it yourself, ‘A blog is not a teaching medium. It should simply arouse the reader’s interest.’ And there’s one more problem with a blog.”
“Oh, what?”
“Although the A3 is great, the blog isn’t visual enough. Remember, Curmudge, my generation grew up in front of a TV set.”
Affinity’s Kaizen Curmudgeon
P.S.—Cindy Jimmerson’s workshops as well as her book, reVIEW, are excellent. See also an older, all-text report, A3 Reports: Tools for Process Improvement and Organizational Transformation, by Durward K. Sobek, and Cindy Jimmerson, found at http://leanhealthcarewest.com/a3_problemsolving.html.
Thursday, September 11, 2008
Thursday, September 4, 2008
The A3 Report
“Curmudge, conventional wisdom says that people don’t read anymore.”
“I hope it’s not that bad, Jaded Julie, but I agree that people are very selective about what they read. They rarely read deeply enough to become well informed or to broaden their education. Mrs. Curmudgeon reads the comics and checks up on our friends in the obituaries.”
“If it’s not on the TV or in the sports pages, my husband never sees it. Information is filtered, spun, and condensed into 30-second sound bites. These days, a Renaissance man (or woman) is someone who takes the time to look up something in Google. Come to think of it, that sounds like you, Curmudge. But why are we talking about this? What do people’s reading habits have to do with Lean?”
“Julie, as Lean proponents we must be effective communicators. Our Lean communications must fit the attention span of a 21st century person, and the best way to do that is to use A3 reports.”
“At this point I feel obligated to ask, ‘What is an A3 report?’”
“Thank you for asking; I knew you would. Physically, an A3 report is an 11-inch by 17-inch sheet of paper viewed with its long axis horizontal. The term, A3, refers to paper of the designated size, which would be about 30 cm X 42 cm outside of the U.S. An A3 report—all on one sheet of paper—is most commonly used in a process called ‘A3 Problem Solving’ in which the report depicts the problem, what is known about it, and how it might be solved. Key elements of the process and of the report include:
· Issue
· Background and current condition
· Problem analysis
· Target condition
· Countermeasures
· Implementation plan, including cost/benefit analysis
· Test of implementation plan
· Follow-up”
“You mean that the whole caboodle is on a single sheet of paper, right up there for everyone to see? That’s visual communication to the max. Who but the Japanese could have thought of that? I assume, Curmudge, that like much of Lean this A3 stuff originated with the Toyota Motor Corporation.”
“That’s where the application of A3 reports in problem solving began. However, most of us don’t realize that the principal concept and greatest attribute of an A3 report, simplicity, is much older than Toyota. A 14th century Franciscan friar, William of Ockham, stated that ‘entities should not be multiplied beyond necessity.’ This statement, meaning that one should cut away all that is not necessary, became known as ‘Ockham’s razor.’ (We credit Group 8020’s blog for the history lesson.)”
“I’ve got it, Curmudge! The modern translation of Ockham’s razor is KISS (keep it simple, Stupid). Something simple, like an A3 report, is the best way to communicate with 21st century readers who won’t read long documents.”
“Your perspicacity continues to amaze me. Now that we have laid the groundwork, in our next conversation we’ll probe more deeply into A3 Problem Solving.”
“I look forward to it, Curmudge, but remember to KISS.”
Affinity’s Kaizen Curmudgeon
“I hope it’s not that bad, Jaded Julie, but I agree that people are very selective about what they read. They rarely read deeply enough to become well informed or to broaden their education. Mrs. Curmudgeon reads the comics and checks up on our friends in the obituaries.”
“If it’s not on the TV or in the sports pages, my husband never sees it. Information is filtered, spun, and condensed into 30-second sound bites. These days, a Renaissance man (or woman) is someone who takes the time to look up something in Google. Come to think of it, that sounds like you, Curmudge. But why are we talking about this? What do people’s reading habits have to do with Lean?”
“Julie, as Lean proponents we must be effective communicators. Our Lean communications must fit the attention span of a 21st century person, and the best way to do that is to use A3 reports.”
“At this point I feel obligated to ask, ‘What is an A3 report?’”
“Thank you for asking; I knew you would. Physically, an A3 report is an 11-inch by 17-inch sheet of paper viewed with its long axis horizontal. The term, A3, refers to paper of the designated size, which would be about 30 cm X 42 cm outside of the U.S. An A3 report—all on one sheet of paper—is most commonly used in a process called ‘A3 Problem Solving’ in which the report depicts the problem, what is known about it, and how it might be solved. Key elements of the process and of the report include:
· Issue
· Background and current condition
· Problem analysis
· Target condition
· Countermeasures
· Implementation plan, including cost/benefit analysis
· Test of implementation plan
· Follow-up”
“You mean that the whole caboodle is on a single sheet of paper, right up there for everyone to see? That’s visual communication to the max. Who but the Japanese could have thought of that? I assume, Curmudge, that like much of Lean this A3 stuff originated with the Toyota Motor Corporation.”
“That’s where the application of A3 reports in problem solving began. However, most of us don’t realize that the principal concept and greatest attribute of an A3 report, simplicity, is much older than Toyota. A 14th century Franciscan friar, William of Ockham, stated that ‘entities should not be multiplied beyond necessity.’ This statement, meaning that one should cut away all that is not necessary, became known as ‘Ockham’s razor.’ (We credit Group 8020’s blog for the history lesson.)”
“I’ve got it, Curmudge! The modern translation of Ockham’s razor is KISS (keep it simple, Stupid). Something simple, like an A3 report, is the best way to communicate with 21st century readers who won’t read long documents.”
“Your perspicacity continues to amaze me. Now that we have laid the groundwork, in our next conversation we’ll probe more deeply into A3 Problem Solving.”
“I look forward to it, Curmudge, but remember to KISS.”
Affinity’s Kaizen Curmudgeon
Wednesday, August 27, 2008
A value stream map without pictures?
“Okay, Curmudge, how are you going to do it? No one can teach value stream mapping without pictures.”
“You’re right as usual, Jaded Julie. It would be like trying to teach chemistry without a blackboard, or a whiteboard, or these days without a ‘smart board.’ So I won’t try to teach value stream mapping; I’ll just introduce the concept. Anyone with a bit of imagination should be able to handle that.”
“Oh, I should be able to do that all right. I once imagined that my husband would become a millionaire, but then reality set in.”
“Remember reading about the nurses in Nord 92? They said they didn’t utilize mapping, but I’ll bet they were able to clearly envision their processes. So sit back and try to conceptualize what I describe. But don’t close your eyes or you’ll fall asleep as we senior citizens do.”
“G’night, Curmudge.”
“Up and at ‘em, Julie! Let’s start by imagining a simple flow chart…just a few rectangles connected by lines or arrows. A value stream map (VSM) is a sketch of a process showing procedures in the boxes with intervals between procedures shown by the connecting lines. It differs from a flow chart by showing times for value-added activities (what the customer is willing to pay for) and non-value-added activities (when nothing constructive is happening, from the customer’s view). Think of an appointment with a physician. Your time spent with the nurse and the doctor should be value-added, but any waiting time is non-value-added. Unless you have been on vacation all summer, you should recognize the waiting time as waste or muda.”
“Me! Vacation? Curmudge, you are the one who has been on vacation.”
“How can you tell, Julie? As a retired person, I am on vacation 24/7…or at least that’s what some people think. So back to VSM. A process for study is identified, a team is formed to study the process, and they create the current state value stream map. This reveals the sources of waste in the process. The team then brainstorms ways to improve the process and reduce waste using special symbols for people and activities, storm clouds for problems, and ‘Kaizen bursts’ (stars) for ideas. A future state value stream map depicts the product of their efforts, and it serves as a blueprint for the action plan to upgrade the process.”
“The ‘VSM Game’ sounds like something my kids would like to play. So the team fixes the process and they live happily ever after, right?”
“No, Julie. The future state value stream map becomes the new current state value stream map, and that will help the team discern where even further improvements can be made. Remember, this is Lean, where the people in gemba continually strive to make incremental reductions in process waste.”
“Incremental. That means making little improvements but never reaching perfection.”
“Practically speaking, Julie, that’s true. However, a word that might better fit your definition is ‘asymptotic.’ But don’t worry; that’s a word that you don’t have to remember.”
“Consider it forgotten, Curmudge.”
Affinity’s Kaizen Curmudgeon
P.S.—“Julie, if you want to learn about value stream mapping, go to Lean in the Affinity Learning Center on the Affinity intranet. See also Mike Rother and John Shook’s book Learning to See, published by The Lean Enterprise Institute. The book’s title is very appropriate, because that’s what VSM teaches us. Another excellent resource is the section on Value Stream Mapping in Cindy Jimmerson’s reVIEW, second edition. And most recently, Mark Graban has a chapter that covers VSM in his new book, Lean Hospitals.”
“You’re right as usual, Jaded Julie. It would be like trying to teach chemistry without a blackboard, or a whiteboard, or these days without a ‘smart board.’ So I won’t try to teach value stream mapping; I’ll just introduce the concept. Anyone with a bit of imagination should be able to handle that.”
“Oh, I should be able to do that all right. I once imagined that my husband would become a millionaire, but then reality set in.”
“Remember reading about the nurses in Nord 92? They said they didn’t utilize mapping, but I’ll bet they were able to clearly envision their processes. So sit back and try to conceptualize what I describe. But don’t close your eyes or you’ll fall asleep as we senior citizens do.”
“G’night, Curmudge.”
“Up and at ‘em, Julie! Let’s start by imagining a simple flow chart…just a few rectangles connected by lines or arrows. A value stream map (VSM) is a sketch of a process showing procedures in the boxes with intervals between procedures shown by the connecting lines. It differs from a flow chart by showing times for value-added activities (what the customer is willing to pay for) and non-value-added activities (when nothing constructive is happening, from the customer’s view). Think of an appointment with a physician. Your time spent with the nurse and the doctor should be value-added, but any waiting time is non-value-added. Unless you have been on vacation all summer, you should recognize the waiting time as waste or muda.”
“Me! Vacation? Curmudge, you are the one who has been on vacation.”
“How can you tell, Julie? As a retired person, I am on vacation 24/7…or at least that’s what some people think. So back to VSM. A process for study is identified, a team is formed to study the process, and they create the current state value stream map. This reveals the sources of waste in the process. The team then brainstorms ways to improve the process and reduce waste using special symbols for people and activities, storm clouds for problems, and ‘Kaizen bursts’ (stars) for ideas. A future state value stream map depicts the product of their efforts, and it serves as a blueprint for the action plan to upgrade the process.”
“The ‘VSM Game’ sounds like something my kids would like to play. So the team fixes the process and they live happily ever after, right?”
“No, Julie. The future state value stream map becomes the new current state value stream map, and that will help the team discern where even further improvements can be made. Remember, this is Lean, where the people in gemba continually strive to make incremental reductions in process waste.”
“Incremental. That means making little improvements but never reaching perfection.”
“Practically speaking, Julie, that’s true. However, a word that might better fit your definition is ‘asymptotic.’ But don’t worry; that’s a word that you don’t have to remember.”
“Consider it forgotten, Curmudge.”
Affinity’s Kaizen Curmudgeon
P.S.—“Julie, if you want to learn about value stream mapping, go to Lean in the Affinity Learning Center on the Affinity intranet. See also Mike Rother and John Shook’s book Learning to See, published by The Lean Enterprise Institute. The book’s title is very appropriate, because that’s what VSM teaches us. Another excellent resource is the section on Value Stream Mapping in Cindy Jimmerson’s reVIEW, second edition. And most recently, Mark Graban has a chapter that covers VSM in his new book, Lean Hospitals.”
Future State VSM--Triage in the ED
P.P.S.—“Look up, Julie, I’ve got one—a VSM picture. Janice found it for us.”
“That’s not much of a VSM; it doesn’t even show value-added and non-value-added times.”
“Hey, beggars can’t be choosers. Besides, this is a future state VSM. On these, times are only hoped-for estimates.”
“Now you’ll have to revise the title, Curmudge. It’s no longer ‘without pictures.’”
“Not a chance, Julie. We’d need to rewrite the first half page, and I don’t want to delete your dream about your husband becoming a millionaire. Mrs. Curmudgeon once had the same dream about me."
Thursday, August 21, 2008
Problem Solving Then and Now
“Curmudge, were you involved in problem solving in your earlier life?”
“Lives, Jaded Julie. I had several of them. I was a chemist, and problem solving was what scientists and engineers did. If we weren’t fairly good at it, the men became mill workers and the women home economics teachers.”
“Tell me how you solved problems back in the last century. It sounds as if it were the exclusive purview (purview; did I say that?) of professionals.”
“Like management in those days, problem solving was essentially a seat-of-the-pants endeavor. For problems requiring research, we followed a sequence sort of like this: Define the problem. Learn what was already known by studying the literature, sometimes in a foreign language. Plan the investigation, and then do it. We didn’t know Plan, Do, Check, Act, although we probably did it intuitively. Dr. Deming may have still been in Japan.”
“That sounds difficult, Curmudge, especially the foreign language part. It’s pretty evident why the Toyota Production System had to be developed if they wanted everyone to become a problem solver. On January 25 and 31 we talked about some general aspects of the TPS; perhaps it’s time to tackle the specifics.”
“I agree, Julie. To sum up the two approaches to problem solving, let’s call the old way ‘seat-of-the-pants for scientists and engineers’ and the new way ‘organized common sense, i.e., Lean tools, for the people in gemba.’ The beauty of Lean tools is that everyone can use them.”
“My brain is in gear. When do we start?”
“We already did. On January 18 we used The Five Why’s to identify the root cause of a problem. More recently, on July 10, we introduced 5S, and on August 14 we talked about The Eight Wastes of Health Care. Although the Eight Wastes is not really a tool, it helps guide our thinking. Recall once again, however, that in a blog we can only introduce a concept. Taking a workshop, studying a dedicated text, or working with an experienced person will be necessary before one can rigorously apply a Lean tool.”
“Curmudge, I believe you once said that one of the principles of a Lean transformation is continuous improvement of processes. If we are going to solve problems in processes, we’d better understand the difference between a process and a procedure.”
“Okay, here it is, courtesy of an international standard (ISO 9000) and a seminar at SEH by Lucia Berte on 10/12/06. A process is a sequence of activities involving more than one person (usually) across a span of time. A process description defines who does what in the proper sequence (when). Typically, a process involves several procedures. Thus, the process description, outline, or flow chart is the tie that binds the procedures into a coordinated effort to achieve the desired outcome. A procedure tells how to do something. It is a set of instructions that describe the stepwise actions taken to complete an activity identified in a process. It usually involves just one person. Here is a simple example: Getting up and going to work is a process; brushing one’s teeth is a procedure.”
“The definitions sound reasonable to me, Curmudge. I think the term, ‘procedure,’ is overworked. It is too often used to refer to processes as well as procedures, and we throw in surgical procedures for good measure. Is it really important for us to differentiate between processes and procedures?”
“If people become too absorbed in performing their own procedures, they are apt to acquire a ‘silo’ mentality. In a Lean transformation we need to remove the boundaries between silos and think about how we are going to move patients through processes efficiently.”
“Curmudge, for an old chemist, you’ve covered a lot of ground in two pages. I noticed that you mentioned using a flow chart to describe a process. Does that mean that we’ll talk about value stream mapping sometime soon?”
“Of course, Julie. You can depend on me to be here. After 40 years of getting up and going to work, I’ve hardwired the process.”
Affinity’s Kaizen Curmudgeon
“Lives, Jaded Julie. I had several of them. I was a chemist, and problem solving was what scientists and engineers did. If we weren’t fairly good at it, the men became mill workers and the women home economics teachers.”
“Tell me how you solved problems back in the last century. It sounds as if it were the exclusive purview (purview; did I say that?) of professionals.”
“Like management in those days, problem solving was essentially a seat-of-the-pants endeavor. For problems requiring research, we followed a sequence sort of like this: Define the problem. Learn what was already known by studying the literature, sometimes in a foreign language. Plan the investigation, and then do it. We didn’t know Plan, Do, Check, Act, although we probably did it intuitively. Dr. Deming may have still been in Japan.”
“That sounds difficult, Curmudge, especially the foreign language part. It’s pretty evident why the Toyota Production System had to be developed if they wanted everyone to become a problem solver. On January 25 and 31 we talked about some general aspects of the TPS; perhaps it’s time to tackle the specifics.”
“I agree, Julie. To sum up the two approaches to problem solving, let’s call the old way ‘seat-of-the-pants for scientists and engineers’ and the new way ‘organized common sense, i.e., Lean tools, for the people in gemba.’ The beauty of Lean tools is that everyone can use them.”
“My brain is in gear. When do we start?”
“We already did. On January 18 we used The Five Why’s to identify the root cause of a problem. More recently, on July 10, we introduced 5S, and on August 14 we talked about The Eight Wastes of Health Care. Although the Eight Wastes is not really a tool, it helps guide our thinking. Recall once again, however, that in a blog we can only introduce a concept. Taking a workshop, studying a dedicated text, or working with an experienced person will be necessary before one can rigorously apply a Lean tool.”
“Curmudge, I believe you once said that one of the principles of a Lean transformation is continuous improvement of processes. If we are going to solve problems in processes, we’d better understand the difference between a process and a procedure.”
“Okay, here it is, courtesy of an international standard (ISO 9000) and a seminar at SEH by Lucia Berte on 10/12/06. A process is a sequence of activities involving more than one person (usually) across a span of time. A process description defines who does what in the proper sequence (when). Typically, a process involves several procedures. Thus, the process description, outline, or flow chart is the tie that binds the procedures into a coordinated effort to achieve the desired outcome. A procedure tells how to do something. It is a set of instructions that describe the stepwise actions taken to complete an activity identified in a process. It usually involves just one person. Here is a simple example: Getting up and going to work is a process; brushing one’s teeth is a procedure.”
“The definitions sound reasonable to me, Curmudge. I think the term, ‘procedure,’ is overworked. It is too often used to refer to processes as well as procedures, and we throw in surgical procedures for good measure. Is it really important for us to differentiate between processes and procedures?”
“If people become too absorbed in performing their own procedures, they are apt to acquire a ‘silo’ mentality. In a Lean transformation we need to remove the boundaries between silos and think about how we are going to move patients through processes efficiently.”
“Curmudge, for an old chemist, you’ve covered a lot of ground in two pages. I noticed that you mentioned using a flow chart to describe a process. Does that mean that we’ll talk about value stream mapping sometime soon?”
“Of course, Julie. You can depend on me to be here. After 40 years of getting up and going to work, I’ve hardwired the process.”
Affinity’s Kaizen Curmudgeon
Thursday, August 14, 2008
The Eight Wastes of Health Care
“Jaded Julie, I’ve forgotten something.”
“Of course you have, Curmudge. You’ve spent the past 40 years forgetting most everything you learned in the preceding 20.”
“You are probably right, Julie, but more to the point, we haven’t said much about Lean tools. Several months ago we decided to focus on the Lean culture, and that’s what we have done. Things like the Toyota Way pyramid, leadership, The Flywheel.”
“I recall learning about The Eight Wastes of Health Care. That’s not a tool, but it’s a Lean fundamental that everyone must know. When did we discuss that?”
“It was back in the winter of ’07, Julie. Before my transformation into the Kaizen Curmudgeon. The list was published on the Affinity intranet but not in a blog. Why don’t I name a type of waste, and you can provide some health care examples? Then the blog readers won’t feel neglected.”
“Okay, let’s do it.”
“Waiting:”
“To be seen in the ED
To be admitted to the hospital from the ED
For testing, treatment, or discharge
For laboratory test results”
“Motion:”
“Searching for meds, charts, supplies, patients
Handling paperwork”
“Transportation:”
“Moving patients for testing or treatment
Moving specimens”
“Defects:”
“Wrong patient or procedure
Medication error or omission
Missing information”
“Processing:”
“Unnecessary testing (defensive medicine)
Excessive paperwork”
“Inventory:”
“Pharmacy stock and lab supplies
Paperwork in process”
“Overproduction:”
“Any testing or treatments done at the convenience of the institution rather than the patient”
“Underutilization of Human Resources:”
“Lack of involvement and participation of all members of the workforce”
“Good job, Julie. Did I ever tell you that the Japanese word for waste is muda?”
“You just did, and I am forever in your debt. How did I ever live this past year without knowing that? I must admit that as Japanese words go, muda isn’t too tough. At least it’s easier than genchi genbutsu. By the way, Curmudge, what does genchi genbutsu mean?”
“You know me, Julie; I forgot. We’d better look it up in Liker’s The Toyota Way.”
Affinity’s Kaizen Curmudgeon
Tuesday, July 29, 2008
More Lean Lessons from Hôpital Nord 92
“So, Curmudge, what more are we going to learn from Hôpital Nord 92?”
“Jaded Julie, I hope we’ll learn more about safety and efficiency in nursing.”
“By the way, Curmudge, how does one say 92 in French?”
“Quatre-vingt-douze. It means four twenties twelve. Why do you ask?”
“Well, their math is okay, but it’s sure not a very efficient way to say ninety-two. Can the French really teach us anything about efficiency?”
“You’re in luck, Julie. Ballé and Régnier cite an American author, Steven Spear. Dr. Spear contends that ambiguity and workarounds contribute to medical errors*. They are also undeniable sources of inefficiency. Think of what must be known for any process to occur: who (patient as well as caregiver)? what? when? where? why? how? Ambiguity in answering any of these questions leads to inefficiency and time wasting. If root causes of problems in a process or procedure are not resolved, workarounds must be developed each time it is performed.”
“I can certainly see that ambiguity can lead to inefficiency, but in what ways might it compromise patient safety?”
“Answering the ‘how?’ question is one of the most critical. Here’s what people tend to do when they are uncertain about how to do something (from a seminar at SEH by Lucia Berte):
· They ask someone.
· They look it up (if the document is easy to interpret and not too long).
· They make it up.
· They might not do it. (In Nord 92, the nurses sometimes skipped steps in procedures.)”
“Wow, Curmudge, the last two options are kind of scary. I can understand how they might lead to errors. So how did the nurses at Nord 92 respond to Dr. Spear’s teachings, especially his urging that patient care practices be highly specified, i.e., standardized?”
“Because checklists had been developed in order to achieve the basic stability that we discussed last week, the nurses were familiar with the concept. They were, as might be expected, protective of their autonomy and reluctant to use checklists on themselves. So the effort started on a small scale with a checklist on basic patient care. Early checklists likely avoided topics that might be considered efforts to standardize nursing judgment. Later, however, the program grew to standardize more technical aspects of patient care.”
“It sounds as if the folks at Nord 92 jumped headlong into the Toyota Production System.”
“They did, Julie. And they used some other Lean techniques that we’ll cover in later discussions. Remember that they accomplished all of this using teams of nurses guided by their managers. If these changes had been dictated by management, they would have been accepted about as fast as if they had been written in German (or maybe in English).”
“The French have taught us a valuable lesson. After basic stability is achieved, standard work can be applied to patient care. Say, Curmudge, do you have any other examples of French efficiency?”
“Sure. Est-ce que at the beginning of a sentence means that the sentence will be a question. You don’t have to wait for the question mark at the end.”
“Well, that’s not as efficient as the inverted question mark (¿) in Spanish.”
“Good observation, but did you ever hear anyone speak an inverted question mark?”
“Hey! That’s pretty quick for an old guy. See you after your trip, Curmudge?”
“Of course, Julie.”
Affinity’s Kaizen Curmudgeon
*http://www.annals.org/cgi/reprint/142/8/627.pdf
P.S.—“Check this out, Julie. It’s a timely blog posting that provides strong support for standardized processes in patient care.” http://www.dailykaizen.org/archives/564
“Jaded Julie, I hope we’ll learn more about safety and efficiency in nursing.”
“By the way, Curmudge, how does one say 92 in French?”
“Quatre-vingt-douze. It means four twenties twelve. Why do you ask?”
“Well, their math is okay, but it’s sure not a very efficient way to say ninety-two. Can the French really teach us anything about efficiency?”
“You’re in luck, Julie. Ballé and Régnier cite an American author, Steven Spear. Dr. Spear contends that ambiguity and workarounds contribute to medical errors*. They are also undeniable sources of inefficiency. Think of what must be known for any process to occur: who (patient as well as caregiver)? what? when? where? why? how? Ambiguity in answering any of these questions leads to inefficiency and time wasting. If root causes of problems in a process or procedure are not resolved, workarounds must be developed each time it is performed.”
“I can certainly see that ambiguity can lead to inefficiency, but in what ways might it compromise patient safety?”
“Answering the ‘how?’ question is one of the most critical. Here’s what people tend to do when they are uncertain about how to do something (from a seminar at SEH by Lucia Berte):
· They ask someone.
· They look it up (if the document is easy to interpret and not too long).
· They make it up.
· They might not do it. (In Nord 92, the nurses sometimes skipped steps in procedures.)”
“Wow, Curmudge, the last two options are kind of scary. I can understand how they might lead to errors. So how did the nurses at Nord 92 respond to Dr. Spear’s teachings, especially his urging that patient care practices be highly specified, i.e., standardized?”
“Because checklists had been developed in order to achieve the basic stability that we discussed last week, the nurses were familiar with the concept. They were, as might be expected, protective of their autonomy and reluctant to use checklists on themselves. So the effort started on a small scale with a checklist on basic patient care. Early checklists likely avoided topics that might be considered efforts to standardize nursing judgment. Later, however, the program grew to standardize more technical aspects of patient care.”
“It sounds as if the folks at Nord 92 jumped headlong into the Toyota Production System.”
“They did, Julie. And they used some other Lean techniques that we’ll cover in later discussions. Remember that they accomplished all of this using teams of nurses guided by their managers. If these changes had been dictated by management, they would have been accepted about as fast as if they had been written in German (or maybe in English).”
“The French have taught us a valuable lesson. After basic stability is achieved, standard work can be applied to patient care. Say, Curmudge, do you have any other examples of French efficiency?”
“Sure. Est-ce que at the beginning of a sentence means that the sentence will be a question. You don’t have to wait for the question mark at the end.”
“Well, that’s not as efficient as the inverted question mark (¿) in Spanish.”
“Good observation, but did you ever hear anyone speak an inverted question mark?”
“Hey! That’s pretty quick for an old guy. See you after your trip, Curmudge?”
“Of course, Julie.”
Affinity’s Kaizen Curmudgeon
*http://www.annals.org/cgi/reprint/142/8/627.pdf
P.S.—“Check this out, Julie. It’s a timely blog posting that provides strong support for standardized processes in patient care.” http://www.dailykaizen.org/archives/564
Thursday, July 24, 2008
Lean in a French Hospital
“Have you ever been in a French hospital, Curmudge?”
“No, Jaded Julie, but we came very close. Mrs. Curmudgeon contracted food poisoning in Paris several years ago. We stayed in the hotel because my wife was too sick to move—except frequently to the bathroom. I went to the local pharmacy, and the pharmacist provided something that seemed to be effective. Perhaps pharmacists there can dispense without a prescription more powerful stuff than here. Although my wife felt like dying, she eventually got better.”
“It sounds as if the French have become more helpful to Americans than in years past.”
”I suppose so. You can depend on the French; they are always there when they need us.”
“Curmudge, did you say that right? Considering the source, I guess you did. So anyway, tell me about the paper you found—the one about a hospital in France.”
“I was googling ‘Lean in nursing’ and encountered the paper, Lean as a Learning System in a Hospital Ward. I’ll give you the URL*, but Word refuses to open the file. Perhaps it has the same French bug that my wife had. At least it can be accessed via Google.”
“Please proceed, Professor. We’ve already used a half page.”
“The staff at the hospital, Hôpital Nord 92, used Lean tools, especially 5S, and encountered what the authors call the ‘pillowcase syndrome’. If one squeezes at one end, it bulges elsewhere. When they made an isolated improvement, it shifted the burden to another element in the system. The authors, Ballé and Régnier, attributed their lack of meaningful progress to the lack of basic stability in their unit. Although the ‘basic stability’ problem has been described by Smalley in the manufacturing context**, it can be translated into health care.”
“Okay, Curmudge. I think at this point you want me to ask, ‘How can one achieve basic stability in a patient care unit?’”
“The folks at Park Nicollet Health Services in Minneapolis provide some inspiration in their listing of the ‘7 Flows of Medicine’***. These are factors that they consider in designing changes in processes or delivery of services:
· Flow of patients
· Flow of providers
· Flow of medications
· Flow of supplies
· Flow of information
· Flow of equipment
· Flow of instruments and processes”
“I think I get it, Curmudge. The better one can control these flows, the greater the unit’s basic stability. Did the nurses at Nord 92 improve any of their flows, perhaps without even knowing of Park Nicollet’s list?”
“Yes, they really made significant progress toward basic stability. They initiated a ‘clear corridor’ policy so that wheelchairs and trolleys (carts) were properly located and not scattered all over. Materials handling and storage were studied and improved. They adopted a ‘supermarket’ (first in, first out) policy for storage areas. A clear benefit of these changes was that anything out of date or out of place would stand out. Success in these projects convinced the nurses that there might be value in achieving basic stability in nursing care itself. At the end of the paper, the nurses were developing checklists and devising what we would call ‘standard work’ for some of their processes and procedures.”
“That’s great, Curmudge. I understand that we’ll talk more about Nord 92 in our next conversation. By the way, did your wife ever return to Paris?”
“Never. And she refuses to eat foie gras.”
Affinity’s Kaizen Curmudgeon
*http://lean.enst.fr/wiki/pub/Lean/LesPublications/HospitalLearning.pdf
**http://www.superfactory.com/articles/Smalley_Basic_Stability.htm
***http://www.msp-ifma.org/0702prgnotes5S3PLeanCaseStudyDSpiegle.ppt
“No, Jaded Julie, but we came very close. Mrs. Curmudgeon contracted food poisoning in Paris several years ago. We stayed in the hotel because my wife was too sick to move—except frequently to the bathroom. I went to the local pharmacy, and the pharmacist provided something that seemed to be effective. Perhaps pharmacists there can dispense without a prescription more powerful stuff than here. Although my wife felt like dying, she eventually got better.”
“It sounds as if the French have become more helpful to Americans than in years past.”
”I suppose so. You can depend on the French; they are always there when they need us.”
“Curmudge, did you say that right? Considering the source, I guess you did. So anyway, tell me about the paper you found—the one about a hospital in France.”
“I was googling ‘Lean in nursing’ and encountered the paper, Lean as a Learning System in a Hospital Ward. I’ll give you the URL*, but Word refuses to open the file. Perhaps it has the same French bug that my wife had. At least it can be accessed via Google.”
“Please proceed, Professor. We’ve already used a half page.”
“The staff at the hospital, Hôpital Nord 92, used Lean tools, especially 5S, and encountered what the authors call the ‘pillowcase syndrome’. If one squeezes at one end, it bulges elsewhere. When they made an isolated improvement, it shifted the burden to another element in the system. The authors, Ballé and Régnier, attributed their lack of meaningful progress to the lack of basic stability in their unit. Although the ‘basic stability’ problem has been described by Smalley in the manufacturing context**, it can be translated into health care.”
“Okay, Curmudge. I think at this point you want me to ask, ‘How can one achieve basic stability in a patient care unit?’”
“The folks at Park Nicollet Health Services in Minneapolis provide some inspiration in their listing of the ‘7 Flows of Medicine’***. These are factors that they consider in designing changes in processes or delivery of services:
· Flow of patients
· Flow of providers
· Flow of medications
· Flow of supplies
· Flow of information
· Flow of equipment
· Flow of instruments and processes”
“I think I get it, Curmudge. The better one can control these flows, the greater the unit’s basic stability. Did the nurses at Nord 92 improve any of their flows, perhaps without even knowing of Park Nicollet’s list?”
“Yes, they really made significant progress toward basic stability. They initiated a ‘clear corridor’ policy so that wheelchairs and trolleys (carts) were properly located and not scattered all over. Materials handling and storage were studied and improved. They adopted a ‘supermarket’ (first in, first out) policy for storage areas. A clear benefit of these changes was that anything out of date or out of place would stand out. Success in these projects convinced the nurses that there might be value in achieving basic stability in nursing care itself. At the end of the paper, the nurses were developing checklists and devising what we would call ‘standard work’ for some of their processes and procedures.”
“That’s great, Curmudge. I understand that we’ll talk more about Nord 92 in our next conversation. By the way, did your wife ever return to Paris?”
“Never. And she refuses to eat foie gras.”
Affinity’s Kaizen Curmudgeon
*http://lean.enst.fr/wiki/pub/Lean/LesPublications/HospitalLearning.pdf
**http://www.superfactory.com/articles/Smalley_Basic_Stability.htm
***http://www.msp-ifma.org/0702prgnotes5S3PLeanCaseStudyDSpiegle.ppt
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