Stan's Story Redux

“You’ve already heard most of this story, Jaded Julie, but not the ending. In January of 2007 I visited Stan (not his real name), a very close friend from my college days. When Mrs. Curmudgeon and I entered their house, Stan recognized me and said, ‘hello,’ but I couldn’t understand much else that he said.”

“I remember our posting the original Stan’s Story on October 30, 2008. I guess more has happened in Stan’s life since then. In any case, because of its lessons on patient safety, the story merits retelling. Please repeat the original Stan’s Story and bring us up to date on what occurred after it was posted.”

“Shortly after his retirement, Stan, who lived very far away from here, suffered a stroke. While he was recovering in the hospital, he sustained a tragic fall that injured his brain much more than the stroke had. After the fall, Stan, always a gentle giant, could not speak a coherent sentence. Although he was cared for by his devoted wife, this was not the way Stan planned to spend his ‘golden years.’

Here are some of the details as provided by Stan’s wife: Stan experienced a severe stroke early one evening a few years ago, and his wife rushed him to the hospital a few minutes away. She anticipated that Stan would be treated with thrombolytics within the ‘golden three hours.’ (However, I never did learn whether the stroke was ischemic or hemorrhagic.) Stan was first seen by a physician in the ED two hours after they had arrived; he apparently did nothing. At 2:00 a.m., a cardiologist appeared, and he pronounced that it was ‘too late’ for treatment with t-PA (or whatever). So Stan was admitted to the ICU.

While in the ICU, Stan fell and crushed the bones around one of his eyes. The eyeball was out of the socket, and 15 stitches were required to close the cut. After performing the necessary repairs, the physician checked the sight in Stan’s eye by holding up three fingers and asking Stan to count them. At that point, Stan was in no condition to count anything.

When Stan’s wife left the hospital the night of his fall, the rails of the bed were up and an alarm was in place. Stan’s condition would have prevented his lowering the rail by himself, and the alarm should have alerted the nurse had he done so. Yet the nurse in the ICU said that the rail was down when Stan fell (of course it was, but who lowered it?). Stan was her only patient. And so the risk management and legal issues began. Ultimately, Stan and his wife had to accept what they considered a very inadequate settlement from the hospital.

The final outcome as of January 2007 was as I described at the beginning of our conversation. Stan’s wife became his constant caregiver. Stan recognized me but not the names or anything about many of our close college friends. He could say ‘hello’ and ‘good-by,’ but his long sentences were quite incomprehensible. We planned to see Stan and his wife whenever we visited the far-away city where they lived, but reminiscing about our college days would have been pretty difficult.”

“Curmudge, that is so sad. And it appears to have been preventable. So what occurred in Stan’s life between your last visit and now?”

“It was not good. Stan experienced a botched removal of a kidney stone that resulted in a nosocomial infection that kept him hospitalized for a month. Then on December 18, 2008 Stan died of an apparent heart attack.”

“The latter years of Stan’s life appear to have been a tragedy of errors. I guess that explains why you became a patient safety zealot.”

“Julie, everyone should be a patient safety zealot, but it’s inevitable when tragedy strikes close to home.”

Affinity’s Kaizen Curmudgeon

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.    

Fifty More Curmudgeons

“Golly, Curmudge! Isn’t one Curmudgeon enough?”

“I hope there’s only one Kaizen Curmudgeon, because that’s my nom de plume. The world may be filled with curmudgeons (lower case ‘c’) or nasty old men. But, Jaded Julie, what I was referring to were the fifty more Kaizen Curmudgeon postings since October 29, 2009, when we celebrated the first hundred.”

“So we’ve had 150 postings on 150 ideas of things to write about. It’s too bad that most of the ideas weren’t very good.”

“Many thanks for your vote of confidence, Julie. Please remember that you were co-author. So what can we do for our readers to celebrate this sort-of anniversary?”

“It’s really hard to find a specific posting unless you know when it was posted. So why don’t we add to this note the Table of Contents for our most recent 50 postings? Then the reader can scan down the list, find a title of interest, and then click on its Date Posted to be linked to the posting.”

“Setting up all those links will be a lot of work, Julie. I trust that you will do that for me.”

“Of course, Curmudge. (I’d do most anything for the old codger.)”

Kaizen Curmudgeon Blog Title--Date Posted

101 Curmudgeons--10/29/09
Change Your Primary Care Mindset—the Physician 2--11/05/09
Change Your Primary Care Mindset—the Rest of the Team--11/12/09
The Medical Home Team Comes Together--11/19/09
It Takes More Than a Team--12/04/09
“I’m from Corporate, and I’m here to help you.”--12/10/09
Holiday Greetings from Curmudge and Jaded Julie--12/17/09
Volunteering: the Seniors’ Raison D’être--1/07/10
Curmudgeon’s Wastebasket--1/13/10
Father Clark’s Sequence--1/22/10
“Welcome to my (our) world.”--1/28/10
The First Step in New Health Care Construction: the Voice of the Patient--2/04/10
From Customer Ideas to Project Choices--2/11/10
Heart, Lung & Vascular Center: From Current State to Future State--2/18/10
Lean Lessons from Long Ago--2/25/10
Packrattery, Chaos and their Countermeasure, 5S--3/04/10
Kanban--3/11/10
What do you say after, “Lean is based on the Toyota Production System”?--3/18/10
A Culture of Elegance--3/25/10
Mistakes--4/01/10
Mistakes 2--4/08/10
Operas and Hospitals--4/15/10
Assisting Clinical Excellence (ACE) Awards--4/22/10
Hey patients, checklists are okay.--4/29/10
The Sensei is Concerned--5/06/10
Twice Blessed--5/13/10
Teamwork—It’s the People--5/20/10
Happy Third Birthday--5/28/10
The Guys in the Yellow Shirts--6/10/10
Judgment--6/18/10
AIDET Redux--7/01/10
Docs on a Treadmill--7/15/10
Mistakes 3--7/22/10
Amazing Devices--8/05/10
Amazing Devices 2--8/12/10
The World Health Congress--8/19/10
Medical Home Workflows--8/26/10
Amazing Devices 3--9/02/10
Amazing Devices 4--9/09/10
Evidence-Based Medicine—The Patient’s Perspective--9/23/10
Evidence-Based Medicine—The Patient’s Perspective 2--9/30/10
Evidence-Based Medicine—The Patient’s Perspective 3--10/14/10
Evidence-Based Medicine—The Patient’s Perspective 4--10/14/10
Evidence-Based Medicine—The Patient’s Perspective 5--10/21/10
The Robot--11/03/10
Superbugs--11/04/10
The Old Scout’s Funeral--11/18/10
The Evolution of Lean Education at Affinity--11/26/10
Why Lean?--12/02/10
The Evolution of Lean Education at Affinity 2--12/09/10

Affinity’s Kaizen Curmudgeon

Holiday Greetings from Curmudge and Jaded Julie

“Get with it, Curmudge. The holiday season is upon us.”

“I know, I know, Jaded Julie. It’s a joyous time for most folks, but for blog writers, it’s a real challenge to say something new and profound every year. Over the past three years we’ve written about political correctness, family gatherings, and macro and micro happiness and unhappiness.”

“How about something about Lean? It’s hard to relate Lean to the holidays, but you should be safe from criticism.”

“I’ve got it, Julie. W. Edwards Deming’s Eighth Point, ‘Drive out fear.’ I could preach a sermon on that, and I’m the world’s least likely person to be a member of the clergy.”

“Go to it, Curmudge. I’ll be right here wave’n my arms and shout’n ‘Amen’ or ‘Hallelujah’ periodically (oops, that’s not politically correct).”

“To begin with, the intensity of fear is a continuum. In addition, fear can be only an occasional raising of the hairs on the back of your neck to a continuous gnawing in one’s innards.”

“I believe the fear that Dr. Deming had in mind was a low-level, obsessive feeling of insecurity within an organization. But I don’t see what that has to do with holidays. Perhaps if you provided some more examples…”

“A very low-intensity fear might be a teenager concerned about acceptance by her peers. At the highest end of the scale would be a soldier on a mission in Afghanistan fearful that his next step will be on an IED that could blow him to bits. Also at the high end would be an Afghan woman’s continuous fear that she could be beaten or her nose cut off by her husband (see page 39 in the December 2010 National Geographic). Here is an example that is downscale a bit: A senior citizen concerned that her next illness will be ‘the big one’ that will be debilitating or terminal.”

“I think I have the picture, Curmudge, and it’s not a pretty one. How can these people drive out their fear, and what does it have to do with the holidays?”

“In some cases the fear will be permanent, like the Afghan woman’s having to live with her fear, mutilation, and humiliation. However, she might be able to hold out some hope for her daughter. The soldier’s fears will be temporarily allayed when he is back at the forward operating base (if it is not mortared) eating a big holiday meal in the mess tent or opening a package from home. The senior citizen’s worries about her health will be momentarily forgotten with the first hug from her grandchild. And the teenage girl’s concerns about her social life will be swept away by an invitation to a holiday party.”

“I’ve got it, Curmudge. Holidays are for driving out our fears. Occasionally the respite is permanent, most often it is temporary, and sometimes it is just not in the cards. But with the help of our friends and families during the holiday season, we’ll give it our best shot.”

“Merry Christmas, Jaded Julie.”

“Happy Holidays, Curmudge.”

Affinity’s Kaizen Curmudgeon

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.   

The Evolution of Lean Education at Affinity 2

“Curmudge, you promised to start today’s discussion with one of your illogical-and-funky-but-true tales from long ago.”

“Albert Einstein would occasionally visit Professor Hubert Alyea’s lectures on physical chemistry at Princeton University. When the professor made a particularly important point in his lecture, he would look to the back of the room and see Einstein’s white head nodding in approval. Alyea’s tacit and illogical conclusion was that if Einstein understood, everyone in the class would understand.”

“I’ll admit that your story is nonsensical, but does it have a parallel in our teaching of Lean?”

“Sure, Jaded Julie. If you can design a course that is viewed as worthwhile by a physician, it will be worthwhile for everyone.”

“Well Curmudge, it took you a long time to point out that several physicians have attended our one-day Lean Overview class, and they haven’t gotten up and walked out. For docs to view something as valuable, it must help their patients, their practice, or their personal life. Lean should do all three. Our congrats to the course designers and presenters.”

“Julie, in my professorial days I taught for just 50 minutes several times per week. Standing before a class for almost eight hours would require exceptional concentration and physical stamina. Our Lean presenters have to make that sacrifice in order to cover the Lean essentials in a one-day time period acceptable to physicians and others who require a basic knowledge of Lean.”

“From my experience I know that nurses follow the physicians’ lead. That’s why physicians—especially those in a position to influence others—must learn the Lean basics. One cannot do anything of real significance in a hospital or clinic without the understanding and support of the physicians. So Curmudge, just what is in this one-day blockbuster Lean Overview course?”

“Everything…sort of. The principles and most of the tools of Lean; they are familiar to most of us and don’t need to be recited here. However, it’s important to note that it would be futile to attempt to cover every detail of Lean manufacturing discussed in The Toyota Way and The Toyota Way Fieldbook.”

“I agree. It would be sort of like insisting that one study the Bible in the original Hebrew and Greek.”

“In addition to the Lean manufacturing classics, there are several books available now that are devoted exclusively to Lean in health care. These would be efficient resources for the course presenter and appropriate for the students’ further reading.”

“Okay, Curmudge, some examples please.”

“One might use Graban’s Lean Hospitals as a how-to-do-it fieldbook. For case studies on ‘how we did it,’ read Grunden’s The Pittsburgh Way, Toussaint’s On the Mend, and Kenney’s Transforming Health Care (about Virginia Mason Medical Center—just published). Of course, one could remain a strict purest and stick to the classics on manufacturing, but that’s a route I haven’t followed. When I was a student I might have used ‘Cliff’s Notes,’ but they hadn’t been invented yet.”

“Thanks for being a paragon of virtue, Old Guy. So in addition to appropriate resources, are there other features of the Lean Overview course that are worthy of mention?”

“The handout booklet of PowerPoints has space beside each slide for the student to take notes. When the presenter makes a point that’s not on the slide, the student should feel compelled to write it down. That keeps the brain engaged in moving one’s fingers and hopefully paying attention in class. Another valuable feature of the course is the showing of the video, Hospitals Healing Themselves. That should convince the students that Lean in health care is for real. And finally, the students put to use what they have learned in a simulated process that they perform, study, and improve. Recall the quotation from Benjamin Franklin, ‘Tell me and I forget. Teach me and I remember. Involve me and I learn.’”

“If you haven’t already forgotten them, do you have any final thoughts?”

“Lean education at Affinity is a good example of kaizen—continuous improvement. The courses are continuously being revised and improved. Stay tuned for updates.”

Affinity’s Kaizen Curmudgeon

Why Lean?

“Hey Curmudge, last week we had the cart before the horse. We talked about Lean training before we explained why it is Lean, and not something else, that we are teaching.”

“Good catch, Julie. We older folks who wish we could live life backward sometimes get things out of order. Let’s go back one step and explain why we are doing what we are doing.”

“I understand that you have some stories from long ago—back when you were middle-aged—that illustrate the need for more efficient processes in health care.”

“There was a story about Pope John XXIII. In an audience with the Pope, a visitor asked the Holy Father, ‘How many people work in the Vatican?’ He answered, ‘Oh, about half of them.’ When I was living in the Northwest, I went to the local hospital for some outpatient testing. There were employees all over the place standing around and chatting. I thought, ‘This must be the Vatican. Which way to the Sistine Chapel?’”

“You concluded that health care back then was not very efficient and needed help?”

“That’s it, Julie. Fast forward to six years ago. My last paying job had ended, and like the city’s other derelicts I spent a lot of time in the public library. I found books on Six Sigma, Gemba Kaizen, Total Improvement Management, and other systems for process improvement. In my last employment I had worked with ISO 9001 and had learned about the Baldrige Award. All of the programs had some common elements, but ISO and Baldrige were very heavy on documentation. Six Sigma was felt to require a lot of training before any payoffs could be achieved.”

“So Curmudge, of the documents you could find, you favored Gemba Kaizen.”

“Right. Kaizen was used not only at Toyota but throughout Japan’s manufacturing sector. It might have been properly called, ‘The Japanese Production System.’ The focus of Kaizen was process-oriented management, as contrasted against results-oriented management used in the West. As Masaaki Imai (1) stated, ‘Many Japanese management practices (Kaizen) succeed because they are good management practices.’”

“Then, somewhat later, you learned about Lean.”

“It appears that Kaizen came to the U.S. and for most users acquired a new name, Lean manufacturing. An English word (Lean) that is often misinterpreted is better than a phrase in Japanese (Gemba Kaizen) that happens to be trademarked. It is also more palatable to Americans to speak of the Toyota Production System than the Japanese Production System. The two systems are essentially identical—same tools and same management principles.”

“Okay Curmudge, back to my original question. Why are we adopting Lean as our culture at Affinity?”

“What really matters is what one does and not what name one gives to the program. (Whenever I write that I am reminded of the line in ‘My Fair Lady’ that says the exact opposite, ‘The French don’t care what they do, really, as long as they pronounce it correctly.’) We could just as easily call Lean the ‘Affinity Performance Excellence System.’ One reason for keeping the term, Lean, is that it identifies, in general, what we are doing to all who are also striving for performance excellence.”

“So much for terminology. What I am really asking is why Lean—irrespective of its name—was selected by Affinity management to be the cultural target for Affinity Health System?”

“Our top management appreciated the value of continuous improvement, a hallmark of Lean. Our immediate boss learned about Lean in his graduate studies. Lean has been used with success in many health care locations. And Lean’s successes at Affinity are validating their choice on a daily basis.”

“Curmudge, you once told me that culture is the summation of everyone’s perception of ‘the way we do things around here.’ And that’s why Lean education is essential for as many people as possible in the organization.”

“You’re exactly right, Jaded Julie. You must have been reading my mind. I’ve always wondered how you do that.”

Affinity’s Kaizen Curmudgeon

(1) Imai, Masaaki. Kaizen (McGraw-Hill, 1986)

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.  

The Evolution of Lean Education at Affinity

“Most people speak of Lean training, Curmudge, but we have education in our title. Is there a real difference between the terms, or are you just being curmudgeonly in your old age?”

“Me? Curmudgeonly? I’ve read that education is for people and training is for dogs. We do have some poodles as hospital volunteers to cheer up our patients, but none has signed up for a Lean course.”

“So other than the hominid vs. canine situation, what are the differences between education and training?”

“In my opinion, Jaded Julie, education tries to answer the questions, who, what, where, and especially why, and training teaches us how. Although a dog sometimes cocks his head in presumed wonderment, I’ve never heard one ask ‘why?’ Lean learning contains both education and training. Education involves leaning the Lean culture and principles, and training teaches us how to apply the Lean tools.”

“Despite your semantic nit-picking, Curmudge, training is used more than education in health care; so let’s consider training to include ’why’ as well as ‘how.’ I trust your ossified brain can handle that.”

“No problem, so let’s get on with our topic. Attendees at the initial Lean instruction at Affinity, the Lean Health Care Tool Kit, came from two populations: (1) top management, directors, and some managers, and (2) Lean facilitators-in-training recently selected to staff the incipient Kaizen Promotion Office (KPO). Those in the management group had been told that Lean represented Affinity’s future, and they attended the initial training to prepare them for service in Affinity’s guiding coalition for change. Two weeks of comprehensive Lean training might have been excessive for this group, but it was essential that they receive training at the outset of Affinity’s Lean journey.”

“In contrast with the management folks, the first crop of Lean facilitators needed the comprehensive training to prepare them to spread Lean to the far corners of Affinity. They would require a command of Lean principles and culture, Lean tools and examples of their use, and—as you would say, Curmudge—the whole geschäft. Like you once advised, ‘they should always know more than they teach.’”

“This training ran for two weeks, contained a lot of PowerPoints, and had an open-book exam at the end of each topic. Presenters were from WCM (World Class Manufacturing) and were affiliated with the Milwaukee School of Engineering. Participants received several books (Liker, Dennis, Kotter, Rubrich & Watson) that are now considered Lean classics. Those two weeks were undoubtedly a busy period for course participants. For the KPO people, a one-week course on being a facilitator was presented later.”

“That sounds pretty intense, Curmudge, but the KPO staff taking the course knew that their future at Affinity depended on their ability to apply what they learned. Everyone appreciates that a mid-career course correction can’t be taken lightly. Learning is not very easy when one has to sit and watch PowerPoints fly by, but they did it.”

“For the record, Julie, the two-week course ran through 2007 and attracted 151 participants. For any adult learner, the gain from a course must be worth the time required. Two weeks is a pretty big time demand for busy people, so the KPO decided to shorten the course to one week for 2008. Participation by mid-level management is key to a Lean transformation, and the KPO felt that a one-week course would be attractive to managers and provide them with an adequate introduction to Lean.”

“How did the one-week course differ from the two-week course?”

“Topics were not covered as extensively, and there were no exams. The PowerPoints were from WCM, but the course presenters were from our Kaizen Promotion Office. The shorter duration of this course and the lack of out-of-class assignments made it easier for the middle-management participants to keep their fingers on the pulse of work in their regular jobs. In 2008 and 2009 the one-week course had 58 participants.”

“And then in 2010 the one-week course was subdivided into three one-day classes. These include one on Lean principles (Lean Overview), and two on tools (A3 Problem Solving and 5S and Kanban). I presume we’ll discuss the rationale behind these changes, Old Guy?”

“We will, but not today. It’s time for lunch followed by my afternoon nap.”

Affinity’s Kaizen Curmudgeon


Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link. 

The Old Scout's Funeral

“A few weeks ago I attended the funeral of a former assistant scoutmaster of the troop to which our sons belonged. It seemed as if about half of the attendees were either former scouts or parents of scouts.”

“I assume, Curmudge, that you were there to show your respect for the deceased.”

“If it were only respect for the deceased, Jaded Julie, we should have visited him while he was alive. It was more than that. I believe it was respect for what he stood for and for what Scouting—with the involvement of all of us—had done for our sons many years ago.”

“That sounds pretty important; and since we are talking about it here, it must have something to do with Lean.”

“Although Scouting and Lean occur at different points in a person’s life, i.e., they are not contemporaneous, they are quite complementary. Here are some Lean (and Scouting) examples: Respect for people (Do a good turn daily. Help other people at all times. A Scout is trustworthy.). Continuous improvement (advancement from Tenderfoot to Eagle Scout). Leadership (Patrol Leader, Senior Patrol Leader, and leading a team in the scout’s Eagle project).”

“Let’s talk about that ‘not contemporaneous’ thing, Curmudge. A lot of time can pass between Scouting in adolescence and when an adult assumes a leadership role in industry, the military, or a hospital. What keeps the lessons of Scouting from being lost in the interim?”

“They need to become hardwired, Julie. That comes from repetition, dedication, and advancement, and that’s why Eagle Scouts are valued in any organization. I know of a young man who enlisted in the Marines and because of his Eagle rank was promoted almost immediately.”

“Scouting sounds like a unique opportunity for boys, Curmudge, but these days being unique is not always considered a virtue.”

“The Venturing program of the Boy Scouts includes young women aged 13-21. Many cultural mores similar to those of Scouting are taught in other organizations ranging from Girl Scouts to kindergarten to Sunday school. Even in service clubs for adults, like Rotary International. It certainly appears, however, that Scouting is more fun. Here’s an interesting observation: ‘Scouting's genuinely egalitarian goals and instincts are more important now than they've ever been. It's one of the only things that kids do that's genuinely cooperative, not competitive.’ (1)”

“It would appear that former Scouts and members of many other groups will have a head start in learning Lean.”

“You’re right, Julie. They already have a humanizing background and should readily understand Lean principles and culture. Next they’ll need to hone their leadership skills and learn to use Lean tools and procedures. Ultimately, these people would be ‘early adopters’ and perhaps members of the organization’s guiding coalition. If you found these people in a Lean Overview class you were teaching, you’d feel glad all over.”

“I certaily would. But what if people had become corrupted by working in a command-and-control, dog-eat-dog environment?”

“They would need to start Lean training at square one. If they couldn’t adapt to a Lean culture, it might be better if they ‘got off the bus.’”

“Although over 30 years have passed, Curmudge, you seem to be as enthusiastic about Scouting as you are about Lean. What did you do in Scouting that was so great?”

“Camping with the troop in the north woods and running the Pestigo River rapids in open canoes. Developing the required coordination between father (paddling in the stern) and son (paddling in the bow) builds a bond that lasts a lifetime.”

Affinity’s Kaizen Curmudgeon

(1) Applebome, Peter (2003). Scout's Honor: A Father's Unlikely Foray Into the Woods. http://en.wikipedia.org/wiki/Boy_Scouts_of_America

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.