NC State of Business

We all know what walls are, what they look like, and why they exist. That is generally true for walls we can literally see, but it is not necessarily true for those walls we can not see. Walls we can't see; what does that mean?
Well, let's take a moment to both explain and reflect on this concept. In lean discussions, we often use the term "silos" to indicate the presence of walls or barriers to the elimination of waste and improvement of flow in our processes. The fix to these silos often lies in moving the culture of an organization toward a true lean enviornment.
How do we manage the true and effective removal of these barriers to continuous improvement, generate more flow of improvement ideas, and thereby grow a truly lean culture. The first step, right after getting top management committment is the education of the team. People need to know and understand the what's, the why's, and the how's to Lean Tranformation. The level of true understanding at all levels takes time. The light comes on at different rates for different individuals.
Some of the specifics necessary to break down the barriers are as follows:

* Teach and attain a clear understanding of the concept of true value add for the customer at all levels of the organization.
* Make sure everyone understands the true "goal", and that winning teams perform as a cooridinated unit, not as individuals.
* Speak with data, and make the primary focus on improving the process, not on blaming people.
* As managers, understand that coaching and team building is a critical need and a priority of their position. Do not be afraid or reluctant to change the team as required.
* "Listen" to both your associates and your customer. Emphasize the concept of internal as well as external customers.
* Pursue improvement continuously, never get totally satisfied or confortable with the current state.
* Communicate results to all levels, and make sure performance metrics are fair, understandable, pertinent to the goal, and tie to true bottomline performance.

In conclusion, in our world today with businesses that are as diverse as they could possibily be, there is a common thread that runs thru most. They all have "WALLS", which they themselves often recognize. The challenge for all is really how to bring these barriers to Continuous Improvement down. The success of the Transformation is dependent on the results of that effort.

In this blog, Marianne Jackson, a physician that has recently emerged herself into the Toyota Production System (TPS) or ‘lean’ philosophy for continuous improvement, explores a very important subject of engaging physicians into lean transformation. Specifically, she focuses her thoughts around the subject of standardization and its meaning to physicians. Not only this subject is relevant and important, but it challenges us to search for common ground to exchange and share knowledge with physicians in one industry in serious operational crisis – healthcare.

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Immersed as I am now in Lean literature and methodology, it is sometimes hard to recall my first reactions as a physician to the words Standardization and Compliance. I am reminded, however, of my negative reflexes when I see the responses of physicians who attend Lean educational sessions. Those who are following along contentedly through Value Stream Mapping and A3s suddenly throw up walls of defensiveness when they hear Standardization and Compliance.

The response of Quality Assurance staff and facilitators often is to become frustrated and critical of us physicians for being too conservative and wedded to our autonomy. They may proceed with improvement efforts without physician participation. I’d like to explore the physician context and in so doing, suggest means for introducing Standardization and Compliance in ways that physicians can accept because physician engagement is critical to the success of the majority of Lean Healthcare transformations.

Lean has only been aggressively adapted to the healthcare market for about a decade. We promoters understand it to be an integrated approach to improving processes and systems using the innovations of all of the workers who touch the process, top to bottom and bottom to top. Prior to Lean, quality initiatives came strictly from the top and often from outside the hospital walls. Regulatory agencies developed and imposed “standards” and only negative indicators of poor outcomes such as infection rates, low APGAR scores and returns to OR without the input of those who provided the care.

Enforcement of “standards” or compliance was given to the Quality Control Officer (intimidating language) whose job it was to comb through charts finding the omissions, failures and faults in order to display them for the Medical Staff for review and report to the Board. Such statistical methods applied to very small sample sizes and minimally meaningful indicators created anger and rejection of the process among medical staff. For example, a physician who had saved a life by diagnosing a post-operative bleed, who took the patient back to the OR was “dinged” and judged as culpable by the indicators. Many of these practices continue today. If an error is caught in a non-Lean regulatory environment, what are the incentives to identify and disclose it if you are going to be penalized?

Physicians work with many sharply competing incentives. Reduce costs, see more patients, make no errors, document to satisfy even the harshest malpractice lawyer, be compassionate, spend more time with all patients, screen for seatbelt or tobacco use, complete required authorizations for HMO’s, coordinate care with all providers, and be prepared to respond to any emergencies. We will resist Standards if they feel like another burdensome injunction to “remember to do” one more thing that is going to be measured.

On being introduced to Lean, physicians are likely to think of it is a means of meeting current reporting requirements while we know it can have much greater impact. I saw a recent example at Scotland Memorial Hospital in Laurinburg. Surgeons began using Lean to investigate why they had deficiencies in meeting SCIPS DVT prophylaxis indicators and why orders for heparin were omitted. When they went on a Gemba walk they discovered the many wastes in their whole pre-operative admission process. They discovered how Lean methodology could be used to simplify, not burden their practices. They discovered how standardization is about having resources, routines and safeguards in place that protect their practice of medicine. Simple examples of standards and routines include having laboratory results reported in an accurate and timely manner, for having outside records available prior to consults, for medication refills ready for signing after checking for allergies, for check lists for pre surgical authorizations and registrations. These examples and others can demonstrate how standardized work can avoid errors, redundancy, waiting, and rework while simplifying medical practice but not constraining it.

To engage physicians, emphasize that Lean Methodology is devoted to establishing processes throughout an organization that reliably support the physician’s efforts. Demonstrate how standardization links the physicians’ work to those who come before and after in the sequence. Compliance with standard work is a means of confidently controlling the mundane work and focusing the physician’s efforts on the exceptional and unusual cases. Physicians will see that the processes associated with standard work assist them to provide individualized care and responsiveness to unpredictable need.

For assurance, we should emphasize what Lean is not – it is not a means of controlling, policing or punishing. It is not a set of Do’s to remember. It is not a denial of individual patient or physician needs. It is not strictly an efficiency tool. And it is not the enemy of innovation. Atul Gawande, MD, in his outstanding book “Better” examines several stories of clinics and practitioners whose outstanding outcomes are many percentage points above the expected. He challenges us to look at that variability for the sources of true excellence. Compliance with standards by everyone in the workflow is not going to eliminate all variability or stifle innovation but it will provide an unprecedented level of support and stability to highly competent physicians who will be able to focus on excellence.

We physicians are not necessarily resistant or obstructionist when it comes to Lean or quality improvement efforts. The Lean transformations of Virginia Mason and Theda Care were led by physicians. Engaging physicians is critical for success in Lean Healthcare. As a facilitator, sensei or change agent, success will be when you find the ways to align the Lean principles with the physicians’ goals – they are not incompatible. The true transformation in the medical culture will be achieved when this alignment results in trust and cooperation among all providers of patients’ care.

Written by Marianne Jackson, MD, MPH
Forwarded by Lukasz Mazur, Ph.D.

I am certainly fortunate to be able to work with so many different types of clients and to be a part of the journey to improve the ability to meet their customer’s needs. It is quite easy to get caught up in the fast paced activities and the overwhelming demand to out-perform the competition. The reliance on striking gold on every dig can push resources to the edge and, in most cases, will divert associates from working on the items needed to sustain the company. Dissatisfaction sets in and associate involvement disappears. A lot of us know to apply common sense solutions; but, for some reason or another, we often forget that just because it sounds like the right thing to do; it might just be the right thing to do. One local automotive glass manufacturer that I have had the opportunity to spend a good amount of time with does just that. They utilize common sense in their lean approach. While some of the glitz and glamour may not always be present; the results sure speak for themselves.

It starts with the direction from the top. Senior management provides the direction and the time to train. They then allow associates the time to participate. Yeah, I know you have heard this recipe before; but, how many of you can honestly say you give your folks the time to participate in the improvement activity. If you do, then you are probably shaking your head in agreement that this ingredient in the recipe makes the bread rise. This is where common sense ideas are incorporated into solutions. Senior management ensures that the teams work on opportunities that are strategic to the operation’s goals and objectives. The teams are cross-functional and consist of diverse blends of talents and operational responsibilities. For example, to reduce lead time to the customer, they used kaizen teams to drive down lengthy changeover times. They now can make more changeovers to accommodate the daily demand required by their vast number of customers. Many companies would tie up significant quantities of cash purchasing additional capacity or add-ons which take time to implement and leave them with higher costs to produce the same waste. They took a similar approach to drive out waste in their processing lines. The objective was to balance the flow at the demand of the customer. By getting all operations to perform to takt time, they are able to reduce overproduction and focus on the quality of the product. Improvements in quality translated directly back into meeting customer expectations and reducing time each operation had to spend re-making a good part.

These successes breed other successes. Team members want to participate and believe that their ideas can contribute. Slow down. Quit shooting in all directions. Target your efforts and focus on involving your associates. As the above team members will tell you, keeping it common sense simple, often means getting it right.

I’m a native Princetonian, born down the street from the historic university in New Jersey. Okay, so I only spent a few days there before I left the hospital and went home to the town I lived in down the road, but it sounds cool to say “native Princetonian”. I also love basketball. So I’ve always had a bit of a soft spot for Princeton University basketball. I grew up during the Pete Carril coaching era. Pete was the Tigers’ coach from 1967 through 1996. As you can see from his Hall of Fame link, during his reign, Princeton won over 500 games, won 13 Ivy League titles, and made 11 NCAA tournament appearances. This was accomplished in the face of very selective admissions standards, little television exposure, and a conference policy of no athletic scholarships. Carril and his fellow Ivy League coaches weren’t able to recruit very many blue chip players. He had a number of players with famous connections (e.g., the sons of coaching legend John Thompson and all-star player Bill Walton, and another solid player, Craig Robinson, who is President Obama’s brother-in-law), but they, like their teammates, were not household names while playing for Princeton. How did he do it? In addition to his natural coaching and teaching skills, a lot of credit is given to his offensive system, which has come to be known as the “Princeton Offense”. It’s characterized by total team involvement and patience (e.g., a lot of passing until a player is open for a very high-percentage shot near the basket).

What are some key points about Pete Carril and the Princeton Offense that relate to Lean thinking?

Strong Human Support System and Teamwork. Carril built his rosters with talented and unselfish players who put their trust in the system. Each had to understand their role and not veer from the “standardized work” in the playbook. Likewise, in a strong Lean business, it is essential to have a well-trained and motivated staff to execute all of the good tools and methodologies that have been introduced to them.

Simple is Best. In its purest form, the Princeton Offense features only a handful of plays, with well-defined roles. In a lean process, we seek to not overcomplicate things.

Teach Others to See. Carril once said, “The measure of any teacher, provided he’s not an egomaniac, is to see anybody that he taught do better than he did.” This is the mindset that a strong Lean leader or sensei must have. Many of Carril’s players went on to become successful coaches in their own right. For example, John Thompson III took his Georgetown team to the 2007 NCAA semifinals.

Work Hard for Results, Not Attention. Like Toyota, Princeton had a very successful operating system that “flew below the radar” for many years. Toyota’s system became well known after books such as The Machine that Changed the World and Lean Thinking came out. Carril’s system gained notoriety after the Tigers upset a much higher seeded UCLA team in the 1996 NCAA tournament.

Benchmark and Adopt Best Practices. Many coaches at the NBA (professional) and college level have consulted with Pete Carril over the years and adopted the offense to suit their teams. Many companies benchmark Toyota and other strong Lean companies in order to improve their own processes.

Can you think of other sports or team analogies that link well to Lean thinking?

Perspective is a very powerful thing. Over the past few years my primary interaction with the medical industry has been that of a continuous improvement expert. Recently I had the opportunity to experience things from a different perspective: not as a consultant but as the family member of a patient who required minor surgery. From the moment we arrived at the center we were greeted by courteous people, each who took the time to introduce themselves and to explain their function in ensuring that things went smoothly. With each new person came the introduction and explanation of purpose and with most of them several common questions. Among these were questions necessary to confirm identity as well as the presence of any medical allergies. This treatment was consistent from the moment we arrived until the moment we left after a successful procedure.

It wasn’t until we stopped to pick up the prescription for medication that a problem arose. It appears that even though several nurses had asked about medical allergies, the information did not get properly communicated or applied, the result being that the prescribed medication contained ingredients which would have brought about an allergic reaction. Fortunately the error was caught before the medication was taken but it very easily might not have been.

How does information so important and gathered so many times not make a process fail safe? The right questions were asked, but somehow the information didn’t make it to the place it needed to be. As we employ computerized and other complex systems to manage information we mustn’t lose sight of what is most important: that the right information is gathered, analyzed and applied at the right times. It isn’t bigger, more complex information systems and more protocols that are needed. Rather, we need to keep our focus on simple, concise, standard work systems on which we can rely time after time to produce consistent, effective results.