Patrick M. Anderson, Executive Director
Chugachmiut
1840 Bragaw St., Suite 110
Anchorage, Alaska 99508
(907) 334-0147
As a new chief executive for an Alaska Native non-profit organization in 2004, Chugachmiut, Inc., I heard the message about Lean from Brian Jones, President of Nypro Precision Plastics based in Clinton, MA. During lunch Brian explained Nypro’s “High Velocity System” to three of us. I asked Brian whether Nypro ever utilized Lean for their administrative processes, and while he said they did not, they were looking into it. He piqued my interest and I returned to Alaska to talk about Lean with my Executive Staff. They were willing to give it a try. I then sought out the first available conference that discussed Administrative Lean, and worked around my schedule to attend The 2004 Shingo Prize in Lexington, Kentucky. I could only attend 2 days of the conference if I traveled all night the first day and returned home in the early morning following the last day in order to fulfill obligations. My commitment to learning about Lean was intense.
At the Shingo Prize, I attended a number of presentations, but none by the host for this Blog, Dr. Tom Jackson. I was fortunate enough to stop Dr. Jackson on my way to another presentation and meet him. He ended up becoming Chugachmiut’s Sensei about a year later.
I must confess that I was already very knowledgeable about the principles taught by Dr. W. Edwards Deming, so I was predisposed to process management. The Lean training and simulations I experienced at Shingo convinced me to start a Lean initiative at Chugachmiut. 5 years later, we have achieved considerable success, and learned a lot about resistance to change.
It’s not my intention to talk about Chugachmiut’s Lean improvements here. Our website talks about a number of our lean initiatives. Instead I want to discuss resistance to Lean management in Alaska, and elsewhere, to this proven and true improvement method. What I have learned is that the Lean management message is very hard to sell. Persistence, results, and a network of true believers are necessary to make an impact.
Why am I even trying to sell the message? I explain I through one of the Lean Management principles of working with the supply chains that serve your customers. Our patients at Chugachmiut also receive health care services from two other Alaska Native health care organizations. I realized that both organizations could benefit our patients through adoption of Lean Healthcare and Lean Administration.
So in December of 2006, I sent a letter to the heads of the largest Alaska Native health care programs in the state of Alaska. By then one of the organizations had conducted a Kaizen for one of its smaller but critically important processes. They achieved about a 40 day reduction in the length of the process, an increase of quality from somewhere in the 5% range to somewhere in the 90% range, and a savings of 80% from the original cost of the process. What I found was that the middle management staff that engaged in the Kaizen were sold on the idea quickly. They have quietly advocated for slow spread of the culture. Through their efforts, and the many examples of successful hospital lean healthcare implementations such as occurred at Virginia Mason, Theda Care, Park Nicollet and others are pointing the way for other executives.
Shortly afterwards, I learned about the Lean Production advocacy coming from the Alaska Manufacturing Extension Partnership. Their staff includes a Lean Sensei. Together he and I wrote to the former Governor of Alaska recommending that she look at the use of Lean Production for managing the now defunct Matanuska Susitna Dairy and the Alaska Office of Children’s Services, two highly distressed organizations. We did not receive a response.
I also discovered the Alaska Performance Excellence Network, an organization dedicated to spread the gospel of process management and the Baldrige Quality Criteria.
Lean Healthcare is finally making some inroads in one of the two Alaska Native Healthcare organizations. One high level administrator has expressed considerable interest and a number of Kaizen events are scheduled this year. This brave executive needs support among his policy makers and the other executive leadership at his organization. This organization is on it’s way, and if Lean is implemented properly, the successes will soon pile up and hopefully encourage deeper involvement.
I also spoke to 2 heads of Alaska’s Department of Health and Social Services, 2 Anchorage Mayors, the Anchorage Chief of Police (he sent 2 of his staff to learn more and was starting an implementation when he was removed from his position), and countless other business leaders in Alaska. I don’t get discouraged. Again, our customers are served by each of these organizations, and I firmly believe they could benefit from the application of Lean Management.
By the way, if you have avoided learning about Lean and its benefits, take a second look. The quality of your organizations work will go up, the productivity of your work force will increase, and one of the nice benefits of a Lean implementation is that you will save money. You won’t even have to try if you implement well.
Sunday, October 25, 2009
Thursday, October 8, 2009
9 Points (conclusion)
J. Michael Rona
Principal, Rona Consulting Group
Mercer Island, Washington
This is the fourth and final post in a series about 9 Points that define the lean heatlh care enterprise:
1. A Compelling Vision
2. Enlightened and Fearless Leadership
3. Values Driven
4. Respect for the Customer and Customer Driven
5. Quality Driven
6. Obsessed with Safety
7. Respect for Staff
8. Continuous Improvement
9. Generate Higher Margins or Create Greater Capability
These nine points help characterize a lean health care organization. When implemented and fully engrained, the organization is transformed. Then it lives the principles of the Toyota Management System and produces perfect products, one at a time, in flow synchronized to the demand of the customer. This is what a lean health care organization looks like and how it behaves.
In this post I cover Point 7, 8, and 9.
7. Respect for Staff
A lean healthcare enterprise recognizes and behaves as if its staff were its most precious and irreplaceable resource. It respects its staff and demonstrates a profound commitment to enabling the best performance of its people. It sees as its second most important challenge to its leadership, the creation of a supportive environment in which it engages its people in creating excellence. Lean health care organizations enable perfectly competent and capable people to perform at extraordinary levels. Such organizations develop processes that allow their people to soar every day.
Lean health care organizations, in their actions, recognize and believe that releasing the creativity and brilliance of their workers is the key to breakthrough innovation and the success of the company.
8. Continuous Improvement
Lean health care organizations are constantly improving their processes and reducing their lead times (delivery times) through the vigorous elimination of waste. At every level, one can see the organizational learning cycle of PDCA (Plan, Do, Check, Act) at work. They are never satisfied with the current state and while they are not routinely looking for quantum changes in their processes, their steady, tortoise like constancy on waste reduction, they far outpace their competition in perfecting their processes
9. Generate Higher Margins or Create Greater Capability
Lean health care organizations generate margins that far exceed those of organization which do not use lean management approaches. This is because their source of value creation starts with a focus on customers, respect for staff and the elimination of waste to improve unit costs, reduce lead times, dramatically improve throughput and increase capacity with no added costs. These organizations do not rely on layoffs and other short-term strategies to generate margins, they rely on their people to find better ways and see their investment in their people as their most important strategic advantage. In organizations that are on fixed budgets, the elimination of waste enables greater capacity to serve customers using the same or less resources.
The effectiveness of these nine principles are clearly demonstrated in the results of the implementation of lean healthcare at the Virginia Mason Medical Center in Seattle, where we achieved productivity increases between 45 to 75%, cost reductions between 25 to 55%, improvements in throughput between 60 to 90%, quality improvements between 50 to 90%, inventory reductions between 35 to 50%, and lead time reductions between 50 to 90%.
The effectiveness of these same principles has been demonstrated more recently by our clients, who report similar achievements and confirm that the return on their investment in lean healthcare ranges from a low of 100% to over 1000%.
Principal, Rona Consulting Group
Mercer Island, Washington
This is the fourth and final post in a series about 9 Points that define the lean heatlh care enterprise:
1. A Compelling Vision
2. Enlightened and Fearless Leadership
3. Values Driven
4. Respect for the Customer and Customer Driven
5. Quality Driven
6. Obsessed with Safety
7. Respect for Staff
8. Continuous Improvement
9. Generate Higher Margins or Create Greater Capability
These nine points help characterize a lean health care organization. When implemented and fully engrained, the organization is transformed. Then it lives the principles of the Toyota Management System and produces perfect products, one at a time, in flow synchronized to the demand of the customer. This is what a lean health care organization looks like and how it behaves.
In this post I cover Point 7, 8, and 9.
7. Respect for Staff
A lean healthcare enterprise recognizes and behaves as if its staff were its most precious and irreplaceable resource. It respects its staff and demonstrates a profound commitment to enabling the best performance of its people. It sees as its second most important challenge to its leadership, the creation of a supportive environment in which it engages its people in creating excellence. Lean health care organizations enable perfectly competent and capable people to perform at extraordinary levels. Such organizations develop processes that allow their people to soar every day.
Lean health care organizations, in their actions, recognize and believe that releasing the creativity and brilliance of their workers is the key to breakthrough innovation and the success of the company.
8. Continuous Improvement
Lean health care organizations are constantly improving their processes and reducing their lead times (delivery times) through the vigorous elimination of waste. At every level, one can see the organizational learning cycle of PDCA (Plan, Do, Check, Act) at work. They are never satisfied with the current state and while they are not routinely looking for quantum changes in their processes, their steady, tortoise like constancy on waste reduction, they far outpace their competition in perfecting their processes
9. Generate Higher Margins or Create Greater Capability
Lean health care organizations generate margins that far exceed those of organization which do not use lean management approaches. This is because their source of value creation starts with a focus on customers, respect for staff and the elimination of waste to improve unit costs, reduce lead times, dramatically improve throughput and increase capacity with no added costs. These organizations do not rely on layoffs and other short-term strategies to generate margins, they rely on their people to find better ways and see their investment in their people as their most important strategic advantage. In organizations that are on fixed budgets, the elimination of waste enables greater capacity to serve customers using the same or less resources.
The effectiveness of these nine principles are clearly demonstrated in the results of the implementation of lean healthcare at the Virginia Mason Medical Center in Seattle, where we achieved productivity increases between 45 to 75%, cost reductions between 25 to 55%, improvements in throughput between 60 to 90%, quality improvements between 50 to 90%, inventory reductions between 35 to 50%, and lead time reductions between 50 to 90%.
The effectiveness of these same principles has been demonstrated more recently by our clients, who report similar achievements and confirm that the return on their investment in lean healthcare ranges from a low of 100% to over 1000%.
Monday, October 5, 2009
9 Points (continued)
J. Michael Rona
Principal, Rona Consulting Group
Mercer Island, Washington
This is the third in a series of posts about 9 Points that define the lean heatlh care enterprise:
1. A Compelling Vision
2. Enlightened and Fearless Leadership
3. Values Driven
4. Respect for the Customer and Customer Driven
5. Quality Driven
6. Obsessed with Safety
7. Respect for Staff
8. Continuous Improvement
9. Generate Higher Margins or Create Greater Capability
These nine points help characterize a lean health care organization. When implemented and fully engrained, the organization is transformed. Then it lives the principles of the Toyota Management System and produces perfect products, one at a time, in flow synchronized to the demand of the customer. This is what a lean health care organization looks like and how it behaves.
In the first two post in this series, I covered Points 1, 2, and 3. In this post, I cover Points 4, 5, and 6.
4. Respect for the Customer and Customer Driven
In all of its manifestations, such an organization would demonstrate the concept of “Customer First”. In every way, in the layout of facilities, the flow of healthcare processes, in communications, and in the behavior of providers and staff, one would see that there is a deep understanding of customer needs and wants. In every respect, the organization’s production processes would demonstrate a complete understanding of customer rate of demand by product family. In all of its written and verbal communications, the organization would demonstrate a deep respect for the customer. In every way, the presence of the customer would be felt within the organization and Toyota’s concept of “Customer In”, the idea that for the staff, the customer is always present, would be evident. We would call this for health care “Patient on shoulder”; the concept of the ever observant and present patient as customer.
5. Quality Driven
The lean health care enterprise is obsessed with quality. It has a deep understanding of the key quality characteristics, which its customers desire and of the products it delivers. It knows immediately when defects occur in the process and the process stops until the defect is fixed. It is uncompromising in its attack on defects as they occur. It has defect alert systems in place to allow the staff to know when defects occur and to stop the production process if defects cannot be resolved in the process. Quality is assured along the way, or what would be termed through “in-line inspection”, along the production process, so that essentially zero retrospective quality assurance is required. Each staff member is a front-line quality inspector and the role of management is to ensure that the staff can do perfect work.
6. Obsessed with Safety
Safety for the customer and the staff is paramount in a lean health care enterprise. As the organization understands the needs of the customer, it is constantly looking for ways to make the product safer. It not only looks at obvious areas for improving safety and what the customer tells it, but it looks ahead and simulates what could happen in the future and builds in safety for that possible eventuality before the potential safety issue even presents itself. This type of organization is obsessed with safety and cannot imagine that the customer would ever be the one to alert the organization about a defect that has occurred to them.
This kind of organization is similarly obsessed with safety for the staff. It addresses issues of physical safety and stress caused by the working environment to ensure the safety of its staff.
Principal, Rona Consulting Group
Mercer Island, Washington
This is the third in a series of posts about 9 Points that define the lean heatlh care enterprise:
1. A Compelling Vision
2. Enlightened and Fearless Leadership
3. Values Driven
4. Respect for the Customer and Customer Driven
5. Quality Driven
6. Obsessed with Safety
7. Respect for Staff
8. Continuous Improvement
9. Generate Higher Margins or Create Greater Capability
These nine points help characterize a lean health care organization. When implemented and fully engrained, the organization is transformed. Then it lives the principles of the Toyota Management System and produces perfect products, one at a time, in flow synchronized to the demand of the customer. This is what a lean health care organization looks like and how it behaves.
In the first two post in this series, I covered Points 1, 2, and 3. In this post, I cover Points 4, 5, and 6.
4. Respect for the Customer and Customer Driven
In all of its manifestations, such an organization would demonstrate the concept of “Customer First”. In every way, in the layout of facilities, the flow of healthcare processes, in communications, and in the behavior of providers and staff, one would see that there is a deep understanding of customer needs and wants. In every respect, the organization’s production processes would demonstrate a complete understanding of customer rate of demand by product family. In all of its written and verbal communications, the organization would demonstrate a deep respect for the customer. In every way, the presence of the customer would be felt within the organization and Toyota’s concept of “Customer In”, the idea that for the staff, the customer is always present, would be evident. We would call this for health care “Patient on shoulder”; the concept of the ever observant and present patient as customer.
5. Quality Driven
The lean health care enterprise is obsessed with quality. It has a deep understanding of the key quality characteristics, which its customers desire and of the products it delivers. It knows immediately when defects occur in the process and the process stops until the defect is fixed. It is uncompromising in its attack on defects as they occur. It has defect alert systems in place to allow the staff to know when defects occur and to stop the production process if defects cannot be resolved in the process. Quality is assured along the way, or what would be termed through “in-line inspection”, along the production process, so that essentially zero retrospective quality assurance is required. Each staff member is a front-line quality inspector and the role of management is to ensure that the staff can do perfect work.
6. Obsessed with Safety
Safety for the customer and the staff is paramount in a lean health care enterprise. As the organization understands the needs of the customer, it is constantly looking for ways to make the product safer. It not only looks at obvious areas for improving safety and what the customer tells it, but it looks ahead and simulates what could happen in the future and builds in safety for that possible eventuality before the potential safety issue even presents itself. This type of organization is obsessed with safety and cannot imagine that the customer would ever be the one to alert the organization about a defect that has occurred to them.
This kind of organization is similarly obsessed with safety for the staff. It addresses issues of physical safety and stress caused by the working environment to ensure the safety of its staff.
Wednesday, September 30, 2009
9 Points (continued)
J. Michael Rona
Principal, Rona Consulting Group
Mercer Island, Washington
This is the second in a series of posts about 9 Points that define the lean heatlh care enterprise:
1. A Compelling Vision
2. Enlightened and Fearless Leadership
3. Values Driven
4. Respect for the Customer and Customer Driven
5. Quality Driven
6. Obsessed with Safety
7. Respect for Staff
8. Continuous Improvement
9. Generate Higher Margins or Create Greater Capability
These nine points help characterize a lean health care organization. When implemented and fully engrained, the organization is transformed. Then it lives the principles of the Toyota Management System and produces perfect products, one at a time, in flow synchronized to the demand of the customer. This is what a lean health care organization looks like and how it behaves.
In the first post in this series, I covered Points 1 and 2. In this post, I cover Point 3 and discuss the value that drive the lean healthcare enterprise.
3. Values Driven
The lean health care enterprise is guided by its values. They are living foundational beliefs, which drive all behavior and become the yardsticks by which the day-to-day conduct of the organization is measured. The primary value is service to the customer. If service to the customer is flagging, then nothing else matters. It is this priority which is essential in understanding the failings of the current state and which drive priorities for improvement.
The second value is teamwork. Lean health care enterprises understand the different value which the broad range of workers in health care bring to the processes of health care but do not let this create a hierarchy of power. It is this hierarchy of power which inhibits freedom by all to work together in a fear free environment and which then diminishes the product for the customer. These organizations recognize the interdependency of all members of the organization and the importance of minimizing traditional power relationships.
The third value is continuous improvement. Lean health care enterprises are never satisfied with the current state. They believe that things can and must improve all the time. They believe in teaching and learning and becoming excellent at every position in the organization. They invest significant resources in training and giving time to their workers to improve processes. They insist on each worker participating in improvement and at least monthly improvement suggestions implemented by each worker for their own processes.
The final value of lean health care enterprises is integrity. These kinds of organizations conduct themselves with the highest level of integrity, which is modeled by the leadership. This principle starts with always doing things that are right from the customer’s perspective and is linked to a commitment to requiring the unvarnished truth about the current state to be publicly stated within the organization and with the organization’s customers. This truth telling is the key to enabling improvement. Without it, the real story is never surfaced, customers are harmed and the workers are burdened with truths that cannot be told. Organizations, which hold integrity as a foundational value, have no fear of public disclosure since they see such things as the truth about the current state and a driver of even more rapid improvement. Truly enlightened lean enterprises willingly “put their defects at the front door” for customers and workers to see to drive improvement and trust.
Principal, Rona Consulting Group
Mercer Island, Washington
This is the second in a series of posts about 9 Points that define the lean heatlh care enterprise:
1. A Compelling Vision
2. Enlightened and Fearless Leadership
3. Values Driven
4. Respect for the Customer and Customer Driven
5. Quality Driven
6. Obsessed with Safety
7. Respect for Staff
8. Continuous Improvement
9. Generate Higher Margins or Create Greater Capability
These nine points help characterize a lean health care organization. When implemented and fully engrained, the organization is transformed. Then it lives the principles of the Toyota Management System and produces perfect products, one at a time, in flow synchronized to the demand of the customer. This is what a lean health care organization looks like and how it behaves.
In the first post in this series, I covered Points 1 and 2. In this post, I cover Point 3 and discuss the value that drive the lean healthcare enterprise.
3. Values Driven
The lean health care enterprise is guided by its values. They are living foundational beliefs, which drive all behavior and become the yardsticks by which the day-to-day conduct of the organization is measured. The primary value is service to the customer. If service to the customer is flagging, then nothing else matters. It is this priority which is essential in understanding the failings of the current state and which drive priorities for improvement.
The second value is teamwork. Lean health care enterprises understand the different value which the broad range of workers in health care bring to the processes of health care but do not let this create a hierarchy of power. It is this hierarchy of power which inhibits freedom by all to work together in a fear free environment and which then diminishes the product for the customer. These organizations recognize the interdependency of all members of the organization and the importance of minimizing traditional power relationships.
The third value is continuous improvement. Lean health care enterprises are never satisfied with the current state. They believe that things can and must improve all the time. They believe in teaching and learning and becoming excellent at every position in the organization. They invest significant resources in training and giving time to their workers to improve processes. They insist on each worker participating in improvement and at least monthly improvement suggestions implemented by each worker for their own processes.
The final value of lean health care enterprises is integrity. These kinds of organizations conduct themselves with the highest level of integrity, which is modeled by the leadership. This principle starts with always doing things that are right from the customer’s perspective and is linked to a commitment to requiring the unvarnished truth about the current state to be publicly stated within the organization and with the organization’s customers. This truth telling is the key to enabling improvement. Without it, the real story is never surfaced, customers are harmed and the workers are burdened with truths that cannot be told. Organizations, which hold integrity as a foundational value, have no fear of public disclosure since they see such things as the truth about the current state and a driver of even more rapid improvement. Truly enlightened lean enterprises willingly “put their defects at the front door” for customers and workers to see to drive improvement and trust.
Monday, September 28, 2009
9 Points
J. Michael Rona
Principal, Rona Consulting Group
Mercer Island, Washington U.S.A.
The definition of a lean health care enterprise would be a health care system, which had in every manner patterned its management philosophy and system after the Toyota Management System. It would have the following characteristics upon close examination:
1. A Compelling Vision
2. Enlightened and Fearless Leadership
3. Values Driven
4. Respect for the Customer and Customer Driven
5. Quality Driven
6. Obsessed with Safety
7. Respect for Staff
8. Continuous Improvement
9. Generate Higher Margins or Create Greater Capability
These nine points help characterize a lean health care organization. When implemented and fully engrained, the organization is transformed. Then it lives the principles of the Toyota Management System and produces perfect products, one at a time, in flow synchronized to the demand of the customer. This is what a lean health care organization looks like and how it behaves.
Below I describe each of the 9 Points in detail:
1. A Compelling Vision
A clear and compelling vision is the critical starting point for any organization, but in particular for an organization that is pursuing a transformation. The question is transformation to what and why? The vision is a short and concise statement of what it is that the organization strives to be. By definition it declares a gap between the current state of the organization and its desired future state. The vision must be inspirational and a statement of aspiration. It must be a long view that would be welcomed by its customers and embraced by its people. It is a statement of quantum change and one that when achieved creates a major point of differentiation in the marketplace and pride for the organization’s workers.
2. Enlightened and Fearless Leadership
The lean healthcare enterprise is led by leaders who think very differently from the mainstream of health care leaders. They think first of the vision and have a clear sense of the future state. They understand that the key to transformation is a change in the management philosophy of the organization. They are unafraid of abandoning the current management paradigm and are comfortable with the uncertainty and ambiguity that exists in the transition from the current ways to the future way. They change themselves first and demonstrate the new way and are absolutely understanding but rigorously intolerant of individual managers defaulting to old ways. These leaders understand the changing of the mind of management that is occurring and help the transition by connecting the turmoil of change to the possibilities of the new way.
These leaders are passionate for the customers and constantly bring the voice and mind of the customer into the daily management of the organization. They are impatient with the traditional pace of management and relentlessly push for improvement. They are constant on the themes of change and what the new paradigm will bring. They have a deep knowledge and understanding of the new management process and philosophy. They have a constant view on the long term. They are unyielding in their belief in zero defects and the elimination of waste. They leave their offices and go to the “shop floor” to see with their own eyes the state of processes that are burdening their workers. And, they change things quickly.
I will describe Points 3 through 9 in posts to follow....
Principal, Rona Consulting Group
Mercer Island, Washington U.S.A.
The definition of a lean health care enterprise would be a health care system, which had in every manner patterned its management philosophy and system after the Toyota Management System. It would have the following characteristics upon close examination:
1. A Compelling Vision
2. Enlightened and Fearless Leadership
3. Values Driven
4. Respect for the Customer and Customer Driven
5. Quality Driven
6. Obsessed with Safety
7. Respect for Staff
8. Continuous Improvement
9. Generate Higher Margins or Create Greater Capability
These nine points help characterize a lean health care organization. When implemented and fully engrained, the organization is transformed. Then it lives the principles of the Toyota Management System and produces perfect products, one at a time, in flow synchronized to the demand of the customer. This is what a lean health care organization looks like and how it behaves.
Below I describe each of the 9 Points in detail:
1. A Compelling Vision
A clear and compelling vision is the critical starting point for any organization, but in particular for an organization that is pursuing a transformation. The question is transformation to what and why? The vision is a short and concise statement of what it is that the organization strives to be. By definition it declares a gap between the current state of the organization and its desired future state. The vision must be inspirational and a statement of aspiration. It must be a long view that would be welcomed by its customers and embraced by its people. It is a statement of quantum change and one that when achieved creates a major point of differentiation in the marketplace and pride for the organization’s workers.
2. Enlightened and Fearless Leadership
The lean healthcare enterprise is led by leaders who think very differently from the mainstream of health care leaders. They think first of the vision and have a clear sense of the future state. They understand that the key to transformation is a change in the management philosophy of the organization. They are unafraid of abandoning the current management paradigm and are comfortable with the uncertainty and ambiguity that exists in the transition from the current ways to the future way. They change themselves first and demonstrate the new way and are absolutely understanding but rigorously intolerant of individual managers defaulting to old ways. These leaders understand the changing of the mind of management that is occurring and help the transition by connecting the turmoil of change to the possibilities of the new way.
These leaders are passionate for the customers and constantly bring the voice and mind of the customer into the daily management of the organization. They are impatient with the traditional pace of management and relentlessly push for improvement. They are constant on the themes of change and what the new paradigm will bring. They have a deep knowledge and understanding of the new management process and philosophy. They have a constant view on the long term. They are unyielding in their belief in zero defects and the elimination of waste. They leave their offices and go to the “shop floor” to see with their own eyes the state of processes that are burdening their workers. And, they change things quickly.
I will describe Points 3 through 9 in posts to follow....
Wednesday, September 23, 2009
A Natural Match
By Deborah Dolezal
Senior Director, Kaizen Promotion Office
Park Nicollet Health Services
Minneapolis, Minnesota
As a healthcare worker and an implementer of lean, I am often struck by the similarity of the human body and the lean methodologies. They are both systems, each unique part doing a necessary function –
Circulatory, digestive, endocrine, immune, lymphatic, muscular, nervous, reproductive, respiratory, skeletal, urinary
Standard work, JIT, pull, one piece flow, mistake proofing, set up reduction, level loading, 5S.
Each function independently is unique in nature but cannot be successful without all parts working together. Each has a strong emphasis on flow and waste removal. When something is not operating properly, no one solution is right for everyone.
If chronic disease strikes, we instruct our patients to apply counter measures – usually involving a new form of standard work and are often surprised when these recommended changes are not immediately embraced, reminding us that change is hard and people need to be part of the solution, using their own creativity to fully define their best outcomes.
Current data from the Centers for Disease Control and Prevention:
• Percent of adults age 20 years and over with high serum cholesterol: 16% (2003-2006)
• Percent of noninstitutionalized adults 20 years and older with diabetes (diagnosed or undiagnosed): 10% (2003-2006)
• Number of noninstitutionalized adults with diagnosed heart disease: 25.1 million
• Percent of non-institutionalized adults ages 20 and over with hypertension: 32% (2003-2006)
• Percent of noninstitutionalized adults age 20 years and over who are overweight or obese: 67% (2005-2006)
The CDC also tells us that the medical care costs of people with chronic diseases account for more than 75% of the nation’s $2 trillion medical care costs. Experts who have recently testified to Congress say that 30 to 50% of these costs do not add value to patients.
Both the healthcare provider and the lean implementer have similar goals:
• Do no harm
• Add value
Healthcare and Lean - seems like a natural match.
Senior Director, Kaizen Promotion Office
Park Nicollet Health Services
Minneapolis, Minnesota
As a healthcare worker and an implementer of lean, I am often struck by the similarity of the human body and the lean methodologies. They are both systems, each unique part doing a necessary function –
Circulatory, digestive, endocrine, immune, lymphatic, muscular, nervous, reproductive, respiratory, skeletal, urinary
Standard work, JIT, pull, one piece flow, mistake proofing, set up reduction, level loading, 5S.
Each function independently is unique in nature but cannot be successful without all parts working together. Each has a strong emphasis on flow and waste removal. When something is not operating properly, no one solution is right for everyone.
If chronic disease strikes, we instruct our patients to apply counter measures – usually involving a new form of standard work and are often surprised when these recommended changes are not immediately embraced, reminding us that change is hard and people need to be part of the solution, using their own creativity to fully define their best outcomes.
Current data from the Centers for Disease Control and Prevention:
• Percent of adults age 20 years and over with high serum cholesterol: 16% (2003-2006)
• Percent of noninstitutionalized adults 20 years and older with diabetes (diagnosed or undiagnosed): 10% (2003-2006)
• Number of noninstitutionalized adults with diagnosed heart disease: 25.1 million
• Percent of non-institutionalized adults ages 20 and over with hypertension: 32% (2003-2006)
• Percent of noninstitutionalized adults age 20 years and over who are overweight or obese: 67% (2005-2006)
The CDC also tells us that the medical care costs of people with chronic diseases account for more than 75% of the nation’s $2 trillion medical care costs. Experts who have recently testified to Congress say that 30 to 50% of these costs do not add value to patients.
Both the healthcare provider and the lean implementer have similar goals:
• Do no harm
• Add value
Healthcare and Lean - seems like a natural match.
Sunday, September 20, 2009
Making Sense of Alphabet Soup
By:
Patti Crome, RN, MA, CNA, FACMPE
Principal, Rona Consulting Group
CQI/TQM, Six Sigma, TPS…how does one deal with the alphabet soup and decide which quality method being used in health care today is right for their organization? Some of us remember our introduction to what was known as Continuous Quality Improvement (CQI), others may be familiar with Total Quality Management (TQM). Together with our clinical colleagues we were relieved there was finally a shift from a cost only focus to quality, actually stemming from Deming’s PDCA (Plan-Do-Check-Act) cycle of improvement.
TQM has a very clear focus on quality consciousness. It emphasizes that every organization has a direct customer and needs to understand what the customer needs and how to achieve quality with zero defects. This philosophy is engrained in a quality initiative referred to as the Toyota Way. This method was developed in the 1960’s when automobile manufacturer, Toyota, set a goal to win the prestigious Deming Prize, which rewards companies’ major advances in quality improvement. Toyota won the prize twice. TQM is powerful and became one very central piece of the Toyota Way (Liker and Hoseus, 2008).
A little later Six Sigma came on the health care scene. Based on TQM, Six Sigma boasts bottom line results that can be measured in dollars and cents. At its best, this method teaches problem solving throughout the organization but at its worst, it reverts back to the cost-only philosophy of organizational improvement. Lean Six Sigma is a compilation of tools and training focused on isolated projects to drive down unit costs… it tends to be results oriented and top down (Liker and Hoseus, 2008).
Another quality initiative known as the Toyota Production System (TPS), commonly known as “Lean—the ‘Toyota Way,’” is based on two pillars: continuous improvement and respect for people. Respect for people includes not only having a relentless focus on what is important to the patient (eliminating wait time, waste or non-value added work and emphasizing the services they are willing to pay for), but also, respect for the employees, recognizing they have the understanding and knowledge of the work being performed. In this method, the front line employees work with the patients and know the opportunities for improvement and more importantly, they are given the authority to design necessary changes and implement them as standard work. This system becomes both a “bottom up” and “top down” improvement method. Toyota Way “Leaders,” as opposed to the “Black Belts” in Six Sigma, must establish the vision, support the improvements and hold people accountable for the standard work designed in the improvement processes.
Standard work and accountability are both key to creating a quality patient environment, yet many times in health care, one or both are lacking. As Taiichi Ohno, one of the founders of the Toyota Management System says, “Without standards there can be no improvement (Womack and Jones, 1996).”
Lean methods adopted from the Toyota Management System are very powerful in supporting the pursuit of perfection that is desperately needed to transform health care today. Using the scientific method and focusing on the customer—our patients—will result in significant gains in patient quality when the role of the employee is kept central to that improvement work. The transformation will not be easy, but our patients and our staff deserve no less.
Patti Crome, RN, MA, CNA, FACMPE
Principal, Rona Consulting Group
CQI/TQM, Six Sigma, TPS…how does one deal with the alphabet soup and decide which quality method being used in health care today is right for their organization? Some of us remember our introduction to what was known as Continuous Quality Improvement (CQI), others may be familiar with Total Quality Management (TQM). Together with our clinical colleagues we were relieved there was finally a shift from a cost only focus to quality, actually stemming from Deming’s PDCA (Plan-Do-Check-Act) cycle of improvement.
TQM has a very clear focus on quality consciousness. It emphasizes that every organization has a direct customer and needs to understand what the customer needs and how to achieve quality with zero defects. This philosophy is engrained in a quality initiative referred to as the Toyota Way. This method was developed in the 1960’s when automobile manufacturer, Toyota, set a goal to win the prestigious Deming Prize, which rewards companies’ major advances in quality improvement. Toyota won the prize twice. TQM is powerful and became one very central piece of the Toyota Way (Liker and Hoseus, 2008).
A little later Six Sigma came on the health care scene. Based on TQM, Six Sigma boasts bottom line results that can be measured in dollars and cents. At its best, this method teaches problem solving throughout the organization but at its worst, it reverts back to the cost-only philosophy of organizational improvement. Lean Six Sigma is a compilation of tools and training focused on isolated projects to drive down unit costs… it tends to be results oriented and top down (Liker and Hoseus, 2008).
Another quality initiative known as the Toyota Production System (TPS), commonly known as “Lean—the ‘Toyota Way,’” is based on two pillars: continuous improvement and respect for people. Respect for people includes not only having a relentless focus on what is important to the patient (eliminating wait time, waste or non-value added work and emphasizing the services they are willing to pay for), but also, respect for the employees, recognizing they have the understanding and knowledge of the work being performed. In this method, the front line employees work with the patients and know the opportunities for improvement and more importantly, they are given the authority to design necessary changes and implement them as standard work. This system becomes both a “bottom up” and “top down” improvement method. Toyota Way “Leaders,” as opposed to the “Black Belts” in Six Sigma, must establish the vision, support the improvements and hold people accountable for the standard work designed in the improvement processes.
Standard work and accountability are both key to creating a quality patient environment, yet many times in health care, one or both are lacking. As Taiichi Ohno, one of the founders of the Toyota Management System says, “Without standards there can be no improvement (Womack and Jones, 1996).”
Lean methods adopted from the Toyota Management System are very powerful in supporting the pursuit of perfection that is desperately needed to transform health care today. Using the scientific method and focusing on the customer—our patients—will result in significant gains in patient quality when the role of the employee is kept central to that improvement work. The transformation will not be easy, but our patients and our staff deserve no less.
Monday, September 14, 2009
Becoming a Lean Enterprise: New Insights from Along the Journey
I have worked with Lean in the hospital/health care environment for the past several years, and recently decided to take a step back and attempt to focus on the most critical factors which have determined success or failure in our various initiatives and strategies.
As part of my professional experience, I have both served as the COO of a major university teaching hospital, as well as the CEO of an organization that operated 139 hospitals across the U.S.
Because of this background, I have tended to focus on the more strategic aspects of Lean, and the role that it can play in the redesign of our delivery systems, and have reached several conclusions which may be of interest.
First, while many health care providers indicate that they have engaged in the use of Lean Thinking in one or several areas of operations, few have made the strategic commitment to become a Lean Enterprise.
While the first is relatively easy and painless, the second is substantially more complex, and requires a comprehensive assessment of the entire organization and it’s “current state”. That assessment includes its’ beliefs and values, it’s current management practices, and the structure of its’ key management jobs across the entire enterprise.
It also involves the important insight that the traditional hospital hierarchy was never designed to effectively manage productivity, cost or quality, and was certainly never designed to function as a Lean enterprise. Work and tasks in our hospitals tend to be organized around the health care professions (Nursing, Pharmacy, Clinical Laboratories, etc.) and do not lend themselves to effectively managing flow and value streams.
Even though, over the years, we have seen significant measurable improvements in the four critical areas around which our strategic plan is designed much is left to be done. (These four areas are Patient Safety, Customer Service, Clinical Quality, and Profitability.)
As a result of our Lean initiatives, we have seen substantial gains in these strategically important areas, including a 55% reduction in patient falls, a 41% reduction in urinary tract infections, a 7% reduction in labor costs on our inpatient units, and elimination of over 15,000 miles of nurse walking through flow redesign .
However, as we continue to assess our progress to date, it has become clear that to sustain these and many other gains, we must now focus our attention on policy deployment. . This step is critical in assuring that we have clear alignment from the “board to the bedside” in our strategic priorities.
Second, to that end, we are now redesigning the jobs of all key managers to assure that we have a new system of accountability which reflects our commitment to Lean. From top to bottom, we are formally realigning manager responsibilities around the “four pillars” of our Lean “house,” Patient Safety, Clinical Quality, Customer Service and Profitability
We are also creating new performance metrics and Key Performance Measures (“KPI’S”), which are closely linked with annual individual
performance evaluations and individual financial incentives.
Finally, we have realized that new skills are required of our managers, in order to successfully execute and sustain our gains. To that end, we have created a new entity called “Signature University” which provides certification training in critical areas of Lean and Leadership. All managers must become certified in eight critical skill areas to remain in their newly defined jobs, and financially progress within the organization.
All of these new insights are helping us more quickly transform our delivery systems, and move toward becoming a Lean enterprise.
David Spencer
Senior Vice President
Signature Hospital Corporation
As part of my professional experience, I have both served as the COO of a major university teaching hospital, as well as the CEO of an organization that operated 139 hospitals across the U.S.
Because of this background, I have tended to focus on the more strategic aspects of Lean, and the role that it can play in the redesign of our delivery systems, and have reached several conclusions which may be of interest.
First, while many health care providers indicate that they have engaged in the use of Lean Thinking in one or several areas of operations, few have made the strategic commitment to become a Lean Enterprise.
While the first is relatively easy and painless, the second is substantially more complex, and requires a comprehensive assessment of the entire organization and it’s “current state”. That assessment includes its’ beliefs and values, it’s current management practices, and the structure of its’ key management jobs across the entire enterprise.
It also involves the important insight that the traditional hospital hierarchy was never designed to effectively manage productivity, cost or quality, and was certainly never designed to function as a Lean enterprise. Work and tasks in our hospitals tend to be organized around the health care professions (Nursing, Pharmacy, Clinical Laboratories, etc.) and do not lend themselves to effectively managing flow and value streams.
Even though, over the years, we have seen significant measurable improvements in the four critical areas around which our strategic plan is designed much is left to be done. (These four areas are Patient Safety, Customer Service, Clinical Quality, and Profitability.)
As a result of our Lean initiatives, we have seen substantial gains in these strategically important areas, including a 55% reduction in patient falls, a 41% reduction in urinary tract infections, a 7% reduction in labor costs on our inpatient units, and elimination of over 15,000 miles of nurse walking through flow redesign .
However, as we continue to assess our progress to date, it has become clear that to sustain these and many other gains, we must now focus our attention on policy deployment. . This step is critical in assuring that we have clear alignment from the “board to the bedside” in our strategic priorities.
Second, to that end, we are now redesigning the jobs of all key managers to assure that we have a new system of accountability which reflects our commitment to Lean. From top to bottom, we are formally realigning manager responsibilities around the “four pillars” of our Lean “house,” Patient Safety, Clinical Quality, Customer Service and Profitability
We are also creating new performance metrics and Key Performance Measures (“KPI’S”), which are closely linked with annual individual
performance evaluations and individual financial incentives.
Finally, we have realized that new skills are required of our managers, in order to successfully execute and sustain our gains. To that end, we have created a new entity called “Signature University” which provides certification training in critical areas of Lean and Leadership. All managers must become certified in eight critical skill areas to remain in their newly defined jobs, and financially progress within the organization.
All of these new insights are helping us more quickly transform our delivery systems, and move toward becoming a Lean enterprise.
David Spencer
Senior Vice President
Signature Hospital Corporation
Sunday, August 30, 2009
Five myths about health care around the world
Okay, it's been an entire week since reporter T. R. Reid, published an interesting article, "Five myths about health care around the world," in the Washington Post (Sunday, August 23, 2009). If offer this link, because our readers may find it useful in debunking the next wild statement they hear about healthcare in foreign countries.
Myth #1. It's all socialized medicine out there. Nope. Only a few Anglo countries, and Cuba. And what about Medicare and the Veterans Administration?
Myth #2. Overseas, care is rationed through limited choices or long lines. Nope. In Japan people don't even bother with appointments.
Myth #3. Foreign health care systems are inefficient, bloated bureaucracies. Not unless you put our system at the top of the list.
Myth #4. Cost controls stifle innovation. And so that would explain French hip and knee replacements? Canadian deep brain stimulation for depression? Wonder drugs from labs in Britain, Switzerland, and Japan?
Myth #5. Health insurance has to be cruel. It's a business! Hm. The last time I looked into this, when I was in law school, the social purpose of insurance was to spread risk, not make money for insurers.
Reid concludes his article with a thought that echoes my own, "Given our remarkable medical assets--the best-educated doctors and nurses, the most advanced hosptials, world-class research--the United States could be, and should be, the best in the world. To get there, though, we have to be willing to learn some lessons about health-care administration from the other industrialized democracies."
Tom Jackson
Principal, Rona Consulting Group
Clinical Associate Professor, University of Washington School of Public Health
Myth #1. It's all socialized medicine out there. Nope. Only a few Anglo countries, and Cuba. And what about Medicare and the Veterans Administration?
Myth #2. Overseas, care is rationed through limited choices or long lines. Nope. In Japan people don't even bother with appointments.
Myth #3. Foreign health care systems are inefficient, bloated bureaucracies. Not unless you put our system at the top of the list.
Myth #4. Cost controls stifle innovation. And so that would explain French hip and knee replacements? Canadian deep brain stimulation for depression? Wonder drugs from labs in Britain, Switzerland, and Japan?
Myth #5. Health insurance has to be cruel. It's a business! Hm. The last time I looked into this, when I was in law school, the social purpose of insurance was to spread risk, not make money for insurers.
Reid concludes his article with a thought that echoes my own, "Given our remarkable medical assets--the best-educated doctors and nurses, the most advanced hosptials, world-class research--the United States could be, and should be, the best in the world. To get there, though, we have to be willing to learn some lessons about health-care administration from the other industrialized democracies."
Tom Jackson
Principal, Rona Consulting Group
Clinical Associate Professor, University of Washington School of Public Health
Friday, August 28, 2009
Dear Doctor
This past week, I was privileged to facilitate a 5-day kaizen event at the San Mateo Medical Center in San Mateo, California. This was the last of 4 such events focused on reducing expensive (and risky) admissions of CHF (congestive heart failure) patients to the hospital. The events have been funded by the California Healthcare Foundation and the California Safety Net Institute. In our final event, we made a concerted effort to reach out to two of SMMC's clinics, where it is often difficult for CHF patients to get follow up appointments after being discharged from either the ER or the hospital. One of the clinic's doctors graciously agreed to participate in our event for an entire day, but asked for a briefing on lean healthcare before attending. She had not been able to attend the short introduction to lean healthcare that we deliver on Day 1 of each kaizen event. Here is the email that I sent.
Dear Doctor __________,
I would be happy to answer any questions you might have about the "lean healthcare" concept when we meet tomorrow morning. In the meantime, here is a very short introduction to lean healthcare from the perspective of the history of management thinking.
Of course, the lean concept originated at the Toyota Motor Company and it is sometimes referred to as the Toyota Production System. This is an unfortunate name that conveys a misconception. Ultimately, Toyota's method has nothing to do with automobiles or with manufacturing. Toyota's methods all aim at one thing: finding errors and defects in any type of step-by-step process and fixing them in as close to real time as possible. For example, the clinical path for CHF patients is full of defects that we have identified and have been trying to fix over the past four months.
When Toyota thinks about defects, however, it thinks a little more broadly than we normally do. Normally, we think of a defect as a material outcome (i.e. what happened?) that does not meet some predetermined specification. Toyota uses this definition, of course; but it also recognizes another kind of defect, in which a temporal outcome (i.e., when did it happen?) does not meet a specification. In other words, to be "perfect" in a "lean" system in manufacturing or healthcare, the right things must happen and happen on schedule.
Toyota sums this dual requirement up in one word: value. A good example of value is ordering dinner for 8 in a nice restaurant. The food might all be materially perfect. But if it is not served to everyone at the same time, there is a temporal defect, and consequently poor value. We have all had similar experiences with our respective families. Mom's salad comes after her entre. Sister Susie's entre comes after everyone has finished theirs. And of course we often have to wait long after we are all ready to leave for the check.... Most industries, including healthcare, are like this restaurant.
Historically speaking, the lean concept integrates two streams of management thinking, one that originated in Bell Labs in the 1920s and 30s that became known as Total Quality Management and another that originated in Ford Motor Company in around 1914 that applied the concept of process flow and time studies to manual operations. Ford's idea was to make cars the way that Andrew Carnegie made steel (in a continuous process) by eliminating all types of waste from operations. Ford used time to measure flow.
It was Toyota that put quality and flow together in the timeframe 1948 to 1963, creating what we know today as the Toyota Production System or "lean manufacturing."
After the publication in 1999 of To Err is Human, the healthcare industry has been forced to pay considerable attention to the methods of quality (and safety) developed at Bell Labs. Meanwhile, as healthcare costs continue to spiral out of control (and access is further restricted to marginal populations), more attention is being paid to the methods of flow developed at Ford and perfected at Toyota.
Another way to put this is that, under pressure to improve its dreadful quality and it horrific cost (compared to other nations, especially), U.S. healthcare is moving from being a craft-based industry to being a modern knowledge-based or, in the unique phraseology of healthcare, evidence-based industry. Incidentally, all of Toyota's methods are based upon the rigorous application of scientific thinking.
The counterintuitive truth of the matter is that by focusing on quality and safety (First, do no harm), healthcare can decrease cost as well (Time is money). In other words, the two streams of management thinking mentioned above can be integrated. They are not in conflict, as many people still believe. Moreover, it has been shown in several implementations (Virginia Mason Medical Center in Seattle and Park Nicollet in Minneapolis are two major examples) that Toyota's management methods apply in a surprisingly straightforward manner to healthcare processes.
The result, after a lot of hard work, is reliable healthcare processes that are devoid of workarounds. Not only does this greatly improve quality it also reduces the amount of time and energy involved, and significantly reduces both the cost of delivering care and the risk of harming patients instead of making them better.
How good can it get with lean healthcare? Well, in many instances cost can be cut in half and quality rates begin to approach 100% (i.e., zero defects). Of course, this does not happen overnight. Also, zero defects, we mean zero defects in the clinical process. The clinical outcomes frequently depend upon the participation of the patient, over which we have some influence but no absolute control.
Can lean healthcare be applied in a clinic? Absolutely. My partner, Patti Crome, as Senior Vice President of Virginia Mason did it in multiple clinics sprinkled throughout the Seattle area.
I look forward to meeting you tomorrow. Thanks for making time for us.
Best regards,
Tom
Thomas Jackson, JD, MBA, PhD
Principal, Rona Consulting Group
Clinical Associate Professor, University of Washington School of Public Health
[m] 503.880.8622
transforming healthcare; pursuing perfection
Tuesday, August 25, 2009
Lucky, or good?
David K. Wessner
President, CEO
Park Nicollet Health Services
Last week at our weekly operations stand up review it was noted that we had gone for 8 days without a patient fall. The concern was that we would "jinx" the result if by talking about it. While the comment was playful and light-hearted, it exposed a deep belief that much of what we do and accomplish is a result of blind luck and that we best not anger the gods of luck if we expect to improve.
As absurd as that interpretation may sound, it describes a cultural norm in health care that is reluctant to design for a perfect outcome for fear that the uncounted uncontrolled variables would frustrate the best efforts of an earnest team.
We've all had those frustrations. The patient that tries to help out his nurse by getting to the bathroom on his own this time, or, a patient who is not identified as a falls risk because they are in the hospital to mend from a fracture from a previous fall and are not considered ambulatory. It's always something.
Lean learning would lead us in a different direction. As each of our teams experience a fall and then asks why 5 times we learn what root causes we can eliminate as a future risk to patient safety. As our leaders encourage those teams to accept no risk as acceptable and design counter-measures that reduce just one risk at a time we begin to drain the swamp.
Examples of counter-measures implemented to prevent falls (provided by Autumn Anderson, RN MS, Director):
David K. Wessner
President, CEO
Park Nicollet Health Services
6500 Excelsior Blvd.
St. Louis Park, MN 55426
952-993-5013
david.wessner@parknicollet.com
President, CEO
Park Nicollet Health Services
Last week at our weekly operations stand up review it was noted that we had gone for 8 days without a patient fall. The concern was that we would "jinx" the result if by talking about it. While the comment was playful and light-hearted, it exposed a deep belief that much of what we do and accomplish is a result of blind luck and that we best not anger the gods of luck if we expect to improve.
As absurd as that interpretation may sound, it describes a cultural norm in health care that is reluctant to design for a perfect outcome for fear that the uncounted uncontrolled variables would frustrate the best efforts of an earnest team.
We've all had those frustrations. The patient that tries to help out his nurse by getting to the bathroom on his own this time, or, a patient who is not identified as a falls risk because they are in the hospital to mend from a fracture from a previous fall and are not considered ambulatory. It's always something.
Lean learning would lead us in a different direction. As each of our teams experience a fall and then asks why 5 times we learn what root causes we can eliminate as a future risk to patient safety. As our leaders encourage those teams to accept no risk as acceptable and design counter-measures that reduce just one risk at a time we begin to drain the swamp.
Examples of counter-measures implemented to prevent falls (provided by Autumn Anderson, RN MS, Director):
- Hourly Rounding: this includes purposeful visits to the patient’s room every hour by the RN or NA and ensuring they are not in pain, do not have to go to the bathroom, are positioned comfortably in bed, and have everything they need within reach. These are the most common reasons hospitalized patients get out of bed without assistance.
- Low Beds: The RNs on all units can place an order for a low bed. This is a rental bed that is delivered by an outside company, however we have a small kanban in CSR with two beds that are immediately available for use. The bed also come with a “gym mat” that goes on the floor in case a patient rolls out of bed. The beds all have alarms built in them that sound when a patient attempts to get out of bed without assistance. These beds are low to the ground for good reason- a person must use their thigh muscles to get out of bed, and the lower you are the more muscle you have to use to get from the sitting to standing position. Falls risk patients typically do not have this leg strength.
- Post-Fall Huddles: These huddles have evolved over the last year, and they now included the 5-Whys process. Huddles occur on the floor after a fall occurs and before the next shift starts. The flying squad RNs facilitate this huddle, and they assist staff and leadership with understanding defects.
- There are currently andons on the door before you enter a patient room. Yellow “falling star” signs indicate a patient is at moderate risk for falling, and red “falling star” signs indicate high falls risk.
- Patients will have a yellow falls sticker on their armband starting 8/24/09, which indicates they are at risk for falling. RNs view armbands when they are giving medications.
- Patients at risk for falling also have the yellow falls sticker on the Kardex, which RNs review and update at the beginning and throughout their shift.
- The Falls Leadership Team communicates is involved with the SAFE from Falls initiative from the MN Hospital Association, and we also communicate with other organizations throughout the United States. This provides us with evidence based practice and educates us on new initiatives that may not be published at this time.
- The Falls Workgroup meets monthly. This workgroup consists of RN representatives from each unit. They have standard work which includes the monthly meeting, auditing patients on their unit for appropriate falls assessment and interventions, collaborating with unit leadership, and providing positive peer feedback or recommendations for improvement.
- There is Visual Daily Management on in the Visual Control Room where Nursing Leadership has daily huddles at 11:30am. This tool keeps track of the date the last fall occurred, the unit it occurred on, the number of days since the last fall, and the record number of days. There is also a Visual Daily Management tool on each unit that keeps track of individual unit information.
- Red slippers (instead of regular grey hospital slippers) are going to be trialed for three months on two units starting 9/1/09. Other facilities in the United States have used this andon for high falls risk patients, however there is a lack of evidence regarding its success.
- Posey sitters for beds and chairs are pads that patients sit on. When a patient attempts to get up on their own, and the weight is taken off of the pad, the alarm sounds.
- Defective shower chairs have been removed from the hospital. It was found that these shower chairs caused three patient falls. We have a new vendor for shower chairs.
- The Falls Leadership Team has a Kaizen Event planned in September that will help us better understand the relationships between falls risk assessment, assistance level, mobility level, and the activity level the clinician orders.
David K. Wessner
President, CEO
Park Nicollet Health Services
6500 Excelsior Blvd.
St. Louis Park, MN 55426
952-993-5013
david.wessner@parknicollet.com
Tuesday, August 11, 2009
The paradox of lean healthcare
Welcome to Lean Healthcare Grand Rounds, a blog devoted to the people and the organizations that are transforming healthcare through the application of the principles of the Toyota Management System.
Since the publication in 1999 of Institute of Medicine's report To Err is Human, the need not merely to reform but to transform healthcare in the United States is painfully clear. So, how much better does healthcare need to be? Mike Rona, former President of Seattle's Virginia Mason Medical Center, makes the case that the goal should be zero defects. See J. Michael Rona, "97.1 Percent Perfect," Journal of Healthcare Management 50:2 March/April 2005. Possible? Using the Toyota Production System, Virginia Mason reduced Ventilator Associated Pneumonia (VAP) by 92%. See J. Michael Rona, "The American Health Care System: A Wasteland of Opportunity," Future State, Summer 2007.
What about cost? The Institute for Healthcare Improvement's President, Donald Berwick, estimates that the waste in healthcare is at least 30% of healthcare production costs. If we could eliminate this, it would be worth $780 billion per year (.30 x $2.6 trillion = $780 billion), or--in the cost savings for one year alone--enough month to pay for a plan that the White House Office of Management and Budget estimates will call $1 trillion over the entire decade! Possible? Virginia Mason reports an average cost reduction of 50% as the result applying the Toyota Production System. See Rona, "The American Health Care System: A Wasteland of Opportunity."
As Steven Spear maintains, Toyota's methods offer us a way to transform healthcare from inside, today. See Spear, "Fixing Healthcare from the Inside, Today," Harvard Business Review (September 2005). In other words, the healthcare industry should transform itself. Alas, our present approach as an industry and as a nation is, of course, to transform healthcare from outside, eventually, if ever. Apparently we view healthcare reform as a Hobson's choice between providing access to our 40 million uninsured on the one hand and reducing cost on the other. And quality? It hasn't come up yet during the course of our public debate, has it? In the August 3rd edition of Newsweek, Samuelson says, "The [Obama] administration had to make choices: it could emphasize expanded insurance coverage ("access") or cost control, but not both." As a result, if the present legislation is passed, Samuelson expects healthcare costs to rise substantially. Read the complete Newsweek article: "Health 'Reform' That Isn't.' Also see Newsweek reporter Jeneen Interlandi's blog post, "Cleveland Clinic CEO Speaks on Healthcare Reform: 'We May End Up Making the Problem Substantially Worse." As Dr. Cosgrove says, "If it’s just access, we will be back in a few years dealing with cost, and it will be even worse."
Access, cost, or for that matter, quality do not necessarily present us with a Hobson's choice, because, costs will fall as we reduce healthcare's long lead times, and quality, well, quality is free. This is why most six sigma programs (originally characterized in terms of quality) have morphed into "lean" six sigma programs. For what appears to be the paradox of lean healthcare is actually a simple formula. If we stop to fix healthcare's problems, from the inside, today, it won't be long before we will find ourselves spending less time dealing with the consequences of poor quality. And as we waste less time mopping up after ourselves, the cost of healthcare will come down. Thus what appears to be a Hobson's choice is in reality a false dilemma. With Toyota's philosophy and methodology, we can have it all: all-inclusive access, zero defects, and affordable cost.
This blog will be organized into four major topics of conversation:
Best regards,
Tom Jackson, Moderator
Thomas L. Jackson, JD, MBA, PhD
Principal, Rona Consulting Group
Clinical Associate Professor, University of Washington School of Public Health
August 15, 2009
Since the publication in 1999 of Institute of Medicine's report To Err is Human, the need not merely to reform but to transform healthcare in the United States is painfully clear. So, how much better does healthcare need to be? Mike Rona, former President of Seattle's Virginia Mason Medical Center, makes the case that the goal should be zero defects. See J. Michael Rona, "97.1 Percent Perfect," Journal of Healthcare Management 50:2 March/April 2005. Possible? Using the Toyota Production System, Virginia Mason reduced Ventilator Associated Pneumonia (VAP) by 92%. See J. Michael Rona, "The American Health Care System: A Wasteland of Opportunity," Future State, Summer 2007.
What about cost? The Institute for Healthcare Improvement's President, Donald Berwick, estimates that the waste in healthcare is at least 30% of healthcare production costs. If we could eliminate this, it would be worth $780 billion per year (.30 x $2.6 trillion = $780 billion), or--in the cost savings for one year alone--enough month to pay for a plan that the White House Office of Management and Budget estimates will call $1 trillion over the entire decade! Possible? Virginia Mason reports an average cost reduction of 50% as the result applying the Toyota Production System. See Rona, "The American Health Care System: A Wasteland of Opportunity."
As Steven Spear maintains, Toyota's methods offer us a way to transform healthcare from inside, today. See Spear, "Fixing Healthcare from the Inside, Today," Harvard Business Review (September 2005). In other words, the healthcare industry should transform itself. Alas, our present approach as an industry and as a nation is, of course, to transform healthcare from outside, eventually, if ever. Apparently we view healthcare reform as a Hobson's choice between providing access to our 40 million uninsured on the one hand and reducing cost on the other. And quality? It hasn't come up yet during the course of our public debate, has it? In the August 3rd edition of Newsweek, Samuelson says, "The [Obama] administration had to make choices: it could emphasize expanded insurance coverage ("access") or cost control, but not both." As a result, if the present legislation is passed, Samuelson expects healthcare costs to rise substantially. Read the complete Newsweek article: "Health 'Reform' That Isn't.' Also see Newsweek reporter Jeneen Interlandi's blog post, "Cleveland Clinic CEO Speaks on Healthcare Reform: 'We May End Up Making the Problem Substantially Worse." As Dr. Cosgrove says, "If it’s just access, we will be back in a few years dealing with cost, and it will be even worse."
Access, cost, or for that matter, quality do not necessarily present us with a Hobson's choice, because, costs will fall as we reduce healthcare's long lead times, and quality, well, quality is free. This is why most six sigma programs (originally characterized in terms of quality) have morphed into "lean" six sigma programs. For what appears to be the paradox of lean healthcare is actually a simple formula. If we stop to fix healthcare's problems, from the inside, today, it won't be long before we will find ourselves spending less time dealing with the consequences of poor quality. And as we waste less time mopping up after ourselves, the cost of healthcare will come down. Thus what appears to be a Hobson's choice is in reality a false dilemma. With Toyota's philosophy and methodology, we can have it all: all-inclusive access, zero defects, and affordable cost.
This blog will be organized into four major topics of conversation:
- The long term philosophy of the healthcare profession--in other words, how should we interpret "Do no harm?" in a way that makes healthcare more affordable to those that need it;
- The process of delivering healthcare services effectively, safely, efficiently;
- The development of healthcare professionals, managers, and support staff; and
- How to turn helathcare organizations into learning organizations.
Best regards,
Tom Jackson, Moderator
Thomas L. Jackson, JD, MBA, PhD
Principal, Rona Consulting Group
Clinical Associate Professor, University of Washington School of Public Health
August 15, 2009
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