Economy I and II - Never the Twain Shall Meet?

By Pascal Dennis (bio)

In a previous blog I introduced the idea of Economy I & II

The former comprises private sector companies like Apple, Amazon, Toyota and GE.

These companies face withering competition every day.

As a result, they're wonderful at creating value, but not so good at creating jobs.

Economy II, by contrast, comprises government and quasi-government organizations like schools, universities and hospitals.

These organizations face comparatively little competition (or in the case of government agencies, none at all.)

As a result, they're wasteful and inefficient -- but good at creating 'jobs', of a sort.

But Economy II is bankrupting America (and Europe, for that matter). Economy I can no longer create enough off-setting value and wealth.

What to do?

Conservatives argue that Economy II can only be mended by applying the disciplines of Economy I.

Essentially, this means enabling and applying Lean thinking:

• Understanding your customers, and thereby, value & waste,
• Visual management and 5 S,
• Standardized work,
• Jidoka (building quality into the process,
• Heijunka (level loading), and
• Point, flow and system kaizen

Enablers to this approach include education and health care vouchers that put choice into the hands of the customer.

Liberals ("progressives") argue that the philosophies & techniques of Economy II are not necessary and wouldn't be effective in any event.

A better approach, they argue, is to elect capable, charismatic political leaders, who can reform Economy II by force of personality.

They cite Rahm Emanuel, former mayor of Chicago, as such a leader.

What do I think?

Being an engineer and a businessperson, I'm naturally inclined to the practices I learned at Toyota.

Over the many years, our Lean Pathways team has applied them with great success in a variety of industries.

Toyota thinking is rocket fuel. Stick to the recipe and wonderful things happen.

This is the evidence of my eyes and whole being.

The liberal/progressive argument seems, forgive me, to entail 'magical thinking'.

Even if it were based in fact, how many Rahm Emanuel's are there?

The broken processes mean a rapid regression to the bankrupt mean.

Sorry,

Pascal




In case you missed our last few blogs... please feel free to have another look…

Strategy is Not About Doing What’s “Important”
Agriculture - The Next Frontier?
Lean Thinking in Software Design
Problem Solving and the Worlds of Reflection & Experience

Your Pain is Your Genius

By Pascal Dennis (bio)

The Obstacle is the Way - Epictetus

I quote one of my heroes, the Stoic philosopher Epictetus. Ryan Holiday also turned the phrase into a fine book [ LINK ]

What’s it mean in the context of management and leadership?

In Strategy one of our most important tasks is identifying ‘where the shoe pinches’. Imagine we’re a hospital and our biggest problem is Patient Harm. Do we have the courage and humility to talk it openly?

“Folks, we have a big problem…” Can we analyse our mis-medications, infections, and medical errors openly? Can we look at historical trends, compare ourselves to other hospitals and other industries, and produce Pareto charts by type of harm, care line, procedure, time, location and the like?

Or imagine we’re a provider of on-line streaming and our biggest problem is Downtime. Can we talk it openly? Can we analyze incidents, quality rate, overall equipment effectiveness, Mean-Time-To-Repair, Mean-Time-Between-Failure and the like?

Can we also look at historical trends and compare our performance to that of industry leaders like Netflix? Can we break our incidents down and produce Pareto charts by type of outage, service, channel, type of equipment, location and the like?

The obstacle is the way – for the hospital and for the on-line streaming provider. Finding where the shoe pinches, and fixing it, is the path to excellence. To be sure, Design is also central. We have to connect with our patients or customers and understand their needs and journeys.

But there too, the obstacle is the way. Understanding the patient or customer journey entails understanding the ‘pain points’, and designing them out. (And if you get really good, designing in delightful moments, but that’s a topic for another blog.)

As an aside, football fans will recognize this principle in the great teams & coaches. The great Alabama Crimson Tide coach, Nick Saban, invariably talks about it in interviews. (Same is true for New England Patriot’s coach Bill Belichick, though some believe he is nefarious =)

All this takes courage & humility, of course, qualities that have always been rare. (Otherwise, would we talk about them so much?)

Much of my personal practice entails coaches senior executives and Boards. Job One is often dispelling the ‘Everything is Just Great’ syndrome.

But that too, is a topic for another blog.

Be strong, be honest and remember that your pain is your genius.

Best regards,

Pascal

One for the Docs

By Pascal Dennis

Doctors are taking a lot of heat these days. Medical mishaps are front page news. A demanding & vocal public no longer accepts substandard patient safety & quality results.

The profession and industry are being held to the same demanding standards as industries like automotive, aerospace and consumer goods. Moreover, physicians are frequently portrayed as the bad guys, the ones holding the organization back.

Much of my personal practice entails coaching senior healthcare leaders, many of them physicians.

The profession is in the midst of great change. Used to be, most docs worked for themselves. Now most docs work for large organizations, and the trend will only accelerate.

Are physicians used to working in teams in complex value streams in large organizations? Do they learn the principles of production physics and system dynamics that govern such value streams?

Does medical school include instruction in the Toyota Production System or in management systems at all, the countermeasures to the daunting Safety, Quality, Delivery and Cost problems hospitals face?

The healing arts entail a demanding apprenticeship. My late father-in-law, the great Dr Robert Guselle, ran Ontario’s biggest clinic. Bob was an intuitive Lean thinker, and early on grasped the promise Toyota methods entailed for healthcare.

But he was a realist too. “I spent ten years in the hermetically sealed tube called medical school. I learned to be imperious and infallible. Changing that mindset is difficult…”

And yet, that’s what we’re beginning to see in a growing number of major hospitals – physician-leaders changing and deepening their mental models and management style, and opening up to learning and proven methods from very different industries.

So here’s a deep bow to the physician-leaders who are spear-heading heart-felt transformation in major hospitals around the world.

You all don`t have to do this. It`s heavy lifting, it’s humbling and sometimes hurts. (You could go to the golf course, cottage, fishing hole…)

I`m lucky enough to work with some of you.

In my mind you walk through porticoes of honor.

Best regards,

Pascal

Pascal Dennis Bio

Pulling the Health Care Andon, part 2

Pulling the Health Care Andon, part 2

I few months back I pulled the andon (Japanese for ‘Help Chain’) on a major Toronto hospital where my mom had suffered a number of indignities.

Thought I’d let you know what happened.

Quick overview: Mama went in for lower back surgery to treat a very painful spinal stenosis. The operation was a success and her orthopedic surgeon and OR staff, superb.

Convalescent care was another story. Here’s a key point summary:

1. No target discharge date or discharge plan


2. No standard discharge process. Everybody we spoke to had a different opinion.


3. Poor communication. Key staff members repeatedly failed to return phone calls or provide clear information on Mama’s condition, treatment and support plan


4. Poor hand-off with community chronic care system


5. A rogue ‘case manager’ who tried to hustle an 82 year-old patient, who was in great pain from an 8 inch incision in her back, out of the hospital after 2 days – and declined to attend agreed upon patient conferences or respond to calls.

The events could easily have taken place in an American, British, or Australian hospital.

The Rest of the Story
I sent letters to the hospital CEO and the Minister of Health. No response from the latter – and no surprise. Ontario’s vast Ministry of Health has 32 Deputy Ministers. Guess how many are focused on patient experience?

To be fair, Ontario has belatedly acknowledged the problem and appointed a ‘patient ombudsman’

We did receive a letter from the hospital’s ‘Director of Patient Experience’. Sorry to say, it’s full of howlers

1. Everything is just great at our hospital – we have no problems at all


2. Your mom was walking around and was ready to leave on the second day – (??)


3. Any problems are all your family’s fault

Denial, deflection and disrespect for patients.

“No problem is a big problem,” my Toyota senseis used to say.

How can they possibly improve their processes and outcomes? How can patient experience be anything by a crapshoot?

I’ll forward all this to Ontario’s new ‘patient ombudsman’, and send another note to the hospital CEO. I’m not expecting anything, but you have to give feedback.

Let me salute again the growing number of hospitals around the world that are in the midst of heartfelt process and cultural transformations.

I’m lucky enough to work with some of you. You’re fighting the good fight, and though it’ll take a long time, you’re going to win.

Best wishes,

Pascal

Pascal Dennis Bio

Anaesthesiology 101?

By Pascal Dennis

‘Hierarchy, Intimidation, Outright Abuse’

Is this part of Anaesthesiology 101? According to a just-published Canadian study, it’s standard fare for anaesthesiologists in training.

The paper is based on interviews with 49 young resident at a couple of major Canadian hospitals.

Are these hospitals freakish outliers? Or does the study reflect a broader culture of shame and blame? If so, are Surgeries especially prone?

I must declare a bias. My team and I are lucky enough to work with fine hospitals in which such behavior is unthinkable. But we have the privilege of choosing who we work with.

The authors have done a great service. Hopefully, the study will trigger much-needed soul-searching, and more importantly, better checking.

To wit, at present surgery is a black box.

Here’s a binary question I’ve asked a number of senior surgeons:

How do you know a surgery is Okay or Not Okay?

And its corollary: What are the end-of-pipe and process measures that help to answer the question?

So far, nobody has been able to provide a satisfactory answer.

More to come.

Best regards,

Pascal

Pascal Dennis Bio

Reprise: What is a Key Thinker?

By Pascal Dennis

Deployment leader, Pacemaker, Key Thinking Guy/Gal, Chief Engineer -- these are all synonyms for this critical role.

As a chemical engineer, I see the role as akin to an enzyme in a chemical reaction.

Some reactions are glacial & take forever to come to completion. But once you add the enzyme -- whoosh!

These are leaders who 'wrap their arms around the critical breakthrough zones' -- like Safety or Quality or Cost.

They go see, reflect, talk to people at all levels, and thereby grasp the situation.

As a result, our Key Thinker is able to formulate a hypothesis: "If we do A, B and C, then X will happen!"

Testable hypotheses gives us insight about the Black Box known as our business.

Keep doing it, and pretty soon (say, 3 or 4 years) you have profound knowledge.

("Do this -- don't do that! We tried it six years ago, and it was a mess, for these reasons.")

That's what profound knowledge looks like: stories, examples, nuance, finesse.

The best known example is, perhaps, Toyota's famous 'Heavyweight Chief Engineer'.

Famously, Chief Engineers have few direct reports, but are the most powerful person in the value stream (or, in the auto industry, Platform).

Key Thinkers are rare people with rare qualities:

Passionate about their zone, impatient with the status quo, ornery, yet able, at the end of the day, to forge a consensus.

They're a critical enabler in any transformation, our conscience, and the eyes and ears of the CEO.

Thus, a key strategic question is:

"How will we develop more Key Thinkers?"

Moreover, the CEO and COO need to ask, "How will we support out Key Thinkers?"

Here's an example. Imagine you are senior leaders in a major hospital system. Your over-riding objective is "No Infections!"

How would we start? Perhaps we can agree that a committee won't do.

We'd need to start with a person with the qualities described above -- in other words, with a Key Thinker.

If we lacked such people, we’d have to develop them, and we’d have to think deeply about how we, as senior leaders, would support them.

Best,

Pascal

Pascal Dennis Bio

Economy I and II - Never the Twain Shall Meet?

By Pascal Dennis

In a previous blog I introduced the idea of Economy I & II

The former comprises private sector companies like Apple, Amazon, Toyota and GE.

These companies face withering competition every day.

As a result, they're wonderful at creating value, but not so good at creating jobs.

Economy II, by contrast, comprises government and quasi-government organizations like schools, universities and hospitals.

These organizations face comparatively little competition (or in the case of government agencies, none at all.)

As a result, they're wasteful and inefficient -- but good at creating 'jobs', of a sort.

But Economy II is bankrupting America (and Europe, for that matter). Economy I can no longer create enough off-setting value and wealth.

What to do?

Conservatives argue that Economy II can only be mended by applying the disciplines of Economy I.

Essentially, this means enabling and applying Lean thinking:

• Understanding your customers, and thereby, value & waste,
• Visual management and 5 S,
• Standardized work,
• Jidoka (building quality into the process,
• Heijunka (level loading), and
• Point, flow and system kaizen

Enablers to this approach include education and health care vouchers that put choice into the hands of the customer.

Liberals ("progressives") argue that the philosophies & techniques of Economy II are not necessary and wouldn't be effective in any event.

A better approach, they argue, is to elect capable, charismatic political leaders, who can reform Economy II by force of personality.

They cite Rahm Emanuel, mayor of Chicago, as such a leader.

What do I think?

Being an engineer and a businessperson, I'm naturally inclined to the practices I learned at Toyota.

The past twelve years, our Lean Pathways team has applied them with great success in a variety of industries.

Toyota thinking is rocket fuel. Stick to the recipe and wonderful things happen.

This is the evidence of my eyes and whole being.

The liberal/progressive argument seems, forgive me, to entail 'magical thinking'.

Even if it were based in fact, how many Rahm Emanuel's are there? And what happens when Rahm inevitably resigns as mayor of Chicago?

(Insiders say Rahm is there for one term.)

The broken processes mean a rapid regression to the bankrupt mean.

Sorry,

Pascal

Curing What Ails Our Hospitals

By Al Norval

I read this article in a recent issue of Fortune magazine and have to admit it was the catchy title that caught my interest. "Curing What Ails Our Hospitals” went on to talk about a new design for hospitals that dealt with three problems that afflict most current hospitals. That is:

Infections
Energy Efficiency
High Cost

The article stated that infections were the leading cause of death in US hospitals.

In a play on words, the article quoted Norman Cousins saying that “A hospital is no place for a person who was seriously ill”.

I think that one line summarizes the state of Healthcare in North America.

Rather than just stating the obvious, the authors did offer several countermeasures. I’ve summarized the approach this way – improving the quality of patient care by reducing hospital induced infections will result in lower a length of stay for many patients. A shorter length of stay translates into savings and improved patient (Customer) satisfaction. Combine that with energy efficient buildings and a focus on prevention using team based care and the costs of healthcare can be brought back into line. Makes sense to me – I’d be interested in your opinions.

Their ideas for team based care included small neighbourhood hospitals which sounded a lot like SMED and small lot size needed for flow. Flow occurs in the absence of waste and I could visualize many waste reduction ideas in their design. Having the doctors, nurses, pharmacists, and others involved in patient care work as a team eliminates many forms of waste and more importantly allows the team to problem solve quickly and efficiently.

It all comes back to the basics of Lean:

Eliminate waste
Focus on the Customer
Engage team members in problem solving

By doing this, costs will take care of themselves.