Lean in Government - Part II

By Pascal Dennis

A colleague, who I'll call Anne, returned to work a few years ago after raising her two boys.

She had been a senior leader with an international firm famous for its Lean activities.

As you might imagine, head-hunters beat a path to Anne's door.

Given her interest in health care, she decided to join a world-renowned Canadian hospital.



Its executives had painted a rosy picture indeed:

"We're a cutting-edge organization, a world leader!"

(I should explain that Canadian hospitals are funded by the state.)

Within a month Anne realized the so-called 'world leader' was stuck in the 1970's.

Slow, inert, backward in its thinking and processes. Full of so-called leaders biding their time to retirement.

Turns out, the hospital's reputation was entirely due to brilliant, dedicated researchers -- and not all to the somnambulists in management.

"People who join us either leave very quickly," a colleague told her,"or they stay forever..."

As you might imagine, Anne skedaddled, and now is a leader in a truly world class company.

A happy ending for Anne, but not for our society.

Knowing what I know, I'll never trust the hospital in question.

If a family member has to spend any time there, I'll question every prescription, every procedure.

And yet, I've no doubt the people want to do a good job, and are full of ideas of how to make things better.

If only they were given the chance...

Last time I asked, "How will we engage civil servants in continuous improvement?"

A corollary is, "How will we encourage professional management in the civil service?"

I'd love to hear your thoughts.

Cheers,

Alpha and Omega

By Pascal Dennis

One of the great ironies of our time is the performance gap between Health Care and the so-called Quick Service Restaurant (QSR) industry.

As anybody who has spent time in the "Waiting Room" will attest. Value-Added time is microscopically small in the former.

By contrast, the good people in the QSR industry are getting better every day -- by applying the Toyota Business System.

Indeed, Business Week has had a series of articles highlighting their achievements.

I grew up in a restaurant, so my heart goes out to people who make the best of slim profit margins, long hours of often difficult work.

Well done, QSR and please continue!

It's easy to make fun, but the best QSR organizations provide excellent value and reliable service, while respecting the customer.

Can Health Care say the same?

Cheers

Pascal

Waste in Hospitals – Healthcare

By Al Norval,

I had an interesting case recently to observe firsthand the waste in some typical Healthcare processes.

My son enjoys playing rugby and plays on the school varsity team. I have to admit, it’s a sport I don’t understand as I never played it as I grew up. To me it’s players bashing each other back and forth trying to score a “touch” all with no pads and little stoppage in the action. In any case, the boys love it and that’s the main thing.

Like any parent, I went to the games to support the home team. At the last game of the season my son broke his thumb making a tackle. So, we iced it up and off we went to the local hospital’s Emergency Department. As we arrived I called my wife and said we’d be back home in about five hours. Surely, it can’t take that long to X-ray his thumb and set it in a cast. We’ll see I said.

As we entered the waiting area I noticed a short line up in front of the triage nurse. After a short wait it was our turn to answer the questions and fill out the forms after which we took our places in the appropriately named waiting room. Without getting into all the details, I’ll highlight the Value Added steps:
- Thumb examined by Emergency Department (ED) physician.

- Thumb X-rayed by ED technician

- X-rays read by physician

- Broken thumb set in a cast

Needless to say, there were many other steps in the process all of which were waste. Some were necessary steps and the waste was necessary such as the initial filling out of forms, answering questions and even having the thumb re X-rayed in the cast to ensure the bone had set properly. Others such as waiting for the X-ray to be taken and read, waiting for the physician to examine the thumb and answering the same questions several times were pure waste.

As I pondered this during one of our many waiting steps, I realized the key to improvement in Healthcare is no different than any other process. We need to divide the process steps into Value adding, necessary waste and pure waste. We then need to engage our team members in:

- Reducing the necessary waste, and

- Eliminating the pure waste

The overall measure of how much improvement we are making is through examining the Lead time of the process. As we eliminate waste, the Lead time of the process will go down.

How much Lead time did it take for my son’s broken thumb to set in a cast? Five hours...

How much of that time was value added? One hour...

Therefore the waste in the process was about four hours. Fertile ground for making improvements indeed.

Root Cause of Health Care Crisis?

By Pascal Dennis,



Health Care is a disaster North & South of the border.

Neither Americans, nor Canadians can look on their situation with any satisfaction.

Costs are exploding -- and crowding out other critical expenditures like education, R & D and infrastructure.
Health care outcomes are disappointing. Miracles occur within the silos, catastrophe across them.

What's the root cause of this sorry state of affairs?

Why can't smart, skilled and caring medical professionals do what they're trying to do?

Deming taught us that the problem is in the system -- and he's right again.

Mis-medication, wrong site surgery, infection and other nosocomial calamities occur despite the heroics of nurses, doctors, pharmacists and the many other specialists who keep hospitals going. Indeed, things would likely be much worse but for their heroics.

So what's the root cause of our health care crisis?

Tom Papas, the protagonist of the business novel, The Remedy, tries to answer this question in chapter 13.

He is in rough shape -- he might be losing his father to a mis-medication.

Tom's conclusion: the customer is not the customer.

Only patients, he concludes, can arbitrate the millions of daily decisions that comprise the provision of medical care.

Yet the patient is not the customer in these transactions.

As evidence he reflects on how difficult it has been for his family to get Safety, Quality or Cost information from hospitals.

"And why should they give me info?" he laments. "I'm not the customer."

I've gotten a lot of mail about this chapter!

So what do ya'll think? Is Tom right, or is he not thinking clearly because of his desperate situation?

Are there other root causes that are more important? Any other thoughts or insights?

I'd be pleased to hear from you.

Going to Gemba

by Pascal Dennis

Most of us know the value of going to Gemba and few disputes that it’s the right thing to do. So why do so few Executives actually “Go to Gemba”?

The most common issue I hear is they don’t have time to “Go to Gemba”. There is some truth in that so here are a couple of potential countermeasures that will create time for leaders. Biggest item is to spend less time on e-mail. It’s a business killer complete with interruptions and distractions that break your train of thought. Instead, get out of the office and put away the BlackBerry or iPhone and spend time walking around actually talking to employees.

Not just idle chit chat but actually talking about the business. Learn what is actually happening, seek employee input, listen for obstacles preventing them from doing their job, and help them solve their problems in a way which is consistent with the values of the organization. Teach people to fish rather than just giving them a fish. Imagine the power behind that.

Another method to use is the half hour meeting. Each meeting needs to have a Purpose, Agenda and Expected Outcome. Without that we just have milling around which becomes a huge time waster. Follow a set process and you’ll be amazed at what you can accomplish in half the time.

I’m often amazed by the synergistic effect between these two. The more time spent at Gemba, the more you know about what’s actually happening, so the less time you need to spend in meetings trying to figure out what’s going on, and the faster you’ll solve small problems before they become large business killers.

Lean in Healthcare

By Al Norval

There’s an interesting groundswell occurring in the Healthcare industry that’s long overdue. Lean applied to processes that deliver care to patients and not just too administrative processes. The result – improved quality of patient care and less cost in delivering healthcare. Talk about a win-win situation. We can argue about what triggered this. Whether it was government legislation or a public outcry over rising costs, it doesn’t matter. Bottom line is there is an incentive now to change.

In the past, attempts to change the value streams of patient care were met with resistance in the form of arguments against “robotic medicine” and “standardized medicine”. Understandable considering the years of training medical practitioners receive.

The difference now is that we understand all work is a process and all processes have waste. By taking the waste out of the process and standardizing the value adding steps that are left, we create more value for the patient (customer). The standards form a platform for continuous improvement.

In the words of Taiichi Ohno “without standards, there can be no improvement”.

The healthcare provider teams are then more like a great jazz band, all following basic standards that allow them to riff and end up playing great music.

Healthcare teams riff according to the needs of the patient but the team must all be playing from the same sheet of music. The end result a significant decrease in medical induced errors and infections which are leading indicators of improved patient care and lower healthcare costs.