But take a look anyway, if you have an interest in process improvement in hospitals. This is a collection of my best posts on this topic.

Tuesday, December 11, 2012

La méthode Toyota pervertie

An article last month in Montreal's La Presse, entitled "Soins à domicile: tollé contre la méthode Toyota" ("Home Care: Outcry against the Toyota Way") set forth a terrible scenario in which the wrong application of the Lean approach in the home health care setting led to awful results.

Here's a rough translation of some excerpts (with thanks to Google translator and apologies for inaccuracies. Je ne parle pas français.):

The implementation of the famous Toyota Way in home care in Montreal by a private firm is currently causing nurses, social workers and occupational therapists to be on the verge of hysterics. And it is on track to cost a small fortune in the health care system in a context of budgetary restrictions. The new Minister of Health, Dr. Réjean Hébert, has also pledged to hold accountable those health centers that are in the process of implementing the method.

In Montreal, a dozen centers of health and social services centers (CSSS) recently approved contracts with a private firm for a sum of at least $12 million. Fees are up to $27,540 per week (excluding taxes) for a period up to 35 weeks, it was found.

The firm, named Proaction, was founded in 2004 and first imposed its approach in the manufacturing sector. Its founders had never set foot in a hospital or a health center before 2009.

"Currently, many employees are exhausted, emotional and in physical distress. And when we try to denounce the situation it is perceived as a sign of weakness and we are afraid of the consequences," said a social worker from CSSS Canvendish. The lady preferred anonymity for fear of reprisal, but a dozen nurses, social workers and occupational therapists with whom La Presse spoke were outraged by the situation.

According to what La Presse has seen, the Proaction method is largely based on the creation of a grid of "planning and implementation" on which all acts . . . are timed. This grid is developed by an internal committee consisting of a few handpicked employees. For example, washing one ear by a nurse should take 15 minutes. Two ears 20 minutes. A single wound care should not take more than 15 minutes. There is provided a time of 30 minutes for follow-up "post death". 

On the ground, it will even tell therapists not to intervene with patients in cases of psychological distress, and transfer the task of the social worker to save time. If an employee has not been able to perform his or her task in a timely manner, he or she shall explain the reasons.

In a follow-up article, "La méthode Toyota pervertie," ethics consultant Pierre Deschamps noted, "The correct approach would not have led home care nurses to the edge of a nervous breakdown."

In fact, what it is has nothing to do with the Toyota method, but instead is a practice of Lean, disembodied from the fundamental values of the Toyota approach.

At Toyota, the continuous improvement process is based on the respect that the company provides to its customers, suppliers and employees. Continuous improvement, yes, but never at the expense of respect for persons.

In recent years, several consulting firms who see the Toyota approach as a business opportunity have appropriated some of its processes and argued that organizations that adopt it would rapidly increase their performance and efficiency.

What these companies have forgotten is that the Toyota is successful when it is part of a corporate culture that is strong and in businesses where there is a healthy work environment. There is no success in organizations where there is a significant psychological distress and mental suffering high among employees, as appears to be the case with several employees of the health system.

In addition, the Toyota approach to be successful within an organization requires that those who want to use have an excellent knowledge of the culture and to develop a profile of the organization in terms of governance, leadership, ethics, practices, traditions, etc.

In a book called The Toyota Way to Lean Leadership, the authors make a serious warning in regard to the use of external consultants.

The traditional role of external consultants is to manage a project and produce a plan of action. Indeed, the consultants step into the customer's shoes. They claim to have expertise in Lean methods and guarantee that they will make the client organization more efficient by eliminating all unnecessary tasks and standardizing work.

However, in reality, learning new methods remains with consultants and what they leave at the end of their mandate is very fragile.

Several months ago, I declaimed:

If there were a form of medical malpractice lawsuit that I would like to encourage, it would be against those consulting firms that promise hospitals that they will teach them how to "do Lean."

[They] leave behind your "trained" cadre of managers to carry on -- which they cannot or will not do.  Charge the hospital several hundred thousand dollars for this "service."  But not before you have given Lean a bad name and, worse, have caused it to be associated with layoffs.

In their search to find financial savings, hospitals and health care administrators are often carried along by the latest fad.  Governments, too.  Here, the previous government health minister of Quebec opened the financial gates to support his "transformation" intentions several years ago.  But the concept was not well thought through.  The consultant community responded as you would expect.

As I have said:

You don't "do Lean."  Lean is not a program.  It is a long-term philosophy of corporate leadership and organization that is based, above all, on respect shown to front-line staff.  There are two essential aspects, training front-line workers to be empowered and encouraged to call out problems on the "factory floor," and training managers to understand that their job is to serve those front-line workers by knowing what is going on on the front lines and responding in real time (when problems are fresh) to the call-outs.

Please, if you are hospital or government leader and are not prepared to adopt the overall philosophy, don't start down this path.  You will just pervert the nature of Lean.  Soon enough, la merde va frapper le ventilateur.  (Again, a Google-assisted translation.  No doubt there is a better idiomatic version, but you get the point.)

Monday, December 10, 2012

Who needs a waiting room? (Part 3)

In a post below, I report on Dr. Sami Bahri's use of Lean principles to improve patient flow in his clinic.  In their comments, Sami and others explain more about how this is done.  Upon reflection, I need to issue a caveat:

You cannot just extract Sami's recipe for scheduling appointments and expect it to work  The cultural and thinking shift that he led for his staff is really central. Having now watched a lot of medical people in hospitals and outpatient settings, I have seen a tendency to try to take shortcuts, not knowing the depth of what is involved.   As I have said before, you don't "do" Lean:

Lean is not a program.  It is a long-term philosophy of corporate leadership and organization that is based, above all, on respect shown to front-line staff.  There are two essential aspects, training front-line workers to be empowered and encouraged to call out problems on the "factory floor," and training managers to understand that their job is to serve those front-line workers by knowing what is going on on the front lines and responding in real time (when problems are fresh) to the call-outs.   Yes, there are all kinds of methods and tools and terminology, and as Virginia Mason Medical Center's Sarah Patterson notes, "Lean provides a common language for process improvement." She also reminded us, though, that it is a focus on process, not on the outcomes.  The idea is to "build key features into processes that are waste free, continuous flow."  To do this we need to "grow leaders-- to respect, develop, and challenge your people."

This may scare some of you away, but it's important to know there is no silver bullet.  This is hard work and needs a strong and steady commitment from senior clinical and administrative leaders.

Sunday, December 9, 2012

Who needs a waiting room? (Part 2)

In a post below, I give a short summary of Dr. Sami Bahri's dental clinic in Jacksonville, FL, and how he has employed Lean principles to make things better for patients and staff.  That elicited some good questions.  Answers have now been provided by some real experts, including Sami himself. 

If you are at all interested in applying Lean to clinical settings, these comments are worth a look.  Click here.

Friday, December 7, 2012

Who needs a waiting room?

Passing through Jacksonville, FL, I took the opportunity to catch up with "the Lean dentist," Sami Bahri, about whom I have written before.  Walking into his office, I was struck by this view of his waiting room.  This is a more or less typical situation.  Patients entering the clinic are immediately escorted into a treatment room.  Organizing a clinic's work flow to produce an efficient treatment of patient flows is a direct result of Lean process improvements.  I joked with Sami that he should find some other use for this space, like starting a book store or something!

One of the things I like about this clinic is the practice of treating a patient for all of his or her needs during one visit.  Most of us go to dentists who require us to come back for a second visit if we have a cavity that needs filling or some other procedure that emerges from the cleaning and examination.  Not here.  If they find a cavity, they fill it on the spot.  The result has been a 24% reduction in the number of appointments at the clinic (for the same number of patients.)  Besides making life more convenient for the patients, the office has eliminated the make-work associated with second or third visits: scheduling, confirmation, extra cleaning of each exam room, billing and collection.

Sami and his staff are very proud of customers' reviews on Angie's List--all "A" grades.  Comments reflect the perspectives of patients.  They don't know that this is a Lean clinic, but they do notice the aspects of customer service that result from the Lean philosophy:

This group is wonderful. Personnel are all low key.  I had a crown pop off.  No pain but they offered me a same day appointment if I wanted it.  Fixed tooth with the same crown.  None of this high-priced push for work you don't need.  I can really get intimidated at dental office and I didn't here.  My old dentist had retired and the new one was sell sell sell.

Thorough, professional and kind.  I was seen today and will be taking my children to this office also.

They are kind and compassionate.  They are all encompassing.  They will squeeze you in if you need them even if it is night.  You never seem to have to wait more than 10 minutes.  The staff is great and knows you by name.

There is not a single person there that I would not trust to provide 100% excellent service with skills, knowledge and compassion.

Wednesday, December 5, 2012

"What" before "Why"

As the Lean Coaching Summit drew to a close, John Shook, head of the Lean Enterprise Institute, offered a summation that included the slide above.  Although I have been practicing and/or coaching Lean for many years, it made a big impression on me.  Let me explain.

One of the techniques used in Lean and other process improvement approaches like Six Sigma is to employ the "5 Whys."  Wikipedia explains:

The 5 Whys is a question-asking technique used to explore the cause-and-effect relationships underlying a particular problem. The primary goal of the technique is to determine the root cause of a defect or problem.

The premise is that the root cause is often hidden and requires inquiry beyond the simple first answer.  Wikipedia goes on to give an example:
  • The vehicle will not start. (the problem).
  1. Why? - The battery is dead. (first why)
  2. Why? - The alternator is not functioning. (second why)
  3. Why? - The alternator belt has broken. (third why)
  4. Why? - The alternator belt was well beyond its useful service life and not replaced. (fourth why)
  5. Why? - The vehicle was not maintained according to the recommended service schedule. (fifth why, a root cause)
Lean practitioners spend a lot of time on the 5 Whys, and John's slide properly incorporates the "why" portion of a problem solving.  But he also reemphasizes the need to understand "what" happened.  As he said to me before the talk, we often do not spend enough time at the site of the problem to comprehend fully its characteristics and nature.  Failing to know what happened means that the root cause analysis can be off track, and the designed solutions therefore will not offer a complete or sustainable solution.

As in many things related to Lean, this kind of advice can either appear to be self-evident and simple, or too nerdy or techy for real-world situations.  But it is neither.  It represents a codification of an essential aspect of process improvement, an aspect often observed in the breach.

How often have you been in an organization where a supervisor learns of a problem, does a cursory review, and then decides what has happened without a full understanding of important factors and details?  I know I have been guilty of this flawed approach in every leadership position I have had.  It occurs because we are creatures of habit, and the framework we use in viewing problems or defects has developed over the years based on experience, anecdote, and impressions.  It takes real insight to overcome our habitual view of the world and have the clear vision to see a problem and fully comprehend its characteristics.

It also takes a lot of practice to learn how to see a problem and to fully comprehend its characteristics.  An essential aspect of leadership training should be to create comfort in spending time on the front lines, where the work is done and value is delivered to customers.  Beyond physical presence, leaders have to be taught to quietly observe the work patterns of the front-line staff, and especially to see how the staff people create work-arounds to overcome obstacles to the tasks they are trying to carry out.  Excellent coaching is required to teach leaders the observational skills they need to answer the question, "What happened here?" 

Tuesday, December 4, 2012

Double-Lean focus on coaching

The Lean Enterprise Institute and Lean Frontiers joined together to create the Inaugural Lean Coaching Summit, a collaborative and hands-on learning environment to address coaching in companies and institutions that have adopted the Lean process improvement philosophy.  As noted by the hosts:

“Most lean practitioners have heard the principle ‘Before we make product, we make people.’ This embodies respect for people and describes the two responsibilities of every leader: Get work done and develop people. To accomplish these as separate activities is difficult, if not impossible. So the lean leader’s solution is to develop people through getting the work done. Easy to say, but what does it take? It takes coaching.” 

I was pleased to be invited to deliver the keynote address, based on the coaching themes and stories from my book Goal Play! But as usual in these sessions, I learned a lot of new things.  There was one bit of history from the original Toyota Lean work several decades ago.  They employed a four-part mantra that could apply to any organization today that hopes to become a learning organization:

Build people before cars;

Establish mutual trust;
Lead as if you have no power;
No problem is problem.

Monday, November 12, 2012

We shouldn't need a waiting room.

Our Lean workshops at Jeroen Bosch Ziekenhuis ended today with a session about the differences between batch and flow processing.  It turns out that many hospital settings are based on batches of patients or tests or procedures.  This is often less efficient than a flow-based process.  It is also a lot less customer-centric.

Frederieke Berendsen (above) started talking about this with regard to out-patient clinics, noting that the waiting rooms are often full of people who arrive in batches (or near-batches) and then often wait to be seen.  She noted that in an efficient system, "We shouldn't need a waiting room."

I immediately awarded her with the astute-observation-of-the-week prize, as she had codified one of the Lean principles in a simple declarative sentence.  I then related the story of Dr. Sami Bahri, the Lean dentist in Jacksonville, Florida, whose "clinic prides itself on minimizing the amount of time patients spend waiting -- whether for an appointment, sitting in the front area, sitting in the procedure chair, or whatever."

Brava to Frederieke--and also to the other people in our workshops--for their attentive participation and excellent observations during our sessions!

Sunday, November 11, 2012

Coffee breaks demonstrate Lean essentials

The essence of Lean is to have a focus on the needs of the customer and, when problems become evident in the workplace, to think about the obstacles and apply the scientific method to invent incremental improvements.  Such change originates with the front-line staff, but it is the job of leaders to encourage an environment in which this is encouraged.

An example arose recently at Jeroen Bosch hospital in the Netherlands.  It was the brainchild of Jeanne Smith, whose job includes serving coffee to patients on the wards.  You see her here. 

Jeanne was hearing complaints from patients about the temperature of the coffee.  It was highly variable, ranging from properly hot to less so to just warm.  She conducted a root cause analysis as she walked through the wards and noticed that coffee stored in the larger thermos containers stayed hot longer than the coffee served from the smaller containers.  (The greater thermal mass of the larger container held the temperature better.)  So, the solution was simply to use the larger containers.

Immediately, the complaints disappeared, as the coffee was served at a uniform temperature throughout the wards.

Now, admittedly, this is not an item of high clinical importance, but it is an indication of patient satisfaction.  After all, if you are going to offer coffee, why not make sure it is the correct temperature?

Jeanne's improvement won first prize in the poster portion of the hospital's Quality and Safety Day last week. Her poster title was "Dit is andere koffie!"  ("This is different coffee!")  CEO Willy Spaan said, "This is just the kind of sense of initiative and constant improvement that we are trying to encourage."

Saturday, November 10, 2012

Wesley and Ziko's fine Lean adventure

One goal of conducting Lean workshops at Jeroen Bosch Ziekenhuis was to create an archive of pedagogical material that could be used by the training staff in future sessions.  We decided to supplement the various games and exercises with a collection of pertinent video clips.  So we had two nice young film production students from Koning Willem 1 College join us.  You see them here, Wesley Martens and Ziko Assink. 

They followed several participants during the gemba walks and shadowing.

What they did not expect was the moment we had an odd number of students to participate in a game requiring an even number.  One of our film-makers found himself immersed in the 5-S game, learning to be Lean (while his partner looked on with amusement!)

Wednesday, November 7, 2012

Lean games in Den Bosch

We played a couple of my favorite games in the last two days at our Lean training workshops at Jeroen Bosch Ziekenhuis.  The value in using simple and amusing games is to remove the participants from their day-to-day frameworks and allow them to focus on exercises that reinforce Lean principles.

Yesterday's game was designed to illustrate the concepts of 5-S, fixing the workplace so it is conducive to easy acquisition or use of needed supplies by removing extraneous materials, organizing according to how often they are used, keeping the workplace neat, reducing variation across the institution, and ensuring that these practices are persistent.  The terms used to describe these steps are: sorting, setting in order, shining, standardizing, and sustaining.

The game is a simple number sorting game.  Teams of two are asked to look at a sheet of paper and tick off the numbers between 1 and 49, in order.  The first sheet starts with a jumble of numbers going up to 100 (top picture).  The next sheet, having been sorted, appears with no numbers after 49 (see above).  The next sheet places the numbers on a grid (see below), so it is easier to find the next one in sequence.  

The next sheet offers the numbers in sequence. The final two sheets require the players to perform a quality audit, as two numbers are missing.  First, they are all presented in a jumble.  Next, they are presented in sequence.  Our students quickly saw the value of the 5-S principles, and we later went up to areas of the hospital to see how it might be applied in settings like supply rooms.

Today's game, an all-time favorite, was Pig.  It is meant to demonstrate the value and power of standardized work.  In round one, participants are asked to draw a pig on a grid, following oral instructions.  The results, to say the least, are mixed!  Compare the drawings above and below this paragraph.

In round two, written instructions are provided, and things improve a bit.  In round three, a picture is provided along with the written instructions and there are high quality, consistent results (as seen below).

Beyond fun and games, the issue of standardization is a deadly serious concept when we turn to the problem of clinical variation.  We always want to leave doctors and nurses with the discretion to vary from protocols when necessary; but, for the most part, we want to remove creativity from the workplace with many clinical procedures.  Our class viewed this problem as we watched a video of two nurses carrying out a straight-forward, but important, procedure, cleaning a central line.  Even though a written protocol exists, it contains some ambiguity.  It might be that the ambiguity resulted in the nurses carrying out the procedure in slightly different manners; or it might be that they had committed the protocol to memory rather than reviewing the documentation each time; or it might be that they simply had habitual variations in how they conducted the procedure.  But the lesson was clear to our participants:  Achieving standardized work in the clinical setting is important but difficult.

Tuesday, November 6, 2012

"No such thing as bad student, only bad teacher."

As we head into day two of our Lean workshop here at Jeroen Bosch Ziekenhuis (hospital) in the Netherlands, it is good to reflect on the nature of complex organizations and the messages given by an organization's leaders to the staff.  Why is it that people in hospitals engage in wasteful activities and behavior?

I posed the question in a slightly different form to our participants as a huiswerk (homework) assignment, asking them to write a short essay in response to this true-false question:  "Waste exists at JBZ because people are uncaring and lazy.  Provide evidence for your answer."  As expected, the unanimous answer was "false," and people offered the following commentaries. 

John replied with some evidence of the staff's good intentions:

Last Saturday we had an disaster exercise where a few hundred employees of the JBZ took part on their day off.  We saw a lot of enthusiasm and willingness to learn.

The employees on my unit are happy to share their knowledge with other units, in collaboration, teaching, exchanges.  They also did this for a television series about emergency care.

Anne-Marie agreed about these good intentions:

The willingness of the staff is great. They are willing to do something extra.

Monique observed, though, how people can be trained to become resigned to the way things are:

Employees are often not listened to when so they report on a problem. When people say something several times, where nothing is done, they get a resigned attitude and do things no longer. 

Hélène expanded on this thought:
If nothing is done by managers with signals of ineffectiveness from the staff, indifference arises and there will be more wasteful actions. 

Judith concurred, noting the inevitable presence of inertia in such situations:

A lot of things that we do we do because “we always do this like that”.

Or, noted Paul, the staff are forced to invent work-arounds:

The employees are very creative in circumventing problems that occur, causing many inefficiencies.

And then Monique offered the following underlying causes:

There are too many islands in within the hospital.  People can not or will not "watch each other's kitchen" so everyone re-invents the wheel and things are not aligned. 

If you are a long time in the same spot you will get, whether you intend to or not, a tubular vision. Someone from outside your processes can give you a whole new image and ensures that your own eyes widen.

Riny gave a similar diagnosis:

People who work in the JBZ are certainly not lazy and indifferent. It is working protocols and regulations that are not kept up to date that cause waste to occur. People in the JBZ work hard but must abide by certain old rules that are not based on the current situation. This results in noise and miscommunication, making much unnecessary work.

Jacqueline agreed, noting:

Preconditions do not always exist for employees to be efficient, and to experience the pleasure of  satisfaction. This frequently leads to demotivation and resignation.

Karin asserted that change is difficult because of the multitude of constituencies found in a hospital:

The people working there are involved and are willing to think about changes and improvements. Very often, secretaries in the clinic indicate that some things do not work. Often they already have an idea of ​​how it could be otherwise. To carry out these solutions, though, is complex. Often they must then be discussed with other stakeholders (other secretaries, nurses and medical specialists) because they would also have consequences for those people. Sometimes there is no agreement about the proposed solution.

But Jo then emphasized the importance of leadership in resolving those complicated interactions:

Leadership is crucial in achieving results and how we work on a unit.

And Hélène explained,

To prevent indifference, an equal dialogue with respect and trust is necessary, between a manager displaying serving leadership and the employee.

Izaak expanded on this, saying:

I think there are lots of initiatives that show the enthusiasm of staff to improve quality and safety. Sometimes the enthusiasm gets lost because of the lack of empowerment by the management. We forget to celebrate the success in improvements that are made on the initiative of staff members.  This gets back to them as lack of interest from the management in their efforts.

The answers are an important reminder that the introduction and dissemination of the Lean philosophy--or other any approach to improving quality, safety, and efficiency--requires leadership attention to the nature of how people learn and improve.  Our goal is to create a learning organization, to be "good at getting better" in the face of exogenous and endogenous challenges.  Leaders must have sufficient empathy to respond appropriately as the staff goes through the stages of learning--interest, distress, and pleasure.  If leaders are not attuned these stages, the staff will not learn the right lessons.  Then, we will be reminded me of Master Miyagi's statement in The Karate Kid: "No such thing as bad student, only bad teacher."

It is not the fault of well-intentioned and dedicated staff if they do not learn the aspects of process improvement that can transform a hospital: It is a failure of leadership.  As set forth by the great basketball coach, John Wooden, "You haven't taught them if they haven't learned." 

Monday, November 5, 2012

Lean lessons at Jeroen Bosch Ziekenhuis

I was so pleased to be invited back to Jeroen Bosch hospital in the Netherlands to conduct some three-day workshops on the Lean philosophy for a number of the senior managers.  Now, you can't learn everything about Lean in three days, but this set of seminars is designed to cover some of the basic principles--and especially to get participants out on the floors to see what life is like for the front-line staff.

After being greeted by hospital CEO Willy Spaan with a pertinent quote from William Glasser's Choice Theory, we started with the marvelous video Toast, produced by the GBMP.  Here, you see participants chuckling as Bruce Hamilton displays the simple inefficiencies of the toast "production" process in his home kitchen.  By viewing waste in this kind of neutral setting, people avoid getting defensive and applying preconceptions and then are better able to apply the lessons to their own workplaces.

Then it was off to gemba, to shadow various people throughout the hospital.  The point here was to identify the obstacles that people face in doing their day-to-day work and to learn better how to see waste in the organization.  Not by interviewing the staff people, but by just watching them do their work.  For example, here you see Paul van Hall, unit manager of Perinatology, as he has a chance to watch Evelyn in the central sterilization area as she organizes surgical instruments for cleaning. 

(This kind of exercise has to be done very respectfully and carefully, lest those being shadowed fear that they are being judged.  Instead, they are told, truthfully, that the point is for senior leaders to learn about how things are done in the hospital.  Most people being shadowed soon forget they are being watched, and many later express appreciation for the interest shown in their work.)

Upon their return, we asked all the participants to tell some stories of waste they had seen and to enter the examples into the categories symbolized by the acronym UWITDMOP, standing for Unused Human Talent, Waiting, Inventory, Transportation, Defects, Motion, Overproduction and Processing. (Check Mark Wroblewski's blog for a variant, WORMPIT!)  The examples seen at Jeroen Bosch were quite similar to what I have seen in other hospitals and are common to all kinds of large, complex organizations.  Also, the experience of going to gemba opened the eyes of many of these managers, as they gained appreciation for the obstacles encountered by staff every day and for the tendency to invent work-arounds to carry out their tasks.

Thursday, October 25, 2012

Bad Lean training is not Lean

A friend writes:

I spent the last 3 days immersed in Lean training. It was not fun. Important knowledge taught by good people using lousy slides and a rigid format.  And the chairs were terrible so my body aches as much as my head.

I responded:

There is nothing worse than bad Lean training.  It violates the Lean philosophy.

Tuesday, October 2, 2012

Lean is not negotiable

Please check out this article by @SusanCarr (Susan Carr) on Patient Safety and Quality Healthcare, summarizing a recent Lean session at Atrius Health.  I am pleased, but not at all surprised, that my friends and colleagues at Atrius continue to pursue a Lean philosophy and vision.  That approach has already paid huge dividends for the patients and staff at this multi-specialty practice, and the leadership of the organization understands that you don't do Lean, you embed it into the corporate culture for everyone, every day.  Excerpts from Susan's article:

Last week I attended a three-hour presentation given by Lean guru George Koenigsaecker to Atrius Health, an alliance of community-based medical groups in Massachusetts.

In his presentation, Koenigsaecker emphasized the role of leadership in implementing Lean, pointing out that Lean requires adults to learn new attitudes and behaviors—a far more sustained and challenging leadership effort than getting everyone on board with new technology and processes. Success with Lean takes time and involves culture change. That is always challenging, but traditional Lean teaching, beginning with Toyota, did not include leadership training of the sort that interests us today. TPS was taught and fostered through mentorship, without documented leadership principles.

I particularly like the last piece of advice raised by Koenigsaecker, as part of his suggestions to achieve this end:

Lean walk-the-talk.  Practicing Lean as a way of life. It starts to affect your thinking. You are teaching and contributing to the evolution of Lean. Lean is not negotiable; it’s who you are; it’s how you do what you do.

Thursday, September 20, 2012

The business case for Lean

Does Lean pay?  CFOs always want to know!  Joshua Rapoza at the Lean Enterprise Institute, Inc.writes:

I want to invite you to our latest webinar, The Business Case for Lean, with Michael Ballé, taking place at 2:00 p.m. Eastern on October 10, 2012. This is a one hour, free webinar.

"Executives have been asking about the ROI of Lean programs forever. Lean practitioners answer that it's the wrong kind of question. They are absolutely right, but we must get better at showing the business benefits of Lean. That's where I can help." - Michael Ballé.

Ballé is the award winning author of The Lean Manager and The Gold Mine, as well as the writer of the very popular Gemba Coach Column on lean.org.

Click here to register for this free webinar, and don't forget to invite your colleagues as well.

While you are on lean.org, take a minute or two to learn about Ballé’s upcoming (one time only) workshop of the same name at LEI's Cambridge headquarters this November.

Monday, July 30, 2012

Bravo, Ipswich! (And I don't mean the Tractor Boys.)

John Watson, director of operations at Ipswich Hospital NHS Trust in the UK, included the following message in this week's staff newsletter.  Going to gemba is at the heart of Lean.  This is a great start!

Many hospital managers find their time tied to countless meetings, reviews of performance targets and other duties that take them away from the ‘front line’. We lose contact and understanding. However, what we know is once we spend more time out where the work is being done watching what is going on we will be surprised what we learn. We learn that the jobs we are asking our staff to do every day are often not do-able because there are not stable and reliable processes to support them. It helps managers to know what the problems are every day that are preventing our staff delivering waste-free care because we can then prioritise our work.

Therefore we have started a weekly process where a group of 20 senior Trust managers block every Tuesday morning to just go out to the front line and respectfully watch what’s happening. Each week we plan to place these managers, myself included, into 20 different areas. This is not checking up on colleagues. This is watching to learn and see where we can better help.

Last week I observed Sarah Willingham undertaking the receptioning of the Ophthalmology Outpatient clinic. I was struck by her calmness and professionalism despite the relentless pace of how her job needed to be done. I noticed small things that we simply haven’t designed properly to help such staff. Her phone was on another desk and she had to get up repeatedly to answer it or use it to chase notes. My hope is that gradually we find ways to learn from such observations and correct the countless little things that our dedicated staff have to find a way through.

If you have an area you would like us to come and watch or if you would like to be involved please let me know. If you have to deal with a work process that you think could be made better and have an idea please let me know or ask us to come along and observe how you try to work with it. This is a simple but small yet crucial step into how we think and act differently.

Friday, July 20, 2012

No hype on Lean

I sometimes hear skepticism from hospital CEOs who are presented with the idea of adopting the Lean philosophy for their institution.  "Why does this feel like a religious sect?"  "I have no interest in learning Japanese."

Putting aside the ethnocentric context for the latter statement, in that the philosophy was actually introduced to the Japanese by W. Edwards Deming, let's admit that Lean is not for everybody.  But let's also acknowledge that it can make a huge difference for hospital staff and patients when it is undertaken carefully and in good spirit, with commitment from senior leaders.

Here is a short and thoughtful summary of some experience to date, an article in Hospitals and Health Neworks by Steven Garfinkel based on research conducted for the Agency for Healthcare Research and Quality.  The bottom line:

At every institution, staff at all levels reported improved employee satisfaction. They cited opportunities for front-line involvement in problem solving, employee collaboration across ranks and units, efficiency improvements, opportunities to spend more time with patients, and improved patient experience. 

Not surprisingly, cost-benefit ratios and return on investment were never explicitly considered when the organizations we studied adopted Lean. Instead, senior executives were committed to improving quality and efficiency. They adopted Lean because it was tractable — particularly when reliable estimates of cost and benefit were difficult to make. Once leaders adopted Lean, none paid much attention to implementation costs. Top managers saw Lean as part of an array of available quality-improvement tools. All said they were pleased with Lean's results. They viewed Lean as yielding long-term process and quality improvements that enhanced their institution's efficiency and financial viability.

We cannot be sure that Lean is more effective than other process improvement techniques. But we did find that Lean can be successfully adapted from manufacturing to fit the complexities of health care.

Wednesday, July 11, 2012

Lean stories at Hadassah Mt. Scopus

Jim Womack and I changed venues in our Lean mission today, moving from the main campus of the Hadassah Medical Organization in Ein Kerem, Jerusalem, to the smaller (300-bed) community academic hospital at Mt. Scopus.  This was the original Hadassah hospital, abandoned in 1948 after several dozen staff members, including the director-general, were massacred on their way to work.  It re-opened in the 1960s, but after planning and construction for the new large hospital had occurred.  It serves a mixed Jewish and Arab clientele, and its staff also reflects that mixture.  The building is lovely -- old-fashioned and warm -- as are the people working in it.

We started with a quick gemba walk.  Here Jim is seen with emergency department chief Ruth Stalnikovitz and hospital director-general Osnat Levztion-Korach -- historical note, formerly known as just a regular doctor!)  Then it was off to a general assembly with staff about the nature of the Lean philosophy.  Jim pointed out that, properly executed, it can lead to better patient outcomes, a better patient experience, a better staff experience, and not coincidentally, lower costs.  The last is true because many activities that lead to bad outcomes, and poor patient and staff experience, add cost.

I then provided examples from BIDMC, including a dramatic improvement in the patient experience in the orthopaedic clinic and improved viability of blood samples from the emergency department.  I added some thoughts about the importance of transparency in an organization that wishes to hold itself accountable to the standard of care to which it aspires.

Jim and I both left with the feeling that the Mt. Scopus hospital has tremendous potential to benefit from the Lean philosophy and hoping that the leadership and staff of the hospital will choose to embrace it.

Tuesday, July 10, 2012

Getting past "kacha zeh" at Hadassah

Jim Womack and I continued our Lean mission today at the main campus of the Hadassah Medical Organization in Ein Kerem, Jerusalem.  We started with a gemba walk through the emergency department and then up to the internal medicine wards.  I had seen these areas a couple of days ago, but Jim has just arrived.  As always, he asked great questions and had thoughtful observations, particularly about the problem of patient boarding in the ED.

Later, we both participated in a hospital-wide session organized by CEO Ehud Kokia.  His purpose was to provide the staff with an overview of the purpose of the Lean journey and also to offer progress reports on some of the process improvement work that has been occurring to date.  Jim and I were then asked to provide our view of the Lean philosophy and its chance for success at Hadassah.  Jim was characteristically blunt, noting that he had reached a diagnosis -- a hospital characterized by a traditional management system -- a prescription -- a hospital in which both horizontal management and vertical management would exist to support cross-functional process improvement.  But he demurred on the prognosis, saying it was too soon to tell.  Quoting Henry Ford (an irony in light of that person's creation of the dehumanized assembly line model), he said, "It depends on you.  "Whether you think you can or you think you can't -- you're right.'"

My talk followed with some stories from our Lean experience at BIDMC, with (no surprise to this group of readers) analogies to soccer.  Picking up on Jim's conclusion, I suggested that a sign of success at Hadassah would be the elimination from conversations of two words that suggest defeatism and acceptance of the status quo, kacha zeh, "It is what it is."

Monday, July 9, 2012

How do you say "Lean" in Hebrew? "Lean."

Boaz Tamir of Israel Lean Enterprise has created a "Lean Club" comprising a small group of Israeli corporations and institutions who get together four times a year to share experiences, problems and success as they undergo their Lean journeys.  The group includes senior level executives from banking, insurance, food processing, high-tech, and health care.  Because the firms are all at different stages of Lean adoption, the diversity of viewpoints is stimulating and valuable to all.

Boaz started today's session with a reminder about the differences between traditional managerial approaches and that envisioned in a Lean organization.  The slide shown here presents a quick summary.  Boaz stressed that changes in the world economy would be filtering through to these businesses in Israel and suggested that Lean principles could help companies survive and thrive in the face of an avalanche of difficult events.

Today's special guests included Jim Womack, acknowledged world expert in the field.  Jim has a way with words, spinning out stories and theories about Lean and non-Lean organizations.  Both entertaining and informative, he makes it easy to learn.  He reminded the group that a firm needs to be clear about its purpose, but that this needs to be thought about from the customer's point of view.  He noted the schizophrenia we all exhibit -- being providers and producers in our corporate roles, but immediately flipping over to consumers when we go home from work.

Jim drew some comparisons between the desires of the two groups.  For examples, customers want transparency about the cost and quality of goods and services.  Businesses have often relied on opacity in selling their products and services.

He reminded those in the room, "All of you are mature businesses," and so your assets are threatened by changes in the marketplace.  "You think of how you can protect your undepreciated assets, but your consumers want something new."  Thus, "there is a disconnect between customers' and companies' valuation of assets."

Jim said, "This is part of life."  Firms need to adjust to the fact that the frequency of the need to re-evaluate customers' needs is accelerating.

But, he noted, "It is not just assets that are threatened.  It is your processes."  He pointed out that traditional corporate folks who conduct process evaluation often do not think about customers.  They often pursue enhancement to processes that don't bring value to customers.

He reminded us that "all processes involve people."  Therefore it can be threatening and frightening to people in a firm when process design is coming.  The irony, though, "is that you can't develop new processes without people."  Hearkening back to Boaz's points, he said that it takes a different kind of management to work in a Lean way.  Unfortunately, he noted, "management thinking is often impoverished."

These were sobering thoughts, even for this group of executives who are committed to Lean, but the group had an upbeat attitude and took Jim's comments in stride as they engaged in collaborative learning during the session, sharing stories and challenges from their own experiences.

Sunday, July 8, 2012

First Lean steps in Jerusalem

I spent the day at the main campus of the Hadassah Medical Organization today in Ein Kerem, Jerusalem, with staff members engaged in learning about and experimenting with Lean process improvement.  I think the hardest thing for people to accept about Lean is that it is a philosophy based on incremental steps rather than major revamping of complex systems.  The idea is that small advances lead to great gains over time.  Your front-line staff encounter a problem in the workplace and then you design an experiment to try to solve the problem.  Then you evaluate the effectiveness of the experiment and, if necessary, redesign it.  If it works, the new "current state" becomes the basis on which you then try to move to yet another improved "future state."  The process never ends.

Every hospital I have ever visited has a problem discharging patients in a timely manner, and Hadassah is no exception.  This is an important problem to fix for obvious reasons, but there is a not-so-obvious reason as well:  When patients do not leave the wards, it creates a back-up in the emergency department.  Patients find themselves spending hours awaiting a room upstairs.

On one internal medicine ward, Murielle Cohen, the chief nurse, and Professor Dror Mevorah, the chief attending physician, are testing out a simple experiment, whether a white board listing all patients possibly eligible for discharge, along with each step required in the discharge process, might facilitate communication between the nursing staff and the doctors and others to move things along.  During my tour today, they were joined by Chana Tsurel, manager of the internal medicine department, and Pnina Sharon, head nurse of the ER, both of whom have been working to improve communication between the two departments.

In the eye clinic, another approach was taken by head nurse Sigalit Cohen and her physician and technician colleagues.  They faced a problem of long waiting times because a certain injection procedure was batched once per day.  By adding a second session, they were able to improve the flow of patients through the clinic.

Both of these examples are small steps forward in a big hospital that has not yet become fully engaged with Lean.  But they offer the possibility of confidence building measures that will help persuade doctors and nurses that there is potential for broader improvement if people make the commitment to Lean principles.

Saturday, July 7, 2012

You don't "do Lean"

If there were a form of medical malpractice lawsuit that I would like to encourage, it would be against those consulting firms that promise hospitals that they will teach them how to "do Lean."  I recently encountered a hospital in which a well known international consulting firm did it this way:  Assemble 25 top level managers for a week-long off-site seminar, teaching them all the Lean terminology and getting them ready to do Lean projects.  Then keep one or two of your consultants in residence for a few months to provide aid and comfort to the managers as they attempt to run rapid improvement events in areas of the hospital chosen by somebody as "high priority" areas needing cost savings.  Then leave behind your "trained" cadre of managers to carry on -- which they cannot or will not do.  Charge the hospital several hundred thousand dollars for this "service."  But not before you have given Lean a bad name and, worse, have caused it to be associated with layoffs (or redundancies, as they say in the UK.)

I'd like to explain all the things wrong with this, but I would just get upset.  Let me provide the simple explanation.  You don't "do Lean."  Lean is not a program.  It is a long-term philosophy of corporate leadership and organization that is based, above all, on respect shown to front-line staff.  There are two essential aspects, training front-line workers to be empowered and encouraged to call out problems on the "factory floor," and training managers to understand that their job is to serve those front-line workers by knowing what is going on on the front lines and responding in real time (when problems are fresh) to the call-outs.  Yes, there are all kinds of methods and tools and terminology, and as Virginia Mason Medical Center's Sarah Patterson notes, "Lean provides a common language for process improvement." She also reminded us, though, that it is a focus on process, not on the outcomes.  The idea is to "build key features into processes that are waste free, continuous flow."  To do this we need to "grow leaders-- to respect, develop, and challenge your people."

I hope that those of you who have been following my commentary about our Lean workshops at Ipswich Hospital NHS Trust will have seen an emphasis on these points.  You will have also seen that we employed on a pedagogical approach that relied heavily on going to gemba.  You cannot teach respect for front-line staff by sticking people in an off-site conference facility for a week.  You cannot teach people to notice the problems in work flows if they are not looking at the work flows.  You cannot teach the principles of incremental improvement and experimentation if you direct managers and staff to spend all their "Lean time" on time-consuming projects in "priority areas."

Jim Craig (seen here shadowing a person during the workshop) told me this story after we were done.  He was walking through a ward and heard a trainee grumbling about something.  He went up to her and said, in a friendly way, "I happen to overhear that you were upset about something.  Would you mind telling me what it was?"  The answer was that, many times per day, the resident would need to print out a form from the computer.  But the ward was a large ward, and the one printer was at the extreme end of the floor.  So, when she was seeing patients at one end of the floor, the resident would have to spend 5 minutes each time walking across the floor and back as she collected the form.  Jim said, "Would it help to have a printer at each end of the floor?"  "Oh, yes," was the reply.  Then and there, he called the IT department to arrange a printer to be delivered.  Result: A very grateful trainee, who will now have more time to be with patients rather than fetching papers.

The Lean aficionados out there are already fidgeting, for they have noticed other potential solutions to this problem.  And they are asking questions like, "What is the form itself, and does its production add value."  Those would be good things to explore.  The lesson, though, is that Jim was at gemba, heard the (unintentional) call-out, responded respectfully, and analyzed and solved the problem while it was fresh.  I give him an A+ for demonstrating what he learned at the workshop.  Well, let's make it an A- so he knows there is always the potential to improve!

Thursday, July 5, 2012

An eye clinic helps us see Lean more clearly

One of the lovely aspects of Lean that we discussed during this week's training workshops at Ipswich Hospital was the concept of kaizen, process improvement accomplished by incremental change.  I often add another characteristic to the approach:  Can we achieve an improvement with no incremental cost?  Strictly speaking, that cost constraint is not part of Lean.  After all, sometimes you have to make an investment in personnel or equipment, and it often has an excellent return to consumers, the firm, or both.  But I have found that asking people to think about how to change things at no cost opens up floodgates of creativity.

Here's an example from our discussions.  Ipswich Hospital operates an eye clinic and has an open access policy, i.e., you do not need an appointment.  The open hours are from 9am to 1pm, and then from 2pm to 5pm.  The idea of open access is terrific: More and more organizations have employed it.

What happens here, though, is not quite terrific.  A patient goes to a GP and is told that s/he needs an eye exam or other treatment.  S/he shows up the next day at 9am, only to discover that the people referred by any number of the several dozen GPs have also decided to go first thing in the morning.  The staff cannot handle this huge batch of people, and many are left waiting for two or more hours to be seen.  These are often elderly people with vision problems, and so you can imagine the discomfort and, ultimately, the frustration and anger that result.  Also, as word has gotten out about this problem, people have started to show up even earlier, at 8:30, in the hope of getting to the head of the queue. It feels like a case of "no good deed going unpunished," but it is actually a classic case of batch processing when what is desired is a flow.

When this scenario was presented to our class, I asked them to invent an improvement with which we could experiment that might alleviate the problem.  How do we transform the batch to a flow, to match the consumers' needs with the resources available in the clinic?  People immediately started by adding steps to the process:  Perhaps GPs would have pre-printed chits, with different times of day, that would be handed to patients.  (But how would we coordinate the chits across all of the GPs, with changing numbers of patients every day?)  Perhaps the staff in the GPs' offices could call ahead and see how busy the clinic was.  (But then we would add to their work and would also be interrupting the people working in the clinic.)  Perhaps we could install a computer system that would post on a website the number of people waiting at the clinic and the expected delay in appointments.  (But then we have to pay for that system and have someone at the clinic enter the information throughout the day.)

I then asked the group to consider a process that would involve no new steps and add no costs.  The answer emerged:  Make it clear with a simple one-time message to GPs and a poster on the clinic entrance that the clinic would prefer (but not require) that people whose surnames began with "A" to "F" would be welcome at 9am; "G" to "M" at 10am; and so on.  "Ah!," said the person who had mentioned this problem, "So simple.  Let's try it."

Wednesday, July 4, 2012

Ipswich pigs teach the value of standardization

Standardization, or reduction of variation, is a big part of the Lean philosophy, and that was our topic today during our training workshops at Ipswich Hospital NHS Trust.  To illustrate the value of standardization in helping to bring about consistent quality of output with less effort, we employed the pig exercise.  Regular readers are familiar with it.  You can see the first of the sequence of three blog posts describing it here.  In part one, participants are asked to draw a pig on a grid, following oral instructions.  In part two, written instructions are provided.  In part three, the written instructions are accompanied by a picture of the desired work product.

Fortunately for his patients, resident Satheesh Iype is a better surgeon than artist.  With good humor, he accepted the friendly ribbing of the entire group at his depiction of a rabbit -- or goat -- or pig.

By round three, all participants were able to produce an accurate and speedy rendition of the desired pig design.

On a more serious note, Sateesh offered the following thoughts after the workshops and particularly after spending time at gemba, shadowing and observing workers in the hospital:

I think my greatest achievement [from this week] is a change in attitude.  I am taking a positive attitude.  Over the last two days, I have been observing other employees of the Trust, i.e Darren, the X-ray porter, and Tom, the HSDU stock manager.  I respect them even more and understand the important role they are playing in the process.  I see things with a different perspective and will try to take every effort to cut down time wasting.

Tuesday, July 3, 2012

Supplying Ipswich Hospital

As we continued our Lean training workshops at Ipswich Hospital, we spent some time with Thomas, the young man who is in charge of the major receiving and distribution center for supplies entering the hospital.  Specifically, the HSDU ("hospital sterile and disinfection unit") storeroom contains medical devices and supplies and sterile equipment and packs for wards, departments and theatres (i.e., ORs).
All of the managers taking the workshop were tremendously impressed with Thomas -- his devotion to the health care mission of the hospital, his sense of initiative, and his strong sense of responsibility to the patients whose care depends on maintaining an adequate supply of mission-critical equipment.  And yet they also quickly came to understand that Thomas, in essence, is working with one hand tied behind his back, i.e., in an environment that is designed to be inefficient and wasteful.  In that regard, I told the group, he typifies many other inventory supply people in hospitals worldwide.

Thomas and his colleagues in many places live in a world in which they are put in the middle, receiving no visual cues as to incoming supplies from vendors and also no visual cues as to the demands of customers, the wards and ORs upstairs.  Some of his suppliers are reliable, but at least one is not, sending packages slowly and in deficient quantities.  On the demand side, if there is a surge in, say, OR utilization, he learns of it by a quicker depletion of his stocks.  He also has no idea how much inventory is being stored on the wards or, as here, in trolleys in the hallways outside the wards.

So Thomas does what you or I would do.  He plans conservatively, using rules of thumb that result in over-stocking of supplies.  After all, the last thing he would want to do is run short when a patient's life is at stake.  For example, knowing that one supplier is slow and unreliable, he over-orders from that supplier.  If he still runs short, he can pay extra for an emergency delivery.  In both instances, he is essentially rewarding the unreliable supplier.  Because Thomas is not in charge of the procurement process itself and has no influence with that department, it does not matter if he calls out this problem to a superior. 

The knowledge Thomas needs to do his job is essentially inside his head.  If he were to get sick and injured, there is no one else in the hospital with his abilities.  When he leaves for a two-week holiday, he pre-orders extra supplies for those two weeks.  "When I am on leave, I have to cover stock whilst I'm off."

The managers in our Lean workshop left with a greater appreciation for people like Thomas, but also with an understanding that their role as hospital leaders must evolve.  In a health care system facing ongoing cost pressures, the kind of inefficiency represented by the environment within which Thomas is working is unacceptable.  He should be given the tools he needs and the support he deserves to efficiently stock and deliver the millions of dollars of inventory needed for safe and effective patient care.  I believe that, whether or not Lean becomes a hospital-wide philosophy,  our team felt strongly a new sense of responsibility to take steps to adopt its principles in their own work environments.

Monday, July 2, 2012

Learning Lean in Ipswich

Today was the first of a series of workshops on the Lean process improvement philosophy at Ipswich Hospital, and I was pleased to meet two dozen people from various jobs around the hospital.  We started with an introduction based on the Toast Kaizen video produced by and featuring GBMP president Bruce Hamilton.  Then it was off to gemba, the "factory shop" floor, where the class members shadowed a member of the staff. The idea was to practice observation skills and try to identify the various types of waste found in all organizations.  (You see one example above, with a student watching the work done by the unit coordinator of one of the wards, and another below, observing a staff member keeping up with the status of his patients.)

The class members gained a new appreciation for the degree of difficulty faced by their colleagues in doing their everyday jobs.  They noticed impediments, inefficiencies, and work-arounds.  We listed these and posted them to compare the experiences from different areas of the hospital.  Later, I gave everyone a homework assignment, which was to answer the following question: 

Waste exists in Ipswich Hospital because the people who work here are uncaring and lazy. True or False? Provide evidence in support of your answer.

I suspected (and hoped!) that the answer would be "false," and it always was.  People understood that the well-intentioned and hard working people in the hospital face the common problems of complex organizations.  I promised to include the "best" answer here, but they were all excellent, so I have chosen a few a random.

Gary Picken wrote: 

False. I believe the large majority of staff at Ipswich Hospital are caring people who want to make a difference to patient's lives. Waste exists there because we are working in systems and with processes that are inefficient. These have often come about more by accident and the legacy of history, than by design and gathered evidence. The waste continues because we either do not see it or we feel impotent to effect change. Certainly, as clinicians in this organisation, we have not received the investment of the training for such leadership in the past. 

An example of waste:  An elderly man with lower limb arterial insufficiency referred to me for a femoral arteriogram, a procedure involving puncture of a large artery in the groin and an overnight stay in hospital.

Imagine, he has the worry of waiting for the 'test', the myriad of social arrangements to enable him to be there on the allotted day, his hospital bed and slot on the list are ring fenced so unavailable to anyone else.

He arrives in the angio suite after being admitted to the ward (time of ward clerk, nurse, junior doctor, porter) only to have his procedure cancelled because nobody has told him to stop taking his clopidegrel (strong blood thinning medication).

None of the staff wanted that outcome for him, just the opposite. The system had failed him. An ancient system that relied totally on the experienced medical secretary and faltered when she was absent, ill or made redundant.

That's where LEAN, I hope, can improve our hospital.

Jenna Ackerly noted:

The statement that waste exists at Ipswich Hospital because the people who work here are uncaring and lazy is false.  My experience in EAU today and from working in the hospital generally, proves this by constantly demonstrating dedicated, hard working and caring staff, going about their work in good humour.  Waste in fact exists because people are so busy going about their day jobs, in the same way they have always done (or been shown to do), that they fail to spot duplication, waste and inefficiency – or if they do, they feel that they do not have the responsibility to change it. 

Often new processes are introduced without explicit instruction that the old process can be dropped – thus creating confusion and duplication.  In my experience the only problem with our dedicated and caring workforce is that they work hard but not always smart, thus refuting that they are lazy or uncaring.

Jonathan Douse opined: 

Waste does exist at Ipswich Hospital but I dont think it is because people are uncaring or lazy:
1)      I chose to work at Ipswich Hospital because it is a friendly place to work and because people generally say yes when I ask for their help.  If they say no it is because they have a good reason.
2)      When I walk down the corridor I see people directing the lost visitors and patients.
3)      My clinic receptionist is frustrated by her inability to get inefficient processes changed. 
4)      Many  of my colleagues work far more than their scheduled hours.

And Sam Bower offered this thought:

Waste exists because we do not dedicate the time to think about how to eliminate waste and improve process. For example the ward clerk redirecting all the mail today. She knew it was a problem as it "annoyed" her but when does she have an opportunity to tell someone it's a problem? She did today when I dedicated an hour of my time to observe her work. We need to do this more often. An hour a week with a colleague to identify waste and to embed the philosophy of lean thinking into our organisational culture. Not linked to finance, not linked to targets, but linked to improving the working lives of staff and improving morale.