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.

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.

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.

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."

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.

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.

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!

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."

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.

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.

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 don’t 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.