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!

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."

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!)

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.

"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." 

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.