On learning organizations

Please check out this new article I wrote for the Athenahealth Leadership Forum.  The lede:

A colleague once said, “Every plan is excellent, until it’s tested. It’s execution that’s the problem.” And so it is. 

Excerpts:

Project advocates enter every endeavor with a theory of the case, a vision of how things should be. But, as my late colleague Donald Schön noted, reflective practitioners are constantly reviewing the evidence to modify their framework in response to reality.

Lean organizations understand that there is no group of central planners clever enough to design an optimum complex process. Lean leaders do not lack for a strong purpose—indeed audacious goals are favored—but neither do they lack humility. 

Lean and other similarly designed organizations can only exist where the senior leadership is a strong advocate for the proposition that reflective practice is the best way to achieve outstanding performance for their customers. The leaders of such organizations embed that modesty and reflection in every aspect of their lives.

Oatmeal at IHI: The sequel

I never thought that I would be compelled to write another post about the manner in which oatmeal is served at the IHI Annual National Forum at the Marriott World Center in Orlando.

Let me take you back to the original posts from 2010: 1, 2, 3, 4.  Short version: The ladles (see above) provided to guests on the breakfast buffet were too large relative to the bowls, so oatmeal was being spilled all over people's hands and their bowls.  

Unsanitary and messy work-arounds were developed by the guests (like using the tea cup seen above.)  I wrote a blog post about the issue, and the hotel responded by eliminating self-service and assigning staff to serve oatmeal at several stations, providing them with slightly smaller ladles.

Now, three years later, I stopped by an oatmeal station and noticed that the ladle used by the server was still too large relative to the bowl size. So even with an experienced server, the oatmeal often spills over the edge of the bowl onto the hand of the server and the outside of the bowl.  The server then has to use a small towel to clean off both the hand and the bowl.

I say, sympathetically, "That would be easier with a smaller ladle."

Response, "These are the smaller ladles. We use them instead of the regular ones when this group [i.e., IHI] is here.

"You mean you use bigger ones when there are other groups here?"

"Right."

I'm speechless.

MVP is a most valuable principle

A few weeks ago, I wrote about the tendency of many start-up companies who try to sell their wares to hospitals to ignore the needs of the various constituencies and therefore fail to make sales.  I concluded:

It is possible to sell great new ideas to hospitals, but they need to satisfy the interests of several constituencies in those organizations.  They must improve the work flow of the staff on the floor and units, making day-to-day life easier and not harder. They must improve the safety and quality of care, but in a manner that does not expose the hospital to greater liability: Indeed they should help reduce liability. Finally, they should demonstrate cost savings and be priced in such a manner as to allow the hospital to show cash flow improvements rather than be a drain.

I was reminded this week by Caren Weinberg, senior lecturer of invovation and entrepreneurship at Ruppin Academic Center in Israel, that even this prescription is not necessarily going to result in a successful product roll-out.  The element that I neglected to mention is the Lean concept of minimum viable product.  Taking off on the practice of PDCA (plan, do, check, act) cycles, Ash Maurya notes that "the basic idea is to maximize validated learning for the least amount of effort. After all, why waste effort building out a product without first testing if it’s worth it?"

Coincidentally, this message was reinforced at an MIT Enterprise Forum at Tel Aviv University, where Wix founder & CEO Avishai Abrahami was providing advice to entepreneuers.  Here's one of his slides:

Over time, he explained, the firm can add incremental features and improvements, all the while testing them with customers.

The alternative approach that I have seen is for a firm to spend inordinate amounts of time and effort designing a spectacular technological fix to a series of problems without testing early concepts or prototypes against customers' needs and wants.  It enters the market with a perfectly engineered product, only to discover that it is off track from what the market demands. Having depleted the company's capital, it falls into a financial hole and has trouble digging out.

Thanks to Caren for the reminder that MVP stands for a "most valuable principle!"

Joining Lean practictioners in Israel

Many thanks to Boaz Tamir, head of Israel Lean Enterprise (part of the Lean Global Network), for an invitation to present at a session for a number of businesses that are involved in adopting the Lean process improvement philosophy in their organizations.  Examples included Intel, the Strauss Group (food and beverage supplier), Bank Hapoalim, and yes (satellite broadcasting.)  The attendees were intrigued with the lessons from my book Goal Play! about how to create learning organizations.

I was honored to share the stage with Micha Popper, from Haifa University, who studies and teaches about leadership.  He told a particularly apt story about how the Israeli Air Force improved their learning process.  Years ago, after the missions, the pilots would sit around and tell each other stories about what had happened during their flights. Later, when technology had improved to document the actual flight conditions and history of each flight, their stories were bolstered by actual data.  The debrief sessions that resulted were much more accurate. More to the point, the flight teams–who previously had a natural tendency to hide or forget their mistakes–became much more open about disclosing their errors, comparing them one with the other, and then learning from the experience.  The result was a documented improvement in pilots’ abilities.

Exploring Lean in Tel Aviv

A colleague and I are in the midst of an introductory training session about the Lean process improvement philosophy at Sheba Medical Center on the outskirts of Tel Aviv, Israel.  We were invited by Dr. Eyal Zimlichman, head of quality management for the hospital (seen here with Jessica Livneh, head nurse of the oncology outpatient unit.) As is often the case, we find highly committed, engaged staff and managers facing the usual assortment of hospital management problems. Their interest in the opportunities offered by Lean is palpable, but part of our job is to explain that adoption of this philosophy takes extensive time and effort. Our hope is that this session will give them a taste of the possibilities so they and their leaders can make a more informed decision about the path forward.

We were honored to be joined by Boaz Tamir, Israel's Lean guru.  You see him here with (from right to left--appropriately!) Yoav Shalem (pharmacist); Dr. Einav Nili Gal-Yam (head of the oncology outptient unit); and Miriam Adam (director of pharmacy services).

Pigs in service to America

The NSA probably knows this already, so I think it is all right to spread the word.

I noticed in my blog statistics that someone from the Department of Homeland Security was looking at a series of my favorite Lean training blog posts.  They are about drawing a pig.  Hey they are: Part 1, Part 2, and Part 3.

But I wondered what led them to these sites.  Well, the statistics app suggests that they came to it via a process improvement website from the UK.

However they got here, I am pleased, and I hope they find the exercises useful. I hope someone lets me know someday if the training will be used. And where? At the airports?

Lean good news from the Midwest

I received this announcement recently.  This sounds like an interesting and useful venture.

The ThedaCare Center for Healthcare Value and the Ohio State University Fisher College of Business are excited to announce the creation of the Center for Lean Healthcare Research. This new center will be housed at Fisher and will build the body of research on the emerging trend of process improvement in healthcare.

A press release elaborated:

As health care organizations continue to seek ways to improve patient care quality and reduce costs, the ThedaCare Center for Healthcare Value and The Ohio State University Fisher College of Business are partnering to build the body of research on the emerging trend of process improvement in healthcare. The organizations have announced the creation of the Center for Lean Healthcare Research, to be housed at Fisher. This collaboration will focus on studying and documenting how the Lean methodology is producing lasting change in hospitals around the nation. Sharon Schweikhart, associate professor and director of the Master’s in Health Administration program at Ohio State, has been appointed director of the center.

The ultimate goal of the Center for Lean Healthcare Research is to create a peer- reviewed body of research that elevates the profile of these Lean health care practices and better equips hospitals and other organizations to deploy them.

A solution to clutter

#GBMP1 Sometimes unexpected proposed countermeasures to problems called out during Lean process improvement efforts come up.  Look at the one proposed here on a suggestion form!  While Lean envisions countermeasures as temporary or iterative or interim solutions to problems, I don't think even the most creative of Lean experts would have come up with this one--even for the short term.

Thanks to Gary Peterson at O. C. Tanner for this humorous example.

Notes from a Lean conference

#GBMP1 I'm currently attending the 9th Annual Northeast Shingo Prize Conference presented by GBMP, a non-profit that is engaged in Lean educational programs.  Entitled, "True North: Set the Course, Make Waves," the conference began with a short introduction by GBMP's president, Bruce Hamilton.  Regular readers will recognize Bruce as the star of Toast Kaizen, a wonderful video illustrating Lean principles in the "production" of toast in a kitchen.  He began with the concept of "True North," which he defined as "the way things should be," but importantly the way things should be for both customers and those providing service to customer.

The keynote speaker was Gary Peterson, EVP for supply chain and production at The O.C. Tanner Company.  "We've made a ton of mistakes" with our Lean journey, he began:

Most of the mistakes we've made centered on our people.  We implemented tools and imposed them on our people.  They worked, but people hated it. We hired "a cop" to enforce use of the tools.  "That should have made it obvious that we were doing something wrong!"

The fundamental principle has to be respect for people, he noted.  He suggested that there are four things that are critical for getting people involved:

(1) Setting a clear vision:  Establishing an understanding of True North (an aspirational vision of what might be achieved--but paradoxically might be unlikely ever to be achieved), provide free flowing information, engage in true transparency.  "By the way," he noted, "Things somehow move from aspirational to the way things are!"

(2) Providing a powerful reason for engagement.  Don't use, "If we don't do this we may go out of business."  Focus on the purpose of the organization, the intrinsic reasons that make daily work meaningful and create a sense of pride.  (By the way, check out his company's blog to get a sense of this.)

(3) Engaging in a thoughtful and good improvement methodology.  Develop people for contribution, particularly helping people evolve into leadership roles that are supportive of the philosophy.  "We want eveyone to become leaders." Minimize rules that control: Avoid systems that get in the way. "Don't act like you are cutting them loose and then have them drag a chain behind themselves." Hire well: Ensure that they believe in the elements of a living culture--safety, continuous improvement, trust, respect for others, we are all in this together, Arbinger principles (avoiding self-deception.)

(4) Inspiring a desire to continue to do it and stay engaged.  Make it fun to learn and safe to venture into unknown territory.  Above all, "Show me you value my efforts."  Help people believe: "There is no secret ingredient."

How to keep Lean while eating

One of the dangers of becoming a Lean aficionado is that you see opportunities for process improvement everywhere.  Also, you feel an affinity for people who are able to go to gemba (the place where work is done) and, either by training or by intuition, look at work flows and find ways to improve them.  You have sympathy for them when their supervisors are unable to recognize their helpful suggestions or respond approrpriately.

I was giving a talk at a conference in Connecticut today and walked up to the lunch buffet table when I heard one of the servers say to her supervisor, "Shouldn't we move the chocolate cake closer to the coffee? Then, the potato chips can be closer to the sandwiches, too."

Of course, she was right.  Look above.  The flow of customers gathering their main course is from right to left, using a large plate (not seen here) for their sandwiches, using the condiments, and adding a bag of chips to their plate.  The flow of customers getting desert would be from the far end of the table, moving left to right, getting their coffee or tea and picking up some cake using the small plates. As the table is organized, when the two flows get busy, they would interfere with each other.

Her supervisor said, "No, the cake has to be near the B&Bs [the bread and butter plates], so we can't move it."

Well, as you can see, it would be possible to switch the chips and the cake and reconfigure things slightly to still allow the B&Bs to be near the cake.

Sure enough, as lunch proceeded, traffic jams ensued between the people who were picking up their main courses and the ones who had already progressed to coffee and dessert.

I offer this not as a treatise in the proper placement of luncheon foods on a buffet line.  I offer it more as an example of a manager who quickly dismissed a suggestion from a staff member without engaging in a reasoned discussion of the alternatives.  We see this all the time in hospitals and other organizations, where a manager becomes blindly wedded to "the way we've always done it," and in so doing discourages front-line staff from offering suggestions for process improvement.

Ipswich leaders offer next steps on Lean

As we ended our Lean training workshops at Ipswich Hospital NHS Trust, I asked the participants to send me an email indicating what concrete steps or actions they would take in the next week to practice or implement some of the principles we had discussed.  Understand that I was not asking for a full implementation of the Lean philosophy in the hospital:  That requires a huge commitment at all levels of the organization and is something not lightly entered into.  Rather, I suggested that the basic principles of Lean can be practiced by managers and leaders at any time.  Quoting Don Berwick's line that "soon is not a time," I suggested that if you don't actually begin to practice those principles, they are easily left aside during day-to-day activities.  Here are some responses, with names omitted:

-- I think we do not do enough of this, that is the reflecting on the work we do and how we do it. There have been a few gems over these events, but one for me to highlight was the response that I did not get time to write after the second day of the course, when I was going to tell you how much I hated my office. It’s actually a nice room, light, airy, and well located, but I’m in it too much, and that’s why I don’t like it. The trip we had to stores was an important reminder for me to get out and about more – and I have now scheduled time in my weekly diary to do just this. In my own unit we have initiated a new ideas scheme, and I think this is a good practice, but your element of calling out issues, build on that even more, and I am now thinking about how we can recognise and encourage such behaviour. It’s funny that last night I realised that one of our excellent middle grades in the Oral department has called out just recently, pointing out an important issue with our outcome forms that we are now resolving. I intend to write about this in my next newsletter.

-- You might have already worked out the NHS problems such as long waiting period for clinic appointment, long waiting list for routine surgical operations, failure to meet targets,  ineffective utilization of theatre and some of the staffing issues in the department. I observed the measures the management teams are taking and miserably failing to sort out the problem or fixing it temporarily and finding them in the same situation again. I do not have any management training, but I try to put myself in a mangers position and think. Often, I think if they try a certain approach it could work. As a clinician, being in similar situation at other hospitals and seen different management strategies which work, I wish I could shout out my ideas and open a dialogue, eventually solve the crisis. But often people in management or power don't listen. I feel embarrassed and often apprehensive as how others take your opinion. Also, I do not want to offend my colleagues and consultants with ideas which will direct implication on them.  I sincerely hope this Lean workshop will help Ipswich Hospital to work out the areas which needs careful management intervention.

-- I will use every opportunity to visit the shop floor and in doing so change my approach to one of observation and learning. I will start referring to little changes that I have made each week when I meet with my senior team, and I will begin to ask them the same so that we can all learn from our changes and how these have been achieved.

-- In the next few weeks I want to implement a number of small projects implementing the Lean principles. These include looking at the way my colleague and I process colorectal referrals, which currently come to us in batches and take ages to work through, with the resultant work being delivered to the secretary all in one go. I am sure we can turn this into a continuous work flow.

This morning, I saw in the store room, theatre gowns, which I was told had stopped being ordered. They prevent my forearms being covered in blood after long abdominal and pelvic surgery. I will speak to the relevant people to ensure they are delivered to theatres on a regular basis. 

-- I have long thought that Lean is a system that we must embrace. I have read often of the benefits of its application in healthcare. However from your tutelage I now understand that it is a methodology first and foremost to improve the quality of care we give our patients. Any financial benefits are as a result of this ‘the virtuous relationship between quality and finance’ as you put it.  I think this fact is lost often in translation (the pun is intended!) and certainly has been an impediment to its dissemination in healthcare in the Ipswich.

It is my hope that as a result of your visit we now have a nidus of colleagues who have seen the huge potential of working in this way. I will try to bring us together, initially informally, once a fortnight to share our experiences and our successes. I am going to suggest that we each try to cascade Lean to one other individual every month and so on and so forth (a bit like Amway!). In time incrementally we will develop a philosophy across our shop floor of continuous improvements.  From our group we will identify someone to receive more comprehensive training to become our Lean coordinator or sensei.

-- I believe that the changes we make have to be sustainable. Small changes will make a difference. As an organisation facing many challenges, we must ensure we do not waste energy by repeating processes that do not work.

My mission will be to engender a 'can do ' attitude.I will challenge any negativity from staff, and  I will challenge myself to ensure I have the systems in place to allow all my staff the opportunity to contribute ideas and comments. I will work with my team leaders to action these.

I will challenge myself to visit areas in the Hospital I am unfamiliar with, in relation to the patient pathways and processes that affect patients who are cared for in my areas. This will help me understand the real experience the patient has and allow me to examine ways to improve the systems.

I will also invest some time to reorganise my office to improve my access to information etc!

-- Pledge to spend 1 hour a week with a colleague observing work with an aim to make improvements to their working life. And do this with respect for a co-worker who knows more about their job than I (as a manager) will ever know. Then ask that person to do the same for 1 of their colleagues to rapidly spread lean principles across the organisation.

-- After an energised afternoon looking at the 5S, I and my other 'Lean' colleagues returned to our offices. At least four of these colleagues took this opportunity to check their inbox. As responses hit my inbox during the time I sat also responding to emails. I asked myself 'Is email the best way to communicate this message?'

There must be alternative ways of conveying a message. I plan to involve staff by asking them to discuss the benefits and drawbacks of looking at other channels of communication

Could we consider a no email day? Why do we send an email when a face to face meeting or a phone call maybe more effective & even quicker than waiting for an email response.

Perhaps a coffee or lunch break with a group could be utilised to share information and we can encourage staff to think of alternative ways of communicating information.

I will review the types of information that I regularly send and receive. Many of them are to request information required on weekly or monthly. Instead of chasing on a weekly or monthly basis perhaps develop a timetable of the information required. 

My initial thoughts are that perhaps phone calls and face to face meetings could be more time consuming however as an organisation we need to make a real effort to reduce email overload and I believe this has the potential to ensure better teamwork, a quicker problem solving approach and a happier workforce.

-- Next week I plan to improve our ultrasound scanning service to inpatients.

At present, at the start of the day, all the pending inpatient ultrasound scan request forms are reviewed by the radiologist scheduled to perform the scans. This means there is a flurry of activity (batching of work) in the early morning with the radiologist sorting through a large pile of paper forms, the imaging assistant ringing the wards with instructions and writing out collection slips for the porters, the ward clerks receiving those instructions and passing on the information to the relevant nursing staff who in turn speak to their patients about what is about to happen. It is all a mini whirlwind as this needs to occur before the radiologist starts scanning the first patients on the list (who are outpatients arranged in advance - to prevent downtime whilst waiting for the first inpatient to arrive). 

The rush means it is stressful for all in the chain. For the imaging assistant it means time on the phone and liaising with the porters when she should be helping with the first (out)patients. On the ward other tasks are interrupted to prepare their patients to come down for their scan. Because of the short notice often the doctors on the ward rounds do not know that the scans have been scheduled and ring up to enquire if and when the scans will be performed thereby disturbing the radiologist who has to stop scanning the patient of the moment. Additionally, there is frequently inadequate time to get the necessary preparation right, e.g. the patient for a pelvic scan has an under filled bladder and the scan is inadequate or worse still needs to be repeated. Most importantly, the patient and their relatives, who have usually been told by their attending ward doctors that they need a scan, are anxiously waiting not knowing what is happening for longer. 

How can we make this better? 

One possible way would be to review all outstanding request forms at the end of each afternoon and schedule the scans for the next day. That way everyone knows well in advance and can be planned to fit in around other activities. Waste could be reduced. 

Can I persuade my colleagues to change? Will they come up with a better solution? Watch this space.

-- Have largely been doing this process for the last 7 years thus the result of a large well functioning AMU which is Nationally acclaimed for its results.  My steps now will be to insist other departments work with us in the same way to allow a smooth patient journey...first e mail has been met with horror so far!!

-- I am currently tidying my office!

Last week we had a crisis meeting about an inability to find slots for patients to have lung function tests. I now realise how we can make the situation better but using existing capacity in a smarter way. In the next week I intent to meet with our lung function unit manager to find a way of better matching his work load to the chest clinics. His team appear to run the same timetable every day even though the chest clinics are not evenly distributed.  Also, if I go on holiday, I don’t warn him that this is the case and so he can’t plan a different task for his technicians.  Given enough warning they could book more patients for routine tests on these days that don’t have to be coordinated with my clinic.

-- I have today agreed to mentor a colleague who works at a supervisory level in the Trust, meeting her once a fortnight to discuss the issues she faces, and help her to work through them.  I plan to share practical Lean principles during these sessions with her.

Whatever I am doing I will always watch, listen to and spend time with my teams to truly identify the root of problems/obstacles; working with the team to resolve them together – this is the crux of every manager’s job!

Please be persistently dissatisfied

A tweet by @dripchamber caught my eye:

If I ever say, "Overall we're happy with the way the hospital is headed, infection-wise," please shoot me.

And the s/he links to this article in the Baltimore Brew.  An excerpt:

After one of the deadliest weekends in Baltimore in several years – 8 people dead, 20 shot in all during the period from Friday afternoon to Monday morning – comments by the city police spokesman are prompting blistering criticism in some quarters. 

“This is a little bit of a spike in terms of the weekend, but all in all, we’re pretty satisfied with the way the city is headed, violence-wise,” Guglielmi said, in Carrie Wells’ story in today’s Baltimore Sun. 

I loved@dripchamber's comment, not only for the clever directive that alludes to the violence covered in the article, but more importantly for what it stands for about quality improvement in hospitals.  Indeed, about quality improvement anywhere.

I have yet to meet any serious adherent to the concept of quality improvement who is ever satisfied with regard to progress made.  As my friend and colleague Roger Berkowitz, CEO of Legal Sea Foods, is wont to say about quality in his restaurants: "This is always a work in progress."  (Disclosure: I am on the LSF board.  Mainly because of Roger's commitment to quality.  But also because of the clam chowder!)

In the hospital world, whether people are engaged in Lean process improvement or another approach to the issue, the primary characteristic of those furthest along is modesty.  "We've learned a lot," they might say, "but mainly we've learned how far we have to go."

This implies a need for curiosity and experminentation and a leadership cadre that encourages blame-free learning at all levels in the organization.

As Virginia Mason's Sarah Patterson has said: "Just tell them to do it. Don't be afraid. It won't be perfect. Try it. Fail. Try it. Change. Keep going."

Creating an insatiable appetite for improvement

John S. Toussaint and Leonard L. Berry masterfully set forth the essence of Lean in an article entitled, "The Promise of Lean in Health Care."

Lean is not a program; it is not a set of quality improvement tools; it is not a quick fix; it is not a responsibility that can be delegated. Rather, Lean is a cultural transformation that changes how an organization works; no one stays on the sidelines in the quest to discover how to improve the daily work. It requires new habits, new skills, and often a new attitude throughout the organization from senior management to front-line service providers. Lean is a journey, not a destination. Unlike specific programs, Lean has no finish line. Creating a culture of Lean is to create an insatiable appetite for improvement; there is no turning back. As Lean consultant Joan Wellman states,“With Lean, you will keep changing your definition of what ‘good’ is."

Mayo Foundation for Medical Education and Research: Mayo Clin Proc. 2013;88(1):74-8.

John Toussaint provides a roadmap to Lean success

This should be an excellent (and free) webinar, given by John Toussaint, one of the true experts in hospital process improvement.  Here's a description from Joshua Rapoza at the Lean Enterprise Institute.

I'd like to invite you to join us April 16, 2013, at 2:00 pm (Eastern) for the 60-minute, free webinar "A Roadmap to Lean Healthcare Success" with John Toussaint, MD, CEO of the ThedaCare Center for Healthcare Value, author of On the Mend, and a national leader in improving healthcare through lean principles.

As CEO of ThedaCare, Dr. Toussaint introduced the successful ThedaCare Improvement System, a lean healthcare system.

In this webinar and Q&A, he'll describe a roadmap to lean healthcare success, based on his visits to 120 healthcare organizations as well as many visits to leading lean manufacturing companies.

Learn what Dr. Toussaint will cover and how to register.

When the doors of the mind open

I’ve often wondered why the psychiatric wards are the most drab and depressing parts of hospitals.  After all, you’d think that the architects and interior designers would be instructed by the facilities administrators to brighten things up for those patients suffering from mental illness and for the clinical staff who take care of them.  But no.  You know, even from the outside of the ward, that this is an unpleasant environment.  The door to a locked ward, with at best a small window looking in and out, is placed at the end of a dark corridor, surrounded by a wall colored in institutional gray or green, and often with no sign indicating what is inside.  Hope is quashed.

That despair is precisely what Teresa Pasquini, the mother of a young man with mental disease, noticed at Contra Costa Medical Center in Martinez, CA.  She notes: “The doors of the psychiatric units were seen as the hospital’s property and a way to control access.  Visitors were also controlled, and the mysterious world of the psychiatric units were misunderstood and often feared.  The entry into this emergency service was bare and unwelcoming.”

But change was possible, through a broadly inclusive Lean behavioral health rapid improvement event.  She explains:  “The Lean process takes you away from the meeting room and puts you on the front line of care observing each process.  This allows you to recognize what is waste and what has value.  Lean lets you see across the silos of the system and recognize the delays, the redundancies and harm.”

Indeed, while much of the focus of Lean is often on waste attributed to classical manufacturing concepts like excess transport, inventory, and waiting, those of us engaged in Lean often point out that one of the key wastes is “the waste of human potential.”  Unfortunately, if there is ever a part of a hospital that is likely to feature the waste of human potential--both of staff and patients--it is in the mental health areas.

Look at this simple result.  Teresa explains:  “With the help of a community partnership and three mental health consumers, who designed and painted the entrance to the psychiatric emergency area, this door now symbolizes the commitment to patient and family partnership and to co-producing a more welcoming and accessible experience for all who come here for care.”

Rabble rousers say, "We are the expert system navigators"

Teresa Pasquini (above, left) is a self-styled rabble rouser, "the queen of the letter writers," who used to spend hours trying to get her local hospital to do a better job caring for patients.  Who better then for CEO Anna Roth (above, right) to recruit as one of the first Family Member Partners for the Contra Costa County Regional Medical Center & Health Centers.

Patient-family advisory councils have been described as "the next blockbuster drug," the single most important advance in the delivery of medical care that is likely to show up in hospitals.  I had the pleasure today as Teresa and Anna participated in a webinar offered by the National Association of Public Hospitals on the topic of patient an family engagement.  Appropriately, most of the time in the webinar was taken by Teresa describing her motivation and involvement in the PFE process.  Her first statement got my attention, and the rest of her talk kept it.  Here are some excerpts:

I need to start my comments by sharing what drives my passion and commitment to this work.  I am the proud mom of a 30-year-old son with schizoaffective disorder who has spent the majority of the past 14 years in psychiatric facilities behind locked doors.

Doors, hope and harm have been a running theme in our life since our son was diagnosed.

My son has been hospitalized over 30 times in several locked facilities.  The past 14 years have been a blur of suicide attempts, over 40 involuntary holds, revolving hospitalizations, and a permanent conservatorship.  With a diagnosis at age 16, we began to navigate a maze of services in one of the most integrated health care systems.  It was a nightmare.

I was an angry mom when I was invited to my first Lean event at CCRMC.

Prior to this event, there was concern about me whispered around the tables and behind closed doors.  Cautious warnings were shared about my outspoken, even radical, direct action approach.  Fortunately, the Administration of CCRMC took a risk and opened their doors and minds and even encouraged me to push them forward.  The first event was the beginning of a special human connection that ignited our shared vision of hope.

Our partnership started off without clear direction.  There were underlying control issues.  We moved cautiously building trust and respect.  By staying at the table we began to overcome our fears and find our way to the "field beyond right and wrong."

We were teaching and learning together and laying down the tools that had been failing.  We were challenging the system and embracing the tension that comes from change.  And there was tension.

The tension was often whispered offline or subtly felt in meetings.  The staff was not trained to be open with "outsiders" in the room.  The patients and families were not familiar with "medicine speak." But through determination, courage, and leadership, the comfort level increased and transformation began.

Contra Costa County Health Services has shown bold courage by offering our community a trusting, authentic, shared learning experience and partnership that goes beyond the traditional advisory role.  We are not token advisors but rather equal and respected partners.  We have learned to speak the truth, hear the truth, and go and see the truth.  With constancy of purpose and focused direct action, we are co-creating a system where the consumers, families, community organizations, clinicians and staff work in a true partnership.  No politics, no discrimination, no special interest, no egos, just pure ethical health care based on the needs of the patient.  I have seen it happen.  It is possible.

Nothing is scarier that the health system when your child is sick.  Please, don't be afraid of an an angry mom or patient.  Invite family members like mine to tell you our experiences and let us help you create solutions.  Nobody comes to work to harm others.  We are the expert system navigators and we will help you design a better system for all.

Organizations That Can’t Fall . . . Die on Their Feet

A not entirely unintended consequence of the various aspects of health care reform in the United States is the growing concentration of ownership of hospitals and physician organizations.  This is occurring because hospitals and doctors are predicting that they will be forced to take on a greater portion of the financial risk of patient care.  Creating larger networks is one strategy for dealing with this.  Larger networks provide more actuarial support, in terms of a diverse risk pool.  Also, by incorporating primary, secondary, and tertiary care into a network, the potential exists for more effective case management.  Finally, a larger market share is viewed as helpful in asserting leverage over the insurance companies.

I seek not to discuss in this post whether today's management cadre is capable of executing the business strategy of a system, as compared to a single hospital or physician group. While that is a topic worthy of discussion, my purpose today is to focus on broader issues.  In particular, let's explore the possibility that the growth of hospital networks can lead to such a reduction in competition that the result is one or more systems that are "too big to fail" in a given geographic area.  When firms reach this status in society, there can be dangerous ramifications.

My Israeli colleague Boaz Tamir (Israel Lean Enterprise) recently wrote about these dangers in a paper originally published in Hebrew.  I offer excerpts from an English translation here.  The discussion covers several types of industries, but there is a clear connection to the health care world that is evolving in the US. The title:

Organizations That Can’t Fall . . . Die on Their Feet

Here in the empty land, in the ebbing time

      We live and do not live, die and do not die.*

Does the fact that an organization’s fall is likely to shake the foundations of the economy and the society in which it operates justify preserving it at any price? When the central-bank commissioner prevents the bank’s collapse in the name of “banking stability,” does he take into account the damage this entails for how the bank is managed, for the market and the customers? Does the insurance supervisor who prevents the collapse of an insurance company really help the public of insured persons?

Is it not clear that no government would dare close a hospital even it slid into bankruptcy because of failures of corporate governance and administrative atrophy? But does anyone take into account the destructive effects of this premise on the possibility of correcting the defects of management and service, or on the number of patients who will die as a result of them?

The dream of managers, workers, suppliers, and financiers is to belong to an organization that cannot fall. Once they are part of such an organization their niche is guaranteed, along with the future of their families and associates. But what about the future of the customers who were forgotten—the insured, the patients, or the small households?

An organization that cannot fall lives inside a bubble. The price of its services is determined according to its operating costs, padded by its cost-plus. Such an organization, if it lacks a leader capable of working against the “force of gravity,” will naturally oppose any change, show no interest in developments in its environment, and fail to repair administrative failures or systems that have atrophied within it. When there are no mechanisms for seriously assessing its efficiency, nothing will lead management to insist on operational excellence, attract professionals and excellent workers, prevent waste, reduce hidden unemployment, and focus on creating value for the customers—the declared goal of an organization that operates in a competitive environment and is not immune to a fall. 

Any organization, from the moment its existence is not dependent on its customers, is like a body whose nervous system is impaired and has lost the sense of pain that was intended to protect it. It has no real impulse to streamline, upgrade its capacity, or create value for customers, who are seen as a nuisance instead of the source of its life. Therefore, the default option of such an organization is to atrophy from within. The mission, the goal, and the vision that led to its establishment are already faded memories that hang on the walls of the building’s entrance beside pictures of CEOs. 

The raison d’tre of an organization that cannot fall, that is maintained at any price even when it has gone hollow, is preservation of a body that lacks any vital sign of value for the customer, or in other words, preservation of the interests of the managers, the workers, the local authority, the ruling party, or the shareholders—everyone except its real customers, whose benefit was the original justification for its existence. Sadly, experience teaches that from the moment an organization is “sanctified” as an institution and cannot fall, the process of systemic atrophy cannot be reversed. Nor can the inflated results, unwieldiness, inflexibility, and damaged functioning.  

It is, though, an illusion to think that an organization that cannot fall has not died. Arriving at atrophy and systemic collapse, its end is to die on its feet. No one dares uproot this tree even when its fruits have long expired and its higher managerial levels have dried out. No one will dare proclaim the end of an organization that cannot fall even if it stands only as a silent monument—not even to make way for the growth of a young, naïve organization that seeks to justify its existence by achieving its goal: providing service to its customers.
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*"Here in the Land," from the book by Amir Or, Masah Meshugah, Keshev l’Shira, 2012 (in Hebrew).

Inspired at Children's Mercy Hospitals

I have visited dozens of hospitals over the past two years, spreading the gospel codified in the upper right-hand corner of this blog--patient-driven care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement.  My audiences are invariably polite and engaged, and I try to leave them with a sense of the possibilities before them.  I know that some are inspired to take action, and some are not.  I sometimes wonder if I make a difference.  Is there a more useful way to spend my time?

And then I visit a place like Children's Mercy Hospital in Kansas City and get a jolt of renewed energy and optimism.  And, lo and behold, they tell me that I help do the same for them.  What karma!

I had a jam-packed day at CMH today.  First, it was multidisciplinary Grand Rounds, with a presentation to several hundred people in the auditorium and outlying facilities.  Here's my host, Executive Vice President Karen Cox.  The theme:  "These Things Happen: How Harm Occurs in Hospitals and What We Can Do About It."

But then I got to see the team in action.  I attended the Daily Safety Update, a short (9:10-9:30am) huddle of people from throughout the hospital reporting on operational matters and other issues that could affect patient safety.  It is chaired by Jason Newland, medical director for safety, and Cheri Hunt, chief nursing officer (seen here).

One of the things that Lean organizations do is to promote and encourage standard work in clinical and operational settings.  But managers have to engage in standard work, too.  You may recall that Virginia Mason's COO, Sarah Patterson, explained this when she discussed important aspects of daily management: 

Elements of daily management = leader standard work + visual controls + daily accountability process + discipline.

Whoa! Leader standard work, too! What a concept. Can't be "too busy" for this!

With leader standard work made visible, staff now know, "Oh that's what leaders do!"

The CMH people have put this into place in a clear and effective way.  All participants in the meeting orally fill in the chart of a daily operational report covering key areas.  The reporting is efficient and direct, with areas of action set forth.  For example, Rachael Dameron (above) presented data on the total number of ventilators in use in the various units of the hospital, staff on site last night and today, and any key events.  Meanwhile Sherry McCool (below) reported on transport:  How many runs in the last 24 hours, how many missed runs, how many delayed runs, and anticipated concerns for the next 24 hours.

The Daily Safety Update has created precursor and following events.  Pre-huddles occur in the departments beforehand, so that the required data and status reports will be accurate.  After the 20 minute meeting, subgroups will often coalesce to follow up on issues raised during the huddle.

CMH is not the only hospital that engages in this kind of huddle, but the process they use is as effective as any I have seen.

The rest of my morning was spent with people who work on programs to increase patient involvement in the hospitals' delivery of care.  CMH has several family advisory boards, volunteers from the community who work with the hospital staff to help deliver more patient-centered care.  Here, for example, you see DeeJo Miller, a family centered care coordinator, with Terrance Gallagher, a patient's father, who volunteers his time on one such FAB.   DeeJo is one of the hospital's "parents on staff," paid people whose job functions include special attention to the needs of patients and families.

Among other things, DeeJo and her colleagues conduct educational programs for residents on the issue of patient- and family-centeredness.  One part of that curriculum is to send residents on in-home visits, to see patients and families in their real life settings.  She presented some verbatim reactions from some of the residents as their eyes were opened to life "out there."  Here's a small sample:

Thoughts or concerns prior to your visit:

Looking forward to seeing a family's house.  Dreading the fact that it was 2 hours.  I didn't really know what I was supposed to do.

Tell us about you in-home visit:

It was more laid back than expected.  the whole family was involved.  Mom stated at the beginning that there is "no wrong way to ask a question."  Helpful to talk to the sibling.

What strengths did you see in the family?

Amazing support among the siblings.  "Supervised independence"--The parents let the daughter manage her diabetes; however, they always check on her and double check what she is doing.  They do it in such a discreet way the daughter may not even realize that they are checking on her.

What surprised you the most?

Daughter was insulted by the doctor's attempt to equate her insulin pump to video game Mario Cart.  She said it was "cheesy."  High functioning children--they were more adult-like than kid-like.  Don't remember what life was like before the diagnosis.  child's openness, how much she knew and verbalized what she didn't want to talk about.  Child's attitude mimicked Mom's attitude.  The normalcy of it all. 

What, if any, is the value of meeting in the home versus meeting somewhere else?

Made me think about the difference between just telling a family what to do and realizing how much work it takes to follow the instructions.  Makes you think more about making sure that the family has what they need for home.

I sat admiringly through all these sessions, which demonstrated a thoughtful execution of the principles I mentioned at the start of this blog post.  But I was even more impressed by the constant, "What do you think of this?"  "Can we do it better?", questioning I received from the staff as the day went along.  This is a group of people who are discontented with the status quo, who are modest about what they know and what they have accomplished, and who insist on getting better.  I was told later than my visit gave them a shot in the arm, a reminder of what is possible, but it was actually they who did that for me.  What a marvelous day with marvelous people!

Leaning at Mt. Scopus

I am in Jerusalem and joined with a colleague to conduct a couple of workshops for senior managers and physicians on the basics of Lean process improvement.  As I have noted before, the introduction of Lean into a hospital or any other complex organization is not something to be undertaken lightly.  Lean is not something you do, like a short-term project.  It requires a tremendous commitment on the part of the leadership, extensive training, and the patience to spend years on infusing the Lean philosophy throughout the organization.

Today's workshops at the Mt. Scopus campus of Hadassah Medical Organization were therefore meant to be introductory in nature.  We started with the excellent Toast Kaizen video produced by Bruce Hamilton of GBMP.  Using the seemingly simple preparation of toast in the domestic setting, Bruce demonstrates the various types of waste that occur in organizations.  He helps viewers see these forms of waste in a way that is elegant and simple.

We followed with two simulation games that are designed to teach a couple of aspects of Lean techniques and approaches.  The first game is intended to teach the value of the 5S  system of reorganizing spatial settings.  Students are given sets of numbers in different patterns and ask to perform functions with them.  The process gets easier and more accurate as they apply the steps of 5S improvement: (sort, set in order, shine, standardize, sustain).  As you can see below, our game provokes lots of laughter and engagement.  We seek to break down the defensive barriers to learning as we use non-work-related examples to teach the principles that can then be applied in the workplace.

The second game was designed to teach the difference between batch and continuous flow processes.  While there is a place for both in organizations, there is a tendency for hospitals to create batch processing where continuous flow processing might be more effective in serving customers and in enhancing the work environment.  Our group was divided into two teams, one performing a series of tasks (fold paper, stuff envelope, address envelope, stamp envelope) in a flow pattern and one doing the same in a batch process.  The frustration of the staff involved in the later stages of the batch process--as they awaited the work to arrive to them--was palpable, as you can see below!  Lesson learned.