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.
---
*"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.

La méthode Toyota pervertie

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

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

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

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

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

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

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

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

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

In fact, what it is has nothing to do with the Toyota method, but instead is a practice of Lean, disembodied from the fundamental values of the Toyota approach.
 
At Toyota, the continuous improvement process is based on the respect that the company provides to its customers, suppliers and employees. Continuous improvement, yes, but never at the expense of respect for persons.

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

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

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

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

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

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

Several months ago, I declaimed:

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

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

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

As I have said:

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

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

Who needs a waiting room? (Part 3)

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

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

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

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

Who needs a waiting room? (Part 2)

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

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

Who needs a waiting room?

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

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

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

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

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

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

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