by , on 25 Jun 2014 01:14 pm
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Waiting for Health Care – no longer ‘just the way it is’?

http://www.nydailynews.com/news/politics/obama-mulls-cleveland-clinic-ceo-head-veterans-affairs-article-1.1816789

The Cleveland Clinic’s capability to provide same day access for any specialty came up during a lunch break at a recent kaizen event. The idea of this capability, to me a seminal achievement in the customer first healthcare movement, baffled many in the event, but the fact that Cleveland Clinic actually does it, and advertises this capability nationally, left some dumbfounded.

Following this, you can imagine that I was very excited to see Obama considering the Cleveland Clinic CEO, Dr. Cosgrove, for the vacant secretary of Veteran Affairs job. For me it signaled, on the national stage, that lead time now matters in health care, and that patients, the media, and consumers at large are demanding health care to be on par with other industries in the time it takes from request of good / service through delivery (as retail creatively looks to shave minutes / seconds off of their lead time (see article below), does it not make the weeks / months in health care seem even more outdated?).

http://www.nytimes.com/2013/11/24/technology/in-war-for-same-day-delivery-racing-madly-to-go-last-mile.html

As a practicing lean consultant, working with clinical teams on the front lines, I have the opportunity of seeing this thought revolution occur one team/team member at a time. A transition to:

  • Seeing their work as a process, and a process that needs to be customer first – challenging paradigms, a sense of helplessness, and other perceived barriers as they take action toward better.
  • Experiencing the paradoxical power of diving into the details to produce big results: challenging the steps and sequence of their work – striving toward an ideal, and reducing cycle time and lead time as a result.

I’ve found the most enjoyment in helping teams experience that small improvements in their cycle time can add up fast, as:

  1. 5 minutes taken out of each 30 minute visit means 70 minutes back into their day. And this time back reduces lead time dramatically for other patients, as they can be seen today instead of tomorrow or next week.
  2. They break through the belief that ‘it’s as good as it can be’ and experience that the process can in fact be better for the patient and themselves, they begin to discover opportunities everywhere – big and small.

We have just begun to experience the tremendous possibility of this humble approach at Group Health, and the spread has been rapid as clinical teams rediscover what is possible, and that they are the experts – capable of leading the way to dramatic improvement in lead time, quality, and cost. I am left with high hopes – for what Cosgrove’s consideration (he has since declined) tells us about our nation’s growing expectation for health care, and a local parallel – my teams work to support a transformation in Group Health’s small piece of US healthcare. And why not be optimistic, maybe same day access for any specialty will be the norm across the US very soon…shouldn’t it be?

Popularity: 29% [?]

by , on 06 May 2014 12:04 pm
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Why does it take so long to make things happen? by Sean Sessions

 This year I became a home owner.  With a new interest in the quality of life within my neighborhood, I’ve reached out to local community groups, hoping to combine my loves of civic involvement, and community service, with my passion for process improvement.  Apparently both community service and lean have been married for a while with a movement known as “lean urbanism.”

Lean urbanism is a movement which seeks to challenge the current paradigm of long-standing rules, as a way of reducing the burden on business and development to quickly innovate and implement new ideas.  The challenge comes by simply testing the rules by taking action, gathering people, and mocking up what is possible

The red tape of city ordinances restricting where and when to plant trees and at what cost,  where to install crosswalks, bike lanes, recycling bins, outdoor seating, dog parks, etc., all greatly lengthen the time to build and implement; if the hurdles to implement don’t completely stymie the implementation all together.

In working with city commissioners, building inspectors, and others, lean urbanism seeks to create “pink tape” sandboxes, if you will, to test out mock-ups for business development while challenging timelines, permitting processes and rules preventing rapid implementation of business start-ups.

A community in Texas gathered some people together to build a dog park.  The group brainstormed and thought, we need to find a space that meets the 30-acre city rule for a dog park.  Then we should raise awareness, and get the word out.  Raise some capital to pay for it and design the build.  So, it should take about 5-7 months… Jason Roberts of BetterBlock.org said, “let’s do it tomorrow!”  So they did.  Within a weekend they had a mocked up dog park.  They challenged the rule of the size of the dog park, and were able to work with city government to move the mocked up dog park to a nearby location, at a size smaller than required by law.

In health care I see similar red tape conditions.  Rules determining when and where to appoint patients for care based on tricky clinical schedule templates, complicated staffing schedules, and varying business hours elongate the time between when a patient wants to receive care, and when they do.  Rather than focus on following the rule, why not ask what is ideal for the patient? When does the patient want to be seen?

I encourage those in healthcare to build your own sandbox to try new ways of thinking.  Challenge those rules.  Maybe break a few.  See how quickly you can incite improvement.  Do it quickly…Just try it!

Popularity: 14% [?]

by , on 06 Dec 2013 02:38 pm
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Moonshine in the Home?

As I watched a recent 3P team in action – I could no longer ignore it. a little voice saying: ‘for any home improvement, you must use the 3P moonshine principles!’

Make it physical with zero cost, and then simulate the process within that physical environment many times to experience and improve the process.

Seems simple, but I’ve never thought of doing it at home. To be clear, little voice you’re saying:

  • Before my wife and I knock down the wall that bugs us between our kitchen and living room, and put in the island that looks so cool in the magazines, we should find a way to mock up the physical environment and run through the scenarios of how we’d want to use the space?

 

  • Before we change the furniture arrangement, or buy a new piece of art, or lamp,  we should do the same?

 

Seeing the quality outcomes the team produced quickly and with no cost, the little voice’s answer was definite - ‘YES, absolutely!’  So, why don’t I?

  • It takes time, effort, and creativity to create the mock ups – how could we do it for no money but still real enough that we can have a realistic experience?

 

  • It takes patience. It’s a lot more fun to just tape up a picture on the fridge of the “Kitchen Nirvana” straight from a magazine, and start sledgehammering!

 

However, as I list these barriers, I realize none are in line with the wisdom I hope to live out, especially with the money, time, and energy that a home remodel requires.

So, for me, there are no excuses – I guess you’re right little voice.

Fortunately, a distinct lack of money is preventing me from taking any foolish home improvement actions at this time. However, if that ever changes, I will mock-up, simulate, improve, repeat, and then only after many cycles and the emergence of a thoughtful process, spend money.  

Have you ever done this for your home or another area of your personal life? If yes, how’d it go? If not, what barriers emerged for you?

Popularity: 25% [?]

by , on 22 Nov 2013 02:00 pm
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What Do Customers Want?

 

 

 

 

Can kaizen activities be truly meaningful to the success of the business if we lose sight of what customers actually want versus interpreting the customer’s requirements through the lens of the business’s current capabilities?

I am beginning to believe the answer is no, and that customer responsiveness is at the heart of kaizen.

I’ve used the pictures above in conversation with teams to illustrate the difference between customer requirements and current capabilities. Each new company gained market share by challenging the existing assumption for what customers really want – Netflix asked: Does a physical location have anything to do with the customer’s requirements? Redbox asked: Is mail delivery from an online selection meeting all of the requirements?

  • Was Blockbuster blind to the heavyweight competition Netflix truly was, mistaking past sales / growth as an indicator they’d met the customer needs instead of humbly recognizing ‘we’re just the closest to those requirement right now’?
  • Similarly, was Netflix blind to their weakness in achieving the “exactly when they want” component of the customer requirement that Redbox has exposed?

Of course, the story isn’t over, as each has attempted to respond to the exposed weaknesses. In fact, this will most likely continue forever, as customer requirements will never be perfectly met and sustained. Given this, will the most successful company be the one who is most relentless in their pursuit – the one who never stops believing the requirements could still be better met?

Which brings me to Health Care. At a recent lean health care conference, a CEO of a ‘high performing’ hospital system described their performance as “The Cream of the Crap,” which garnered wide spread applause. I can’t help but wonder if that was because it was not only humorous, but an accurate summary of our current state as an industry – are even the best performers nowhere close to what true customer requirements are?

Are health care organizations so consumed with comparing themselves to other health care organizations that we’ve lost sight of what customers / patients actually want, and how far off we all are?

If true, do we have any choice but to continue resolving the issue by asking:

  • What are the true customer requirements of health care?
  • What’s stopping me /my company from being the Netflix / Redbox of our macro health care system, exposing the perceived barriers that our current capabilities and paradigms create as fallacy?

Popularity: 19% [?]

by , on 11 Nov 2013 09:20 am
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The Importance of Minding the Gap by Lori Heniff

“Mind the gap!”

Travelers and commuters in London Underground tube stations regularly hear that warning to be cautious when crossing the gap between the station platform and the train itself. There might be significant distances or height differences between the two, and someone who didn’t see the disparity could easily step into empty space and find themselves in serious trouble.

 

 I thought about that warning during a recent event to improve the flow of patients between the Urgent Care (UC) and Radiology departments located on different floors at one of our facilities. To prepare, I did onsite observations and saw UC patients having very mixed experiences:

  • Once a patient had left the custody of one department, there was no way to track where they were and when they might be expected to arrive or return.
  • Patients might be given directions to the elevators and sent on their own, or they might be accompanied and dropped off to sit in a waiting room until the next department called them back.  
  • Some patients barely waited while others sat for an hour or more (sometimes wearing a hospital gown in a public seating area).

It was clear to me that staff in each department worked hard to provide exceptional care to “their” patients, but neither group felt ownership over the ones in transit between the two areas.  People were disappearing into the gap, but staff didn’t know because they couldn’t see the whole patient experience.

Years into my own Lean journey I still make a conscious effort to reframe everything in the customer perspective. I learn over and over that the gaps between steps that are invisible to us often provide the most dissatisfaction to patients, and if we don’t look deliberately and continuously we’ll never be able to see them.

The event had happy outcomes for our patients. Team members looked at the flow from the patient perspective and immediately saw the gap. Once they knew it existed and could quantify it, they began rapid cycles of improvement to prevent it. They’re instituting a pull system through which Radiology will regularly tell UC when they have immediate capacity, and staff will escort patients between areas to provide warm handoffs.

It’s amazing how something as seemingly easy as minding the gap can make such a critical difference.

Popularity: 18% [?]

by , on 31 Oct 2013 09:33 am
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The Art of Improvement

Process flows.  Standard work combo sheets.  Spaghetti diagrams.  Material and information flows.  Value stream maps. 

At the end of an improvement effort, we step back, crumple them up and toss them in the recycle bin.  We recycle this beautiful thing that is often the only physical evidence of weeks’ worth of work for the Lean practitioner.

I’ve spent a lot of time admiring these creations and started to daydream about seeing them outside the workplace, outside the recycle bin, and completely out of context.  Not to worry about what they mean or the stories they were designed to tell.  Instead, to step back and admire them as the things of beauty they are.  With a glass of wine in hand!

My best friends at work and my amazing team helped to make this daydream a reality.  We curated a gallery show reusing (upcycling?) these artifacts of improvement without using any additional resources from our employer.  But if anyone can throw a quality party on a shoestring budget it’s a Lean team!

Hope you enjoy seeing our photos from the event.  I hope it inspires you to appreciate the creativity and beauty that you bring into the world.

Click to enlarge

 

Popularity: 24% [?]

by , on 17 Oct 2013 02:20 pm
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Taking Stairs Two at a Time by Jennifer Haury

SMACK!  The other day, I was running late for a meeting and needed to climb 3 flights of stairs because I had no time for the elevator.  Of course, I thought taking the stairs 2 at a time would be a good idea.  I was running short on time and so I charged forward—with my batch of two stairs per step.  Until I tripped…and my papers went everywhere…and I entered my meeting late, unorganized, and out of breath.

It occurred to me this is often how improvement starts—we feel pressure to do better—in my case, it was a time crunch.  Often, it’s some gap between our target state and our current performance.  Instinct would often have us react by doing the work FASTER or leaving steps out!  “Of course, if we just work harder and go faster, that will help us reach our goal sooner!” we tell ourselves or our teams. 

The danger inherent in this level of thinking is that it often leads to quality issues in our process when we speed up the work or “skip steps”.  I remember working on a team responsible for taking incoming calls a few years back.  We made a decision to leave key steps out of our process during a phone call when our incoming demand reached a certain point, intentionally causing defects downstream just to do the work faster in the moment.  While that might seem foolish—don’t we often face the temptation to make shortcuts that undermine our overall goal?

The other day, if I had taken the time to take one stair at a time, I probably would have stepped in just as the meeting began and wouldn’t have scattered my papers.  If I’d taken the time to consider WHY I was running late and avoid those conditions next time, perhaps I’d have found out more about the root cause of my problem. Do you ever find yourself wanting to “take the stairs 2 at a time” to do a little more in your current role?  What helps you avoid this temptation?  Please share your thoughts with us.

Popularity: 23% [?]

by , on 25 Sep 2013 01:19 pm
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Change versus Improvement by Sean S. Sessions

Have you ever struggled to show the difference between change and improvement in a non-threatening way to your clients?

Through an exercise, unrelated to the products or services our clients deliver, we’ve developed an exercise we believe helps frontline staff and leaders realize for themselves that difference.

In addition to the lean principles, and understanding customer requirements, the exercise promotes making the improvement physical, as well as trying and failing quickly in pursuit of improvement toward the lean principles.

Here’s a video of the exercise.

http://www.youtube.com/watch?v=SZh-GE0k_Uw

Popularity: 24% [?]

by , on 15 Aug 2013 03:21 pm
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At the Intersection of No Wait and No Harm – Part II by Sean Sessions

A few weeks ago we shared with you the new process our team is trying – to go out and observe something random, completely unrelated to healthcare, and try to think about what it would ideally look like if it were meeting Lean principles. 

We spent 15 minutes visiting the intersection outside one of our medical centers, then reflected together about what we saw.   We asked how do we eliminate waste, increase quality, increase timeliness, decrease resources required, and improve the physical layout of the intersection in pursuit of “no wait and no harm” for passengers and pedestrians using the intersection?

Data:

  • It takes less than 2 seconds for a car to clear the intersection.  However, it takes nearly 10 seconds for a pedestrian to clear the intersection.
  • Cars can turn right when the light is red, after stopping first.  Pedestrians cannot cross when their light is red.
  • Pedestrians batch up in crosswalks when lights are red and it takes longer for pedestrians to cross/clear the intersection.  The large batches of pedestrians require cars turning right to wait longer to make turns and clear the intersection.
  • The behavior of pedestrians indicate that they cross the street multiple times to avoid shaded and narrow sidewalks to walk in brighter, larger sidewalks, not because they cross to directly reach a destination.

This is what the intersection looks like today:

 

 

 

What if the intersection looked like this?

 

 

Thoughts?

Popularity: 23% [?]

by , on 01 Aug 2013 11:02 am
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What Does Health Care Produce?

This week a department of our organization got together to begin to reimagine what they produce and then the process to deliver it – production preparation process (3P). However, before the 3P process could begin, they had to define the tangible / physical product(s) they produce.

  • What is the customer purchasing? What is this department selling? Is it a product, service, or both?

This has proven to be very challenging.

 

Their Process

Day one of the event they went to a local manufacturing company who uses 3P. From the visit, it became clear that the product is not the outcome, as in this example they referenced: a mattress company doesn’t sell a good night sleep, they sell mattresses. There might be other products (hammock, cot, etc.) to get a good night sleep, but the company must decide what products they want to focus on to aid the customer achieving their goal.

On day two of the event, this group of very smart, passionate people swirled through attributes, aspirational outcomes (i.e. – “wellness”), methodologies, and services on the way to defining a product. Questions they wrestled with included: Is the product an episode of care or each visit? Is it the plan of care or the methodologies they will experience as they work through their plan?

 

Are They Alone?

As they labored to define their product, I wondered how unique their struggle is. Isn’t this representative of where many health care organizations are in their journey as a business? How many primary care provider groups, specialists groups, support departments, etcetera, can articulate and agree on what their product is?

If individuals on teams, teams across an organization, and organizations across the field aren’t yet in agreement, should we be surprised that our health care processes are disjointed, highly variable, and full of rework and heroics?  If one line worker at a manufacturer thought they were producing forklifts, and their colleague thought it was a plane, coordinated, efficient processes they both were apart of would be fairly challenging. Sounds silly, but this is exactly the conversation this team is having. They identified that some providers see their role as returning patients to a predetermined functional baseline, while others believe the patient should drive the direction of treatment.

In the past, individual practitioners with their own philosophy, approach, and goals was the norm, just as a master craftsperson who produced items from raw materials to finished product was the norm. However, over the last century, the manufacturing world has found a much more efficient method to produce – team based production.  

Is health care where manufacturing was many decades ago – moving from individual craftspeople to team based production? The realization by an event team member who said  ‘we’re like blacksmiths (team’s example of individual craftsperson) pretending to be on a line / team!’ would suggest yes.

Can your team, department, organization define its products? Not its aspirational outcomes or mission statement, but the actual, tangible product you’re selling to customers?

  • If not, can improvement progress until they do?
  • If yes, and you’re willing to share, please do. Transformational improvement in healthcare may depend on it.

Popularity: 25% [?]

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