We continue our question and answer session on the topic of lean healthcare with Mark Graban, author of Lean Hospitals:
Q9: You wrote in Lean Hospitals that it takes courage to point out that something is a waste. How have you been able to help create environments within hospitals where it is safe to point out the waste?
There are no quick fixes for this -- it requires leadership, consistent leadership. Managers and executives have to give people permission to raise issues, to let people know they want to hear what the problems are, so improvements can be made. Many hospitals work to create "blame free zones" where quality and safety problems or near misses can be brought up without fear of punishment or retribution. We have to spread and preach the notion of "no problems is a problem" within hospitals. There's a story in my book that I love about a hospital CEO thanking an employee who hold him that she was cutting corners in recording medication errors in the computer system. Rather than yelling or blaming her, he asked why and the discussion led to some systemic fixes that made it easier for the staff members to "do the right thing." In a more traditional setting, people would cover up problems like that, preventing a long-term fix from being put in place.
Q10: Looking back on your years of implementing lean in hospitals, what is one thing you do very differently from when you first started?
I actually spend less time dancing around the fact that the Lean methodology comes from manufacturing. I've found that many healthcare professionals actually appreciate that something new is coming in from outside of the traditional hospital approaches. This gives them hope that things can actually improve instead of Lean just becoming another program of the month like those pushed by hospital industry consultants.
That said, I have always been careful to show respect for what the hospital employees know and what they bring to the improvement process. Sure, I'm teaching them process focused skills that they haven't been exposed to before -- that isn't their fault. We don't spend too much time blaming people for why the current state is what it is today. We focus on fixing things. Lean works because I'm arming these smart, creative, caring people with methods they didn't have before. It's much easier for me to teach them Lean than it is for them to teach me everything about running an emergency room.
Q11: You say that standardized work is written by those who do the work. My understanding is that it is written by team leaders or group leaders. If physicians (the people who do the work) write standardized work within hospitals, how is standardization and consensus achieved between these different medical professionals?
The whole idea that supervisors have to write the standardized work is something I would challenge, going back to my manufacturing days. I was taught, by a plant manager who came from NUMMI, that engineers (like myself) or supervisors could facilitate the writing of standardized work, but the content should come from those directly doing the work. Who knows their jobs better than the ones doing the work every day? I think this is especially true if you have "professional supervisors" who are brought in out of college rather than working their way up.
I think this idea holds true in hospitals. The medical technologists, the nurses, the patient care techs, the physicians -- the ones who do the work are the ones in the best position to write their standardized work. Now, supervisors and managers may give some input or provide some oversight along the way. They aren't kept out of the loop, by any means.
Standardization and consensus can be difficult to achieve, as in any organization. A couple of strategies I use include using data to determine which methods work best and standardizing key methods that impact quality or safety, rather than trying to standardize for the sake of standardization. If team members have two different methods they are proposing, running pilots and measuring results or outcomes can lead to a data-driven or evidence-driven decision instead of one that's based on politics or opinion. When standardized work is agreed upon, managers have a duty to audit the standardized work and review results. If results show that turnaround times (cycle times) for lab testing were abnormally high one day, and you observe that the lead technologist is following a different method (or the old method) for doing work, you can be a leader and show them the data -- showing them that the proper standardized work brings the right results for patients. This works better than top-down management by decree that "forces" everyone to follow the standardized method. As one hospital director I work with likes to say, "You can't make anyone do anything." You have to convince them why they should do it.
The best examples of standardized work for physicians were cases that were completely physician-driven. Nobody forced them to standardize -- they realized it was best for their patients and they took action on their own (here is a link to my blog post about the original NY Times article).
http://www.leanblog.org/2007/05/elements-of-lean-surgery.html
Q12: On the topic of 5S you wrote "we need to take care that we are not using the tool (5S) without thinking about the problem that is being solved or the waste that is being prevented." You gave the example that a heavy printer that is likely not to be moved should not be taped or labeled. Considering the fact that the risk of minor mistakes within hospitals can be so high (and the cost of tape so low) why not remove any possibility of ambiguity by insisting on strict adherence to 5S and that absolutely everything be labeled and its proper location marked
with tape?
Right or wrong, I've seen people get completely turned off to 5S as a meaningful tool when it's been used in what the staff view as "trivial ways." I think tape around the printer or putting tape marking where a mouse is used (which gets in the way of moving the mouse) are uses of 5S that don't have the greatest impact.
There are many situations where 5S can actually help people be more efficient -- such as putting tape around where a shared stapler goes, so it's more likely to be returned and not be lost or missing for the next person who uses it. There are examples where 5S can literally help save a patient's life -- such as making sure that patient safety or recovery supplies are stored and organized in a consistent and visually verifiable way in an MRI room. I'd rather start with the high impact stuff and if people eventually get around to putting tape around the printer that never moves (and never gets misplaced), then OK.
Q13: Can you give us examples of when a you have observed a hospital leader being able to successfully "lead the organization as if I had no power" to use the description by Gary Convis on leadership style at Toyota?
One lab director I work for uses this great expression -- "You can't make anyone do anything." He had a long career in the military and really practices the servant leadership style that Convis also promotes (as does Toyota). What the lab director means is that if he just barked orders, people might just blindly follow what he's told them to do -- but who knows what happens when he isn't looking. Even if you're doing standardized work audits on a regular basis (every shift or every day), you can't watch people 100% of the time.
This director (and other hospital leaders) try to embrace true leadership, where you convince people why they should do something. I've seen another director use data to help make the case of "here's why you need to follow the new standardized work, since turnaround time is clearly worse when you were running the process the old way, with batching." As in any servant leadership model, there is, however, a time and a place for being directive -- such as when safety would immediately be at risk. If someone isn't wearing proper personal protective equipment, it's more appropriate to use that power (while also explaining why it's an important directive).
Q14: In terms of quality, how can a hospital hope to achieve the lean principle of "built in quality" when the physicians, one of the primary influencers of medical outcomes, is in effect a customer of the hospital and not within the span of control of the hospital staff?
This is indeed challenging, when physicians are independent contractors, not employees. In fact, in some states, it is ILLEGAL for a hospital to directly employ physicians. So here's a chance to exercise your "lead as if you have no power" skills of leadership. Physicians are not completely unreasonable. You can work with them to sell them on ideas and new practices -- explaining how Lean methods and concepts can benefit them and/or patients.
Do you have some "concrete heads?" Sure, as in any industry. Hospitals are not completely powerless. One Boston hospital actually threatened to "pull privileges" from surgeons who didn't promptly fill out post-surgical paperwork. If the paperwork wasn't filled out promptly, the hospital wouldn't get paid promptly -- an example of where MD incentives and hospital incentives are out of alignment (the MD might file his own paperwork directly to the payer to get paid, leaving the hospital in the lurch). The hospital followed through on its threat, suspending surgeons (even some very high profile ones). Sometimes leadership has to take a stand that they're willing to lose an MD -- but this is a scary proposition since MDs often drive revenue by steering patients to that particular hospital.
Similar situations may apply when it comes to surgeons or physicians not following patient safety practices, like hand hygiene after patient visits or properly following pre-surgical time-out procedures. You might have to make some tough decisions -- do you value short-term revenue or the long-term quality reputation of your hospital?
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