DailyKaizen

To follow on Lee’s post, making the commitment is just the beginning

There are times, many times, when the answer of what seems to do next does not seem apparent. So I do what one of my surgical mentors once told me, “do something.”

This last week, we completed a rapid process improvement event in one of our Orthopedics Departments. It went well, better than an event we had in another specialty service a few weeks ago. What was better? We knew better in advance what we could accomplish and set out to accomplish it. We checked in with the local leadership before we went and throughout the event. That’s great. Does this mean that we have to know exactly what we are going to work on before we get to a place, or can we allow some flexibility of the discovery, so that front line staff can learn how discovery works? I believe in the latter.

There are times that I feel pushed to have things laid out very carefully before we arrive, and when we get there to pursue a defined course. This worries me. There are also times when I wonder if we are doing enough - exploring enough of the technology that we have at our fingertips. Perhaps we are not, because there’s a pressure to deliver a concrete product. I am sure these worries will be reconciled over the next 5-10 rapid process improvement events.

In the meantime, I want to figure out a way for people and myself to feel nervous. To feel patient. To feel compassionate. Everyone involved are knocking themselves out for our members. I will remind my colleagues of this every day.

In January, the organization made a commitment to strategically focus its limited LEAN resources.  Before this time the LEAN team had worked only with departments that had requested our support and typically only on point improvements.  This change to a strategic focus has meant that leaders throughout the organization are being asked to participate in and support LEAN projects as a requirement of their jobs.  While many leaders have responded with enthusiasm many more are skeptical and resistant. 

 
I believe that this skepticism and resistance is natural and is merely the side effect of change.  LEAN asks leaders and staff to do their jobs differently.  Leaders often ask me to provide proof of concept.  They want me to show them the data that will guarantee results.  My response is always the same; thousands of organizations have implemented LEAN successfully and many more will.  Yes, it is new to healthcare.  No we are not that different. Yes, it will work if we stay the course. Most importantly, it will be extremely challenging and it will require strong leadership so welcome aboard. 

I definitely feel that the medical profession will have a problem with one piece flow. We are absolutely addicted to multi-tasking. It is one of the hardest lesson that a medical student or resident learns - that they cannot truly work with a patient from start to finish and must rely on support systems to provide actual “care.”

I am working with one of our specialty groups, and like all specialists, they are incredibly smart, able to juggle numerous amounts of data (which I don’t think the scope of they even appreciate), and pop in and out of focus. The team that I am with who is serving them are also similarly driven. It is hard for the recovering clinician to think about seeing something through from start to finish. I hate to think that one day I will be knocking on the doors of the Association of American Medical Colleges as part of this journey, but I think I may….

Being a LEAN consultant it is so easy to get caught up in helping others fix their processes that you forget to standardize and improve your own.  This week my team has committed to making sure that we pay more attention to applying continuous improvement methods to our own operations.  Over the next couple of weeks we plan on standardizing all of our processes, creating standard tools for each step of preparing and executing a Kaizen and standardizing our training materials.  Additionally, we will be creating a Visual System that will be located in our office space that will show all of our work and the status of the work.  We hope to make this Visual System electronic soon so that we are completely transparent with the organization. 

On a personal note I need to do a better job at practicing one-piece flow.  I am currently juggling three very large projects all with deliverables that are due at the same time.  My fear is that by not focusing on one piece of work at a time I am wasting a lot of valuable analysis and consulting time. 

To maintain credibility and deliver results it will be important for my team and myself to constantly strive to improve our work.  We need to focus on our internal processes and beware of how we handle our stakeholders needs.  Most of all we need to be sure that we are always practicing what we preach. 

Yesterday, I had two experiences sharing LEAN with the “unitiated.”

In the first instance, it was with one of our key vendors/partners. I explained what we were doing to improve our way of doing business, and how, in the Toyota world, Toyota reaches out to its suppliers and partners with them to improve service. Toyota will even do this with suppliers that also serve its competitors, to serve Toyota’s interests, but also society as a whole. My colleague was interested in the concept, but felt that Group Health is a leading edge innovative organization. If his company adopted a LEAN approach, what about his other clients? We discussed this more, and what this comes down to, is, what would you have dominate your way of doing business, an inefficient way, or an efficient way, and what is your company’s purpose? Are there ways for you to adopt an efficient process and teach others to become efficient? If another client does not wish to be more efficient, can you still become efficient in a way that does not impact them? The studies of this process say the answer is yes.

The second experience was a group of students from the University who were interviewing me about our electronic medical records efforts. As part of the interview, I took them on a tour, and stopped at our “Quality Improvement Support Board.” I am getting better practice of explaining what this board does for us. It is a white board, not a plasma display, not a database. It tells me (or anyone who walks by it):

1. What medical centers or service lines we are supporting, now and two into the future
2. How many small, medium, and big ticket items are planned
3. How many small, medium, and big ticket items are being worked on
4. How many small, medium, and big ticket items are done
5. What each item is
6. How busy each team is

It tells me this in the blink of an eye. I will post a picture of it here soon. In many ways, it is similar to the whiteboard that we (used to) use in our urgent care centers. Interestingly, those have become plasma displays that are computer controlled. Is that more efficient than people keeping up a white board? We will never know. They are an integral part of a larger system we use to automate those care centers, which has tremendous value to our patients.

Today I thought I would talk about something different then Healthcare.  Something timely and fresh on my mind: taxes. 

Simply, I hate doing my taxes. I hate doing my taxes, because I always feel like I am cheating even though I am doing my best to be honest and follow the process.  I literally spend hours every tax season reading and re-reading the small print trying to determine if I qualify for a deduction or what number I should be subtracting from another.  Two years ago a went out and bought Turbo Tax thinking it would make my life easier, which eventually resulted in me getting frustrated with the software and returning to the hand written method. 

This year, knowing that I was going to receive a fairly large return motivated me to finish my taxes in late January.  Last week I still had not gotten a direct deposit so I called the IRS.  It seems that they decided to deposit my check in someone else’s account!  Can you say error proofing?

Why do taxes have to be so complicated?  Like healthcare, there is a lot of opportunity for process simplification and improvement.  To the IRS the tax payer is the customer and I believe they should treat us like one.

In (this article: Fast Company Magazine - Top Scalpel), there’s a discussion of a training program known as Life Wings. They talk about creating checklists for physician teams and looking at communication as a teamwork issue. No fancy technology. Just communication. This approach is very reminiscent of “standard work.” What if physicians don’t really need a new gadget on their belts? What if they just need to learn how to communicate better, for the heatlh of their patients?

Today marks the last day of the first week of being a blogger.  It has taken some discipline and some time, neither of which I have a lot.  Overall, I have found the experience of reflection that comes with blogging to be valuable and will continue to write about my LEAN journey.  Hopefully, my story will be useful to others as well.  

Thus concluding this long week I will end this entry with one of my favorite quotes, since somebody else has already said things better then I.

“Vision without action is merely a dream.  Action without vision just passes the time.  Vision with action can change the world.”
 –Joel A. Barker

The first step of the LEAN process is to interview leaders from the prospective area.  During this interview you ask questions about the process to determine if the opportunities are worth pursuing.  One of the questions that I always ask a local leader is what they believe is the greatest opportunity for improvement in the area.  Without exception the answer is always the same: “we need a new Information System” or “if we only had the ability to automate are problems would go away.”

Yesterday for example I spent three hours walking a process with a group of leaders.  We then returned to a conference room to debrief.  I asked the group what opportunities they identified and got back a list of fourteen ideas, eleven of them having to do with updating or tweaking the IS system.  An unfortunate conclusion since we have zero dollars in our budget to invest in technology.  Once the meeting had adjourned I spent a couple of minutes going over my notes from the walk with the sponsor.  I had identified eight opportunities for improvement and only one related to the IS system (Not using it any more).  The other seven were focused on eliminating handoffs, eliminating batches, measuring FTQ, etc.

The difference in findings does not surprise me, especially since we are looking at an administrative process.  Over the last ten years the organization has invested countless millions of dollars buying IS systems which have been installed with the purpose of automating process.  The problem is that we never had the time or money to clean up and reduce the waste in the process before we automated them, thus we have locked in the waste.  Once automated it is very expensive to change these processes and our Information Services Division does not have nearly enough resources to handle the cries from every corner of the organization for support.

Moving forward I hope the organization requires departments to apply LEAN principles before they are allowed to install new IS systems.  The good news is that we already seem to be moving in that direction with LEAN projects underway pre-implementation in many areas including e-watson, ISD-Ready, EpicCare, etc.

globeandmail.com : Vancouver General’s ER doctors warn patients

In a care sysem like this (Canada), it might feel that leaders have become disconnected from the customer – sometimes it seems that people see their “boss” as the Ministry of Health, rather than the true “boss,” the taxpayer. I suppose we’re fortunate in our care system at Group Health that we’re clear that the member is the boss, since we report to them on paper.

There’s more to look at under the surface. The ER situation is the tip of a very large iceberg. It’s probably not helping patients for physicians to call out their own inefficient and wasteful system. Queuing them in other parts of the hospital and not looking inward (hansei) is a critical mistake. If they value stream mapped the entire care experience from the first symptom to needing to go to the ER, I bet their eyes would be opened.

For example:

1. How many of these patients could have been treated earlier by their primary care doctor?
2. What if the Canadian system embraced e-visits, allowing patients to handle early symptoms and have confidence in their self care?
3. What about the rest of the system is so not valuable to patients that they want to “pay” (with their tax dollars) to sit in a hallway at VGH? If you think about it, that’s pretty extreme for a customer to do.

The challenge for those in health care is that the hospital and ER get all the “glamour” if you will, around issues, yet they only administer 1% of the care. But they get 99% of the press. I always wonder about all of the patients who aren’t on beta blockers for their hearts, or aren’t getting their blood pressure treated. That’s estimated to cause 50,000 deaths annually, a few at a time. That should get our attention – every patient who leaves a doctor’s office with their blood pressure unchecked.

When I read the story, I can feel the feeling that the staff in these institutions (the doctors, too) are victimized by their own system and without leadership cannot realize their own power to change things. That is sad. There’s some room for top-down/bottom-up collaboration, and I’m afraid it seems that the bottom-up includes the doctors, nurses and the patients. That way of treating staff seems thick to me.  The irony is that the “top” is really the taxpayer, who’s paying for their loved ones to sit, unattended to.