Lean Jobs: Still Many Good Opportunities

Problems in the economy aren’t having much of an impact on demand for people with lean expertise. And there are good opportunities for such people in a number of industries.

That is what I am told by Ted Stiles, director of executive search for
Stiles Associates, a headhunting firm specializing in lean jobs.

In my
last post, I discussed how Ted sees strong demand for lean specialists in healthcare. (At Productivity Press, we agree that interest in lean is strong in healthcare, which is why we now offer a growing line of books for that market.)

But healthcare is not the only field with lean opportunities. Manufacturing is still the primary market for lean job candidates. Ted said manufacturing will account for probably 75 percent of all searches done by his firm this year (though that is down significantly from five years ago, when virtually all of the searches were in manufacturing).

And while lean used to be the focus primarily in discrete manufacturing, there has been a lot of growth in lean demand in process manufacturing, Ted says, in a variety of industries: pharmaceutical, oil, metals, food and beverage.

Part of the reason for that, he adds, is that process manufacturers are not following discrete manufacturers in a rush to move to other countries. “The plants (of process manufacturers) tend to be enormous,” he explains. “They represent a great deal of capital investment. They tend to run 24/7. It’s not the kind of thing you can shut down and move overseas.”

Another big trend, Ted says, is that private equity firms – some of which tend to acquire manufacturers – like to hire lean experts to help turn around the acquired company, and in some cases to help with the due diligence before the company is purchased. (Adam Zak, another lean headhunter, also mentioned this trend
when I spoke with him last year.)

And for the job candidate, Ted notes, working for a private equity firm can be a good opportunity because the compensation may include some equity in the acquired firm.

Ted also sees growing demand for lean specialists in service industries.

Stiles Associates saw “a bit of a slowdown” in job searches in the first quarter of this year, he says, but is now seeing improvement. “Overall, we’re not forecasting a downward trend on our total search load. It will probably be flat to last year,” he comments.

He adds, “In downtimes, we end up coming through just fine. More companies realize margins are getting thin, sales are down. They say, ‘we have to figure out some way to survive.’ It is pretty common for our phone to ring with people saying, ‘we’ve thought about this (lean) for a while. We want to dig into it fast.”

And for job-seekers, he advises, “It’s in market conditions like this that lean programs are really tested, and the commitment to programs is tested. If you are with an organization that is cutting back, that may be a pretty good indicator of their commitment (to lean). The ones that ramp up have kind of a refreshed and new appreciation for just how impactful a well-executed lean program can be. Now is the time to shine if you’re in a good program.”


Lean Jobs: Good Prospects in Healthcare

Demand is growing in healthcare for people with lean expertise, and now may be a good time to move from manufacturing to healthcare.

That’s the word from Ted Stiles, director of executive search for
Stiles Associates, a headhunting firm specializing in lean jobs.

“We’re seeing a lot of activity in hospitals,” Ted said when I spoke with him recently. “They are really setting up to be a long-term home for lean. There are a lot of systemic issues that are plaguing the hospital industry that are forcing them to look outside the box.”

Lin Stiles, the founder and CEO of the firm, mentioned the start of search activity in healthcare whe
n I spoke with him a year ago. Now Ted sees the trend growing rapidly. He said the factors driving the trend are clearly evident when he listens to speakers at lean healthcare conferences.

“All of them are basically saying the same thing: Quality of patient care is going down, the cost of delivering that care is going up, and the amount the government is going to refund us for some of these avoidable mistakes is about to come off the table,” he comments. “A lot of these folks are feeling pretty desperate. Sometimes a burning platform is all we need to plant the seed for a lean transformation.”

Hospitals that decide to begin a lean journey typically do so in one of three ways, Ted says. The first approach is, “they take someone from the nursing staff, designate them a lean champion, send them to a seminar and get them some books. A lot of people are doing that.” He notes that at lean healthcare conferences, most attendees “tend to be lower-level administrative managers, or maybe the director of nursing, or in some cases the CNO (chief nursing officer). It’s rare you see the audience full of CMOs (chief medical officers) or CAOs (chief administrative officers), folks who can really be influenced at the top level.”

“And that’s a shame,” he adds. “If it works at all, it’s going to take such a long time going that route.”

The second approach is to hire a consultant. And the third, least common approach, is to actually hire someone with lean expertise (who then might be responsible for also hiring a consultant).

Typically, a hospital going the third route will hire a lean expert to be an internal consultant. One exception was ThedaCare, which actually hired a lean expert from manufacturing to be chief operating officer. “That was really unheard of, and near blasphemy,” Ted comments. “It was also a symbol of how serious they were.”

More commonly, he says, hospitals are “developing special segments of the org chart, creating brand new positions and teams, internal folks who act as consultants.”

And hospitals don’t want those new hires to speak in manufacturing terms. Virginia Mason is one of the few hospitals that openly acknowledged they were basing their approach on the Toyota Production System, Ted says. (Productivity Press will publish a book about Virginia Mason later this year.)

It is much more common to avoid manufacturing talk, which will “shut people down,” Ted says, adding “The healthcare community, and really almost every industry shares this to some level, says ‘You don’t understand our industry. We’re different.’ The healthcare community has that times a thousand.”

Someone moving from manufacturing to a job in healthcare will typically see a 10 percent to 20 percent increase in salary, Ted says. However, once in healthcare (where you often are working for a nonprofit organization), salary increases will be incremental, without the bonuses that would be part of a manufacturing job. “You may be jumping into slower growth in the long run,” Ted says.

But at the same time, he adds, a switch to healthcare can be a good career move. His view is that the hospitals that are giving lean responsibility to someone on the nursing staff “in about five years will probably realize, ‘man, we’re really moving slowly.’” At that point, he says, demand for lean folks – particularly those who already have a few years in healthcare – will be “pretty significant.”

However, he also notes that many of the candidates he has dealt with who are seeking to move from manufacturing to healthcare are doing so not primarily because of the money.

“A lot of people are just drawn on a personal level to fixing the system,” he says. “They are passionate about it, typically because they have been through some horrific experience (in healthcare).”

In my next posting, I’ll describe what Ted said about markets other than healthcare.


Military Projects: A Case Study in How Not to Be Lean

While I’m sure there are many areas of government operations ripe for lean transformations, I’d like to nominate one in particular: The design and development of new military technology.

An article in
The New York Times today focuses on construction of a new combat ship for the Navy. The headline is “Costly Lesson on How Not to Build a Navy Ship.”

A project heralded as the dawning of an innovative, low-cost era in Navy shipbuilding has turned into a case study of how not to build a combat ship. The bill for the ship, being built by Lockheed Martin, has soared to $531 million, more than double the original, and by some calculations could be $100 million more. With an alternate General Dynamics prototype similarly struggling at an Alabama shipyard, the Navy last year temporarily suspended the entire program.

The program’s tribulations speak to what military experts say are profound shortcomings in the Pentagon’s acquisitions system. Even as spending on new projects has risen to its highest point since the Reagan years, being over budget and behind schedule have become the norm: a recent Government Accountability Office audit found that 95 projects — warships, helicopters and satellites — were delayed 21 months on average and cost 26 percent more than initially projected, a bill of $295 billion.


Reading further, it appears the problems have a lot to do with product design as well as the development process.

In a narrow sense, the troubled birth of the coastal ships was rooted in the Navy’s misbegotten faith in a feat of maritime alchemy: building a hardened warship by adapting the design of a high-speed commercial ferry. As Representative Gene Taylor, the Mississippi Democrat who leads the House Armed Services Subcommittee on Seapower and Expeditionary Forces, put it, “Thinking these ships could be built to commercial specs was a dumb move.”

Behind the numbers in the Accountability Office study, experts say, is a dynamic of mutually re-enforcing deficiencies: ever-changing Pentagon design requirements; unrealistic cost estimates and production schedules abetted by companies eager to win contracts, and a fondness for commercial technologies that often, as with the ferry concept, prove unsuitable for specialized military projects.

At the same time, a policy of letting contractors take the lead in managing weapons programs has coincided with an acute shortage of government engineers trained to oversee these increasingly complex enterprises.

We’ve published several books having to do with product design, which is clearly one part of the problem. These include The Toyota Product Development System by James Morgan and Jeffrey Liker, and the just-released Value Stream Mapping for Lean Development by Drew Locher. (Copies of the new book should be available next month.)

It sounds like a good number of people involved in these military projects could benefit from reading them.


Lean Thinking at Google

I don’t know whether Google operates as a lean company, but I was pleased recently to read evidence that the people at Google try to think in a lean way.

Popular Mechanics recently
posted an interview on its website with Udi Manber, who is Google’s vice president in charge of search quality.

While the interview focused on trends and directions in search, the comment I found most interesting was when Manber talked about how Google reacts when a search doesn’t produce the results it should.

At Google we do not manually change results. For example, if we find for a particular query that result No. 4 should be result No. 1, we do not have the capability to manually change it. We made that decision not to put that capability in the algorithm—we have to go and actually change the algorithm. That is, we have to find what weakness in the algorithm caused that result and find a general solution to that, evaluate whether a general solution really works and if it’s better, and then launch a general solution. That makes the process slower, but it puts a lot more discipline on us and makes it more unbiased.

In other words, when there is a problem, don’t create a workaround; identify the root cause and solve the problem.

A good lesson for all of us.


Lean and Green in Hospitals

I’ve been writing recently about lean in healthcare, and I’ve also been writing about how well lean fits with issues of sustainability. Therefore, I was delighted to come across a recent article about how hospitals in the Seattle area are trying to embrace a green approach.

This is important because, as the article notes,

Hospitals have long been seen as one of the top waste-producing industries. In 1998, the American Hospital Association and the Environmental Protection Agency agreed on goals to reduce the effect of health care facilities on the environment. The goals included nearly eliminating mercury-containing waste by 2005 and reducing hospital waste 50 percent by 2010.

The article begins by looking at Evergreen Medical Center in Kirkland, and the efforts there by a nurse, Jim Overton, to make the center more environmentally responsible. It then focuses on other hospitals as well.

Overton's "Green Team" expanded the hospital's battery recycling program and collected 1,200 pounds of batteries during the past year. The hospital also collects used and unused-but-opened medical supplies, such as oxygen and blood tubes considered "contaminated" under U.S. regulations. The supplies are sent to Third World countries where they are sterilized and reused for patients there.

The team put up more recycling signs and bins and got the hospital's recycling container emptied three times a week instead of two. Containers for used needles are sterilized and reused, instead of being thrown away with the needles.
Overton started an internal Web site so staff could learn to become more environmentally friendly.

The team gives a monthly "Green Stewardship Award" to a staff-nominated co-worker who gives extra effort to the hospital's environmental progress. Local restaurants donated gift certificates as prizes.

Other Seattle-area hospitals are improving their bottom line by going greener.

Virginia Mason Medical Center's cafeteria has no garbage cans, since 100 percent of the cafeteria's waste is recycled, said Steve Grose, administrative director for process improvement. The hospital composts 750 pounds of food a day instead of grinding it in garbage disposals, which had needed 4,000 gallons of water a day. The water savings pays for the bags and composting, he said. In January, Virginia Mason began recycling 70 percent of the plastic used in about 70 surgeries a day.

The hospital hopes to eventually eliminate garbage cans throughout the hospital and recycle everything.

(Note: Later this year, Productivity Press will publish a book about how Virginia Mason Medical Center is applying lean methods to its operations.)

The University of Washington Medical Center recently started a paper-shredding program with Weyerhaeuser that the hospital estimates will save $70,000 a year. Surgical instruments are now disinfected with a less hazardous chemical. In 2006, the medical center began buying 100 percent renewable energy from Seattle City Light, which cost the hospital an extra $40,000 a year, but was worth the added expense, said hospital officials.

In two years, a water reuse system at UW Consolidated Laundry has saved 12 million gallons of water for a cost saving of $140,000 in water and $79,000 in natural gas.

Swedish Medical Center estimates saving more than $ 1 million since 2001 by recycling, said Michael Smith, the hospital's waste compliance manager. Swedish eliminated blood pressure monitors containing about 180 pounds of mercury -- and recycles all paper, cardboard, metals, batteries, lamps and printer toner cartridges, he said.

Food composting will begin at the end of March. It is working on a better way to dispose of expired medications and chemotherapy waste.

Children's Hospital and Regional Medical Center recycled more than 40 tons of computer monitors in 2006 and composts food, saving about $8,000 on water a year. Using new technology for cleaning and sterilizing surgical instruments, which uses more high heat and steam, Children's saves 4,100 gallons of water per day and more than $18,000 per year.

The article does not say specifically that lean tools or strategies are being used to accomplish environmental benefits. But at the very least, reducing environmental problems is elimination of waste, a key lean benefit. I hope we see more of this soon, and I expect we will.


Finding the Root Causes of Emergency Room Overcrowding

Identifying the root cause of a problem is a fundamental lean principle. That is the reason we ask “why” five times. Knowing the root cause is critical to achieving true improvement.

A new survey by a group of researchers, published in the Annals of Emergency Medicine, does an excellent job of looking at the root causes of emergency room overcrowding.

The ER is the focus of many current improvement initiatives in healthcare because of frequent overcrowding and long delays in patients being seen by doctors. Many initiatives focus on streamlining processes and improving patient flow, or patient throughput, so that there is less waiting time, and more patients can be seen.

That is all well and good. But the new research takes a step back to ask why ERs are overcrowded.

It is already well-known that demand for ER services has increased significantly in recent years. Conventional wisdom tells us that the cause is growing numbers of uninsured patients using the ER as their primary source of healthcare.

However, the new research demonstrates that conventional wisdom is wrong. The researchers used data from the national Community Tracking Study Household surveys for four different time periods between 1996 and 2004. They connected ER (or ED, for emergency department) visits to insurance status, family income, usual source of care and other factors.

Their findings: The proportion of visits by uninsured persons has not increased. However, there has been an increase in the proportion of visits by people whose usual source of care is a doctor’s office. The authors comment:

Our results provide strong evidence that visits by uninsured persons during this period were not a major cause of the overall increase…

These findings suggest that the rise in ED use is disproportionately due to non-poor individuals who have a usual source of health care. These findings have significant implications for current policy discussions because they suggest that the provision of health insurance will not, in and of itself, address issues of ED crowding or the more general issues of access to, and appropriateness of, health care services…

There are many factors contributing to the rise in ED visits, including population increases, the aging of our population, the increased numbers of time-sensitive interventions requiring state-of-the-art hospital care, larger numbers of patients with complex medical problems requiring evaluation in a setting in which sophisticated testing and consultation are available, and complications from medical and surgical treatments.

Another reason for increased ED use may be difficulty obtaining timely appointments from one’s usual source of care, or physician referrals to EDs because of their diagnostic and treatment capabilities.

Thus, the uninsured are not primarily responsible for the increase in ED utilization. Instead, the increase in ED use may be attributable to lack of ready access to primary care and other structural problems in the health care system.

The next step is to identify and come up with ways to address those structural problems. Now the real work begins.


Buying a Lexus: A Process Not as Lean as the Car

My wife and I bought a car this weekend – a pre-owned Lexus, which we purchased from a Lexus dealer.

I was curious to see what it would be like to purchase a vehicle from a dealer of high-end products from the world’s leading lean company. While generally better than experiences I’ve had at some car dealers, the process was not as lean as it could have been.

Like any Lexus dealership, this one was attractive and pleasant, and everyone we dealt with was polite and eager to help.

There were a few traditional sales tactics I could have done without. For example, we initially looked at a car bearing a large “certified pre-owned” sticker, which means it comes with a three-year warranty. When we began talking seriously about that car, it turned out it really wasn’t certified. It met the company’s guidelines for certification, and they were prepared to certify it, but that significantly increased the cost. (We ultimately bought a different car.)

And of course, we had to go through the charade of our salesman running back and forth between us and his manager during negotiations.

However, what I really want to talk about is the subject that resonates with any lean devotee: waste in the process.

There is a lot of paperwork involved in buying a car, and the initial parts of it with our salesman were all completed by hand. Often this involved writing down the same information on several different forms.

Lean is not, and should not be, primarily about technology, but this was clearly a case where some good software would have streamlined the process. Our salesman should have been able to enter all our information into a computer once, and then have a content management system copy that information into the various forms that were required.
(And were they all really required? I’m guessing the answer is probably not.)

We chose to finance the car through Lexus, so when we were done meeting with our salesman in the pre-owned building, we had to walk across the property to the main, new-car building, where the finance people were located. (Can you say waste of movement?) After waiting for half an hour, we met with a finance guy, who seemed to have the right software – all of his forms were easily printed from a computer.

Again, there were some sales tactics I didn’t care for. Lexus wanted us to enroll for several kinds of insurance coverage, which I deemed unnecessary. But it was only through my continued questioning that we were supplied with clear information on the costs of this insurance, and we had to opt out, rather than being asked if we wanted to opt in.

I’m happy with the car we got. But I wish Toyota would do a bit more to work with its dealers. Lean is supposed to be focused on providing value, as defined by customers. I see value in the product we got, but not as much in the process of getting it.


Two Approaches to Explaining Lean Thinking

We lean devotees have often said that lean is not just a set of tools, but a way of thinking about your business. Two of our most recent books reflect this fact.

The A3 report is a well-known lean tool. It refers to a report that summarizes the steps in identifying and solving a problem. Everything in the report appears on one page, and the name “A3” refers to the size of the paper used.

One of our newest books is Understanding A3 Thinking: A Critical Component of Toyota’s PDCA Management System, by Durward Sobek and Art Smalley. Note the word “thinking” in the title. The book is not just about how you create an A3 report; it describes in detail the learning and development that occur from the process leading to development and management of the reports. Ultimately, that can be more important than the report itself.

You might say that Sobek and Smalley discuss lean thinking with a kind of “bottom-up” approach, starting with a tool and moving into a broader explanation of the processes behind it.

If that is true, then you might also say that Raymond Floyd provides something of a “top-down” explanation of lean thinking. His new book is A Culture of Rapid Improvement: Creating and Sustaining an Engaged Workforce. Or if not top-down, then perhaps more macro than micro.

Floyd understands how critical culture is to lean transformation. The sections of his book explore establishing cultural values and beliefs; engaging people in the culture; the social design of the culture; managing and sustaining cultural change, and how to get started in your organization.

Not only are these kinds of issues important, but there seems to be a real hunger in the marketplace for information about them. In the three years since we first published Creating a Lean Culture: Tools to Sustain Lean Conversions by David Mann, that book has consistently been one of our best-sellers.

Does lean thinking exist in your organization? How challenging has it been to transform your culture so that your workforce is truly engaged in a lean approach?


Apple: A Successful, “Anti-Lean” Company

A company that embodies the lean principle of respect for people would likely have teams of empowered employees, strong communication among teams and individuals, ongoing recognition of employee and team achievements, and managers at all levels who are not autocratic but encourage independent thinking.

The antithesis of this – call it an “anti-lean” company – might have functional silos, obsessive secrecy and limited internal communication, little praise and frequent criticism of employees, and a dictatorial, micro-managing CEO who treats employees badly.

Welcome to Apple.

cover story in the April issue of Wired magazine profiles Apple and its well-known CEO Steve Jobs, with the headline “How Apple Got Everything Right By Doing Everything Wrong.”

What the headline means is that Apple ignores conventional Silicon Valley wisdom encouraging open platforms, transparency in communication and operations, “management by walking around,” and treating employees like gods.

According to the article, written by Leander Kahney,

Jobs is a notorious micromanager. No product escapes Cupertino without meeting Jobs’ exacting standards, which are said to cover such esoteric details as the number of screws on the bottom of a laptop and the curve of a monitor’s corners…

Whereas as the rest of the tech industry may motivate employees with carrots, Jobs is known as an inveterate stick man. Even the most favored employee could find themselves on the receiving end of a tirade. Insiders have a term for it: the “hero-shithead roller coaster.” Says Edward Eigerman, a former Apple engineer, “More than anywhere else I’ve worked before or since, there’s a lot of concern about being fired...”

Apple employees often have no idea what their own company is up to. Workers’ electronic security badges are programmed to restrict access to various areas of the campus. (Signs warning NO TAILGATING are posted on doors to discourage the curious from sneaking into off-limit areas.) Software and hardware designers are housed in separate buildings and kept from seeing each other’s work, so neither gets a complete sense of the project. “We have cells, like a terrorist organization,” Jon Rubinstein, former head of Apple’s hardware and iPod divisions and now executive chair at Palm, told Business Week in 2000.

At times, Apple’s secrecy approaches paranoia. Talking to outsiders is forbidden; employees are warned against telling their families what they are working on.

By many measures, Apple today is an extremely successful company. How can an anti-lean company be so strong? And why do employees want to work there?

While Apple’s tactics may seem like Industrial Revolution relics, they’ve helped the company position itself ahead of its competitors and at the forefront of the tech industry. Sometimes, evil works…

Jobs’ employees remain devoted. That’s because his autocracy is balanced by his famous charisma – he can make the task of designing a power supply feel like a mission from God… And because Jobs’ approval is so hard to win, Apple staffers labor tirelessly to please him…

Apple’s successes in the years since Jobs’ return – iMac, iPod, iPhone – suggest an alternate vision to the worker-is-always-right school of management. In Cupertino, innovation doesn’t come from coddling employees and collecting whatever froth rises to the surface; it is the product of an intense, hard-fought process, where people’s feelings are irrelevant…

“Steve proves that it’s OK to be an asshole,” says Guy Kawasaki, Apple’s former chief evangelist. “I can’t relate to the way he does things, but it’s not his problem. It’s mine. He just has a different OS…”

No other company has proven as adept at giving customers what they want before they know they want it. Undoubtedly, this is due to Jobs’ unique creative vision. But it’s also a function of his management practices. By exerting unrelenting control over his employees, his image and even his customers, Jobs exerts unrelenting control over his products and how they’re used. And in a consumer-focused tech industry, the products are what matter.

Do you agree? Would Apple be more or less successful if it embraced a lean strategy? Is an anti-lean approach ever better? Post your comments below.


Empowered Employee Teams: What is Old is New Again

It is always amusing when someone “discovers” a “new” management concept that has actually been around for a long time.

The concept I’m referring to is having teams of empowered employees – something that is fundamental to lean production and has been in place at Toyota and some other companies for years (and, in some cases, decades).

The most recent discovery of this concept has apparently been made by management guru Gary Hamel, who has written several books and for a good number of years has been widely considered a management expert.

His latest book is The Future of Management. I haven’t read it, or any of Hamel’s books, but I did hear him speak some years ago. He is a bright man, and I believe he does know what he is talking about.

That applies to his latest book, which was discussed in The New York Times. According to the article, written by William Holstein, the book focuses on three companies – Whole Foods, W.L. Gore & Associates, and Google – and their use of empowered employee teams.

Mr. Hamel argues that these innovative companies realize that employees should not be treated like 13-year-olds who need clear boundaries on their freedom. Employees are on the front lines and are often closest to customer needs. As a result, they should have power to reveal to their hierarchies what products and services are needed, and they should be involved in deciding how the company’s time and money are spent. Moreover, they should be pursuing a passion or a mission, not just quarterly profits.

The implication of all this is that we don’t need as many managers in organizations. Yes, we still need some managers and some centralized processes to prevent an organization from spinning wildly in all directions. But the best organizations will be those whose employees have the power to innovate, not just follow orders from on high, Mr. Hamel says. In such an environment, the notion of a whole class of managers evaluating and re-evaluating each action of those below them in a vertical hierarchy becomes nonsensical.

That’s a fine message, and one with which I certainly agree. But Gary Hamel is by no means the first person to deliver it.


“Doctor Nurses”: Cross-Training for Flexibility

Cross-training is a staple of lean manufacturing. Having workers able to do a variety of jobs increases flexibility, making it easier for a business to respond to changing market conditions that require shifts in production.

I don’t know whether you would consider this a good example of cross-training, but in healthcare, there is a movement to have some nurses do more by becoming “doctor nurses.” According to the Wall Street Journal,

More than 200 nursing schools have established or plan to launch doctorate of nursing practice programs to equip graduates with skills the schools say are equivalent to primary-care physicians. The two-year programs, including a one-year residency, create a "hybrid practitioner" with more skills, knowledge and training than a nurse practitioner with a master's degree, says Mary Mundinger, dean of New York's Columbia University School of Nursing. She says DNPs are being trained to have more focus than doctors on coordinating care among many specialists and health-care settings.

Why is this being pushed? According to the article (written by Laura Landro), it is because there aren’t enough doctors.

Dr. Mundinger, of Columbia, says the primary aim of the DNP is not to usurp the role of the physician, but to deal with the fact that there simply won't be enough of them to care for patients with increasingly complex care needs. As doctors face shrinking insurance reimbursements and rising malpractice-insurance costs, more medical students are forsaking primary care for specialty practices with higher incomes and more predictable hours. As a result, there could be a shortfall ranging from 85,000 to 200,000 primary-care physicians by 2020, according to various estimates.

But there are concerns:

Some physician groups warn that blurring the line between doctors and nurses will confuse patients and jeopardize care. Nurses with doctorates use DrNP after their name, and can also use the designation Dr. as a title. Physician groups want DNPs to be required to clearly state to patients and prospective students that they are not medical doctors. "Nurses with an advanced degree are not the same as doctors who have been to medical school," says Roger Moore, incoming president of the American Society of Anesthesiologists.

"With four years of medical school and three years of residency training, physicians' understanding of complex medical issues and clinical expertise is unequaled," adds James King, president of the American Academy of Family Physicians. While nurses with advanced degrees play an important role in delivering care, Dr. King says they should work as part of a physician-directed team.

The new push for doctor nurses is actually part of an ongoing trend toward increased flexibility.

Nurses have increasingly been moving into more specialized and advanced roles over the past few decades. Advanced-practice nurses include specialists in fields such as nurse midwives and nurse anesthetists, and there are now more than 125,000 nurse practitioners in the U.S. Nurse practitioners in some states are required to work with or be supervised by physicians, but often have independent practices in family medicine, adult care, pediatrics and oncology.

A study led by Columbia's Dr. Mundinger and published in the Journal of the American Medical Association in 2000 showed comparable patient outcomes in patients randomly assigned to nurse practitioners and primary-care physicians.

What do you think? Is this an example of lean cross-training? Is it a sign of significant change in how healthcare is delivered? Post your comments below.


SME Creates Online Lean Community

The Society of Manufacturing Engineers has come up with a new way for lean practitioners to connect online.

It is called the
Lean Registry, described by SME as a free community connection and collaboration space. According to an SME news release, this online community “allows users to post needs/expertise directly to their profile, create virtual groups and make safe connections more easily. You can search through shared profiles to find who might match your need and send an invitation to connect. You control if/when you accept a connection and/or share contact info.”

The Registry is an outgrowth of a Lean Certification program developed in 2005. The concept for the Registry was developed at that time because

The Lean Certification program includes knowledge-testing, experience portfolio and mentoring. Candidates progressing to the Silver or Gold levels must demonstrate that they have mentored and trained others along the way. Practitioners frequently need to look outside their company to get mentoring and support. Besides hosting events, how else could we foster meaningful connection in the context of lean 24/7?

How else? Well, there are other websites that attempt to create lean communities, ranging from Yahoo groups to those of some lean businesses or non-profit groups.

But it never hurts to have another, and the Lean Registry looks reasonably good. If SME does a good job of promoting and maintaining the site, it could be a valuable resource. I wish them luck.