Book Talk: The Performance Paradox

Today we’re launching Book Talk, a new feature on the blog. Every Friday I will discuss a book or books from Productivity Press. I may talk about a particular book I find interesting, how two related books are different, or anything else that comes to mind.

Today’s book is The Performance Paradox: Understanding the Real Drivers that Critically Affect Outcomes, by Dr. Jerry L. Harbour.

In this book, Harbour focuses on the question of how performance improves – something he believes has not been sufficiently addressed in the past. The book’s title refers to performance-related assumptions that are believed to be well-known truths, but often do not hold up under close scrutiny.

The book is divided into two major sections. The first is what Harbour calls the “about” section and discusses several basic performance themes as a conceptual overview of performance. Topics include S-curves, performance limits and how innovation (sometimes) begets performance.

The second is the “how-to” section and covers modeling, measuring and improving performance. A final chapter ties everything together.

The book, which includes a glossary, is not specific to any industry or area of operation. As such, it can prove useful to almost any organization interested in performance improvement.

Harbour is the author of three other books: The Basics of Performance Measurement, Cycle Time Reduction and The Process Reengineering Workbook.

Do you have a question or comment about a book(s) that you would like addressed in Book Talk? Email me directly at Ralph.bernstein@taylorandfrancis.com.


A Hospital Makes Wheelchairs Cleaner and More Available

I’ve heard of hospital improvements focusing on issues ranging from emergency room time to distribution of medicine to hand-washing. Now our friends at the Lean Healthcare Exchange have described one I’ve never heard of before, and it is a wonderful example of how lean methods can be used to attack an everyday, ordinary and almost invisible problem to produce significant benefits.

The challenge: Increasing the cleanliness and availability of wheelchairs.

The blog article notes the importance of wheelchairs in a hospital, and how often people are frustrated when looking for one. Further, dirty wheelchairs can spread disease.

Wheelchairs are used by multiple clinical departments, outpatients, volunteers, families and even visitors. Often like a grocery cart, wheelchairs are picked up in one location and dropped off somewhere totally different. Until recent increased awareness to prevent the spread of infections, wheelchairs and grocery carts were often not cleaned between uses. ..

Only 1% of staff felt wheelchairs were always available when they were needed. Audits found that only 69% of the designated locations had the available par levels of wheelchairs. More importantly to the patient and despite intense emphasis on infection prevention practices, observations of wheelchair use found that only 7% were actually cleaned between use. The event team took cultures from a sample of wheelchairs and found 4 out of 10 positive for bacterial growth.

As with so many lean improvements, the steps taken to improve the situation were simple and basic.

The wheelchair team modified previous visual markings for wheelchairs by placing pictures at eye level showing staff members cleaning wheelchairs and the number of wheelchairs to be placed in each location. They also ensured cleaning wipes were stocked in each wheelchair location with cards for replenishment. Standard work was implemented for volunteers to round and ensure wheelchairs were up to PAR.

The results were dramatic.

Observation 60 days following the event found cleaning of wheelchairs was carried out 75% of the time. Time spent by staff searching for wheelchairs was decreased by 50%. The time saved gives back almost two 8 hour shifts per month for staff to spend in value-added direct patient care. Clinical staff at this facility are no longer wishing for a clean wheelchair, they know exactly where to find one and have the supplies immediately available to provide patients with clean and safe transportation.

I’ll bet it never occurred to many people at that hospital that anything could be done to improve wheelchair availability.

What about your company? Do you live with annoying problems every day that you simply assume cannot be solved?


Outsourcing Practices Raise Security Concerns

Could lean strategies help improve the national security of the United States?

While lean produces great business benefits, asking if it could affect national security may seem a bit much. However, I raise this issue after reading an intriguing article in The New York Times about outsourcing by drug manufacturers.

Outsourcing often occurs because manufacturers believe the cost of production is less in other countries. That isn’t always true, when all costs (transportation, lead time, etc.) are taken into account. But even when it is, lean can be a powerful means of streamlining production in this country, removing waste to the point where costs can be competitive with those of foreign producers.

The article, by Gardiner Harris, notes that the majority of drug manufacturing has disappeared from the U.S.

Decades ago, most pills consumed in the United States were made here. But like other manufacturing operations, drug plants have been moving to Asia because labor, construction, regulatory and environmental costs are lower there.

The critical ingredients for most antibiotics are now made almost exclusively in China and India. The same is true for dozens of other crucial medicines, including the popular allergy medicine prednisone; metformin, for diabetes; and amlodipine, for high blood pressure.

Of the 1,154 pharmaceutical plants mentioned in generic drug applications to the Food and Drug Administration in 2007, only 13 percent were in the United States. Forty-three percent were in China, and 39 percent were in India

Drug labels often claim that the pills are manufactured in the United States, but the listed plants are often the sites where foreign-made drug powders are pounded into pills and packaged.

The situation has real security implications.

Officials have said that during a pandemic the United States would not be able to rely on vaccines manufactured largely in Europe because of possible border closures and supply shortages. And the situation is similar with antibiotics like penicillin...

The Centers for Disease Control and Prevention has a stockpile of medicines with enough antibiotics to treat 40 million people. If more are needed, however, the nation lacks the plants to produce them. A penicillin fermenter would take two years to build from scratch, said Enrico Polastro, a Belgian drug industry consultant who is an expert in antibiotics.

Dr. Yusuf K. Hamied, chairman of Cipla, one of the world’s most important suppliers of pharmaceutical ingredients, says his company and others have grown increasingly dependent on Chinese suppliers. “If tomorrow China stopped supplying pharmaceutical ingredients, the worldwide pharmaceutical industry would collapse,” he said…

The world’s growing dependence on Chinese drug manufacturers became apparent in the heparin scare. A year ago, Baxter International and APP Pharmaceuticals split the domestic market for heparin, an anticlotting drug needed for surgery and dialysis.

When federal drug regulators discovered that Baxter’s product had been contaminated by Chinese suppliers, the F.D.A. banned Baxter’s product and turned almost exclusively to the one from APP. But APP also got its product from China.

So for now, like it or not, China has the upper hand. As Mr. Polastro put it, “If China ever got very upset with President Obama, it could be a big problem.”

The question I am raising is whether drug manufacturers would have kept production in this country – enhancing our security – if they had been pursuing a lean transformation to become more competitive, rather than running around the world in pursuit of lower costs.

However, it is also true that China distorted the situation through incentives set up to attract the manufacturers.

China’s position as the pre-eminent supplier of medicines is a result of government policy, said Guy Villax, the chief executive of Hovione, a maker of crucial drug ingredients with plants in Portugal and China.

The regional government in Shanghai has promised to pay local drug makers about $15,000 for any drug approval they garner from the F.D.A. and about $5,000 for any approval from European regulators, according to a document Mr. Villax provided.

“This shows that there has been a government plan in China to become a pharmaceutical industry leader,” Mr. Villax said.

While I believe government should tread very lightly in offering incentives to businesses or industries, it might make sense to offer support – in the form of lean consulting, as is currently provided with the quasi-governmental Manufacturing Extension Partnership – as an incentive to companies to encourage them to remain onshore.

Your thoughts?


Obama Likes Lean!

OK, our president-elect didn’t actually say he likes lean. But to promote his economic stimulus plan, he spent part of Friday touring a manufacturing company in Bedford Heights, Ohio – and it’s a company that embraces lean.

The business is Cardinal Fastener & Specialty Company. As CNNMoney notes, “The company is a carefully chosen poster child for Obama's stimulus plans: While so many manufacturers struggle with slowing sales, Cardinal Fastener is growing and adding staff, thanks to its focus on the green energy industry.”

With any luck, at least some news organizations will observe that there may be more to Cardinal’s success than just its choice of customers.

The company has been on a lean journey since 1998, and on its own website, it directly credits its adoption of lean principles as the basis for significant benefits, both for itself and its customers.

This places a wonderful spotlight on the value of lean manufacturing. Fantastic!


Technology Problems in Hospitals Need Lean Solutions

Sometimes I read about problems in hospitals and I want to start yelling at people to tell them how obvious it is that a lean approach would help.

The ECRI Institute, which researches patient safety issues, has issued its second annual report on the top 10 technology hazards that every hospital should pay more attention to.

As reported in The Wall Street Journal Health Blog, the issues are:

1. Alarm hazards

2. Needle-sticks and injuries from sharps

3. Air embolisms from contrast media injectors

4. Retained devices and fragments left in patients

5. Surgical fires

By the way, the list is much longer than five items. Those are just the ones that appear to be most prevalent this year. (The top items change from year to year.)

The WSJ blog quotes Dan Ault, author of the report, as saying the intent is to point out problems so they can be solved.

However, what I find most significant is what Ault has to say about the causes of the problems.

While some problems involve a faulty device alone, he says, there’s usually some contribution from the operator. “No one reads the manual, or even has the manual after day one,” he says. Even if they are trained properly, he adds, “they get busy or move on to something else.”

Yes, but the way to solve these problems is to apply lean methods. First, ask why five times (or as many times as it takes to get a meaningful answer) to find out the true causes of the problems. I’m sure it is not just operator negligence, though lack of training might be an issue.

The solutions may involve better training, implementing standard work, mistake-proofing or a variety of other lean tools.

I am glad ECRI issues the report, but it needs follow-up. Someone should write a report suggesting solutions – or better yet, identify institutions that have the lowest problem rates and report on how they achieved that.

Any volunteers?


Obama’s Picks for Top Health Posts Could Use Some Lean Guidance

Healthcare reform may not be the most pressing issue facing the incoming Obama administration, but it is certainly high on the list. Improving healthcare processes ought to be a key focus of those reform efforts – and I worry that it won’t be.

Applying lean and other improvement methods to delivery of healthcare services has already gained strong support in from a range of industry executives, though they are still in the minority. We are rapidly expanding the healthcare management books we publish.

Obama had previously announced his choice of former Senator Tom Daschle to be Secretary of Health and Human Services. Now he has announced his choice of William Corr to be deputy secretary.

Corr has 23 years experience in politics and government. He used to work for Daschle as the senator’s chief counsel and policy director. Corr also served as chief of staff and principal advisor to Donna Shalala when she was HHS secretary.

Currently Corr is executive director of the private Campaign for Tobacco-Free Kids. Early in his career, he worked in non-profit, community-run health care centers.

The primary battles over healthcare reform will be fought in Congress, so it makes sense that Obama has chosen two people who understand Congress and healthcare issues for these two posts.

However, as Congress debates how to change healthcare funding, what to mandate, and all the other tough issues involved here, it would be tremendously helpful to have input from people who really understand how to achieve healthcare improvement. So far, I’ve seen no evidence that any such people will be involved in the discussions. Daschle and Corr may be very good people with much healthcare knowledge, but I don’t believe they know lean or six sigma.

I take no position on whether Obama’s specific healthcare proposals are good or bad. Like all lean advocates, I focus on process improvement. An improvement effort can succeed only if it is based on good, complete information. The healthcare reform process that will shortly be getting under way does not yet have that information.


Lean Strategies Reduce Waits in Emergency Rooms

USA Today recently published a good article highlighting a few of the ways in which emergency rooms are reducing wait times, some of which involve lean-like improvements to their processes.

• Hospitals such as Cooper Hospital-University Medical Center in Camden, N.J., are forming "fast-track" areas in their emergency departments to more quickly treat patients with minor illnesses and injuries, such as small cuts or ankle sprains. Often, these areas are staffed by physician assistants or nurse practitioners, leaving the doctors to treat more serious problems.

• Hospitals such as Dublin (Ohio) Methodist Hospital are using computerized physician ordering systems to speed patients' ability to get blood tests and other diagnostic tests. All patient records are computerized, making it easier for nurses and doctors to check on a patient's status; all tests can be ordered electronically, which can reduce delays, says Dave Boehmer, the ER medical director.

Scripps Mercy Hospital in San Diego and Chula Vista has installed a computerized tracking system to help better monitor patients and available bed space to reduce the time patients wait for an in-patient bed. The hospital has also added a second triage area and put a full-time phlebotomist in the emergency department to speed blood testing.

Hudson Valley Hospital Center in Westchester, N.Y., has implemented what it calls a "no-wait" ER by letting its triage nurse start caring for the patient by ordering tests and moving the patient registration to the bedside via portable computers.

I particularly like the first and the last of those efforts. Creating “fast-track” areas for minor problems is like the lean technique of setting up different manufacturing cells for different families of products. And letting triage nurses immediately begin patient care certainly eliminates some wasteful waiting time from the process.

The article notes that the average waiting time in an emergency room has nearly doubled over the past decade. It is good to know that at least some hospitals are trying to reverse that trend.


A Lean Strategy Can Prevent Bedsores

The number of hospital patients with bedsores is increasing dramatically – and if ever a problem cried out for a lean solution, this is it.

The problem was described recently in The New York Times. The article, by Roni Caryn Rabin, noted that more than half a million patients admitted to U.S. hospitals in 2006 suffered bedsores, an increase of 78.9 percent since 1993. Total hospital admissions increased only 15 percent during the same period.

“Bedsores are preventable, but it’s not easy,” said William Spector, a researcher at the federal Agency for Healthcare Research and Quality. “It’s not like you just get a prescription and one physician can take care of it. It’s a major team effort that requires a multidisciplinary team of dietary aides, nurses aides, physical therapists and physicians all playing a role.”

Although the report did not explain why bedsores had become so much more frequent, an official with the American Hospital Association speculated that the increase may be due to rising numbers of very frail, elderly patients arriving in hospitals.

“We know we’re seeing older patients, patients who are sicker than they were a decade or more ago, and more patients whose immune systems are compromised by advanced age and some drug regimens,” said Nancy Foster, vice president for quality and patient safety policy with the A.H.A.

It’s also possible that greater attention to bedsores by hospital staff has led to improved record-keeping and a more accurate accounting of their numbers, she said.

Elderly patients and those who are bedridden or immobile are most vulnerable to bedsores, especially if the patients are not well-nourished or their immune systems are compromised. The sores, called decubitus ulcers, develop when there is constant pressure on the skin, and they can lead to serious, life-threatening infections.

Turning bedridden patients every two hours helps to reduce pressure on the skin. One hospital has started playing the song “Turn, Turn, Turn” to remind nurses that they should be turning their patients, Ms. Foster said.

So this is a preventable problem, and preventing it also prevents more serious complications. Further, the solution involves making sure certain actions are taken at certain times – in other words, the problem can be addressed by improving the process. And nothing improves a process better than a lean approach.


Will Obama’s “Chief Performance Officer” Improve Government?

President-elect Obama is reportedly going to appoint a “chief performance officer” for the federal government, a new position intended to work on the federal budget and reform government.

His choice for the job is Nancy Killefer, a senior director with McKinsey & Company and a former assistant secretary of the treasury.

Will this do any good? More specifically, will it help to make the federal government lean?

The first issue is whether this position will have any real authority or top-level support to drive change in the administration. That cannot be predicted at this point.

The second issue is whether Killefer is the right person for the job.

On the one hand, Killefer seems to have some relevant credentials. She has experience in working with the public sector to improve productivity, which has been the focus of her career.

On the other hand, in what I’ve read about Killefer, there is no mention of lean principles or strategy. And despite the size and prominence of McKinsey, the consulting firm is not known as a bastion of lean thinking.

I did come across an article Killefer co-authored for Business Week in 2006 discussing the need to make government more productive. She argued that what is missing from government is competitive pressure. She and her co-author made several proposals:

We think a radical new approach to transparency of how government programs are performing is required. Only this will push Congress to exert performance pressure on government agencies. First, government should measure public productivity again and set national targets for productivity growth against which everyone can be held accountable. Next, political leaders should create a body we call "Gov-Star," modeled after fund-rating agency Morningstar Inc. to provide completely independent measurement of government program performance; to develop comparable program data over time -- between programs, between governments, and with the private sector; and to make the data and their implications clear to appropriators and citizens.

But in government, pressure without support can yield demoralization and underperformance. So we also need to adopt key transformation initiatives: incentives that allow agencies to reinvest savings to the top line of programs; the introduction of chief operating officers at public agencies, to be appointed based on management experience in government or leading corporations; and a SWAT team of management experts at the Office of Management & Budget to help lagging agencies.

I have no problem with those proposals, though knowledge of how to implement improvements is just as important as the forces driving improvement.

If Killefer actually does have knowledge of lean, or is at least open-minded enough to listen to people who do, this appointment may have some value. I certainly hope so.


How to Reduce Waiting Time at Disneyland

I was in California during the holiday period. During most of that time, the lean advocate inside me was in hibernation while I was on vacation. But he woke up and had a few things to say during the day we spent at Disneyland.

First, a word of advice: Never go to Disneyland during the week between Christmas and New Year’s. It’s a great place, and we had a good time. But with all the kids off from school, thousands of people in town for the Rose Bowl, and beautiful weather, the place was mobbed. There were several days that week when the park closed early because it had reached maximum capacity.

What this meant was that the most popular rides had waiting times of up to 90 minutes for much of the day. On one ride, after we were done, we had to wait in line to get out. That never happened to me before.

Disney does have a program called Fastpass, where you can get a pass several hours in advance for quick entry into a ride, though you can only use it for one ride at a time. That helps, but it has its limitations.

As a lean person, whenever I experience long lines, I can’t help but look for improvement opportunities. When the park is as crowded as it was during our trip, it would be unrealistic to think the lines can be eliminated. But I do have a few minor suggestions.

First, a couple of points about food service. We had lunch at the Hungry Bear Restaurant, which is essentially a fast food place. You give your order to a cashier, then pick up the food at a counter.

Each cashier was at a standalone register dealing with two lines, going past the register on either side. I’m not sure that was the most efficient system, though it seemed to work reasonably well.

But delivery of the food at the counter was a lot slower than any fast food restaurant I’ve ever seen. The problem seemed to be the hot food, such as burgers and fries, rather than the cold sandwiches and salads, which were pre-packaged. I couldn’t see what was happening with the hot food, but I think Disney could learn a few things from McDonald’s, Wendy’s, Burger King or any other successful fast food chain.

Later, we stopped at another fast food place for some snacks. The cashier had to walk about 15 feet from the register to get one of the items we ordered. Now there’s an obvious problem.

I also have some thoughts related to the purchase of tickets to get into the park. Disneyland sells both “Annual Passports” and one-day passes. You can buy the passports online, but not the one-day passes. Why not? If I can print an airline boarding pass online, why not a park ticket?

When you get to the park, the only way to buy any kind of ticket is by waiting in line for a cashier (a wait of more than half an hour). It seems to me that Disney could help streamline the process by also offering self-service kiosks for at least some categories of tickets.

I know Disney employs some pretty sharp engineers. Maybe they have good reasons for not doing these things. Or maybe they just never thought about it.

Even the happiest place on earth should be pursuing continuous improvement.