Taking a Break

As much as I enjoy blogging, we all need a break now and then. See you in two weeks!

Book Talk: Andy & Me

In the middle of summer, people are often looking for novels or other summer reading they can take to the beach. So today I thought I would discuss Andy & Me: Crisis and Transformation on the Lean Journey – the one novel published by Productivity Press.

Originally released in 1995, Andy & Me is set in a failing New Jersey auto plant focusing on the tribulations of Tom Pappas, the plant manager. It follows Tom's relationship with Andy Saito, a reclusive, retired Toyota guru whom Tom persuades to help save his plant through the teaching of the legendary Toyota Production System.

The writer is noted lean expert Pascal Dennis, who also authored a non-fiction work, Lean Production Simplified, Second Edition: A Plain-Language Guide to the World's Most Powerful Production System. Both books were awarded the Shingo Prize for Excellence in Manufacturing Research.

So if you’re looking for an entertaining way for your mind to absorb lean principles while your body soaks up some rays, place an order and we’ll be happy to send you a copy of Andy & Me. (Sunscreen not included.)

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.

Doctors Should Not Impose Gag Orders on Patients

A successful lean strategy requires transparency. Information should flow freely, and accurate data about performance should be available to all concerned parties.

With that in mind, I was disturbed by the juxtaposition of two articles that appeared recently on the same day in The Washington Post.

One article focused on laws that have taken effect recently in Virginia, Maryland and the District of Columbia that require hospitals to report to regulators serious injuries that patients suffer in the course of treatment – often due to medical mistakes.

Overall, I view this as a good thing. The three laws described in the article have different requirements, and there will be some problems along the way, I’m sure, as regulators and executives come to learn which requirements and systems work best.

But transparency of this kind of information will, I hope, drive improvement. The article notes that, increasingly, insurance companies are refusing to pay for medical errors, which encourages hospitals to find ways to prevent them.

The other article focused on a push away from transparency. It described how some individual doctors, concerned about websites that publish ratings of doctors, are requiring patients to sign documents in which they agree not to post anything on the Internet without the doctor’s consent.

The article notes that many experts say such agreements are unethical and unenforceable.

I agree with that last point. As a journalist, I react strongly when anyone tries to put a limit on free speech.

In fairness, the doctors have some legitimate concerns. Some websites allow comments to be posted anonymously, and do nothing to verify whether the comments are true.

But a gag order is not the solution. The way to deal with misinformation is with more, accurate information. (Which, by the way, doctors would have if they measured their performance using lean methodologies.)

Your thoughts?

‘Chinese Labor Cost is Not That Big a Factor’

We lean advocates tend to rant about how so many businesses wrongly believe they need to outsource production to other countries, especially those in Asia, in order to be competitive. We argue that a lean strategy, along with recognition of the problems and costs of a far-flung supply chain, can make up for lower costs overseas.

But maybe some businesses are smarter than we think.

These thoughts came to mind after I read an article in The New York Times about the Obama administration’s lack of a coordinated policy to revive manufacturing in the United States.

The article includes comments from Douglas Bartlett, who is closing a circuit-board factory in Illinois. Bartlett says he was done in by cheaper products from China, and he contends that the Chinese products are cheaper because the Chinese undervalue their currency.

“I can compete against Chinese entrepreneurs, and Chinese labor cost is not that big a factor,” he said, “but I cannot compete against the Chinese government’s manufacturing policies.”

Currency manipulation is a serious issue, though it is not my intent to address it here. What I find fascinating is the first part of that quote, in which Bartlett says he CAN compete against the Chinese if there is no government interference.

I am saddened by the closing of Bartlett’s factory, and I agree that currency manipulation issues need to be addressed.

I simply wish to make the point that Bartlett made so well – U.S. businesses do not have to go running after cheap overseas labor in order to compete.

How to Ease the Conflict Between Medicine and Money

Culture change is often the most difficult part of a lean transformation. That may be doubly true in healthcare, where culture – how people think – is already subject to significant stress.

This problem was highlighted recently in a thoughtful essay in The New York Times by Dr. Sandeep Jauhar, a cardiologist and author of the recent memoir “Intern: A Doctor’s Initiation.”

Jauhar is disturbed by the fact that, while doctors want to focus on medicine, too often they find themselves focusing on money.

The reality is that most doctors today, whether in academic or private practice, constantly have to think about money. Last January, Dr. Pamela Hartzband and Dr. Jerome Groopman, physicians at Beth Israel Deaconess Medical Center in Boston, wrote in The New England Journal of Medicine that “price tags are being applied to every aspect of a doctor’s day, creating an acute awareness of costs and reimbursement.” And they added, “Today’s medical students are being inducted into a culture in which their profession is seen increasingly in financial terms.”

The rising commercialism, driven in part by increasing expenses and decreasing reimbursement, has obvious consequences for the public: ballooning costs, fraying of the traditional doctor-patient relationship. What is not so obvious is the harmful effects on doctors themselves. We were trained to think like caregivers, not businesspeople. The constant intrusion of the marketplace is creating serious and deepening anxiety in the profession…

Financial considerations have never been as prominent as they are today, probably because so many hospitals and doctors, especially in large metropolitan areas, are in financial trouble. More and more doctors are trying to sell their practices, or are negotiating with hospitals for jobs, equipment or financial aid…

Among my colleagues I sense an emotional emptiness created by the relentless consideration of money…

Reforming healthcare involves many complex issues, including insurance and reimbursement systems as well as the needs of the uninsured.

Applying lean thinking to healthcare is one part of the solution. By giving doctors and other healthcare professionals the means to eliminate waste (and cost) from healthcare processes, while simultaneously maintaining or improving quality, perhaps we can help ease the sense of emptiness that Jauhar describes.

Book Talk: Value Stream Mapping for Healthcare Made Easy

Lean tools used in manufacturing can be applied to other industries. But there may be some differences in the details of their application, it may not be perfectly clear how to shift from one industry to another, and people working in a given industry may be skeptical of how something used in another field applies to them.

That is why there can be value in industry-specific books. A good example, and one we believe should be of strong interest to healthcare professionals, is Value Stream Mapping for Healthcare Made Easy, a new book to be published next month. (Orders can be placed now.)

This book is by Amy and Cindy Jimmerson. Cindy is also the author of another healthcare-specific book, A3 Problem Solving for Healthcare.

The authors have written the book in two parts. The first part introduces healthcare workers to value stream mapping and explains how to look at any process with eyes that probe all the value-added and non-value-added activities.

The second part reviews real value stream maps at real healthcare facilities created by teams of administrators, managers, physicians, and staff members.

With growing interest in lean in healthcare, and with so many healthcare professionals still relatively new to lean, this paperbound book can be a valuable resource for those embarking on a new lean journey.

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.

Lean Job Guarantees are Practical – And Ethical

I came across a well-written expression of a lean manufacturing principle recently – in a column about ethics.

I am referring to the principle that employees who come up with process improvements that reduce staffing requirements should be promised that their jobs will not be eliminated as a result. This not only goes to the heart of the lean principle of respect for people, but is also simple, practical common sense – employees will not look for improvements if they believe doing so would jeopardize their jobs.

In “The Ethicist” column, which appears every Sunday in The New York Times magazine, writer Randy Cohen addresses issues raised by readers. Recently he received a question from a man who said he is a computer programmer in a large company in Pittsburgh, and who occasionally is asked by workers if he can automate repetitive tasks, such as data entry. The programmer said that while he can, “what happens next usually involves the person who wanted to save the company time and money looking for a box to hold their personal effects — and for a new job.”

In his reply, Cohen does not mention lean manufacturing. But he understands the principle involved here.

It would be grotesque to encourage employees to innovate and then, when they do, have a couple of goons rough them up and give them the old heave-ho. Even without the goons, it is not ethical to punish someone for doing just what you want (and urge) him to do. Someone who comes up with a useful idea should expect a bonus, not a pink slip. A management strategy that fires the most resourceful workers bears reconsidering.

All who contribute to the success of a venture should share in its rewards. At a minimum, the company must guarantee the job of so effective and dedicated an employee, perhaps shifting him or her to another position or cutting staff through attrition. If the company declines to take such steps, then you should give your co-workers an honest account of the possible consequences of their request.

I couldn’t have said it better myself.

Process Improvements Help Hospital Reduce Specimen-Label Errors

Huge numbers of patients, medications, specimens and test results circulate through a hospital, so it is critical that all of them be properly identified.

A hospital in South Carolina found that misidentification is a serious problem – and one that can be easily addressed, at least partly through lean approaches.

An article from HealthLeaders Media describes how Self Regional Healthcare (SRH) in Greenwood, S.C., put together a cross-functional team to study safety “events” (read: problems). The team found that the majority of safety events were identification events – primarily specimens that were either mislabeled or not labeled at all.

By developing and implementing an improvement plan, the hospital reduced ID events by 65 percent after only one month.

Part of the plan involved technology – a network of scanners and bar-code printers used to coordinate patient ID bands with the labels on medications and specimens. The team took a system designed to coordinate the patient and medication bar codes and extended it to cover specimen labels as well.

But to the credit of the team, its members recognized that addressing the problem involved more than just technology.

"Things like where the patient received their bar-coded arm band, who collected the specimen versus how and when it was labeled, and how the specimen was then sent on to the lab all varied depending on the area," says Leisa Butler, RHIA, CPHQ, performance manager in the quality management services department. "So as a team, we decided to come up with a core common process."

In developing a common core process, the team decided that there could be no exceptions to key components. This was decided as a means of decreasing the variability found during the initial assessment. However, the team decided to allow specialty areas to add a step in the process, if necessary. For example, in the OR, there are additional steps for processing and transferring specimens.

Along with that process, Butler and her team noted that steps could be added, but no steps could be left out during the processing or transferring of specimens.

"If an event occurs that deals with specimen labeling or ID labeling, then the standard flow chart must be reviewed, and it has to be noted where in the process things failed," says Butler.

I applaud SRH for their efforts, and hope they serve as a model for other hospitals.

Who Knew Fiat was a Lean Company?

And the foreign automaker doing a good job of implementing lean manufacturing is… Fiat.

Fiat?

Yes, Fiat. The Italian car company has transformed itself from a maker of poor-quality cars 20 years ago into a nimble, highly efficient producer of high-quality small vehicles. Hordes of executives from Chrysler, which is now effectively controlled by Fiat, are traveling to Fiat’s plant in Tychy, Poland, to see how it’s done.

A recent article in The New York Times describes the plant.

At Tychy (pronounced TICK-ee), one secret is flexibility: The latest robotic technology is balanced by workers who can quickly shift models to match demand. That is one reason Tychy is operating around the clock, six days a week, while most other auto plants in Europe and the United States are running at a fraction of capacity, increasing costly nonproductive downtime.

And according to the director of the Tychy plant, Zdzislaw Arlet, it’s all about lean.

Mr. Arlet is also constantly on the lookout for time- and money-saving improvements, adding that he himself looks to Toyota’s famous Kaizen system for inspiration: Instead of filling up cars at different production points with brake fluid, gasoline, water and other liquids, one machine on each of Tychy’s three lines fills each vehicle.

“A car comes off the assembly line every 55 seconds,” Mr. Arlet said. “In 1996, it took twice as long.”

An infusion of lean thinking by itself won’t be enough to save Chrysler. But it helps give the Detroit company a chance.

Book Talk: Learning Packages

Today I want to discuss the learning packages we sell, and hopefully spark a dialogue about what types of learning materials you would like to see.

The learning packages are based on our popular Shopfloor books, a series of easy-to-read paperbacks, each focused on a specific aspect of lean. With clearly written copy and illustrations, these are a useful learning tool for employees on the shop floor.

To facilitate their use in training or instruction, for many years we have sold some of the more popular Shopfloor books in learning packages. A typical learning package includes five copies of the Shopfloor book, a Leader’s Guide, one copy of another relevant book, and additional materials on CD. Learning packages generally sell for $350 to $375 each. (In some cases, the Leader’s Guide can also be purchased separately.)

The packages we offer include:

• 5S for Operators Learning Package
• Cellular Manufacturing Learning Package
• Focused Equipment Improvement for TPM Teams Learning Package
• Kaizen for the Shopfloor Learning Package
• Kanban for the Shopfloor Learning Package
• Mistake-Proofing for Operators Learning Package
• Quick Changeover for Operators Learning Package

The question I have for those of you who work on the shop floor is whether this type of package appeals to you, and whether there is any other type of package – with different materials, or a different format – that would be of equal or greater interest.

As lean advocates, we at Productivity Press recognize that we need to focus on providing value for our customers, and that our customers define value.

What do you value?

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.

Canadian Politician: Elect Me Because I am Lean

In what may be a first, and is certainly a first to me, a Canadian politician is claiming that his work with lean manufacturing makes him a better leader.

Mark Taylor is running for the federal council of the Green Party in Canada. The council is the party’s governing body.

Like other candidates for the council, Taylor responded to a questionnaire they were all sent. An engineer by profession, he referenced lean manufacturing in describing his qualifications.

My company is a practitioner of Lean Manufacturing and I am learning skill sets there that are directly applicable to the Green Party. Consensus building, constant improvement and the efficient use of resources are just three of many tools in the Lean tool box that will help.

I know nothing about Canadian politics, and I am not endorsing the candidacy of Taylor or anyone else.

But I hope Taylor’s comments are an indication of growing respect for lean principles.

A Nursing Home Death Should Raise Process Issues

When a problem exists – and is recognized as a problem – the lean approach is to ask “why” as many times as necessary to identify the cause of the problem and develop a solution,

A recent tragic incident in California cries out for that approach.

The California Department of Public Health levied a $100,000 fine (the highest possible under state law) on Aviara Healthcare Center, a nursing home located in Encinitas (San Diego County).

A news release from the department describes in clear, simple terms the reason for the fine.

The facility created a hazard by improperly storing a large mechanical patient lift in a hallway. A patient grabbed the lift during a fall, tipping it over. The resulting injuries led to the patient’s death.

The first question is why the lift was being stored in the hallway. Is there a specific place where it should have been stored? If not, why not? Is there no storage space for it anywhere? Are there no procedures in place for checking lifts in and out of storage, or for returning them to storage once they have been used?

But those aren’t the only questions. Imagine that the lift had not been in the hallway. Was there anything that could have been done to prevent the patient from falling? Are there railings in the hallway, for example? Falls are a common occurrence among elderly, infirm patients, and not all falls can be prevented. But the question is worth asking.

Unfortunately, I suspect that these questions may not get asked. Too often in this kind of situation, those in charge focus only on the obvious – i.e., a patient died and we got fined for leaving a lift in a hallway, so let’s not leave lifts in hallways. They may not know how to think in lean terms to identify broader issues in their processes.

That is not always true. Sometimes a serious incident such as this one can serve as a wake-up call. I hope it does in this case.

Simplicity Helps Improve AIDS Treatment Programs

One of the more counterintuitive aspects of lean is that the best approach may involve spending less money. People tend to assume the most expensive is always the best. But sometimes a simple, low-tech approach produces the most significant results.

Therefore, I was pleased to read a recent article in The Wall Street Journal describing efforts to find new ways to run AIDS treatment programs – by studying what is being done in Africa.

With health-care costs soaring in the U.S. and more than 50,000 new HIV infections every year, many are starting to ask: If it can be done over there, why can't we do it here?

The obstacles range from the complexities of insurance reimbursement to regulations designed to protect patients. Another hurdle is cultural: There is a deep-seated reluctance to accept that simpler and less expensive treatments like those used abroad might be good enough.

"We're building Cadillacs, and they're offering us VW Beetles," says William Vodra, who drafted U.S. Food & Drug Administration rules while working at the agency, and now specializes in regulatory issues involving medical products as a lawyer at Arnold & Porter in Washington, D.C.

One example cited in the article (written by Amy Dockser Marcus) involved appointment procedures at a University of Alabama AIDS clinic.

"Project Connect" is based on a program used in AIDS clinics in Zambia. In the Alabama program, patients were given appointments with doctors within five days of calling the clinic. Blood tests were taken during the first visit. A social worker did an interview, trying to identify and address any issues that might prevent patients from coming back. The no-show rate dropped from 31% in 2007 to 18% through June 2009.

Another example involved using non-medical personnel to help patients stick with treatment.

For Heidi Behforouz, it has been an education. Dr. Behforouz started running the Prevention and Access to Care and Treatment Project in Boston based on a program first used successfully in rural Haiti. PACT trains community health workers to persuade AIDS patients to adhere to treatment regimens. The hope is this will reduce rates of emergency-room use and hospitalizations, big drivers of health costs.

The strategy appears to work; according to data PACT collected, total medical expenses for 20 patients fell 40%. But PACT, which is expanding to sites in New York, still pays for the program out of private donations and fund raising, since insurers don't cover it.

Dr. Behforouz presented data to an advisory council that recommended to the Massachusetts State Legislature that community health workers be trained and reimbursed, but the process for approval is likely to take years before it is implemented, if ever. "This is still a nascent field," Dr. Behforouz says. "They don't wear white coats. Their training is different than doctors or nurses. It's hard to get them recognized as health-care workers."

In other words, the biggest obstacles standing in the way of low-tech approaches tend to be cultural. That is so often the case with lean.

By the way, while lean is not mentioned in the WSJ article, I do regard some of what it describes as lean approaches. In the Alabama example, the focus was clearly on eliminating wasted time in the appointment and intake process.

Have you ever achieved improvement with a low-tech counterintuitive approach? Share your experience below.

Book Talk: Innovative Lean Development

Steelcase is a company with a solid reputation of implementing lean principles – in all areas, not just manufacturing. Now two of the company’s internal lean consultants have written a book about lean in product development.

Innovative Lean Development: How to Create, Implement and Maintain a Learning Culture Using Fast Learning Cycles by Timothy Schipper and Mark Swets focuses on the six key areas necessary for dramatic development: innovation, rapid prototyping, knowledge capture, learning cycles, process stabilization, and lean management standards.

This book, available next month, is a manual that serves as a template for starting and maintaining the lean process. It includes both explanations and real examples, and explains how to integrate innovation into product development processes, including IT development.

Innovative Lean Development joins other books we publish on product development, including The Toyota Product Development System by James Morgan and Jeffrey Liker, and Value Stream Mapping for Lean Development by Drew Locher, to name just a couple.

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.

The Key to Mining Safety is… a Whiteboard

We lean advocates love simple visual controls. And I recently saw a television program that included a marvelous example of such controls.

I was watching an episode of “Build It Bigger” on the Discovery Channel. The episode focused on efforts to dig a water tunnel in California to bring water to the southern part of the state.

The tunnel, which extends for many miles, is under construction far below the surface of the ground. It uses highly sophisticated machinery to chew through the dirt and rock, then install pre-fabricated concrete sections into five-foot-wide rings that form the wall of the tunnel. The miners install four to six rings per day.

But what caught my eye was what happens before the workers go underground.

A large whiteboard stands near the tunnel entrance. The names of all workers – and any visitors – are listed on the whiteboard. Two hooks are next to each name, one in a column labeled “In”, the other column labeled “Out.” A plain metal tag hangs from each “Out” hook.

Just before heading into the tunnel, each miner moves the tag by his name over to the “In” hook. The result: The whiteboard clearly displays which workers are in the tunnel at any given time – valuable information in case of a problem or accident.

I can’t think of any other system – a computer display or anything else – that would work better than this simple whiteboard.

Can you?

Financial Incentives May Help Reduce Hospital Readmissions

I wrote a few months ago about how many patients are readmitted to hospitals for costly visits that could be avoided. That posting described the results of a recent study that included suggestions to reduce readmissions, including better patient education and better scheduling of follow-up appointments.

A recent article in The Washington Post covers much of the same ground, but also talks about using financial incentives to address the problem.

Right now, hospitals -- such as Inova Mount Vernon -- that do a better job of preventing readmissions sometimes end up losing money because the health-care system doesn't pay for the extra work they do. Some health reform proposals would change the way hospitals are paid, so that stopping readmissions becomes good business.

One idea is to bundle the payments to hospitals, doctors and perhaps nursing homes or rehabilitation centers, to cover both the hospitalization and those first critical weeks after discharge.

Another proposal is to have Medicare penalize hospitals with high readmission rates for eight common chronic diseases. Members of both parties have been looking at ways of paying primary care doctors more to help patients manage their chronic diseases and avoid trips to the hospital every few weeks or months.

The key to reducing readmissions is to improve hospital processes. Financial incentives do not do that directly. But they can serve as a driver – a burning platform – to get hospitals to focus on what needs to be done.

Do you agree?

What Anecdotes Tell Us About Culture at a General Motors Plant

Sometimes the most intriguing insights about lean come not from general statements, but from anecdotes. A recent article in The New York Times Sunday magazine falls into that category.

The article profiles the devastating effect the collapse of GM is having on middle-class blacks in Michigan, for whom the automaker has been a major source of employment.

Mark Graban wrote about the article in the Lean Blog, highlighting a few passages he thought had lean relevance. I agree with his comments, and I’d like to mention some additional sections.

The article, written by Jonathan Mahler, focuses on Marvin Powell, who started working at a GM plant in Pontiac 13 years ago when he was 26 (and is now losing his job).

I am fascinated by the description of the plant at the time Powell started.

It was stressful at first. The line moved faster than he anticipated, and as a new hire who could be let go without cause during his first 90 days, he didn’t want to be the one to slow it down.

Contrast that with a well-run lean plant (Toyota), where a worker is more likely to get into trouble for NOT stopping the line if there is a problem.

But even more fascinating is this description of what I will call the plant’s extra-curricular activities:

Adjusting to the culture of the factory was a challenge, too. A practicing Christian, Powell was taken aback by what he saw taking place around him. The plant was a world of temptations unto itself, with drugs, alcohol, numbers runners, bookies and even “parking-lot girls” who would come to the plant during lunch breaks to service male workers. “Anything you can find outside the plant, you can find inside the plant,” Powell says. “You either get caught up in it, or stay apart from it.”

Even in a well-run plant, I’m sure, auto employees work hard. And everyone likes to blow off some steam. But this description goes beyond that.

Now I’ve never worked in an auto plant. I don’t know whether this kind of situation was unique to that one plant (which I doubt) or whether similar situations exist in Toyota plants (which I also doubt).

The Big Three rarely showed their workers the kind of respect for people that is a fundamental lean principle. They tended to treat workers as drones, expecting them to get the job done, with management not seeking (and even discouraging) ideas or feedback from workers. In such an environment, workers can feel unappreciated and discouraged, which can increase desire for, shall we say, diversions.

Of course, that’s largely speculation on my part. Do any of you have experience with this kind of working environment? What do you believe were the causes?

Book Talk: Freedom from Command and Control

I’m posting Book Talk a day early this week, because of the holiday tomorrow. And in the spirit of Independence Day, I thought it might be appropriate to write about Freedom from Command and Control: Rethinking Management for Lean Service by John Seddon, a book originally published in 2005.

Why? Because the word “freedom” is in the title. Because this book talks about the importance of not being dictatorial, and having employees engaged and involved – maybe not to the point of being a democracy, but certainly in a collaborative way. Even the cover of the book is red, white and blue.

But seriously… Seddon demonstrates that decision-making based on purpose-related measures (such as putting customers first and improving services) can help managers reconnect with operations, see waste, and exploit opportunities for improvement.

This book is focused on service industries. Seddon argues that service is fundamentally different from manufacturing, and shows how Toyota production principles must be transformed for application in service organizations.

For those of you who work in service, this book can be a valuable addition to your library.

Happy 4^th of July!

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.

Report: Medical Schools Should Teach Doctors About Lean

I’ve taken some liberties with the headline on this posting. The report to which I refer is a new document from the Medicare Payment Advisory Commission (MedPAC), which advises Congress on Medicare. And the report did not actually say lean should be on the curriculum of medical schools.

What it did say is that medical schools need to change their curriculums. And part of that change involves focusing on what sound to me like lean principles.

Reforms in payment policies need to be accompanied by reforms in medical education. This pairing is important to ensure that students and residents learn the skills they need to provide care and leadership in new delivery models under restructured payment and incentives.

These skills include quality measurement and practice improvement, care coordination, multidisciplinary teamwork, cost awareness, and interpersonal skills. Research on internal medicine residency programs found several gaps in formal instruction on many of these skills.

Coordination, teamwork and measurement of cost are all central to a lean strategy, just as interpersonal skills are part of the fundamental lean principle of respect for people.

And let’s not forget about the central goal of lean, process improvement.

A Commission-sponsored study, conducted by RAND researchers, found that, although most internal medicine residency programs provide at least some instruction and experience in topics associated with quality and efficiency improvements, their curricula fall short of recommendations from the Institute of Medicine (IOM) and other experts…

The IOM states that physicians must be able to assess the quality of care they provide and implement changes in their practice for improvement…

The RAND researchers found that, while many residency programs provide some exposure to quality assurance and system change, only a small share require residents to complete their own systematic data collection, analysis, and resulting system change. Fewer than half the programs (11 of 26 programs) have lectures or computer-based training on quality assurance, but more (18 programs) require that residents work on quality assessment at the hospital. Fewer than a third (seven programs) have established curricula in which residents collect and analyze data on their own patients. The same share of programs introduces residents to chronic disease registries and provides lectures or computer-based training on implementing system change. Fewer still (four programs) have residents work directly on projects to implement system changes.

The section on medical education is actually only one part of the wide-ranging, 299-page MedPAC report, which is entitled “Improving Incentives in the Medicare Program.” For those interested in healthcare reform, it makes for interesting reading.

And I’m glad to see that lean principles are part of it, even if the word lean is not mentioned.