Video of Author Steven Hoeft

Last week in Book Talk I wrote about Stories From My Sensei, the new book by author Steven Hoeft.

He now has a couple of videos on YouTube. In this one, he tells an amusing (and educational) story entitled “Must Cut Inventory in Half.”

Hospitals Must Learn to Focus on Results

While growing numbers of hospitals are learning how to apply lean concepts to their operations, they have a lot to learn about how to measure performance.

I come to that conclusion after reading an article from Hospitals and Health Networks Digital Magazine, which said that hospitals are hiring more doctors.

The authors of the article believe, and I agree, that this is a good trend. It is driven by several factors, including the fact that many young physicians entering the profession are wary of the hassles involved in running a private practice today and prefer the stability of a hospital job.

However, the article notes that contracts between hospitals and doctors typically include productivity targets and incentives that represent a greater portion of the physician’s compensation than in the past.

Data available from previous employment efforts are enabling hospitals and physicians to design "smarter" contracts. Examples of smarter incentives include both group and individual incentives, better calibrated productivity measurement (whether productivity is measured in patient volume, RVUs, gross charges, collections, etc.) and other measures designed to tightly align the hospital employer's goals with the physician's, such as quality outcomes. Hospitals that directly employ physicians have tighter control over productivity and tracking.

I am concerned that the emphasis will be more on quantity – the aforementioned patient volume, gross charges, etc. – than on quality outcomes.

We publish several books by Mark Graham Brown, who is an expert on metrics and incentives. Several years ago, Mark taught me the basic rule of incentives: They should be based on results, not activity.

Quality outcomes (meaning patients with improved health) are results. Patient volume is activity. If you pay your doctors to see more patients, they will see more patients. But what matters is whether they are improving the health of their patients.

I hope hospitals come to understand that and revise their metrics and incentives accordingly.

Book Talk: Stories From My Sensei

You can learn a lot about lean from books, which may discuss lean theory, provide how-to instructions for use of lean tools, or present case studies of lean implementations.

But anyone with actual experience will tell you that book learning must be complemented by experience, and that one of the best ways to learn is under the guidance of an experienced sensei, or teacher.

A new book we are publishing next month takes that kind of learning and distills it into a series of lessons. Stories from My Sensei: Two Decades of Lessons Learned Implementing Toyota-Style Systems describes a range of experiences in several different industries, organized according to the “Toyota house” model of lean. Each chapter includes a detailed description of the tools and principles relevant to that lesson, and is accompanied by questions for the reader on how to apply the principles.

The author is Steven E. Hoeft of Altarum Institute. He has worked in several industries, at one time trained with Eli Goldratt, and has helped various organizations win more than a dozen Shingo prizes.

This insightful and entertaining book could be one of the more fascinating books in your lean library.

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 Dirty Truth About Clean Hands in Hospitals

Efforts to reduce infections in hospitals by getting workers to wash their hands more often got a boost recently, with the Joint Commission Center for Transforming Healthcare – part of the agency that accredits hospitals – announcing a new program in partnership with eight hospitals and health systems.

An article from Health Leaders Media about the effort quotes Joint Commission President Mark Chassin, MD, as saying the participants recognize “that simply posting more signs or demanding that healthcare workers try harder isn't enough.”

That is encouraging. But what I found more interesting, and perhaps more encouraging, is a recognition that data about hand-washing programs must be accurate – and often isn’t.

The center has already determined that many hospitals have been lulled by faulty data into thinking that hand washing is occurring more than is actually the case. In fact, using The Joint Commission-developed enhanced measuring standards, the eight hospitals in the study found that their caregivers washed their hands less than 50% of the time.

A fundamental principle of any improvement effort is that you must be able to accurately measure performance, both before and after implementing initiatives.

The article also mentions some of the initiatives that may be implemented.

To improve compliance, new strategies being tested include: Holding everyone accountable—doctors, nurses, food service staff, housekeepers, chaplains, technicians, and therapists; using a reliable method to measure performance; communicate frequently and use real time performance feedback; and tailor education in proper hand hygiene for specific disciplines.

This is one of a series of Joint Commission efforts. Future programs will target breakdowns in hand-off communications, improving infection control, mix-ups in patient identification, and medication errors.

Eliminating Waste in Fashion Design

Those experienced in lean know that probably the best way to reduce the cost of manufacturing a product is to design it better. By selecting the right raw materials and by creating a design that is easy to assemble, the product costs less and takes less time to produce.

Kathleen Fasanella, in her blog Fashion Incubator, highlights an interesting application of the concept. She focuses on the work of Timo Rissanen, a fashion professor who tries to design products with zero waste.

We’ve all heard about the problems that occur with silos in manufacturing, and that seems to be part of the problems that Kathleen says Rissanen tries to address.

Timo says waste reduction must be realized at the front of the line in design, which is then incorporated in patterns rather than leaving all the responsibility for waste reduction and reducing fabric costs with the cutters.

Rissanen’s approach is to fit the pieces of a garment together in a pattern so artfully designed that when they are cut from a length of fabric, virtually nothing is left over. You can see a couple of examples of these types of patterns on Kathleen’s blog.

I imagine this type of approach has applications in certain kinds of manufacturing as well. Do you know of any?

In the Future, Patients Are Engaged And Involved

You often hear about the importance of working closely with suppliers to optimize the supply chain. What is equally important, and perhaps more difficult, is working with customers. When you collaborate with your customers, rather than simply try to sell them products or services, they can provide valuable insights, and help you to eliminate waste and produce greater value

That kind of partnership with customers is the future of healthcare, according to an intriguing article from Health Leaders magazine entitled “The Patient of the Future.”

The article, by Gienna Shaw, focuses on what will likely be the much greater use of technology in the future. But the key point Shaw makes is that technology gives patients much greater access to information – which transforms them.

"A whole bunch of improvements that have happened over the past 30 years with IT in other industries are going to evolve in healthcare and that will result in transformation as to how the whole process will work," says Dave deBronkart, an advocate for patient engagement and empowerment and communication as well as patient-caregiver collaboration…

"The major change that's going to happen is about people getting their hands on their own medical data and their data traveling with them, rather than being bottled up inside a particular hospital," deBronkart says…

Effective e-patients are involved in their own health in a number of ways, deBronkart says:

• They look at their medical records online
• They may share medical records with family and friends who know medicine
• They use e-mail to correspond with their doctors
• They are active partners with the various physicians involved in their care
• They're often active in patient communities
• They may become active researchers

The article notes resistance from doctors, particularly because this trend inevitably produces some patients who try to tell the doctor how to do his or her job. But it also includes mention of some doctors who believe they should embrace the trend.

Ken Davis, MD, doesn't wait for his patients to come to him with their research—he helps them gather it. At the end of an appointment, the Conroe, TX-based physician brings his patient out into the hallway to a computer with Internet access. He shows her how to use MedScape and gives her a quick tutorial on how to find more information about the diagnosis. Taking a few minutes to do that saves him time, he says. A patient will come to the next appointment better informed and ready to work in partnership with the physician.

"You can engage patients with technology instead of it being a barrier," Davis says. "You can use technology to your advantage or you can get real upset because the patient went ahead and got a second opinion from the Internet. Doctors just have to get over themselves."

I believe movement toward this vision of the future will occur in fits and starts, unevenly throughout the country. But I believe it to be correct.

Book Talk: Compression

I believe Compression: Meeting the Challenges of Sustainability Through Vigorous Learning Enterprises, a new book we have coming out next month, is an important work, for two reasons.

First, this book addresses the timely and significant issue of sustainability, and how approaching the problem with a lean mindset offers the greatest opportunity for developing solutions. The main emphasis of the book is on what leaders can do to change the mindset of stakeholders at all levels.

Second, the author of the book is Dr. Robert W. Hall, founding member of the Association for Manufacturing Excellence, former editor of AME’s Target magazine, and a widely respected leader of the lean movement. We are delighted to have “Doc” Hall as an author, and believe his decades of experience and insight make this book a valuable contribution to the body of knowledge on both lean and sustainability.

If your company is confronting the challenges of sustainability, and/or is embarking on a lean journey, you may wish to add this book to your library.

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.

Hospital’s ‘Universal Floor’ Produces Numerous Benefits

Flexibility is a key concept of lean production. Ideally, a manufacturing line or cell should be able to produce a variety of products. And employees should be cross-trained to work on any one of those products.

This concept is now being applied in healthcare, in the form of what is called a “universal floor” in a hospital. A recent article from Health Leaders Media highlights use of this approach at Cedars-Sinai Medical Center in Los Angeles (which copied it from Methodist Hospital of Clarian Health in Indiana).

Since implementing the concept in 2007, the article says, “Cedars-Sinai's innovation has lowered wait times for patients being admitted from the ED and elsewhere, reduced the number of patient safety events, and increased staff member satisfaction.”

A universal floor is one on which most patient consultations can take place. Rooms are created with multiple types of patient care in mind and staff members are trained in many specialties to facilitate patients' needs on the one floor. This reduces the need for patients to travel throughout the hospital…

Cedars-Sinai wanted to address patient flow issues occurring due to a lack of available beds and a constant influx of patients needing beds, similar to many hospitals in the country. Ideally, the universal floor would be able to accept patients who were visiting with their doctors and complaining of chest pain, for example, without having to go through the ED. Often physicians will send patients to the ED as a last resort because of the lack of open beds.

In addition to improving patient flow throughout the hospital and reducing patient safety errors, the universal floor has allowed staff members to spend more time with patients, making for a more comfortable patient stay.

Sounds like a win-win situation all around.

Why Haven’t Toyota Workers Joined the UAW?

Toyota’s decision to close the NUMMI plant in California (after partner GM pulled out) prompted an interesting observation on something called The Car Gurus Blog. The writer called it “the best move Toyota could’ve made” because it was the only unionized Toyota plant, and the closing means Toyota no longer has to deal with the United Auto Workers.

That raised an interesting question in my mind. NUMMI was launched 25 years ago. At the time, I’m sure the UAW was delighted to be representing workers at a Toyota plant, even if Toyota was only one-half of the joint venture. And I would bet the union was hoping it could build on that toehold to represent workers at other Toyota facilities.

But it didn’t. In 25 years, the UAW never created another union local anywhere else in Toyota.

Why not?

Could it be because Toyota shows more respect for people (a lean principle) than the Big Three, treating its employees better, with the result that Toyota’s employees just never felt any compelling need for a union?

As I’ve never worked for an auto company, I’m just guessing. What do you think?

By the way, to my knowledge, the UAW does not represent workers at the U.S. plants of any foreign automaker, not just Toyota. If any of you believe that is incorrect, please let me know.

Learn From Mistakes; Don’t Try to Hide Them

Hospitals are beginning to realize that admitting and learning from mistakes is better than trying to cover them up, according to an article in The Wall Street Journal.

Some hospitals like Baptist Children's are taking steps to admit grievous mistakes and to learn from them in order to overhaul flawed procedures. That represents a sharp departure from hospitals' traditional response when something goes terribly wrong—retreating behind a wall of silence to guard against potential lawsuits.

Now, some hospitals are hoping to stem the tide of lawsuits by being more open with aggrieved patients and their families. While some experts warn that disclosure will lead to an increase in litigation and costs, there are some indications that patients are less likely to sue if they receive full disclosure and an apology, along with an offer of compensation. But longer term, some administrators say the solution is to improve hospital safety records.

"Sorry alone doesn't work unless we learn from our mistakes," says Timothy McDonald, a pediatric anesthesiologist and chief safety officer at the University of Illinois Medical Center in Chicago. "We have to also make promises that this won't happen again and get patients and families engaged in the effort to improve our performance."

One example cited in the article is the University of Illinois.

The University of Illinois center set up a specialized service in 2004 to help staff communicate with patients and families after harm occurs. Since 2006, the center has had a policy of fully disclosing medical errors, apologizing when they occur, and swiftly offering a financial settlement. And patient-family members sit alongside staff on a board charged with overseeing plans to prevent errors.

Dr. McDonald says that over the past four years, the number of lawsuits against the center is down 40% compared to the period between 1999 and 2004, even though the number of procedures increased 23%. While it can't say for certain that the disclosure program was responsible for the decreases, "we can certainly say that it has not caused an increase in lawsuits or payouts," he says.

While I’m sure the hospital is pleased by having fewer lawsuits, I am more interested in whether its efforts resulted in fewer medical mistakes – and there were actions taken to reduce mistakes. The result:

Despite such efforts, the federal Agency for Healthcare Research and Quality reported in May that the rate of adverse events—a key measure of patient safety defined as unintended harm during medical care—has risen by about 1% in each of the past six years, in part because of a rise in hospital infections. The old and the young are especially vulnerable: One in seven hospitalized Medicare patients experience one or more adverse events, and one in 15 hospitalized children are harmed by medication errors, other studies show.

The focus should now be on reducing the infection rate.

This trend away from covering up mistakes is healthy, and I applaud those hospitals taking the lead.

How does your company deal with mistakes?

Book Talk: Insights on Implementation Series

Some of you may remember Lean Manufacturing Advisor, a monthly paid-subscription newsletter we used to publish. (I was the editor.)

LMA ceased publication four years ago, the victim of declining circulation caused primarily by competition from free information on the Internet. But much of the content lives on.

We took many of the articles that had been appeared in LMA and published them as a series of books, each one a compilation of articles in a particular subject area. We call the series “Insights on Implementation.”

These inexpensive paperbacks ($15.95 each) are not manuals or how-to books. Most of the articles are case studies, descriptions of how companies have applied lean concepts and tools. Their primary value might be in helping you become aware of possibilities, and the many different ways lean can benefit your company.

The books are:

· Lean Culture

· The Lean Office

· Lean Supply Chain

· Visual Tools

· Improving Flow

· TPM

Each one has the subtitle “Collected Practices and Cases.”

They are easy to read and, I hope, can enrich your appreciation of the value of lean practices.

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.

Australia to Tired Doctors: Drink More Coffee

Health officials in Australia are telling doctors who work up to 80 hours without a break to drink up to six cups of coffee to stay awake. According to Reuters, officials say it’s the only way to cope with a doctor shortage.

In advocating the use of caffeine by doctors, the health department document said that compared with other psychoactive drugs, such as the prescription-only stimulant modafinil, caffeine was more readily available and less expensive.

Salaried Doctors Queensland, representing medicos, countered that pumping doctors full of caffeine was not an effective way to deal with fatigue and doctor shortages, often filled in Australia through recruitment overseas.

Queensland Labor Health Minister Paul Lucas said the state was aiming to train more doctors and cap hospital work shifts at 12 hours over the next two years, but had no immediate solution to fatigue and staff shortages.

"If the doctors are not there, we can't do it," he said. "We can't say we'd rather not have it as it is and create doctors out of the air."

Are you kidding me?

By the way, the Reuters article says Queensland officials issued their recommendations “after warnings that patients were dying.”

I wrote previously about the hours worked by medical residents in the United States. I described this as a lean issue involving respect for people (the overworked doctors) and what customers, meaning patients, regard as value (having an alert, well-rested doctor).

I’m sure the doctor shortage in Australia is real. But is this the best they can come up with? How about some lean initiatives that would increase the capacity of Australian hospitals, enabling them to deal with more patients in less time?

Remind me not to get sick in Australia.

Obama’s New Manufacturing Advisor Isn’t a Manufacturer

President Obama has named a new advisor on manufacturing policy, and I’m disappointed in his choice. The man he has chosen, Ron Bloom, has never actually worked in manufacturing, and there is nothing in his background to indicate he knows anything about lean.

Bloom has been named senior counselor for manufacturing policy and will help develop policy aimed at revitalizing manufacturing in the U.S. Most recently, he was a senior advisor to the treasury secretary and part of the administration’s auto industry task force, positions he will continue to hold. Bloom helped negotiate deals with labor unions as part of efforts to rescue the auto industry.

Before joining the administration early this year, Bloom was a special assistant with the United Steelworkers, helping the union affect corporate business restructuring, investments, bankruptcies and mergers. He is particularly known for working on deals related to recent steel industry bankruptcies. Before that, he spent 10 years as an investment banker. He holds an MBA from Harvard Business School.

I want to be fair to Bloom. I’m sure he’s a bright guy, and maybe he does have a good understanding of the issues facing manufacturing and related government policy.

But I would prefer if this post were held by someone who had worked in the industry, confronted the issues on a daily basis, and understood how valuable lean can be in any attempt at revitalization.

Your thoughts?

Reducing Costs By Getting Patients to Take Their Medication

Are customers responsible for following a lean strategy?

I ask that question after reading about a new report that describes the high healthcare costs that stem from patients not taking their medication.

The report is from the New England Healthcare Institute. As described in an article by Health Leaders Media, the report notes that problems with what is called medication adherence account for as much as 13 percent of total national healthcare expenditures.

The four most promising solutions, according to the report, are:

• Creation of health care teams that can increase the number of checks on adherence as patients move through the healthcare system
• Patient engagement and education so patients will better understand their role in improving their condition
• Payment reform to give providers financial incentives to improve adherence
• Leveraging use of information technologies for better tracking of adherence

It’s an interesting issue from a lean perspective. If you think of the goal of a healthcare organization not just as providing services, but as helping patients improve their health, then patient involvement is critical. It is kind of like a manufacturer working with his customer to focus on creating the most value.

By the way, in terms of technology, I recently came across something interesting directly related to adherence. Vitality, Inc. makes a product called GlowCaps. It is a prescription-bottle cap containing a wireless chip that links to a network and a plug-in light. After it is programmed, it can trigger the light to flash, and can even trigger a phone call, to remind you to take your pill. You can also arrange to have reports sent to you and your doctor, and it can connect you to your pharmacy when it’s time for a refill. Now that’s cool!

Book Talk: Dr. Shigeo Shingo

If you want to gain a fundamental understanding of the principles of lean manufacturing, you can’t do much better than to read the works of Dr. Shigeo Shingo.

The namesake of the Shingo Prize for Excellence in Manufacturing, Dr. Shingo was the Toyota engineer who first explained on paper the concepts behind Toyota’s manufacturing system.

We publish five books by Dr. Shingo

• A Study of the Toyota Production System: From an Industrial Engineering Viewpoint
• The Sayings of Shigeo Shingo: Key Strategies for Plant Improvement
• A Revolution in Manufacturing: The SMED System
• Non-Stock Production: The Shingo System of Continuous Improvement
• Zero Quality Control: Source Inspection and the Poka-Yoke System

Other sources for classic information about lean manufacturing include Toyota Production System: Beyond Large-Scale Production by Taiichi Ohno, often regarded as the inventor of the Toyota Production System, and, for case studies, Becoming Lean: Inside Stories of U.S. Manufacturers by Jeffrey K. Liker.

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 Success is Employee Motivation

Companies with motivated employees produce better returns for their shareholders, according to a study by the Workplace Research Foundation in cooperation with the University of Michigan.

That won’t come as a surprise to lean advocates, but it is nice to have our faith in lean principles validated by a study.

As described in an article on Forbes.com, the study took place over seven years, from 2001 through 2007, and examined survey data from 3,490 employees at 841 corporations that were listed in the Wall Street Journal 1000--an index of firms that encompasses 98% of U.S. gross domestic product.

One example, according to the article, was what researchers came across at Dollar Thrifty Automotive Group.

One thing they found at Dollar Thrifty was that employees valued being "in the loop," in this case getting to participate in discussions about the surveys and what they meant. When management reached out to make this happen the firm saw its repeat business strengthen and its stock has crushed its peers.

I feel pretty confident in saying that efforts to motivate employees were probably not the only positive attributes of the companies that were studied – particularly since stock prices improve based on financial results, not just the levels of employee motivation. This is probably a correlation rather than a cause-and-effect relationship.

Most likely, the top companies in the study also actually listened to what their employees said and sought to improve their operations by implementing employee suggestions.

Are your employees motivated?

Is the Doctor Experienced? It Doesn’t Matter Much in a Well-Organized ER

When it comes to saving your life, the overall organization of the trauma department matters more than the experience of the doctors.

That is the conclusion drawn by researchers in the trauma surgery program at Johns Hopkins in a study published in the journal Archives of Survery.

The doctors examined whether having more experienced staff on duty made a difference – and found it didn’t.

In a structured trauma program, there is no mortality difference between novice surgeons and their experienced trauma director. The organized trauma program and senior surgical mentoring overpower any influence of individual surgeon inexperience.

That validates lean concepts, which maintain that the process is more important that any one person.

The study’s conclusion is debatable, as noted in a report from ABC News.

The study did have some limitations, notably in its use of survival as the primary measure of experience. Dr. David Feliciano, a trauma surgeon at Emory University, in his invited commentary accompanying the article, noted that details of the most complex surgical cases and of how avoidable the deaths were in this study, would help to better answer the questions regarding experience.

"Mortality is also likely to be the factor least impacted by surgeon experience," West said, noting that the amount of blood transfused, number of complications, length of hospital stay, and number of infections would also help to better gauge experience.

Another weakness of the study comes from the numbers themselves, West said. A study that makes a conclusion based on a "lack of statistical significance" is weaker than a study that makes a conclusion based on the presence of one and would require either much larger numbers of patients or much greater differences between the groups than those present in this study to be meaningful.

Still, the study was strong enough to win publication in a peer-reviewed journal. And I believe this is another indicator of the value of applying lean principles to healthcare.