The Lean Insider blog will be taking a break for the rest of this month, as we all devote ourselves to holidays, celebration, family and doing things likely to make us less lean.
I will not be returning to the blog from that break, but will be off pursuing new opportunities.
I’ve been writing Lean Insider for close to three and a half years. It’s been a lot of fun, and I hope you’ve found it to be at least occasionally informative and/or entertaining.
You may see postings here from my Productivity Press colleague Mike Sinocchi. As our senior acquisitions editor (meaning he has edited vast numbers of our books), he is well-versed in the concepts and language of lean, and I’m sure will have some interesting things to say.
And I hope that those of you who share our advocacy of lean ideas will continue your pursuit of perfection and the elimination of waste, and your dedication to creating value for customers.
In the debate over reforming healthcare, one issue that is rarely discussed is how to reform the way insurance companies pay for healthcare.
One recent change that received a lot of publicity was a decision by Medicare (and some private insurers) to stop paying for treatments required as the result of serious medical errors – so-called “never events.”
A couple of recent postings in The Wall Street Journal Health Blog have explored the issue of reimbursements.One posting noted a push by Blue Cross Blue Shield in Massachusetts to shift away from paying for every procedure to a system in which a flat fee is paid to take care of people, healthy or sick – with bonuses for meeting certain targets concerning patients’ health. (An interesting idea.)
More recently the Health Blog reported on a study published in the Journal of the American Medical Association. The study stemmed from the idea that doctors should be paid for the quality of the care they provide, not the quantity. Some people propose doing that by measuring how a doctor’s practice compares to (or deviates from) national averages for particular quality measures, such as blood-sugar control in diabetics. The study examined whether small practices see enough patients for valid conclusions about quality of care (and concluded that the number of patients is too small at many practices for valid comparisons).
I have problems with that last concept. In any situation where quality matters, we lean advocates believe you should not be striving to match others, but striving continuously to achieve perfection.
However, that begs the question of what should be the basis for payment. The Health Blog notes that the same issue of JAMA that reports on the study also contains an editorial written by Don Berwick of the Institute for Healthcare Improvement, who makes some suggestions.
They include asking patients “how well they feel treated,” to measure qualities such as timeliness and responsiveness. Another possibility, he says, is moving toward measuring actual outcomes that are the reason people go to the doctor: “health, function and comfort.”
From a lean standpoint, measuring outcomes makes the most sense. It all relates to value, which is what lean is all about. Payment should be made for that which the customer defines as value. And if the customer is the patient, value is most likely defined as good health.
But it’s more complicated than that, since medical outcomes cannot be guaranteed. For example, doctors may do all the right things in treating someone critically ill, yet the patient may die anyway. The doctors still deserve to be paid for their efforts.
It is a tricky, complex situation with no easy answers. Any suggestions?
What lean book would you give for the holidays this year?
There are many different types of lean books, and what you buy for a particular person depends on who they are and what they would find interesting or useful – not just on whether the book is good.
So I’ll offer some suggestions in different categories. But I encourage you to post comments with alternative suggestions.
Green and Lean: Green Intentionsand Compressionare the two books we have published so far about the relationship between lean principles and sustainability. Both are works that could prove fascinating to anyone interested in this area.
An item about a consulting-firm acquisition caught my eye the other day. Broadlane, a Dallas-based company that describes itself as a “cost-management company for healthcare providers,” is buying another consulting firm, Healthcare Performance Partners (HPP).
I’m not familiar with either firm, but what I found interesting is that Broadlane is buying HPP because the latter firm’s specialty is providing lean and Six Sigma consulting and training to healthcare organizations.
According to Tom Sherry, chief operating officer, Broadlane, “While Lean and Six Sigma have long been cornerstones of manufacturing, healthcare providers are only now beginning to more broadly implement these approaches to remove waste and cost from their systems while improving quality of care.”
In case you hadn’t heard, it sounds like this lean thing is catching on in healthcare.
We lean thinkers know that when errors or defects are widespread, the problem usually lies in flaws in the process, not with individual errors. Those flaws often involve a lack of training, or a lack of standard work to ensure something is done the same way every time.
That seems to be the case when it comes to medical imaging. According to DiagnosticImaging.com, insurer Blue Care Network hired consulting firm RadMetrics to study the work of imaging providers. They examined 3,794 studies from 100 providers, with disturbing results.
11% of the sample studies had significant quality defects that potentially led to missed pathology or inappropriate therapy. They included studies where the selected field-of-view made it impossible for the clinician to fully appreciate the presence or extent of disease. Ultrasound studies were performed with the wrong transducer. Prostate ultrasound was performed without an endorectal coil. Obsolete equipment produced spinal images so poor that the edge of the spinal facets could not be seen. BrainCT produced artifacts that mimicked brain tumors.
In addition, about 20 percent of the studies involved coding, compliance or billing mistakes.
By the way, credit should go to the Health Business Blog, which is where I first learned about the DiagnosticImaging report.
A lack of standard work procedures in the imaging industry has to be a key reason for this problem. Inadequate training is the flip side of the same issue.
I hope that whatever agencies or organizations are involved in the training or certification of radiologists and their businesses become aware of this problem and take steps to address it.
The job market is strong for senior executives who can lead lean enterprise-wide transformations. And overall, lean employment in the year ahead is likely to be better than this past year.
Those are the beliefs of Matthew Ayers, vice president of executive search for Stiles Associates, a recruiting firm specializing in filling lean jobs.
“We’ve weathered the storm of 2009,” he says. “We’re very optimistic 2010 will be much stronger.”
Ayers says his firm saw companies putting searches on hold beginning around March and April of this year. But after what he describes as a slow summer, “the past month or two, it’s really lit up. Whether it’s folks looking for releasing funds in their budgets, or to capitalize on Q1, the lean world is on fire right now.”
Stiles Associates specializes in higher-level lean positions, “from the plant manager and lean deployment leaders to the CEO,” Ayers says.(And occasionally “we do have clients who ask us to build their entire lean team,” he notes.) The biggest demand, he says, is for people with the highest levels of experience.
“The folks that really know how to come in, and know policy deployment, can cascade lean across the business, the folks that have the ability to lead and orchestrate those rollouts are in big demand,” he comments.
So much so, in fact, that despite the large numbers of people looking for work, it can be challenging to find the top people. “The folks that are highly sought after, that have a reputation with them of successful transformations, are not on the market as long as you would think,” he adds.
Stiles Associates works with several private equity firms, which are seeking lean executives for the companies in their portfolios. And those companies cover a wide range of industries – pharmaceuticals, textiles, packaging, discrete manufacturing, life sciences. In addition, Ayers says, “we do a lot of work in healthcare. We have seen the interest in healthcare continue to be very strong.”
In what Ayers agrees is a change from the past, companies today seem more willing to consider candidates from outside their own industry.
“More than the majority of our clients do not have a problem looking at completely different industries. It’s all about personality and cultural fit,” he comments. “That does represent a change from the past. In the past, the majority of our clients would say ‘would you find us a head of a line and recruit specifically out of Toyota.’ We’ve been able to educate clients. They now look at other mature companies that have gone through a lean transformation.”
Ayers’ advice to employers is “really know who you’re going to be hiring. Invest the time to properly screen when referencing. Spend the time and spend the money to go out and find the proper fit.”
For candidates, he suggests, “because there are some very good folks at the middle to senior level out there on the market, continue to work your personal network. Networking is so important in this day and age.”
He adds, “Candidates at a senior level should not be posting their resumes on job boards that are too junior. Find somebody you can trust. You should be represented by a retained search firm. Do your homework on the search firms, and only work with a handful, I recommend three to five.”
Corporations like the future to be predictable so planning is easier, but that’s not the way the world works. Life is full of uncertainty, and businesses have to be prepared to deal with it.
A new book scheduled for publication next week by our sister division CRC Press addresses this issue. In Flexibility: Flexible Companies for the Uncertain World, author Gill Eapen contends that the best way to manage effectively in an uncertain world is through the conscious application of flexibility — an ability to absorb constantly shifting variables and adapt quickly. He Presents specific ways to improve performance, reduce risk, and improve the probability of long-term organizational success
Eapen is the founder and managing principal of consulting firm Decision Options. He has worked with dozens of companies, including Fortune 100 companies, and is also the author of Decision Options, The Art and Science of Making Decisions.
This is a thoughtful, high-level book that anyone involved in strategic planning may find well worth reading.
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 recent article in the Miami Heralddescribes efforts by a team at the University of Miami-Jackson Memorial Hospital to eliminate waste, but in an area I hadn’t seen discussed before – overuse of antibiotics.
Such drugs often are overused, and as the article (by John Dorschner) points out, too much medicine can be a bad thing.
Though proper use can mean cost savings, ``the key factor for this program is patient safety,'' said Thomas Hooton, a University of Miami professor who was once head of the antimicrobial program for the Infectious Diseases Society of America. ``And there is a cost to society.''
Microorganisms are constantly becoming resistant to antibiotics, which are everywhere these days. A patient flushes them out of their body and into the sewer system. Livestock get fed them by the ton.
As bugs become resistant to the older drugs, doctors have to use newer, often more expensive alternatives. That's why institutions around the world have developed antimicrobial programs.
The article notes that antibiotics should be given to certain surgical patients, but the patients should stop receiving the drugs within 24 hours of surgery. To make sure this is done, the hospital has made the anesthesiologist responsible for administering the antibiotics.
That is a process improvement, in keeping with lean principles (though lean is not mentioned in the article).
A more challenging problem is doctors in private practice who prescribe unnecessary antibiotics because patients insist that they do something, and don’t want to hear that the drugs won’t do anything for their particular illness.
Goldschmidt, the UM dean, said the University of Miami and Jackson are working together to establish an evidence-based system that can serve as a blueprint for efficient, effective care by using computerized physician order entry, in which doctors work from a template for specific conditions, in ordering tests, prescribing drugs and such.
I’m not sure that is a lean solution, though it might be considered standard work. I’d like to hear other approaches, if any of you know of some.
But certainly any effort to eliminate waste is positive, if done properly. And that’s the kind of lean thinking I like to see.
I’ve written in the past about the need to increase the capacity of medical schools because of doctor shortages. The same thing is true when it comes to nursing schools and the current shortage of nurses.
Nearly 40,000 qualified applicants were turned away from undergraduate nursing-school programs in 2009 (though enrollment did increase 3.5 percent), according to a just-released annual survey by the American Association of Colleges of Nursing.
Based on data received from 318 schools of nursing, the primary barriers to accepting all qualified students at nursing colleges and universities continue to be a shortage of faculty (60.7%) and an insufficient number of clinical placement sites (61%). With cuts in state funding to schools of nursing last year, the number of schools reporting budget cuts/insufficient budget as a primary reason for turning students away more than doubled from 14.8% in 2008 to 31.1% in 2009.
The article also notes that there is some good news: Enrollments in graduate nursing programs increased significantly, about 10 percent in master’s programs and about 20 percent in doctoral programs.
I write about this because one of the biggest benefits of lean principles is often an increase in capacity.
In this case, the limiting factors listed above seem to be largely outside the control of nursing schools. But if the schools and the agencies they work with can cooperate to view the system holistically, and use lean thinking to study the way applicants/students flow through the system, I suspect a lot can be achieved.
But has it? I question the article’s conclusion because I believe it misses a major point.
The article, by Josh Cable, notes how quality and productivity have improved at the Big Three, basing that conclusion partly on figures from the most recent Harbour Report, which measures productivity. I’ve quoted the Harbour Report myself.
Additional information in the article notes the increased emphasis the Detroit automakers are putting on having flexible operations that can adapt quickly to changes in the marketplace.
All of this is true, and yes, progress has been made. But there is a word missing from the article that goes to the heart of a lean transformation.
Culture.
Applying lean techniques to make your processes more efficient and flexible is all well and good. It does produce benefits.
But to become a truly lean organization, you need to transform your culture. You need to become an organization where everyone, from the corner office to the shop floor, thinks in lean terms, never viewing the job as done, always striving for perfection, and endlessly pursuing continuous improvement.
Do the Detroit car companies think that way? Perhaps some people in those organizations do. But I am not convinced that any of the Big Three has achieved the kind of enterprise-wide cultural transformation that would put them in the same league as Toyota.
I hope they make progress in that regard. But I’m not holding my breath.
The book is divided into three sections: Defining the VOM, How to Listen, and How to Use the VOM.
Reidenbach, who holds a Ph.D. in marketing, is principal and founding partner of Market Value Solutions. He has extensive consulting experience, and is the author or co-author of 18 books on marketing research, marketing management, and marketing.
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 thinking means showing respect for people, both employees and customers. Equally important, it means looking at things from the customer’s point of view.
The American Medical Association just doesn’t get it.
I’m referring to the issue of how long doctors – specifically, residents – should be required to work, something I’ve written about before.
Residents have traditionally been required to work exhausting hours, and for too long the establishment has turned a blind eye to the problems that can result. A recent study reported in the AMA’s own journal found that complications are more likely when surgery is performed by surgeons who are sleep-deprived.
The Institute of Medicine has recommended that five-hour naps be mandatory for any hospital shift longer than 16 hours.
At its recent meeting, the AMA adopted a new policy to oppose the guaranteed sleep time. Mandatory naps could “have significant unintended consequences for continuity of patient care and safety, as well as being difficult and expensive to implement and monitor,” the AMA’s recommendations say.
While the AMA may be raising legitimate concerns, these are problems to be overcome, not reasons to reject mandatory naps.
More to the point, the AMA is focusing on cost and continuity of care while ignoring the issue of quality of care – which is undoubtedly the chief concern of patients.
I suspect the AMA officials who are opposing the naps haven’t considered what it would be like to be a hospital patient confronting these issues. Would any of them want to be treated by a doctor who had been working for 30 hours straight? Somehow, I don’t think so.
Handoffs can be a problem in any process. They slow down the process, and there is always a risk of communication being incomplete or misunderstood.
An interesting article from Health Leaders Media describes the difficulties involved when nurses on one shift hand off patient information to the next shift at IngallsMemorialHospital in Harvey, IL.
For years, nurses nationwide have used different methods for handling handoff reports. One technology was the use of taped records. This caused problems because if an interruption occurred while the nurse was reporting, the nurse had to make a note on the recorder where the tape left off, causing confusion later on.
There were also instances when the tape recorder broke or someone had recorded over a report, causing the nurses to take more time to re-record each patient report.
More recently, handoffs involved nurse-to-nurse interaction between shifts. As the nightshift was coming on and the day shift was leaving, and vice versa, the nurses discussed each patient and how the shift went.
Although effective, this process takes a lot of time, and many nurses went into overtime at Ingalls.
At Ingalls, Kathleen Mikos, RN, MSN, vice president of patient care and chief nursing officer, came up with a better idea using OptiVox technology from The Whitestone Group.
Nurses can dial into OptiVox and record their patient reports, or listen to the patient reports from any phone in the health system.
Nurses coming off a shift and needing to report on their patients dial in an individual access code, pull up each patient's medical record number, and begin recording a report on that patient…
To identify each patient in the system, Ingalls uses the patient's medical record number to prevent confusion…
When nurses arrive to start their shifts, they can access the reports from the previous shift the same way nurses record them. Using any phone in the health system, the nurse dials in with an individual access code and using his or her patients' medical record number; the nurse can then listen to the reports.
I don’t view technology as a panacea, but when used properly, it can improve a process. It sounds as if Ingalls is using it properly.
