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.
A thoughtful segment on 60 Minutesrecently explored the thorny issues surrounding the costs of caring for people at the end of their lives. It struck me that some of those issues relate to lean principles.
The story, reported by Steve Kroft, noted that last year, Medicare paid $50 billion just for doctor and hospital bills during the last two months of patients' lives – and it has been estimated that 20 to 30 percent of those medical expenditures may have had no meaningful impact.
I was particularly struck by comments from Dr. Ira Byock of Dartmouth-HitchcockMedicalCenter in Lebanon, N.H., who leads a team that treats and counsels patients with advanced illnesses.
By law, Medicare cannot reject any treatment based upon cost. It will pay $55,000 for patients with advanced breast cancer to receive the chemotherapy drug Avastin, even though it extends life only an average of a month and a half; it will pay $40,000 for a 93-year-old man with terminal cancer to get a surgically implanted defibrillator if he happens to have heart problems too.
"I think you cannot make these decisions on a case-by-case basis," Byock said. "It would be much easier for us to say 'We simply do not put defibrillators into people in this condition.' Meaning your age, your functional status, the ability to make full benefit of the defibrillator. Now that's going to outrage a lot of people."
In lean operations, we argue in favor of standard work – doing something the same way every time. What Byock is arguing for is not exactly the same thing, but the principle is similar.
And before you argue that not all patients are the same – which is true – consider the words of David Walker, former head of the Government Accountability Office and how head of the Peter G. Peterson Foundation. He commented in the story that this is not just about medical care, but what government pays for medical care.
“Let me be clear: Individuals and employers ought to be able to spend as much money as they want to have things done. But when you're talking about taxpayer resources, there's a limit as to how much resources we have."
One other lean concept I’d like to mention is that there must be complete information about what is happening in order to choose the best course of action. In lean terms, that typically means choosing the right improvement, and measuring its results. I mention the concept here in a slightly different way, in terms of choosing the most appropriate course of action based on a full understanding of the likely impact of that action.
The 60 Minutes report noted that studies have shown most dying patients and their families would prefer the last days be spent at home (though most end up dying in hospitals). But to make a choice, patients and their families must understand the situation – which is often not the case, according to another person interviewed for the segment, Dr. Elliott Fisher, a researcher at the Dartmouth Institute for Health Policy.
"At some point, most doctors know that a patient's not likely to get better," Kroft remarked.
"Absolutely," Fisher agreed. "Sometimes there's a good conversation. Often there's not. You know, patients are left alone to sort of figure it out themselves."
I was once involved in a difficult, end-of-life decision. The fact that the doctors involved were clear and honest about the situation was important and helpful.
Dealing with these kinds of issues is one of the toughest aspects of improving healthcare. Perhaps lean principles can help.
Can lean strategies help doctors make fewer diagnostic errors?
Most healthcare process improvement efforts focus on preventing treatment errors – making sure patients are given the correct course of treatment after a diagnosis has been made. But diagnostic errors also occur, an issue I wrote about nearly a year and a half ago.
I’m revisiting that issue now because a new survey has shed some light on diagnostic errors. A group of researchers led by Gordon Schiff, MD, associate director at the Center for Patient Safety Research and Practice at Brigham and Women's Hospital in Boston, asked doctors to describe – anonymously – diagnostic errors they had made or witnessed.
The two most frequently listed conditions involved pulmonary embolism and adverse drug reactions, including overdoses and poisoning. Lung cancer diagnostic mistakes ranked a close third, followed by colorectal cancer, acute coronary syndrome, breast cancer, and stroke.
The doctors failed to: order tests, report the results to their patients or follow-up when testing revealed abnormal findings.
As it turns out, lab and radiology testing errors, including test ordering, test performance, and clinician processing, accounted for 44% of the missed diagnoses, which was the greatest share.
Most lean advocates would probably suspect that system problems contributed to the errors, as much or more so than physician error. The article, by Heather Comak and Cheryl Clark, discusses that issue.
While the notion of overconfident, arrogant physicians being the cause of diagnosis error is not wholly wrong, those qualities alone are certainly not the reason that misdiagnoses are made, said Schiff. Other factors include spotty follow-up, time pressure, failure of physicians to share their uncertainties, malpractice fears, defensiveness, and inadequate feedback.
Schiff likened this last factor to the lawn sprinkler system that goes on automatically, regardless of whether it has rained that day. Instead of acting in a closed-loop system that provides feedback about whether diagnoses were right or wrong, often physicians work in an environment that does not allow for this follow-up or does not attempt to capture this feedback.
The article goes on to note that cultural biases and culture change – the most difficult aspect of any improvement effort – are at the heart of the situation.
Another way of thinking that has become ingrained in most physicians is the idea that an overconfident, perhaps wrong diagnosis is better than not diagnosing a patient at all. Most patients don't appreciate when their physicians don't seem decisive about a diagnosis, and historically, physicians have been more successful when they confidently make a diagnosis, said Croskerry. Additionally, physicians validate their ability to make diagnoses when they are confident.
"Physicians tend to place a lot of faith in their own diagnoses—most physicians think it's the most important skill that they have," said Croskerry. "It's a lot easier, if you give the patient wrong medication, to admit to something like that than to actually admit to your thinking processes having gone astray. People take that far more personally..."
Both Schiff and Croskerry agreed that more emphasis should be placed on physicians admitting to their patients uncertainty about diagnosis and that more work needs to be done at an earlier stage, perhaps in medical school, to introduce the idea of feeling comfortable with uncertainty to physicians. Additionally, Schiff said the question of physicians admitting a diagnosis error is first and foremost about a patient safety culture.
"This idea about patient safety culture—creating a system where people can honestly look at errors in a blame-free way, learning from mistakes and improving from those, rather than covering them up or having to defend them—is so central for us learning," said Schiff.
It is going to take a long time and a lot of work to achieve this kind of culture change. I hope this new survey will contribute to that effort.
I’ve often heard people argue that the lean tool of 5S – whose five words are most commonly listed as sort, set in order, shine, standardize and sustain – really ought to be 6S, and that the sixth “S” should be safety.
Regardless of where you stand on that debate, if you believe safety is important in the workplace – and everyone should – then you may be interested in Lean Safety: Transforming your Safety Culture with Lean Managementby Robert Hafey, a new book we are publishing next month.
Hafey, who has 40 years manufacturing experience and has been active in the Association for Manufacturing Excellence, emphasizes that building a top safety program requires building a world-class safety culture. He demonstrates how basic Lean tools are as applicable to safety as they are to Lean, such as the A3 problem-solving process and the facilitated kaizen blitz.
Additionally, he establishes standards and metrics for safety management that are clearly definable and measurable. That is also consistent with a lean approach, where any improvement should be definable and measurable.
Companies adopt lean strategies for a variety of reasons – improving time to market, increasing capacity, reducing costs. If your focus is on improving safety, then this book is for you.
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.
Like IBM and HP, Xerox is a technology company that transformed itself from just being a hardware provider into a services company as well. (You may not think of Xerox as a technology company, since it doesn’t make computers, but what else would you call printers, copiers and fax machines?)
What is interesting about Xerox is that they promote Lean Six Sigma as an essential part of their expertise. There are plenty of lean consulting firms, but not many (if any) that are focused on document and information management.
Xerox understandably boasts about its accomplishments. I’m writing about them today not to discuss whether Xerox is a good company, but to note how lean initiatives can yield big benefits in regard to something as unglamorous as printing.
Procter & Gamble hired Xerox to manage its worldwide print operations. According to the Environmental Leader website, Xerox “has been able to help P&G cut operational costs 20-25 percent by helping control when and how printers, copier and fax machines work… At P&G, it’s predicted that the improvements will cut printer-related power usage by 30 percent and paper consumption by 20-30 percent.”
Earlier this year, Xerox issued a news release describing its work with KeyCorp.
The financial services company reduced operating costs by more than $6 million over six years, working with Xerox to better manage the volume of documents flowing through its 120 offices - and the costs associated with printing, sharing and updating them…
Using a Xerox Lean Six Sigma-based assessment, Xerox Global Services and KeyCorp evaluated employees' daily work processes to design a document management strategy that saves millions on print costs. By decreasing the number of output devices, like printers, fax machines, copiers and scanners, from 10,000 to 3,500, KeyCorp also boosted productivity, reduced paper consumption, decreased power usage and eliminated tons of landfill waste…
While I believe any statement in a news release should be taken with a grain of salt, I’m sure KeyCorp wouldn’t have agreed to the release unless there were some truth to what is being said.
Even the most ordinary or mundane operations can be improved with a lean approach.
