Unfortunately, my road as a blogger for the iSixSigma Blogosphere has come to an end. At this time, my plate has become too full and I must make more time for events in my life of higher priority. Currently, my wife and I are both completing our Master's Degrees. More recently, we have found out that we are going to be parents for the first time. This, of course, is the most exciting news for us, and at the same time has made our lives extremely busy. As we prepare for the birth of our first child and complete our schooling, we have little time for extra joys in our life. I mention joys because writing this blog has been such an extremely exciting opportunity for me, and I am very disappointed to have to give it up. I have enjoyed writing about my experiences with Lean in health care, and I have enjoyed reading all the feedback I have received from my blogs. I have connected with many other great professionals, and I hope to maintain that network (we will never know all there is to know about Lean in health care if we go it alone). However, all great things must come to an end. For any of you that wish to keep in contact with me, please feel free to utilize the email address listed in my profile (and below).

I look forward to perhaps being able to write about Lean in health care in the future.

Thanks to you all!!!

Andy
hilligam23@uww.edu

Can you help the unwilling? My co-worker and I are completely paralyzed by a group of staff members in an implementation that refuse to adopt the principles of Lean because it takes away the "joy" of working and the group cohesion. According to them, now that Lean has been implemented, they don't have time to talk anymore...they're always working.

The thing here is Lean has not taken away the group cohesion, it has just made them do something they have not done before - WORK!!! I may be from a different school of thought, but when I come to work I work. I am not there to socialize and catch up on the latest lunch room gossip. Being that I work in health care, there is no dictating when the work comes in either. So, as a health care worker, you have to assume that your day is going to be filled with work, and when and how hard you work is completely determined by the patient. Patient's don't chose when they get ill, and that is why health care is a continuous operation. That's the purpose of implementing Lean. The patient doesn't care that you don't have time to talk to your co-worker about their vacation, the patient wants to know what is wrong with them so they can be treated and go home. In mind, it is completely insensitive of this group of employees who feel that their sense of joy from the workplace has been eliminated from their job. You are not paid to chat, you are paid to work. What keeps the doors of our hospitals open is being able to have a patient turnover rate that is more than acceptable to the patient.

Never more has this concept been evident than when we recently closed the doors on one of our hospitals after being in business for over 50 years. We couldn't meet the demands of the patient, and unfortunately for us time beat Lean to the punch. With this in mind, the staff at the other hospital, the ones refusing to adopt Lean, should be extremely mindful of this and should be working diligently to make sure the same doesn't happen at their place of employment. After all, the joy of coming to work is knowing that you have a job to come to.

The struggle for me is being able to successfully implement the Lean principles into this type of environment. The staff have dug their heels in 100%, and aren't budging. Now, most Lean experts would say this is the point where you must rely on management to enforce the changes. However, the staff have a hold on management as well, and management can get no where with them. So now what; do we clean house? Will that solve anything? In the end, we're stuck, deflated, and out of ideas.

Let me know your thoughts and experiences on this scenario.

Ok, I have to pose a question for the general "Lean Thinkers" out there who are aware of how conservative healthcare is. I have been reading so many articles that highlight the success of Kaizen events in healthcare settings. However, I have to ask myself, do they really work? Do the changes really sustain? Is it possible to make dramatic changes to a setting within a healthcare facility in five days? The team of implementers at my organization have never done what is defined as a "kaizen event," and we’re not sure we want to try.

The biggest concern for me is that there will be no staff buy-in as a result of a five day implementation. Because healthcare is filled with skilled autonomous workers, change seems very difficult to overcome. It’s quite ironic in an industry that constantly changes with new regulations and technology, but replacing complex thinking with common sense is overwhelming to healthcare workers. Also, when you do have a group of the willing, there isn’t enough of them with enough time to devote to such a fundamental revolution.

Secondly, can you pull the resources needed in less than five days? Can you have members from the IT department, facilities department, etc. on-board and able to assist the whole time? Obviously, these people would have to be on hand working side-by-side with the implementers in order to achieve the results. It’s almost like that home makeover show: everyone is working side-by-side to have a house built in a week. It may work for them, but it has been my reality that these people aren’t always available at a great length of time.

Finally, are the champions, stakeholders, executives ready and willing to commit to such drastic policy changes in such a short period of time? It seems, from the case studies I’ve read, policy changes happen on the fly and with little executive involvement. How can these changes sustain?

Of course, the optimist in me says that making such drastic changes in such a short period of time eliminates the opportunity for the "what if..." flag to be flown in my face. Drawing out a plan and strategically implementing it over time has committed me to a life of "firefighting." It seems I am perpetually stuck in a "one step forward, two steps back" routine. So I can see how a dramatic overhaul would not allow enough time mull over the natural resistance to change.

Can anyone describe a typical Kaizen event in a healthcare setting, and how it was able to be successful in an industry that is bound and determined to maintain its conservative roots in an industry experienced in change?

I have spent the last couple of months banging my head against a wall trying to figure out why one group of employees at one of my implementations just can’t align with a Lean way of life. Each time we 5S an area, it gets changed. Each time we try to implement standard work, it gets delayed by management. Each time we try to implement Kanban, we get no where. Why are these people fighting this implementation so much? Most importantly, why are they being allowed to resist this implementation? They seem to have a complete disregard for authority. Above all else, they can’t seem to wrap their minds around the fact that if we don’t cut costs and improve efficiency, we will cease to exist as a healthcare facility.

I’ve been over it thousands of times, and I came to a realization just the other day - healthcare is made up of a myriad of individual thinkers. It makes sense, the culture of healthcare has allowed for autonomy to prevail for so many years. Caregivers are encouraged to "create the wheel" with each and every patient. Because an inidividual’s anatomy and physiology are so unique, it is sometimes necessary to treat using non-conventional ways. With that said, it makes sense to me that healthcare workers can’t grasp on to something as simple as Lean Thinking. It’s ironic that something so simple is so difficult. As someone pointed out to me the other day, "Lean just makes sense; it’s easy to do, and we probably do it already in our private lives." I couldn’t agree more with this. Lean is simple, and that is why it is hard to accept in such a complex system. Simplifying our lives seems like an injustice to the patient. However, if we boil it down, it is what is best the patient. A process that operates free of variation does decrease error, which does increase the quality of care.

The problem is, how do I get the employees to realize this? You can give them real world examples and you can play little games to show them how efficient a process is when you cut the waste from it, but they still come back to the ideology that the real world is different than healthcare. "In healthcare, we’re different." Really? If I were a patron of a fast food restaurant, I don’t want to wait for a burger with no pickles for 15 minutes and receive it cold. As a buyer of a new automobile, I don’t want to wait an extra six weeks to get leather seats instead of the standard fabric interior. As an airline passenger, I don’t want to pay for first class and have to sit in coach. As a patient, I don’t want to pay a premium to wait and ultimately receive poor care. That’s the point, it’s not about the employee, it’s about the patient. That is what everyone in healthcare must realize in order for Lean to sustain. Treat the patient like you were treating yourself. Would you feel comfortable walking into a treatment room that was filthy, unorganized, and where no two rooms looked alike? Would you want to sit and wait for 3 hours before you’re seen by anyone? When we realize this is when we begin to live in a Lean world.

Unfortunately, the complexity of healthcare, combined with its autonomy is what is keeping healthcare from changing its attitude from "we’re as good as we can be" to "we must be even better." Further, management must be willing to take a stand and promote continuous improvement as a way of life. The autonomy that healthcare workers have had for so long is just not going to work. As the saying goes, "if you do what you’ve always done, you’ll get what you’ve always got." It’s time the delivery of care catches up to the 21st century.

As it's put, "the airline industry doesn't need a plane crash to learn how to crash planes." The great majority of learning is extracted from incidents which had the potential to result in accidents, not from accidents themselves. So why does healthcare feel that it must make an error to learn from an error? For the quality of healthcare to improve, it must be willing to identify and eliminate the opportunities for error.

For every 1 major death or injury, there are literally thousands of unsafe practices and working conditions. The irony in this is that we spend all of our time trying to figure out who is to blame for this death or injury. While the combination of individual mistakes that causes a sentinnel event may be unique, the individual mistakes rarely are. With that said, why do we strive to learn as much as we can about this one death or injury so that we can create new ways to prevent this sentinnel event from happening again? Why don't we ever bother to take a look at all of the contributing factors that lead up to this one event - those thousands of unsafe practices and working conditions. If we only could just admit that healthcare is a wealth of highly intelligent people who are working in a broken system.

We need to improve the working conditions and eliminate unsafe practices in order to prevent near misses, minor injuries, and sentinnel events. Lean Six Sigma is the combination of tools necessary to identify opportunities for error, and eliminate them. Further, using Lean Six Sigma to improve working conditions will lead to improved employee satisfaction. Improving working conditions involves putting systems in place that nearly eliminate the chance of making a mistake. Studies have shown that there is a direct correlation between improved employee satisfaction and quality of care (perhaps this is why Southwest Airlines has such great employee loyalty). There is a natural progression towards the elimination of error when the employee is not pressured to perform perfectly in a flawed system. Most importantly, it cannot be forgotten that interacting with the employee when implementing Lean Six Sigma will success and sustainability. Be sure to involve the employees and ask for opinions and suggestions. After all, they are the one's working in broken system every day. They know best what aspects of their job lead them to feel overwhelmed and pressured to perform perfectly.

Once the employee is satisafied and they are working in a quality system, the customer satisfaction will improve. Common knowledge, again, says that a delighted customer also contributes to a successful, sustainable business. For healthcare, a delighted customer/patient improves the patient outcome as well. A patient who is less concerned about their care, who feels more comfortable in the hands of experts, is proven to have improved outcomes in regards to their treatments. With this in mind, why aren't we doing more to improve the current conditions?

Healthcare is a very traditional and conservative industry. Never more has this been apparent that after a few seminars I have recently attended on quality in healthcare. After the seminars, two things stood out in my mind: 1. Healthcare is, generally, not willing to take advice from folks "outside" of healthcare; 2. Physicians are the hardest to change.

While healthcare, at this point, is desperately trying to adopt successful manufacturing principles to reform the delivery of care in this country, they are unwilling to allow quality engineers to help them "re-invent the wheel." What I have been taught, and believe myself, is that a quality expert (from any field) can be successful so long as they build teams of experts from the field. So, in my mind, healthcare professionals need to become more open to the ideas and teachings of quality experts in order to get the wheels of reform rolling. With time, the quality experts will have trained enough healthcare professionals, like myself, to carry the torch and lead healthcare into the next generation of delivery - patient centered healthcare.

Secondly, the hardest group to convince that healthcare is in need of change are the physicians. It seems that when re-designing healthcare facilities, the focus is often centered on the physicians and not the patient. This is because the physicians tend to dig their feet in to what they think is appropriate for the patient, which usually turns out to be not so patient-focused. Further, the physicians are the last ones to admit that they make mistakes. With the legal system being what it is today this is completely understandable. This is perhaps why, the IOM report has been speculated to be underestimated by about 4-fold. However, studies prove that patients are less likely to sue if they are told the truth about the error that occurred during their treatment or procedure than if the truth is covered up. The patient just wants to be told the truth about their care.

In order to completely reform healthcare, we must get physicians on board with the quality movement. Their view that they are infallible needs too be changed, and they must realize that the patient deserves better. Finally, physicians must respect the teams of professionals that help them to treat their patients on a daily basis. Too often, I experience physicians "passing the buck" on to the nursing staff, lab staff, etc. for errors that occurred. Physicians need to realize that these people are the frontline workers, the faces of quality, that are very passionate about the service they provide. The teams of professionals work very hard and take patient care very personally, which is perhaps why the turn over rate for nurses is so high. No one purposely makes a mistake, it’s the current processes that leave the door wide open for an error to occur. Overall, everyone needs to realize that if an error occurs, it is everyone’s responsibility as the system has failed them.

Like Deming and other quality pioneers, everyone in healthcare must realize that it’s the not the people at the center of poor quality, its poor processes that are leading to medical error. Until physicians and healthcare professional, alike, can admit that medical error occurs as a result of processes designed 40 years ago, there will never be any improvement in the delivery of care.

Fortunately, physicians are starting to understand the need to reform the quality of healthcare. Unfortunately, they are just "blips on the map." In order for the movement to be launched in the physician sector, these blips need to connect the dots and create a contingency of followers that suggest to physicians across the country that the time to adopt new practices is now.

The technology that had made healthcare so great in this country has also been at the center of many roadblocks to quality. It has long been the notion that as technology advances in healthcare, so should the quality and efficiency of the process. Therefore, it is the tendency to add technology wherever technology can be added. This adds cost to an industry that is already experiencing increased cost, as well as decreased reimbursement rates. Further, as a Lean Six Sigma expert stated at a conference I recently attended, adding technology to an inefficient process only produces inefficiencies at the "speed of light." Therefore, it is the opinion of many industry experts that innovation in healthcare requires not only technology, but improved processes to assist the delivery of technological advances. To gain efficiencies, a systematic review of the processes, using Lean Six Sigma, is necessary to enhance the delivery of healthcare.

According to Deming and his 85/15 rule, 85% of the inefficiencies within an organization are due to flaws in the process while 15% of the inefficiencies were due to human error. It cannot be argued that human error is an inevitable fact. While no one in healthcare purposely errors, it becomes unavoidable in a complex system composed of numerous, multi-departmental, processes. Unfortunately, identifying the errors is easier than fixing them in such a complex system. Application of Lean Six Sigma to healthcare requires all departments of a healthcare organization to set standards that all must follow. All of the tools of Lean, combined with Six Sigma, aim at identifying aspects of the process that can be eliminated in order to gain efficiencies in process flow and eliminate error.

There is no cookbook for a successful Lean Six Sigma implementation because of the reality that each organization has its own unique products, processes, and people. However, there is no excuse for not using the tools that Lean and Six Sigma provide to solve a problem. These methodologies, while rooted in manufacturing, have no boundaries for what kind of organization they can be applied to. So long as an organization is compelled to identify an opportunity to eliminate waste and standardize their processes, the combination of Lean Six Sigma can be a powerful vehicle to drive an organization’s success.

Once these efficiencies have been achieved, processes will begin to move at the "speed of light," and technology can then further enhance the delivery of care.

Before beginning any implementation of Lean Six Sigma in health care, it is important to get support and buy-in from management. Health care is a very conservative industry filled with professionals that maintain a traditional school of thought. Even though the health care industry has grown accustomed to change, the uneasiness of implementing a process improvement initiative like Lean Six Sigma is not well received. Those entrenched in the field find it difficult to understand the application of a manufacturing technique to the human element. Therefore, a great deal of effort is spent trying to encourage staff to embrace and adopt the Lean Six Sigma way of life.

With the amount of time that is spent trying to establish and maintain buy-in from those working at the forefront of health care, little thought is every put in to how much buy-in must be gained from the management staff. It is because of this, that a good number of Lean Six Sigma implementations, in health care, are unable to sustain. A mistake that myself, as well as fellow implementers, have made is assuming that the project champions have spent the time necessary communicating the impending changes to the management staff, as well as establishing buy-in from them. Likewise, the project champions have mistakenly assumed that the initial buy-in from the management staff has been established by the implementer. As a result, management is often left looking for answers on how to sustain after the Kaizen event or the implementation. While they are able to, as innovative leaders in the organization, see the big picture of what Lean Six Sigma is trying to accomplish, they are not equipped with the necessary tools to sustain the way of life that successful companies like Toyota have withheld. Therefore, it is critical that proper project management be in place to ensure that management is able to maintain this new, radical, culture in health care. When creating a project charter and defining the scope of the project, it is essential that one of the deliverables of a successful implementation be to have unwavering support from the mid-level management. This should include intense training that is apart from the necessary training that the staff receives prior to starting any kaizen event. Further, at some level, it is extremely important to keep the management staff involved in whatever type of kaizen event that is occurring. Doing this will allow the management to follow the progression of a Lean Six Sigma implementation and develop a formula for accountability and sustainability.

It has been widely accepted that the middle managers are the key innovators of the organization. As such, the managers of an innovative process such as Lean Six Sigma must be allowed to understand and embrace the process as they help to ensure that it becomes a way of life and not just the "flavor of the month."

There are 8 wastes associated with a Lean Six Sigma process that are vital to the success of the implementation. The 8 wastes are: over production, excessive processing, non-productive inventory, excessive motion, unnecessary transportation, non-standard work, waiting, and intellectual capital. Eliminating these 8 wastes will add more value to the processes, and increase customer satisfaction. The intellectual capital of the staff involved with the implementation is the most important tool that cannot be emphasized enough with any movement of change. Trained, skilled workers are a precious attribute to the organization and they are critical to the success of a Lean Six Sigma implementation. The knowledge of the staff must be utilized in order to create a free-form flow of ideas, opinions, and suggestions.

Executing these ideas will require a few courageous, visionary, leaders to turn these ideas into action. There will be initial skepticism, but this will disappear as results begin to appear. It is also important to realize that "non-value added" activities are not the people trying to do something wrong. These employees are just working at trying to provide the best service possible. The true barrier is the existing system. Once Lean Six Sigma is applied to the system, employees will find that they are able to respond to and serve the patients faster and more efficiently. The result is higher satisfaction for the patients and for the staff, and lower costs of providing service.

The hesitation of incorporating the system of Lean Six Sigma lies in the biology of human beings and the natural inertia to change. To react to this fear of change, Lean Six Sigma teams should be sure to incorporate a minimal training of Lean Six Sigma into employee orientation modules, and it should be worked into performance reviews. Most importantly, it should be emphasized that the Lean Six Sigma principles do not advocate labor reduction by way of lay-offs. Efficiencies will be gained, and positions will be eliminated through attrition. In other words, staff should not be afraid to offer improvement.

The thing that sets apart “Great Leaders” from “Good Leaders” is the ability to care about others. Great Leaders do not have the luxury of acting on their fight or flight response mechanism. They must constantly be ready to fight at a moments notice, and how they choose to fight can mean the difference in how their followers judge them. It is the most recent actions that others judge the leader, regardless of how the leader judges them self.

In implementing Lean Six Sigma into a health care setting, it is important to be strong ambassadors of change and lead staff into a new era of quality not experienced in health care previously. To do this, the implementers of Lean Six Sigma should remember to follow the following guidelines that will effectively attain buy-in from the staff affected by the implementation as well as ensure that the implementers are accepted as strong leaders in the Lean Six Sigma movement.

Limbic Leadership and Lean

1. Set Clear Standards

a. Focus on the target/goal of the implementation

b. Everyone should be aware and understand the standards

c. Standards should be visual as a reminder to all

d. Constant communication of the standards is essential

e. Keep your eye on the prize

2. Expect the Best, and Tolerate nothing less

a. Lead by example

b. Accountability

c. “You get what you expect, and you deserve what you tolerate!”

3. Awareness

a. What’s working and what’s not working

b. Provide individual feedback – positive feedback

4. History

a. Tell stories to inspire

i. Stories of the past, present, and future help to bring together the group.

ii. Shows the group that the leader(s) is attentive and aware

b. Teach Company Standards

5. Recognition

a. Personalize recognition as much as possible – Lets them know “you’re important to the success of the organization”

6. Group Celebration

a. Sense of belonging and sense of community

b. Inspires and motivates

7. Set Examples

a. Express Affection

b. Show vulnerability