Earlier this morning, I attended a presentation at SHS/ASQ about Lean implementation in multiple emergency rooms in a large health system. There were a lot of positives and one red flag that I heard that might be worth discussion.
- There was a large emphasis on the front line staff owning the process design with a high level of reinvigorated patient focus
- They didn't use the circumstances and culture of the E.D. as an excuse to not use kaizen (or, really, the typical 5-day kaizen event). Much as Barnes Jewish got creative with their 6/3 process, this system developed a 2-day kaizen event model that would work for them.
The red flag, which comes back to an issue of management commitment and senior leadership focus:
The presenters said, basically, that “strict productivity guidelines” get in the way of having time for process improvement. Yes, productivity is important (quality is more important, but then again these things go hand in hand). Productivity is important, but productivity measures, goals, targets, and guidelines are NOT the end goal.
Why would you let your productivity goals get in the way of freeing up time for improvement? How else are you going to improve productivity if you don't give nurses and staff enough time to work on the process? You're NOT going to improve productivity by setting more goals and different targets. You have to staff properly so you can take care of patients (of course) and work on improvements. Too many hospitals habitually underinvest in improvement time and resources it seems.
Productivity goals are NOT a matter of federal law. These goals are set by management. Management can change them — IF they're serious about Lean (and, more importantly, if they're serious about improvement).
Seems like senior leadership at this organization doesn't get it (or doesn't realize the dysfunction their goals are creating). Do you see similar dysfunctions in your organization? Have you been able to influence your senior leaders or have they managed to see the light?
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Yes, in an organisation whose process are very much less complicated compared to an ED of a hospital. But it is quite difficult to find people who understand the concept of ‘mismanaged and mis-organised’ processes as a concern in efficiency, productivity and the final outcome. Regardless of whether the process follow ‘lean’ or not.
This isn’t just limited to productivity goals. For instance, safety goals can get in the way of safety improvement. I’ve seen people refuse to report injuries and mishaps in order to meet goals, especially when accomplishing those goals is tied to some reward system or performance evaluation (or, equivalently, punishment results from failure to meet the goals). This can leave the root cause of the injury or mishap untouched, causing further injuries and mishaps, and also can result in exacerbation of an injury that isn’t treated immediately. On more than one occasion, I’ve even had to insist that a bleeding injury be reported. In other words, safety goals can make a work place unsafer. Customer satisfaction goals can lead to customer dissatisfaction when employees pressure customers for good evaluations. I’ve also experienced environments in which quality goals led to worse quality in a system where people regularly corrected errors made by others without reporting them in order to keep error rates down, or returned defective work to the people who made it so they could fix mistakes without getting caught and penalized for them (the errors go unrecorded officially), again leaving root causes intact ready to cause further errors. Etc.
Yes, I agree “strict productivity guidelines” can reflect a gap in lean understanding. Health care workers are often running on empty, have little “free” time and unfortunately little job satisfaction. The industry is full of heroic and compassionate people who struggle with sub-optimized value streams, poor processes and often underdeveloped leadership.
Progressive thinkers employ concepts like “float teams” – extra provider and staff resources who can cover for others while they engage in kaizen activities. This does much to remove the physical and psychological burdens of the everyday grind and enable providers and staff to do kaizen and help transform the value streams and the culture. Similarly it is critical to schedule daily 10 minute or so chunks of time so that the natural work teams (provider, nurse, medical assistant, etc.) can conduct tier I meetings (“huddles” in health care speak). Within these huddles members review past 24 hour performance issues and improvement opportunities (think daily kaizen) and plan for the next 24 hours. If these times are not scheduled, they will not happen. Often these times can be “discovered” by applying new scheduling strategies (i.e. open access and wave scheduling) and by eliminating non-value added activities around in-box management, rooming, etc.
It requires bold leadership to make “investments” in things like float teams. The pain should be short-term, heck productivity may even stagnate for a bit, but there will be tremendous dividends in the areas of patient satisfaction (quality, wait times, access), and provider and staff satisfaction and ultimately…productivity.
.-= Mark R Hamel ´s last blog ..Leader Standard Work Should Be…Work! =-.
Well said, Mark and Simon! I think my blog has the best reader comments of any of the sites in the lean blogosphere…
I was in a Target store the other day…couldn’t find something and used their (very badly designed) customer service phone system to request an employee come to where I was. When she got there, the first thing she did was fiddle with the phone thing, obviously to reset some timer that kept track of response times…before asking me what I needed or even saying hello.
Measurement systems need to be carefully thought through to avoid screwing up whatever process they are supposed to be helping to improve.
Mark-I can almost echo your observations in another SHS 2010 session I attended this morning abt ER Wait times. The speaker on this occasion seemed to suggest that Lean is about doing ‘more with less’.I think this conjures up more of a sweatshop image than a progressive one.And this after he suggested that he was a physician and a lean expert took me by surprise.
I wonder if this is due to a lack of a standards organization or guidelines in the Lean world (like say the USB 2.0 standard in the consumer electronics world). Do you think we need a Lean principles standard or guideline?
Mark – I am pleased to see that you identified this topic. It has bothered me for years, still does. I see it every day. Just recently I was helping an imaging department try to reduce the amount of time that patients are waiting (unattended) in the imaging department hallway. We used the A3 format, and during analysis of issues with current state (5 whys) we discovered that one of the primary causes for the patient wait times was due to department-level productivity standards. It was not only causing issues within the department (keep the transporter hours per procedure down), but also hampered collaboration between departments (why should nursing help imaging if it would affect nursing hours per patient day?) In the end, management wishes to spend unnecessary dollars to create a room to house patients while they wait (building “waiting” into the process). It’s ironic that their logic behind department-level productivity targets s to save dollars. They’ll spend lots more with the new space, and the patients will continue to experience non-value-added activity.
Great comment, Mike – thanks for adding to the discussion. We should start cataloging examples like this, maybe there’s a book to be written!
As some companies say “we’ll save money no matter what it costs us!!!”
The sad thing is that this has all been seen (and understood) before so many times! A first step in healthcare lean should probably be a commitment to receiving some of the wisdom of those who have trod the path before. In this case the lessons of Dr. Deming on goals and objectives and their effects are front and center, as are the lessons of Shigeo Shingo. While continuous cost reduction is a desired outcome, you don’t start by trying to be cheaper. Easier, better, faster, cheaper. Easier first, then better, at which point faster is already starting to happen… and by then most of “cheaper” is probably already taken care of.
Starting out trying to be faster and cheaper, they may never get there because they don’t understand the means to achieve these desirable outcomes.
Karthik – you’re right, the focus is too often on the “with less” aspect of that equation. Lean typically creates opportunities for growth, so it’s “do even more with the same” instead of “do the same with less.”
People can say or do anything and call it lean. I don’t know what we can do about that other than “call out” situations where we see what some call “fake lean” or what I’ve called L.A.M.E.:
http://leanblog.org/lame
Andrew Bishop writes: “…continuous cost reduction is a desired outcome, you don’t start by trying to be cheaper. Easier, better, faster, cheaper. Easier first, then better, at which point faster is already starting to happen… and by then most of “cheaper” is probably already taken care of.”
Shingo studied his mentor Frederick Taylor well!
Taylor met great resistance in factories where he suggested that workers be paid more for their work and that the jobs be made easier and assigned to those who could carry them out the best.
.-= Jefferson Martin/synfluent ´s last blog ..Value Stream Mapping. Worth the Time? Part 1 =-.
A good portion of our work has been around productivity mainly to help meet current demand. We have an additional challenge with this because we are growing. We are improving our access and more patients are coming. The trick is, the gains we received from earlier improvements are now being replaced with higher volumes. (I guess that is whay they call it continuous improvement huh?)
When I went on a facotry tour last year, the local guide advised they give 15% daily time to focus on improvement. That number may be a bit high but I have been crusading to the best of my ability to get my organization to plan for improvement time on a daily basis. We may free people up for a 5 day kaizen event, but the daily improvements are still overburden waste for front line and their leadership.
Someday I will convince someone to make their problem statement to be around freeing up staff for daily improvments! I am convinced this focus will bring us to a whole new level.
.-= Brian Buck ´s last blog ..Growth Versus Development Warning =-.
No doubt every location has different struggles with how to free up folks, but we made many small gains routine using a daily shift overlap meeting format to review issues.
Getting an expensive multiple day meeting was always a struggle, and was only really doable if a particular significant issue that needed that type of focus had been identified. I always felt that that was a reasonable management approach.
Brian – 15% sounds great… 15 minutes would be a good start even for many organizations!
I’ve found you have to PREPARE for those 15 minutes. Having idea boards with ideas or problems queued up gives you something to work on, otherwise those 15 minutes might just get wasted since it’s so small. Or, plan 15 minutes at a point in the shift, let shifts overlap, the OT might be worth it financially or from the boost to staff morale.
I don’t think we’re likely to get American workers to do the Japanese thing of staying over on their own time, I would never ask people to do that.
I can only speak to manufacturing and not medical situations though I would think there would be many similarities. Typically our folks were in the place for 8 1/2 hours for an 8 hour shift and took their 30 min lunches in rotation as equipment didn’t shut down, so that gave us 30 minutes of overlap time to work with without overtime. Organizations and States have differing rules, but there has to be some way that works.
It really took some creative, persistent facilitation to get the process going, to get folks routinely involved and bringing solid info to the meetings. But the biggest part was people realizing that they were participating and making improvement.