Paul Levy has shared some photos and a video, from Boston's Beth Israel Deaconness Medical Center, that gives a glimpse into the design of their new pharmacy. He wrote, in part:
We have an old pharmacy on one side of our campus, and it is time to rehabilitate it. We decided to use Lean principles in designing the new space. To do this, we pulled together a team of people, virtually anyone who touches the pharmacy or its products to look at work flows, find waste, and design a future state.
This idea of pulling together a team of those who actually do the work is so simple, yet so revolutionary.
“3P” is a lesser-known Lean method called the “Production Preparation Process.” That's a lousy name for a hospital — here, it could be called “Pharmacy Preparation Process.“
Far too often, space in a hospital is designed by architects, not the people who will actually have to work there. I'm not saying architects aren't needed. They have their role, and it's important one. The best architects have not only general knowledge about their hospital clients and their workflow and they also involve people from the client. The worst architects throw in cookie-cutter layouts that they use everywhere. I've seen this happen a lot with hospital laboratories, for example.
If the space isn't designed with process and workflow in mind, there's so much waste built in from the get-go, you might really be stuck with it for a while. Layouts often just evolve — why is that pharmacy carousel over there? Because that's where we had space when we bought it, that's what you often hear.
When redesigning space or designing new space, you HAVE to involve those who actually work there. They know their needs best and when you teach them Lean methods, they can find layouts that make their workplace more efficient – making their work easier and providing better patient care.
A good pharmacy layout can impact teamwork and productivity. Better teamwork and collaboration (driven by the layout) can lead to better quality – we can do more than just improve flow and reduce walking distances.
We often start 3P with “paper doll” layout design – using a architectural layout and to-scale cutouts of tables and equipment. A next step often involves full-size mockups (as shown in the pictures from BIDMC) that allow people to really test out their designs BEFORE things get too fixed.
Here is the video from his blog post, thanks to BIDMC for sharing this good practice. I've seen it practiced in full at a few other hospitals. In my previous consulting work, we definitely had the staff engagement and the paper cutouts. We mocked up benches and workstations with paper and cardboard, but not the full space as you see and can read about here.
What do you think? Would you be able to make use of a process like this in your organization?
Here is a case study about 3P from Joan Wellman, an outstanding and experienced lean healthcare consultant.
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This reminds me of doing layout for new production areas, in which we did full-scale paper or cardboard footprints of all machinery, with cardboard mock-ups of the places were people related to the machines. If done early enough, it could even lead to modifications to the machines. The guiding principles involved ways of eliminating as much muda of all types as possible, with a special emphasis on one-piece-flow on the shortest possible route. I haven’t done this in years. It worked great!
.-= Bob Duckles ´s last blog ..Speak With Data =-.
We’ve done 4 of them at Spencer Hospital very much in the manner described in this blogspot. Saved a lot of space, $ in construction, and motion. I definitely recommend the process.
Mark,
From a systems thinking perspective I am afraid that the way that you have presented this case on your blog illustrates much of what is wrong with Lean in its current construction.
I recently spent some time helping a hospital pharmacy department to learn about their system. As I gathered my thoughts the night before, if I am honest my mind did turn towards solutions like moving high frequency drugs closer to the counter as shown in the video. But when we studied demand a very different problem revealed itself. We were focussing our attention on the pharmacy itself, whereas demand was being placed by doctors writing drug charts and prescriptions in wards and clinics. And they were getting it wrong.
A lot.
In a very small hospital (<300 beds), the pharmacy team were making more than 20,000 corrections a year to "orders" placed by clinicians. There were simple things like the classic unclear handwriting, but also a surprisingly large number of incorrect doses. As you have done a great job in highlighting elsewhere on this blog, this was not due to bad people, but more to a bad system. However, the result was a great deal of pharmacy capacity consumed with sorting out what John Seddon has labelled "failure demand" – certainly much more time and effort than was consumed walking a few extra yards within the dispensary.
In the original BIDMC blog there is a picture of a FMEA chart which highlights many of these issues. But by starting with tools we end up with a problem which looks like "How can we construct this pharmacy area to best meet value for the customer coming to the counter?". By taking a systems thinking approach the team decided that they didn't need a central pharmacy at all! Rejecting economies of scale thinking they decided that purpose could be better met and variation absorbed by placing dedicated pharmacists and small dispensaries in clinics and wards. That way the pharmacists could develop strong, learning relationships with doctors in the work, constructively working together to reduce failure demand, rather than being the nagging voice at the end of the phone berating them for yet another incorrect prescription.
My worry is that readers of your blog will spend their precious time, attention and money re-designing their geographical spaces rather than re-designing their system. If you help people to see the system they will find the tools they need themselves, and the learning will continue. If you teach people tools, managers will use them to reinforce command and control thinking, measuring activity times like how long it takes to turn around a prescription. Learning will be crushed.
This is a tragic misinterpretation of Deming and Ohno's legacy to us.
John Seddon fashions himself a modern-day Deming or Ohno (based on what exactly, I have no idea).
I knew Dr. Deming. John Seddon, you’re no Dr. Deming.
David, you raise some important issues and it’s somewhat arrogant to assume BIDMC didn’t consider (or isn’t considering) those factors. Just once, I’d like to see a systems thinker raise an issue without the know-it-all tone.
I am sorry if my tone came across as know-it-all. That was not my intention.
BS, your comment demonstrates exactly my issue. We do not know the factors BIDMC did or did not consider, because the story here is all about the 3P tool. Why aren’t we hearing about the thinking?
If you illustrate the philosophy with tools, the very real danger is that you lose sight of the thinking. I’ve done it myself on countless occasions.
BS, careful, let’s try to practice “respect for people” here. We’re not “new systems thinkers” who throw insults and call names. I agree with you that the tone from David seemed a bit snotty, but I’m biased by my experience with people like John Seddon and Tripp Babbitt.
David – when you say “lean in its current construction,” that means what exactly? That would be helpful background because “lean” has become almost a meaningless blanket term that describes all sorts of practices that people and organizations label as “lean.” If it’s a command-and-control “thou shalt put tape around the stapler on your desk,” I’d agree with you that’s bad. I call stuff like that “L.A.M.E.” – http://www.leanblog.org/lame – we are in agreement about some bad practices called “lean.”
You say:
You don’t think they are doing integrated space/process design? That’s what it looked like to me. Neither of us were there – but you’re assuming they are taking a limited view (and then criticizing them for something that maybe didn’t happen).
You say:
You don’t think people are learning to see the system? You don’t think there is learning going on there?
You say:
How do you know they are reinforcing c-and-c thinking? You seem to be transferring other experiences onto this situation at BIDMC. Seek first to understand.
One reason I get turned off by the “new systems thinking” crowd is the tone in which discussion occurs.
Think of how your message would be received had you written something like this, being respectful and asking questions:
“I applaud BIDMC for taking thoughtful action to improve their system, engaging their people in the process. This is a far leap ahead from top-down management driven mandates of how the department needs to be.
From their description, they focus a lot on the design of the physical department. But have they also considered the end-to-end value stream? We should also take care to not suboptimize part of the system. Do we really understand the demand the customer needs? Are we designing a process that helps prevent errors and defects instead of fixing them more efficiently?
Redesigning space is important, but 3P should be an integrated space/process design process. I hope they are doing both.
Maybe they will eventually move beyond designing a better centralized pharmacy. I know of one organization where the team decided that they didn’t need a central pharmacy at all! Rejecting economies of scale thinking they decided that purpose could be better met and variation absorbed by placing dedicated pharmacists and small dispensaries in clinics and wards. That way the pharmacists could develop strong, learning relationships with doctors in the work, constructively working together to reduce failure demand, rather than being the nagging voice at the end of the phone berating them for yet another incorrect prescription.
Thanks to BIDMC for sharing their story.”
A tone like that (asking questions, being respectful, not slobbering all over John Seddon and mentioning him constantly) might be more constructive and get you further.
Or, now it’s your turn to call me a “tool head.”
Thanks for visiting the blog.
Oh Mark,
Forgive me for being wary of accepting advice on being respectful from someone who then proceeds to label my words “snotty” and “slobbering”, but at least we have moved on from yesterday’s “bitter old a-hole”. I understand your emotion, though, and admire your attempts to find common ground.
This could easily become a pointless tit-for-tat from which none of us learns anything, and I would like for you to have the opportunity to have the last word on the matter as it is your blog, after all. This will therefore be my final comment, and its intention is to clarify my position.
Stapler-taping bad practitioners of Lean do not worry me, as the ludicrousness of their results helps them to dig their own graves, with little collateral damage done with fair-minded leaders. What is infinitely more damaging is mainstream Lean’s obsession with tools. As you correctly state, neither of us understands what happened at BIDMC, and I have never sought to criticize them (although I can see how a criticism might be inferred). My issue, as I stated in the first paragraph, is with how this case is presented here, and the perspective it reveals.
You are right that Lean “has become almost a meaningless blanket term that describes all sorts of practices”. Absolutely right. And why is that? Well, could it be that when people engage with Lean they are bombarded with just that, practices. Very seductive practices, even very successful practices, but practices all the same. So the temptation for leaders is to take these practices/tools and use them to solve the problems that they perceive they have today. This is really, really dangerous. Not because the results are disastrous, as that would prompt people to reject them more forcefully. No, they are dangerous because the opportunity to make dramatic, radical and sustainable improvement through changed thinking is lost.
If you learn a tool, even one like VSM or error-proofing, and place it in your tool-box, then nothing has fundamentally changed about the way you manage. If you study the system, and understand WHY it looks the way it does, then your whole perspective on management changes. It becomes impossible not to act.
By showing glimpses of practices/ tools we perpetuate this situation. You (and the majority of Lean practitioners) hold a different view. I spent several years as a Lean practitioner before really starting to learn to see from a systems thinking perspective. I would encourage you to try and get past any issues you have with tone and have a go yourself – you never know!
Thank you for having me.
David,
Give it a rest and hit the sack. Pretty late in the U.K., isn’t it? Time to walk away from this one.
MW
David – I was being intentionally rude. I don’t normally write that way or talk to people that way. There’s a certain systemic rudeness to the “new systems thinking” crowd, as if being rude and insulting people is a deliberate sales strategy. If NST’s can dish it out, they should be able to take it. Again, I don’t like operating that way and it’s not much of a defense to say Babbitt and Seddon started this nastiness.
I understand and care deeply about systems thinking and new thinking. Can every blog post fully express what? Well, no.
There are two distinct camps, camps that will probably never see eye to eye:
1) Lean = tools are helpful but only if it helps build new awareness and new thinking, that tools have to fit as part of culture and system change
2) new systems thinking = tools are useless, you need to just think different, you idiots (I’m paraphrasing how it comes across)
Group 1 says “it’s easier to act your way to a new way of thinking than vice versa” and Group 2 says “don’t act differently, think differently.”
I don’t see how you get magical changes in thinking. People are more complex than that. If you can affect change with your NST approach great — why not focus on that and quit trying to tear down those in Group 1.
That’s my last word.
[…] the article mentions “3P” (Production Preparation Process) work done at Bolton, similar to what I wrote about at Boston’s BIDMC (via Paul Levy’s blog): When redesigning the blood science laboratory at Bolton, the team even […]
For the “system thinkers” versus the “just do its”, don’t we need both? The activity shown in the video is a base hit. Even if we fixed the prescription error problem wouldn’t we want an efficient layout for the workers filling the prescriptions? I fully agree that we want a group looking for root cause of the major problems but this shouldn’t stop improvement in the workplace. Look at the energy increase from workshop participants on the video as their thinking of workplace organization came together. This was not a wasted effort.
David – yes, I agree that we need both strategic systemic improvement AND smaller, more local staff-driven kaizen. The morale impact of kaizen – leading to more improvement and greater improvements is one of the major benefits of kaizen, not just ROI.