Thursday, March 11, 2010

Lean retreat, day 4: Synchronize / align, and the House of Lean

Yesterday was hard work, because we stepped out of "supposedly" and into "Okay, what CAN we accomplish in 3-6 months?" Because Lean isn't about massive centralized re-engineering, it's about small practical improvements - continuously.

Today we took the results of that work and honed it down to small projects that the hospital will actually pursue. (I didn't realize that when the week started.) The day's byword was "synchronize," not in the time-sync sense, but in the sense of getting aligned and coordinated, rowing in a common direction.

We brought together our different learnings from the week into an action plan that fits into the "house of lean" diagram we started with on Monday. I didn't grab a snapshot of it then, but here's today's hand-drawn reconstruction. See legend below.

The foundation has three layers:

  1. Stability: You cannot improve steadily without a stable process. So, a lot of work goes into stabilizing how work is done. In any industry including healthcare this can require giving up a certain amount of craftsmanship - but in my view the predictable, repeatable part of the work is what gets stabilized, and craftsmanship moves out onto the frontiers, where it's most needed.
  2. Standardization: As I described yesterday, this is about having a shared, continuously improved, agreed approach to the parts of the work that can be standardized.
  3. "Kaizen mindset": Kaizen is continuous small improvements: every day do something a little bit better.
On this foundation stand two parallel pillars:
  • Flow: a hallmark of Lean is the idea that inventory and uneven workflow are wasteful. When MIT Sloan's Mike Cusumano went to Japan in the 1980s to study Japan's car makers, he found that although they were all good, Toyota produced the same number of cars with half the floor space and half the people. That's because they managed every aspect of the process to produce steady flow.
    Yes, inventory and uneven workload can be managed to a minimal state. And when that happens, all kinds of wasteful workarounds disappear.
  • Quality at the Source ("Jidoka"): in Lean it's absolute folly to achieve quality by manufacturing defective things and then spending labor to find the defects (inspection) and weed them out. Make everything in a quality fashion the first time.
    This week I learned that a vast amount of time on a hospital floor is spent re-checking things because errors are so costly. To me, as someone from industry, this gives the lie to any healthcare executive who takes an arrogant position because of the supposed vast intellect of people in healthcare. I know healthcare executives are smart, but if they're not working on improving quality, they're guilty of ignoring existing knowledge from other disciplines. That's not scientific.
And the roof, the healthcare platform that's supported by the foundation and pillars, the "true north," is Patient Centered Care. In Lean healthcare, all the other activities are of value only to the extent that they carry this load.

There's another aspect - the center of this house - that doesn't appear in many diagrams of the "House of Lean," but was prominently taught to us today: human development. All lean practitioners talk about "respect for people" or "respect for humanity," but not everyone emphasizes it in this way, as the center of the House. The other day Lean Hospitals author Mark Graban described it to me as respect for human potential, and indeed one of the 8 forms of waste we were taught is "Unused Human Talent."

So you can imagine how pleased I was to be a voice of the patient in this exercise. Because as the week went on, I saw that when we clear out the clutter that keeps clinicians from doing their job, we make it easier for them to make the most of their talent. And by empowering patients and families to be active (participatory medicine), we make the most of their talent too.

What a thrill to be involved in this week. Thanks so much to Beth Israel Deaconess for inviting me and helping to make it possible.


  1. Dave -
    I think you make great points - in addition you did an outstanding job of making the information understandable. Too many times people throw around the terminology because "Lean" is such a catch phrase right now but your ability to translate it is great.
    Thanks for sharing
    Kourtney Govro

  2. This is a fascinating discussion of lean and kaizen. This post in particular highlights the things that have to take place in order to accomplish the objectives of "lean."

    Getting to lean is similar to the use of the balanced scorecard in achieving strategic objectives. Balanced scorecard starts with the premise that you can't manage what you don't measure, and the strategy map starts at the top with the overall objective -- "Reduce Cost" or "Improve Patient Outcomes" -- and then dissects what has to happen in order to actually accomplish the overall objective, right down to what each individual or group needs to do. And then metrics are put in place to evaluate how well people are doing in accomplishing their part of the overall goal.

    The set of things that have to happen in the House of Lean to meet the overall goal is quite similar. For example, human development is one of the levels of a strategy map.

    The drop in infections from central lines is a good metric for the overall result. It would be interesting for you to consider how to meaure the steps that lead to this kind of success (and perhaps you did this during the week). For example, if standardization is one key to success, how do you measure adherance to specific standards?

    Mike Sandman

  3. Courtney, thanks for your kind words. I've always believed that any guru is a quack if his/her point can't be expressed clearly to a grade schooler. (Quantum mechanics doesn't count.:-)) Plus, if the point isn't clear to readers, it doesn't enable improvement.

    Michael, thanks; as pre-reading I studied a little about Lean and learned that indeed it shares a lot with other quality initiatives such as Balanced Scorecard.

    I don't have information on whether any intermediate metrics were gathered during the central line initiative. I'll see if I can find out.


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