Lean retreat, day 5: Reporting to leadership, taking it back to gemba

Here's our class photo. A whole bunch of inspiring residents, some attendings (full doctors, I believe?), some nurses, and a couple of patients:

Today we reported to leadership on the process we'd gone through. One of Lean's principles is to ask the experts, and if you've been paying attention you know that in Lean the experts are the ones who do the work. So after introductions, the presentation was delivered by us - the students.

Of course, this being a major teaching hospital, the leadership provided some, ahem, clear feedback. :-) But this hospital being a great place, the "clear feedback" was delivered respectfully and with good, open dialog.

A big part of our thinking today was about taking it back to gemba - the workplace. Anyone who reads Dilbert knows that too often a retreat like this ends up as an impotent misfire. So our leaders Alice Lee and Julius Yang MD led discussion of how we'll work at bringing these changes to life, while fitting the work into everyone's full workday. I look forward to seeing how it goes.

I pointed out that this process of building bridges, from the "decision room" into the next step, parallels the work we did on the patient discharge process: building a bridge from the staff's intentions out to the patient's home. Without that work, handoffs of either type are unlikely to bear fruit.
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I want to say again what a great experience it is to be actively engaged in the process of improving care delivery at my hospital. I know patient engagement isn't new; I'm just so happy to be involved in this way. Believe me, I was a full and active participant, and I wasn't just "surveyed" and sent packing, I was part of the team. What a great experience. And what fun!

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.

Lean retreat, day 3: The Pig Game (learning about standardized work)

Modern healthcare is complex, and managing complexity is no laughing matter: it can be life and death. (More on this below.) As always this leaves us with the question, what can we do that would make any difference? That's where Lean comes in.

One aspect of Lean is standardized work - where "standardized" means a shared and continuously improved standard approach. Physicians are given leeway to use their judgment, but all in the enterprise must agree that the right way is to agree on a method, all use it, all contribute their ideas for improvement. And track what works.

That's how we know, for instance, that the central line infection rate has dropped so dramatically, as I mentioned the other day.

Well, to teach us about standardized work, today we did a classic Lean exercise: the Pig Game. Everyone is given a "tic tac toe" grid, and instructions on what to draw. In round 1 everyone's pig comes out vastly different, though all had the same spoken instruction. In rounds 2 and 3 .... well, I won't spoil it, but I'll say that the same group of humans produced far more uniform results when the work was defined more effectively. :)
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This morning we heard from Steven J. Spear, author of Chasing the Rabbit. For homework we read chapters 2 and 3, which made a compelling case that in today's enterprises complexity is the rule and it's the thing that must be managed: no longer is it sufficient to be good at what each of us does - we must manage, together, the uncontrollably complex interaction between our areas of knowledge.

And yes, when I say "we," I'm including patients. I understand more clearly than ever why patients must be engaged in their care, in and out of the hospital. (Actually that's only true if they want the best possible outcome from their treatment. I do.)

The book relates a heart-rending story of a woman who was accidentally given the wrong fluid and died. I won't try to depict the circumstances because anything short of the whole story would give you the wrong impression; I'll just say that when I read it I cried, not just for the patient but for the nurse who did it. (Apparently the wrong tiny vial, looking almost identical, was in the cart.)

It was heart-rending, as I say; then he documents how very similar failures in process and policy led to NASA's Challenger disaster.
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The very first business transformation course I ever took, many years ago, was from a company named Innovation Associates. The course leaders were Charlie Siefert (coincidentally a fellow member of my college glee club) and Peter Senge, who has since become famous for the "Learning Organization" concept, about enterprises whose central competence is to learn new competences. In that course we were taught two fundamentals:

• How to envison a future, unconstrained by current reality. Very right-brain.
  
• System dynamics: an understanding of how complex systems work. Totally left-brain.
  

It was a full weekend, back and forth between the cerebral hemispheres. The climax was apocalyptic: on the last afternoon an exercise led us, unsuspecting, to a conclusion that's horrid to any engineer: you can't figure it all out. You have to think it out as best you can, start operating, and see how it goes, adjusting on the fly.

And since in a complex system problems are likely to arise no matter how much you plan, you need to be really honest about how it's going. It's truly inspiring to work with a group that's dedicated to improvement like this. (And producing great results.)
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And for the raw-business data junkies out there, here's today's Results Tidbit:

Yesterday I described how the Beth Israel Deaconess business transformation team worked with the orthopedics department. One outcome was a total rework of how hip replacement surgery was done. Not only did they improve quality, they can now schedule three total hip replacements per day, not two.

Yeah, folks, that's a 50% increase in business and better quality.

Lean retreat, day 2

Previous post here

Continuing our exploration of how to reduce how many Medicare patients are readmitted after leaving the hospital, this morning we started getting our hands dirty, thinking out all the activities that take place - and can go wrong - when a patient is sent home.

Now, I have some experience with this, having been sent home seven times from my seven admissions in 2007, but I never had any idea how many things were going on behind the scenes. In particular I had no clue how often "final" paperwork (in the computer) had to get "unfinalized" and modified - and much how of a pain the computer systems make it. Plus, there are many many places where information can fall through the cracks, because this is all far less automated than I would have, naively, thought.

As always, the useful question quickly becomes, what can we do to improve this? It's no good ranting, because even a rant leaves you with this: "Okay, got it. Now: you're at where you're at. What can we do that will make any difference?"

And here's where it gets inspiring, because Lean has produced remarkable results without requiring vast new IT systems, and especially since its methods are well within the reach of ordinary people. For one thing, you don't have to figure it all out first - you think, and try things, and see what works. For another, today's eye-opening exercise was done with Post-Its, paper, and Sharpies.

More formally, "think, try, see what works" is called PDCA: Plan, Do, Check, Act [or Adjust]. It's really the scientific method applied to practical managerial problem solving. And it works. I've personally witnessed the transformation of the customer experience in this hospital's orthopedics department; when I first went there the wait was horrid (three hour visits were not unusual), and today people are in and out in 52-56 minutes - consistently.

This stuff works.

In the exercise pictured here, we mapped out four different stages of a patient being discharged, going home, and eventually returning to the clinic (doctor's office) for a follow-up visit. Apologies for the poor picture, but you can vaguely see "swim lanes" for the different people involved: the top row, with green Post-Its, is the patient; the row below is the case manager; other rows are the inpatient MD, the nurse, pharmacist, etc. All these people have specific responsibilities in discharging a patient. Each activity was written on a stickie. There were hundreds.

Then we went back and, as a group, looked at every single activity and marked it in the Lean way:

• Value Added. (Is this specific activity something the customer came here for?) Getting instructions or therapy: yes. Waiting: no.
• Not Value Added. Everything else: filling out paperwork, re-checking medication lists, paging the attending physician, you name it. Some might be necessary, but none of them is what the customer came here for. Lean strives to eliminate these.
• Not Value Added, but Required. A subset of Not Value Added.

In principle all "Not Value Added / Not Required" items should be eliminated. But a vital part of the Lean method is that you start where you're at, try things, and improve incrementally. And even if you did eliminate all such things, you'd still continue making everything leaner and leaner.

Yellow and orange stickies, known as "stormclouds," were added, showing areas where things can go awry. Clusters indicate key areas to engineering reliability into the process.


Does it work? Heck yes: more data on that in tomorrow's installment.

Participating in my hospital's Lean quality improvement retreat

I'm very, very honored to be indulging this week in a new form of "patient engagement": I'm participating in the annual "Lean" quality improvement retreat at my hospital, Boston's Beth Israel Deaconess Medical Center.

In the workshop with me are about 20 BID staffers - mostly residents, some nurses and other staff. Having been on the receiving end of care in seven admissions during my near-fatal 2007 illness, it's an honor to be behind the scenes now and helping work on the continuous improvement that's a hallmark of Lean.

Here's the team leading the workshop, from the hospital's Business Transformation team. From left: Jenine Davignon, Kim Eng, Julius Yang, Bonnie Baker, Alice Lee, Anjala Tess.

"Lean" is the methodology that's transformed many industries in recent decades. It's about identifying what you do that creates value for your customer - as defined by the customer - and eliminating everything you do that's not that. Marvelously, when you follow this method, not only does quality go up but costs go down, and things tend to get done faster, too - a pretty slick combination.

Hospital CEO Paul Levy has written often on his blog about how they've been applying Lean methods for five years. A recent example is here. In this workshop we're all learning about the Lean approach, and even on our first day we applied it by "going to gemba," the place where work happens.

Our homework is from the book Lean Hospitals by Mark Graban of the Lean Enterprise Institute in Cambridge. He was the guest lecturer during today's working lunch.

The focus of our workshop this week is the hospital discharge process. I never would have known it's such a big deal, but it turns out nationwide 20% of all patients discharged from hospitals are readmitted within a month - and Beth Israel Deaconess is a bit worse than that. So we'll be looking at all the various factors that might contribute to unsuccessful handoffs, and how process improvements might help.

This place has some success with Lean. One of the first big initiatives was to reduce the rate of central line infections. In January Paul announced that the infection rate per 1,000 patient days has dropped 83%. To me this is a big deal because:

• 25% of central line infections lead to death
• During my treatment in 2007, I had four central lines put in, for a total of 28 days.

The hospital is open about this process - openly disclosing their failure rates and progress: (CL-BSI is central line blood stream infection.)



So before my admission I'd read all about this initiative, and I was able to chat about it with the surgeons each time they did it to me. And I was, like, really glad they'd undertaken this Lean improvement before my time came.

That kind of openness is only possible if you're committed to improvement, more than anything else.

That's part of why I'm honored and thrilled to be part of their next Lean workshop. So much in healthcare needs improving, and here we are, actively at work on making caregivers' jobs more effective.

Next post in the series here

About the Renal Tumor Program at my hospital

As some of you know, a while ago my oncologist and surgeon, David McDermott and Drew Wagner, asked if I'd be willing to be videotaped talking about what I think about the Renal Tumor program they offer. Well, you know me – please don't throw me in that briar patch! Besides, since I feel pretty strongly that I owe them my life, the least I can do is tell the story to a million people or so.



In a couple of shots you can see my wife Ginny. And, very sharp-eyed long-time Bostonians may be able to recognize that the unnamed fellow in those shots is Gary Gillis, former sportscaster for WHDH-TV. He's the producer of this video.

More details about the Beth Israel Deaconess Renal Tumor Program are on their web site.

(As I write this, the video player is behaving very balkily for me. I don't know if it's my computer or the Brightcove video server. I expect they'll get it worked out.)

Why I love participating in blogs (and in healthcare)

We hear people talking about "social media" – Facebook, blogs, Twitter and all that – and I often hear folks wonder, "Is this making any difference or is it just another way for idiots to waste time?"

Well, in healthcare it's sure making a difference. For one (big) thing, it brings together people who very likely would never have connected. Like, I mentioned Albert Schweitzer, and I just got a reply from the president of the Albert Schweitzer Foundation.

That's amazing, and so is the context in which it happened: patients being welcome in discussion of changing healthcare. This post shares what happened, and my perspective as an observer of these social media changes.

---

12/21/08: Paul Levy writes What if?, inviting other Boston hospitals to share ideas and information to try and eliminate common causes of hospital-acquired infections. In one comment, I wrote:

I sure love the idea of cooperating across hospital lines. And I can't imagine anyone with the spirit of an Albert Schweitzer who'd say no. (And yeah, that's the spirit I want in my medical community.)

1/15/09: Paul writes What does it take?, noting that not a single hospital replied to his invitation, not even to say "Nice idea, but you overlooked x, y and z." He cites that day's big news story that pre- and post-surgical checklists reduce errors. He comments that people from all other walks of life think checklists are an obvious way to be sure you didn't forget something, but many people in healthcare prefer to "go commando" (my term - no checklists), like "we don't need no steenkin checklists" (also my words, not Paul's).

A vigorous discussion has ensued - 38 comments so far - some doctors saying change is hard, another observer says changing culture is hard, a few patients piping up. I wrote an irked comment and posted here and on the e-patient blog, and got some constructive criticism. I commented again, repeating my Schweitzer thought. And here's what I got in response:

To what e-patient Dave said:

Albert Schweitzer taught: "Example is not the main thing in influencing others, it is the ONLY thing." Atul's report on Seattle confirms this once again. It's seeming clear that what Paul is saying on his blog has limited influence on other academic centers, at least in Boston. But if/when we at BIDMC have a demonstrably safer hospital than we do now, and medical, nursing, and other staff who are thus even more proud than of working here than they are now (and thus attract others), and if/when we are then attracting patients who trust us even more than they do now, THEN there would be no one in health care who wouldn't listen (or at least look!).

The different views expressed here are unlikely to be resolved through discussion. Schweitzer said "My LIFE is my argument". What Atul reports from Seattle and Jordan is a pretty powerful argument indeed. ...

Lachlan Forrow, MD
President, The Albert Schweitzer Fellowship
Director, Ethics Programs, BIDMC

My mind got blown as I wrote my reply (the links are worth chasing if change interests you):

Lachlan, thank you so much for your kind, informative and illuminating response.

I'm always humbled and grateful when a doctor takes time to teach me something. Sometimes I speak strongly because of my passion for a new world of healthcare, where patients and professionals collaborate in sharing responsibility and creating solutions. (See October discussion of the forthcoming Society of Participatory Medicine, and the recent discussion Embrace Knowledge Symmetry, as BIDMC's Danny Sands put it).

But I'm keenly aware that in absolute terms I don't know squat compared to the vast elephant-sized picture. So I'm always a little afraid to assert a position, and I'm always grateful when someone teaches me.

It's wonderful that social media and increasing transparency are letting lay voices in on the conversation. In developing the idea of participatory medicine, the e-patient scholars group has largely talked about patients participating in their care. But it's evolved beyond that: on his own blog, Ted Eytan MD led a discussion that defined Health 2.0 as "...participatory healthcare. Enabled by information, software, and community that we collect or create, we the patients can be effective partners in our own healthcare, and we the people can participate in reshaping the health system itself."

I participate with all humility, I hope, and I'm grateful for the chance.

And, just to be complete, I popped out of humility mode and ended by returning to the point:

--So, like, what is UP with hospitals (and perhaps their boards?) not "participating" in sharing information and ideas as the post suggests?? My guess is that whatever is stopping us, it's causing as much harm as a disease.

The comments are where bloggage gets really productive, people. Without comments, blogs are one-way. You should comment more, here and everywhere. You do get to speak up now.

Beth Israel Deaconess on ... Jeopardy??

One of my earliest posts on this blog was a thank-you to Dr. Drew Wagner, the amazing surgeon who removed my yucky-sticky-rude-tumored kidney, without cutting me wide open - just little tiny slits. Amazing.

In that post was a mention of the amazing simulation/training facility at his hospital (and mine), Beth Israel Deaconess. Well, today while chasing a link in the blog of that hospital's CEO, I came across this video clip: last December, their simulation center was featured on Jeopardy's Tournament of Champions!



And yes, they inflated my belly with that unnamed gas. (Yes, I have a bikini scar, and no, you may not see it.)

p.s. To be amazed at the openness of communication at that hospital, and the transparency they're bringing to the world of healthcare, go directly to that video site and page through the "More from this show" items on the right side. The video featured today is a real-life sample of how the hospital now approaches suggestions from workers at every level of the enterprise. What a beautiful example of empowering everyone, and the results it produces.

Thank you, Dr. Drew Wagner!

Y'know, as I posted my thanks to the hospital the other day for the cancer care I received this year, I knew I was overlooking someone. I asked a couple of people who it could be, and they too didn't see anyone missing from the cancer team.

Then it hit me: oh yeah, I forgot the miracle surgeon who relieved me of that stinky kidney in the first place! Until he did his work, the oncology team couldn't start theirs. (See, their work was to get rid of all the metastases throughout my body. But that wouldn't have been too productive as long as the source of trouble was still there.)

Dr. Drew Wagner is the surgeon who did the deed for me. He does the really fancy stuff, laparoscopic kidney removal. Three little incisions to stick the instruments through, and a 2-3" bikini incision (yes, I have a bikini scar, and no you can't see it) through which they remove the culprit.

Now, here's the thing, and I really want you to get this: they inflate the belly to give themselves room, then they stick the tools in through the tiny incisions, and do the work by watching it on a TV. They remove the organ (which is large) by basically snipping it off, putting it in a Baggie, zipping it up, and sliding it out through the bikini cut.

Of course, they have to do this with surgical precision, in the dark except for the flashlight they stuck in there. And here's the thing: the TV is 2D, but your guts (including the location of blood vessels etc) are 3D. And p.s., you don't get to accidentally bump into anything with your knife.

In my case, it got a bit tougher than that. Here's how my sister wrote about it in my cancer journal (March 7, 1:29 a.m.):

The procedure took longer than expected for two reasons: 1) the adrenal gland was involved with the tumor and was also removed (as planned) making for two surgeries in one for all intents and purposes; and, 2) the tumor had attached to the wall of the bowel as well as the psoas muscle which embraces the side of the lumbar spine and had to be very carefully peeled away from both surfaces. Dr. Wagner was concerned that he might have to effectively start all over with a more commonly used incision but was remarkably able to perform the very intricate procedure laparoscopically.

"More commonly used incision" is a bit of an understatement. It's a very large incision, and they have to (permanently) remove a rib. It hurts like hell and takes 6-8 weeks to recover. Instead, I was out of the hospital in 2 days and off all pain meds in less than a week.

I had a unique opportunity to experience what laparoscopy is like. Beth Israel Deaconess has an amazing simulation and training center, where students can actually handle laparoscopic equipment. The very first training exercise involves holding two long-armed gripper tools, and all you have to do is use them to pick up some little white beans and put them in a cup. A foot away, and several inches higher.

That's plenty rough when you can see what you're doing. But when you're good at it, they put a drape over the plastic box that contains all this, and you lose all depth perception because now you're watching it on TV.

Then, don't get nervous or anything, but just remember that while you're trying to do this, the patient is bleeding (or might be) and every extra minute under anesthesia adds risk. So don't screw up. Oh, and pick up that bean you just dropped, because it rolled under the pancreas and it's really a piece of tumor. Or something.

And don't nick any blood vessels or other organs.

And then they tell you that this is the first of the laparoscopic training hurdles. You don't get to move to the next machine until you can move 50 beans from lower left to the cup in one minute, with no depth perception.

Until I tried this myself, it had never dawned on me that a surgeon has to be damned athletic as well as smart. And when I think of this guy going into my inflated belly through these little incisions and delicately peeling that super-aggressive tumor off the bowel, and off that muscle attached to my spine.... both of which the tumor was on the verge of invading... and then the adrenal gland got away, and had to be chased down ... well, the surgery took 5.5 hours,* almost had to convert to the rib-removing version, and yet I went home two days later.

Is this guy good, or what?

My gratitude: well, as that cancer journal excerpt said, when I finally got back to my room all I could say was "Mommy, they hurt me!", and I meant it. And when I (groggily) laid eyes on my cane, I (groggily) considered using it to whack the surgeon. But he moved faster than me, and took it out of my reach. (I am not making this up.) It seems somewhere along the line he developed quick reflexes and manual dexterity.

So thank you, Dr. Drew. You are an amazing guy, and I'm really glad your fingers work that well.

* See comment for update.

Thank you, Beth Israel Deaconess!

People have different views of what causes what in life, and that's fine with me. On this blog you'll hear lots of thoughts about that.

Here's one of my strongest opinions: I wouldn't be here writing this if it weren't for some extraordinarily good people at Beth Israel Deaconess Medical Center (BIDMC) in Boston.

It's not fair to include some names and not others, but since they have 6,000 employees, I've got to stop somewhere. Here are my heroes:

• Dr. David McDermott, of the famous Atkins & McDermott team - among the best in the world for RCC (renal cell carcinoma). You may be a Yankees fan, but I love ya anyway, Dr. McDreamy.
  
• Kendra Bradley, RN and a dozen other initials, from Dr. McDermott's "biologics therapy" team. Kendra is one of those extraordinary individuals who knows what people need before they say it. "I have to," she says. "I've worked a lot with little kids who have cancer, and they don't always have the words to say what they want." You go, KB. You've been fabulous in handling this overgrown kid.
• Mee-Young Lee and Virginia Seery, both nurse practitioners. One of the defining memories of my many days in the hospital this year is the sight of one or both of them standing at the foot of my bed, with their constant beaming smiles and confident voices. What they said wasn't always good news, but these women have mastered the art of conveying strength, encouragement and confidence. I love strong, confident women.
  
• Dr. Megan Anderson, the orthopedic surgeon who fixed my leg when the cancer led to its fracture (and again when my Frisky Pony act broke the screws she'd put in). She too works with kids (do we see a pattern here?) and won me over when, on our first visit, she reached for my foot and said "Let's check the pulse in your little feeties."
  
• The nurses of Stoneman 7, whose quiet competencies are the gold standard of care, in my book. My life was at stake as I received a dangerous treatment, and they did it all right.
  
• Dr. Danny Sands, my primary care physician, and co-manager of the creation of PatientSite, BIDMC's out-of-the-ordinary patient communication web site.

Finally, last in this list (which is where he'd want to be), Paul Levy, not MD nor NP nor RN nor medical nuttin' - he's just President & CEO of BIDMC, and he's the template for how I'd like every CEO in the world to operate. He is open, honest, feeling, compassionate, and tenaciously dedicated to doing good in the world - and competent, on top of all that. Competent enough to run a billion dollar enterprise, pulling it out of a tailspin five years ago so it's now flying high. Boy am I glad he did that.

Characteristically, Paul writes Running A Hospital, the first blog by a hospital CEO. You should read it - he's getting worldwide attention for his openness ("transparency") about the challenges of running a hospital, and for generally shaking up the conventional style of healthcare management. On that blog my "handle" is Patient Dave.

And so begins this blog: the New Life of Patient Dave. Let the games begin!