## Toyota Kata: What If There Is No Takt Time?

The default Starter Kata for “Grasp the Current Condition” places heavy emphasis on takt time and variation in timing of a regular process. However a lot of processes, both within manufacturing as well as in other domains such as health care, don’t seem to have any kind of regular heartbeat.

As Steve Medland pointed out at KataCon, this can present a struggle for a novice learner, as well as for a lot of coaches.

Before we get into ways to deal with this, I want to level set on what takt time is, and what it does for us.

## Why Takt Time?

From an industrial engineering standpoint, takt time is an expression of how much capacity you need.

The traditional way to calculate takt time is to divide the total time available by the output required in that time. This gives us a “time per unit of output” that we have to achieve if we are going to get everything done. In other words, takt time is the required rate of production.

The whole goal of an ideal “Just-in-Time” system is that we have only the capacity required to meet the demand. If the system is even able to run faster than the takt time, we have excess capacity. Excess capacity = extra cost, and “overproduction” is a symptom of having excess capacity. Note that this is the “ideal” – it isn’t anything we can realistically achieve. The concept gives us a direction to strive toward.

Also Note: Determining how much capacity you need has absolutely nothing to do with how much capacity you have.

OK, that answered the question “What is takt time?” but not the question I posed: “Why takt time?” After all, I could just as easily say I need the capacity to product 96 units per day. But that doesn’t answer the question, “How fast do I need to go?” And that is what takt time gives us.

Think of it this way. If I need to make 96 units during the course of an 8 hour day, then I need to have made 48 units in four hours.

To make 48 units in four hours, I need to make 24 units in 2 hours. Which means 12 units in 1 hour. 6 units in 30 minutes. 3 units in 15 minutes. One unit every 5 minutes. And that is my takt time. (This is an oversimplification since I did not subtract break times to make the math easier to make the point.)

Thinking of it this way gives the people doing the work a quick way to know, very quickly, if they are ahead or behind. They can ask, “How long did this unit take?” and compare that with, “How long did we have?”

## A Point of Comparison

Which brings us to the “Why.”

If I measure the time between units output at the end of the line, I can compare the actual time interval (the cycle time) with the required time interval (the takt time).

• If we need to complete a unit every five minutes (takt time), AND
• We know that our process can do that when there are NO problems, THEN
• We can see very quickly if there IS a problem. We have to attack a source of variation and work on stability.

On the other hand,

• If we need to complete a unit every five minutes (takt time), and
• We know that our process is not capable of doing so even when running smoothly, then
• We know we have to change the entire system to make rate.

Distinguishing between these two conditions is the main benefit of building a cycle time run chart (step 3 in the Starter Kata of Grasp the Current Condition.) That is a topic for another post, or just get a copy of the Toyota Kata Practice Guide ;).

The issue comes when people don’t see a steady rate of demand.

Sometimes they generally know how much time is in the day, but they see demand fluctuating all over the place.

This is true in manufacturing work as well as other cases, such as engineering work, software development, and a lot of cases in health care. The time to complete one “unit of work” varies, so it is hard to see any kind of cadence to the output even if the work is steady.

## Key Question: Are you ahead or behind?

And how can you tell?

Regardless of all of the variation, though, we still want to know the answer to questions such as “Are we on track to get everything done today?” or “Has my load exceeded my capacity?” or “Is the backlog increasing, decreasing, or holding steady?” unless we are simply relying on luck. Asking and answering these questions is the purpose of many of the “lean tools” – including takt time.

## When to Bring it Up

Everything above, though, is information for the coach to keep in mind. What a lot of us (myself included) do all too often is take beginners into advanced application way too fast. We forget what it is like to be overwhelmed with just getting through the day, and the limits that places on anyone for taking in new concepts.

I bring it up for the coach because I think the chances of the learner discovering it on their own are significantly lower (perhaps close to zero) if the coach is starting in the same place.

If you are getting pushback on the concept, it might be time to back off a bit and give your learner some space.

Steve Medland had a mini (5 minute) presentation at KataCon 2020 that briefly addressed some of his experience with this situation.

He pointed out that the default worksheet templates for Grasp the Current Condition and Establishing a Target Condition emphasize process timing and cadence pretty heavily.

And the alternative is a blank template:

Steve makes a good case that there ought to be something that provides a more general structure without removing all structure. I agree – as a coach, structure is one of the things you are bringing to the table. Any learner, at any level of expertise, is more deeply embroiled in the process itself than in the process of improving the process. Having some structure really helps.

The key is to adjust the structure to fit the situation.

With beginners, the concept of takt time can be distracting, even paralyzing. Even more so if we use alien jargon like “takt time.”*

Using a hybrid structure like Steve proposes can get the learner moving into process analysis without getting wrapped up on terminology, or struggling with something she sincerely believes has nothing resembling a cadence.

Then, when the opportunity arises, the coach can still gently, but persistently, ask “How often does this need to be done?” and “How do we know if we are ahead or behind?”

Often the resistance is less about knowing there is some kind of schedule, and more about just being overwhelmed by all of the chaos that prevents any kind of stability.

Steve and I agree that timing is important. And I agree that it is important enough that it might be best to hold off on introducing it as a concept so we don’t create resistance unnecessarily.

But please don’t completely throw away measuring time just because it is hard. In fact, the harder it is, the more important it likely is. When it is easy to determine takt time, we likely already have an idea how long things are taking. The less appropriate takt time seems, the more critical it becomes to dig deep into where the time is going.

*Believe it or not, Godwin’s Law can even be applied to “takt time” if you research your history enough.

## Background:

I wrote an article appearing in the current (October 2017) issue of AME Target Magazine (page 20) that profiles two very different organizations that have both seen really positive shifts in their culture. (And yes, my wife pointed out the misspelling “continous” on the magazine cover.)

The second case study was about Meritus Health in Hagerstown, Maryland, and I want to go into a little more depth here about an element that has, so far, been a keystone to the positive changes they are seeing.

Sara Abshari and Eileen Jaskuta are presenting the Meritus story at the AME conference next week (October 9, 2017).

Sara is a manager (and excellent kata coach) in the Meritus CI office. Eileen is now at Main Line Health System, but was the Chief Quality Officer at Meritus at the time Joe was presenting at KataCon.

Their presentation is titled Death From Kaizen to Daily Improvement and outlines the journey at Meritus, including the development of executive rounding. If you are attending the conference, I encourage you to seek them out – as well as Craig Stritar – and talk to them about their experiences.

## Mark’s Word Quibble

In addition, honestly, the Target Magazine editors made a single-word change in the article that I feel substantially changed the contextual meaning of the paragraph, and I am using this forum to explain the significance.

Here is paragraph from the draft as originally submitted. (Highlighting added to point out the difference):

[…][Meritus][…] executives follow a similar structure as they round several times a week to check-in with the front line and ensure there are no obstacles to making progress. Like the Managing Daily improvement meetings at Idex, the executive rounding at Meritus has evolved as they have learned how to connect the front-line improvements to the strategic priorities.

This is what appears in print in the magazine:

[…][Meritus][…] executives follow a similar structure as they visit several times a week to check in with the frontline and ensure there are no obstacles to making progress. Like the MDI meetings at Idex, the executive visiting at Meritus has evolved as they have learned how to connect the front-line improvements to the strategic priorities.

While this editing quibble can easily be dismissed as a pedantic author (me), the positive here is it gives me an opportunity to highlight different meanings in context, go into more depth on the back-story than I could in the magazine article, and invite those of you who will be attending the upcoming AME conference to talk to some of the key people who will be presenting their story there.

## Rounding vs. Visiting

In the world of healthcare, “rounding” is the standard work performed by nurses and physicians as they check on the status of each patient. During rounds, they should be deliberately comparing key metrics and indicators of the patient’s health (vital signs, etc.) against what is expected. If something is out of the expected range, that becomes a signal for further investigation or intervention.

“Visiting” is what the patient’s family and friends do. They stop by, and engage socially.

In industry, we talk about “gemba walks,” and if they are done well, they serve the same purpose as “rounding” on patients in healthcare. A gemba walk should be standard work that determines if things are operating normally, and if they are not, investigating further or intervening in some way.

I am speculating that if I had used the term “structured leader standard work” rather than “rounding” it would not have been changed to “visiting.”

## Executive Rounding

Joe Ross, the CEO at Meritus Health, presented a keynote at the Kata Summit last February (2017). You can actually download a copy of his presentation here: http://katasummit.com/2017presentations/. The title of his presentation was “Creating Healthy Disruption with Kata.” More about that in a bit.

The keystone of his presentation was about the executives doing structured rounding on various departments several times a week. These are the C-Level executives, and senior Vice Presidents. They round in teams, and change the routes they are rounding on every couple of weeks. Thus, the entire executive team is getting a sense of what is going on in the entire hospital, not just in their departments.

Rather than just “visiting,” they have a formal structure of questions, built from the Coaching Kata questions + some additional information. Since everyone is asking the same basic questions, the teams can be well prepared and the actual time spent in a particular department is programmed to be about 5 minutes. The schedule is tight, so there isn’t time to linger. This is deliberate.

After the teams round, the executives meet to share what they have learned, identify system-wide issues that need their attention, and reflect on what they have learned.

In this case, rather than rounding on patients, the executives are rounding to check the operational health of the hospital. They are checking the vital signs and making sure nothing is impeding people from doing the right thing – do people know the right thing to do? If not, then the executives know they need to provide clarity. Do people know how to do the right thing? If not, then the executives need to work on building capability and competence.

In both cases, executives are getting information they need so they can ensure that routine things happen routinely, and the right people are working to improve the right things, the right way. In the long-term, spending this time building those capabilities and mechanisms for alignment deep into the operational hierarchy gives those executives more time to deal with real strategic issues. Simply put, they are investing time now to build a far more robust organization that can take on bigger and bigger challenges with less and less drama.

## Results

Though they were only a little more than a year in when Joe presented at KataCon, he reported some pretty interesting results. I’ll let you look at the presentation to see the statistically significant positive changes in employee surveys, patient safety and patient satisfaction scores. What I want to bring attention to are the cultural changes that he reported:

Actually points 1. and 2. above are both about leadership development. The executives are far more in touch with what is happening, not only in their own departments, but in others. Even if they don’t round on their own departments, they hear from executives who did, and get valuable perspectives and questions from outsiders. This helps break down silo walls, build more robust horizontal linkages, and gives their people a stage to show what they are working on.

Since executives can’t be the ones with all of the solutions, they are (or should be) mostly concerned with developing the problem solving capabilities in their departments. At the same time, rounding gives them perspective on problems that only executive action can fix. In a many organizations mid-manager facing these systemic obstacles would try to work around them, ignore them, or just accept “that’s the way it is” and nothing gets done about these things. That breeds helplessness rather than empowerment.

On the other hand, if a manager should be able to solve the problem, then there is a leader development opportunity. That is the point when the executive should double down on ensuring the directors and upper managers are coaching well, have target conditions for developing their staff, and are aware of who is struggling and who is not. You can’t delegate knowing what is actually going on. Replying on reports from subordinates without ever checking in a couple of levels down invites well-meaning people to gloss over issues they don’t want to bother anyone about.

## Breaking Down Silos by Providing Transparency

The side-benefit of this type of process is that the old cultures of “stay out of my area” silos get broken down. It becomes OK to raise problems. The opposite is a culture where executives consider it betrayal if someone mentions a problem to anyone outside of the department. That control of information and deliberate isolation in the name of maintaining power doesn’t work here. Nobody likes to work in a place like that. Once an organization has started down the road toward openness and no-blame problem solving, it’s hard to turn back without creating backlash of some kind within the ranks.

## Creating Disruption

Joe used the term “Disruption” in the title of his presentation. Disruption is really more about emotions than process. There is a crucial period of transition because this new transparency makes people uncomfortable if they come from a long history of trying hard to make sure everything looks great in the eyes of the boss. Even if the top executive wants transparency and getting things out in the open, that often doesn’t play well with leaders who have been steeped in the opposite.

Thus, this process also gives a CEO and top leaders an opportunity to check, not only the responses of others, but their own responses, to the openness. If there are tensions, that is an opportunity to address them and seek to understand what is driving the fear.

In reality, that is very difficult. In our world of “just the facts, ma’am” we don’t like to talk about emotions, feelings, things that make us uncomfortable. Those things can be perceived as weakness, and in the Old World, weakness could never be shown. Being open about the issues can be a level of vulnerability that many executives haven’t been previously conditioned to handle. Inoculation happens by sticking with the process structure, even in the face of pushback, until people become comfortable with talking to each other openly and honestly. The cross-functional rounding into other departments is a vital part of this process. Backing off is like stopping taking your antibiotics because you feel better. It only emboldens the fear.

These kinds of changes can challenge people’s tacit assumptions about what is right or wrong. Emotions can run high – often without people even being aware of why.

## KataCon 2017 Keynote: Joe Ross

Last year I nominated Joe Ross, the CEO of Meritus Health in Hagerstown, MD to be a keynote speaker at the 2017 KataCon. I did so because I think Meritus has a compelling story.

Like many organizations, Meritus had engaged in several years of staff-led improvement focused on events and things like “A3 Training.” And like many organizations, while the individual events seemed successful, the actual long-term traction was limited.

A little over a year ago Meritus started exploring Toyota Kata as a possible way to change the cultural dynamic. The 2017 KataCon will be on the anniversary of our first training session.

In the meantime, Meritus also applied the same thinking to how they did their senior leader rounding, as well as applying the thinking shifting the way the staff interacts with patients and each other.

Joe’s talk will cover these key points and the lessons they have learned along the way.

I hope you will be there to hear his message and meet him as well some of his key people.

## Delivering the Patient Satisfaction Experience

“Our challenge is to improve our patient satisfaction scores.”

This seems to be a fairly common theme as I continue to work in the health care arena.

## Background

In the U.S. at least, most major health care operations use one of a couple of major service providers (such as Press Ganey) to survey their patients, and report aggregated patient satisfaction scores to them. Those scores provide a percentile rank of how that facility stacks up against others across various categories. The scores are also made public, and often influence public funding decisions within a region. Thus, they are a big deal.

## Chasing the Patient Satisfaction Numbers Doesn’t Work

Here’s the problem. More than a few times I have seen an improver working on a challenge to improve these patient satisfaction numbers. It might be something like “Achieve a 70th percentile score on ___.) with a specific score that has to do with their area.

So far, that’s not a real problem. But what happens next might be.

It is very common to focus solely on the end result, without a lot of thought into the underlying things that drive that result.

Specifically, I have seen more than a couple of cases where a manager is working to directly influence how a patient (customer) will answer the questions on the survey. They parse the question, and try to determine what this word, or that word, actually means to “the patient.” The worst case was trying to introduce fairly heavy handed scripting… “Is there anything I can do for you to be more comfortable?” into every patient interaction.

I certainly can’t speak for the population of patients, but I can say that when I pick up on a scripted phrase, I become very aware of what it is, and it leaves a disingenuous taste.

## It’s About the Patient Experience

The patients’ experience is what drives how (and even if) they will answer the questions on these surveys. If their experience was overall favorable, they will be biased to give favorable replies. The opposite is even more true. One bad experience will negatively bias all of their answers.

Here’s the question I ask that sometimes stumps people:

What experience to you want the patient to have?

(If you aren’t in health care, substitute the word “customer” for “patient.”)

If your scores on “Were the staff concerned for my comfort?” are low, think about what experience would give the patient confidence that staff were concerned. Being continuously asked about it with a rote phrase probably isn’t going to do it. But leaving them parked in the hallways with no interaction might be (for example), something that creates discomfort.  (“Comfort” has a psychological, as well as a physical component.) People will put up with a lot of discomfort if they know the higher purpose. It’s hard to make the case for parking the patient in the hallway. That just says “I don’t have anywhere to take you.”

So think deliberately. If everything the patient experienced were something you were doing on purpose, because it contributed to the experience you want the patient to have, what would that look like?

Don’t worry right now about whether that is hard or not. Let go of your internal issues for a while. Just sketch out that awesome “insanely great” patient experience. You don’t have to think of every detail. What are the attributes? What is the flow, from the patient’s perspective – the sequence of events they will experience.

For example, construct a story, told from the patient’s point of view, of coming in for outpatient surgery.

What happens from the time they have their initial consultation until they are on their way home. (And what happens after they get home?) Again, don’t worry about “we can’t do that because…” stuff, we’ll deal with that later.

What experience, what story, would leave the patient with the impression that you are working as a team, that you know what you are doing, that there is a competent process at work to provide safe, effective care and actually care about their experience?

Don’t forget to include your administrative communications in this process – what phone calls do they get? What paperwork do they get? What does crystal-clear billing look like?

Build a block diagram, a story board, of the patients’ ideal flow through the system.

What would a wait-free, smooth flowing experience look like?

## Learning From Disney

In Disney theme parks, they make a clear distinction between “On Stage” and “Off Stage.” Their employees (all of them) are referred to as “Cast Members.” Anytime a Cast Member is visible to guests, they are “On Stage.” They are performing. They are part of creating the story, the experience, they want the guest to have.

Meanwhile, behind the scenes, in the tunnels, off stage, are the processes required to create the “On Stage” performance. It’s a show.

The guest experience is designed. Once it is designed, it is created by the process.

Disney’s priorities (in order) are:

• Safety
• Courtesy
• Show
• Efficiency

Translated, they place putting an a good performance above being efficient. But if pushed, a cast member may break character if required to be courteous. And they will get snippy with someone who persists in doing something unsafe in spite of courteous requests.

What on Earth does this have to do with health care?

Everything. That is if you are trying to create a safe, professional and competent impression to your patients.

## What is the Actual Patient Experience?

Now we have a sense of the ideal, it’s time to understand what is really happening. Again, start with the patient’s experience.

What happens at each interaction? What questions are asked? Who asks them? How often are they moved? Where and when are they waiting, and why?

Use “typical” rather than exceptional cases here. One thing I am seeing is, yes, every case is different but in reality, most are handled within a routine.

Pay attention to the “on stage” part of your process. This is what the patient sees, and what creates their experience.

At the same time, look at the behind-the-scenes “off stage” flow to see what might be causing a less-than-ideal patient flow. For example – The patient’s experience is that he is alone in an exam room waiting, reading Time Magazine for 20 minutes. That is the “on stage” part.

Meanwhile, “back stage” you have a nurse on the phone trying to get the results of tests that were done by another provider. (This is a real-life example.)* (There was also a physician waiting on them!)

## Your Processes Create the Patient Experience

(Again, substitute “customer” for “patient” and this becomes an essay for everyone.)

Your Patient Satisfaction scores are driven by the patients’ experience.

The patients’ experience is established by your “on-stage” (patient facing) process.

The people making the improvements need to be challenged, and focused on, creating a specific experience for the patient.

All of that begs the question: Who should make the linkage between process performance and patient satisfaction, because those scores do matter, in a very big way.

Let’s look at this from a policy deployment standpoint.

Certainly Administration (the executives) should be tracking their scores. From their perspective, these are an important (along with patient safety, quality, length-of-stay, financial performance, etc) aspects of how the organization is performing.

They see the overall performance and trends. And they can see how each department is performing.

But the patient’s experience is cross-functional. The patient only sees “the hospital.” He doesn’t see, and doesn’t care, that Admissions, the lab, the Emergency Department, Outpatient Surgery, Environmental Services (who cleans his room) and Radiology are all different departments. The patient doesn’t see, and doesn’t care, that “the clinic” and “the hospital” are separate legal entities.

As part of Policy Deployment, Administration should be establishing operational standards and challenging the Department Directors to meet them. Those standards are based on what Administration believes will move the needle on the patient satisfaction scores. In reality, this is also an experiment. Does this operational standard meet our customer’s expectations?

They also are making sure the Directors are working on the cross-functional interfaces between their departments. (If it isn’t the Directors’ job to do this, whose job is it?)

Key Point: Until you are consistently delivering the product or service, there is little point in trying to change things up. Set a standard, strive to meet it. Once things are somewhat stable, then you can evaluate whether your standard is adequate or not. Think about it… what is the alternative? You have random execution that is randomly working. You don’t know why. You can’t talk to people about performance until they can demonstrate consistent execution.

## Summary

Your patient satisfaction scores reflect the experience of the patient.

The patient experience is the outcome of your on stage process performance.

Your on stage process performance is ultimately driven by your back stage process execution.

If you want to improve your patient satisfaction scores, establish the operational standard you want to strive for that you think will improve patient satisfaction.

Then strive to develop a process that meets that operational standard.

_________

*This was an obstacle in front of a target condition focusing on hitting a standard for “In, Seen and Out” within a specific time frame for routine pre-procedure consultations. They fixed it. Patients no longer have to sit and wait while someone hunts down those test results.

## Toyota Kata in Health Care

I’m about four months into helping a major regional hospital develop a solid foundation for applying the Improvement Kata and Coaching Kata to learn “improvement thinking.”

They now have active improvement boards running in pre-op, post-op, surgery, radiology, the lab, the emergency department, the cardio-vascular floor, medical-surgery floor, ICU, cardiac rehab, billing, admissions, case management, and supplies. I think that’s everything going right now.

Several of these departments have more than one board, and a few are beginning to get started spontaneously.

We are starting to see the culture begin to shift in many of these departments. Staff are getting engaged in improving the work flows, administration team members are more engaged with the staff.

Directors and managers are starting to reach across organizational boundaries to deal with obstacles and problems at the departmental interfaces.

And the organizations are starting to shift how they talk. When confronted with a list of problems, leaders are starting to ask “OK, which one are we addressing first?” Leaders are asking “What do you expect to happen?” and “What did we learn?” when talking about actions. They are working to engage thinking in their organizations vs. just giving direction.

Is it all rainbows and unicorns? Of course not. But the effort is clearly being made, and it shows. My overall process coaching is getting much more nuanced, because they are “getting” the fundamentals.

OK, so what did we do?

We started out with two weeks of pretty intense “kick-start.” One week was half-days of training and simulation (with a morning and afternoon group), getting a feel for the rhythm of the improvement kata, and a taste of the coaching kata, and culminating with the first round of improvement boards getting set up with at least a direction, if not a clear challenge.

We deliberately did not use industrial examples. And now that I’ve done it a few times, I can incorporate more health care language and examples into the sessions, which just makes it easier.

Week two was pairs of learners/coaches being coached through grasping the current condition, establishing a target condition, and the first couple of PDCA cycles / experiments.

But what made it work is they kept at it.

The next month, we did it again. We coached the established boards to tighten up their game, while establishing a series of new ones.

Because they had kept at it, the first round of boards now had a routine for their improvement cycles and coaching. And once there is a pattern, then we can work on improving it.

What I am learning.

Just get them going, then leave them alone for a while to keep at it. That lets the team establish a baseline routine for how they are practicing. Then I can come back periodically and propose adjustments on one or two items that let them step it up to the next level.

I am finding this much more effective than demanding they get it perfectly from day one. There is just too much to think about.

Establish a target condition, have them practice to that pattern, grasp the current condition, establish a new target… for the team’s practice. Get the improvement engine running, even if roughly, then work on tuning it for performance.

To be clear, this is my normal approach (and it is different, I am told, from what a lot of others try to do), but I am getting a lot of validation for it here.

Results

A member of the administration (leadership team) who is actively coaching shared this chart with me today. I have “sanitized” it a bit. Suffice it to say these three lines represent the percentage of deliveries of three separate (but related) processes within or before the target turn-around time of 30 minutes. Their challenge is to turn 95% of them around in 30 minutes or less.

The vertical red line represents when they started applying the Improvement Kata to this process.

Otherwise, the picture speaks for itself.

They have recognized that there is no silver bullet here. Rather, there have been dozens (or more) of changes that each save a little bit of time that is adding up.

As one of my early Japanese teachers said “To save a minute, you must find sixty ways to save a second.” and that is exactly what they are doing here. They are finding a minute here, a few seconds there, and anchoring them in changes to the way they organize the work flow.

Lab Team: “Way to go!”

## NPR: Hospitals New Face Pressure to Reduce Infection Rates

This article on NPR is chiefly about the dilemma that hospital administrators are facing as escalating government reporting requirements are being tied to their Medicare payments. (For my non-US readers, Medicare is the U.S. government medical insurance program for seniors and retirees. It pays a huge portion of hospital’s revenue, and thus, its policies carry a lot of weight).

The article’s lead does a good job of summing up the issue:

Under laws in more than two dozen states and new Medicare rules that went into effect earlier this year, hospitals are required to report infections — risking their reputations as sterile sanctuaries — or pay a penalty. That’s left hospital administrators weighing the cost of ‘fessing up against the cost of fines.

So, in effect, the administrators are faced with weighing the financial impact of lost Medicare payments vs. the financial impact of telling the truth about their infection rates. This is, in my mind, yet another symptom of the General Motors style of management that is taught by every MBA program in the world.

It also suggests that there is a viable alternative of continuing to maintain the illusion that it is not a problem.

Is it a problem? Hospital infections kill about 90,000 people a year in the USA. Compare that with the 40,000 or so that are killed in traffic accidents, and you get the idea.

Add to that the fact that the patient ends up getting billed (and usually insurance pays the bulk) for the treatment of these infections.

Fundamentally this is about quality, and the problem is certainly not limited to health care. (it is just that lives are at stake)

How does your company respond when there is a known issue that is impacting quality?

If you deliver a defective product or service, do you charge your customers for the rework? This is not a facetious question. Some companies do.

Do you avoid collecting information for fear of revealing the true magnitude of a problem?

Do your workers fear bringing it up when they are directed to carry out inappropriate actions, or actions which violate the company’s written policies and procedures?

Is it OK to improvise outside of your known process in order to get the part out the door?

Back to the hospital – we know how to tackle this problem. It is merely extremely difficult. That doesn’t make it impossible. I am glad it is getting attention. I am disappointed that it takes government generated threats of visibility to get action.

## Some Healthcare Observations

A couple of weeks ago I had the opportunity to return and see my friends in the Netherlands, and I’d like to share some observations from the Lean Thinking in Healthcare Symposium I attended over there.

But that conference was on Friday. I arrived in-country on Monday morning at 7:30am. By 10:30 am I was in sterile scrubs in an operating room observing a knee replacement operation. (I was told of this agenda while on the way there, at about 9:30.) I’ve got to say it was quite an interesting experience, and here is my public, if belated, thanks to Dr. Jacob Caron, who graciously brought me into his domain. Thanks, also, to his patient for allowing me into this bit of her life as well.

The experience was fascinating, and enlightening. Here is the core value-add of a long and complex process as the patient is moved through the various stages of treatment. And at that core, things are organized, quiet, efficient. Of course it is nothing like an O.R. on television. Drama is the last thing a real-life surgeon (or patient, for that matter) wants in the O.R.

The work flow of instruments caught my eye. We all know that the surgeon asks for the instrument he needs, and the O.R. nurse hands it to him, usually anticipating his request.

But there is a return flow as well. As the surgeon is done with an instrument, he puts it down as he asks for the next one. The O.R. nurse then quickly picks it up, wipes it (if necessary), and re-orients it so she can pick it up quickly when it is needed again.

None of this is really surprising with a little thought. I imagine the tight circle around the patient is organized pretty much the same way in every operating room in technologically advanced countries. In manufacturing, we use the “like a surgeon” analogy to describe how team members who directly add value should be supported.

Later that afternoon, I was touring the ward where the orthopedic surgery ward with the supervisor.

They are working on kaizen, they have an Problem – Improvement board and do a decent job keeping track of things that disrupt work.

“No time” seemed to come up a lot as a reason for the nurses. And, from what I know of the workload of hospital nurses, this is not a surprise either.

But where does their time go?

Let’s consider that nurses are the front line. Yes, the physicians get the attention, but aside from cases like surgery, it is the nurses who actually deliver the care to the patient. In other words, though the physicians design the care, it is the nurses who actually carry it out.

So here was my question / challenge to the audience at the conference:

No operating room in the developed world would ever tolerate a situation where the surgeon had to go look for what he needed to deliver care to the patient. The surgeon’s world is fully optimized so she can devote 100% of her attention to the patient.

Yet, in those very same hospitals, all over the world, we tolerate – every day – conditions where nurses, who are also primary care providers, spend too much of their time fighting entropy, looking for what they need, improvising, dealing with interruptions – all of the things we would never tolerate in the O.R.

Why the disparity?

## British NHS Executive Talks About Lean

Lesley Doherty, the Chief Executive at NHS Bolton in the U.K. was recently interviewed by IQPC as a precursor for her being a keynote speaker at a conference IQPC is sponsoring in December (Zurich). In the spirit of full disclosure, IQPC had invited me to participate in a “blogger’s panel discussion” (along with Karen Wilhelm, author of Lean Reflections) earlier this year in Chicago.

The Chicago conference turned out to be very Six Sigma centric – in spite of having Mike Rother as a keynote. But that is history.

I want to reflect a bit about this podcast. I invite you to listen yourself- it is an interesting perspective from a senior executive who discusses her own learning and discovery. I will warn you that you may have to “register” on the web site – though you can uncheck the “send marketing stuff” box. I will also say that the interview’s sound is pretty bad, so it is hard to hear the questions, but I was able to reconstruct most of it from context.

What is interesting, to me a least, is that the methods and experiences are pretty standard stuff – common to nearly all organization undertaking this kind of transformation.

A summary of the notes I took:

They have to deliver hard budget level savings on the order of 5% a year for the next several years. That is new to them as a government organization.

They started out with an education campaign across the organization.

Initial efforts were on increasing capacity, but those efforts didn’t result in budget savings. In one case, costs actually increased. They don’t need more capacity, they need to deliver the same with less.

They have identified process streams (value streams), and run “rapid improvement events.”

Senior people have been on benchmarking or study trips to other organizations, both within and outside of the health care arena.

They are struggling to sustain the momentum after the few months after an “event” and seeing the “standard” erode a bit – interpreting this as needing to increase accountability and saying “This is how we do things here.”

“Sustaining, getting accountability at the lowest level is the biggest challenge.”

In addition, now that they are under budget pressure, they are starting to look at how to link their improvements to the bottom line, but there isn’t a standardized way to do this.

They believe they are at a “tipping point” now.

There is more, having do to with Ms. Doherty’s personal journey and learning, and knowledge sharing across organizations who are working on the same things, but the key points I want to address are above.

Please don’t think that this interview is as cold as I have depicted it. It is about 20 minutes long, and Ms. Doherty is very open and candid about what is working and what is not. It is not a “rah-rah see what we have done?” session.

As I listened, I was intently trying to parse and pull out a few key points. I would have really liked it if these kinds of questions had been asked.

What is their overall long term vision? Other than meeting budgetary pressure and “radically reviewing” processes, and “transformation.” What is the “true north” or the guide point on the horizon you are steering for?

What is the leadership doing to set focus the improvement effort on the things that are important to the organization? What does the process have to look like to deliver the same level and quality of care at 5% lower costs? What kinds of things are, today, in the way of doing that? Which of those problems are you focused on right now? How is that going? What are you learning?

What did they try that didn’t work, and what did they learn from that experience?

When you say “local accountability” to prevent process erosion, what would that look like? What are you learning about the process when it begins to erode?

The “tipping point” is a great analogy. What behaviors are you looking for to tell you that a fundamental shift is taking place?

As you listen, see if you can parse out what NHS Bolton is actually doing.

Is their approach going to sustain, or are they about to hit the “lean plateau?”

What would the “tipping point” look like to you in this organization?

What advice would you give them, based on what you hear in this interview?

## Information Transfer Fail

While the dentist was looking over my x-rays, he saw something he would like checked out by a specialist. He used words like “sometimes they..” and “might be…” when describing the issue he saw.

I get a referral. The information on the referral slip is the name of the referring dentist (which I can’t read), no boxes checked, and “#31” in the comments.

I call the specialist and start getting technical questions about what my dentist wants them to look at / look for, etc.

So the process is to use the patient as a conduit for vaguely expressed (in layman’s terms) technical information between highly trained specialists.

Sadly, I think this happens all of the time in the health care industry. It seems that there is so much focus on optimizing the nodes that nobody really “gets” that the patient’s experience (and ultimately the outcome of the process) is defined more by the interactions and interfaces than it is by the nodes themselves.

I am really not sure how fundamentally different this is from a pilot asking a passenger to find the maintenance supervisor and tell the mechanic about a problem with a plane.

The net effect is, as I am writing this, the specialist’s office is calling the referring dentist and asking them what, exactly, they want done.. a net increase of 100% in the time involved for all parties to communicate.

While the national debate is on how we pay for all of this, we aren’t asking why it costs so much (or kills more people than automobile accidents do).