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?

Toyota Under Fire

Toyota Under FireSo many of us were wringing our hands a year ago. Our idealized vision of Toyota as the source of all perfection and example was tarnished and crumbling before our eyes. Prominent “names” in our field were talking about the need to go beyond Toyota. The vaunted TPS was clearly failing.

Or was it?

Like everyone else, I could only speculate based on a mix of the (mis) information emerging from regular press reports, the opinions of some insiders, and the insights I could glean from contacts with direct access into the company.

When McGraw-Hill offered an early copy of the book for review, I eagerly accepted because I, too, wanted to know the whole story. (<— smooth, seamless disclosure for the benefit of the FTC)

What really happened?

That is the question that Jeff Liker (with Timothy Ogden) set out to answer in the book Toyota Under Fire.

Losing Money

When I hear the term “Toyota under fire” I think of the “sudden uncontrolled acceleration” debacle from late 2009 through the spring and summer of 2010.

Perhaps that is because I didn’t consider that reporting three quarters of losses was the kind of adversity I would consider “under fire.” At least not for Toyota.

In retrospect, I probably glossed over that period because I felt I could predict Toyota’s response to the great recession and the economic problems it caused them – they would double down on what they have always done, and strive to do it even better than they had in the past.

They would first work to get the problem contained – and return to profitability without compromising their core values.

Then they would work to eliminate the root cause(s) of the problem by reducing their break even point.

The result would be the emergence of an even more formidable competitor that is capable of weathering an identical recession without incurring these losses.

And, according to Liker and Ogden, that is exactly what happened.

In the first half of the book, they tell the story of how Toyota responded to the recession in a rich detail that captures how this amazing corporate culture functions when it is under financial pressure it has not experienced since 1950.

What we see is the entire company mobilizing and carrying out its kata pretty much as described by Mike Rother in his book.

But there is also more. We see that this was only possible because the company had worked hard in the good times to be prepared for this kind of adversity, even as it was unthinkable. This enabled Toyota to do things that only Toyota could do.

No matter what other companies may say about their values around team members and suppliers, there are few that could (or would) continue to make payroll, support key suppliers, and continue to invest in R&D while reporting losses and facing a 30% drop in their top line, even if they wanted to.

And we see another side of the story – how an incredibly ignorant, uninformed and uncurious press force-fit the things they saw into their own management paradigms – turning a show of strength in the face of adversity into a negative story. It turns out this is a precursor for what was to follow.

Losing Faith

In August 2009, just as the financial crisis was coming under control, a tragedy set a series of events into motion that would test the company to its very core.

…Mark Saylor and his wife, daughter and brother-in-law were killed when their Lexus, on loan from a dealer who was servicing the family’s own vehicle, careened out of control at more than 100 mph, collided with another vehicle, and crashed into a ravine, setting the car ablaze.

Liker and Ogden offer a comprehensive account of the events that unfolded over the next year while this story spun out of control as the press, politicians, attorneys all fed on – and added to – the public’s fears about the safety of their automobiles.

The story is both fascinating and frustrating as Toyota’s technically oriented culture is focused on facts and data while it is confounded and overwhelmed by a political and litigation culture that focuses on sensationalizing rumors and innuendo.

Toyota learns a hard lesson – that reputation has less to do with the truth than about perception, and decades of work can be destroyed in weeks in the political-legal-press feeding frenzy.

In the end, though, the Toyota Way emerges. Just as they did in the recession, they accept responsibility for the things that affect them, regain focus on their customer’s needs – technical as well as emotional – and double down on what Toyota does best. This time, though, they learn to do that in a different context – the global / cultural one.

A great story in the classic mold of the protagonist emerging stronger from adversity while confronting his personal shortcomings.

Overall

I strongly recommend this book for anyone who wants to be able to articulate the story of how Toyota persevered through the most trying time in their history since they emerged as a global company. This was a transformative time for the company, possibly as significant as the losses and strike in the late 1940’s that set the path for the future.

That being said, there are two areas where I think Toyota Under Fire could have done better conveying this story.

The first is context. And context begins with background.

In the decades prior to all of this unfolding, Toyota had done little (in my opinion) to alter the public’s view of them as a “foreign” company even though they directly employed tens of thousands of people in the U.S. and sourced many millions of dollars of parts from U.S. companies. I believe they failed to put a human face on the American side of the company. They allowed the product to speak for them. In effect, they allowed their competitors to control a large part of Toyota’s cultural positioning.

Hal-9000Next is the aspect of technology. Liker and Ogden address the gap between engineering reliability of the electronic controls and the public’s emotional confidence in them.

However I am not sure they convey the cultural gap between that emotional confidence (or lack of it) in the USA vs. what would be felt in Japan or even Europe. Simply put, Americans are less trusting of technology in their cars. I am not certain the engineers in Japan fully grasped this gap. If they did, I am not certain they didn’t dismiss it.

With all of that as background, while the Saylor’s accident would have been tragic at any time, late August 2009 could not have been a worse moment for Toyota.

The accident was a scant two months after General Motors’ controlled immolation into government-owned bankruptcy, and the company was still breaking up. Chrysler was sold off to Fiat. Ford’s stock was selling for under $5.

And the day before the Saylor accident, Toyota had announced that the NUMMI joint venture was being closed after GM had pulled out.

With Toyota relatively healthy (compared to everyone else), still perceived as a “foreign” company, and seen by many as “responsible” for the demise of GM, they were operating in a public and political atmosphere that was fuel and oxygen rich. The Saylor accident was a spark.

Had Toyota grasped how precarious their political and cultural standing was, they might have acted much more aggressively and much sooner when this story started to unfold.

The fall of 2009 and spring of 2010 was slow for domestic U.S. news, so there was nothing to push the Toyota story out of the news cycle.

While Liker and Ogden correctly and accurately relate how Toyota managed to finally “get ahead of the story,” the precipitous drop in negative press reports about Toyota occurs in August 2010 – as the drama of the trapped miners in Chile begins to unfold.

I mention this context because it is not only important for the reader, but equally important for Toyota. They learned a hard lesson about the U.S. news cycle, especially how a story can get legs under it. This had to be tough for a company used to dealing in a world of verifiable facts and data.

To a company who values, above all, being in control of their own destiny, they had allowed much of the background to be written by others.

This story was as much about Toyota’s total lack of an emotional connection into the overall U.S. culture as it was about their cars and engineering. And while Liker and Ogden talk extensively about Toyota’s aggressive countermeasures to establish better connections to customer’s perceptions, I would like to have read about how Toyota addressed (or didn’t) this cultural positioning as well.

The only other quibble I have is I believe the book could have been a little more tightly edited. I am giving this a pass, though, because the final technical report from NASA came out in March 2011, and this book landed on my porch a scant couple of weeks later – the ink was still wet. So from that standpoint, I recognize the last minute frenzy of writing and editing that had to be done to include the latest relevant information.

In the end – buy the book but recognize it is still a bit insular – much as Toyota can be. That is perhaps something they still need to address.

Breaking News

Two stories of interest as I am writing this.

Toyota Wins Key Unintended Acceleration Case

(April 1) After deliberating for approximately 45 minutes, a jury reached a defense verdict in favor of Toyota Motor Sales, U.S.A., Inc. in an alleged unintended acceleration case brought by Dr. Amir Sitafalwalla, who claimed that an unsecured driver’s side floor mat was the primary cause of the crash of his Scion vehicle in August 2005.

During the course of the week-long trial, Dr. Sitafalwalla’s primary expert, Dr. Anthony Storace, withdrew his assertion that the Electronic Throttle Control System in the Scion could also have been a cause of the accident based on his acknowledgment that he had no basis to support that claim.

Of note is that the news reporting of this story is buried.

This story, however, was on the news tonight (April 4):

Toyota: N. American plant closures likely in April

By BRUCE SCHREINER, Associated Press – Mon Apr 4, 4:56 pm ET

LOUISVILLE, Ky. – Toyota Motor Corp. said Monday that it’s inevitable that the company will be forced to temporarily shut down all of its North American factories because of parts shortages due to the earthquake that hit Japan.

The temporary shutdowns are likely to take place later this month, affecting 25,000 workers, but no layoffs are expected, spokesman Mike Goss said. Just how long the shutdowns last or whether all 13 of Toyota’s factories will be affected at the same is unknown and depends on when parts production can restart in Japan, he said.

So far the North American plants have been using parts in their inventory or relying on those that were shipped before the earthquake, Goss noted. But those supplies are running low.

“We’re going to get to a point this month where that gap in the pipeline starts to show up. So we’ll have to suspend production for a while,” he said.

While interesting, this story buries the lead into the middle of the second paragraph: “… affecting 25,000 workers, but no layoffs are expected.”

This statement is ambiguous, but if it means “we are going to keep paying everyone and working on improving the work while the plant is shut down” that is the story here. Otherwise, this sounds like a routine shutdown-and-furlough-the-workers story.

What makes it more interesting is that Toyota’s press release site refutes the story altogether:

Toyota Statement Regarding Status of North American Production

NEW YORK, NY (April 4, 2011; Posted at 3:15 PM EDT) Contrary to recent headlines, nothing has changed from our update from March 23rd regarding our North American operations.

We continue to assess our supply base in Japan following the earthquake/tsunami. We have communicated to team members, associates and dealers here that some production interruptions in North America are likely. It’s too early to predict location or duration.

Currently, the greatest majority of parts for our North America-built vehicles come from approximately 500 suppliers in North America. Also, we continue to receive parts from Japan that were already in the pipeline, limiting the immediate impact. We will continue to work closely with suppliers in North America and Japan to minimize any disruptions to Toyota’s overall North American operations.

The reason I bring up this little chain of news stories is that it reinforces my notion that Toyota is still playing “business as usual” in how they manage the news cycle. In this case, no harm, but my questions for them are:

  • What is your target condition for public perception of these stories?
  • What is the current public perception?
  • If there is a gap, what is keeping it from being closed?
  • What is your plan to address that issue?
  • When can we see what you have learned from the first step?
because every process is subject to kaizen.

Why before What

In this TED video, Simon Sinek summarizes a key thing that differentiates an idea that catches on vs. one that plops.

This is relevant to us at a couple of levels.

First, as Sinek points out, truly great companies succeed because they stand for something higher. They have a “why” that drives what they do and how they do it.

Companies that cannot articulate what they stand for are at a competitive disadvantage vs. those who can.

But these concepts are also critical to those of us who are trying to sell the concept of changing the way our own organizations run. Watch the video – then continue below.

In spite of what is taught in the business schools, business decisions are rarely made based on financial analysis and rates of return. Those things are carefully constructed, but often after the fact to justify what someone wants to do already (i.e. has already decided to do).

When we try to sell our changes, we often try to address the “what’s in it for me?” but still continue to try to make logical “what” type arguments.

That doesn’t work. It has to feel right.

Think about your own organization. When or where do things feel like they are going really well, what is aligning? What values are being realized? How do those moments differ from times or places where things are not going so well?

What makes people say “OH Yeah!” ?

As you try to make the case for “lean” or continuous improvement in your organization, are you crystal clear what you believe in? Can you articulate it? Do others in the company want to believe in the same things?

The Report-Out

The classic one-week kaizen event ends with a report-out by the team that outlines the improvements they have made, and the results they have achieved.

Actual results, though, are notorious for falling short of what was reported. Action items are left over, and things frequently peter out unless there is a huge effort to force sustainment.

Let’s look at this a little differently.

Typically what happens during the kaizen week is that a new process is designed, and some things are put into place to enable it – point of use, rearranging things for flow, etc.

The report out is describing expected results, and how the process must operate to deliver them.

In other words, a very common outcome of a kaizen event is a pretty well thought out target condition. This is how we want the process to operate, this is the result we are going to strive to achieve. It is all future tense.

What happens next will make or break things.

The next question that should be asked is “Great! When are you going to try it, and what do you expect to learn?” If the report-out does not directly address this question, then you can expect the typical result – steady erosion.

In fact, the process of seeing and addressing those problems must be embedded into the daily management process itself.

The report-out is the beginning of kaizen, not the end. The next phase is not “follow-up.” It is a natural continuation, if less intense, of the kaizen process. The report-out is describing an engineering prototype. Now it is time to test it and discover what we didn’t know during the design process.

 

Lean Facilitators are Countermeasures

What is the role of your lean facilitator?

This question comes up now and again, was recently posed on the LEI forums by someone looking for help with a job description.

I extrapolated from his question that he was looking to the job description as a line of defense against dilution of the facilitator’s focus and effort by projects that might not be going in the appropriate direction.

In effect, this is putting the lean facilitator in the role of a weakened zampolit with the role of educating the “correct view” and challenging decisions that run counter to it. Except that more often he has to sell the “correct view” rather than impose it.

The fact that the question is being asked at all indicates that the organization has not really thought through what their operational vision is. How will the company work, what are the responsibilities and roles of the leaders?

What are the leaders’ job descriptions in this new world?

Those job descriptions become a target condition for each of them.

What is the gap?

If there are gaps in skills and knowledge, then we need countermeasures.

At this point, the role and responsibility of a lean facilitator might begin to emerge as one of those countermeasures. Don’t have the expertise? Import it.

What doesn’t work, though, is to use the lean facilitator to substitute for the leader’s full and direct participation in the process of improvement. And no job description, no matter how carefully crafted, can fix that.

Notes on A White Board

WHAT STOPPED THE WORK TODAY?

Identify each step (details!)

For each step ask:

Why is this necessary? What is its purpose? —-> Eliminate unnecessary, wasteful details.

Can this detail be done outside of the critical flow? —-> re-sequence. Prior to the start, everything ready to go.

Clearly define who must do what and when.

  • Content
  • Sequence
  • Timing
  • Outcome

How will we continuously verify actual work vs. the plan?

Ask “What stopped the work?”

  • Why must the team member leave the work area?
  • What slows him down?

(Back to start)

ART: Capturing the Flow in Photographs

I wouldn’t normally post something like this, except for the subject matter: the Toyota assembly line in Valenciennes, France. Stéphane Couturier is a photographer who tries to capture urban and industrial scenes as organic living forms.

Others have found strong metaphors between the Toyota Production System and the organization of natural processes, but these photographs are, well, just cool (to me at least). See the others at this link: http://www.prixpictet.com/2010/view/995

Série "Melting Point" - Usine Toyota n°15 - Valenciennes
2005 - 
C-Print - 160 x 212 cm + marges - 5ex.
C-print - 75,5 x 100 cm + marges - 8 ex.

The artist’s statement seems to have suffered a bit in translation, but the last phrase sums up a Toyota plant:

In front of the Toyota factory assembly line, that is say confronted by a veritable metaphor of movement that is perpetual and implacable as is today’s technological world, rationalized, disembodied, automated and more and more subject to the silent and ruthless profit logic, Stéphane Couturier knows that reality is no longer made up of isolated things, of fixed geometrical shapes, but that it has become a reality of flux, in continuous movement and transformation.

Cool pics, I just wanted to share them.

The Benefits of Continuous Improvement

There are a lot of variations on a theme where someone asks an Internet forum how to quantify or justify the benefits of implementing a continuous improvement program.

If you think about it, though, this is really interesting question.

What are the benefits of NOT having continuous improvement? Why would managers deliberately decide not to have a learning organization, not to have continuous improvement, not to fully engage the intelligence of their workers?

Why would managers deliberately decide not to improve safety, quality, delivery, lead times?

What if we asked the question that way?

What is the benefit of not having these things?

If that question is subsequently dismissed as stupid (which I hope it would be), then the question is no longer whether they should be pursued, but how.

Release the Constraints of Reality

One of the more effective facilitation tools I have come across is to have a team first construct an ideal flow, without the constraints of the space geometry, known flow-busters, or even too much concern about the takt time.

Just make things flow as smoothly and efficiently as you can envision. Develop the flow as though a single person were performing the entire process from start to finish. Make it as smooth as possible for this person. No back tracking, no awkward motions. Everything is where it needs to be, when it needs to be there.

This allows the team to let go of all of the “reasons why not” for a while, and see the possibilities.

Then, one by one, re-introduce the constraints of reality.

How can we make it work when we introduce this problem? Does the process still meet the target objective?

Approaching it this way helps teams that are so embedded in the stormy ocean of day-to-day problems that they can’t see things possibly working smoothly.

It also reinforces the notion that we want to see things, not as “what can we improve from the baseline” but rather “how far are we from the target?”

In slightly modified form, this approach worked pretty well this week. Slightly modified? I, too, sometimes have to bend things around how the world presents itself to me.

One, Zero and Zero

Sometimes we like to talk in abstracts. “Reduce batch sizes” or “reduce lead time.”

But let’s be clear what we are striving for. With every improvement we make, we want to converge on the idea of:

  • Batch size of one.
  • Lead time of zero.
  • Zero waste of resources.

Lest anyone thinks that is impossible, consider the post before this one about 3D printing technology, and look where it is going.

As Mike Rother emphasizes in his teaching the trend throughout the history of making things has been in this direction.

The pendulum swung in favor of volume in the industrial revolution as production shifted from craft (batch size of one, long lead times, high costs) toward large batches, in order to achieve better economics.

Somewhere along the way, we lost sight of the fact that we gave something up for those lower costs.

The companies that can return the benefits of one-off production while holding the costs are going to win.

But.. make no mistake… the suppliers of cheap mass molded and cast parts have a disruptive technology headed their way that fits the model perfectly.