Article: 'Approach to efficiency is not well thought through'

Recently, an article ‘Approach to efficiency in healthcare is not well thought through’ (Aanpak effieicny in de zorg is ondoordacht) appeared in 'Medisch Contact' by W.H. van Harten, E.W. Hans en W.A.M. van Lent. In this article, they assess the business methods of the last years in Dutch hospitals, including lean management. They conclude that the methods are often accidentally or fashionably chosen. They also argue that there is little scientific evidence for the methods. Click here to read the whole article (in Dutch).

What I like about the article is the long-term perspective with which they look at the application of the methods. I also l and that they base this on the current problems of individual hospitals and they thus emphasize the importance of customization. Their final conclusion is:

“The variety of combinations of organizational development, type of problems and available methods requires a customized solution. Approaches that stress a culture of continuous improvement and that leave room for personal interpretation, such as lean management, seem therefore to offer currently the most perspective and besides that, they are easy to maintain. And that is very important, because introduction takes years in large organizations.”

I illustrate a few statements about the various methods:

How to mobilize an entire nursing unit

A recurring question is how you can mobilize an entire team, unit or department to work with lean. Too often, I see small groups of enthusiastic people who are wondering how to get the rest involved. One element you can use is a training for the entire unit. For the department of Orthopaedics this seemed to work well.

Recently, the department of Orthopaedics organised one evening and one day training in the Lean principles and tools for the entire care unit (60 nurses). They were very well prepared! Four months before the training day, they started to prepare and work towards it. All three departments (secretary, nursery department and outpatient clinic) got a digital camera in November to photograph improvement points or irritations (based on an idea of Neruosurgery, see previous blog), which provided more than 50 photographs of concrete waste or unsafe or unpleasant situations. These pictures have been printed on A3 size and laminated. At the training a reward was given to the person with the most striking picture. These pictures were used as starting points for improvements. Smart, because in this way you directly got 50 points of improvements provided by the people themselves on which they want to work.
 
They also made a movie for the training. They have put the process in scene from the moment that the OR calls for a patient to come for surgery until the patient is ready to leave the nursing department. This process takes 15 minutes, because the patient must change clothes, visit the toilet, medication is given and the bed prepared. The movie showed a lot of types of waste (that were actually not put in scene, but really happened). Employees recognized these immediately. A few examples:

Book: If Disney ran your hospital

I finally got around to start reading the book “If Disney ran your hospital’ by Fred Lee. I have heard a lot about it last year, and I am curious whether it can help our lean journey. Or will my predisposition be confirmed that the approach to care will be too simplistic, as if we should just entertain the patients more? Well, the first chapter did not disappoint me. Fred Lee has worked in a hospital for a long time and his mother, sister, partner, and daughter are nurses. One can feel that he is used to think from a care perspective. The most important connection with ‘lean thinking’ is in the first place his reflection on ‘value’, the core of lean thinking.

Fred reflects on the value that is of importance to gain patients’ loyalty. The elements care providers have to pay special attention to in order to accomplish this loyalty are:
- Be alert on peoples needs, before they ask for it (initiative)
- Help each other (teamwork)
- Recognize the feelings of people (empathy)
- Respect the dignity and privacy of others (courtesy)
- Explain what is happening (communication)

Intuitive this list gives me a good feeling. However, does it offer new points of application for the care we are giving at this moment?

Photo contest to bring lean thinking closer

Part of lean thinking is activating and recognizing all grey areas in your team. The ward Neurosurgery of the St. Elisabeth Hospital created a beautiful intervention for this: a photo contest to visualize improvement opportunities.

They purchased a digital camera and placed it on an easily accessible place. Everyone of the ward was invited to take a picture of something that annoys them at that time. A few weeks later this resulted into 40 (!) photos. The prize for the best photo was two cinema tickets (cinema= seeing….of waste). Here is the winning photo:

Angela Rutten, who is quality officer of the department, gives an explanation of the photo:

Flow in the hospital: Aravind Eye Hospital

One of the key principles of Lean thinking is the creation of flow. Flow as in no waiting time if it has no added value (time to think and reflect or time to process bad news are examples of waiting times with added value).

What would a hospital look like without waiting time? So far, I have only seen this question answered as a “what if…” exercise. However, there appears to be a hospital in India, which seems to know the answer to this question.

How do you start with lean?

I am frequently asked how to make a start with lean and how to determine the objectives when starting with lean. First of, lean is an improvement strategy. So there are no lean objectives. There are only team, division or hospital related objectives. The lean principles, instruments and way of thinking, can be used to accomplish these objectives. Where to start, thus depends on what you want to accomplish with a team, division or hospital. 

Are your issues for example:

• A declining number of patients?
• Enough patients, financially healthy, but we want to improve quality and service delivery, because this is our vision and/or we want to achieve stronger patient loyalty?
• The workload is too high; the work of the care providers does not provide enough fulfillment anymore?
• We see the world changing, and are worried whether we are able to change rapidly enough to keep up with these changes? We want to become more flexible and improve on a systematic basis.

Are you making a start with lean only to solve short term problems? The use of a few relevant instruments will be sufficient. Or do you desire to develop your team or organization on the long run? Do you want to work on the DNA of your organization? Your answers to these questions are relevant for how to make a start with lean.  

Toyota in trouble

Last week Toyota announced their unprecedented worldwide recall of millions of cars. What does this mean? Is this a sign that the Toyota Production System does not function well after all? Should we be more critical of lean thinking?

I think that Toyota is indeed in trouble and suffers a fundamental problem in their quality system. This can also be deducted from the statements Toyota itself makes. Aiko Toyoda, grandson of the founder of Toyota and CEO since 2009, stated recently:

"Toyota is no longer a winner"

What happened? What can we learn from this? Recently Takeshi Uchiyamada, vice-president of Toyota and responsible for research and development recently, stated that Toyota has been:

"thinking of market share first and only then of the development of products"

Earlier, in October, Aiko Toyoda went even further in an interview. He stated:

"Toyota is a step away from capitulation to irrelevance or death. The company is grasping for salvation."

Until the end of the last century Toyota was known for the extraordinary way they were able to think from the customers point of view. Somewhere in the beginning of this century this has shifted towards becoming  the biggest car manufacturer in the world. In 2008 they achieved this (they sold more cars then any other car manufacturer), but now it seems at the expense of the quality system. A conclusion could be that the principles and instruments only work if your main focus is not market share or profit. They only work if you truly think from the point of view of the customer (or in healthcare from the point of view of the patient) en really focus on quality from a long term perspective.

As noted by John Shook, it' makes sense to distinguish between the Toyota Production System (TPS) and Toyota's production system. TPS are the principles and methods that Toyota developed over the years and until recently Toyota has been world class in applying them. Toyota's production system however has declined recently because of loosing the core values that made the company special. That does not make TPS less powerful, but it does mean that we should look differently towards current Toyota for inspiration.

The statements of Toyota give confidence that the top level acknowledges the extend of the problems and that they are already working on going back to the core values. If they manage to achieve this, it will certainly be interesting to study and learn from how they become world class again.

Continuous improvement with the 'improvement chart'

When we our lean journey in the St. Elisabeth Hospital en we read about 'continuous improvement' we first thought that it implied that we will be running much more improvement projects. We have come to understand that Toyota acts very differently. At Toyota everybody works continuously on improvement. Put differently: improvement is part of your daily work. You perform your activities to create value and you think about how you can do it a little bit better tomorrow.

Which methods support this? Toyota uses many methods, but one of the most well known is the 'andon''  chords. When someone sees that a process is not performing as it should, they pull the chord. A specific music starts to play and several people come and analyze on the spot what the problem is and which countermeasures can be taken to prevent it to occur again. At the picture the arrows point at the 'andon' chords.

This is difficult to apply when treating patients. We can't just stop the care process (or maybe we can, but at this moment it is hard to imagine). That's why we embraced an instrument that has proven to perform a similar function very well in our hospital: the 'improvement chart'. The picture below shows an example of the improvement chart on the Neurosurgery ward.

The chart on the picture is in Dutch. The headings translate in to:
- Date
- Problem
- Countermeasure
- Action: who does what?
- Evaluation date

The method is:

• When someone can't perform his or her work as it should be, he or she writes it on the chart. E.g. this patient has been twice to the ED and has been treated by two different neurologists. I need to book a follow-up appointment, but I don't know with which Neurologist.
• Every day or several times a week the whole team gathers at the improvement chart for 15 minutes. People who wrote on it explain the problem. There is a check: is the problem clear?
• The team discusses the cause of the problem. Do we understand why this problem occurs?
• The team discusses possible countermeasures. What can we test to prevent this from occurring again or what can we agree so that the next time we know what action to take?
• The team decides who does what and when they will evaluate the effects of the test.

The decided actions of the former discussions are reflect on:

• Those who too actions tell the team what they did. The team evaluates the effects they have experienced and decide whether the new way of working becomes the new standard or whether further tests are needed.
• If it is the new standard, it is removed from the improvement chart and on a second chart, the 'This is how we work' chart,  the new method is written down. If relevant, it becomes a procedure ow work instruction. It is also noted on a digital chart so that later all improvement activity can be reviewed.
  
• periodically the team evaluates the improvement chart and discusses which theme's keep occurring on it. They can decide themes to improve on.
  

The underlying principles correlate with an earlier blog: 'the art of making things small'.

The first improvement chart was tested in October 2008. One year later there are over fifty improvement charts in use in our hospital, in every type of department. Almost every week a department requests support to also introduce it in their teams. Apparently it addresses a strong need and appeals to the teams.

We also learned that about a third of the teams struggle to use it well. They sometimes tend to make problems big, turn the improvement chart in a complaining chart and consequently don't see enough progress. They sometimes don't have (nor create) enough time to work on improvements. Sometimes they lack the skills to apply the method thoroughly.Sometimes also they chart is to isolated. If the team works too much on improvements that are not a priority for the department, the support diminishes.

Despite these problems, the improvement chart is very popular and clearly the most applied instrument in our lean journey untill now. It's indicative that it spreads itself by word of mouth.

The chart enables teams to draw problems into their sphere of influence. By visualizing problem and having a format handle them they become much more productive in the improvement efforts. They experinece it as an intuitive method. Improvement indeed becomes a normal part of everydays work.

Lean leadership

How do managers lead at Toyota? When we (two groups of doctors and managers from the St. Elisabeth Hospital) were trained in the Toyota Training Centre in the Netherlands it became clear that Toyota has a very different leadership style then what we are used to. For example, progress is reported with three symbols:

• A circle: progress is good
• A triangle: progress is problematic, but I'm working on it
• A cross: I don't know what to do, help!
  

At first, it felt similar to the traffic light symbols we see often in dashboards in Dutch hospitals, usually based on system measurements: green is above the norm, orange is below the norm, but within a close margin, red is too far below the norm. The three symbols of Toyota however are a personal reflection: that is how I think progress is. Furthermore, they are about 'progress', not status.

In the Dutch culture (Western culture?) I'm used to it that management wants to see as much green as possible. The more green, the better. Reporting on orange or red is something to be avoided. You try to solve your problems before you need to report them. When this does not work, the temptation is strong to influence the numbers to reach the green levels. People get a compliment for green. Conversations become difficult when there's orange and red to talk about.

Learning from problems
At Toyota the circles are pushed aside. They are not interesting. The triangles, they are interesting. How are problems dealt with? How are they analyzed? How are countermeasures searched for and how are they being tested? How does the team learn? The manager coaches on the application of the methods and principles when dealing with problems. Do they go to the source? Are tests fully evaluated?

Their approach is that someone who reports a lot of green does not stretch the boundaries, he does not learn much. The do not give compliments for green, but for the learning process at orange. But what if you are very effective and your results are simply good? If a process is stable (green), a manager at Toyota might take away either ten percent of the time that is spent on the process or ten percent of the throughput time. This will make the process unstable (orange). Then the operational manager coaches the team to stabilize the process again (green). The manager of the operational manager coaches him or her on that learning process. There lies the essence of quality thinking at Toyota. It can always be just a little bit better tomorrow.

Their philosophy is: be hard on the process en soft on the people. This works with very short cycles. Coaching happens on a weekly or even daily basis. Crosses are almost never reported before a triangle has been reported before. Upper management is already involved in solving problems when they are small. Surprises are rare.

Another difference: they coach on the shop floor. By visualizing their processes, the problems and the countermeasures as they occur (for example with colors and improvement boards) they directly see the triangles in the processes. That enables them to coach from a deep understanding of the situation en conclusions can be applied directly.

To enforce the methods and principles of lean thinking, we will also need to address the way we lead and the way we develop leadership in healthcare.

Can you relate to this?

The art of making things small

There are different ways to improve processes. 'The art of making things small' refers to the choice to reach your goals in small steps. This relates to principle 14 of the Toyota Way: "Become a learning organization through relentless reflection (hansei) and continuous improvement (kaizen)". Why would you want to make things small? Because a pitfall of projects is that we discuss for weeks or even months before anything changes. The  risks with this approach are:

• The longer it takes for the first change to take shape, the more people who experience the problem loose faith that it will be resolved. The support for any change crumbles.
• Many of those who perform the work in the process where the problem occurs are not involved in the thinking process. This means that you need good communication (which is often problematic) and often the much feared 'resistance to change' starts to take shape.
• The solutions are developed separate from the work floor, separate from the (physical) place where the problem occurs. That means there's a real risk that the solution will not exactly fit the complexity of the situation where it's supposed to work.
• Perhaps the solution will be piloted, but by now those who are in favor of the solution have argued for weeks or months to promote it and they now have to prove that it works.They have connected their personal reputation to the solution and will not like to see that it fails. Those who are not in favor of the solution hope that it will not work, they might even influence the results of the test to make it not work. Will this be a good test?

Recognizable? I have seen this happen over and over again. The art of making things small is a method that approaches it very differently. It is based on the teachings of Roger Resar on Reliability. The essence is simple: reduce changes to a size that you can literally test tomorrow. A team can use the next steps do achieve this:

1. Define the process where change is needed.
   For example: it takes too long before general practitioners receive the letters form the specialist about the results of patients.
2. Describe the process in four or five steps.
   For example: appointment - dictate letter - write letter - send letter.
3. Define where a problem occurs. If necessary: describe this step in four or fives steps.
   For example: time between appointment and dictating takes too long.
4. Define a change that you can test tomorrow. Choose the most easy circumstances for the test.
   For example: one specialist will dictate one letter for one patient right after the last appointment on the less busiest day of the week.
5. Evaluate whether the test worked. Just yes or no. Evaluate why it did or did not work. Define the next test.
6. Keep on testing the idea or new ideas until a good countermeasure has proven itself in practice. Make this the standard new way of working.

To solve the complete problem of the total throughput time, the time between the appointment and dictating is probably only part of the problem. There are likely to be multiple causes. The idea is that more then one test run simultaneously. If a team is experienced, four tests can run at the same time, each test lasting one day or week.


Except addressing the risks as described above, there are other reasons to apply this method:

• By making changes smaller, they are pulled into the sphere of influence of the team. They can achieve more changes themselves.
• There will be more learning. Learning by doing is more effective.
• Decisions are more based on facts, more based on experience. Opinions and emotion become less influential. 
• Changing becomes more fun, because the people that undergo the change decide and evaluate the change themselves. There is more ownership, more pride.
• Less time is spent on meetings.

This method is based on the 'plan-do-check-act' cycle of Deming or perhaps more accurately from Shewart. Reread the six steps above to recognize them.

There are also pitfalls with applying the art of making things small:

• Not enough analysis why there is a problem
  Suggestion: you do need an understanding of the cause of the problem. Often this is clear enough and you can start testing directly. But sometimes you do need further analysis to assure that you are not addressing aspects that are not relevant to the problem. 
• Not enough coordination of the tests. The team goes testing changes without keeping track of the effect on the problem that needs to be solved.
  Suggestion: keep going through the complete cycle (see above). Not only for each test, but for the complete problem. Someone is responsible for the coordination (the owner of the problem).
• Reluctance to start testing because the person that does the test is not convinced it will work as the new method of working.
  In the example the specialist might not want to test dictating directly after the session for one patient, because she expects it might work for one patient per session for one test, but not for all patients every day.
  Suggestion: test anyway! Doing a test is no obligation to keep doing it, also not if it works. You can only judge whether the idea is feasible after the test. Then you can decide based on facts instead of imagination. More importantly, doing the test can lead to a better idea that is feasible.

Achieve great things by making them small!