Please visit my (translated) Dutch blog

This weblog used to get frequent translations from my Dutch blog. It is however not updated anymore because Google Translate does a pretty good job at it. I still blog weekly in Dutch on http://leandenkenindezorg.blogspot.com/ and you can use this link to have it translated into English.

What is leadership?

Inspired by Stephen Parry

Resolution

Learning to see

Nurses: what is the meaning of lean for you?

To prepare for a training, the Elisabeth Nursing Surgery Ward (B2) posed all nurses the following question:

What is the meaning of lean for you?

This offers the opportunity to get an idea of how lean thinking is experienced by nurses. Before interpreting their answers, it is good to know that they have had a basic introduction of lean thinking one year ago, and especially started to employ 5S for Workplace Organization with enthusiasm. Furthermore they have put the Lean principles impressively into practice during the development of care pathways. However it was not explicitly communicated to the nurses that they were applying lean (and that explains why you don't see that in their answers).

Their answers to the question per nurse:

Book: Toyota Kata

I started reading the book Toyota Kata by Mike Rother and I read the first three chapters so far. He argues that the world has only looked at the visible aspects of Toyota, the processes, methods and principles. He stated that you should not look at those aspects, because the real explanation what makes Toyota so special is invisible. He refers to way of thinking and the routines that are normal at Toyota: the Kata’s. This is a Japanese term, normally used in martial arts for patterns that are repeated again and again into perfection. The book describes two Kata’s at Toyota:

• The Improvement Kata
• The Coaching Kata

If you get past his slightly arrogant introduction that he finally figured the real secret out, he offers a number of rich insights. He explains quite well how organizations keep repeating the same mistake when they want to change something: they fall in the blind implementation mode. The consequence is that they try to make the change process as predictable as possible. We find it hard to accept the fact that organizational development is an inherently unpredictable process.

It is the art to release the urge to want to control what changes at what moment (I recognize that this can be difficult). It is the art to continuously adjust the direction based on new insights. In an implementation mode, there are unpredictable events and problems that distract you from your goal. But those unexpected events are always there. How many time is spend on making plans and how much time is spend on explaining why they are not implemented as planned?

A wise strategy would accept the inherent unpredictability of development processes and would seek strength in the adaptive capacity of the organization. You need some method that provides the needed confidence that good progress will be made. And that method is often lacking as one falls back into the implementation mode.

He states it is exactly the ‘Improvement Kata’ and ‘Coaching Kata’ that enable Toyota to adapt adequately. Rother described how Toyota makes improvement very specific in three conditions:

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!

The tendency to erect a wall around lean

Recently I reflected with two teams on their progress with applying the lean principles. Both teams stated that the past months nothing had happened.

Nothing?

We discussed that they did not have time due to illnesses in the team and different other reasons why they were so buried under work that they did not have the opportunity. Then someone asked whether a period like that doesn't create a pressure to make changes to keep everything running. Sure, was the answer. And to the question how they had managed that they gave a range of examples how they had made improvements that reduced the time needed for activities, so that they could perform the work with less people. Different scheduling of nurses, different scheduling of patients, other task division, stop unneeded activities.

Nothing?

If that's not working on lean, what is?

They soon concluded that they did apply the principles. Why did they at first answer that they had done nothing? It became clear that they work 'on lean' when it explicitly carries that label. They apply lean when:

• a change is introduced by the 'lean team' that regularly meets and thinks of new things
• a change is decided on a workshop or so that carries the name lean in the title
• or when it is directly connected to one of the instruments of lean

Changes that are made that reduce waste, increase value, improve flow etc., but without explicitly being labeled lean were, until now, not considered lean.

Ah, now I understand 'nothing'!

Why do we erect a wall around lean? Why do we create boundaries to say when activities are part of lean and when not? In this way lean can only have a very limited effect. We do not systematic lean from experiences that are relevant, but not labeled as lean. We do not acknowledge good progress that's made. We do not integrate the principles with other activities. We get less close to the hearts of people, because lean stays something foreign, that needs a label to work on. Every team has reduced waste or improved their working conditions etc. If we recognize those improvements as good examples of lean thinking, we can integrate the principles with daily practice. We can integrate it in the DNA of the team. So, we lack so far in this ability?

I consider lean thinking as a set of principles, a coherent way of thinking and seeing that can be inspiring. Lean asks questions why you do things as you do. Lean gives examples from other organizations that give food for thought, not least examples from Toyota. Lean challenges you to reach higher. lean thinking also describes instruments that have proved themselves, but that is secondary. But apparantly that's not how we communicate it?

In my view, embracing lean thinking means that you systematically elevate your efforts to reach higher levels of performance. Lean thinking means per definition that you apply the way of thinking onto everything where it can be relevant, even in your private life. If you think according to the principles, you cannot not-apply them.

Do you recognize the tendency to erect a wall around lean? What causes this tendency? What is the root cause of 'nothing'?

What is your first association with lean?

Often I ask people what their first association is with lean. I invite you to answer that question for yourself. What is your first association with lean?

................. .............

The answers I get usually are synonyms  for 'reducing waste' or 'improving efficiency'. That was also my first association when I started to dive into lean. By now I regret it. My first association is now 'value'. I'd state that if you don't take 'value' as the starting point of lean, your efforts sooner or later will work against you. A personal anecdote:

As a physiotherapist, my mother often treated people at their homes. When I came out of school, I often went with her. One day, we visited a woman that was not able anymore to move her fingers well. My mother asked her what she would like to do again with her hands. She said shet would love to play bridge again with her friends. My mother asked whether she had a deck of cards in the house en I got them. Then my mother invented exercises with the cards.

Care providers connect to a person asking a personal question. They try to understand what is of value for this person. It does not make much sense to reduce waste if this process is not well understood. It can be useful to consider two types of value:

1. The reason why someone asks a question to a care provider. What's happening to me? What should I do? Why? Activities that help answer those type of questions add value, for example a consultation, diagnostic research and an operation.
2. That what is important for a patient during the process. Comforting a restless patient, touching a confused patient, giving attention during vulnerable moments. These are not activities that help answer the questions that the patient came for to the hospital, but at that moment they are of value.

If we reduce waste without first understanding value we start of the wrong side. The risk is real that reducing waste will become a goal in itself. Perhaps the biggest risk of introducing lean is becoming anorexic. Few people working in healthcare have a passion for reducing waste. They want to be of meaning to other people. From that motivation, they are willing to improve processes and to reduce waste so that they can spend more time on valuable activities. But in that order.

I'd state that the effects of lean should not be measured by how much waste is reduced, but how much more or better value is created.

What was your first association with lean? How does that relate to value? I invite you to share your association!

Lean thinking and compassionate care

Recently O&I published an interview (in Dutch) with Jacob Caron, Orthopedic Surgeon and chairman of the medical staff of the St. Elisabeth Hospital in Tilburg in the Netherlands. Jacob talks about the relation between 'lean thinking' and 'compassionate care'. A reflection on several quotes using the 14 principles of The Toyota Way.

"...it's typical of 'lean thinking''  not to think from big, future plans, but to initiate change process from problems and issues in the current processes. By staying close to the existing processes, changes are kept small."

Principle 5: Build a culture of stopping to fix problems, to get quality right the first time

Fixing problems directly can only be done by the people that encounter the problems. That implies that every team member considers improving a normal part of every days' work. By keeping lean thinking small you bring it into the zone of influence of teams.

"... this approach creates a deep learning process that leads to sustainable change, because the change process does not limit itself to fighting fires, but is aimed at adressing the root causes"

Principle 14: Become a learning organization through relentless reflection and continuous improvement

Relentless reflection is confronting. Our (health care) culture tends not to show that you have a problem. To learn deeply, people need to be able to make themselves vulnerable so that root causes can be addressed and more fundamental change processes can take place. Trust is a basic condition. To create a culture of trust is very demanding of leadership.

"...it's important to anchor the 'lean thinking' philosophy in a long term vision on excellent care. This vision must include the core values of the hospital and gives direction to the process of continuous improvement that 'lean thinking' initiates. The St. Elisabeth Hospital chooses as a core value: 'compassionate care'.

Principle 1: Base your management decisions on a long-term philosophy, even at the expense of short-term financial goals

The long term philosophy will need to be so well connected to what the hospital stands for and what the environment needs that it will also provide direction in difficult times. In good times buffers need to be created that enable to hold on to the principles in the more difficult times.

It might seem contradictory that the earlier quote he stated that lean thinking does not start from a big future plan, and here he states that a long term philosophy is important. The difference is that, for me, a future plan is not value drive, but control driven. It's oriented at what is not. A long term philosophy is based on values and that provides direction to take decision in the here and now. It's oriented on what is. A future plan takes away initiative from most and gives it to a few. A long term philosophy can and increase initiative.

"Administration and leaders must stay connected to the primary processes and let that feed the vision."

Principle 12: Go and see for yourself to thoroughly understand the situation

Going to the source to base decisions on observations and experience from the work floor. This is extra difficult in health care, because many actions literally take place behind closed doors and because many steps are not taking place right after another (and many should not be). That makes it the more important to do effort to go to the source in health care. For example by attending daily or weekly (short) gatherings of teams that reflect on the day or week.

"In summary, 'lean thinking' creates space for compassionate care if the change process is anchored in a long term philosophy on excellent care. Compassionate care is part of the core value that is being optimized with 'lean health care'."

Principle 1: Base your management decisions on a long-term philosophy, even at the expense of short-term financial goals

"You need to understand your patient, what he wants and expects. Try then, each time again, to meet that expectation perfectly."

Principle 14: Become a learning organization through relentless reflection and continuous improvement

By connecting the first and the last principle it becomes full circle: relentless reflection on the way value is created, related to the changing expectations and values of patients, feeds the continuous, steadily improvements to deliver better value.

How does 'pull' work in a hospital?

The 'pull' principle is probably the most important logistical innovation of Toyota. Because it uses a different way of thinking it already requires some effort to understand the principle in a factory. But how can you apply it in a hospital?

How does 'pull' work in a factory of Toyota?
The traditional way to manufacture is in stock. Production is based on demand forecasts, or sometimes just as much as possible, then we'll try to sell it. Because there are many different versions of a product (e.g. different colors and options for a car) a lot of supply is needed to prevent that you can't produce enough of each version of your poduct. This is part of the reason why so much money is tied up in the stock in factories. This is also one of the reasons that led Henry Ford to his classical quote: 'You can order any color T-Ford, as long as it is black'. The less versions of your product, the less stock you need to produce it.

In the nineteen fifties Toyota understood that the future lies in more variations of cars. At the same time Toyota was in deep financial problems and spend a lot of money on their stock. For both reasons they wanted their production processes to become flexible, so that customers can get their preference fast, with minimal stock. Inspired by American supermarkets where the shelves were filled with the same quantaties that were just 'pulled' out by the customers, Taiichi Ohno translated that 'pull' principle to the Toyota factory. An example how that works:

Imagine you make door handles. Pete next to you puts the handles in the doors. Between you and Pete is a table with three drawings of door handles. When you finish one, you put it on the drawing. Pete takes them from the table. Now imagine that Pete is falling behind because the doors don't reach him anymore. He can't install your handles. Soon the three drawings are filled with three handles. You can't produce any handles anymore, because you can't put them anywhere. You stand still untill Pete starts again to take one away (or better yet, you help the team that builds the doors). Thát is the essence of 'pull': the step after you gives you a signal that you can do your part. Because the whole factory works like this, there are no stocks. The system simply makes this impossible. Also, not one car leaves the factory that is not ordered by a customer. Because 'pull' starts with the order of a customer.

It took Toyota fifteen years before the deceptively simple 'pull' principle was applied in one complete factory. Now, 35 years later, all car manufacturers and many other companies try to work according the 'pull' principle. Between delivery of the 20.000 different parts from many suppliers and the assembly of each part in one Toyota now is on average four (!) hours. They manage this with their 'pull' system. 

How does 'pull' work in a hospital?
A hospital can't produce in stock (let's put twenty CT scans in stock?), so the problem of large supplies is unknown to hospitals. Is the 'pull' principle relevant in a hospital?

We don't have any stock, but we do have a lot of waiting in between steps in care processes. The throughput time from first contact until diagnosis often takes weeks if not months. Despite that the addition of the time spend on each step often is less then a day or only several days. From the perspective of a patient our care processes are a stop-and-go experience. The cause lies in the 'push' way of organizing the characterizes hospital flow.

Essentially 'pull' is:

respond to demand

When care is 'pull' organized the demand determines where care providers spend their time on. In hospitals we currently determine where time is spent on long before care is demanded (= 'push' logistics). Some examples of 'push' logistics:

The number of sessions in an outpatient clinic depends on the availability of specialists and perhaps of supporting staff. It is not based on current demand.

Sessions are programmed with fixed appointments, for example six new patients and twelve follow-up appointments. These programms are not based on actual demand, but on the preferences of the care deliverers. The numbers of each type of appointment will not respond to actual demand in a given week, resulting in unnecessary waiting times.

Supporting staff of outpatient clinics are scheduled two months in advance, when the number of sessions is not yet definite. Often sessions will be canceled or added afterwards. It will be difficult to reschedule the staff (and they will not like it). This results in overstaffing and shortage of staff. Also, the canceling of sessions is not based on less demand, but absence of care providers.

The number of OR (operating theaters) for a specialism per week is determined every year with a fixed planning for each week (on Mondays General Surgery has three OR's, Orthopedics two etc.). This is done before any patient is known. Why? In the words of professor Frits van Merode: the division of OR capacity is not a planning instrument, but a 'peace treaty'.

These are all symptoms of 'push' logistics: demand has to comply to our scheduling of capacity, instead that we respond to demand (by the way, that's why my phd research is about the 'reactive capacity of hospitals').

What would 'pull' logistics look like in a hospital? An example:

If in January more patient request an appointment for a Gynecologist, he or she takes more time to see patients and gets more staff support for the extra sessions. Later he or she performs more operations for these patients and gets more OR capacity to do so.

OR capacity is not divided anymore per specialism, but on actual demand. OR capacity is given to individual patients.

This requires a large flexibility from the system. It also requires trust from the care providers in the system 'I'll receive OR capacity for my patients when they need it'.

How can you recognize the consequences of a 'push' system?

General practitioners call to arrange priority for their patients ('push')

This lab result needs priority ('push')

The surgeon needs to call the radiologist to make sure his patient gets a MRI slot sooner ('push')

Or more in general:

'I push todays demand to tomorrow, because today I'm full" ('push')

Instead of:

'I do todays work today' ('pull', as proposed by general practitioner Mark Murray in his 'Adanced Access' concept)

Push and pull in a hospital
 I don't believe that a hospital can be organized completely 'pull'. There are two major reasons why 'push' is for some part inevitable:

1. Uncertainty what the value stream will be. When I order a car the factory knows exactly the specifications before the car is assembled and all steps required to build it. In care processes next steps are often determined during the process (for example: only after diagnosis treatment can be determined). Better yet, often steps change during the process because of complications or because a patient changes his or her mind.
2. Natural variability in care processes. Installing a door handle can be repeated each time in the same time. The same operation will take more time with this patient then the other because one body is not the same as the other.

Because of both factors a hospital cannot create complete work load leveling ('heijunka'). To organize care processes completely 'pull' unacceptable levels of overcapacity are needed. That's why a mix of 'push' and 'pull' will be required. However, it is evident that a lot more 'pull' is needed. For the benefit of patient flow, but also for the benefit of care providers. 'Push' systems lead to strong tensions (who gets how much capacity? Why do my patients need to wait for your department?). 'Push' systems tend to stimulate people to look after their own interest, even at the cost of the common interest.

'Pull' is not better then 'push'. They are two logistical principles that both can be useful, depending on the situation. The interest is to create 'flow': no unnecessary waiting. And that every care provider can spend as much time as possible on providing care (instead of pushing patients through the system or to claim as much capacity as possible). The interest is to have patients experience care as one, fluent process.

How to start?
A good starting point is the planning processes and policies (e.g. scheduling staff, scheduling sessions, programming sessions, OR capacity planning etc.). Use these questions:

• do we base our decisions on actual demand, or on internal (non-demand related) criteria?
• which information do we use concerning actual demand? If there is none: how can we get it?
• does this policy change increase or decrease the flexibility to respond to actual demand?

Finally, we should improve the flow of care processes in respons to the problems that are experienced on the work floor ('pull').