Lets go hi-tech

A few years ago, I was working with nurses, pharmacists and physicians to understand the chemotherapy administration process at a cancer center. They all had a common problem: Too many screens Way too many. As I observed a nurse as she was walking me through the process of activating a chemo treatment, I noticed she went through 19 screens as she toggled through the multiple systems to access all the information she needed to do her work.

In the lean world, this is described as “overprocessing” waste.

Electronic Medical Record
Electronic medical record screenshot courtesy ophmanagement.com

I’ve been a part of a number of IT system implementations where organizations hold out hope that it will solve all the problems they face. Many hospitals, for example, implement new or upgrade old electronic medical record systems to reduce errors and speed up the documentation process. There’s logic here: With electronic records there’s easy access, no file cabinets, no scribbled notes, one centralized hub for information and a much weaker chance it will get lost or delayed. Clearly there are many advantages.

The problem here is the blind reliance on IT systems to solve the complexities of organizational processes. An IT system isn’t going to help if your chemo activation process requires 19 steps because it won’t solve a problem that arises from a complex process. First, we must simplify the processes and base our IT systems on that, not vice-versa.

A prime example: Toyota was among the early adopters of hybrid electric engines and other state-of-the-art technology, but the automaker thoroughly tests anything to make sure it’s reliable and serves its people and processes. If systems aren’t tested they could lead to additional work flow issues. As Dr. Jeff Liker writes in his book The Toyota Way, management should conduct pilot tests to determine if new technology is suitable for the organizations business (or clinical) processes, operations systems or products. Management, Liker writes, also should reject or modify any technology that might cause disruptions or unreliability.

Many organizations, unfortunately, don’t follow that advice.

What kind of issues do you come across using IT systems at your place of work? How do you address them? What would you do differently?

Kind of a big deal

We’re pretty proud of the successes we’ve seen in just three years running Fisher’s Master of Business Operational Excellence program. And the same can be said of the industry heavy-hitters we line up to give students top-notch wisdom in lean leadership. Among those big deals is John Shook, the CEO of the Lean Enterprise Institute in the Boston area. Modest and easy-going as Shook is, he wouldn’t tell you that, but having him spend a day with our students is like taking a film-school course on westerns with Clint Eastwood as the prof.

Shook was kind enough to sit down with me after a full day of breaking down A3s with the MBOE cohort for a wide-ranging chat on the future of lean and some of his personal experiences (read the full interview). If you don’t know much about him, he spent time in Japan at Toyota Motor Corp. about 30 years ago and, quite simply, is one of the reasons lean is alive and well in the U.S. today.

John Shook Lean Enterprise Institute Fisher MBOE
Photo by Peg Pennington

While our chat was full of insight, one thing Shook said near the end has stuck with me since, and it’s about why companies make mistakes in a lean transformation, and more specifically in using A3s to solve problems. “All lean tools and processes,” he told me, “are like an iceberg. There’s more underneath them that embody different ways of thinking and going about work, and if we just copy the tools it’s possible for us to miss that and be implementing the tool for the tool’s sake.” Shook then referenced an old saying about hammers in search of nails.

He’s not talking about carpentry here. This is the heart of the matter when it comes to lean, the idea that we shouldn’t just be putting out fires (hammering nails) but digging deep behind them to discover what caused that spark. Switching metaphors here: A layer beneath the tip of that iceberg is the crucial root cause.

So what does digging for that root cause, maybe with the help of an A3, do for your company? Shook says it best:

“It helps us solve problems and create a problem-solving culture all at the same time so it can help us choose the right hammer.”

What’s in a name?

In a recent session for Fisher’s Master of Business Operational Excellence class, we had the pleasure of hearing James Hereford, COO of the Palo Alto Medical foundation. While discussing lean deployment in the health-care sector, he touched on using Japanese terms for the tools and methodologies of the Toyota Production System. It’s Hereford’s preference to use the original terms. His succinct defense:

“When you go to a Japanese restaurant, do you order sushi or do you say something like, ‘Please get me raw fish rolled in a leaf and rice?’”

Photo by Mrinalini Gadkari

What is in a name, really? If we’re doing what the words mean, does it matter if they’re Japanese or English? For many words in lean there isn’t even an exact translation. The closest translation of a simple word like gemba, for example, would be “actual place where the value is created” (Google it for many others).

So is it necessary to expend energy inventing words that convey the meaning instead of using the original words, especially if the tools and methods will be used regardless? Many people tell me, however, that in process improvement they get better buy-in when not using Japanese terms. Whatever works!

Have you had to deal with a divide in using Japanese terms with lean?


Now I’m a Believer

Unlike my blog-posting colleague, I’m a relative newbie at lean, having spent my years out of college in the newspaper business and only recently making the jump to Fisher’s Center for Operational Excellence. I’ve pored over the Lean Enterprise Institute’s Lean Lexicon, scratched my head at A3s and learned very well how to nod politely at jargon as I scribble down mental notes for later. No amount of memorization, however, has taught me more about the transformative power of a lean approach than my first simulation.

Only weeks into my employment at COE, I joined a small group of my colleagues and employees from member companies for the three-part, day-long effort, hosted by Institute for Lean Systems Executive Director David Veech. My table’s task: To cobble together the hull and carry out final assembly of a Star Wars-inspired Lego aircraft with enough small pieces to strike fear into a playground full of toddlers’ parents.

lego naboo starfighter
An example of the final product in the lean simulation.

With a stack of directions, the first round seemed simple enough, mimicking a batch production system still used by many companies. But when game time came, the results were an unmitigated disaster, wasted pieces and frustrated “factory workers” everywhere. The second round, a simulation of a company partway through a lean transformation, wasn’t much better as purchase orders piled up and attempts at “milk runs” for Lego pieces floundered.

Round three, a simulation of a fully lean enterprise, was catharsis defined. Tasked with picking up a carefully chosen selection of Lego parts for the final product, I flew around the room and handed off deliveries with a smile. Completed Star Wars fighters began piling up and the collective morale – as grim as a Netflix boardroom at times – skyrocketed. Literally and figuratively, the pieces were locking into place. And the jargon made sense.

Only after the dust cleared did I realize it was necessary to feel the intense frustration of a wasteful production system before I could appreciate the logic of lean. The problem in many industries today, however, is that operations don’t realize they’re in round one because the status quo is so ingrained. Even once the “Aha!” moment comes, much work remains to be done, and change – even for the better – isn’t easy.

It’s the job of those of who have experienced round three to communicate its value. I’ll certainly never look at Legos the same way again.

Lean Principles: Are they really applicable to me?

Because lean principles have their roots in automobile manufacturing, people in the service industry are prone to bristle at the thought that their organization could benefit from them. Health care is a prime example and its workers sing a common refrain:

My patients aren’t cars. They are human beings.

I agree, but there’s a hidden distinction that’s key here. Health-care workers with this complaint mean to imply that humans not only are different but superior (though who hasn’t had a car more reliable than some people?). If that’s the case, patients must be given even better treatment than cars. A health-care setting, where potentially deadly errors lurk around every corner, should have:

  1. Safe customers
  2. Safe employees
  3. Reduced defects
  4. Standardized processes

The Catch

These are all pillars of lean thinking, embodied in the Toyota Production System. That process aims to create safe processes for employees and workers, turn out well-tested cars and produce them with as few defects as possible to reduce the potential for recalls. Their processes are standard and led by cross-trained employees in a way that someone from a different factory can step in and work without any problem. How is this anything but a win-win for health care?

We want our nurses, doctors and staff safe. We want our patients to be treated right and on the road to recovery. And we want them out the door for good when they’re discharged as readmissions are costly to the hospital and the patient’s quality of life. Strategies vary patient to patient but the core processes are the same, from check-in to admission to follow-ups. Yet every department has a different way of doing things and doctors even within the same discipline follow different processes. This results in staff and customer dissatisfaction and increased chances of errors, which lead to an unsafe environment for everyone.

The core process seems so simple, but we’ve managed to complicate it because we don’t understand the process and its defects – but some organizations are working to change that. Thedacare Health System, Seattle Childrens, Cleveland Clinic, Akron Childrens, GroupHealth and others have successfully experimented and implemented lean principles, proving they’re not just for cars. And these organizations are reaping the benefits.

What are some of the concerns that hold back service organizations from implementing lean? What are some ideas that could help them see differently?

Understanding the Problem

Picture this:  You’re a leader in an organization, perusing financial and safety reports compiled by managers tasked to boost sales, cut costs, and grow safety and quality. In one report, you see exactly the opposite happening. So what do you do?

You call that manager, have him or her explain why this is happening and he or she insists: “There’s nothing to worry about. That has happened before, it was taken care of and this time it won’t be any different.” You hand out targets and a deadline and ask to stay updated. Case closed.

A great lean leader takes a different path early on in this process. The manager is called in, but the first priority is understanding every messy detail of the problem and making sure he or she does as well. Per the Merriam-Webster dictionary, a problem is “a question raised for inquiry, consideration, or solution.” The word “solution” isn’t last by accident.

While many of us are equipped to be “firefighters” and immediately jump to solutions, that’s tantamount to giving fever-suppressing paracetamol to a hospital patient. The symptom is resolved but the underlying cause is just waiting to come back.

First, we must recognize the type of problem at hand.

Author John Shook in his book Managing to Learn defines two types of problems:

Shook Problem Types
John Shook's Problem Types

It is important to understand that the presenting problem e.g. increase costs, a safety hazard, decreasing sales in some way relates to the way work is designed or being done.

What is the Right Thing to Do?

When I moved to the United States from India nine years ago, an important early addition to my vocabulary was the word “silo.” In agriculture, it’s a structure used for the bulk storage of grains. Outside that trade, though, it’s used widely to describe the compartmentalization that forms inside organizations.

Ohio Silo
Ohio Silo by Mrinalina Gadkari

When I saw a silo for the first time upon moving to Ohio six months ago, I snapped a photo, a reminder to myself and my students of how difficult it would be for departments and units with that mentality to communicate with each other.

This happens in many organizations. Everyone follows protocol in their own department, happy they’re meeting targets set by management. The notion of how one’s job is affecting workers in another department rarely surfaces, nor does a worker’s idea of how his or her job is affecting the overall service, product or customer base. “Us” and “them” sentiments are predominant, as is the phrase, “I followed protocol. It’s not my problem.” But it is. The silo problem is a reality in most organizations in all industries.

So how do you deal with it?

Start by asking a simple question: “What is the right thing to do?” With those seven words, barriers break, people step up and take responsibility and what is “not my problem” becomes everyone’s problem.

As author John Shook writes in his book Managing to Learn, switching from a so-called authority based debate (Who is at fault?) to a responsibility focused conversation (What is the right thing to do?) has a radical impact on decision-making. Consensus forms and decisions are made by focusing on indisputable facts, not projecting blame.

How have you worked to break silos in your organization?