Health care: Too much on the plate?

Earlier this month, Shingo Prize-winning author and Master of Business Operational Excellence instructor Beau Keyte wrote a fascinating article on the Huffington Post titled “The Silent Killer of Health Care Transformation: Being Overburdened by Too Many Choices.” This addresses a key concept in lean called “muri,” or overburdening.

Keyte defines overburden a phenomenon where equipment or people are pushed to run at a harder pace and with more effort than is appropriate.  Using the analogy of going to a Brazilian steakhouse faced with multiple choices, with an eager waiter waiting for a signal from you to bring more varieties of meat, Keyte makes the point of how health-care organizations are laden with a vast range of priorities. As a customer at the steakhouse you can choose what you want to have on your plate but leaders in health-care organizations do not have the choice. Multiple stakeholders, internal and external bombard the leadership with ideas that are important to them with a very restricted timeline. The executives take on the burden of execution of these great ideas to the employees in the organization that are already overburdened with a previous task list.

Similar to the customer in the steakhouse who leaves half-eaten good food on the plate to try the new kind of meat, the employees leave projects halfway to bite on the new initiatives. Due to lack of time and resources, the new initiatives do not get the kind of attention they need and this nips the possibility of transformation in the bud. How do you address this problem? Keyte emphasizes that it is the leaders in the organization who can LEAD the organization on a path that reduces the burden – but how?

The first thing is to focus on the real stakeholder, the patient. Think about how the initiatives suggested by the other stakeholders impact the patient. Would the initiative result in the right outcome for the right patient at the right time? Do the initiatives align with the strategic goals? Do you have the human resources to work on these initiatives? Do you need to do all the initiatives? What are the few things that you NEED to get done to meet the three to five most critical goals this year? Could you drop or delay some? By answering these questions, leaders can dedicate the available resources to only the critical projects. This way, employees can spend their time wisely while providing patient-centered care.

The second thing the leaders can do is to think long term instead of saying yes to all the projects and trying to instantly gratify the stakeholders.  However, it is important to think forward and pick three to five strategic initiatives to work on in future and plan on carving out capacity to take these on.

Keyte puts it well in the last paragraph: “Like all silent killers, overburden sneaks up on you and your organization. Learn to sense it, see it, analyze it, and deal with it to help your organization not only survive, but thrive.”

The waiting game: Dispatches from urgent care

After spending years as a practicing physician and later working with others to improve processes in health-care delivery, it’s still refreshing to spend some time on the other side of the exam table.

urgent careI recently lacerated my toe when a blender jar fell from the counter top and, bleeding profusely, went with my partner to a nearby urgent care, my toe tightly wrapped in a bandage. We entered a large waiting room with 20 chairs and only one other patient only to spend 10 minutes waiting for a medical technician to enter my information into a computer. This is after I spent five minutes completing the form on paper. This made me very, very pessimistic about how long I might have to wait to see a physician. The television playing a History Channel documentary showing bridges falling and the destruction of surrounding areas didn’t help.

The registration process triggered my lean thinking: Many hospitals are spending a lot of money installing kiosks for self-registering patients. The idea is great but the cost ultimately isn’t justified. Filling out the forms, I thought of how efficient it would be if the registrar had turned her own computer screen to me and asked me to enter the information directly on the computer. With a quick confirmation of some key information, that would save 10 minutes. Small change, big benefit.

Patient intake is only one challenge, though. Patient variation is an entirely different issue.

While in the waiting room, I saw a female patient in her late 60s arrive with her daughter. At least another 15 minutes passed as the new arrivals scrambled to find an insurance card and driver’s license and another patient in the waiting room was called back. Eventually, we were called back to sit in an exam room, where my mind was still lingering, thinking about the fate of the older patient and her daughter.

What transpired in the waiting room over a half-hour is nothing but patient variation: I was signed in within 15 minutes, while another lady waited for more than 30. So how do you apply lean/six sigma to the business of health care with so much variation? The answer: With empathy! Some experts in the field tend to downplay the very existence of patient variation, which only evokes defensiveness from health-care professionals who treat patients day in and day out. Ultimately, it’s important to examine data on the number of times events deviate from the normal and develop an improvement plan that incorporates that variation.

On our way to the exam room, my partner asked if I’ll need an X-ray. The answer: “I can take your X-ray if you want.” I was shocked. When I practiced medicine, patients weren’t entertained this way. I’d always have a reason for any labs or X-rays. In turn, I responded that I didn’t want an x-ray unless there was a reason for one. She shrugged her shoulders and said: “If you don’t want the X-ray, we won’t do it. It’s up to you.”

Once in the exam room, my vitals were taken and I asked to unwrap my bandage but was told “Not yet.” It’s essential to take vitals, but I was getting desperate for the provider to open my bandage, examine the wound and treat me.

We waited some more. I flipped through a WebMD magazine labeled “complementary waiting room copy.” This made me realize how much we’ve built waiting into providing care.

A half-hour later, my toe was finally examined but I waited another five minutes for the doctor, who went directly to the wound and got down to the suturing business. He explained what he was going to do, but didn’t say whether I should continue to sit or lie down. Four painful stitches later, he took off his gloves and left the room with the instruction to take painkillers on and off and change the bandage every day. But I realized that he hadn’t put any bandage on my toe. After waiting for about 10 minutes, my partner went out to get someone to bandage my toe. Five minutes later, someone arrived, put on a fresh pair of gloves and dressed my wound.

The doctor came after 15 minutes and handed me a two-page document, asking me to come back in a week to 10 days to get the stitches removed.

There are a multitude of problems here. The doctor didn’t put a bandage on my wound, but he had gloves on and it only would have taken a few more minutes. He preferred to leave me without a bandage and type out a two-page document, which, frankly, I still haven’t read. A physician’s assistant in scrubs had to waste a pair of gloves to do the dressing. Here, we’re providing more assistants and nurses so doctors can focus on clinical work – but a patient really doesn’t really care how or how much a physician writes notes. A hospital doesn’t benefit from wasting supplies, and a doctor isn’t doing clinical work when he or she is documenting.

The solution here is to help physicians by slashing the amount of documentation and keeping only value-added information. When I practiced, I used to take the vitals and history. I sutured and dressed the wound myself. There were almost no handoffs. I also documented with the patient sitting with me in my clinic. I could finish a regular visit in fewer than 15 minutes.

We’re asking providers to document a bit too much. And even though we are providing them additional resources to “save” them time, that savings isn’t benefitting who it truly should: Patients. This is never more apparent than when you’re the one on the exam table.

MBOE recap: What’s your sigma level?

For most of us, the sigma level – or defects per million opportunities – for New Year’s resolutions would be abysmal. We have 365 opportunities in a year to implement what we resolve to stick to and in reality, how many do we take advantage of? Whether it is skipping that dessert or going out for a run or practicing that hobby, rarely do we stick to our plan – but we keep complaining and hoping that we will achieve that goal. New Year’s resolutions are hard to keep.

MBOE faculty member Peg Pennington works with MBOE students on the SigmaBrew simulation

Thankfully, our Master of Business Operational Excellence students had an easier task at hand during the Six Sigma Week of the year-long degree program. In the four days they worked on improving the sigma level for a coffee company called Sigma Brew, a simulation created by Sigma Brew is fraught with many issues: Long lead time and wrong orders, to name a couple. Until now the students have been reading and learning the online MoreSteam modules on the Six Sigma body of knowledge. This week they had the opportunity to apply the theory to a simulated real business problem with the usual constraints of cost and resources.

Students first were challenged to define the problem correctly. Tons of data were provided but their job was to pull only those data that made sense to the business and helped them make meaningful decisions. This is not very different from what happens in companies. The true problem is hidden well below myriad symptoms. Data are available but they may not be relevant. It is only after defining a problem one can start to think about what data would make sense.

Data provide the baseline for the current performance of the company. Measuring the correct metrics guides you to not only make right decisions but also show you the impact of the solutions/countermeasures that you implement.

If the problem is not analyzed correctly, the countermeasures will only address the symptoms and the problem will continue. A cause map helps you drill down the root causes of the problem. Statistical tools such as hypothesis testing, regression analysis, ANOVA and others help you understand the degree of impact different root causes can have on the outcome you are measuring.

Improvement occurs when you implement the countermeasures in a systematic manner. It is important to track the metrics to confirm improvement. If there is not impact or the metrics are going in the opposite direction, it becomes important to start from the very beginning to identify the root causes and experiment until you are able to improve.

Improvements last only so long, especially if there are no controls in place to check the progress of the project. Control charts and standard work for leaders can take organizations a long way. There must be a system in place that helps visualize not only the progress but also any roadblocks that come up in way of progress. It is the job of all involved to solve and/or to escalate matter at the right levels to resolve the issues.

Students went through the DMAIC phase to address the issues that Sigma Brew was facing. Each group positively impacted process and the sigma levels went from a one to six up to eight!

MBOE recap: How confident are you?

One of the greatest challenges organizations face is choosing among multiple alternatives for improving a product or service. Our Master of Business Operational Excellence students last week got a crash course in a great decision-making tool.


Holly Stein, director of operational excellence at Cardinal Health, introduced our students to the “design of experiments” concept, which helps organizations facing options where each alternative by itself or in combination with others could have a positive or negative impact on the business goal. Students in this exercise were tasked with creating paper helicopters with different characteristics: Some short, some long, some with wide wings and some with narrow wings. Their goal was to create a helicopter that, if dropped from a height of 6 feet, would fall exactly or very close to a target on the floor. Using design of experiments, teams created models that met the business criteria.

Design of experiments is very commonly used in product development and in clinical trials, but the health-care and service industries don’t use it on a day-to-day basis. The goal of the helicopter exercise was to help students see the applicability of the concept and trigger any ideas for how they can use it in their organizations.

But how did students make the final decision on which model worked best? Stein also introduced the concept of statistical analysis, which businesses use to help them make meaningful decisions. An option at a 95 percent confidence level, for example, means you are willing to take the risk of 5 percent that the decision could be wrong.

“How nice it would be if you knew that 95 percent of the time you’re right about the decisions you make every day!” Stein told the students.

Analyzing data is key in driving decision-making, but continuous improvement is all about designing small experiments and observing the impact on the business problem.

The invisible made visible

A common complaint from those resistant to lean thinking is that it can’t be applied to processes that aren’t visible, particularly office processes where most decisions are made with e-mail and phone calls. The InBox Simulation our Master of Business Operational Excellence students recently ran with the help of Peg Pennington, Gary Butler and yours truly disproves it.

The simulation uses’s SigmaBrew case study, which looks at a large (and fictional) specialty coffee retailer struggling with quality and customer service issues amid an increasingly competitive commercial market. Senior management identifies the unacceptably long cycle time required to open new stores as one of the major issues to be addressed in a Kaizen event.

Each MBOE student had a role to play in the process involved in opening a new store, from market and site research workers to lawyers, landlords, government officials and more. The catch: The communication occurs mostly through e-mail. After the first simulation, students realized they needed a lot more information than they were working with. They also needed to know they were working with to get the work done efficiently. This is how a lot of processes exist in reality. People know only their jobs. They do not know what is being done with the information they generate and how it impacts the whole process.

In one full day, students created an A3 to describe the problem, a value stream map to highlight the problems, and a future state map to design a new and efficient process. The students had the ability to run as many simulations as possible to try their improvements. Each group came up with improved processes that were very different and yet very promising.

Our students return in June to begin the second half of the MBOE program year…

‘You are a virus!’

When our Master of Business Operational Excellence health-care students spent some with Kathryn Correia, chief of Minnesota’s HealthEast Care System, she brought up a great point about the things that slow us down. Most of the interruptions that impede the flow of care, she said, aren’t surprises. If a machine breaks down, we know that somewhere we missed out on the preventive maintenance. If patients, providers or staffs are waiting for too long, we know that we have not really designed our processes to meet the demand. Defects occur because we have long been fixing symptoms but not the root causes.

This was one interesting insight in a busy week for the students, who heard from a number of instructors.

art byrne
Lean expert Art Byrne, speaking to our MBOE cohort.

Bill Boyd, director plan development at Wisconsin’s ThedaCare, spent some time with students explaining how the company has adopted the value stream approach to enhance the patient experience and quality and efficiency of care. He emphasized how important it is to stop working in silos and come together as a team to address the care needs of patients.

Post-lunch, the health-care and industry cohorts spent three hours with Gary Butler and yours truly in an emergency department simulation. They applied their learnings in understanding the wastes in the process and improving the efficiency and quality of care the patients received. The simulation is designed to help understand how lean principles apply to a non-manufacturing process.

The day came to an end with a visit from Art Byrne, an expert in lean strategy, and Tom Mooney, manager of Lean Transformations at Goodyear. Byrne has been implementing lean from the position of a President, CEO or Chairman of the organizations he worked with since the last 20 years. He shared his perspective on the role the leaders have to play to successfully implement lean and sustain the gains. He left the students with a thought his sensei Chihiro Nakao once said to him: “Byrne San, if you don’t try something, no knowledge will visit you.” Lean is all about trying out ideas. If you don’t try, how will you know about the process you are improving?

Mooney gave a different twist to the challenges of a lean practitioner. He said to the students, “You are a virus!” He emphasized that the change agents always get resistance from almost everyone. The resistors are like the antibodies who are trying to dissuade and destroy the change agents. He urged the students to keep going, coach others and multiply the lean knowledge rapidly to bring change in the organization.

MBOE recap: Lean in the grocery aisle

Some processes in our daily lives we easily take for granted – grocery shopping, for example. Our Master of Business Operational Excellence students in a recent visit to the Dublin, Ohio, Giant Eagle location saw firsthand that the grocery business is serious business.

Giant Eagle
Giant Eagle has adjusted its inventory strategy to allow for a closer link between back-room supply and customer demand.

Pittsburgh-based Giant Eagle, a member of the Center for Operational Excellence, has implemented lean principles in its stores to improve cost, efficiency, and customer experience. They call this system the Giant Eagle Business System, or GEBS. The MBOE program is designed to provide students all possible perspectives and experiences for a holistic learning experience, thus we brought them to Giant Eagle to give them yet another example of how a non-manufacturing process has successfully adopted lean principles to its advantage. So what did Giant Eagle implement and what were their gains? Well, first of all, the chain looked at the eight wastes in its processes. They differentiated what is value-added and non-value-added from the customer standpoint. Then they attacked the wastes.

Giant Eagle also addressed the variation in how inventory is stocked and developed a standardized process for that. They looked at the amount of inventory they carry in their back room. Giant Eagle used to operate as a wholesaler who just so happened to sell groceries.  Being wholesalers, their tendency was to buy as much in bulk, so warehouses and back rooms were filled with too many products. To pick the right item, material handlers would need to move or lift a lot of products before they could get down to the one they needed to stock the shelf.

To become lean, Giant Eagle looked closely at the demand, and started ordering only how much was being used. They were also able to convince some of their suppliers to change their packaging to allow only enough quantities of products that can fit their shelves. They increased the frequency of deliveries from their warehouse and, as a result, drastically reduced how much inventory they hold in stores. One glance at the back room and it’s evident that inventory is minimal.

The students got a preview of how lean can be applied in a grocery store to ensure that customers can easily see and get the products they need as they walk around in the aisles.

MBOE recap: Lean in the back office

Last week, we hosted our industry and health-care MBOE cohorts on campus, bringing together dozens of professionals in a range of different fields. The principles and leadership skills we teach in each program carry many similarities, but there remain some key differences between health care and the rest of the pack. Shingo prize-winning author Jean Cunningham highlighted one of those when she visited our health-care cohort last week.

jean cunningham consulting lean accounting
Jean Cunningham (courtesy

Health care might be the only industry, Cunningham said, where you put a charge on a bill but only end up collecting a partial amount. That amount is based on the contracts and agreements organizations make with public and private insurance companies. Cunningham, author of the book Real Numbers, said traditional cost accounting systems are designed for all the resources to be used fully all the time. You create capability to create demand, and gather all resources such as people, materials and equipment and then produce what the customer needs. Taiichi Ohno, father of the Toyota Production System, once said that costs don’t exist to be calculated – they exist to be reduced. Lean accounting, Cunningham’s area of expertise, helps do exactly that by identifying and eliminating non-value add waste in the accounting process and helping managers understand the numbers to make meaningful decisions.

When organizations bring in lean, the first place they apply it is the “shop floor,” where patient care is actually provided. As the changes are being implemented, Cunningham said, it’s important to indicate them on financial statements. How do you do that? Well, the most important thing to do is to get the financial folks to plunge into operations and lean activities. Make them a part of the improvement teams so they can understand the changes that are being implemented and how they impact the financials. Lean accounting is about applying lean tools to streamline accounting and finance processes and also accounting for lean transformations.

Explaining lean accounting isn’t possible in the space of a single blog, but the key takeaway here is knowing that people outside of accounting need fewer, and easier-to-understand transactions. When they make transformations the key is to provide information that takes the right calculations into accounting and reflect gains and losses.

Interested to hear more about lean accounting from Cunningham? Click here

A vandalized car and some leadership lessons

Our car was vandalized. We don’t know when it happened but we found it a couple of days ago. It was a shocking sight. The glass on the driver’s side of the window was broken and the shards were all over the seat and below. The center part of the dashboard was ripped apart and insides of the dashboard were hanging below. We do not know who did it and why they did it but the fact is that we felt violated. No one has the right to even touch let alone destroy what belongs to us.

Anyway, we called 911. Our first surprise was that 911 does not deal with vehicle break-ins. They gave us the number to call the Columbus police department. Surprise number two: The police department is closed on weekends! There was an option on the voice recording to stay on the line if there is a need to dispatch a police officer. We stayed on line. After a really weird ringtone, a lady spoke. We explained her what happened. Our biggest surprise followed. She said this is an unsolvable problem. It could be anybody who could have done this. It is impossible to investigate such cases. So go ahead and file that report. We asked her what happens after filing the report. Her response was, “Well, you inform your insurance company and they take it from there.” Bewildered, we asked, “So are you saying that the police will do nothing about this? No investigation at all?” Very condescendingly, she replied, “Ma’am, all I am saying is that you file the report. It is really a small problem.” First let me just tell you I hate it especially when they ‘Ma’am’ me. The word is respectful but you don’t feel any respect because the tone of their voice is degrading and anything but respectful. But think about how scary such a response is coming from someone we rely on for safety, security and assurance!

You are probably wondering, where exactly I am going with this? Well this goes back to leadership and how we respond to our associates when we implement changes. We go out to the gemba, teach people how to look for problems and encourage them to solve the problem. How do we actually respond when they do bring up the problem? The associates are in a vulnerable state of mind. Firstly, they fear losing their job. Secondly, they are afraid to bring up problems because until now they have survived because they hid the problems or fixed on their own. Guess what? It is not easy to handle change. Now what if they bring up a problem that has been there for a while and is “unsolvable” like above? The issue is too sensitive or political? What do you tell your associates? That you really cannot do anything about it? Do you tell them to focus only on a certain kind of problems? Or do you listen to them, go observe the process and understand the difficulties they are actually experiencing while doing their job? Do you or associates gather the data (observations, measurements, taking pictures or shoot a video of the process), asking other associates if they are experiencing similar difficulties and bring it to the attention of the senior leaders? You may get a no for an answer from the leaders but do you at least try? Do you ensure that your associates feel safe to discuss problems? Do you assure them that you will take actions and actually do it? Are you consistent with your words and action that they feel secured about their jobs?

There are lots of tools and methods of process improvement. You can open the tool-box and implement any tool when you want. However you cannot rely on the tool box to exert leadership. As a leader, you have to be out there. You encourage, listen, observe and empower under all circumstances unlike the above incident where they shrug off the responsibility labeling it as an intractable problem.

Share with me your experiences as you are implementing changes in your organization. What is your approach? What are your challenges and ‘aha’ moments that made you grow as a leader?

What you see is what you get

Walk into most any company, and the only signage you’ll see is the name of a department and the names of the people who work there. At the Master of Business Operational Excellence program, we teach our students that visuals can be used for much more, indicating the purpose for the existence of a department or a function within a company.

Drew Locher, Shingo Prize-winning author, recently shared with our MBOE students a quote while making a case for visual management. This comes from György Kepes, founder of the Center for Advanced Visual Studies at MIT:

“The visual language is capable of disseminating knowledge more effectively than almost any other vehicle of communication.  Visual Communication is universal and international; it knows no limits of tongue, vocabulary, or grammar.  Visual language can convey facts and ideas in a wider and deeper range than almost any other means of communication.”

Companies generally work in functional silos. Within the functional silos, many times people don’t know what their colleagues are working on and what the expectations are. People within the department know of their roles mostly from the job responsibilities they had read from the job posting and any projects that are thrown at them by the supervisor. The information lies within the heads of people.

How does visual management help? Locher says it helps once you understand the key elements of visual management:

  • What is the purpose or function of the area?
  • What activities are performed in the area?
  • How do people know what to do?
  • How do they know how to do it?
  • How do they know how they are doing?
  • What is done if expectations are not being met?
  • Last but not the least: How will we drive Continuous Improvement via visual management?

Organizations that care about operational excellence must care about these questions and think about simple and visual ways of conveying this information. Visual management aids in better use of the employee talent, builds in accountability, and leads to the right action when the visuals indicate so.

The idea is not to have just the visuals but a process to manage what you see in the visuals.

On their most recent visit to campus, our MBOE students also mastered the elusive solution to solve the Rubik’s cube puzzle. Executive-in-Residence and MBOE faculty member R. Gary Butler found an innovative way to help students learn the principles of standardized work and training within industry and apply it to the process of solving the puzzle.

Students were asked to first find the solution. They then created critical steps necessary to solve the puzzle and developed a simple process to train anyone who may have/have not solved the Rubik’s cube puzzle in the past. The group that developed the best method won a prize.