Make your mark with Fisher’s MBOE program

A friend of mine who’s a cardiothoracic surgeon at a renowned hospital in India emailed me with a problem. Here’s what he wrote: “The people at my hospital are motivated, hardworking and some are brilliant, too. But the processes are abysmal. It takes three days to discharge a patient after I actually decide to; an admission entails eight signatures across four buildings; and my wait list is 24 days to surgery after admission.”

Operation room hospital electrical wires
Systems in organizations – such as the wiring behind the scenes of an operating room pictured here – often are more complex than they need to be.

Digging into these problems and helping organizations eliminate “wastes” in their processes to improve efficiency happens to be what I do for work. A subsequent chat reminded me of how process inefficiency is pervasive globally in all occupations. If you’re looking to make lasting change in your organization, we have a one-of-a-kind program at the Fisher College of Business to get you there.

It’s called the Master of Business Operational Excellence, or MBOE, program, and it helps organizations address these inefficiencies and achieve operational excellence. Working with an industrial cohort and a health-care cohort, we are addressing the major challenge of working professionals of not having enough time outside of work to attend school. Some basics:

  • It’s a one-year degree program accredited by the Association to Advance Collegiate Schools of Business.
  • Students come on campus only eight times through the year, or every five to six weeks. When they are on campus, they spend four full days that week from Wednesday to Saturday.
  • Students work on a major capstone project, creating a positive impact on the organization where they work.
  • Each student’s supervisor is a “sponsor” who commits to support the student throughout the year and help remove any obstacles.
  • A coach, hand-picked by us and equipped with extensive experience, works with the student throughout the year

In short, it’s possible to get a master’s degree from THE Ohio State University and tackle a major work project all in one year!

Time’s ticking. Apply now.

‘Adversity is a part of life’

The arc of Gail Marsh’s personal and professional life is part success story and part cautionary tale – and she’d acknowledge that as much as anyone.

Gail was gracious enough to share that story as part of a regular series of women’s leadership breakfasts the Center for Operational Excellence hosts, sparking a discussion with nearly two-dozen women from our member companies and students at the Fisher College of Business (check out more photos here). The strategy chief for the gargantuan operation that is the Wexner Medical Center at Ohio State University, Gail also is actively involved in community efforts around town. Those garnered her the honor of being named one of six Women of Achievement by the YWCA of Columbus last year.

Gail Marsh Wexner Medical Center
Gail Marsh shared her story and offered insights at a COE women's leadership forum.

If that isn’t enough, she’s a mother to three children she raises with her husband, Dr. Clay Marsh, an OSU professor and vice dean for research in Health Sciences and the College of Medicine.

Listening to Gail speak last week, I was impressed with how her story contains not only great wisdom for women but for anyone who works hard for what he or she earns and takes a step back, wondering how to balance it all. An undergraduate and master’s degree-earner from OSU, Gail was the proud owner of post-graduate student loans as she worked her way up in the male-dominated world of health-care administration, found love and started a family. It was the loss her mother that prompted her to realize she was moving too fast, life was too short and she needed to hit the reset button. With that, she began to create a work-life balance she says she’s still working to perfect, even though it has the flexibility she needs.

Not that her flexible schedule came on a silver platter.

“You have to be stellar at what you do for people to give you flexibility,” she said. “Everybody is balancing things.”

Some other wisdom Gail imparted at our event:

On taking the plunge into community service: “If you wait until all your work is done, your laundry’s done and all your kids have straight As you’ll never do it.”

On the secret to her own life: “Understanding that adversity is a part of life is the secret to my life now. It’s just going to be that way.”

On career mobility: “I like to think my promotions in the medical center have been because I know how to solve problems.”

Check out more from Gail in a video tied to her Women of Achievement honor.

Trust me, I’m a doctor

How do you define a good doctor? Is it one known to have never made mistakes or one who made them, learned from them and got better?

This came to mind as I was watching a video where Dr. Brian Goldman, an emergency room physician in Toronto and host of CBC Radio’s White Coat, Black Art, discusses the shame and embarrassment doctors feel when they make mistakes. They can’t share this with colleagues because it makes them uncomfortable and they can’t share it with patients over fear of getting axed or sued.

In the video, Goldman says a baseball player with a 400 batting average is a legend, but if you applied that 4-in-10 success rate to a surgeon, what would they be called? There are no statistics to denote a good surgeon or doctor.

While a problem-free health-care experience is an ideal for all of us, in the Toyota Production System whose principles are making their way into hospitals, no problem is a problem. With a problem at hand, you can find out the root cause(s), developing countermeasures and mistake-proof the process so it won’t occur again. This goes for living, breathing human beings, too. It’s even more important that we talk about mistakes without any guilt or shame. The more we talk about them, the more we’ll be able to understand the reason behind our mistakes and fix the problem by cutting to the root cause.

Surgical Errors
Surgical errors, while formally reported, remain a hush-hush matter in the medical profession

Many hospitals have started having nurses report any errors they make during their shifts anonymously or openly into a reporting system. The nurse manager then works with a risk manager to address the incidents. Medical and surgical errors are addressed to a certain extent in the peer review and morbidity and mortality forums, but this is still a hush-hush affair.

Doctors get their education in one medical school but eventually work in a new organization with completely new systems, equipment and culture. A resident might not want to wake up their consultant in the wee hours, instead dealing with it on his or her own, but if the right decision isn’t made, there’s fear nurses and other ancillary staff may be judgmental. Doctors are expected to be perfect – patients choose those they haven’t heard anything bad about. That’s likely the case, however, because no one has ever reported anything.

It’s about time that we accept that doctors are human beings and we can, like everyone else, make mistakes. Create an environment where we can openly speak about our mistakes so that it will help with the greater good, helping patients become healthy and lead a quality life.

MBOE recap: What are you hiding?

It’s impossible to sum up all the great content we covered with our Master of Business Operational Excellence and MBOE Healthcare students on campus last week, so let’s settle on some worthwhile tidbits that could help you in your organization:

Share with the rest of the class. Drew Locher, Shingo Prize winning author, challenged the class by asking, “What do managers know that the employees don’t know? And why can’t you share this information with the employees so that they can make better decision using this information?”

Lean works anywhereTaking organizations in the service industry lean is a challenge (remember “Airplanes aren’t cars!”?), but Locher insists it’s not only possible but important because these companies deal directly with customers. Using visual management principles, such as a call-center signal light when an employee needs help, can increase productivity, communication and morale. Locher even helped a company that makes graphics for CDs, driving home the point that lean can work in creative processes as well.

In the MBOE program, Ellis New with his usual energetic and passionate style emphasized the importance of Total Preventive Maintenance. What point is there in waiting for the equipment to breakdown and then wait for the service people come fix it? Would you fight an 18 feet alligator or rather squish their eggs? In other words how long will you wait to fix the problem? The students were trying to find the answers to these questions while they were being a part of TPM at Tigerpoly, a supplier to major car companies and one of our of gemba learning sites.

…especially in health care. MBOE Healthcare students visited Akron Children’s Hospital to learn about visual management and its application in health-care settings. Anne Musitano, a process improvement expert at the hospital, MBOE grad and 2012 IQPCfinalist, organized an action-packed day for the students, having them observe daily huddles and visual management practices in several departments. Students also got to speak to area managers and understand the joys and pains of implementing changes in their departments.

Ann Musitano
MBOE grad Ann Musitano greets the latest health-care cohort at Akron Children’

Are you S.M.A.R.T.? File this acronym away, per coach Gary Butler: Metrics won’t work unless they’re Specific, Measurable, Achievable/actionable, Relevant/reliable and Timely. I also spent time with senior lecturer and COE Executive Director Peg Pennington discussing measurement systems, particularly the concept of Gage R&R. This helps you determine if your measurement system is repeatable (similar readings with the same operator) and reproducible (similar readings with two different operators).

Tune in for our students’ return to Fisher in early May.

Time to change over

Understanding setup time in the manufacturing world is easy: A machine makes products with different specifications, and parts must be changed to meet those. The time you take to make those changes is setup time. The more setup time, the more wasted time and resources. Lean companies focus on reducing changeover times to make a range of products in a given period of time to meet customer demand.

How this applies to health-care is occasionally tough, so let’s start with the easiest example. In an operating room, the time needed to turn it over for the next surgery would be setup time. The quicker you clean, disinfect and stock the room with the relevant tools, the more surgeries can be done in a day.      

Setup time and its opportunities for greater efficiencies go far beyond an operating room, though. Take a blood draw for testing. Supplies are situated outside patient rooms for safety reasons and, once ordered, require a nurse to walk to a storage area. Then, depending on how a supply closet is organized, the nurse may need to spend time looking for the correct, unexpired tools before placing them on a tray and walking back into the patient room to do the draw – provided he or she hasn’t forgotten anything. Drawing the blood takes no more than a few minutes, but the time spent in preparation can create a great deal of waste, reducing the time a health-care provider can spend with patients. At its worse, these inefficiencies can result in delays in diagnosis and treatment, affecting the length of stay and patient satisfaction.

Just think of how much could be changed by just placing a phlebotomy cart right outside the patient room or spending some much-needed 5S time on the supply closet.

Blood Draw
A simple blood draw can become a nightmare of inefficiency for a health-care organization

That’s not the only waste-prone procedure in this setting. Just think about turning over patient rooms, adjusting diagnostic equipment or starting a new round of chemotherapy. Any sort of walking, waiting or looking around is waste and if a highly paid staff is spending a major chunk of its day doing it, those are resources down the drain.

Many employees aren’t even aware of the wastes that run rampant in settings like these. Instead, they consider it part of their work because that’s what they’re used to doing. All it takes is for someone to take a look at the process and separate truly value-adding activities from the waste.

Problem-solving starts with a look in the mirror

It’s not uncommon to blame other departments or people for the inefficiencies in your own processes. While working on process improvement projects, I’ve heard it all: “It’s the doctors who are the problem,” “Finance just gets paid to make things difficult for us,” “It’s the emergency department’s fault.”

The sterile processing department at OhioHealth Corp. has tackled that culture by focusing inwardly. They’ve accepted the fact that they can’t control how surgeons or ORs function. What they care about is how they can modify and standardize their own processes to meet the variation in demand from the ORs.

Gary Butler
“Fisher Executive-In-Residence Gary Butler with the OhioHealth team.”

And have they.

“Five hours, that’s our turnaround time,” Nikki Ross, sterile processing’s systems director, announced proudly as I toured the process with my colleague Gary Butler. That’s the time from when the trays arrive at the decontamination area to when they are ready to be sent to the OR. The national average: 12 to 24 hours!  

So how did they do it? Ross focused on the elimination of waste, first pinpointing what exactly waste is and then going to gembato observe the process, empathizing and asking questions along the way. Armed with the knowledge and training of an OhioHealth process improvement specialist she was able to figure out not just the wastes in the process but also the value of just-in-time production and one-piece flow. Just as Rome wasn’t built in a day, it took Ross a few years to create a smooth and efficient process equipped with the ability to process faster with fewer errors.

Instruments
“OhioHealth’s processing rates in sterile supply are much faster than the national average.”

In health care, it’s common for some to say the processes in the system are too complex for a lean transformation, but surgical kits are no different than a car assembly line. OhioHealth has proven this. As I walked through Ross’ department, I noticed evidence of standard work, visuals for setting up trays, and very little inventory.  As a result, they are able to process the kits and track errors faster while continuing to improve.

Discuss: Any success stories at your organization?

MBOE recap: Mr. Potato Head teaches lean

Students in Fisher’s Master of Business Operational Excellence cohort are back on campus for their second week together in the year-long program. Senior lecturer Mrinalini Gadkari is on the scene for daily recaps.

In my last MBOE recap, I stressed the importance of “shine” in 5S. Yesterday, Senior lecturer and COE Executive Director Peg Pennington demonstrated how 5S and visual management apply to the workplace with a little help from Mr. Potato Head.

Who knew Mr. Potato Head could be so educational? Organizing limbs, mustaches and hats, it got me thinking about how in hospitals it isn’t uncommon for nurses and doctors to hoard supplies so they can have them when they need them and won’t be scrambling at the last moment. If the workplace isn’t organized it’s easy to misplace or even lose things. If you can’t find them, you spend valuable time searching, hoard product or order more. 5S removes that waste, eliminates unnecessary items, creates a safer work area with more space – and, of course, saves you time. 

Mr. Potato Head
“This iconic, bespectacled lecturer led students through a look at workplace visual management.”

Once your workplace is organized and all items have a standard place, what work remains to be done on your processes? Each one of us has ordered something online and gotten the wrong product. Heard of wrong-side surgery? It’s easy to see opportunities for improvement in someone else’s processes. Our MBOE students, for example, took a trip to the Ohio State University Medical Center to view Central Sterile Supply and Nutrition Services. Some students say their “Aha! moment” came by watching technicians and nutrition aides.

In his lecture on training within industry on standardized work, Fisher Executive in Residence Gary Butler drove it home, telling students that a combination of standardized work and visual management stabilizes working condition, flags the abnormal from the normal and keeps staff on task toward reaching daily goals.

Discuss: Do you have an “Aha! moment” for your own organization, on the shop floor or in the service area? How did that lead you to standardize processes?

What’s your problem?

I recently had to take a friend to an urgent care facility in town after she broke out in hives and itchy skin, likely an allergic reaction to a food item. After making it into the exam room, the medical technician very efficiently completed the vitals and reconciled medication and past illness history. Next in was a physician’s assistant, who performed a quick assessment and confirmed our suspicions about the food allergy.

But what food? We still weren’t sure, even as the hives were quickly spreading and my friend agreed to a Benadryl shot. Within 20 minutes, the itching was gone with the hives almost disappeared. One crisis averted, one very drowsy friend.

I have prescribed and given Benadryl shots to my patients in the past but this was the first time as a non-physician that I noticed how quickly the drug acts and makes the reaction disappear. It got me thinking about how a lot of the countermeasures many organizations implement to solve a problem act like Benadryl. Symptoms disappear but the root cause remains.

Cause Map
Cause map slide courtesy Peg Pennington

Most people, in fact, aren’t sure what problem they’re trying to solve. For example, if sales go down, marketing goes up. But what if your products are defective? What if customers are getting the wrong product or are waiting too long to receive it? What if a competitor is turning out a better, faster alternative?

You will only be treating the symptoms if you don’t know the:

–          actual problem you are trying to solve

–          root cause of the problem

There are many tools available to get to the root cause of the problem such as the 5Whys and Fishbone diagram.  I recently learned from a colleague a new method, causal mapping, which I prefer because it is visual and loose in structures, allowing for a free flow of ideas until you find the root cause.

My friend, by the way, is on her way to an allergist to nail down the real culprit.

Tell me where it hurts

Fair warning: This is one of those articles you read that makes you think twice about checking into an emergency room.

I’m still reeling from a recent New York Times article on a Department of Health and Human Services study that found hospital employees note and report only one in seven errors and other incidents of harm to hospitalized Medicare patients. One in seven: That’s an F in a classroom and includes instances that range from bedsores, acquired infections and other mishaps that could even result in death.

Medical error
This x-ray, courtesy BigHealthReport.com, illustrates a much-feared medical error.

The point here isn’t to encourage you to hit the Advil next time you fall off a roof. Read deeper and the lean alarm bells start sounding. According to the article, federal researchers say it isn’t shame or embarrassment that’s keeping these instances from being reported. Rather, it’s hospital employees not recognizing what constitutes patient harm or realizing a procedure has harmed a patient. In lean-speak, researchers hint the root cause lies deep within the procedures and training that line the backbone of hospitals’ operations.

The most staggering sentence in the article comes later: “In some cases … employees assumed someone else would report the episode, or they thought it was so common that it not need to be reported, or ‘suspected that the events were isolated incidents unlikely to recur.’”

This is a shining example of how a finger-pointing, siloed approach to daily work and problem-solving can infect an organization. On a shop floor, this could mean a malfunctioning widget. In a hospital, this could mean one less vacancy in the basement morgue.

The report is mostly, but not all, bad news. Medicare officials told the Times they’ll develop a list of “reportable events” to clear up confusion, a sure sign of progress. But much work remains to be done – a major problem in the system these days, the report states, is that once problems are recognized they very rarely lead to changes in policy or procedure. It’s a good start, though, to define what a problem is, design processes so they expose problems and then have a process in place to address them.

Reading the article, I’m reminded of a chat I had with lean guru Steven Spear when he visited Fisher to coach our Master of Business Operational Excellence cohort in November. Spear has loudly advocated that health-care providers should focus less on problems in the market and more on reforms in specific processes to effect meaningful change.

“I’m not sure that’s caught on in health care in a broad-based way,” he told me.

Unfortunately, he’s right.

Don’t let the Zen garden fool you

I wish you a very happy 2012 as you make progress in your journey of operational excellence.

I am sure many of you must have traveled during the holiday week. On a recent trip I took to Orlando to attend the Annual Institute for Healthcare Improvement (IHI) conference, a very common occurrence got me thinking. We all know how first-class and business-class members get the preferential treatment of boarding the flight before economy class passengers. In terms of customer service, that makes sense. They pay more and get to board earlier. 

What I find extremely ridiculous is that they get to walk on a small piece of carpet when they board the plane, while economy class passengers are diverted to a separate passage that bypasses the carpet. But only one entrance leads to the plane. As you can see in the picture, the airline managed to create a fake sense of “specialness” for first- and business-class passengers.

We see the same thing in hospital waiting rooms and other service operations. Excellent customer service would be no wait at all but service industries use the band-aid approach for the problem. They build Zen gardens and embellish the walls with beautiful artwork in waiting rooms to distract customers. Instead of improving the processes to reduce redundancies and waste, they focus on the perception of customers regarding wait times. If wait times increase beyond a certain time because of “unavoidable” circumstances, customers are given freebies in the form of free parking passes or gift certificates.

The key is to attack inefficiencies in the processes and give customers what they came for. If you went to a grocery store looking for your favorite box of cereal and had to spend a half-hour hunting, guess where you’d go next time? A competitor.

Customers can’t be fooled by superficial embellishments. Give them what they want. Improve the process, not the ambience. That’s true customer service.