‘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 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 jeancunninghamconsulting.com)

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?

The flow of the 411

Most of our MBOE students have now finished creating the value-stream maps that they can work with for their capstone projects, the culmination of our year-long program. The flow of information, one of the key components within a value stream, many times gets neglected. It is very important to indicate the flow on the map to highlight the intricacies and the challenges faced by the people who do work on a daily basis.

info flow symbols value stream map
A quick how-to on value-stream map symbols

In health care, the staff might be using the Electronic Medical Record for the most part to access or enter information. But if some staff members don’t have access to all modules, they might wind up making a phone call or writing an e-mail to someone who does. This adds a layer of complexity and non-value added activity to the work.

In manufacturing, lead time sometimes can be hidden when the customer places an order until the sales and operations group has made a decision to go into production.

In transactional processes, information flows through an online system, e-mail, fax, and phone or in-person conversation.

Regardless of your value stream, it’s important to show in detail how information flows. This highlights how long it takes to get to the receiver and what kind of decision he or she makes as a result. Does this information help provide a signal or authorization on whether to produce a product or advance an application – or does it just result in a need for more clarity or information? A value stream must expose all possible wastes that could be affecting lead time.

The key thing to remember here is that whether it’s a pull or a push system, information always flows from left to right in the value stream. You can use symbols in the picture to show manual and electronic information flow. Use symbols to indicate phone or fax or e-mail. Indicate rework, redundancies or breaks in information flow using angry clouds or starbursts.

In the end, any information flows in the value stream must have a purpose. Everything else is noise.

MBOE recap: Lessons from the pharmacy

Value stream mapping has been widely used in the manufacturing industry to understand flow. Our MBOE students learned how value stream mapping can be effectively used in a pharmacy setting using a case based on Giant Eagle’s pharmacy, authored by Gary Butler, pictured.

One of the many things that the case addresses is the question that commonly comes up when mapping a value stream in a service industry: Variation in how customers come in. There are peak periods and then there are low periods.

How do you then calculate the demand and takt time? When you draw the current state value stream map, it’s not surprising to see multiple takt times: Shorter during busy times of the day and longer during the slower periods.

In health-care settings it’s very common to have multiple people with varying skills performing various tasks in the process. A value stream can give you the metrics to calculate their utilization, which can help you understand how to allocate resources so that every resource can spend their time on only those activities based on their expertise that add value to their customers.

MBOE recap: Learning from observing

With the theory of value stream mapping internalized, our MBOE program’s health-care cohort traveled to Ohio State’s Wexner Medical Center while the industry cohort headed to Center for Operational Excellence member Tosoh USA Inc.  A key step before launching a value stream mapping exercise is to go to the gemba. You can’t really map a value stream unless you’ve seen the process and have the relevant data, and you can’t do it accurately without the people who are a part of the process.

MBOE students value-stream mapping following a visit to Wexner Medical Center

Legend has it that Taiichi Ohno, the father of the Toyota Production System, had his engineers stand inside a circle for eight hours to observe the process. There is a lot of learning that results from just observing. Once you understand how the process flows you go speak with the people who do the work. Share your findings with them. Ask them to validate the findings. Ask them why they do what you observed. Note the issues they point out and ask them what would make the process better and why.

On the hospital gemba, students went to three different areas: Outpatient endoscopy, inpatient endoscopy and Invasive Prep and Recovery (IPR). Ryan Haley, Peg Pennington, Jill Treece, Jason Swartz and Tim Nelson were key in assisting.

The biggest hurdle in getting started with the value stream map is selecting the correct group of product or services to represent on a single flow map. For example, in IPR, the manager was interested in understanding the flow of EP (Electrophysiology) patients. Within this group there were multiple procedures, such as ablation (that took the longest to perform and recover) and cardioversion (the shortest procedure to perform and recover). There are many more within that range. What procedure should one focus on? The answer: Select the family of procedures that if improved upon will have the most benefit to the patients and organization.

The students spent three hours on the gemba and mapping the process and later presented their findings to hospital leaders. As our students benefit from gemba partnerships, so do these organizations. In fact, many departments have implemented the recommendations made by the students and achieved positive results.

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.

MBOE groups hit the road to see lean leadership in action

It’s a busy time for gemba walks, folks. Fisher’s Master of Business Operational Excellence cohort recently spent time visiting Center for Operational Excellence members Nationwide Insurance and Cardinal Health. Meanwhile, MBOE’s health-care cohort met out in Seattle, visiting Seattle Children’s and Seattle GroupHealth, learning what role leaders take on in a lean environment. 

David Mann, author of Creating a Lean Culture, spent a day with the students explaining and demonstrating the tasks that lay ahead of a lean leader.  Lean, Mann said, is a higher-maintenance way of managing because there isn’t much of a buffer, or waste, built in the process. As a result it is important that leaders adhere to standard work. So what does standard work for leaders involve and how do you build in accountability? Per Mann, here are some questions one can start answering to find out what is lacking and eventually build a system to have the answers:  

Having tasks and deadlines on public display improves accountability
Having tasks and deadlines on public display improves accountability
  • Does your standard work involve going to the workplace or the ‘gemba’? How frequently? 
  • What do you do in the gemba? Are you problem solving or empowering people to identify and solve problems?
  • What feedback will you give the people about their processes?
  • How does information flow from the corporate level to the shop floor? What is the chain of command? How will you identify if there is a break in the link?
  • Are there standard work visual controls? What is their intent? How do they tie to the strategic goal?

According to Mann, if visual controls for leader standard work are easily visible to the public, have due dates for completion of tasks and name of the responsible person, you automatically build in accountability in the process. To summarize, focusing on the process, adding visual controls with built in accountability and having the discipline for following up the first three elements are the basis of leader standard work. 

The MBOE cohort got the insight on developing efficient teams by hiring the right people by Larry Inks, faculty at the Fisher College of Business. The MBOE healthcare team learned about team building and basics of 3P taught by Barb Bouche, Director of process improvement at Seattle Childrens’. The students also witnessed seamless flow at Seattle Children’s outpatient surgical facility in Bellevue, which was built by implementing the principles of the 3P and involving all the stakeholders responsible for providing care.


The 411 on 5S

and execution:

Select a team: Selecting the right team members makes a huge difference when planning a 5S event. If the frontline staff works in shifts, ensure you have representation from each shift. You can communicate the changes via email or in person but it doesn’t have the same impact. A staff member coming in the night, for example, might feel frustrated for not finding the items in their usual place. The items that you red-tagged in the ‘Sort’ phase to dispose of later could be something used in the night shift.

Communicate, Communicate, Communicate: Everyone involved should be able to get a straight answer from you when they ask these questions:

1.    What changes are you making?
2.    Why are you making the change? What’s in it for me?
3.    How long will it take?
4.    How will I be impacted by the change?
5.    What is my role in the change?

If this is 5 day-long event, make sure you communicate everyday at the end of the day via email or a visual board in the area.

Involve all relevant departments:  5S Kaizen involves a lot of real-time changes. A spaghetti diagram gives you an idea of the convoluted flow due to the wrong placement of equipment and supplies. When you plan to move the equipment around to a new location, make sure you have a representative from facilities involved to create a new electrical socket. If you are going to reduce the inventory or move it around, involve materials management. They might have great ideas to dispose of extra supplies either to other departments or send back to the vendors and get some credit.

5S Pictures
Using pictures of items in a 5S review can save confusion and problems

Ask why: Before you remove or move things around, ask why an item is on the shop floor/work area and in that particular location to the people who work there. If the answer is, “Oh that’s where it has always been,” don’t hesitate to organize it such that it enhances the workflow. However, you might find some really good reasons why things are where they are. At one of the hospitals where I facilitated a 5S event, our team found that the entire bar-coded supplies were organized in a way that matched the online ordering system. If we made any changes to the location or quantity of supplies it would have messed their ordering system.

Use the same language: It is very common in hospitals for nurses and materials handlers to have a different nomenclature for the same item. Water for Oxygen for a nurse could be prefilled humidifier for the material handler. Use pictures to ensure everyone is on the same page.

Post a Suggestion Board: Post a white board or flip chart in the area to capture suggestions, issues and/or compliments regarding the event. You will be surprised how quickly the board gets filled up. This is a good way of getting people involved and getting their buy-in by incorporating relevant suggestions.

Sustain: Communicate changes and train staff not involved in the 5S event regarding their responsibilities. As a manager you should set up some time on your calendar, weekly in the beginning, to walk through the 5S areas and do a 5S score to see if the changes are maintained. Have people assigned to refill supplies, maintain location and quantities. Capture any issues that people face due to the changes. There will be a learning curve in the beginning, but if the changes are adversely affecting flow, discuss with the team and make changes accordingly. Make sure the new changes are communicated promptly to everyone involved. Gradually you can change the frequency of the walkthrough to monthly and quarterly.

Any other tips to add to the list?

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.