The lean secret of … Indian bread?

I never fail to be reminded that lean thinking makes sense anywhere – and everywhere. The latest occasion was at a friend’s house a few weekends ago making an Indian bread called paratha. I had made them in the past, but this was the first time it really registered to me as a process. Just watch how lean thinking takes over in the kitchen.

My friend began the setup by making a large dough ball, kneading wheat flour,salt and water. The process steps entailed

bread making
The Indian bread paratha takes teamwork – and some lean principles – to make a successful meal.

her making a small ball from the dough, rolling it flat and placing it on a pan where I cooked it. I then removed it from the pan, placed it in a casserole to keep it warm.

Here’s where it gets tricky – just like any process a few steps away from its future state. Initially, we weren’t synchronized to create one-piece flow. If she slowed down, my pan sat empty and overheated, creating waste in the form of time and human potential and winding up the pitch for a defect. If I slowed down, she already would have rolled the bread, standing there and waiting for my pan to be empty. As a countermeasure, my friend kept a plate between the pan and her rolling unit where the rolled bread  began to stack up. With the pressure on, I pushed to cook the parathas faster, turning up the heat and burning the bread. When I turned the gas down, the bread would be undercooked. More defects. If you’re still with me, you see her countermeasure covered up a symptom of the problem but didn’t get at the root cause.

It took us time to get things under control, but we “stopped the line,” huddled and came up with the most efficient way of cooking the bread. This involved using the correct amount of heat so I wouldn’t burn or undercook the bread. We paced our share of work so we produced at the same rate, or takt time. We decided the empty pan would be the kanban for my friend to start rolling the next bread. If the pan was filled, she would use that time to undertake some standard work: Making the ball for the next bread.

Voila! The lean recipe worked for our recipe: Warm parathas with delicious egg curry. Take a stab at it yourself – and learn from our mistakes.

 

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?

What a wonderful World Café

As a journalist, I was taught to eschew jargon and cut to the heart of the matter, sending corporate buzzwords like “synergy” to the trash bin along with serial commas. I’m pre-emptively asking for forgiveness, then, as I describe the great things that went on in a recent Center for Operational Excellence-sponsored event. If our first attempt at a World Café wasn’t a textbook example of synergy, I don’t know what is.

If you’ve never heard of a World Café (or, like I did, immediately think of the NPR music program), here’s a crash course: A group of people assemble with the goal to tackle a topic in an actionable way. They’re split up into small groups, each at a table, and switch at regular periods with the exception of that table’s moderator. For the event we hosted with the Operations and Logistics Management Association last week, we put the spotlight on logistics and opened the doors of the Blackwell Hotel ballroom to Fisher faculty, students and industry players, some of whom were COE board members. Check out a slide show of the event here.

World Cafe
The World Café event allowed Fisher students and faculty to interact with logistics industry players.

Like any maiden voyage, nerves were on high alert and expectations were uncertain, but a healthy and enthusiastic turnout led to rounds of stimulating discussion. We design the COE experience for our members in ways that connect them with faculty, students and industry peers but it’s rare that this occurs, well, at the same table. Just strolling around taking photos, I could feel the energy, and the session-ending report-outs were rich with thought-provoking conclusions on a range of different facets of the logistics trade.

Tom Goldsby, a Fisher logistics professor and COE associate director, tells me “our students benefited from the viewpoints offered and the very interaction with business professionals. The business professionals, meanwhile, seemed to enjoy the interaction just as much and indicated that the students provided fresh insights on the table topics.”

A crucial sign things were going well: Goldsby says several participants wanted to linger at the tables longer.

“In sum, it seems this first-ever event was a great success – one that we will repeat soon,” Goldsby said.

MBOE HC Recap: Where’s your one second?

Students in Fisher’s Master of Business Operational Excellence Healthcare cohort spent four days last week at the Thedacare Healthcare System in Appleton, Wis., as part of the year-long program. Senior lecturer Mrinalini Gadkari was on the scene for daily recaps.

Ever think about how much time you spend, and often waste, in meetings? Let’s do the math: Let’s assume you’re in one hour-long meeting in an eight-hour workday. Five meetings a week, 20 meetings a month, 240 meetings/hours a year. That’s the equivalent of 30 workdays.

Time
"Time is a valuable commodity, and one easily wasted, in many organizations."

I got to thinking of this as lean consultant Tracey Richardson discussed the importance of even a wasted second while teaching our MBOE students the A3 problem-solving method. When Richardson started working at Toyota Motor Corp., one of her trainers translated the cost of one second lost to the company. Saving one second per plant worker, she said, was the equivalent of adding eight more cars per shift! One second to Richardson meant job security.

“I started looking for seconds everywhere,” she said, urging students to look at their own processes. Seconds might not make sense but probably hours or days or weeks or months would. Any unit of time could be translated into a dollar amount or, in health care, someone’s life.

Back to that one-hour-meeting calculation: With that much time invested, you’re pulling away key people in meetings that go on for years without achieving much. How does that translate into dollars or productivity?

How about going to the gemba instead? How about huddling with your team for a few minutes in a day and tackling real problems?

MBOE recap: The blame game and the Challenger explosion

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.

The 1986 Challenger disaster killed seven astronauts and consumed more than $5 billion as the shuttle broke apart less than two minutes into flight, sending fragments of the craft hurtling into the ocean and putting the nation’s space program on ice for nearly three years. But what caused it? Was it the O-ring failure or that the NASA operational officials’ ignored the warnings of the engineering experts? Was it the absence of clear goals for launching the shuttle? Or was it a problem in their policies? As COE Executive Director Peg Pennington and Senior Lecturer and Executive-in-Residence Gary Butlertold our MBOE students in their final session this weekend, there were multiple causes to the problem – just as there are with any. 

The 1986 Challenger
The 1986 Challenger explosion, captured in this National Geographic photo, killed seven crew members and launched a massive investigation

In a previous blog, I mentioned the importance of defining what your problem really is, whether it’s an exploded space shuttle or a missing file. In hunting the causes, most of us simply go after that root cause that led to the problem. But there’s never just one cause. Problems occur because of multiple causes that underlie the entire system.

Cause mapping, which you’ve read about here before, is a retrospective tool that helps you find out why something happened. This weekend Gary Butler introduced students to a new one – Failure Mode Effects Analysis, or FMEA – that helps you proactively look for when and how things can go wrong before they go wrong. 

How much time do organizations spend on assessing their processes with an FMEA or other tools? If they install new information systems, do they go beyond the cost-benefit analysis? Do they think about the impact they will have on staff, customers or suppliers?  Many organizations have a very narrow-minded outlook and forget to plan for the catastrophes that could be avoided with detailed analysis.

Discuss: Have an incident to share that led to extensive root-cause analysis? Any FMEA stories of your own?

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?

5S: More to ‘shine’ than the surface

Regardless of where you are in your lean journey, it’s likely you’ve heard of 5S, the set of five words that serves as a methodology for organizing the workplace. In English, they’re Sort, Set in order, Shine, Standardize and Sustain. That’s derived from the Japanese origin of Seiri, Seiton, Seiso, Seiketsu and Shitsuke.

Detractors might say 5S is simply a “spring cleaning” activity where trash is discarded to make room for more, but it’s a great deal more than that. When you sort, you separate and eventually throw away items that are unneeded. You set in order items according to the frequency and sequence of use. You get rid of dirt, dust and any leakages and shine the workplace. Once you organize the items, you standardize their location and level of use. To sustain that organization, you create paperwork that operators or managers can use to reach that goal. 

If it all works so well, then, why do some still consider shine a dusting and cleaning activity? Some say it’s played a part in saving lives. Ever heard of the controversial “Broken Windows Theory? It posits that simple disorder can increase the tendency for crime in urban areas – if more trash isn’t removed, more will pile up. The New York City Transit Authority in the 1990s applied this to stop an increasing graffiti problem on subways, scrubbing down trains each night before resuming service the next morning. Over time, they got rid of the problem as other initiatives were put in place around the city, contributing to a remarkable decrease in vandalism and the crime rate.

When you ‘shine’ the workplace it has a positive impact on the operators working there. A dirty workplace tends to cause distraction and reduce employee morale and doesn’t convey a positive message about the company. With items in ready-to-use condition, working is safer with dust and dirt gone along with slipping and tripping hazards.

In short, a clean and safe workplace begets a safe and clean workplace.

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.