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Apologizing Does NOT Get to the Root Cause

Making the Most Of Customer Complaints - WSJ.com:

Here's a good article from the WSJ about customer focus and quality improvement:

"All too often, companies have customer service sort out the immediate problem, offer an apology or some compensation, and then assume all is well. This approach is particularly damaging because it does nothing to address the underlying problem, practically guaranteeing similar failures and complaints."

Of course, if you're just putting the fire out without looking for a root cause or for prevention, you're going to have the same problem occur again. It seems that many organizations respond to each problem (overreact even) as if it's a "special cause" when the problem is really a "common cause" that's a result of some underlying process or system. The article continues:

"The chief aim of managers in service recovery is to help the company learn from service failures so it doesn't repeat them. Learning from failures is more important than simply fixing problems for individual customers, because process improvements increase overall customer satisfaction and thus have a direct impact on the bottom line."

That starts sounding like a Lean mindset -- a " Lean Solutions" approach even. There are many examples in that book (including Fujitsu) where companies were able to turn complaints into the starting point for a real process improvement process. The goal of any complaints department should be to help initiate improvements that drive future complaints to zero.

If employees aren't allowed to help improve the process, they may take a turn for the worse after getting frustrated with the continued complaints:

"Even though complaining customers represent an opportunity to fix problems and improve satisfaction, alienated employees often see them as the enemy. In a study of a major European bank, employees in Switzerland consistently indicated that they did not consider reports of missing account statements to be complaints. As one said: "These things happen. There is nothing we can do about that."

One way to keep employees engaged and serving customers is to give them some freedom:

"Ritz-Carlton, for example, the luxury brand of Marriott International Inc., authorizes personnel at the front desks of its hotels to credit unhappy customers up to $2,000 without asking a supervisor's approval. On the other hand, in one of our consulting projects, a client reacted very negatively to this approach, claiming that such a policy would be too expensive for his company. We replied that the high cost of poor service is exactly what makes this system work so well: It forces management to eliminate service failures in the first place."

Just recently, I complained to a Hampton Inn I was staying at in Illinois (and was booked to stay at again for multiple weeks). The "high-speed" wireless internet service was the furthest thing from high-speed. I complained the first night and the hotel was unable to fix anything. The second night, I called the 800 tech support number and they were unable to fix anything. The third and final night, I received this in my room after complaining and pointing out that I'd have to choose a different hotel for my future weeks if they didn't have good internet access:

Do you have similar experiences, as a customer or in your business?

Muda Reducers for Computer Users

Tech Tips for the Basic Computer User - Pogue’s Posts - Technology - New York Times Blog

This isn't really a "Lean" post, as much as it is a very helpful collection of time savers and "tips and tricks" for Windows or Mac OS X use.

Be sure to check out not just David Pogue's piece, but the very helpful reader comments that follow (more tips and more tricks).

So many of us use computers as part of our work - don't we all have an obligation to practice "kaizen", find new and better ways to do our work?

Laying off Lean People

Mass General cuts 200 jobs - Daily Business Update - The Boston Globe

Times are tough, financially, for many organizations -- hospitals included. About two weeks back, a Lean specialist at Massachusetts General Hospital in Boston posted on the Yahoo "HME" list (Healthcare Management Engineers) said she was getting laid off from MGH and was looking for a new opportunity.

Doesn't this seem short sighted, firing the very resources who should be able to help reduce costs and improve the organization for the long-run? Who knows the particular situation here, but are you seeing similar things in your organization -- factory or hospital??

I know one hospital that tells the story of how "back in the day" they were under financial pressure and reacted by firing the whole "Management Engineering" department (industrial engineers). They're trying to be careful that they don't repeat the same situation with any dedicated Lean resources that they might add.

What are your experiences?

Apple's Newly Discovered Manufacturing Prowess?

The 'Brick' is... | 9 to 5 Mac

There's news that Apple is going to announce new laptops. I love my MacBook that I just bought earlier this year, but I'm not an Apple "Fanboy" (this was my first Mac ever).

What caught my eye about these new products are the rumors about manufacturing process. Huh? Normally, we talk about "speeds and feeds" (a term borrowed from manufacturing, strangely enough) -- how fast is the processor, what are the features, etc? Nobody talks about how computers are built anymore since it doesn't seem to matter, especially if Dell is going to sell its factories.

The MacBook manufacturing process up to this point has been outsourced to Chinese or Taiwanese manufacturers like Foxconn. Now Apple is in charge. The company has spent the last few years building an entirely new manufacturing process that uses lasers and jets of water to carve the MacBooks out of a brick of aluminum.

This isn't entirely new. Steve Jobs has always had a fondness for having his own plant to produce computers. In 1990, he built a totally automated plant in Fremont California (thanks PED) that could build NeXT machines with only 100 workers. It was a "plant with just about everything: lasers, robots, speed, and remarkably few defects." Unfortunately, the demand wasn't very high at the time. However, Jobs remarked, "I'm as proud of the factory as I am of the computer."

Until recently the 40-person manufacturing staff had more Ph.D.s than the group designing the NeXT machine.

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The Full Q&A at Gemba Pantarei

Thanks again to Jon Miller for his great questions and for hosting the Q&A, all three parts.

Here are links:

Part 1 | Part 2 | Part 3

We've gotten some good feedback and comments/questions on Part 1. If you comment, you have a chance of winning a free copy of my book.

Three Formal Efforts Tie Lean and Green Together

By Jason Turgeon:

It looks like the Lean + Green movement is gathering steam. In the last week, I've seen three pretty big efforts that formalize the relationship. This is great news for members of both camps, as Lean management and Green marketing are both pretty hot in the business and manufacturing worlds right now and this will only reinforce two already positive trends.

First, I recently found out about a year-old publication from EPA (my employer) called the Lean and Energy Toolkit. I've written before about the agency's formal Lean program, but this is a part of it I hadn't seen. In the 56 page document, available as a PDF at the link above, the agency makes the case for accounting for wasted energy in the manufacturing process. It's my understanding that this book is being used in conjunction with Lean trainings given by the Manufacturing Extension Partnership; the MEP is partly funded by EPA in some fashion. Here's a little snip of what to expect:

What is the relationship between Lean and energy use? Substantial energy savings typically ride the coattails of Lean. By eliminating manufacturing wastes, such as unnecessary processing and transportation, businesses also reduce the energy needed to power equipment, lighting, heating, and cooling. Chapter 1 describes benefits of combining Lean and energy improvement efforts. Chapter 2 explores the relationship between Lean and energy use, and provides background information on energy use and costs.

How does one know how much and where energy is used in a facility? A key step in effective Lean and energy efforts is learning where to target energy-reduction activities. Chapter 3 discusses techniques for assessing energy use and identifying opportunities to save energy in the context of Lean. Methods include energy treasure hunts, value stream mapping, Six Sigma, and kaizen events.

How can one reduce energy use with Lean methods? Chapter 4 examines specific opportunities for using Lean to reduce energy use, including Lean methods such as total productive maintenance, right-sized equipment, plant layout, standard work, and visual controls. Chapter 5 discusses additional ideas for achieving process excellence with less energy use and environmental impacts.

Next up, via Greenbiz.com, here's news that IBM is getting into green in a big way. Big Blue is turning into Big Green, in part with the its new "Green Sigma" consultancy. According to the article, "the service can study water and energy use wherever these resources are used, such as in transportation, data centers, IT systems, manufacturing and distribution or retail facilities. The tech giant launched a consulting service based on the Lean Six Sigma strategy at a time when companies are facing growing pressure from stakeholders to lighten their environmental impacts."

This is far from IBM's only green initiative. Another story on GreenBiz links to work that IBM is doing to work that the company is doing to help green both the power grid and watershed management, two areas that have similar distribution issues and management challenges. In these cases, IBM is working to help get everyone on the same page by organizing collaborative meetings between all of the stakeholders and getting them to look at all of the information in the same way. The company makes money by gathering and processing raw data but the effects on the planet are a different kind of green, one that is measured in improved water quality and a more efficient grid. Measurement and verification are at the core of Lean, so this is definitely something that ties right into IBM's Green Sigma program. As an example, the company is deploying data gathering buoys and underwater robots along 300 miles of the Hudson river. The devices will collect info on a wide variety of water quality parameters, then transmit it in real time to IBM software that will analyze it and spit out a constant picture of the river's quality that all the shareholders can use jointly. This kind of information has never really been available before, which can be really frustrating to those of us who work to clean up rivers. By monitoring its health in real time with a multitude of data points, we can have a common platform to say "this is where it is now and these are the areas that need improvement," then we can get to work developing a meaningful plan.

Finally, the Society of Manufacturing Engineers is hosting an event in Portland, OR, at the end of this month called "Take the LEAN Path to GREEN." If you're lucky enough to attend, you'll get to spend a few days in the greenest and most liveable city in the country, enjoying stellar public transit and bikeways while eating plentiful locally grown food and touring neighborhoods that seems to host more green buildings by the minute. You'll also get to attend two pretty full days of learning how to eliminate four waste streams from manufacturing: water, energy, solid waste, and air emissions. Sounds like a pretty good couple of days to me!

A Dutch Review of "Lean Hospitals" (and Part 2 of Q&A)

Centre of Excellence for Care and Cure - Lean Hospitals

I apologize if this is too self reverential, but it always fascinates me to see how Lean is spreading around the world.

The page I've linked to has a 4 star (out of 5) review of my book. The review, translated by Google for me, reads:

Mark Graban - the man behind the lean podcast - describes his experiences as a lean consultant in hospitals. It is an easily readable book that the idea behind lean in hospitals treats and practical tools like Value Stream Mapping Work and standardized. Add to this the many specific examples from hospitals and a practical and very valuable book is therefore at your disposal!

A Lean Guy Reads FORTUNE

As I was reading the latest issue of FORTUNE (October 13), I had a few Lean thoughts based on a few articles (which I can't find online at the moment).

In the "The Best Advice I Ever Got" feature, it's Bill Marriott, Chairman and CEO of the hotel company that bears his name. His advice, stated in brief:

I think Bill is a Lean thinker without realizing it. When teaching courses about Standardized Work, I often cite Marriott (as quoted in Toyota Talent) when he says that having standard processes and methods is NOT about creating "mindless conformity." As Toyota describes it, standard methods are all about eliminating the constant hum of (I think they put) the hundreds of decisions that would take place all day so you can have the mental bandwidth left to focus on the few major problems that pop up.

Marriott (and again I'm paraphrasing) said that standard methods allowed people be creative when that creativity was really needed to solve a truly unique problem. He doesn't want people asking themselves, "How should I make this bed today?" That should be standardized. But he doesn't want unthinking robots. It's brilliant. It's Lean thinking.

Back to asking for input -- this is such a simple suggestion, but one that goes unfollowed in many organizations. In many organizations, the boss is under pressure to be the expert, to know the most, and to provide the answers. It might take a humility that many leaders don't have -- to ask your employees what they think the answers are. If someone comes to you with a complaint or a problem, ask them, "What do you think we should do about it? Is that something you and your teammates can solve on your own? Or, do you need my help?"

Moving on, page 40 has an article titled "Audi's Clean Desk Fetish."

There's no mention of Lean or 5S (thankfully), but they talk about Audi's new U.S. headquarters where"employees were instructted to make sure their desks were paper-free at the end of each day."

This is the classic debate -- does a messy desk inherently create "waste"?? I think you can take a good concept too far. Being a neat freak for the sake of being a neat freak doesn't do anything for me (or a business, I think).

An executive V.P. said, "We want to create a sophisticated atmosphere."

Uh oh, I'm detecting someone who takes himself too seriously (looking at you, Johan de Nysschen). Are we looking for effectiveness and quality in our work or "sophistication"???

As you know, not that it's being done at Audi, I'm not a big fan of the ole' "tape around the keyboard" trick that's sometimes called "Lean." What do you think?

Student Lean Survey

From a student at Missouri University of Science and Technology, posted with permission:

Lean Awareness Survey: I have a Master’s student performing some very interesting research in Lean looking at Lean experience, awareness, and strategies to extend to the supply chain. As part of the research, we are investigating the varying levels of success in different environments, locations, and industries.

We hope that you will participate in this survey. The survey should take less than 10 minutes. Your feedback is very important to us.

How to Adjust your Lean Efforts in this Economic Crisis?

by Jamie Flinchbaugh, Lean Learning Center

I can't count how many times I've said that there is no recipe for lean. You must chart your lean journey based on both where you are and where you want to be. This requires knowing your current condition very well, including factors such as business conditions, resources, culture, and capabilities.

There is no question that we are in the midst of a very unique economic period. The financial markets are in turmoil, banks are collapsing at alarming rates, $700B bailout packages are being developed, and no one is sure where this will all end up. For those of you not fully paying attention, the credit squeeze is not a one-week issue. It has been a growing, very real, and very hard issue that many organizations, in particular manufacturing, have been dealing with for the majority of the year. How might this affect your lean strategy? Here's how.

For many businesses, and perhaps most manufacturing business, lean has been focused on profitability and gross margin, searching for ways to improve productivity, increase outputs, improve yields, and many other supporting metrics. But right now, the biggest and broadest threat to these businesses is a credit crunch. From manufacturers to car dealerships, the ability to get financing regardless of the cost is becoming more and more difficult. That means in preparation for difficult financing challenges ahead, or in response to them being difficult now, focus your lean efforts on cash preservation. Very good businesses may still go bankrupt for lack of credit and capital.

What does this mean? For many of your lean efforts, they are probably appropriately focused. If you are improving productivity, or reducing defects, or improving uptime, then those will in turn improve profitability and cash flow. But some things will change. Here's the short list.

First, those projects that require some investment whether $1k or $1M that will return greater savings in the future should be restrained. When focused on cash preservation, ROI isn't the only metric that matters. Something may have a return on investment of 1000% but if it consumes a large chunk of cash that you'd need to borrow, it just may be a bad idea. Put to collar on your kaizen teams and daily improvement programs with limits on spending, and make your primary message to these groups as "creativity before capital." You might be surprised that while no one likes to be collared, it does improve creativity. With no limits we jump around, but with boundaries we focus and find a way forward.

Second, go after those one time cash benefits. Kaizen your accounts receivable and collections process (if that's struggling) and improve it's effectiveness. Cut just a few days, or for a few of you a few weeks, out of this and that's one time cash in your hand. Lean of course has tended to focus on inventory. Have you done everything you can here? In normal conditions, you don't worry as much about pay-points as you do inventory velocity. Reconsider pay-points as it can free up cash even if it doesn't truly reduce waste. Of course also look at your assets. Organizations almost never look at under- or unused assets unless they are moving or are approaching bankruptcy. How's that pile of scrap metal sitting in the back? How about those machine tools that are underutilized? Or how about the laptops and desks sitting in storage? It's sometimes not about the best use, it's the best use right now, which may be cash. Use your waste lens and go looking for those one-time cash gains.

And if you have more cash that you think you'll need, survey your customers and suppliers very carefully. Who's struggling with their credit? What's value-add? It's providing something the customer values. Maybe, of course for a nice fee, you become a bank of last resort to these folks. It's in your interest to keep your supply chain stable and of course you provide value and get rewarded for it.

When you're turning around a company, cash beats GAAP and cash is king. We're not all in a turnaround situation. Some of you might be doing very well. But [almost] every business needs credit and loans to operate. Don't wait to find out that your credit isn't exactly there. It's a painful experience and one that just might be avoidable.

Mark's Q&A With Jon Miller, Part 1

Lean Manufacturing Blog. Kaizen Articles and Advice | Gemba Panta Rei

Jon Miller, the host of the Gemba Pantarei Blog, is kind enough to be doing a Q&A with me about Lean in healthcare and my book.

Please take a look and visit the rest of site. If you have any response or follow up on the Q&A, let's have the discussion on his site.

Lean (Not Mean!) in a Thai Hospital

Hospital management to become lean and mean

Here’s an article from a Thailand newspaper, where the “Lean and Mean” bug has also bit editors there (and I won’t repeat my ranting about that, though you can click here for some examples of previous rants or click the Lean and Mean link at the bottom of this post).

Lean, done right, is not “mean” to anyone – patients or staff members.

For example, is this Lean improvement at a Thai hospital in the least bit “mean?”

Very soon, patients will not have to spend hours queuing up to see their doctor or waste their time waiting to be discharged - all thanks to the "Lean Manufacturing" principles.

Lean management is based on not wasting resources on anything other than serving customers. This management philosophy was initially used by the Toyota Production System, which cut down on the seven time and resource wasting sins - defects, overproduction, conveyance, waiting, inventory, motion and overprocessing - a decision that helped Toyota grow from a small company into one of the world's largest automakers.

Now, this process is being brought to the health industry.

I’m not sure what to make of this next paragraph, maybe it’s a translation or editing problem:

Under the programme, hospital staff will be trained by Dr Kelvin Loh, a healthcare management expert from Singapore, who will evaluate the services offered, identify the processes that need to be eliminated and design a system that is both flexible and effective.

“…Thailand's healthcare industry faced problems in levels of productivity, the quality of services, and often the safety of patients was compromised. Besides, most hospitals, especially public hospitals, have limited manpower and have to cope with increasing workload.

Under the current process, nurses spend little time tending to patients and instead waste most of their working hours ploughing through paperwork.

Wow, that all sounds very familiar, whether it’s the U.S., Thailand, the U.K., or New Zealand. Hospitals everywhere tend to have the systems (or lack thereof) that create the same results and waste.

Managing to Learn, from John Shook

Managing to Learn: Using the A3 management process to solve problems, gain agreement, mentor, & lead

Published by the Lean Enterprise Institute, John Shook has a new book (available now) on the A3 problem solving process and on Lean leadership. You can download the first two chapters of the book online and see sample A3s.

Managing to Learn by Toyota veteran John Shook, reveals the thinking underlying the vital A3 management process at the heart of lean management and lean leadership. Constructed as a dialogue between a manager and his boss, the book explains how “A3 thinking” helps managers and executives identify, frame, and then act on problems and challenges. Shook calls this approach, which is captured in the simple structure of an A3 report, “the key to Toyota’s entire system of developing talent and continually deepening its knowledge and capabilities.”

The Key to a Successful Lean Journey? Leadership!

By Jamie Flinchbaugh, Lean Learning Center

A friend of mine, Kurt Woolley at Intel, has written an article for Industry Week that is quite popular. I thought I would share it here. It's title is:

The Key to a Successful Lean Journey? Leadership!

1. Removing ambiguity by teaching the organization to structure and standardize its activities;
2. Reinforcing and working on the system by helping people identify and solve problems;
3. Constantly setting the vision and ideal state… which creates healthy tension in the system; and
4. Practicing new learnings through application, application, application.

I encourage you to enjoy Kurt's article and experiences.

Screwed by Bad Software - Be Careful

WD Sync software on the WD Passport drive - WORLD Law Direct Forums

I'm furious. Really, I'm dumbfounded -- too dumbfounded to really be upset.

I thought I was doing all of the right things -- I was backing up my work laptop pretty frequently (or even obsessively) every week or two onto a portable Western Digital Passport hard drive. This was part of my "planned maintenance" plan for my data.

I bought the drive last year and started using the included "WD Sync" software instead of a separate backup program I had been using before... and will be going BACK to (Allway Sync). Here's my story:

My laptop crashed last weekend, NOT the kind of thing you need two days before starting a new client project. It was a Windows crash. The data was still there on the drive. I knew this because (being the geek that I am), I popped the drive out of the ThinkPad and put it into an external drive enclosure (like this), which I attached to my personal laptop (my MacBook) via USB. I pulled off enough files to get me through the week until I got a replacement ThinkPad from corporate.

When I got my replacement ThinkPad, I attached my WD Passport drive and started the WD Sync software. I expected (it turns out WRONGLY) that the software would be smart enough to say, "Hey, the PC's My Documents folder is empty, the user must need to restore a backup."

Um, no. The stupid software is "Sync" software. It SYNCS the laptop HD *to* the Passport drive. Only one direction. So the software basically blasted out my backup. DOH! Big time, DOH!! DOH!! What I thought was a "backup" was not a "backup."

I said worse than "DOH", words I won't type here.

Thankfully, I will get my data off the original ThinkPad from our tech support people. I'm not totally screwed, but please.... consider yourself warned if you use this software. It does NOT work the way you might expect it to work.

I know, "RTFM." Well, I'm sorry, that's bad design. That's why the first link on my post here is for a law firm that seems to be investigating a class-auction product defect lawsuit.

There's also this blog that talks about the problems. Comment #75 is another guy who did the same thing I did -- wrong assumptions about how the software works. The blog review says, in reviewing the drive:

Worst Features

Based on the comments posted to this blog entry, I’d have to say the worst feature is a lack of user guides or online “how to” tutorials for customers.

Additional Limitations of the WD Sync software:

1. The software only SYNCS data. If you backup a folder from your hard drive to the Passport device, this doesn’t mean that you can then delete that folder from your hard drive. Why? The next time you sync the WD Sync software will remove that folder from the Passport device. It considers your hard drive the “master copy” of the data. Any changes that are made to the master copy will be applied to the data on the Passport device when the next time you sync. If you want to avoid this situation, don’t use the WD Sync software that comes with the device. Instead, use the Passport device as a very large flash drive. You can manually copy/paste files to the external drive without using the WD Sync software.
2. Given the issue in #1, I would suggest not using the “automatic synchronization” option in the WD Sync software. This features starts the sync process the moment after you enter in your profile password. Why not? Let’s say that you have a hard drive failure. Luckily, your data is synced to your Passport drive, right? Well, I’m concerned that if you get a new hard drive and connect the Passport device, the WD Sync software will notice that the new hard drive doesn’t have any of the files and folders from the last sync. When it runs automatic synchronization, you may then lose the backup copy of your data! I haven’t tested this theory out (don’t want to risk it), but it seems plausible. Instead, I’d uncheck the automatic synchronization option found on the OPTIONS menu.

Avoiding the Use of Japanese Terms?

Blog reader Kevin wrote with this excellent question (used with his permission):

My question is about the idea I see many using in the lean blogosphere...and that being the continued and rampant use of Japanese terms when dealing with lean.

I have no inherent problem with these terms per se, I've been to Japan and love the culture, and the terms are 100% correct but as a lean implementer and leader of a lean group I don't allow those terms to be used. The simple reason being that using terms in their truest form like, "gemba", "muri, mura, and muda", "kaizen", etc make the perception of the activity jaded in the eyes of your customer, that being the operator on the floor and other members of any implementation.

I mean no disrespect to those that use these terms, but to me it seems that to the operator, when you say "let's go to gemba" instead of "let's hit the shop floor" or something similar, that the perception from the operator and others may be "Who the hell is this guy and why is he using all these fancy words that I don't understand?"

Therefore, I don't use them or permit them to be used. I translate these terms into the simplest form possible for my intended audience, so it doesn't appear that I'm trying to be a "typical" manager in the eyes of my customer or perhaps using words that seem scary or out-of-place to those I'm wanting to help.

Like Thomas Jefferson said, "The most valuable of all talents is that of never using two words when one will do." and Ohno stating that "The most dangerous kind of waste is the waste we don't recognize"....since ultimately you are going to have to explain what these Japanese terms mean then you are in fact violating both men's prophetic words? What are others thoughts and experiences?

My response to his question was this:

I do my best to avoid all but the most common terms, like kanban, gemba, and kaizen. I introduce those terms in initial team and staff training, but just so people are aware if they see the terms in the literature - heijunka, poka yoke, jidoka.... I always emphasize that we shouldn't try to wow anyone with our use of Japanese terms...

I know there will be disagreement about this -- what do you think? What do you practice?

Hospital errors strike again (and again and again and again!)

By Mike Thelen:

Having spent the last 10 years working within Lean disciplines, it is second nature to identify shortcomings in any business model from a Lean perspective. Since I also have two individuals in my immediate family who work in healthcare, I tend to *find* many opportunities for Lean simply by listening to dinner conversation. Thus, when articles like the following cross my homepage, they seem to demand my attention.

RI hospital group says doc operated on wrong knee

Sep 19, 8:18 PM (ET)

PROVIDENCE, R.I. (AP) - State health officials were investigating how a surgeon operated on the wrong knee of a patient Friday at the Miriam Hospital, part of a medical network that was reprimanded and fined $50,000 last year for three mistaken surgeries at another of its facilities.

The latest mistake happened while a surgeon performed a knee arthroscopy, a procedure in which doctors insert a pencil-sized camera into the knee so they can diagnose a malady. In some cases, surgeons will repair or remove damaged tissue.

After the operation was complete, the surgeon realized the mistake and operated on the correct knee, hospital officials said.

Miriam spokeswoman Linda Shelton would not identify the doctor or patient, whom the hospital said was "doing well.” Lifespan, the not-for-profit corporation that operates the hospital, has started an investigation into the accident.

"We deeply regret that such a mistake occurred," Lifespan said in a written statement. "We have apologized to, and are working closely with, the patient and the family."

The state Department of Health was alerted to the mistake Friday and sent a team to investigate, department spokeswoman Helen Drew said.

"We're obviously greatly concerned about the incident and the patient," she said.

Lifespan revised its policies following a string of wrong-side surgeries at Rhode Island Hospital, a teaching facility for Brown University's medical school.

In November, the chief resident started operating on the wrong side of an 82-year-old patient's brain, health officials said. A different doctor performed neurosurgery on the wrong side of another patient's head in February.

In August, a patient died several weeks after a third doctor operated on the wrong side of his brain. Afterward, state health authorities ordered the hospital to take steps to avoid similar accidents in the future, including an independent review of its neurosurgery practices and better verification from doctors of surgery plans.

Creating a Lean Family Practice

Creating a Lean Practice - April 2006 - Family Practice Management

I started a new client project yesterday, so I'm a bit swamped. I'm excited to be doing some work in a direct patient-care setting.

This linked article is a good one about the opportunities for Lean in a family practice type setting. I hope you find it interesting, regardless which side of the provider/patient relationship that you're on.

Ford, Henry Ford, the Model T, and a Hospital

Ok, so I'll combine a mish-mash of Ford related topics into a single post here.

First off, it's the 100th anniversary of the Model T, introduced in 1908. Yesterday's USA Today has an article about the anniversary and some interesting tidbits, including some details about what a different driving experience it was.

For all of the talk about the environmental impact that cars had, or still have, it's an eye-opener to look back and think that cars ("horseless carriages") were a solution to an altogether different environmental (and health) concern:

When the Model T first hit America's roads, cities were choked with people and horses, and the top public health nuisances were horse manure and urine and flies. One New York forecaster warned that by 1930, manure would reach the third story of Manhattan's buildings.

So, thank you, Henry Ford (and the other earlier automotive innovators).

Speaking of Henry, I really like using the following quote from one of his own books -- from almost 90 years ago (1922)!!

My life and work By Henry Ford, Samuel Crowther:

"In the ordinary hospital the nurses must make many useless steps. More of their time is spent in walking than in caring for the patient. This hospital is designed to save steps. Each floor is complete in itself and just as in the factories we have tried to eliminate the necessity for waste motion so have we also tried to eliminate waste motion in the hospital."

Henry Ford not only created the Model T. Not only did he popularize the moving assembly line. He also dabbled in hospitals -- he was helping transform the former Detroit General Hospital -- the "this hospital" in his above quote.

And you know what? He was right then -- and he would be right TODAY if he walked into most hospitals. I show that 1922 quote and it really resonates with people. Much of the wasted motion and wasted time is due to the physical layout of the hospital or the patient care floor/unit. The waste is also driven by processes and lack of proper organization -- where are tools, equipment, and supplies stored?

So with many hospitals today trying to tackled those same challenges, it goes to show that Henry Ford was very much ahead of his time.

Today's modern Henry Ford Hospital (in Dearborn) is now using methods from Lean and the Toyota Production System. Toyota learned a great deal from Henry Ford and adapted and built upon it to create TPS. Proving that things come full circle, Henry Ford Hospital has created the "Henry Ford Production System" in their laboratory/pathology department.

What Is the Henry Ford Production System?

Last week, I saw an outstanding presentation by Dr. Richard Zarbo, the chief pathologist at Henry Ford. His talk focused on leadership and people development in a Lean setting -- as shown by this quote from their web page:

"The Henry Ford Production System provides fertile ground for self growth and it breeds the next generation of our leaders." -Richard Zarbo, MD

Upcoming Charity Auction with Norman Bodek

Some of you might remember that I was offering autographed book copies or autographed labels for "Lean Hospitals" as a fundraiser for the Josie King Foundation (an organization that promotes patient safety). I've had a few people make donations for autographed labels. The offer still stands (again, the link for that is here).

Brainstorming with Norman (before we recorded what will be episode #52 of the LeanBlog Podcast... plus bonus material that will make for another episode), we came up with a way of raising more $$ for the Josie King Foundation.

I'm going to produce a 4 audio-CD set of Norman's collected Podcast interviews. That's four full CD's of Norman's wisdom and thoughts on Lean. There are going to be just three autographed versions of this CD set, a very limited edition -- one for Norman to keep, one for me, and one that we'll auction off on eBay in the near future.

The package will not only include the autographed CD set, but you'll have your choice of one of Norman's PCS Press books personally autographed for you.

If there is demand from people to purchase CD sets, we may offer those for sale, but we'll do the auction first and one winning bidder will have a very unique collector's item set - the autographed CD set AND the autographed book.

Stay tuned -- I'll let you know when more podcast episodes will be released (probably starting next Monday, Oct 6) and when the auction will take place on eBay.

"If you didn't do it in Six Sigma, then it didn't happen."

Guest Columnist - Quality Digest

Wow, this is pretty bad... allegedly about GE. Granted, any dysfunctional Lean company could end up with similar dynamics. So none of this is knock on Six Sigma... it's about human nature and organizational dynamics.

There's an expression that pretty much describes Six Sigma's infiltration at GE: If your only tool is a hammer, every problem starts to look like a nail.

I explained that while I was doing this project, I had found and fixed several other processes. I was immediately admonished by one of the Black Belts for doing so. She told me I should've turned these into Six Sigma projects. I explained that it made more sense to me to quickly make the fixes so we could start reaping the benefits right away. Her retort was, "If you didn't do it in Six Sigma, then it didn't happen." Of course, her metric of preference was dollar savings from Six Sigma projects. She couldn't care less that what I did was the right for the business. She, like many other Six Sigma "devotees," was only interested in managing her career.

Wow, the Joint Commission Moves Slowly

Heparin errors and patient harm have been in the news quite a bit the last few years. So what are hospital regulators doing about it?

Let's look at the time line here:

2006: Heparin error kills 3 babies in Indianapolis

2007: Heparin error harms twins in L.A. (Dennis Quaid's kids)

2008: Regulator says hospitals need strict heparin rules

Really? It took until NOW to get some guidelines and recommendations out to hospitals?

The Joint Commission issued a safety alert saying hospitals need to adopt prevention measures that could include bar-coding technology for medicines or computerized drug orders. It advised hospitals to more closely monitor patients on these drugs and make sure that adult-strength heparin is stored nowhere near children's units.

The alert said 28 deaths are among 32 reports of drug errors involving blood thinners that it received between 1997 and last year.

"We know that there are many more (deaths) and ... that's the reason for issuing this alert," said Dr. Mark Chassin, president of the Oakbrook Terrace, Ill.-based commission.

Christine Cahill, a government inspector, walked in to the operating room of a Los Angeles county hospital and found a technician cleaning a surgical instrument. He told her that he had just washed it, but she noticed no water in the sink, so she questioned how he had cleaned it, and he said he had used a cleaner that was in a bottle on the shelf.

"Give me a Q-Tip," she said. She shoved it into the hollow bore of the instrument.

"Out came this crud," she recalled. It was dried-up fragments of bone and blood.

At one out of every three hospitals Cahill surveyed for the federal government in California from 2004-06, she said she found egregious deficiencies that put patients’ lives at risk. Yet these same hospitals, within a year before her review, had received passing grades from the Joint Commission, America’s top healthcare evaluator.

It gave its most prestigious honor — its trademark Gold Seal of Approval — to Martin Luther King Jr./Drew Medical Center, where Cahill found the filthy surgical instrument.

And the commission also awarded that top honor, symbolizing that a hospital has met the most rigorous standards for patient care and safety, to John Peter Smith Hospital in Fort Worth in spring 2006 — the year before an independent consultant documented pervasive problems that put patients at risk.

Presenting at the Lab Quality Confab

I'm giving a talk this morning at the "Lab Quality Confab," an event for hospital laboratory leaders. The title of my presentation is "Engaging Employees to Embrace Lean and Energize Their Creativity."

I think hospitals have a long way to go in fully engaging their employees and team members in continuous process and quality improvement.

Comments I've heard from hospital staff over the past few years include:

"With all of the automation, I feel like a robot."

This was a 25-year lab veteran who had seen her job "advance" from very manual scientific testing to a role where she "just moved tubes and loaded them into machines." She felt very detached from the science, just pushing buttons on the new generation of equipment. She felt like a robot, partly because she wasn't being engaged in any workplace improvement.

Ironically, you sometimes hear the complaint that Lean will "turn us into robots" because people are afraid that Standardized Work means we want people to shut off their brains. Not at all! While her routine work had become automated, Lean was an opportunity to start getting engaged in solving problems and making things better in the process.

"I've worked here for six years and this is the first time anyone has asked me what I think about anything."

This was a comment from a nurse during an initial Lean implementation. It's always sad to hear things like this (even if it might be a bit of an exaggeration, the "first" part). Or maybe it's not.

The Lean methodology and management system gives supervisors, managers, and leaders some powerful ways of engaging staff and employees, creating an environment where everyone is listened to and considered and involved in daily improvement. That's much better than a "check your brain at the door" mindset.

"They want us to check our brain at the door.... don't bring up problems, don't be a troublemaker."

This is sad to hear whether it's coming from an assembly line worker or a hospital employee. Nobody deserves to be put in a position where they feel like they can't contribute to improvement.

We have to do better. Improving employee satisfaction also leads to better patient care, according to one study (and my intuition). Take care of the people and they'll take care of the patients, don't you think?

What have you done to help engage employees, via Lean, either in a healthcare setting or a factory or someplace else?

Book Review: The Ice Cream Maker

The Ice Cream Maker: An Inspiring Tale About Making Quality The Key Ingredient in Everything You Do

I was reading the WSJ a while back and was intrigued by a book recommendation by Chrysler's Robert Nardelli (you can read that article here, a PDF).

They [Chrysler] also saw a tendency for the company to use the cheapest parts available, even if that compromised quality. In an effort to turn the situation around, people familiar with the matter said, Mr. Nardelli had dozens of top Chrysler executives read "The Ice Cream Maker," a book by quality consultant Subir Chowdhury.

• Quality is defined by the customer
• The surest path to improved quality is getting your front-line employees involved
• Take care of the employees and they'll do the right things for your customers

LeanBlog Podcast Update

Update on the Podcast, since that's fallen to my personal back burner since my book came out.

Good news, though, for those of you who have missed it (and thanks to those of you who have emailed about out) -- the next episode should come out next week, a discussion with retired Lt. Randy Russell from Jacksonville, FL, talking about the use of Lean in law enforcement.

Other upcoming podcasts (with verbal commitments):

• Norman Bodek
• Dan Markovitz (Lean in administrative settings)
  
• Dr. John Toussaint (ThedaCare and Lean)
• Prof. Steve Spear (his upcoming book)
• Dr. Tom Evans (Iowa Healthcare Collaborative)

Lean meets Green in Burt's Bees CSR

By Jason Turgeon:

Burt's Bees started out making natural beeswax lip balm back in the '80's and ended up making hundreds of other similar body-care products before the company was sold to Clorox last year.

I keep a tin of Burt's original beeswax lip balm in my pocket at all times, so I was intrigued when I saw that the company had just released its first-ever Corporate Sustainability Report (CSR). But let's face it--voluntary CSR's