Tag Archives: lean in healthcare

The Final Frontier

On May 5, 1961, Alan Shepard became the first US astronaut to journey to the “final frontier.”  Atop a Mercury rocket, Shepard launched into a fifteen-minute suborbital journey reaching an altitude of about one hundred miles before returning to earth.  His space capsule, Freedom 7, was a wonder of science weighing a little more than one ton and loaded to the max with avionics and life support apparatus. Yet, this pioneering venture into endless space would also afford almost no space for the passenger.  According to launch engineer, Guenter Wendt, “astronauts entered their capsules with a shoehorn and departed with a can opener.”   I remember watching footage of Shephard squeezing into his capsule.  The memory still creates pangs of claustrophobia.

Ironically, space constraints faced by NASA fueled a revolution in miniaturization evident in almost every innovation of modern society – from laptops to cell phones to transportation to medical devices to all things Internet.  The need to pack more utility into a small package has changed everything.  Or almost everything.  Here are some recent exceptions:

“We’re adding a new wing to manufacturing,” a colleague related to me recently, “we’re running out of space.”   As I glanced around a shop floor crowded more with material than machines, I asked, “What are you going to put in the new space?”  “We’re just going to spread out,” he said.  “This is a good time to build before interest rates start to climb.”

Another manufacturer advised recently that he was building a Lean warehouse.  “What’s that?” I asked.   “We’re relocating all of our raw material to a location that’s closer to the main highway,” he said. “We need to add several machines, so were Lean-ing out the space.”    “Aren’t you just adding more space and moving inventory farther from your floor?”  I asked.  His response: “Warehouse space is cheap.”

A major hospital requested Lean assistance to re-design its perinatal services in order to accommodate more patients.  After reviewing the current operation, I recommended that existing space could be repurposed to handle the projected growth. “No,” they said, “We’re cramped. We need more space and the budget is already approved.”

It seems that decisions regarding space are driven more by claustrophobia or perceived worth than actual need.   Flow distance may double or triple as a result of expansion, but additional space somehow still equates to growth.   More space is viewed as an investment, an alluring addition to the balance sheet, or a badge of success.   Only on rare occasions do I encounter a growing business that is interested in reducing space. Perhaps, then, space is the final frontier.  Not more space, but less.   I wonder how much Lean progress would be made if space were seen as a constraint for business as it was for NASA’s Mercury launch.

How much space do you have?  Too much?  Too little? Share a story.

O.L.D.

PS I’m teaching the Shingo Institute workshop “Continuous Improvement” at MassMutual in Springfield next week and a few seats remain if you’d like to join us. Learn more here.

PPS I’m also looking forward to presenting my monthly “Tea Time with The Toast Dude” webinar on June 20th. It’s free! The topic is “Silver Bullet Mania”. Intrigued? Read more and register here.

Ludicrous Speed

speedMel Brooks fans will remember Spaceballs, his jocular jibe at the Star Wars epic. In pursuit of a rebel ship, evil Lord Dark Helmet (Rick Moranis) orders his crew to accelerate their craft beyond the speed of light to “ludicrous speed.” While time travel remains science fiction, our ability to process and transmit data has proceeded apace since I was a young lean dude. In college we expressed data transmission speed as a baud rate, a unit of measure roughly equivalent to one alphanumeric character per second. Geeks like me sat at Teletype machines watching our computer programs transmit programs at the blazing speed of 32 baud (i.e. 32 characters per second) to a shared computer at Dartmouth College, which then processed that information at a rate expressed in IPS, instructions per second.   Information speed was severely limited by the transmission and processing technology of the day.  By the time I graduated college however, speed had progressed to MIPS, millions of instructions per second, then to billions, and more recently FLOPS.   The trend continues today, bounded only by theoretical limits, towards ludicrous speed.

Fascination with information speed has been with us since 1953 when the first commercial computer was sold. At that time UNIVAC (Universal Automatic Computer) processing speeds averaged 0.002 MIPS. Only a handful of the world’s largest corporations could afford the million-dollar price tag for the twenty-nine thousand pound device that filled a four hundred square-foot room.   UNIVAC was the device that coined the term “real-time” defined as the “actual time during which something takes place” plus a few more MIPS for processing.   No doubt, the technological breakthrough was amazing, if only visible to a few persons.

However, compare UNIVAC’s real-time stats to the iPhone 6, weighing in at less than five ounces, and fitting easily in a jacket pocket. In a sixty year span, the speed of real-time has increased by nearly 130 million percent. Ludicrous speed! Moreover, smart phones are ubiquitous. Now everyone can have real-time information, not just a few large corporations. So what’s so ludicrous about that?

From a Lean standpoint, there are a number of challenges:

  1. First, is the barrage of media presented to us every minute of the day. How many emails must I routinely delete each time I handle my smart phone?   How many videos do I need to see on, for example, Kanban? YouTube lists 56,600 entries. Which of these is valuable to me? Which represent misinformation?   How can I confirm? In reality anybody can post any video today – with ludicrous speed.  No doubt, some of these videos will be excellent. But I could sort and sift through the YouTube haystack forever looking for good information.
  2. Second, the promises of automating Lean are alluring but insidious. For example, say some, do away with those pesky cards (kanbans) and replace with them with real-time kanban. This, unfortunately, separates the information from the material, assuring that the two flows will be out of sync. Moreover, the ‘instantaneous’ information becomes invisible.   Cyberspace is not a Gemba. We can’t go there to see queues or delays or problems.
  3. There is a paradox in the lack of connectedness that has derived from this ludicrous speed of information flow. An increasing number of persons labor under the delusion, for example, that texting is “talking to someone.”   At a time when we are finally acknowledging the importance of social science to real Lean transformation, we are at the same time interposing a tool that isolates people, that creates only the illusion of human interaction.
  4. The ludicrous speed with which we can all whip up professional-looking presentations today has blurred the distinction between looking good and being good. In the immortal words of Dave Lee Roth, “It’s not whether you win or lose, it’s how good you look.”   PowerPoint, the original “baffle-them-with-B.S.” application has been around for twenty-five years, but it is quickly being supplanted by a plethora of smartphone apps for 5S, standardized work , Kanban, Kamishibai, and..well…you name it! Why do we do this? Because we can.   The words of my old-school TPS teacher are ringing in my ears.   Responding to my PowerPoint-drawn value stream map, he replied “Don’t make it pretty, make it accurate.
  5. Finally, as with material flow, when we focus primarily on cycle time, those nanoseconds of computer processing and transmission, we lose sight of the often huge stagnation time of computer queues, the automated over-production of information (produced before it is needed), and the total elapsed time for information flow, which includes the batching of information before input and after output. Those times can be truly ludicrous.

I’m admittedly a participant in the information age and I benefit from its ludicrous speed.  I use the Internet, for example, to write my posts and revel in the opportunity to pull in links to humorous video, historical background and scholarly articles.   But I worry that the ludicrous speed with which I send and receive information today may not be leading to more wisdom.

Please share your thoughts. Do you agree or disagree with the challenges I’ve posed? Can you think of other challenges?

O.L.D.

P.S. GBMP has lined up several Shingo Institute workshops this winter and spring. For those who wish to learn how to create and lead sustainable cultures of excellence based on the Shingo Model and its Guiding Principles, we hope you can join one of our exceptional Certified Facilitators at an event near you soon. Read all about the courses and our faciliatators here.

Also, it’s long been a part of my organization’s mission to help build a community of passionate lean practitioners, leaders and learners and we at GBMP are proud of our Membership Mission and program. You can read all about it here. After more than a decade without a change in the annual fee to belong (which has always been an astonishingly low $495 per year for a company-wide membership),  dues are going up in March of 2016. Not without additional benefits, we promise. And not without the option to pay the current price to keep the current level of benefits (plus a few new ones). Beat the increase by signing up for or renewing a current membership now so you’ll get all the benefits of our GOLD Membership for the old price.

Up, Back and Around

up backWatching the US Women’s Team take the World Cup last week caused me to reminisce about my short-term coaching stint of a U12 soccer team. Before becoming a coach, I hadn’t played soccer or even watched a game, but there were not enough coaches in our town league so I volunteered.   After a two-week clinic for new coaches, I’d learned enough to know when I was allowed to substitute players, what was meant by off sides and a few other key rules. I’d even learned how to clumsily dribble and pass, but, like many other coaches, not well enough to actually teach the kids.  Fortunately for the team, however, a parent of one of the players knew John G., a local resident who at one time had played on the Portuguese national team. John seemed to know everything about soccer from basic skills to game tactics and even strategy for the season. Beyond this, John motivated and energized the kids. His personal enthusiasm and love of the game was contagious. Whenever I would thank him for sharing his skill and experience, he’d humbly respond, “The game is the best teacher.”

“No doubt,” I thought, “the boys are learning to play by playing, but John G. observes each boy’s every move, making subtle adjustments in skill and teamwork.”

Practice, after all, does not make perfect; it makes permanent. John had the boys practicing dribbling, passing and kicking the right way. Over the course of the season, every player improved individually, and the group of giggly eleven year old boys became an accomplished team – not World Cup, but pretty darned good.   “Better teams beat better players,” John G. exclaimed when any player appeared to be less than selfless in his play. Along the way I also became a better coach observing and listening to him.

Watching the superb play last week by the US women reminded me of one more of John G.’s lessons, which like his other coaching tips have had direct application to my work. “Up, back and around” he’d shout to the field during scrimmage. “Don’t always try to beat the defender directly. If the resistance is too great, then pass the ball back to your teammate and play around the defense.” While this tactic appeared to be “two steps forward and one step back,” it led ultimately to many goals.

So it is approaching True North.   The goal does not change, but depending upon the resistance at any point we should take John G.’s advice and avoid forcing the play. Don’t try to change the status quo by yourself. Share with your team members, and take the change up, back and around.

Do you trust all of your team, or do you only pass to certain team members? Let me hear from you.

O.L.D.

PS I’ll be in Gorham, Maine on the 23rd of this month at Jotul N/A for an afternoon “Lean Learning Bite” event on Gemba Walks. Maybe you can join us. Here’s more info.

PPS We’re offering The Shingo Institute workshop “Discover Excellence” in Texas for the very first time at the end of the month. Check it out here.

And just one more thing – GBMP just released the agenda for its upcoming 11th Annual Northeast Lean Conference in Springfield MA. See the agenda, get more info about the event and register on the conference website: www.NortheastLeanConference.org

I hope I’ll see you there!

 

 

P-D Ratios

The last few weeks have been all things Shingo for me including a presentation at the Shingo Institute’s International Conference three weeks ago in Provo, Utah, followed by four days of Shingo Institute workshops at Vibco in Richmond, Rhode Island. Questions at both events about assessing for enterprise excellence caused me to reflect on a basic framework that Shingo himself used to explain the progression of what we refer to today as “Lean maturity”.

pdratioThe P-D Ratio was Shingo’s comparison of the time required to Produce a product to the time given by the customer to Deliver the product. A large P-D ratio, for example, was indicative of a producer who took much longer to produce a product than desired by the customer. In 1985, this was the condition in my business. We attempted to match the customer’s short “D” time by stockpiling inventory.   Our push production method, as Dr. Shingo called it, was “speculative”, that is to say we built to forecast. Unfortunately our forecasts were wrong much of the time and there was an abundance of Muda in our production system. The atmosphere in the plant was one of frenetic expediting, particularly at month and quarter end. I don’t recall using the word “culture” at the time, but in today’s terms we did not yet have a culture of improvement. Shortly after I took a job as materials manager, a question posed to me by a buyer from one of our largest customers, a compressor manufacturer, summed up our P-D ratio:

“Welcome to your new job, Mr. Hamilton.   Can you explain to me why your company takes sixteen weeks to fill an order for a product the size of my fist, while my company can make a product as big as a house and deliver it in a week?”

That mortifying question may very well have been the trigger for my first study of TPS. A read of Robert Hall’s Zero Inventories (1982) led via a footnote to Shigeo Shingo’s Study of the Toyota Production System (1981) and this is where the epiphanies began. The book was such a bad translation from the Japanese that it has become a collector’s item. (It was retranslated in 1989 to a more readable but less authentic form.) Using Shingo’s ideas, we began to shift our production from “speculative” to “authorized” – Mr. Shingo’s words to describe the shift from push production to pull. And little by little, the sixteen weeks reduced to ten and then five and eventually, over a period of years, to two weeks for our customer’s product. With starts and stops and lot of TPS learning opportunities, by 1990 we’d reduced the P-D ratio from 16:1 to 2:1, not exactly just-in-time, but improved enough to be recognized in 1990 by the Shingo Prize for Manufacturing Excellence.

By the fall of that year we were asked to tell our TPS story at the annual AME conference in Boston.   A team of seven persons from my company each told a piece of the story: what we’d learned technically and how we worked together to overcome challenges and develop an improvement culture. After our presentation, each team member sat at a different lunch table, anxious to hear from other participants. As I seated myself for lunch, the gentleman to my right was already talking about some impressive results: shorter lead-times, inventory reductions, lower costs. Not to be outdone, someone across the table talked about same day delivery.   Another told a story of enormous cost reductions. “These are really impressive results,” I thought to myself.

I broke my silence by announcing that while my company had worked very hard to improve, our results were not nearly so compelling as those described by others at the table. Hoping to capitalize on the experience of others at my table, I then asked, “What companies are you with?”  To my complete surprise, everyone else at my table was a consultant. One was pushing Theory of Constraints, another was into TPM and a third was an MRP consultant. The rest were Lean consultants, a relatively new idea at that time. All had business cards in hand. Suddenly their improvement claims seemed a bit less credible. In 1985, there had been almost nothing written about TPS and the only Lean (TPS) consultants were from Japan. It was hard to find companies that had even heard of TPS. But, by the 1990 AME conference, Lean consultants were apparently multiplying like lab rats.   The group at my lunch table outnumbered the doers by 9 to 1, a ratio that was later borne out more generally by other of my team members. “Lean is good business for consultants,” I skeptically thought to myself, “but what about their customers.”

pdratio2Revisiting Shingo and his ideas over the last few weeks at conferences and training, I’ve concocted a whimsical P-D ratio for us to keep an eye on: The ratio of Pundits to Doers. (Yes, I am now a Pundit too.)   Today’s pundits have titles superior to consultant: Lean Expert, Lean Practice Expert, Sensei, Master Sensei, Black Belt, Guru and so on. Have a laugh –  We’re even on Weird Al’s radar!   My unscientific application of this Pundit-Doer ratio leads me to believe that while there are many more Doers now than in 1990 (the good news), the Pundit-Doer ratio is getting larger (the bad news.)  There are more of us, both internal and external, than there are doers.

During a recent discussion with my board of directors, the question was posed: “What do we want GBMP to look like in ten years?” One astute board member commented, “Perhaps we should ask ‘What do we want our customers to look like in ten years?’”

Where is your company on Shingo’s P-D scale?   Where do you want to be in ten years? Please share a thought.

O.L.D.

Hey! Speaking of Shingo, there’s still time to register for our next Shingo Institute Discover Excellence Course, June 9-10 at Smith-Midland in Midland, Virginia. You can register here.

Also, this week is the last call for the early bird registration discount for our 11th Annual Northeast L.E.A.N. Conference on September 29-30, 2015 in Springfield MA – a great event to meet, hear from and share with other “doers” just like you.  Read more and register here.

Finally, I hope you’ll join me for my next “Tea Time with The Toast Dude” webinar on June 2. It’s FREE! I’ll be discussing Overcoming Organization Obstacles to Lean. Get the scoop here.

3P – Putting People Phirst

With our 10th Annual Northeast Conference just eight days away, I’ve taken a little poetic license with the conference theme, Putting People First, to highlight just one of the outstanding teams who will be presenting at the conference:

3p Phirst

The “ideas of many” built from cardboard and brown paper.

Two weeks ago I had the honor of attending the ribbon cutting for the West Suburban Cancer Center in Needham, Massachusetts.   This innovative center was conceptualized in the spring and summer of 2012 by a diverse, dedicated cross-functional team of approximately 30 docs, nurses, technicians, physicists, architects, facilities engineers and administrators using a technical method referred to as Production Preparation Process, or “3P”.   While the structured, rapid brainstorming and prototyping methods used to design the new center design were important to the success of this large project, far more crucial were two principles that guided everyone’s thinking:

  1. A single-minded Patient First principle focused everyone’s thinking on the best possible experience and outcome for the patient and patient’s family rather than just maximizing local efficiencies of the providers.   Patient focus groups provided an essential perspective that kept the team grounded. Using tabletop models to simulate the patient flow, in one instance reducing patient moves from twenty-two to five, the team was guided by the philosophical position that the needs of the customer must come first.
  1. The project’s mantra, “The ideas of many are better than the experience of one,” challenged team members to collaborate in a way that encouraged everyone’s ideas.   With encouragement of BIDMC management and support from facilities and architects, the new center was actually designed by the people who work in the space. In the words of one team member, “We ended up with a design that no one could have foreseen when we started the project.”

As I entered the new cancer center and surgical pavilion, I recalled the original cardboard and brown paper structures that the team had built in order to test and improve their design. At the entrance, I was greeted by one of the physicians who participated on the 3P effort.   She remarked excitedly, “This new design really works!” That excitement was shared by other team members who attended the grand opening, and, I must admit, by me also. The technical achievement was outstanding, but would never have been possible without the focus on people.

There is so much more to this success story than I can relate in a post. I hope you’ll join me on October 1 and 2 at the MassMutual Center in Springfield, Massachusetts to hear more from this team and others who are ‘putting people first’. Still time to register and recharge your Lean efforts.

O.L.D.

I’m Against It!

A recent viewing of a Marx Brothers film caused me to reflect on one of the questions I’m frequently asked, “How do you deal with people that are against Lean?”

i'magainstitMy stock response is to quote Shigeo Shingo’s advice that “99% of objection is cautionary,” that is, persons who appear to vigorously object to Lean are really just asking for more information. I confess that, while this answer puts a positive spin on objection, depending upon who is doing the objecting, it doesn’t really answer the question.

For example, very early along in my TPS discovery process while I was away from the plant for a week’s vacation, two of my fellow middle managers, armed with apocalyptic predictions about employee empowerment, took advantage of my absence to make an end run to the corner office. Upon my return, our CEO confronted me: “I understand that you’re turning all of the decision-making over to the employees,” he said.

In another context, I might have taken his words as a compliment, but given the tenor of our organization at the time and the stern visage before me, I quickly understood that I’d been thrown under the bus.   A practiced counterpuncher, I was fortunately able to respond with a few compelling examples of decisions made by frontline employees to make improvements or solve problems, thus diffusing my adversaries’ arguments.  I thought to myself, “Thank goodness I didn’t take a two-week vacation. I might have been fired by then.“

There are several points worth noting here.

  • First, had our CEO occasionally visited the front lines, he would have been in touch with what was actually happening and would not have been vulnerable to the emotional arguments of naysayers.   Unfortunately, too often in the early stages in Lean transformation, the CEO is only passively involved.
  • Secondly, at least some of the time, factual arguments will trump emotional ones. The top manager usually has no ax to grind with any department or division; his/her interests lie in the prosperity of the entire organization.
  • Third, middle managers are often troubled by a perceived loss of authority among their direct reports. If front line employees are empowered, does that make the managers less powerful?
  • Fourth, middle managers may resist a change that they perceive is a threat to their turfs.   For example, “quality at the source” may be seen as an attempt to eliminate the inspection department. Or Kanban may be perceived as a threat to production scheduling.   If improvement implies organizational change to their turf, territorial imperative kicks in.
  • Finally, early Lean successes will sometimes create professional jealousy. Managers may perceive the rising star of a lean leader as a threat to their own advancement. For these managers, the response to the change leader’s ideas is likely to be “whatever it is, I’m against it.”

To be sure each of the concerns above could be characterized as “cautionary.” At a later point in the Lean journey, many managers will come to realize that their early concerns were horse feathers; organizations and individuals do change — for the better.   But in the earlier going, change leaders need to be mindful of and responsive to managerial objections. How we do that is the topic of my October 14 Tea Time with Toast Guy Webinar.

O.L.D.

Alert: Our 10th Annual Northeast Lean Conference is now less than a month away. I hope to see many of my readers there as the theme, “Putting People First,” is recurrent in the O.L.D. annuls.   For the last four years my posts have dealt primarily with management’s responsibility to create an environment that’s favorable to problem solving and continuous improvement – and that too is the theme of this year’s conference. I hope to see you all there!

BTW: Attend my next free Webinar next Tuesday, September 9, and you could win a FREE registration to our 10th Annual Northeast Lean Conference. The topic: “Getting Suppliers Involved – Do’s and Don’ts.”  Register here.

Frankenstein Equivalents

frankensteinI was speaking with a friend about a recent downsizing at his church. After nine years, a popular priest had been reassigned to another parish. In an apparent effort to cut costs, a new priest would now split his time between two parishes in neighboring towns. When I expressed some regret about Father S’s departure, my friend replied, “It’s not so bad. If you look at total staffing, the number of FTE’s hasn’t changed much.”

For the uninitiated, FTE’s or Full Time Equivalents, is a ratio between the total number of paid hours during a period and the number of working hours in that period. The ratio units are FTE units or equivalent employees working full-time. In other words, one FTE is equivalent to one employee working full-time – sort of.

For example, having one priest, presumably with more assignments, commuting between two parishes did not seem “equivalent” to me, but I kept that thought to myself. My friend, a doctor at a nearby hospital knows all about FTE’s. It’s a codeword in healthcare used to describe head chopping in the name of cost reduction. It’s a convenient way to dice up people’s work and then, like Dr. Frankenstein, sew them back together as if they were a whole.

frankenstein2In healthcare, the priest is replaced with a doctor who literally runs between campuses, or a nurse who covers two floors simultaneously. At the front door of a business, the receptionist is gradually loaded with new tasks until there is no time left to greet visitors. Or maybe the receptionist is chopped altogether, and that work is sewn onto another job somewhere in the office to create an FTE. Now there is only a phone and phone list in the lobby. On paper these may look like improvements but, in real life, who benefits? Saving lives, saving souls, saving customers – they all require whole persons, not pieces stitched together as FTE’s.

How about in your organization? Are you employing real persons or Frankenstein Equivalents?   Share a story.

O.L.D.

Don’t forget: Our next Tea Time with Toast Guy Webinar will be on Tuesday, August 12 from 3:00 – 3:45 p.m.   The topic is “Creating a Realistic Pace for Improvement”. Read more and register here. Bonus!  We’ll select one person from the list of participants to win a free registration to our October 1-2 Northeast L.E.A.N. Conference. Learn more about the conference here.