The Venn of Improvement

Those who have worked in quality improvement and problem solving know that there is a lot in common between different improvement or problem solving methods (considering that a problem is any gap in performance according to Toyota experts), and that they follow the same reasoning process, start by understanding the problem, coming up with ideas and implementing them. Concepts like divergent-to-convergent thinking, iterations, and pilot testing are usually applied.

Lean thinking, the model for improvement, and design thinking, are just three of the problem solving or improvement methodologies that are well-known and have shown strong evidence of successful outcome in healthcare (especially the first two), and I believe that they could provide answers to the many issues that plague healthcare systems in the world.

I've developed the Venn diagram shown just trying to get my head around them and see understand how they could be related.

Lean thinking is the term used to refer to Toyota Production System, with it's mindset, tools and methodologies, with A3 thinking as the main frame for problem solving. The model for improvement (MFI) was developed by Associates in Process Improvement as a method for accelerated rapid changes, and is adopted by the Institute for Healthcare Improvement (IHI) as their main frame for quality improvement with many successes world-wide. Design thinking is the process of creative problem solving which was adapted from engineering to business processes by David Kelly, who founded IDEO and the Stanford d-school.

In my opinion, all three methods are based on the scientific method of experimentation, and aim at solving problems using human centered approach. They focus on understanding the current status and the problem at hand first, and emphasize studying the initial results before implementing the changes or solutions. The tools and techniques used in each method are all common quality and problem solving tools, perhaps with some variations among them.

Lean thinking and the MFI share the famous PDSA cycle, which is evident in Lean's A3 thinking as the main framework for planning and implementation if improvements or countermeasures, and as a pilot testing vehicle in the MFI.

Empathy with the people needs, and defining the value from the customer point of view are shared among Lean and design thinking, and considered as the first step in each method.

Lastly, MFI and design thinking uses iterations and testing to reach the best answers possible, with repeated and linked PDSA cycles and prototyping as the major processes in each one, respectively. They also uses different tools for generating ideas at the beginning before coming up with the best ones to test.

What other similarities or differences you could think of?

The Case for Lean-3

... continuing
The Quality Myth:
Complying with best practices or standards, national or international, is a good start to build a foundation for a safe and standardized care. However, this is not how it’s being handled or at least viewed in many healthcare organizations, let alone that meeting standards does NOT guarantee positive results or outcomes of care, according to many experts.

Many organization mistake complying with “accreditation” standards with the notion of achieving the right level of quality and safe care. In fact, doing that may actually jeopardize safety and quality of care by settling with minimum requirements, adopting a very rigid view point, or focusing on documentation rather than sustainable changes in actual practices. And because of that, no rooms is left for creative problem solving or daily continuous improvement. Staff in such organizations, using their own words, have become robots memorizing and following a set of external standards, often without even knowing the rationale behind them. And when a situation arises that call for innovative solutions or new ideas, they seldom step up, much like a linear school system based on fixed subjects evaluated by final exam results only. So, instead of investing on people to lead and improve quality and safety, those hospitals have created disengaged and uninterested work force that get real hype only by signing the final box on a piece of paper.

Decision makers in healthcare organization need to understand clearly that writing a policy or adding a checklist does not guarantee good results in real patient care. They need to ask the questions: what is a “good” outcome of care they aspire to provide to their patients, and how does complying with the same standard over and over again achieve that?.

I recall looking at one Linkedin post by a very famous hospital group in India. The post advertises the attainment of accreditation by the JCI, and states that it has achieved the most prestigious excellence award in healthcare in the world. I’m not sure if JCI accreditation (or any accreditation for that matter) can be considered an excellence award, and I can’t recall JCI referring to that itself!
The problem with many healthcare organizations seeking international or even national accreditation is that their main goal, is to market their services and acquire more patients, and hence more business, or to satisfy regulatory requirements. This is well known among those close to the decision making and strategic planning (assuming there is proper strategic planning).

One of the private hospitals I know which somehow succeeded in achieving multiple international accreditation, mentions in its documents that they support a continuous improvement culture through complying with accreditation standards. Not only this is a flawed understanding of what continuous improvement is, but when you ask the concerned staff about the standards they were accredited for, and are expected to apply in their daily work, you only get blank faces!

I’ve had the chance to come across a number of healthcare organizations, both governmental and private, that have obtained different accreditation status, and yet are notorious among their own staff, let alone the consumers of their services, as providers of poor quality and less compassionate care. This alone indicates without much doubt that obtaining accreditation is in most cases merely a certificate on the wall that has no real impact on the system of care.
The accrediting and regulatory bodies do also play a role in this misconception and malpractice. They need to revisit their strategies, and the criteria used in the evaluation of quality and safety in any healthcare organization, and how big is the value of granting accreditation for the communities served.

The IOM landmark report “Crossing the Quality Chasm” 15 years ago showed that healthcare systems were broken, misaligned, and fragmented. Sadly, the same problems still exist today, and the number of patients suffering from medical errors and poor quality of care are on the rise despite all the advances on the medical field and the efforts to improve quality and safety.
On the brighter side, there are some great examples around the world of healthcare organizations who succeeded somehow in pinpointing reasons of many common issues, whether it’s lack of vision and leadership, rising costs, miscommunication, medical errors, wasted time and energy on things that adds no value, patient dissatisfaction, demotivated or burnt-out workforce, to mention a few. Also, many countermeasures were put in place to overcome those issues with surprising results.
Some organizations adopted lean healthcare and continuous improvement as their everyday philosophy with a great deal of success, setting an example and paving the way for other healthcare organizations to follow or at least look critically at how they view quality and safety of care, and what they really need to change.

                                                                                                                     to be continued...

The Case for Lean-2

... continuing
The Documentation Era:
This has a lot to do with miscommunication, but it deserves a category of its own due to its magnitude and the dysfunctional way it was built into daily clinical practices. Everyone knows how important eye contact when communicating, and we have been taught in Med School how important it’s to talk to your patient without putting barriers between you and them, not even a desk. Nowadays, doctors do exchange good and constant eye contact, but the computer screen, busy typing and clicking while asking the patient for very important and sensitive information, and the poor patient gets only the side profile of the doctor’s face. This shows how much respect there is nowadays between doctors on one side, and patients and their families on another side, and the tiny if any amount of trust and rapport being built. The first step of the healing process!
It’s commonly said that if something was not documented, it’s not done. The reason behind pushing vigorously   towards it by many is an attempt to make sure that necessary information are available and accessible anytime, for better continuum of care, safety, and for medico-legal purposes. It’s clear that healthcare systems have taken the wrong turn on this and lost the essence of the whole value of documentation, to the point that it has become one of the main reasons for broken systems and unsafe practices.
Studies have shown that the national average of nursing time spend at the bedside providing direct care to the patients in the US is less than 50%. Most of the time is spent doing things that adds no direct value to the patient, including documentation. If you have the chance to observe a nurse in an inpatient unit for an extended length of time (the time you are waiting for your doctor, maybe!), you could see the huge amount of time wasted, not in delivering medications, not in assessing patients, not discussing cases or responding to patient and family needs, but in handwriting, typing, punching and stapling, filing and shelving , and getting papers signed or stamped. Nurses who are supposed to be closer to patients more than any healthcare professional have turned into secretaries who are overwhelmed with a great deal of paper or computer work, and the only touch time with patients in one day can be as much as 30 minutes in total!
Documentation is necessary, but over, redundant, and disorganized documentation has become an issue that everyone complains of, and takes providers away from their most important job they signed up for. What went wrong?
One of the clear factors is the requirement of some regulatory and accrediting bodies requiring all sorts of information to be documented in a certain way or format, and in the absence of creative and versatile care systems, or well-educated and smart health informatics professionals,  providers have no choice but to comply in the exact way. If you had to choose, provide better care (not medicine) with less documentation, or complete documentation but less care and compassion, which one would you opt for?
Another major issue is in the design and management of popular information systems in the market, many of which are not co-developed with healthcare professionals, never looked at actual care process, and only focused on what the doctor or nurse need to document or view. Even after incorporating all the requirements on a nice looking system, it turns out to be unfriendly and hard to navigate. On the other side, IT professionals managing those systems in a healthcare organization have no clue about the impact of adding one module after another on the care process, and don’t really bother to rethink and integrate documentation requirements when they arise, causing inflation of data in an already broken system..

                                                                                                             to be continued ...

The Case for Lean-1

During this year I had  unusual several encounters with a number of healthcare providers, sometimes as a patient, and others as a companion or caregiver, both in inpatient and ambulatory settings. This experience has lead me to personally reach a conclusion that  I’ve realized deeply: today’s healthcare is very dysfunctional and full of waste! This is not news for many of providers and consumers of healthcare, and definitely has been the case for decades, but perhaps the blessing (or curse in this care) of learning more about lean, system thinking, continuous improvement..etc, has made the picture so crystal clear and easy to spot, compared to the untrained eye.
The irony lies in that everyone claims they are providing the best quality, most compassionate and patient-centered. You could hardly find a healthcare facility without these as strategic goals, values, and slogans everywhere, while in the bitter fact, most of them are merely average. Another irony is that many for-profit organization assume they are making a lot of profit based on the financial reports, but if you look deeper, they are wasting as much money down the drain. Then we wonder why healthcare costs keep rising, and why quality and safety are not getting any better, at least in the patient’s eye.

Miscommunication:
No two people disagree that communication is one of the most important requirements of safe and good healthcare, and everyone preaches about that during meetings and conferences. So, we try to standardize it in a very restrictive manner, or  purchase high-end automated information systems. However, when it comes to real daily work, miscommunication is very common, and at many instances, highly risky.
One can easily notice the number of repeatedly asked questions by different healthcare professionals at any care setting, whether outpatient, inpatient or in between. It makes one wonder if there is any dialogue actually going on between receptionists and nurses, nurses and doctors, doctors and other doctors, you name it, and whether they really do work as a team like all the nice group photos posted on the walls or websites. This gap will eventually lead to waste in time, effort, and the cost of  sophisticated system, or at least paperwork, let alone patient dissatisfaction. Working in silos is an issue in healthcare that improvement experts talk about all the time, but is still very common and evident.
There are several factors that play part in this. The first in my opinion has nothing to do with the intentions or even the awareness of the providers about the importance of good communication, but with how the clinical care processes are designed in the first place. Most of the care planning is individualized, the information gathered about a patient condition are documented, sometimes overly, but not shared in real-time, and everyone know hot to navigate and fill fields on the computer, but not actually reads.  The other factor is more cultural.
The hierarchical relationship between healthcare professionals where the physician is still an authoritative figure that don’t communicate with others readily and openly, and by that I mean 2-way communication.  I’ve seen many cases where this disconnect lead to patient harm and sometimes death.

                                                                                                                          to be continued...

Lean Presentations

Garr Reynolds talking about effective presentations in  TED Tokyo talk

Da Vinci was credited for saying that simplicity is the ultimate sophistication. It seems that our modern life is plagued with complexity and unnecessary clutter in all aspects of life, one of which is the art and science of presentations design and delivery.

Presentation waste:
Many of the seasoned experts in the art of presentation design like Garr Reynolds, Nancy Duarte, even the late Steve Jobs, all emphasize the concept of simplicity in the content, visual design and delivery of effective presentations.
What does this have to do with lean? Lean is about utilizing the minimum to achieve the maximum, and this is what an effective presentation should do, not only on the visual design part, but also the content, and the way it's delivered. In their books, presentation experts talk about simplicity, restraint, and the signal vs. noise ratio, and editing ruthlessly to remove the unnecessary, where a presenter should use the minimum ideas, visual elements, and even time to deliver the main message without bombarding the audience with too many info and crowded slides that would cloud their perception and attention. When you see some of the great TED talks, you may notice the minimalism in presentation slides and delivery (sometimes even without slides) that the speakers apply.
Garr Reynolds refers to such principles as presentation zen, and he draws a lot of examples from the Japanese culture where he lives and works. Is it a coincidence that such principles share similar cultural roots with Lean?
The same thing applies to presentations of complex data in a simplified manner, much like what Hans Roslings has been doing in his presentations.

Presentations and respect:
As we know that one of the pillars of lean thinking is respect for people, and that also applies very clearly to the principles of effective presentation. "It's not about you, it's all about them", this is what Garr Reynolds and others say when designing their presentations (design is the overall planning process of a presentation, not only the visual part). It's about the audience, their perception, their interests, and their time listening to you. It's not about how good you look on stage or how fascinating the facts you are presenting. In order to do that, an effective speaker must study his audience before even putting in the content of his speech.

I read once that editing is the skill of the 21st century, where everything has become inflated and full of waste. This is in the heart of good presentations, and in the heart of lean.

On the Mend

A gem for any lean healthcare enthusiast or beginner.
In this book, Co-author Dr. John Toussiant explains the lean transformation journey of Thedacare Health System in the US over seven years, the early beginnings, ups and downs, pains and triumphs, managing change, techniques and lessons learned, in an anecdotal and story like fashion.
This book shows how could any healthcare system transform from the traditional management style to a lean management thinking, and what needs to be done to achieve that.
For me, this is the best book I've ever read so far about healthcare lean transformation, and it's a must read for any executive thinking (or not thinking for that matter) about running a health system in a lean way.
There are so many detailed examples of how to build the culture, set standard work for training and actual work, the results of applying lean on both clinical and business sides.
At the end, a nice chapter about how to start and what would Thedacare do differently to start a lean transformation journey, provided to all of us on a silver plate.
Some of the many lessons you could learn are:
1- The critical role of executive leadership in building a lean culture and system. Sounds like a cliche but for a very good reason as explained thoroughly in the book.
2- In Lean management, the focus is always about the patient, not the organization. The organization will definitely benefit along the way.
3- Traditional medical teaching and upbringing of clinicians and the challenges that create for change.
4- The importance of data and info in making the case for change and guiding the improvement work.
5- Aligning everyone in the organization to the true north through Hoshin Kanri..
6- Empowering everyone at all levels to be a problem solver.
7- The need for standard work for managers to lead and manage in a lean way.

If you are looking for one book that shows you how a traditional healthcare system moved into Lean thinking, this is the one!

Accreditation and Lean

It's true that accreditation of a healthcare organization does NOT necessary mean that such organization provide high quality and safety to its patients. There are many differences between compliance and improvement, in terms of goals, motives, scope, targets,and impact on the staff and culture. As a matter of fact, depending on the way compliance is marketed and implemented within an organization, it can be hinder the efforts for continuous improvement.
In this part of the world, compliance is usually mistaken for quality management, and the focus of many organization is just to implement the standards and pass the surveys, that's it. This is evident by the increasing number of healthcare organizations receiving international accreditation compared to the low level of care and safety provided. Sad but true!

Joint Commission International (JCI) , a group which follows the US-based-The Join Commission-had added a new standard for hospitals in 2014 which asks quality professionals to analyze the impact of improvements prioritized by the leadership on efficiency and therefore cost. I remember that a Lean project was the first thing that jumps to my mind when trying to comply to such standard.

It's really interesting to see accreditation bodies starting to look at efficient use of resources in healthcare, and the efforts made to improve that. This could be driven by the long standing and continuous rise in healthcare cost and expenditure not only in US but worldwide, to the point that it has become an international standard. I believe the success of lean healthcare organizations in US and other countries, and the fact that you can provide safe and high quality care while lowering cost through reduction of waste is a reality today proven by facts and figures. Advanced healthcare systems have realized today that a sustainable safe and quality care can't be accomplished without proper and efficient use of resources, with people as the main one.

Is it possible that accreditation bodies will demand healthcare organizations to adopt Lean in the near future ?

Red Beads

Watching the Master playing the Red Bead Game live!

During the recent IHI Middle East Forum in Doha, Dr. Don Berwick, Co-founder,President Emeritus and Senior Fellow of the Institute of Healthcare Improvement, demonstrated to us the famous Red Bead Game, used by Dr.W. Edward Deming in his famous seminars in the late 90's to teach how management should support workers to identify system problems and errors (the red beads), respect their knowledge and skills, and work as a team to improve, rather than blaming them using old management theories and biases.
The moment when Dr. Berwick was on the stage playing the game with a group of attendees was almost magical, delivered in a humorous yet classy way, bringing moments we didn't have the chance to live back from the days of the father of total quality management, Dr. Deming.
According to Dr. Berwick , the originsl games was lengthier, but he demonstrated a shorter version to give us a taste of it. Another interesting confession made by Dr. Berwick is that when first attended the famous 4-day seminar by Dr. Deming as physician back in 1986, he flew back home on the second day frustrated and convinced by the teachings of Dr. Deming, he thought it didn't make sense to him at the beginning. Then at a moment of reflection and uncertainty, he decided to fly back and continue the rest of the seminar, of which he is very proud of.
Some of the main lessons from the Red Bead Experience are:
1- There will be always variation and errors in every process.We must understand variation in data to draw the right conclusions.
2- Staff or workers can only achieve what the system allows them to. There is no point of rewarding or punishing them based on randomness of a system.
3- To fix a problem or improve quality, look at the system instead of the staff. The management has the authority to change it.

Below is a clip of the original Red Bead Experiment run by Dr. Deming. Enjoy!

Living Lean

Kondo Marie doing what she does best in helping others get red of the unnecessary things

Beyond the application of Lean in manufacturing, healthcare or any professional industry, the same principles of reducing waste and getting the maximum value with the minimum resources possible can and do extend to one's personal live.
A very famous expert on organizing homes is Marie Kondo, the Japanese lady (no surprise here) who wrote several books on the subject, with her NY Times best seller "The Life-Changing Majic of Tidying UP" , where she talks about removing waste from homes. Her approach (now referred to as KonMari method) is very similar to the known 5S approach of workplace organization, where you need to start by removing waste and anything that doesn't add value in your home (real value compared to sentimental value), then tidying up the rest in a simple and accessible way. I guess this has it roots in the Japanese culture in organizing living spaces to lead a more zen-like life.

A whole year's worth of trash from Bea's home can be put in a small jar!!!

Another leading expert in the subject of reducing waste at home to almost "ZERO" is Bea Johnson, with her famous book "Zero Waste Home", translated to 9 languages and showcased through  many international media channels. Her 5-step approach is also very similar to the 5S, with words starting with R instead: Reduce, Reuse, Recycle, Rot (only in that order). However, she adds to that the preventive first step of Refusing anything unnecessary that can turn into clutter from coming in our lives.

Both and many similar approaches highlight the life changing effects of minimalist living on the mental and psychological state of the residents, which resembles the positive impact of 5S on the workers in any work place.

I strongly suggest you to take a moment and browse the 2 related websites, the YouTube  videos, and learn some of these principles in de-cluttering your personal life.

Lean is for life!

Let's play Lean !

Completed figures representing patients who went through the system

In one of the regular workshop I have the privilege to run in my organization, we finish the day with a Lean simulation game to introduce some of the Lean concepts to the staff and hopefully make them intrigued to learn more about Lean.
The game is based on similar simulation games run everywhere by Lean practitioners, and I tried to customize it a bit to fit healthcare setting. It's based on the famous assembly vs pull/kanban production, where you compare the volume and quality of the final product, the remaining inventory or work in progress, and the productivity rate. Building blocks similar to Lego (couldn't find the right set of Lego that fits the  number of participants and allotted time) are used to build the final product, in this case it's a "patient", with the target of passing as many patients as possible through the system, with two teams competing. Here is how it goes:
1- Each team is composed of 5 members (can be modified according to situation).
2- Each player gets a set of blocks to complete a specific part of the patient.
3- The scenario simulates patient flow in an outpatient setting, with 5 steps of registration, reception, doctor's office, laboratory and pharmacy. Each member is responsible for one step.
4- The steps of the patient flow builds the patient part by part (e.g. making the trunk, adding legs, arms, head..etc), until the patient figure is completed at the final step, representing the end of the journey.
5- Sticky-notes representing Kanban is placed between steps.
6- The game is played over two rounds, each over 5 minutes.
7- The first round simulates the traditional assembly line system, where players do their part as fast as possible, regardless what's happening downstream (denoting push).
8- The second round simulates pull/kanban system, where the members work only if the sticky-note (kanban) before the next step is free of any unfinished pieces ( denoting pull by the downstream step).
9- At the end of each round, the following parameters are calculated: total# of completed patients, # of patients completed in a correct way, % of quality (# of good ones/ total #), WIP (pieces which are not fully assembled), and the productivity of the team ( # of good ones / minutes).
10- Usually, all numbers go up with the lean/kanban system except for the WIP that goes way down, which indicates the advantages of the Lean system over the traditional system, and the benefits on the customers and staff. This is done through open discussion about the figures, and how the staff perceived the differences between the two systems in terms of work stress, waiting patients, early detection of errors, and collaboration.
We found that this is a fun and practical way to introduce proper patient flow, supported by real numbers. The attendees often cite it as one of the workshop highlights.