Monday, June 11, 2012

Lean Healthcare - Where was it this past week?

At some later point I may question whether writing this post right now was the right thing to do....you see I just had what is called "ACL Reconstruction Using Double-Looped Hamstring Graft" this past Friday June 8th.  So I'm sitting at home with my leg up, stitched holes in my knee and a 3.5" long incision in my upper shin....thank goodness for Percocet....which yes I'm still on, but I've cut it back far enough I haven't fallen asleep yet trying to write this.

My total experience though has really hammered in the need for improvements and a sense of learning organizations in health care....as frankly to my industrial manufacturing mindset, this whole process was a complete and total mess.

I'm not here to name any names, but I will step through my experience and highlight what I saw as serious deficiencies in the diagnosis, scheduling, treatment, and followup steps of the overall process...I will also be submitting such a report in the "survey" back to the center at which I had the procedure completed, in the hopes they will address such issues or search out help in learning how to begin to address them.

About a month ago, the actual event occurred outside my home where I wasn't wearing footwear that offered any support, had my hands full and tried to dramatically change directions on uneven ground...I felt a pop and was dropped to the ground...

The following day I was in the office of a specific Orthopedic center...hoping to find out what damage I'd done to my knee.  Of course the surgeon with the most experience wasn't available but I did have an orthopedic surgeon examine me....this gentlemen quickly decided that I had a torn meniscus and need to have a quick arthroscopic procedure to clean up the tear.  Great I thought, not as major as I'd worried it might be - and they scheduled surgery with another surgeon for me within the week. (Later I'd realize what a mistake it was on my end to not insist on having the experienced surgeon examine me as well, and what a mistake it is for Ortho Centers like that to schedule surgery with a surgeon that hasn't examined his / her patient before surgery as well)

So about a week later I show up for my basic knee arthroscopic procedure to repair my torn meniscus.  Now besides the fact that they couldn't give me the specific time of my surgery until a day prior to the surgery (kind hard to plan for a driver and for someone to watch the kids when you don't know when you'll need them) and the 2+ hour wait to even get prepped for surgery once I got in....I thought things were at least going OK, albeit nothing outside of normal complaints for doctors and health care service. 

I'm finally prepped for surgery, my knee is shaved and disinfected, I'm in a hospital gown and hairnet, IV is in, blood pressure is good, etc...waiting while that nice warm air is being blown up my gown (possibly the highpoint of the visit).  The surgeon that is actually performing the surgery (whom I'd never met before up till now) walks in starts asking me a few questions and doing some basic checks on my knee...within 20 seconds he looks at me and says "well I'm pretty certain you have a torn ACL which we're not ready to fix today".  WHAT?  I'm shocked, stunned and taken aback...wondering if I've wasted my time coming in....the surgeon gives me a quick 5 minute discussion on the process of ACL reconstruction, the different options, including the option of "Some people opt not to have it fixed and seem to do OK"....so he finally gave me 3 options:

1. Cancel today's surgery and come back in 3 weeks or so and have the ACL Reconstruction and meniscus repair done all at once (he said yes that my meniscus was likely damaged if I tore my ACL)
2. Continue with the meniscus repair today and then try out my knee for a while and see if I had stability problems and whether or not I wanted to go through ACL reconstruction
3. Continue with the meniscus repair and go ahead and schedule the ACL Reconstruction.

Well the biggest problem (besides the mis-diagnosis that this surgeon was able to pick up on within seconds of touching my leg) was that I was finally given all this information with little to no time to make a decision as I hadn't researched any ACL surgeries possibilities up till then since that wasn't my diagnosis...so I made what was probably a bad decision, I told him to go ahead with the meniscus repair and I'd see how I did without an ACL and revisit that scenario then.

Well I was under for maybe 20 minutes....when I came to, there was my wife with the pictures of my pristine undamaged meniscus that the surgeon had left with her.  So I got scoped for no good reason whatsoever...oh I guess they confirmed that my ACL was indeed torn, but that seems like an expensive, painful way to get a final diagnosis....

I'm more than a little disgusted at this point, but I figure OK I'll see how I do...well over the next couple of weeks I talk to others that have had the surgery, that haven't have the surgery, I read article after article and even as my knee gets to the point of having a nearly normal walking gait back, I can tell it's just not right....that I'm too young (I'm 33, so yeah I consider that still young) to risk further knee damage, arthritis, and worse case a full knee replacement later in life...so I decide I'm going to have the ACL reconstruction surgery done.

I have a followup visit scheduled where I hpe that I'll get to have this exact discussion with my surgeon (that I've decided to do, what type I'm leaning towards, and what's a good date)....instead I get into the room and a physicians assistant that I've never met comes in and starts talking to me about when to schedule my DLHG (Double Loop Hamstring Graft - a type of ACL reconstruction)....what the hell?  First, this PA wasn't familiar with the fiasco that was my first surgery, and just came in assuming and ready to sign me up for another surgery!  I finally expressed a little of my discontent and WHOA THERE....first of all I never told anyone yet that I wanted surgery (even if I had already decided on exactly what she was describing) and I felt like I was owed a little honest conversation about my thoughts to make sure I was on board....

Long story short, I still didn't get to talk to my surgeon again till Friday when the surgery was completed...it's a good thing I read online about the surgery and the recovery process as none of that has yet to be explained to me....I have a followup in a couple weeks, but they've never talked Physical Therapy with me or given me any timeline on what I should be be doing and not doing during recovery.

SO....guess what, there's many many ortho centers in this area...if I or anyone else in my family or close friends needs to consult or requires the services of such a specialist, guess where we will not be returning for any business?  This place has lost a customer at the expense of trying to "get them in and get them out"....and I will be asking a lot more questions before allowing any procedures to take place that me or my insurance company will be paying for.  The waste and lack of customer service in my experience was to a point where I may very well have gone without the surgery rather than pay them for the service again...I may have to reach out to some of my peers in "Lean Healthcare" to find out what centers are actually worth giving business to in the future.


Ok time for another ice pack and percocet....which generally leads to a nap.  Night everyone.

Tuesday, May 29, 2012

You Gotta Have the "Right Stuff" to be "Lean"

Recently, I had someone give a very basic response that Lean was basically "all that foundational stuff" (5S, Leveling, SW, Kaizen), plus JIT and Jidoka.  When I dug further, asking about their understanding of the concepts just rattled off before me, I got mostly succinct answers until we hit Jidoka.

"What is Jidoka", I asked.  "Why is it important" 

The response I got was that Jidoka was "And On Cords" and "Poke-Yokes"...oh and "Autonomation".  The gentlemen then paused for a moment and added "We have all those things." "

Yes, we do", I replied.  "But how are we USING them?"

The point I was trying to get across is that just about everyone under the sun by now has a decent textbook understanding of the concepts of JIT and at least partially of Jidoka.  But very, very few have the personnel structure in place to properly carry out Jidoka...without it all the other efforts stall, fizz, and fade backwards....and along with it any hopes of forward momentum in exposing new problems.

What you'll see in most businesses is an awful lot of first level employees doing "work" on the product or service the company exchanges for monetary value.  Companies spent a lot of time and energy training employee's on "how to do their jobs"....but for the vast majority, that really only includes the functional and administrative portions of their jobs.  When this happens, do this....when making this part, follow these steps...when a defect occurs, place it here.   What about teaching them how to improve their jobs?  How to solve their own problems?  Or is that a specialty expertise, reserved for the enlightened CI Specialist or Six Sigma Black Belt?

Let's back up for a moment and explore some organizations that assume right from the get go, that things will not go as planned....the military.

Ever heard the expression, "No battle plan survives first contact with the enemy" ? 

Both historically and in modern times, the most effective military organizations have been those with decentralized decision and problem solving structures...to quote Wikipedia's article on John Boyd (one of the most amazing strategists and problem solvers of the century) effective organizations use "objective-driven orders, or directive control, rather than method-driven orders in order to harness the mental capacity and creative abilities of individual commanders at each level." 

That all sounds wonderful, but how does an organization accomplish this?  If you look at the historical make up of military units, you find an interesting parallel between their personnel structure and that of highly effective organizations from other backgrounds.  They work in small hierarchical teams.  For instance, common military unit makeup goes something like this:

Type             
Fireteam         4 people led by a lance corporal or sergeant
Squad          2-4 fireteams led by corporal or staff sergeant
Platoon       2-4 squads led by a first or second lieutenant
Company    2-8 platoons led by a captain or major
Battalion     2–6 companies led by a lieutenant colonel
etc., etc.

This trend holds pretty true regardless of military unit, division, or nationality to the point that there is rarely more than 10 soldiers to a leader in any situation.  There is a leader, and yes they follow orders, but good orders are directional in nature, not specific as to method. 

John Boyd hypothesized that all intelligent organisms and organizations undergo a continuous cycle of interaction with their environment. Boyd breaks this cycle down to four interrelated and overlapping processes through which one cycles continuously which he coined the OODA loop.
  • Observation: the collection of data by means of the senses
  • Orientation: the analysis and synthesis of data to form one's current mental perspective
  • Decision: the determination of a course of action based on one's current mental perspective
  • Action: the physical playing-out of decisions
Of course, while this is taking place, the situation is often changing. Sometimes it's necessary to cancel a planned action in order to meet the new situation one observes.

The teams are responsible for using their training and situational awareness to PROBLEM SOLVE

Good organizations use the mental capacity of their members in this way.  Just as centralized planning is disastrous to national economies, so to is it hurtful to companies.

So what does this have to do with Lean?  If you take a good look at a truly "Lean" company...like Toyota, HON, Danahar, etc, you'll find they share this type of structure.

Team Leader leads a team of 5-7 associates
Group Leader leads 4-5 Team Leaders
Value Stream Manager leads 2-5 Group Leads
Facility Manager leads 2-7 Value Stream Managers
Each leader leads by direction...by establishing "True North" and a set of goals or objectives that drive towards that ideal state, cascaded and aligned from the highest level so that all are working towards the same objectives.  But each is also a teacher and mentor, promoting and developing their subordinates abilities to see and solve problems.

Jidoka, you see, is not about poka-yokes and and on cords, or even multi machine handling.  It's about developing and using people that embody the OODA or PDCA mindset. (Toyota uses the PDCA, or Deming Cycle, but there's more similarities between that and Boyd's cycle then there are differences).  In order to do that however, you can't assign 30-40 people to a single leader...people need coaching and mentoring; someone not to provide the answers...but to ask the right questions.








Thursday, March 8, 2012

Lean Certification

How many of you have either been approached by a recruiter, or gone job shopping yourself and low and behold there in the job description is something like:

"Requires a Lean Certification from a nationally recognized academy"

Really now...so if Hajime Ohba, Tom Harada, or some other well known Toyota Sensei applied, they wouldn't be eligible?  What about the thousands of their lesser known students that learned Lean through years of direct mentoring and coaching, and their students and so on?

What's it mean to have a certification in Lean anyhow?  It could mean several different things, though none of them are quite as valuable as employers seem to think.  According to a post I saw on Linkedin last week, you can get a online Lean Certification in 30 days for free!  Wow...that's some super fast cheap learning right there.  Or you can go the more "elitist" route and get the ultra cool SME / ASQ / Shingo Certificate which is tiered into Bronze, Silver, and Gold Levels.  Of course that will set you back $700 for the Bronze, $2000 for the Silver, and nearly $4,000 for the Gold, not counting exam surcharges.  Now in all fairness, the BOK (Body of Knowledge - ASQ speak for what you got to know to pass our exam) for that certification is pretty extensive, and certainly far better than any others I've seen....but I still have some issues with it.

Besides the exam, "Gold" Level Certifcates require: (Copied straight from SME website)

  • Completion of (200 hours 80 from Bronze, 80 from Silver + 40 additional hours) minimum education/training requirements.
  • One (1) tactical project, Two (2) Integrative (Value Stream) projects and Two(2) Strategic (Enterprise) Projects: events, projects and/or activities to which specific lean principles and tools were applied*
  • Mentoring/Coaching
  • Integrative Portfolio reflection: results of the events, projects and/or activities.
 So basically, spend enough money with them (your training hrs), pass a 150 question 3 hr exam, complete 5 projects and then the last step, an interview.  Wow...exhausting huh?  Why are you doing all this again?  Oh yeah that's right, your employer (or perspective employer) requires it.

Matter of fact, when my last employer brought me on, I got called down to my managers office about a week or so into the job and was asked, "Do you have a copy of your Lean Certification for HR?  I want to grandfather you as "Lean Certified" so you don't have to complete our Lean Leader training".  Well yes, actually I did.

I know, I know... here I am talking certificates down and low and behold I have one.  Well as it turns out, before my first employer seemed to know any better, they went through great pains to get us "certified" through a customized program at the University of Michigan.  It wasn't a "bad" way to spend a week, per se...the class at that time was taught by the likes of Jeff Liker, Mike Rother, Bill Constantino, etc all well established guys in their own right.  But besides a week of classroom sessions and exercises, all we had to do was complete a current and future Value Stream Map when back at our regular jobs and identify the gaps and show progress to get our certificate.  Was I really all "certified" to go out and practice and teach Lean?  Hell No...it would be many, many more years before I even realized what the heck I didn't know at that point (I thought I was pretty good back then...how sad huh?)

But you want to know the worse part?  I've actually now become conditioned to avoid companies that list requirements like this...because I know it's not a place I want to work.  Lean is not a program to be measured, (please God stop sending out Lean Assessments!) nor is it a "proficiency" that you can measure at some static point in time.  Lean is something you practice, every day,  it is literally the process of learning and progressing through the body of knowledge of your own world.  It's not whether you can calculate takt time, or know some stupid formula to calculate the proper number of kanban (which is ridiculous btw, that too should never be static).  Therefore, at any point in our lives, we are all both Sensei (Teacher) and Deshi (Student or disciple)...both Bronze and Gold - do I need to spend $4K, or can you just look at my work history and talk to my mentors and students to see that I do my best to spend every day being both teacher and student?

Tuesday, February 28, 2012

The Pit of Mediocrity

So often it seems that I'm talking to a recruiter, a colleague, or reading some other post and people want to assure me a company in question has "a very mature and well established lean six sigma program"...what does that mean anyway?
I cringe when I hear those words...immediately I hear my mind rattling off things like:
- what the heck does mature mean? Compared to what? Does mature mean you have nothing left to improve on?
- lean six sigma...well see my other posts.
- program? Gosh I wonder who's in charge? Maybe I'm being picky, a bit anal (well OK of course I am) but I've had enough encounters where my fears played out to make me a bit cynical when I hear something like this.

I heard lately that recruitment for lean talent is outpacing that of six sigma talent...so its obvious companies are starting to realize they've stagnated using the ole lean six sigma program approach, but do they know how to attract the talent that is actually capable of taking them past their stagnation?  Lesson 1: don't tell me how mature your Lean Six Sigma Program is...

Friday, February 17, 2012

Lean is not an assignment...

Nearly every company out there has got an active Lean, Six Sigma, Lean Sigma, Continuous Improvement, or Process Excellence "program".  But a problem arises when these same companies appoint "lean leaders" or teams of black belts ...they give into the temptation to use these resources as their delegates rather than as counselors, teachers, and mentors.  Operations leaders "assign" these personnel the chores of implementing 5S, standardized work, mindlessly executing kaizen events (to some preset schedule mind you, as if the number of events were more important), etc...while operations goes on about its business trying to pursue high local optimums, pushing high machine utilization, and generally working in a bubble.  What they don't understand is that Lean is not some task or finite group of tasks that you can delegate...its something that has to have a strong leading presence from the top.  Lean is often spoke of as a bottom up culture and that's true to a point, but leadership means leading....not delegating, not commanding, not herding...it means you have to live this stuff, and live by example.  Lean is not a department, its a behavior that will only take hold if it is an expected behavior by the highest levels of leadership, both of themselves and everyone else.

Saturday, January 28, 2012

Cost Cutting vs. Cost Reducing

No matter how much people know better, no matter how much "lean" training and how many Goldratt books management has read the sad truth is that all that is forgotten when the decree comes down from above to lower costs.  They forget about long term impacts and immediately go to where they can slash costs in the near to short term.  Talk goes almost instantly to cutting "heads" (I hate that term by the way) and slashing the easy (but low impact stuff) things like the free coffee, or employee Christmas party.
Sadly most businesses find themselves in these situations because they don't do the right things earlier before the situation has become dire. There are warning signs that you've run out of time...ie you start losing out on orders and sales...your competition has met or beat your price....and is starting to lower the market price (what your customers are willing to pay for your product or service).  Unfortunately most company's have this cost+margin=price,  formula in their heads and aren't willing to lower their price , or take the healthy approach to lowering the cost... instead assuming that the competition is just accepting a tiny margin or a loss to steal their customers (this can happen, but either way the correct response should be the same) and waste time whining about it or falling under the illusion that the competition won't be able to keep it up and sales will return.
Here's the deal.  Start now, don't wait for the crisis, or it will be too late.  The solution isn't massively cutting labor, a new automated piece of equipment, squeezing your supply chain, or calling (please God no) a consultant.  The solution is your people, engage them, be straight with them, reorganize if needed to give them support...if you don't have a leader for every 10 or so employees (including your hourly staff) then you're doing them a disservice. EVERY person needs a mentor and coach, even the CEO.  Stop delegating problem solving to "experts" or "professionals".  Problem solving shouldn't be a special skill, its THE skill that should be nurtured and coached in everyone at every opportunity. 
Before you discount what I'm saying, let me expand a bit.  What do you think is common amongst all the commercialized problem solving techniques out there?  Six Sigma, A3 problem solving, 8D, 5 Why, etc....they all share a basic method that we are all introduced to by 7th grade science class: The Scientific Method.  Simple, logic based problem solving....have a problem, come up with a hypothesis, test the hypothesis (test group and control group), and finally, learn from the results.  Everything else is fluff and fancy techniques meant to wow and keep the general masses from eliminating the need for high priced professionals and consultants.  (Yeah I'm talking about guys like myself - you don't need us) The problem is that what your people need to get good is practice and a good coach.  Hence my comment about leader to team ratios....heck even the army knows that there should be a leader for every 10-11 soldiers...because more than that and there isn't enough leader to go around.  Our professional salary ranks seem to recognize this too...check your own workplace out...I bet each manager has 5-10 supervisors etc...but as soon as you hit the last level on the salary org chart we find supervisors that are expected to coach and mentor 20,30 or even 40+ employees....do you want mindless employees that check their brains at the door and just need a babysitter?  Or do you want skilled problem solvers that return value to your company?  You're not going to get both....and don't steal their wind by sending in experts to solve their problems for them, you'd be robbing them of the opportunity to practice!  Provide guidance and mentoring, but let the problem be solved at the lowest possible level of the organization.  It will breed better, more confident, and valued employees...and having ALL your employees out there solving problems will get you far further and far healthier than any cost cutting push or swat team of "CI experts".

Friday, November 4, 2011

MRP, ERP, SAP…Whatever You Call It, You’d Do Well to Kill it

Materials Resource Planning…just saying it in my head makes me cringe.  Why?  Well MRP by itself, and used only for what it’s good for, is nothing evil, it’s entirely useful.   But the way MRP systems are used in 99.99% of companies actually PREVENTS them from ever becoming leaders of the pack, and furthermore, since we seem to think the solution is in the “newest” cool software package, they also turn into money pits…sucking up ever larger pools of cash in what has to be the greatest marketing scam ever unleashed on manufacturing…SAP being the worst villain in this con job since the late ‘90s.  SAP does more than just try to manage inventory like MRP, but it does a horribly complicated job at those tasks as well. 

Whenever a recruiter calls me now, I actually research the company and if they are implementing or have implemented SAP, I know exactly what questions to ask to determine if they are using it incorrectly and if I would have to suffer through its usage in all the other company data and applications based systems.

Ok, so why do I have such a bent against MRP (particularly SAP)?  Because instead of using the MRP to perform only long term forecasting for themselves and their suppliers, companies use it to schedule daily production and all manner of material movement between their suppliers, customers, and their own plants.  Using MRP in this way creates a situation where purchased parts and inventory are "pushed" according to a master production schedule (MPS).  This glorious ideal of synchronizing all operations and materials movement with the MPS may seem like a good idea, but in reality it rarely if ever works, and almost always succeeds in exploding inventories, production downtime, and a general sucking of resources.

The problem is that so many things have to go right for the MRP’s MPS to work.  The material flow process is long and ever changing, and when you push on it, it’s a lot like trying to push a rope…it bunches up and generally goes nowhere.  It’s a complicated, unstable process that descends into a death spiral after any significant change.  It is in effect, a magnifier of variation.  Change anything and presto, you get a new production schedule that is very different than the one before.  Therefore, reality on the shop floor and the MRP are rarely even remotely the same.

Because the MRP system requires thousands of inputs—BOMs, Engineering Changes, Model Variations, Stock Levels, Reorder Points, Lead Times, Outstanding Orders, Process Yields, etc the chances of getting all that information correct is so unlikely that it never really happens.   The result is the MRP pushes and pushes, until you start missing shipments.  So it recalculates a recovery schedule and starts the madness all over.  It doesn’t take much effort to see how MRP system wreak havoc in a plant, just take a walk…you’ll see:
  • An over staffed “Planning” department;
  • Complex BOM structures
  • Demand levels that looks like a bull whip throughout the supply chain
  • Loads of unplanned purchase requisitions and orders
  • parts shortages , and therefore more people or staff handling the parts expediting
  • Poor delivery performance
  • Tons and tons of resources consumed and wasted “managing” the system:
o   frequent MRP regeneration
o   back-flushing
o   line-balancing
o   WIP reporting
o   Electronic Transactions, requesting goods, issuing goods, inventory adjustments, etc
o   Order confirmation, etc., etc.

So what's the answer? – KILL IT…at least inside your four walls.  The way to get control of your inventory isn’t to add more complexity to the system, ask yourself “What’s the root cause of poor inventory control?”…

Too much inventory, duh. 

Reduce it; reduce the complexity of the system so that something cheap and simple works.  Don’t tack on more dreadful wastes so you can blame something else…fix your process design, work to customer demand (actual demand), level and smooth your schedule, and FLOW OR PULL, NEVER PUSH.

How do you do that?  Well there are several scheduling concepts that can apply, depending on your situation…

  1. Replenishment Kanban
  • Cell makes what has been consumed. 
    • +: Simple, Easy to Understand
    • +: Good for Runners
    • +: Runs with lower inventories
       -: BUT only if customer stable AND production stable
    • -: Physical cards get lost, Electronic systems get complicated
    • -: Each cell introduces an element of noise into signal
         (Simple load leveling box can help reduce it)
  1. Leveled Production
  • Kanban Plus “Fixed” Schedule Heijunka system
  • Supervisor adjusts “Fixed” element according to Kanban usage.
    • +: Combines Pluses for Kanban and Planned Systems
    • +: Reduced need for supervision outside core hours
    • +: Works for Runners and Repeaters without creating excess noise
    • -: Cards still get lost or planners complicate the electronic system
    • -: Requires marginally more maintenance than Kanban
     3.  Sequenced Production
  • Cell makes what customer wants in exact sequence. 
o    +: No inventory other than “safety” stock
o    +: Minimal handling
o    -: Needs 100% up time and 0 minute changeover
o    -: Needs to be adjacent to customer line or have a remarkably stable customer
o    -: Sends random signals up value stream – will need smoothing

So please for goodness sakes, stop thinking you can keep the cool MRP system and still pull…even if you succeed, you’re missing the point; YOU DON’T NEED THAT COSTLY SYSTEM.  It’s wasteful, even if you get it to work; you’re still working harder than you need to.  GIVE IT UP!
I think there’s a market out there for a “MRP Anonymous” group…step 1: Admit you’ve got a problem.