Book Review The Checklist Manifesto: How to Get Things Right

What makes a good checklist versus a bad checklist?  What are the limits in the power of a checklist?  Sure, checklists work for the weekly run to the grocery store or packing before we go on vacation but can they work to reduce errors in surgery?

The answers to these questions and more can be found in the fascinating book, The Checklist Manifesto by acclaimed writer and surgeon Atul Gawande.  This book is filled with a series of stories from hospital settings to piloting airplanes that makes a compelling argument that using well developed checklists can produce a significant impact on performance success and eliminate errors.  Facing ever-growing complexity in our lives and workplaces along with pressures to get things right the first time, checklists may prove to be a simple yet valuable tool in our error-proofing approach.

The final results of a World Health Organization initiative which is the core study described in this book “showed that the rate of major complications for surgical patients in all eight hospitals fell by 36 percent after the introduction of the checklist.  Deaths fell 47 percent. Overall, in this group of nearly 4,000 patients, 435 would have been expected to develop serious complications based on our earlier observation data. But instead just 277 did.  Using the checklist had spared more than 150 people from harm-and 27 of them from death.”   These results are exciting and hopeful in the quest for improved patient outcomes but it should be clearly understood that the use of checklists is not described as the complete solution to the problem.  It is just a simple one that appears to make a significant impact.

 The Checklist Manifesto is extremely well written that draws the reader along the journey of the author in exploring the power of checklists.  I found the stories interesting and hopeful that the simple checklist might work surprisingly well which the evidence seems to support in this book.

 This book is not a “How-to-do-it” type book however it provides some helpful suggestions in creating useful checklists.  For example, good checklist are designed to only provide critical reminders, practical, precise, easy to use and short and most of all, ones that are used consistently.  In addition, it will take some experimentation and collaboration with the users to develop a good checklist so expect to try out several variations until you create a checklist that works well.

 For more details on building a better checklist, read the chapter The Checklist Factory in which Atul learns about how to create a great checklist from his field trip to Boeing’s “Checklist Factory” under the guidance of uberchecklist master, Daniel Boorman.  I found it fascinating and it opened my eyes to just how difficult it is to create a really good checklist.

 The most significant and insightful observation in this book is the use of checklist as a team activity to enhance communication as a team, to simply talk to each other and coordinate our activities at critical points in the process. Dr. Atul Gawande writes:

 “But like builders, we tried to encompass the simple to the complex, with several narrowly specified checks to ensure stupid stuff isn’t missed (antibiotics, allergies the wrong patient) and a few communication checks to ensure people work as a team to recognize the many other potential traps and subtleties.”

And finally, as we know from our lean and six sigma work, it is not easy to influence culture change, promote new behaviors and sustain improvements, just as the author found in trying to influence surgeons to use checklists. Dr. Atul Gawande writes:

"...using the checklist involved a major cultural change, as well - a shift in authority, responsibility and expectations about care"

As organizations, are we ready and able for a shift in authority, responsibility and expectations for success?  Do we still cling to the illusion of superior lone superstar status or are we ready to humbly work as a member of a well coordinated and trained team?

I enthusiastically recommend this book to all!  This book is easy to read, short and a fascinating story of battling complexity with a simple checklist. The Checklist Manifesto is a must read for anybody working on continuous improvement and reducing errors in any process.

Going from "Oh-oh" to "Ta-da" Faster

As young children, we learn from our experiences through relentless trial and error. It does not take us long to figure out if we touch something hot, for instance fire or a hot skillet, it burns us and we quickly jerk our hand back. This is an example of a fast feedback loop thanks in large part to our central nervous system.

Fast feedback loops are critical to be effective at problem solving. With fast feedback loops we can better link cause and effect. Fast feedback loops within a structured experimental or problem solving process helps us arrive at a solution quicker as we cycle through multiple experiments. Think repetitive, quick PDCA cycles.

One of the obstacles we face in business is slow or disconnected feedback loops. An action takes place and we don’t see the results for a lengthy period of time or sometimes not at all. For example, how long does it take for a quality defect to occur and when it gets detected? We can better solve the problem if it is detected by the operator at the source versus months later by the customer.

Another slow feedback loop typically occurs with many of our metrics and KPIs. How long does it take from the point of process performance till the time it shows up on the chart of graph?

In kaizen, faster feedback loops helps to see quicker if our countermeasure we put into place actually made a positive impact or not. If our countermeasure does not work, we can adjust and try something else quicker.

A great example of the impact in using faster feedback loops can be seen in the Marshmallow challenge. Tom Wujec provides some interesting results when conducting this seeming simple construction challenge. In addition to faster feedback loops, the marshmallow challenge has great insight to team collaboration.

Tom stated “So there are a number of people who have a lot more “oh-oh” moments than others and among the worst are recent graduates of business school. […] An of course, there are teams that have a lot more “ta-da” structures and among the best are recent graduates of kindergarten. […] And that’s pretty amazing. […] not only do they produce the tallest structures, but they’re the most interesting structures of them all.”

When we kaizen, are we more like recent graduates of business school with one PDCA cycle or are we more like recent kindergarten graduates with multiple PDCA cycles?

Where are the opportunities in your business to put in faster feedback loops to quickly move from “oh-oh” to “ta-da”?

Lean Snake Oil Cures what Ails Ya

Step right up Ladies and Gentleman! Do you suffer from bulging inventories? Are you feeling tired and wore down chasing problems everyday at work? Are parts of your organization afflicted by dislocation? Perhaps you suffer from irregularity of flow or constipation and blockage? Do rashes of quality problems create irritability and discomfort? Having trouble applying kanban or finding the time for kaizen? Do you find incorporating lean thinking into your culture just too difficult and painful?

My friends fear not! Your days of suffering are over. Just one bottle of this new and improved formula of lean elixir has been scientifically proven under the most rigorous of conditions to cure what ails ya!

Yes, you heard me correct, my dear friends. This wonderful tonic of the east has the magical like powers to create a self-healing, self-improving, self-regulating system to free you from the hard work, constant coaching and relentless pursuit of perfection. No need to lead by example or get your hands dirty understanding your processes or teach others within your organization. You no longer need to help improve, just let you employees do it on their own under this system of self fixing.

Taking regularly and by explicitly following the directions on the bottle, you will be transformed like never before. And for a few extra dollars, you can speed up the lean process like never before by adding heavy doses of metrics and measurements followed by holding them accountable. Now all you need to do is go back to your office, sit back, relax and let the miracle medicine work its wonder.

Who will be the first to free themselves from the burdens of continuous improvement? Step right up!

Doesn’t this spiel sound just like what you imagine a snake oil salesmen from yesteryear would bark to the crowd gathered around his traveling wagon of wonder cures and concoctions?

Today, there is plenty of snake oil to go around. There seems to be a lot of touting of different models to achieve higher levels of leanness. Some place emphasis on certain lean tools, others promote a specific path or model as the missing link to achieve lean greatness. Really, can a lean system be self healing and self improving? Seriously?

In all my years of experience in learning the lean way and applying lean thinking in various companies and industries, I found that there is no silver bullet and no one best way, despite the boisterous marketing hype. I also learned that lean systems do not run by themselves.

Using kaizen and developing lean thinking into your culture takes time, energy and effort. More time than you think, tons of energy and a tremendous amounts of effort. Even after all your blood, sweat and tears, there are still no guarantees.

The lean approach is not easy and requires practice, perseverance and patience. It takes serious commitment by management that most are not willing to make.

We need everyone involved in kaizen, everyday, everywhere. This certainly includes our management. Everyone needs to make time for kaizen. Management need to be in gemba more often, not less. Bottom line, you can’t delegate kaizen.

So next time you hear about some secret to becoming lean remember that hard work and personal commitment is no secret. In the wise words of our elders before us, “if it sounds too good to be true, it is too good to be true”.

Suffering from Sick Sigma?

My good friend, Jonathan Sands, a Director of Operational Excellence for a large firm, recently told me about his experience with a company six sigma effort years ago. At first go around, he and other leaders undertook their black belt training with a huge burst of energy. Everyone was passionate about their six sigma projects and making huge improvements to their operational performance. The six sigma excitement was as hot as the burning fever with the winter flu.

As the six sigma virus started running its course, management interested grew less interested in dealing with real, significant problems and focused on just adding to the roster the number of people with colored belts. Training was done for training sake.

Anytime a complex problem with no solution known (which you would think is the perfect type for a six sigma black belt to attack) was made visible, it was pushed back and ignored. No real reason why, it just happened.

In just a short time, the six sigma update meetings were held less frequent and attendance started dropping.

Six Sigma projects were just done to get certified. And it seemed that the projects were less and less focused on the customer.

It did not take long for the six sigma fever to break and things started getting back to normal (a return to the status quo).

The six sigma program, left to wither and die, became known around this company as their sick sigma program.

This is not to be critical of the six sigma approach. I know many attempts using lean have met the same fate. Each program starts out with such promise for a bright future only to be found DOA in the morgue a few years later.

And they were so young, such a needless tragedy.

New Webinar "A Day in the Life of a Lean Supervisor"

I invite you to please join me in a free webinar next week “A Day in the Life of a Lean Supervisor” hosted by Gemba Academy on April 4, 2012 at 1:00 pm – 2:00pm (USA-Central Time).

Click here to register.

In this webinar, I will help define standards of daily lean supervision and how to maintain these within your company's lean operating system. Also, I will discuss how supervisors can improve their own performance and promote lean just by focusing on the key needs shared by all employees. I will tell a few stories as examples, talk about a few simple tools and answer as many of your questions as possible.

Listening, Doing, Thinking

The more I listen, the more I know.
The more I do, the more I learn.
The more I think, the more I understand.

Bruce Lee as a Lean Sensei

Growing up I watched plenty of movies, with action movies being my favorite, especially good guy versus bad guy with the good guys always winning in the end with amazing skill, character, courage and perhaps a bit of luck or divine intervention depending on your beliefs. A favorite action hero of mine was Bruce Lee.

I watched in awe, the speed, grace and ability of Bruce Lee’s skill as a martial artist. Learning more about his life, as short as it was, I discovered that Bruce Lee was more than just a gifted martial artist and he actually studied drama and philosophy at the University of Washington.

Here are a few of my favorite Bruce Lee quotes that I find helpful as a source of inspiration:

“The less effort, the faster and more powerful you will be.”

“It's not the daily increase but daily decrease. Hack away at the unessential.”

“If you always put limit on everything you do, physical or anything else. It will spread into your work and into your life. There are no limits. There are only plateaus, and you must not stay there, you must go beyond them.”Obey the principles without being bound by them.

“Fear not the man who has practiced 10,000 kicks once, but I fear the man who has practiced one kick 10,000 times.”

“Knowing is not enough we must apply. Willing is not enough we must do”

“Those who are unaware they are walking in darkness will never seek the light.”

“A wise man can learn more from a foolish question than a fool can learn from a wise answer.”“To know oneself is to study oneself in action with another person.”

“A goal is not always meant to be reached. It often serves simply as something to aim at.”

“To grow, to discover, we need involvement which is something I experience everyday, sometimes good, sometimes frustrating.”

Influenced by Taoism and Buddhism along with his martial arts training, Bruce Lee developed his own set of beliefs and philosophy that challenged the status quo of traditional martial arts and formed his own style. Not only did he have a truly positive attitude and a dedicated spirit for self-improvement, Bruce Lee had some profound insights that we might apply to our lean journey as well as our life journey.

We Don't Know

After a great kaizen event this week, kicking off an eight week project looking at reducing real waste (actually reducing landfill waste generated by the organization), we asked the team members for lessons learned. Our Team Leader, David York, leading his first kaizen experience, shared with our team one of the most insightful reflections I have heard in many years.

“We don’t know what the problems are…..that’s why we make them visible.
We don’t know what the root causes of the problems are….that’s why we ask 5 Whys?
We don’t know what the evidence is….that’s why we collect data.
We don’t know what is actually happening….that’s why we observe.
We don’t know what solutions will succeed….that’s why we experiment.”

Ultimately, it is alright for us “not to know” but in our arrogance and pride, we pretend to “know it all”. Maybe we are afraid of looking of looking stupid? Maybe we wish to look smarter than those around us? Perhaps we believe that our leaders expect us to know it all otherwise we are not worthy?

In reality, acting like we know it all prevents us from improving, learning and growing.

Thank you, David for teaching me this week!

To Get Results, You Gotta do the Work

Some lessons for our lean journey can be easily seen on NBC’s The Biggest Loser in every single episode: To get results, you gotta do the work. The trainers don’t run on the treadmill for you. You must do all the heavy lifting and all the sweating. It’s hard work and requires you to change your behaviors. Nothing comes for free. And we must make the time to do it daily, no excuses.

No secrets. No magic.

Don’t hire Lean consultants to do the work for you and expect to become lean. Any improvements we might see will not stick. Lean consultants can teach, motivate, influence, demonstrate, coach, yell, scream and cuss, but you will only get results by doing it yourself.

Don’t delegate continuous improvement to your lean department. Kaizen is everybody, everyday, everywhere. A culture change towards becoming lean MUST be led by the top, no other way!

Just like you can’t sit on the couch eating ice cream and expect to lose weight, you can’t sit in your office looking at the computer screen and expect to improve your processes.

Too many executives don’t want the labor pains, they just want the baby.

YOU have to get up and get moving. Go to gemba. Don’t say I can’t, I don’t want to hear I can’t. Do what you can. Go, Go Go. You better toughin up. Improve something every day. Again. (Wow, I could get used to this!)

There are many inspirational quotes after many seasons of the Biggest Loser that may help us on our lean journey. As show trainer Bob Harper said it best, “Believe in yourself, trust the process and change forever.” And former show trainer, known for her hard-core, in-your-face style, Jillian Michaels says, “Shut up, focus and do the work” and “Get comfortable with being uncomfortable” and my personal favorite, “Unless you puke, faint or die, Keep Going!”

As an added bonus, here are a few clips of Bob and Jillian in action. Be warned: They have to be bleeped many times for rough language. One of my favorite parts is when Jillian points to her head saying” You are not getting it here”. It reminds me a little of some the Japanese consultants that used to yell at me years ago.

Boeing Delivering First 787 Dreamliner

On our kaizen tour last week in Seattle, we included a stop at Boeing in Everett, Washington to observe their production lines and witness a test flight of the first customer production 787 for ANA (All Nippon Airways). The 787 lifted to the sky smoothly from the airstrip, unlike the bumpy journey of their long and costly production start-up which is only 3 years late in delivering this plane.

On my last visit to Boeing, in January 2007, the 787 Dreamliner production hanger sat empty and idle. This is in sharp contrast to the production area today which is in full swing trying to ramp up to 10 planes per month production level and put a dent into the 821 planes in customer order backlog.

From my vantage point on the observation platform, I looked for signs of improvement in their production process comparing the 747, 777 and 787 lines. With only a short observation time, I can not see the whole story however there are some interesting things I noticed and questioned.

The 787 line is completely surrounded by staff cubicles and offices directly on the production floor. This is not the case for the other lines. It appears that the staff has located as close to gemba as possible with the 787 layout. As you can imagine, this cuts the walking down dramatically. With such a huge facility to begin with this should have a dramatic impact to productivity and responsiveness. I wonder why the other production lines have not copied the 787 line and move more people closer to gemba? I also wonder why so many private cubes and not more work team clusters?

Visual management seemed a little better on the 787 line with many project boards, information centers, etc around the area. It is too hard to tell from a distance the purpose of all these boards so I’ll have to assume at this point. All the lines had plenty of shadow boards, kanban cards, flags and other mechanisms to convey orderly design. I wonder if all these boards add value or if they are just for looks?

The much publicized paced assembly line on the 777 line has been scrapped. I applaud Boeing for experimenting with this concept. Failure in these types of experiments is not a waste if we can learn from them. I wonder what Boeing learned?



Sitting near the paint hanger were 2 of the 4 Boeing 747 Dreamlifers specially designed and built to haul large composite components from distant suppliers. Although I find the Dreamlifter impressive in design and ingenuity, I still question the strategy to make these parts off site and have them hauled in using a specialty aircraft. With two of them sitting idol, I wonder how often the Dreamlifters are being utilized?

The biggest disappointment for me was seeing all the product lines more idle than active. In other words, all the production lines had more people standing around (and sitting) than actually working on the plane. I saw the same thing 4 years ago but expected the 787 line to be different assuming a higher sense of urgency, improved production line design and lessons learned on Boeing’s lean journey. In most manufacturing plants, you can understand the lean culture quickly by simple observation. It makes me wonder about the strength of Boeing's lean culture in general?

Regardless of their difficulties, I find myself rooting for Boeing to succeed. As an American and frequent flyer, I certainly wish them the best of luck as they begin releasing 787s to their customers. Now ramp up that effort with a dose a strong continuous improvement and make us proud again!

Sometimes the Best Lean Approach is to Just Jump into the Mud

“You don’t have to be good to start, but you do have to start to be good.” Unknown Author

Regardless of task, project, or journey, everyone is faced with the same question, where do I start?

This question may take some thought before you decide on what you are going to do or it may leave you paralyzed in fear that you decide to do nothing.

Do you feel overwhelmed?

Do you lack knowledge or skills?

What if you head in the wrong direction? Make a mistake? Make things worse?

Do you fear failure?

Decide on a direction (call it a plan) and jump in the mud (do it).

Yes, you will get dirty! Change is messy and it can be scary. You might even feel some pain, more so in the landing than the jump itself. But most importantly, you make a decision to take action.

I am not saying to be reckless in your action, don’t jump off a cliff to get to the mud hole.

All action has risk. It’s unavoidable. Plan to minimize the risk where possible but it can never be entirely eliminated. So jump.

Once the action is taken, evaluate if you made an improvement or not. What did you learn? Where does it hurt? How can you do it better? (Check)

Make your improvements the new standard or adjust your actions accordingly. (Act)

Jump again. It’s the only way to improve.

You will find at the end of the day that there is no secret, no one-best-way and no perfect method, you just have to power to decide to jump or not.

Top 3 Reasons Apple will be Successful without Steve Jobs

With the recently announced resignation of Steve Jobs as CEO of Apple, many people are already speculating on the future of Apple. Certainly, the exceptional leadership, sage-like insightfulness and huge creative force of Steve Jobs will be greatly missed. However, there are three reasons Apple will continue to be successful:

1. Culture
2. Culture
3. Culture

Unlike other assets on the Apple’s corporate balance sheet or valuation on paper or products in the R&D pipeline, their corporate culture is much harder to quantify but is their single, most important strength. And it is Steve Job’s greatest contribution for their ongoing success.

I’m certainly not an expert in the inner workings of Apple’s corporate culture and not under the illusion that it is perfect, same goes for my understanding of Toyota’s culture for that matter. So simply take it as my humble opinion.

Culture matters. Big time! Cuture = People

Look at these great companies as a group, Apple, Toyota, Honda, Southwest, Starbucks, Disney, Virginia Mason, Group Health Cooperative, Zappos, TOMS. All different yet their common denominator is a great company culture with a great vision.

Here is my favorite quote by Steve Jobs, “I want to put a ding in the Universe.” What kind a corporate culture can be developed behind this vision?

Years ago this Steve Jobs’quote was taken from an Apple corporate poster, which I think gives a small insight to their corporate culture.

“Here’s to the crazy ones. The misfits. The rebels. The troublemakers. The round pegs in the square holes.

The ones who see things differently. They’re not fond of rules. And they have no respect for the status quo. You can quote them, disagree with them, glorify or vilify them.

About the only thing you can’t do is ignore them. Because they change things. They invent. They imagine. They heal. They explore. They create. They inspire. They push the human race forward.

Maybe they have to be crazy.

How else can you stare at an empty canvas and see a work of art? Or sit in silence and hear a song that’s never been written? Or gaze at a red planet and see a laboratory on wheels?

We make tools for these kinds of people.

While some see them as the crazy ones, we see genius. Because the people who are crazy enough to think they can change the world, are the ones who do.”

As Lean Leaders, what can we learn from Apple and leadership of Steve Jobs? Look beyond their approach to “manufacturing” (or lack thereof) or Mr. Jobs’ specific leadership style but rather in the power of their corporate culture.

Are we developing a strong corporate culture or are we just learning Lean tools?

Like It or Not, They are Watching Us

In the hustle and bustle of everyday work, amid the chaos of surviving our broken systems to get things done while juggling our efforts to fix our current processes, we can easily forget that leading by example is our most powerful tool we have for improvement and creating our work culture. Even when we don’t notice it, what we say and what we do are seen by those around us. And they are always watching! Always!

I was reminded of this last week while guiding a kaizen event during a discussion with a newly hired team member. He told me that their team leader regularly wears his safely glasses on top of his head instead of properly over his eyes while walking through the manufacturing plant. As a result, this new employee was not inclined to always properly wear his PPE (personal protection equipment). What example has been set? What kind of work culture are we creating?

This is just one small example, but what is the impact?

What about a healthcare clinician who does not regularly or properly wash their hands before caring for a patient?

What about cutting corners on quality just to get the order out? Even just this once?

What if we get upset at a situation at work, letting our emotions go and say things that would make a sailor blush?

When faced with adversity at work or doing a less then pleasant task, do we show a positive or negative attitude?

When a problem arises, are we quick to blame others or do we try to find the root cause?

What if we see this any of these behaviors by others, do we speak up or turn a blind eye and what example are we setting then?

Growing up, how many of us heard our parents say, when seen in questionable behavior, “Don’t do as I do, do as I say” and that somehow was suppose to erase the example set before us. Is this our motto as a Lean Leader?

Certainly, just like our parents, none of us are perfect in the examples we set but that should not prevent us from trying to improve our behaviors to set a better example. And a funny thing about leading by example, it takes many good examples on a consistent basis to catch on yet it seems that it only takes one bad example to spread like wild fire through our company culture.

Like it or not, we are always being watched and the example we set matters.

4 Ways to Eliminate "That's Not My Job" Thinking

How many times have you heard someone say, “That’s not my job”?

As we moved from the craftsman era to specialized, functional silos of modern management over the last century, it has become more and more common to say “That’s not my job”. That thinking is supported by our specialized, functional silo based job descriptions. And it is easily seen in our work behaviors in both manufacturing and service industries.

It is easy to step over a piece of trash at work, thinking “That’s not my job” because we have a janitorial crew to do this task.

It is easy to let a defect go down the line, thinking “That’s not my job” because it the inspector’s job to catch it.

It is easy to let patients or family members to get lost finding their way around our hospital or clinics, thinking “That’s not my job” because that’s somebody else’s job, even if I don’t know who that somebody else is.

Faced with this problem, we could easily blame it on the new generation as being “lazy” or “apathetic”. Or we could say that people are overburdened and overwhelmed with years of downsizing. Maybe we fall in the same trap and think that “it’s not my job” to change our culture.

In the kaizen way, we must eliminate “That’s not my job” thinking and replace it with “How can I improve it?” and “How can I help?” thinking. In a lean transformation, there is no “That’s not my job” thinking anymore.

As Lean leaders, we must embrace this culture change in thinking and here are a few simple ways:

Lead by example: If we want our employees to take responsibility, we need to also take responsibility. When you see a piece of trash on the floor or hallways, always pick it up yourself. Never step over a piece of trash. If you see an undesirable condition, don’t turn a blind eye. Stop the process, and fix it. Before long, people will see you walking the talk and it will become part of expected behavior.

Brainstorm and Document: What does it mean in your place of work to eliminate “That’s not my job” thinking? You may know what the means in your mind but you cannot expect everyone to know what you have in mind. And there are probably many behaviors that you haven’t thought about that would make a big impact in your business to eliminate “That’s not my job” thinking. Brainstorm with your group to discuss the new ways to act and document them. Share the list.

Training: Make it a theme in your daily huddle meetings. Improve your new employee orientation training process by adding a complete section on expected behaviors. Teach people to recognized opportunities to serve our customers and practice them. Try role playing as part of this training.

Tell Stories: In meetings and newsletters, tell the stories of employees where they improved or helped beyond that “old way of thinking”. Maybe an employee saw a family looking lost and learned that they wanted to know where the Hospital cafeteria was located. Instead of telling them the directions, the employee said, “I’ll take you there, follow me. It's my pleasure, I have the time to help you” even if the employee would be late for a meeting as a result. Praise the employee for their action instead of punishing them for being late.

These are just a few simple ways but these ways are hard to do. Be prepared, it will take hard work and sustained effort to make this cultural shift.

As you eliminate “That’s not my job” thinking, more opportunities for improvement will become visible, teamwork is strengthened, processes will improve and customer satisfaction levels will increase. The best part is that it does not cost a lot of money to eliminate “That’s not my job” thinking.

I'm just fine! Wish I Could Say the Same for Health Care in this Country.

This morning, I read the following email sent to me by my good friend, Jeff Fuchs written to his lean students after a recent medical visit to his local emergency room. Jeff is the Director at The Maryland World Class Consortia and a great lean thinker!


I have copied it below with permission and some edits to remove classroom specific instructions to his students. Please read his story about his patient experience. As Jeff and I both hope, may it help stimulate some healthy and thoughtful commentary as we look to improving not only outcomes but the entire patient-family experience.

From: Jeff Fuchs
Sent: Monday, July 25, 2011
To: (All his Lean Students)
Subject: "I'm just fine!" Wish I could say the same for health care in this country.

All,
I am getting back in control of my in-box after my unfortunate absence on the last of our three days together week. My sincere apologies. As the message header indicates, “rumors of my demise are greatly exaggerated.” Just a reminder: You still have your homework. You still have your capstone projects. And now you have your make-up training on cellular production. More on all that in a while.

I am sorry for throwing your day off last Thursday, but I had to bring my body into the shop for some unscheduled maintenance. As we all heard Sir Ken Robinson observe on Wednesday’s video, some of us just view our bodies “as a way of getting our heads to meetings.” Proper upkeep falls by the wayside from time to time, and this is what happens. A bit of detail is in order. I was up to answer nature’s call at 4:15 a.m. on Thursday, and instead of the usual heartbeat, “thumpita-thump, thumpita-thump, thumpita-thump…,” what I felt was more like “thumpita-thump, eeerrk! thumpita-eeerrk! thumpita-thump…errkk!...”

I grabbed my keys, wallet, cell phone, and a good book and drove to the Emergency Room. You may have missed your day of training, but let me tell you that “class was in session” at the Baltimore Washington Medical Center ER when I showed up for school at 5 a.m. Four hours later, (Let me say that again, “FOUR HOURS LATER”) we were still monkeying around with forgotten paperwork, twice redone blood draws, shift change meetings over my bed, staff that was making three trips to my room to restock inventory, and rolling me through a series of three “patient inventory” transactions between some lab and back to my ER bay of “move, wait, process, wait, move, wait” for X-ray, sonogram, and ECG, respectively.

I told you folks. I TOLD you to your face! “When I am through with you, if I am successful, I will make you as miserable a human being as I am. You will see broken processes all around you.” Welcome to my world. Behold, the sad customer/piece of meat-inventory:


Now seriously, don’t he look sad? Pity the poor victim of broken process.

Naturally, in a case like this I couldn’t resist going into Consultant Mode. In spite of being hooked up to the monitor, IV, oxygen, etc. like a marionette, the monitor kept losing my continuing thumpita-errk heartbeat, so the nurses had to keep walking back to the main desk an average of every 11.3 minutes (but who’s counting) to see if I was dead yet and to reset the monitor. How thoughtful of them to give me an ER bay where I could see their goings on. Their wasted motion, their absence of mistake-proofing or visual controls, their failed attempts to communicate with each other, failed service opportunities, excessive patient transportation, and more. How very thoughtful.

After three hours of fear, boredom, and frustration cocktail, I used a pen left behind by one of the nurses and began sketching out a nurse/patient spaghetti map of my morning on the back of an IV wrapper I found on the floor, along with a crude value stream map. (There are a few things wrong in that last sentence. Please use a black or blue ink pen to circle them. We’ll review your answers next session.) The ER staff found my doodles and efficiency ravings…amusing. I’m sure they did not have much time to be interested in the “bored consultant in room six” at the same time they had to deal with the cut up guy the cop brought in handcuffs, the construction worker who just fell off a scaffold, the guy sleeping on a gurney in the hall who nobody knows where he came from, or the other poor folk who needed their full attention.

The attending physician diagnosed me with “atrial fibrillation”, an eminently treatable condition. We’ll see in a couple weeks what the follow up says. They admitted me for observation, where I was subjected to other process design and systems management horrors which I shall not relate to you with at this time. Suffice it to say, I got an education in that fourteen hours. The lesson for me: Healthcare is broke. It’s broke bad. I mean, if I had a clone army of a thousand Lean Jedi Knights, we’d be swinging our Lean Lightsabers for decades trying to unhose healthcare in this country. Lean Facilitator Certification Program students, your future in this industry is secure.

By the way, one final note on my lean healthcare field trip. The “good book” I mentioned that I snagged on my way out the door was Toyota Kata, the one I described with such admiration on Tuesday morning, lamenting that I had not had the time to read it. Well, there you go. I plowed through half of it. Would have gotten further, but had to watch a really good Jerry Springer and eat my tasteless hospital food (Overcooked mac and cheese, gray asparagus, canned pears, and a drink that arrived completely frozen solid.). So, remember what I said: “A true lean leader is a lifelong learner.”

Put your left hand on the computer screen, raise your right hand, and repeat after me: “A-true-lean-leader-is-a-lifelong-learner.”

Here’s me “enjoying” my incarceration:



Pick up a copy of Toyota Kata. Will change your life. It’s an easy and interesting read. You can finish it in a weekend. Or two bad Emergency Room visits. Whichever.
Thanks, all. I look forward to seeing you again soon!

Very best,
Jeff

Jeff Fuchs
Director
The Maryland World Class Consortia
401 East Pratt Street, 17th Floor
Baltimore, MD 21202
http://www.mwcmc.org/

Thank you Jeff for sharing your story. Despite your scare, you maintained your wit and humor. I wish you a speedy recovery and may God bless you! My prayers are with you.

Masaaki Imai on Gemba Walks in Seattle

Masaaki Imai June 2011 KAIZEN Institute USA forum

View more presentations from Mike Wroblewski

Last week I had the wonderful opportunity to go Gemba Walking with Masaaki Imai to several Seattle Companies. I will talk about that experience in a follow up post but thought you might like to see Mr. Imai in action in this slideshow.

Children’s Hospital of Saskatchewan Getting Lean

One of our hospital clients that we are helping guide on their lean journey, in particular, using the 3P lean approach, is Children’s Hospital of Saskatchewan. It is amazing to see the lean thinking that has grown since we started this build project. As you can see in this video, many care providers are participating in this design following the 7 flows with a patient centered focus. One point not highlighted is that several customers (recent patients) also participated in the 3P process to provide their input.

At this time, we have not completed the 3P process. Next up is the design development where we will mock up life size scale rooms to test out the layout and process improvements before we start construction of the new Children’s Hospital.

Stay tuned as we progress on this lean journey!

Dilbert on Kaizen

Here is a recent Dilbert strip poking fun at Kaizen. Kaizen is NOT something that is done to people as it seems in this joke yet in many companies that is the sad reality. This joke also gives new meaning to having someone with outside eyes on the kaizen team. When done in the correct spirit, kaizen is powerful.

Did this Material Come In?

On a recent business process kaizen to improve a warehouse receiving process, our team was focused on improving the time from when the material arrives at the dock door and it is entered “correctly” into the system as received. On too many occasions, the material does not get entered properly in the system and ends up lost somewhere in the facility.

Typically, the invoice would arrive in Accounting some time later and the Accounting would write “Did this material come in?” on the invoice copy if the system did not show receipt of the material. Then forward the copy to Purchasing. Purchasing would contact the supplier to confirm shipment and send out a search party into the plant to locate this missing material.

This problem is so common that Accounting got tired of hand writing “Did this material come in?” on the invoice. To kaizen this process, they purchased a hand stamp with “Did this material come in? to eliminate the wasted time hand writing.

How often do we improve the wrong tasks? It is not true kaizen to improve something that should not be done at all. Before we jump to improvements, ask what the function is and what the value is. Take the time to look deeper. Our kaizen should look at improving the value. In this case, why did the material not get entered properly in the first place?

That’s just what our kaizen team investigated. After several rounds of experiments, we improved the receiving process and the time to “correctly” enter the material into the system was reduced by 86%. In addition, we set up a measurement system to closely monitor the process for sustainability and further kaizen. Soon this stamp can be eliminated.

Stand Up Meeting Humor

I found a copy of this recent Dilbert Comic Strip on a stand up meeting white board taking a poke at stand up meetings. Funny except for hitting people with office supplies. But it does cause me to reflect on stand up meetings...are they done just because others are doing it? What is the value of our stand up meeting? Can we improve?