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  • Go and see, again

    Same river as before, but a different day. And I went again the next day, to another part of the river with another dam. Each time, the view and experience were different. This time, there was heavy equipment on the dam doing maintenance. I like this as a reminder that workflows, like the infrastructure of roads, bridges, and dams, need maintenance. “Go and see” means seeing if the workplace is tidy, is standard work being followed, does the standard work fit? Are there new issues? Where is maintenance needed? In the Peri-Op Services area of a hospital, we had a solid workflow with daily...
  • Go and see

    A key concept in lean (which can be used in any part of life) is to go see what is happening and watch to understand. Yesterday, after seeing a video of the river overflowing the dam, I went to see for myself. Persevering over the long trek was worth it; seeing the falls in person was a different experience. The view was bigger in person—360 degrees of view. I could see where the water flowed, how the logs on top were held back to protect the dam, and the new safety fencing. The sound was thundering. There was a crowd of at least 10 people watching and taking photos. This is a very small...
  • The beginning: Looking back at our transformation

    I wrote this four years into our journey at Virginia Mason Medical Center. The challenges back then are the same as they are today. The key is always leadership focus.  When it is there constantly, then great things happen. When it is not, then like sails luffing— simply flapping with no direction and no power—nothing goes forward. November 14, 2004 On November 9, 2000, I was on a flight to Atlanta, when I met John Black. I can truly say that there has never been a chance meeting in my professional life that has so changed me as a manager and a leader in healthcare. I think...
  • Improving access part 5: workplace organization and sustainment

    You’ve done the hard work of eliminating your backlog so that patients can be seen when they want to be seen. You are doing “today’s work today.” But how do you sustain these improvements to keep your backlog from returning? It starts with having your workplace organized and then putting into place a robust sustainment plan. In my first blog post, I talked about the importance of the provider and medical assistant working together to complete the indirect care tasks (messages, refills, prescriptions, lab results, etc.) in flow. But beyond working in flow is the need to have an organized...
  • Toyota recalls, leadership, and the long term

    Recently Toyota announced a recall of 3.37 million cars over airbag and emissions control issues. How and why would one of the finest quality global producers of automobiles need a recall, when they are a company committed to practicing mistake proofing and defect reduction? Toyota faces challenges as the largest global automotive manufacturer, selling into the most competitive marketplaces worldwide, where informed consumers demand the latest in full-line products and service innovations. In this marketplace, expectations of value, including the highest quality and product safety, are...
  • Improving access part 4: reducing backlog

    You’ve matched your capacity and demand, so you are able to do today’s work today. But all those appointments scheduled out into the future still need to be addressed. This is your appointment backlog, which is really the waste of inventory—an inventory of appointments. Just like supplies, an inventory of appointments has to be managed and can cause rework. For example, instead of getting care, patients who are scheduled into the future call to reschedule and/or miss their appointments, causing more work for the care team and wasted capacity. There are two types of backlog—good and bad. A...
  • Virginia Mason

    I have been asked in the last week what I made of the recent negative JCAHO accreditation news about Virginia Mason considering the management roots of many of our team and what many would consider the roots of lean in healthcare. My first reaction was how sad for patients and staff. They do not deserve this and are not responsible for this situation. My second was how tragic it is when leaders fail the people. My third was how poorly leadership can behave when the news is bad, yet so publicly visible when it is good. And, the fourth was what can we learn from this and share with our friends...
  • Practicing intentional kindness

    On a typical Sunday my 4-year-old son would have woken up early, seeking his daily dose of Peppa Pig and a trip to the playground. But this was not a normal Sunday. I awoke incensed, for in the past 36 hours Christina Grimmie, a talented 22-year old singer, was gunned down while signing autographs. Her brother instinctively tackling the gunman and risking his own life only to witness the gunman’s suicide. My brother called on Saturday morning and throughout the course of our discussion I came to a deeper appreciation of the current condition in my hometown of Chicago. He shared the harrowing...
  • New England Journal of Medicine Letter to the Editor

    Today, the New England Journal of Medicine published a letter to the editor written by RCG principals Samuel Carlson MD, Thomas L. Jackson MBA PhD, and Joanna Omi MPH. The letter was written in response to an article entitled “Medical Taylorism,” by Pamela Hartzband MD and Jerome Groopman MD, published in the January 14, 2016 issue. That piece drew commentary from many practitioners of lean healthcare, who expressed concerns that the article propagated serious misconceptions about the philosophy and values behind lean and the Toyota Management System. It is unfortunate that in the authors’...
  • Improving access part 3: managing your capacity

    Once you understand your true demand and have modified it by shaping, reducing, and substituting, it’s time to take a close look at your capacity. In ambulatory care, capacity is the number of available appointment slots in your schedule to meet your demand. There are several things you can do to optimize your capacity once you understand how much you have and where the gaps between capacity and demand are occurring. Ultimately, you will want to maximize available capacity. Start by measuring capacity. How many appointment slots do you have? What is your appointment interval length? Does it...

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