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  • Daily management: perception vs. reality

    “Reality is always kinder than the stories we tell about it.” –Byron Katie The perception: I don’t have time for that! Organizations everywhere struggle with fully implementing and sustaining change. How do you spread a new process that proved beneficial during a kaizen week to hundreds of staff that are already overburdened and not adhering to current process standards? Once changes are made, how do you sustain the gains in a culture of competing priorities and new initiatives? The solution to both these problems is “daily management.” Daily management is a set of management routines...
  • Why we do what we do

    I had been trying to ignore it, the nasty hacking cough and shortness of breath. I’d been diagnosed with asthmatic bronchitis during a visit to the ED while on a business trip four weeks earlier. The prescribed antibiotics and inhalers had worked at first, but now I was getting worse again, and fast. “You sound horrible,” my mother said. “Go to the doctor,” my friend the nurse said. Finally, my husband lovingly asked whether my head was located somewhere other than on my neck. “Quit pretending this is getting better,” he said. Like the shoeless cobbler’s child, I was a healthcare...
  • Everett Rogers changed my life

    The day I learned of Everett Rogers’ work on diffusion of innovation, I changed the way I approached managing change. The proverbial light bulb went off in my head when I first saw the normal distribution curve Rogers used to describe categories of innovation adopters, which is crudely reproduced here: “Diffusion,” Rogers wrote, “is the process in which an innovation is communicated through certain channels over time among the members of a social system.”[1] Individuals in any social system will adopt change at different rates, and I wanted the adoption curve for changes in my area to look...
  • Interruptions as Defects

    As an intensive care physician, I have always expected frequent interruptions. After all, patients are critically ill and often unstable, and prescriptions, orders, and communication must be clear and timely. Nurses, respiratory therapists, residents, pharmacists, nutritionists, consultants, and family members often call or have me paged to ask a question or to be sure that I am aware of something. Doctor availability seems like a good idea—one that enhances communication for the entire team. The problem is this: it has been demonstrated that interruptions contribute to mistakes (and to...
  • Engaging patients and families to help us improve

    As healthcare professionals, we spend countless hours in our medical facilities, becoming keenly aware of every nook and cranny. We know the faces on every floor, the intimate details of each process, and the shortcuts across sky bridges and tunnels. We become so accustomed to our daily routines, however, that we often overlook the experience of patients and families who share the same elevators and walk the same hallways. Many of them are coming for the first time, and they see an entirely different hospital. It’s not that we can’t understand the patient perspective. It is just the...
  • The Eighth Waste

    Whether you are a lean leader, lean practitioner or a new student of lean, you’ve heard of the seven wastes in healthcare operations and administration. But are you aware of the eighth waste? Hopefully, many of you have participated in one or more of our gemba waste walks, using our handout that provides a definition and examples of each of the seven wastes in healthcare and administration. At the end of these gemba walks you’ve posted your yellow sticky notes on the waste wheel as you described the current state waste to your workshop team.  We use a fun acronym, TIMWOOD, to help us...
  • “Patients are not cars!”

    When first introduced to lean, many clinicians immediately dismiss the idea that the Toyota Management System (TMS) could help improve healthcare. Doctors have been admonished not to practice “cookie-cutter” medicine. How could lean production allow physicians to provide individualized care, as we have been taught? After all, as the common objection goes, “Patients are not cars!” Let’s explore a few physician concerns about lean management—in particular, the concept of standard work—so we can consider thoughtful responses. Concern: If standard work is created for how we assess patients, we...
  • Lean enterprise = lean body

    A physician leader in a GI procedure area once said to me, “We really run lean here. Most other places have four or five more people to support our level of activity.” Of course the rate of staff turnover was high, the lead time was long, customer satisfaction was low, and they had replaced the nurse manager three times in the last five years. He clearly misunderstood lean. There is danger in describing lean with words like efficiency, throughput, increased productivity, increased value, accountability, and yes, even lean, without making sure others understand what we are saying. Given the...
  • Thinking errors in coaching and healthcare – part 2

    In part 1 of this blog series, I introduced the problem of thinking errors or “cognitive errors” in both coaching and clinical decision making. The shortcuts or “heuristics” we all use to reach conclusions are hard to overcome, perhaps because they do serve a useful purpose. For example, when we hear footsteps coming up behind us at night we’re immediately on alert without even thinking about it. The smell of coffee in the morning tells us there’s a pot brewing in the kitchen. If we hear a noise in the front hall and happen to own a cat or dog, we’re much more likely to attribute that to our...
  • We Can’t!

    During a recent kaizen workshop, the team noticed a lot of motion waste when they analyzed the standard worksheets of medical assistants (MAs) in a diabetes clinic. The MAs would walk between the room in which they took vitals and weighed patients and another room down the hall where they performed fingerstick blood tests for glucose and hemoglobin A1C. One team member (let’s call him John) asked why they did not co-locate the glucometers in the vitals room. The response was, “We can’t.” “Why not?” “Regulations from the state.” The team went about working on other ideas and tests of change...

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