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  • Why communication really does matter

    A patient’s family is asking logical questions, but an intern feels ill-equipped to answer. A resident and attending physician are presenting discharge plans, but they lack information from rehab and nutrition services. Every day, we’re reminded that the quality of the healthcare we provide begins with how well we communicate as a team. Inadequate communication is more than a daily challenge for the healthcare team. It can impact efficiency, the entire patient experience, and, most importantly, outcomes. The Joint Commission projects that approximately 80% of serious medical errors can be...
  • There is no safety in numbers!

    In a small (30-bed) community hospital, operating room staff were struggling with the challenge of efficiently performing operating room turnover. The time to change over the room between operations was too long and too variable.  The average changeover time was 28 minutes, with a range of 15 to 39 minutes. Required tasks were completed inconsistently, with variability in the way they were performed. During one turnover the horizontal table surface was cleaned four times by four different people! Standard work was limited, and participation on the turnover team was variable with anywhere...
  • What does it mean to be “on the gemba”?

    What is the “gemba” anyway? You read about it all the time in books and articles on lean healthcare. Gemba is Japanese for “the real place.” Let’s say I am a reporter in Japan covering the nuclear power plant meltdown in Fukushima. The camera scans the wreckage and then focuses on me, standing in front of the mess. I deliver the latest bad news and then, as I’m signing off, I say, “This is Tom Jackson, reporting from gemba.” In healthcare we use the term gemba to refer to the “real place” where patients are cared for: in the clinic, in the emergency room, in the operating room, on the...
  • Lean vs. six sigma: a pointless fight

    Healthcare leaders are looking for ways to change their organizations and their industry. In the search for solutions to help them, they encounter information, education, and consulting services that tend to fall into two camps: lean and six sigma. Lean and six sigma are often taken to be two different systems that are at odds, with experts and practitioners touting the superior benefits of one or the other. I myself once made a dramatic public presentation in which I described six sigma as a heartless robot. But this is a pointless fight. Lean and six sigma are fraternal twins. First, let’...
  • What do you do when opportunity doesn’t knock loudly?

    Experienced lean practitioners know that there are virtually no processes or work units that are devoid of opportunity for improvement. Indeed, improvement opportunities leap out at practiced observers. As an organization travels down the road of transformation, though, the opportunities become less evident. What happens when those opportunities do not bubble quickly to the surface? Where do we search for them? How do we tease them out from work processes that don’t produce a lot of defects? What if all the “low-hanging fruit” has been harvested? What if there are no customer complaints?...
  • Building connections with IT

    When it comes to planning, creating, and implementing the best improvements, assembling the right team is vital. We’ve probably all been part of a team that could have been strengthened by someone who was left off the invitation list. Who are the folks you most often find missing or disconnected from your improvement teams? At the Lean Enterprise Institute’s recent Lean Summit for Healthcare Transformation, the information technology (IT) department was highlighted as one group that is often left out of lean activities. In his breakout session, “Leveraging Information to Improve Patient Care...
  • Inputs, outputs, and human beings

    Within Rona Consulting Group, we debate how to refer to patients in the context of clinical value streams. Always with respect, of course. My partner, Patti Crome, a former nurse executive, speaks of having “a patient on her shoulder.” But there is a real dilemma when transposing the industrial method of value stream mapping to healthcare. In manufacturing, value stream maps chart the flow of an inventory of parts or materials through a production system. Consultants will spray-paint parts red to measure their travel time from the first through the last process in a value stream. In...
  • Leadership lessons for healthcare leaders

    A healthcare leader recently asked me to recap lessons from my time at Virginia Mason, so that he could share them with his team. Reflecting on my experiences there, I find myself still embarrassed that for the longest time I could not see another way to lead in healthcare nor truly grasp that a dramatically better product was possible. It was my growing discomfort with what we were doing for patients and with the daily duress of healthcare professionals trying to do their jobs that finally forced me, and us, to attempt a different approach. Dr. Don Berwick, co-founder and former president...
  • What does it mean to “meet takt time”?

    Clinical value streams are consciously designed to match patient demand with the supply of clinical services, in a management exercise known as “meeting takt time.” The word “takt” is German for “tempo” or “time.” (Insiders refer to takt time simply as “takt” to avoid redundancy.) Mathematically, takt is defined as:  T = t/d, where: T = takt. t = time scheduled for service production. d = average patient demand for clinical services. For example, let’s say that you run an emergency room. It is open 24 hours per day (that’s t, the time scheduled for service production) and you...
  • Flow, push or pull?

    The language of value stream mapping describes a collection of processes in one of three physical states: “flow,” “push,” or “pull.” These three little words can cause much confusion. With the help of a little economics, I will attempt to clarify these terms for healthcare. Flow. Let’s begin with a process in a state of “flow.” This is the ideal waste-free state of a lean process. In a state of perfect flow, patients never wait to be seen and clinicians are always busy—but never rushed. Medicines, tools, and supplies are always available in the right amount at the right time. What patients...

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