Tag: Mark Graban

Toyota-ism vs Taylor-ism

Jan 16, 2016• 5

By MARK GRABAN

flying cadeucii If you’re new to the idea of “Lean,” I invite you to download and read chapter 1 of my book Lean Hospitals.

Hat tip to Suresh for pointing me toward this article that was just published January 14th in the New England Journal of Medicine: “Medical Taylorism“

NEJM is the same journal that published Dr. Don Berwick’s article about Kaizen and Dr. Deming in 1989, how those concepts would be helpful in healthcare. Dr. Berwick realizes, as he talks about in that article, that not all factories are the same. Some are managed better than others. Employees are treated better in the “Lean” factories. Berwick was right to point out that medicine can learn from other industries… but that doesn’t turn the hospital into an assembly line.

In the article posted this week, Pamela Hartzband, M.D., and Jerome Groopman, M.D. (the later the author of the popular book How Doctors Think), rant about all sorts of things… some of which have nothing to do with Lean.

“Advocates lecture clinicians about Toyota’s “Lean” practices, arguing that patient care should follow standardized systems like those deployed in manufacturing automobiles. Colleagues have told us, for example, that managers with stopwatches have been placed in their clinics and emergency departments to measure the duration of patient visits. Their aim is to determine the optimal time for patient-doctor interactions so that they can be standardized.”

This is wrong headed and insulting toward Toyota. I’m pretty sure Toyota would not alienate physicians or other healthcare professionals this way.

Will the Shinseki Resignation Turn around the VA?

May 30, 2014• 28

By MARK GRABAN

As I wrote on LinkedIn, instead of blaming “bad managers” or a “lack of integrity” at local VA sites, like Phoenix, we have to look at the system.

Dr. W. Edwards Deming always said that senior management is responsible for the system. We need to ask who designed, set in place (or tolerated) things like:

“Unrealistic” 14-day waiting time goals (says the VA Inspector General)
Bonuses and financial incentives driven by hitting these targets
A culture where people can’t ask for help (“don’t make things look bad”)
An environment that tolerates not having enough capacity to meet demand

In circumstances like that, being pressured by distant leaders to hit an unrealistic target… I would GUARANTEE that there would be some level of cheating. And, more than 40 VA sites are under investigation by the Inspector General. This is systemic. It’s too simplistic to label people as “bad” and to then fire them. “Gaming the numbers” is very predictable human behavior (and it happens in other countries’ healthcare systems too).

In his statement, Shinseki did point fingers at himself on one level:

At the end of a speech to an annual conference of the National Coalition for Homeless Veterans in Washington, Shinseki addressed a new interim report on the VA health-care system’s problems. He said he now knows that the problems are “systemic,” rather than isolated as he thought in the past.

“That breach of integrity is irresponsible,” he told the largely supportive audience. “It is indefensible and unacceptable to me.” He said he was “too trusting” of some top officials and “accepted as accurate reports that I now know to have been misleading with regard to patient wait times.”

President Reagan famously quoted an old Russian maxim, “Trust, but verify.” That’s good advice for leaders anywhere.

Toyota’s Taiichi Ohno also famously said:

“Data is of course important in manufacturing, but I place the greatest emphasis on facts.”

“Data” might include spreadsheets and reports on the web. Data are too easily gamed, faked, and fudged. People can manipulate data in many ways and leaders need to be aware of that.

“Facts” are things you can see with your own eyes. Lean leaders “go to the Gemba” (or the actual workplace) to see first hand and to talk to the people who are doing the work. A Lean VA leader would visit locations (or send people) to help verify that data is not being manipulated and that processes are being followed. You’d talk to veterans to see if they have complaints about long waits that aren’t showing up in the data.Continue reading…

Higher Workloads and Fewer Nurses? Not a Recipe for Patient Protection and Affordable Care.

May 8, 2014• 10

By Mark Graban

In further celebration of Nurses Week, it’s worth discussing this TIME article about the “Killer Burden on Nurses” under the Affordable Care Act.

The point I’m raising and highlighting here is not meant to be political or partisan, but really one about nursing workloads, management decisions, and what’s right for patients.

We’ve seen recently that American healthcare spending is UP about 10%(the biggest increase in spending since 1980) – mainly due to newly insured patients getting care. The point is to get people care and treatment, but maybe the law should have been called the “More People Getting Healthcare Act?” That’s a noble goal.

From the TIME article, an opinion piece written by a nurse from California:

“… I worry that the switch may compromise the quality of the care our patients receive.”

The nurse talks about patients who are sicker due to not getting good healthcare previously. These patients require more attention and more nursing time.

In any workplace, the staffing levels should be set based on the total workload. Using “number of patients” is not a good basis, since the acuity of patients (and the resulting workloads) aren’t equal. Not every patient is the same.

Hospitals, due to other industries, do a really poor job of “industrial engineering” work that would establish the right staffing levels based on workloads.

Things That Make Me Worry About My Colonoscopy

Apr 17, 2014• 17

By Mark Graban

Sorry to get all Katie Couric on you, but I’m going to have a colonoscopy on Friday. I turned 40 last October and I have some family history that leads my doctor to get one done now rather than at 50.

Unlike Katie, I won’t be broadcasting mine live, but I’ll share some articles and reflections on the process and, being process focused, what could go wrong. It’s a very necessary procedure, but there are, sadly, some very unnecessary and preventable risks.

According to Dr. Wikipedia (backed by journals):

This procedure has a low (0.35%) risk of serious complications

That’s about 1 in 300 patients, put another way.

For those of you who speak Six Sigma, that’s a 99.65% first time yield and a 4.2 sigma level.

That’s not going to scare me away.

Maybe I should have asked what my physician’s complication rates are. What are the complication rates at the surgical center where this will be done? Is this safer than being at a full-blown hospital or doesn’t it matter? Should I be more of an “engaged patient?”

Should I have asked more questions of my primary care provider? Why did she refer me to this GI specialist? Is he a “Best” doctor? Does that matter?

If I treat them as a supplier (respectfully), should I be able to walk the process and see what they do to prevent, say, instrument or scope disinfection errors?

Should I have asked:

Show me how you disinfect the equipment
Show me your training records for the people doing this work
Show me your equipment maintenance records
How do you verify that the work is being done properly?
Have you had any complaints or incidents in the past?

I had my pre-procedure phone call on Monday. Maybe I should follow up and ask a few of these questions, even if I can’t go “walk the gemba” to check things out myself. What would you do?

Of course, I didn’t have data or information available to me to know: