A Rose By Any Other Name

Can an organization be “Lean” without even knowing the meaning of the word?

I had a personal experience not too long ago where I had to spend some time in a hospital. Don’t worry I’m fine now, feeling better than ever, but at the time there was a sense of urgency. As I reflected on my observations of the operations in the hospital I wondered about whether or not an organization can be truly Lean just by nature or by accident. Do they have to draw upon the conventions of the body of knowledge known as “Lean” along with its lexicon and case studies? Or does it even matter if they know what is meant by the word?

When I walked up to the front desk of the emergency room I explained that my doctor suggested I drop in for some testing. I felt perfectly fine. In fact, I drove myself to the hospital with a friend who wanted to come  so we could get lunch in New Haven afterwards where they have legendary pizza…the irony of this will be clear as the story unfolds.

The registrar at the front desk pulled out a thermometer and blood pressure cuff and started taking my vital signs as he proceeded to ask me the customary questions, but only after having asked the most urgent question first. What is wrong, why are you here? “My doctor suggested I have a cardiologist take a look at me. Nothing urgent but If I just make an appointment it will take weeks.“  He asked for my name and insurance information. Didn’t ask if I had been there before because the system pulled up my prior visit and instead he told me “I see you’ve been here before”. Then he told me my temperature and blood pressure as he entered it in the system. Within minutes he had taken the necessary information and established the urgency of the situation. He asked my friend and I to take a seat nearby. By the time we walked to the seat but before we even sat down, I was asked to come to a nearby room where a doctor was waiting to speak with me. Shortly thereafter that same doctor wheeled me to a nearby area where someone was ready to take a blood sample for testing. Within about a minute that same technician, having taken the blood test, had notified by cell phone the appropriate specialist, and a minute or two later a group of physicians and support staff had me in another room to carry out what turned out to be an urgent procedure. Throughout it all they took great care to explain each step of the way what was happening and at no time did I feel incidental to the process. I was especially heartened that the team gathered around me and took a moment to bring everyone up to speed, out loud, on what was wrong with me and what they were going to do. At no time, did I feel the victim of bureaucracy or organizational confusion. It was obvious to me that the entire team was on the same page each step of the way and  that they took overt steps to maintain that level of communication and error prevention. It went flawlessly and a few hours after my procedure I was in a room resting and allowing my mind to catch up on all that had just occurred.   

 The man at the front desk was taking my vital signs as he gathered other important information.

 Only minutes passed from the time I walked into the door to the time doctors were providing the necessary, and  what turned out to be urgent, care.   

 The waste of waiting was minimized across the board from the moment I walked in the door.

 The waste of transportation was also minimized as I was moved from where the evaluation took place to where the  procedure was carried out.

 The waste of defects was managed closely as the team overtly engaged in mistake proofing what could have  become a very confusing situation.

  Not once did I hear anyone mention poka-yoke or eight step problem solving, or see a standard work sheet.

Now I’m in my room.

A nurse comes in to help me get settled. She introduces herself, walks up to a white board, and writes her name, my medications, as well as any other information important to anyone walking in to provide care. She then shows me how to call her with the call button next to my bed should I need anything. Before leaving she comes back to the bed and asks me if I needed anything or have any questions. I asked her to help me plug in my phone. She helps me find my phone and charger, plugs it into the wall behind the bed, and recommends that I get some rest.  

 After the nurse left, I studied the white board on the wall on which she had just written. It showed all the most basic information across all three shifts of the day. I supposed that if I perceived some problem I could call the nurse and alert her to the nonconformance.

 Not once in my time there did I hear or see the terms “Standard Work”,  “Andon”, or “Visual Management”.

After a while someone came in to give me my medications. The pills were in individual bar coded containers and each container was scanned  as I took them.

 No one used the terms” Kanban” or “Poka-Yoke”. 

After a day or two, as I began to get bored, I started to walk around the floor. I happened across a flat screen display with all the patient statuses (names coded) in front of the centrally located nurse’s station. You could see certain lines on the screen flashing, indicating that attention was required and I observed people reacting to those flashing lines.

 I mused that someone in the hospital must be very process savvy. Maybe some very competent process design  expert designed all these work methods and it was management’s responsibility to make sure that everyone was  fully trained and complied? Certainly, if the workforce knew what Lean was I would recognize it in artifacts and their  vocabulary, right?

The next morning I walked the floor a bit earlier and found the staff huddled around the flat panel display. OK, rounding has been around as long as there have been hospitals, no big deal, but this was not simply a report out. The staff was openly discussing various situations represented on the panel. The conversation was crisp and everyone was encouraged to share their thoughts. It was over in about 15 minutes. The leader was obviously well trained on how to facilitate the meeting. What was most striking was that the participants were very open about the sharing of problems and their ideas for improvement. Not common in the healthcare industry. This structured problem solving was no accident.

I snooped around some more and found a wall where people were being recognized for their ideas. Simple slips of paper on the wall describing who was involved, what the idea was, and how it improved the situation. There were lots of them and none were very old.  

 Wait a minute- great processes can be designed by an expert and deployed by management. But getting the team  together and discussing how those processes performed and how to make them better, that is clear evidence of  Lean. The environment was visual, there was pervasive standard work, the standard work was being improved each  day… but no one used any of the language of Lean in anything that I had seen so far.

Later in the day I was lying in bed reading (a Lean book of course, yea I have no life) and the nurse came to check on me. She spent a few minutes talking with me, as did each nurse, each shift. I came to see these 3-5 minute conversations each shift as normal and just thought they were polite. But it struck me as odd that she always had the time and was interested in who I was and what I did outside the hospital. Don’t get me wrong, it was welcome conversation with all that I was going through, but I wondered why she wasn’t running around like crazy as one might expect from a hospital worker.

 No one used the terms “Ohno Circle”, “Grasping the Situation” or “Humble Inquiry”. Not ever.  

But the oddest part of the conversation was when she asked me what I was reading. I told her it was a book about Lean. “What is Lean, some kind of diet”? She was being serious. I explained to her that it’s a management methodology that centers around creating an environment where people are enabled and encouraged to find and fix problems continually throughout the operation. Especially at the front lines. I gave her some background on its roots with Henry Ford and how Toyota was the first to really develop the entire system on a large scale but now thousands of organizations around the world in every industry adopted these practices. I told her about some of the hospitals around the country that are well known in the Lean community for their success in adopting Lean management systems and improving patient care.

 She never heard any of this before. Here she is, an active participant in a well-known large-scale teaching hospital  focused on customer service, research, and preeminence in patient care. Everybody, everyday using waste  identification, team based structured problem solving, pull systems, visual management tools, leadership coaching  behaviors, and standard work, all the while generating a voluminous flow of ideas for ongoing improvement. But she  had never heard of this thing we call Lean in any of its well published forms. She had no idea that so many  hospitals were openly waving the Lean banner. Is this still Lean or is it something else?

When I returned home, I wanted to just sit quietly for a bit and get my feet back on the ground after all I’d been through. I started to unpack my bag and realized with great frustration that I had left my phone charger plugged in the wall behind the bed where the nurse had put it when I first checked into my room. I let it go thinking that it would be more hassle than I was ready for if I tried to call the hospital. Not the first time I left a charger behind. Probably not the last. Too bad…. 

 Boy I really need a poka-yoke for this problem! That was my favorite cord!

In another experience, I brought my car for an oil change at a well-known branded center in town.  It’s right on the road on the way to the supermarket. With its open parking lot and glass doors it’s easy to see that they are not too backed up, so I pulled in and was met at the driveway by someone who saw me driving in. He asked what I wanted to have done today, told me approximately how much time it would take in queue, and directed me to the appropriate line.

After about five minutes of waiting in my car, the lane cleared and I pulled forward. As we were talking the technician scanned the bar code on my windshield from a previous visit and read which oil I used the last time and asked if I wanted to keep it the same. Once confirmed he asked that I keep the engine running so that he could go around the car and check all my lights.  After confirming that the lights were all in good working order he said “please shut off the engine and put the key on the dashboard ”.  Once he could see the keys on the dash he shouted out “Keys clear” and asked me to open the hood. He checked the oil and shouted out to his teammate working on the car next over, “2012 Ford F150 initial check, oil level OK” and then came around to show me the dip stick. We both confirmed that all seemed in order and to move forward with changing out the oil. As his teammate was draining the old oil and preparing to put fresh oil back, he started to check other fluid oil levels and filters. While doing this, he would shout “transmission level OK, power steering OK, engine air filter OK, cabin air filter OK, all loud enough for his teammate to respond with “check”. He then topped off the windshield washer fluid, and before putting the new oil into the engine he shouted out the oil specification and volume, waited for his teammate to respond with “check”, and then poured in the oil . Stepping back he asked me to take my keys off the dash and start then engine. After a minute he again asked me to shut the engine off and put the keys back on the dash. He pulled the dip stick and shouted out “oil level OK” and his teammate shouted back “check”.  He then came around to show the dip stick so I could confirm that the level was in fact OK.

He closed the hood, took my payment, announced that I was pulling out as he opened the garage door, and then guided me out as though I were a commercial airliner backing away from the jet way.

 Not once did I hear the terms takt time, standard work, visual management, 5S, SMED, or heijunka! 

Does language matter? Or is it simply superfluous branding which can turn people off?

Certainly, as educators we have to understand the origins of what we teach. There is an entire body of hard won knowledge out there that we can access with the Internet and some really great books that reflect deep thinking on the various aspects of the field. Experts come together at events designed to share learning and we need a common language to facilitate that sharing. If we don’t know the common terminology, we will be cut off from these resources. But what about the practitioners who will use these principles and methodologies on a daily basis? And those who work in an environment where the principles become infused into the culture of the organization? Do they need to know these terms?

The point is not that they have implemented a derivative of the Toyota Production System in their hospital and that they must pay respect to its origins. A common description of culture is that it is what you do when no one is looking. The real success of Lean comes from creating an organizational culture where the elements are put in place and the essence of everyone, every day, solving problems in a team setting making processes better and better each day. They do this out of habit, it’s just how things operate in a Lean organization. Do you have to use the generally accepted lexicon? Real life is not simple and clear cut and like so many other things the answer is it depends. There are multiple paths to success and the one best suited to your specific organization’s culture is not the same as another’s. There are many organizations that are distinctly wary of anything imported from outside. Leading with something that is presented with lots of new and foreign sounding language will be looked at with suspicion and met with resistance. Other organizations characterize themselves as early adopters, always at the leading edge with new ideas as their source of energy. The approach to adoption of Lean is situational and should be thought through carefully. Largely it comes down to both culture and the problem being solved.

If you are trying to simply improve performance by fixing operational problems and gain a boost in productivity, quality, or customer service, then it’s quite possible that a group of process experts can analyze a set of solutions against some cost/benefit criteria and implement the ones they feel most appropriate. It’s quite likely that you will see measurable improvement coming out of each of these projects. The challenge will be one of sub optimization, as each project strives to gain the most benefit within the parameters that are being measured within a thin slice of the value stream. The next challenge will be one of sustainability as solutions are handed down to the workforce through standard training methodologies.   

An intermediate approach would be to put such projects in place and engage the workforce in finding ways to further improve it over time. Both of the examples above exhibit evidence of this approach. The essence of Lean is that people have the means to come together, socialize problems and areas of potential improvement, try their ideas, refine them and put them into broad practice. All of this can be done without the use of any of the Lean lexicon. Of course, the handicap will be that every solution will be a new invention and the team will be cut off from the learning that has taken place before them. Inventing things from scratch takes time and energy. Nevertheless, certain organizations with conservative cultures and moderate sense of urgency may find this approach to be the best.

Keep in mind that those that have laid down the foundational principles of Lean spent their lifetimes developing them. Many lessons were counterintuitive at first and took years of trial, error, and persuasion to realize. Imagine the reaction among engineers when Deming first proposed constant cycles of improvement.  Rejecting the concepts of Economic Order Quantity likely made no sense to anyone Ohno and Shingo were trying to convince. I’m sure that these people would not have wanted to go through that learning and adoption experience a second time. If we want to maximize the rate at which organizations learn, we have to augment building basic problem solving capability with access to those who have solved parallel problems in the past. It is the language that provides that access.

The point of all this is to keep a clear image of the problem you are trying to solve and the organizational context within which you are working. An autocratic organization will need to rely on experts identifying and implementing projects that yield discrete benefits.  Such organizations exist both under duress and also in stable prosperous conditions. A benevolent organization will want to engage the workforce in socializing issues while putting solutions in place that lead to more fulfilling work and sustainable improvement curves over time. Other organizations will want to identify themselves as enthusiastic learning organizations and will want access to all that has been learned in order to  build upon that. These organizations will need to have knowledge of those that have gone before them and the journey they are on. To say that we want to develop the learning ability of our people as a centerpiece of our management system is to connect them with other organizations who have fully matured in this model. The lingua franca of Lean and the literature which embodies it is that bridge. 

Meanwhile back home from the hospital visit….

Three days after returning home an envelope came in the mail.It was my charger. This is what Lean is. Everyone, every day, feeling a sense of responsibility to finding ways to make things better. Even when no one is looking or seeking credit for it. There is more than one path to this destination.  

Joe Murli

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