Lean Methodology In Healthcare — hear Mark Graban on 5S, Six Sigma, and “lean Sigma” in the medical world.
Mark Graban is the CIO of KaiNexus, a technology and software company enabling continuous improvement in organizations.
Brandon Nys talks with Mr. Graban about his experience as consultant, speaker and author on lean efficiencies in healthcare. Mark wrote the Shingo Award winning “Lean Hospitals,” plus other books, “Healthcare Kaizen” and “The Executive Guide to Healthcare Kaizen.”
Mark also discusses The Toyota Production System, and industry pioneers W. Edwards Deming, Jim Womack, of the Lean Enterprise Institute.
(:15) Brandon: Hello, and welcome to Safety Experts Talk. I am Brandon Nys, your host, and with me today is Mark Graban. He is an author, consultant and speaker in the Lean healthcare methodology. Mark is author of the Shingo award winning book “Lean Hospitals” and the book “Healthcare Kaizen.” Mark is also the Chief Improvement Officer of KaiNexus, and his newest book “The Executive Guide to Healthcare Kaizen,” is on amazon.com. Mark, thanks for coming on the program with us. How are you today?
(:45) Mark: I’m doing great Brandon. Thanks for having me on the show.
Brandon: So to begin with, please tell us how you became involved with Lean and how it has changed the focus of your life.
Mark: Yeah, its funny that as people get exposed to Lean, I see this with people that I’m working with in healthcare today. When they get exposed to Lean thinking, because it’s a way of thinking it becomes hard to shut that off. It becomes a framework that you use to view not just your workplace but your home life and other settings. When people get keen on continuous improvements it becomes hard to shut off.
(1:20) When I got first introduced to it, it was before I got into health care. I was an industrial engineering student. We learned about Lean, it was definitely a “Lean Production” and it was even at best a subset of Lean methodology. We learned about it as production planning and materials management. But even before I formally learned about Lean I was exposed to the quality and management philosophies of W. Edwards Deming. My dad had taken a four day seminar that Dr. Deming, did at one of the General Motors and so I always have had the interest in the people management side and the quality side.
(2:01) Thankfully, as I moved along in my career I think people in manufacturing had certainly gotten a better understanding that Lean is not just about a tool, or particular tool and its certainly not just about how do you schedule production. It’s an improvement methodology in a management system. People in healthcare are kinda coming up that curve. There’s some great examples people who have really embraced it in a way. Again, you can’t shut it off personally or as an organization. It just becomes the way you do things as opposed to being on just some projects or just being a program.
(2:35) Brandon: So you’re introduced to Lean through your father and with Deming and now you’re a Lean kind of industrial engineer. What lead you down the path of wanting to apply the philosophies of Lean and the tools to the healthcare realm?
Mark: When I first got exposed to the idea of Lean Healthcare I was working for the last manufacturing company I worked for and this was in Phoenix, and we had a local network of people who would get together and talk about our Lean work at different companies. We would do site visits and just exchange notes. None of us were competing with each other.
(3:15) For one of those sessions we had a chance to go visit a hospital in Scottsdale, where two women had left Motorola. They were doing work in the emergency department and it was just really fascinating. It was really eye-opening and so I started reading about Lean in healthcare. Then my wife and I were moving to Texas in 2005 for her career and that put me on the job market and honestly it was little bit of right place right time. I got a call from a recruiter at Johnson & Johnson. They were looking to hire people into a group that did consulting work with hospitals. It seemed like a great group of people and JJ was a great company to work for. I thought this will either be an interesting little detour into healthcare or a career shift and you know, eight years later I think it’s become more of a career shift.
(4:07) It’s been really enjoyable work, really rewarding work and I’m honored and thrilled to have a chance to be part of a large group of people that are trying to help fix some really important problems that were facing the world of healthcare.
Brandon: As you’ve gone into the medical field, talking with medical professionals and hospitals in their leadership, do they readily accept the message of Lean or do they generally show some resistance to it?
(4:37) Mark: Well, I think like any setting there’s a mix, there’s a range. It’s maybe roughly a bell curve because, I mean, the one thing people in healthcare will bring up of course is that, we’re not a factory. Okay, fair enough. Lean is not just about, how do you build cars. Even throughout my career everyone loves to fixate on how they’re different from Toyota assembly line plan. I worked at General Motors in engine manufacturing assembly, in machining and everyone would say, “Look, engine machining is way more complicated than just bolting cars to together. Lean won’t apply here”.
(5:23) And people and in non-automotive manufacturing will talk about how they’re different and people in healthcare will talk about how they’re different. But when you kind of orient the discussion around, it’s not “turning the hospital into a factory” it’s about making the hospital the best hospital it can be. You’re not changing the mission and the values of the organization. In fact, Lean, when it’s applied properly, it enhances that mission.
(5:54) So just one quick example would be; the mission and purpose being around patient care, ensuring quality, ensuring patient safety. When you have kind of a typical starting point in healthcare that’s very inefficient full of waste, it’s not only a frustrating work environment for the staff but that leads to dangerous conditions for patients. So when you orient people around the purpose “why are we looking to improve?” I think that’s a far more important discussion than, “why are we going to do Lean?”
(6:27) The point isn’t to do Lean, the point is to improve safety, quality, reduce waiting time, improve productivity and reduce cost in healthcare. People tend to be engaged about that and I think when we make sure that there’s the good understanding about why we want to improve, that does a lot to bring doctors, nurses and healthcare leaders on board.
(6:54) Now, the challenge a lot of times then becomes in changing the culture and “why do we have existing culture? Why do leaders at different levels resist the idea of change in the culture that senior leaders rose through the ranks in the existing culture, they don’t want to hear necessarily that there’s problems with that culture and so I think a lot of the challenges kind of fall into the category of convincing people that the culture contributes to those problems of safety or quality or efficiency and that therefore the culture needs change and that can be a big part of the improvement.
(7:35) Brandon: So with the healthcare realm, is it typically going to be the upper management you have to convince? Or, it sounds like doctors are usually pretty readily on board.
Mark: That might be overstating it a bit. Again, there’s a range and the one complicating factor in healthcare is that the physicians often are not employees of the organization that’s sponsoring Lean. And this is good in a way because your people from Toyota will teach you the idea that leadership needs to rely less on formal authority.
(8:16) Leaders might want to say to the doctors, “You have to do this because I’m the boss and because I said so.” Well, we are not directly their boss you can’t do that and it’s arguable that you can argue that you shouldn’t do that even when you are directly the boss, that you need to be a leader instead of a dictator and that can be a challenge. I think it’s a good challenge but it can be difficult. Keeping that in mind when when engaging docs or people who aren’t directly your employees.
(8:49) You know, different levels of leadership, senior leaders might be on board and then find challenges in getting the front-line managers on on board with Lean getting them to change the way their operating. I’ve seen some organizations where the directors in middle management are really on board and and they’re struggling to get their senior leaders on board with Lean. It’s really interesting to to see and to ask why leaders at different levels might be threatened by change, why they may feel a sense of loss in shifting from the older culture to a lean culture.
(9:32) And one thing that often comes up is the idea of engaging employees and continuous improvement or Kaizen. Some managers may feel like it somehow reflects badly on them when their employees are coming up with opportunities for improvement. Kind of in the old mindset they may say “Well, that makes me look bad because we had problems.” Well, if they have good supportive senior leaders who are kind of helping them understand that it’s a good thing to have your employees engaged in fixing the problem, we’re not going to blame you for having problems. What matters is working together to fix things.
(10:12) You know, some people can change that mindset. Some people really struggle with that new style of leadership and they may bail out and go back into an individual contributor role because they the don’t agree with that culture change. That’s where it can be complicated. Lean principles are relatively simple but changing an organization and trying get people on board with culture change, is a lot more complicated.
Brandon: Sure, sure. It can be pretty labor-intensive to completely change how a company functions.
(10:48) Mark: It takes time. It takes a lot of work, it takes a lot of leadership and I think that’s one of the challenges with Lean. If people are looking for a quick fix or what Dr. Deming, would have called “instant pudding”. Lean is not instant pudding, it’s not a silver bullet, it requires work and effort. I kept thinking Jim Womack, from the Lean Enterprise Institute would often say, “Managers will try anything easy that doesn’t work before the try something difficult that does work.” I think sometimes Lean and culture change falls into that category of things that are difficult, but do work.
(11:26) Brandon: I’m a big fan of your blog over at leanblog.org and in one of your your most recent blogs you talked a little bit with, you seemed kind of annoyed with the people spreading an incorrect, or I guess what you call up a false dichotomy regarding Lean and Six Sigma. What are some of the points of people that spread those falsities? What are those things and what could you express to the listeners to help them better understand how to not spread those those falsities?
(12:04) Mark: Yeah, the one that comes up a lot and I do get annoyed with, I think it’s something that is factually incorrect as opposed to just being a different opinion. What’s factually incorrect is when people say, Lean is about flow and efficiency and Six Sigma is for quality. Six Sigma is about quality. The falsehood or the thing that’s wrong is to say Lean is only about flow and efficiency, because when you go back to the roots of the Toyota Production System, flow and quality are absolutely intertwined. Quality leads to flow, better flow leads to better quality.
(12:47) The two pillars of the Toyota Production System are: Just In Time, The idea of flow and the Japanese word Jidoka. Which basically means, “Quality at the source or built-in quality.” So Lean provides a rich set of methodologies for error proofing and in other ways of improving quality. To discount that and say the only way to improve quality is to use the more complex methods of Six Sigma is again, I would say is factually incorrect.
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(13:20) There is absolutely a role in a place for the statistical methods of Six Sigma. There’s no denying that, but what I get annoyed with is this kind of incorrect mashup of Lean and Six Sigma into what people will call “Lean Sigma” and that Lean Sigma, approached the way it’s usually taught, just unfortunately spreads a lot of things about Lean that just aren’t right.
Brandon: But you have to admit it does have a pretty good ring to it, Lean Sigma.
(13:55) Mark: I don’t think it does. I mean, that’s where I always say, Lean and Six Sigma.
Brandon: Sure, sure.
Mark: To me it doesn’t become Lean Sigma. I’ll give credit to my friend and fellow blogger Chad Walter’s, for this. Who says “Lean Sigma is a spork. It’s the worst of both worlds. A spork is neither a really good spoon or a really good fork. I would rather have both a fork and the spoon at the table. I wouldn’t combine them into a single thing.
(14:27) Brandon: That’s probably one of the most astute ways of summarizing what that is. That’s actually quite good. So if you’re working with a company or an organization that is looking to just start their journey into the world of Lean, how would you guide them? What are the sources you would point them to? What are the first critical steps? Where would you point them?
(14:55) Mark: Well, I think the first really important point is to understand why you’re looking into Lean. I think sometimes people get off-track when they think about which tools am I going to implement first. I would say, “Wait a minute. Timeout.” It should really be focused on what problems are we trying to solve. As an organization, what are we trying to do for our customers? What are we trying to do for our employees? I think that really needs to be, that’s really the only starting point that I think makes sense, is to figure out why. What are we doing, what are we trying to accomplish?
(15:40) And, I think there is a balance between implementing methods and changing culture. Even if people are going to start, this is a common starting point. I wouldn’t be prescriptive and say you always need to do this. But let’s say you look at your circumstances and you decide you’re going to start with 5S. People often describe 5S as a tool and I think well, wait a minute, there’s actually a lot of of cultural, organizational culture assumptions built into 5S.
(16:16) So you can start examining kind of the philosophy and the culture behind 5S. So people I think sometimes mistakenly think 5S is about going around and putting tape around everything. What problem is that solving? What benefits is that providing? If you look at some of the assumptions behind 5S, there’s an assumption that says we respect our employees and we want to do everything we can to make sure they have the tools and supplies and equipment they need to do their jobs.
(16:44) Mark: I think that kind of understanding as your implementing 5S, helps avoid situations where people are just kinda going through the motions and they’re not really doing anything that is helpful for their customers or for their employees. There’s some people who discount the tools altogether but culture change doesn’t happen overnight. You can’t just think your way to being a lean thinking organization. You have to take steps, you have to start using some methods, you have to start solving problems. It’s kind of what I’ve come to describe as Practicing Lean.
(17:23) You hear physicians talk about practicing medicine, lawyers are practicing law. I think people who are embracing Lean, I think the term Practicing Lean is better than say implementing Lean, because implement sort of implies we did this and we’re done, as opposed to practicing which is more kind of that ongoing approach of trying things, learning from it and then continually adapting and continually moving on. I think that’s a really key point about making sure Lean is meaningful and that we don’t try some tools, not get results and then give up on the promise of Lean.
(18:05) Brandon: With regards to the to the healthcare field, it sounds like you you’ve developed quite a, quite a powerful tool in KaiNexus. In helping in some of those, those organizations really streamline the flow of inefficiencies and things like that. Do you want to take some time to talk little about that?
Mark: Yes. So KaiNexus is a technology and software company that was founded by Dr. Greg Jacobson, an ER doctor and Matt Pollulous who is that the chief technology officer. I got involved with them about two years ago because we have a software platform that enables continuous improvement in an organization and it’s just a tool. Email is just a tool. Email could be really helpful or it could be a big waste of time.
(19:01) A piece of software, like KaiNexus, a web-based software can be really useful when you have of leaders engaged. When there practicing Kaizen principles. Or it could be a piece of software just sits there not being used. So we think our technology is really helpful. We have great results from our customers in healthcare but it’s only as good as how it’s used. It’s not a silver bullet. A piece of software doesn’t force improvement to happen in an organization, but what KaiNexus does, is help manage a lot of the communication and notifications that would take place in improvement work.
(19:44) It provides transparency and visibility to everybody in the organization and we think that’s a big difference from say, the suggestion box, where ideas sit hidden and locked up often never to be seen from again. KaiNexus engages everybody in the improvement process to identify opportunities for improvement in in their own work, in their own department. It allows them to then participate in the improvement process. So it’s really been a fun project and a really interesting startup to be a part of.
(20:19) Brandon: It sounds extremely beneficial for anybody who does decide to implement that tool in their progress towards being Lean and much more efficient all-around.
Mark: We’ve had some customers that use KaiNexus to get started with a continuous improvement program or get started on their Lean journey. Then we also have some customers who have been working, that have been on their Lean journey if you will, for many years and they’ve been practicing Kaizen with with bulletin boards and manual methods.
(20:52) You know, bulletin boards can be great within a local department but it’s really bad in terms of providing visibility to other sites, to other departments. So they’ve been using KaiNexus to improve the way they do improvement which is really exciting to see as well.
Brandon: Well Mark, I mean it’s always a pleasure to talk with you about lean and everything that encompasses. We want to really thank you for taking some time out of your busy schedule to be with us today. What should we be on the lookout for from your camp?
(21:24) Mark: A newer, slightly different edition of our book “Healthcare Kaizen,” with my co-author, Joe Swartz. This edition is going to be called “The Executive Guide to Healthcare Kaizen.” What’s going to be a smaller more introductory book. We hope people would give to their senior leaders and say, “Here, read this on a flight.” It talks more about why Kaizen is an important strategy for healthcare, what are the roles of leaders at different levels of the organization.
(21:54) And so, you know, the full book, “Healthcare Kaizen,” has more than 100 examples, and lots of full-color pictures and a lot of how-to detail. Some of the feedback we’ve gotten on the book is that frankly it’s too heavy to carry a long and so that’s were the executive guide is written more specifically for mid-to senior-level executives about why Kaizen is important and how they can get that started throughout healthcare.
Brandon: Um, is that something we can get directly from from your website at leanblog.org?
(22:26) Mark: Ah, amazon.com. They can also go to hckaizen.com, which is the website for our book.
Brandon: Great. Alright, well thanks again Mark. It’s been truly a privilege to have you here with us and to share your insight and your experience on on Lean and just everything. I’m just always glad to converse with somebody who’s so educated in this journey.
(22:55) Mark: Well, thanks Brandon. I appreciate it and it’s an honor to be with you on the podcast.
Brandon: If you would like to know more about Lean manufacturing and health care from Mark Graban, visit his website, leanblog.org. That’s L E A N B L O G dot org. Once again, this has been Brandon Nys with Safety Experts Talk.
(23:14) (Outro Music with Voiceover)
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