Archive for July, 2011

Undercover Hospital Sensei’s Diagnosis – “Healthcare is Broke” [guest post]

Normally, I introduce the guest post author at the conclusion of the post. However, this one needs a little pre-post explanation. Believe me.

First the introduction. This post was earnestly written by my friend, Jeff Fuchs. He is Director of the Maryland World Class Consortia, a lean non-profit assistance organization in the mid-Atlantic. He is also president of Neovista Consulting, working with large and small organizations on lean, leadership, and organizational change. Jeff has participated in the development and expansion of SME/AME/Shingo Prize/ASQ Lean Certification.  He is Lean Bronze Certified and serves as Co-Chairman of the Lean Certification Oversight Committee.  Jeff received his B.S. in aerospace engineering from West Point.  He is a veteran, and a member of the Shingo Prize Board of Examiners.  His current projects are in lean for personal time management, job shops, and lean government.

Now the explanation/background. At the moment, Jeff is the instructor for three lean training programs.  Recently, a trip to the emergency room interrupted one of his training sessions. Subsequent to the “interruption,” Jeff sent out an apologetic and, ever the sensei, instructive email to his session participants. He also shared the email with some other folks. Unfortunately for him, I was one of those folks. Jeff has graciously agreed to let me post his email (with some slight editing) within Gemba Tales. I think his entertaining letter drives home some of the not insignificant opportunities within health care, the importance of customer focus, and the power of direct observation (even when wearing something lent to you by the hospital). That, and Jeff managed to read a great lean book during his “incarceration” and then give it a plug.

The subject line of Jeff’s email –“I’m just fine!” Wish I could say the same for health care in this country.

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Dear Class,

“Rumors of my demise are greatly exaggerated.” Please accept my sincere apologies for throwing your day off last Thursday. Unfortunately, I had to bring my body into the shop for some unscheduled maintenance.

As we all heard Sir Ken Robinson observe on Wednesday’s video, some of us just view our bodies “as a way of getting our heads to meetings.”  Proper upkeep falls by the wayside from time to time, and this is what happens.  A bit of detail is in order.  I was up to answer nature’s call at 4:15 a.m. on Thursday, and instead of the usual heartbeat, “thumpita-thump, thumpita-thump, thumpita-thump…,” what I felt was more like “thumpita-thump, eeerrk! thumpita-eeerrk! thumpita-thump…errkk!…”

I grabbed my keys, wallet, cell phone, and a good book and drove to the emergency room.  You may have missed your day of training, but let me tell you that “class was in session” at the Baltimore Washington Medical Center ER when I showed up for school at 5 a.m.  Four hours later, (Let me say that again, “FOUR HOURS LATER”) we were still monkeying around with forgotten paperwork, twice redone blood draws, shift change meetings over my bed, staff that was making three trips to my room to restock inventory, and rolling me through a series of three “patient inventory” transactions between some lab and back to my ER bay of “move, wait, process, wait, move, wait” for X-ray, sonogram, and ECG, respectively.

I told you folks.  I TOLD you to your face!  “When I am through with you, if I am successful, I will make you as miserable a human being as I am.  You will see broken processes all around you.”  Welcome to my world.  Behold, the sad customer/piece of meat-inventory:

Now seriously, don’t he look sad?  Pity the poor victim of broken process.

Naturally, in a case like this I couldn’t resist going into Consultant Mode.  In spite of being hooked up to the monitor, IV, oxygen, etc. like a marionette, the monitor kept losing my continuing thumpita-errk heartbeat, so the nurses had to keep walking back to the main desk an average of every 11.3 minutes (but who’s counting) to see if I was dead yet and to reset the monitor.  How thoughtful of them to give me an ER bay where I could see their goings on.  Their wasted motion, their absence of mistake-proofing or visual controls, their failed attempts to communicate with each other, failed service opportunities, excessive patient transportation, and more.  How very thoughtful.

After three hours of fear, boredom, and frustration cocktail, I used a pen left behind by one of the nurses and began sketching out a nurse/patient spaghetti map of my morning on the back of an IV wrapper I found on the floor, along with a crude value stream map.  (There are a few things wrong in that last sentence.  Please use a black or blue ink pen to circle them.  We’ll review your answers next session.)  The ER staff found my doodles and efficiency ravings…amusing.  I’m sure they did not have much time to be interested in the “bored consultant in room six” at the same time they had to deal with the cut up guy the cop brought in handcuffs, the construction worker who just fell off a scaffold, the guy sleeping on a gurney in the hall who nobody knows where he came from, or the other poor folk who needed their full attention.

The attending physician diagnosed me with “atrial fibrillation,” an eminently treatable condition.  We’ll see in a couple weeks what the follow up says.  They admitted me for observation, where I was subjected to other process design and systems management horrors which I shall not relate to you with at this time.  Suffice it to say, I got an education in that fourteen hours.  The lesson for me: Healthcare is broke.  It’s broke bad.  I mean, if I had a clone army of a thousand Lean Jedi Knights, we’d be swinging our Lean Lightsabers for decades trying to unhose healthcare in this country.  Lean Facilitator Certification Program students, your future in this industry is secure.

By the way, one final note on my lean healthcare field trip.  The “good book” I mentioned that I snagged on my way out the door was Toyota Kata, the one I described with such admiration on Tuesday morning, lamenting that I had not had the time to read it.  Well, there you go.  I plowed through half of it.  Would have gotten further, but had to watch a really good Jerry Springer and eat my tasteless hospital food (Overcooked mac and cheese, gray asparagus, canned pears, and a drink that arrived completely frozen solid.).  So, remember what I said: “A true lean leader is a lifelong learner.”

Put your left hand on the computer screen, raise your right hand, and repeat after me: “A-true-lean-leader-is-a-lifelong-learner.”

Here’s me “enjoying” my incarceration:

Pick up a copy of Toyota Kata.  Will change your life.  It’s an easy and interesting read.  You can finish it in a weekend.  Or two bad Emergency Room visits.  Whichever.

Related posts: Beyond Toast Kaizen – Lean Breakfast Concepts, Circa 1937, Lean Management Systems and Actionable Empathy…or, “How Was Your Day?”

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Lean Aerial Photography!?!

Ok, it’s really aerial photography with a lean application. And, it’s not that aerial. Just a guy standing on a big step ladder and taking a picture of stuff below. Yes, there’s a fancy camera in his right hand.

So, where’s the lean in this?

Good question.

When I first saw the ladder in the kaizen team’s breakout room, I was a bit perplexed. But, as it turns out, there was a good reason for the ladder. Actually, it’s pretty cool.

Many of us have participated in the design of future state layouts. This often employs two-dimensional scale models as a team seeks layouts that, among other things, facilitate better flow of product, people, information, tooling, scrap, etc., the use of less floor space, improved visual control, etc.

In an effort to generate multiple ideas and options and converge on the best one, many teams create a number of different alternative designs (think of the popular application of the 7 ways or 7 alternatives). These alternatives are then scored by the team against pre-established, weighted criteria.

Well, creating 7 or so different two-dimensional models can be time AND space consuming. The activity involves materials such as cardboard, plywood, paper cut-outs, sheet metal, magnets, yarn, and so on.

Enter the aerial photographer.

The folks with the ladder had a brilliant idea. After each iteration or alternative design, the designated photographer climbed the ladder and snapped a photo of the layout. (You need a pretty decent camera, by the way.) This way they quickly recorded and printed out the layout and then rapidly proceeded to the next design using the same materials.

More iterations. More ideas. More interaction. More learning. Better output.

Related posts: Lean Space – Some Thoughts and 10 Questions, Without Defined Criteria, (Almost) Everything Looks Good, Ready! Fire! Aim!…Maybe, We Should Have REALLY Simulated First!?

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Calculating Average Daily Demand, Not a No-Brainer

Lean is largely about satisfying customer requirements. That’s near impossible if the lean practitioner does not understand demand. In fact, misunderstand average daily demand (ADD) and the impact can be significant – inaccurate takt times, improper demand segmentation, poorly sized kanban, incorrect reorder points, etc.

Calculating average daily demand can be deceptively complex. There are a handful of things to consider.

  • SKU and part number versus product family. Kanban is applied at the SKU and part number level, so ADD must be calculated at that level as well. When calculating takt time, ADD is often, but not always, determined at the product family level or at least the group of products or services that are produced or delivered within a given line, cell or team.
  • True demand. Do not blindly accept what was sold, produced, processed, purchased, or issued as true historical demand. Often this demand is: 1) capped by internal constraints, whether capacity or execution related, leaving unmet demand (that may or may not be fulfilled by competitors or may become backordered), or 2) artificially inflated due to overproduction, purchasing of excess stock, etc. If the barriers to constrained demand will be addressed in the near future, then include both historical met and unmet demand. In the area of overproduction or over-purchasing, identify the real demand and use it.
  • Historical versus forecasted demand. If forecasted demand is different than historical and the lean practitioner has faith in the forecast accuracy, then forecast should be used to determine ADD (with historical most likely used to determine demand variation). Otherwise, use historical demand.
  • Abnormal historical demand. Historical demand, whether considered for the purpose of determining ADD or/and demand variation may very well contain abnormal data. If it is significant and there is a reasonable probability that something of that nature and magnitude will not occur in the future (i.e. one time order or marketing promotion), then it may be prudent to exclude that data from the analysis.
  • Demand horizon. Demand is rarely constant over extended periods of time. Narrowing the demand horizon will increase the risk of missing seasonality, cyclicality and/or other significant variation. This is important for the calculation of both ADD and demand variation. The historical horizon often should be as much as 12 to 36 months, with forecasted future horizon 3 to 18 plus months. Statistically speaking, the practitioner needs 25 +/- data points to make valid calculations.
  • Demand time buckets. Clearly, the size of demand time buckets does not impact the purely mathematical calculation of ADD. However, the use of daily or weekly demand time buckets, as opposed to monthly or quarterly, does provide the necessary insight to visually identify abnormal demand, inflection points for seasonal demand changes, etc. Furthermore, smaller buckets are required for calculating statistically valid demand variation (really, the coefficient of variation (CV)).
  • Number of operating days. “Average daily” presumes a denominator in days. The number of days must correspond to the number of operating days for the resource that is satisfying the demand. For kanban we have to remember that the resource is the “owner” of the supermarket.
  • Operating days without activity. Demand analysis will sometime reveal SKUs or parts that have days (or even weeks) that do not have any demand. This, by its nature, typically is indicative of relatively high demand variation. Depending upon the situation, the lean practitioner, when sizing kanban, may consciously want to include the zeros within the calculations or not (or not use kanban at all). For example, excluding zeros will drive a higher ADD and a lower CV versus including zeros and calculating a lower ADD and a higher CV. The excluded zero approach will more likely ensure that the kanban can meet the spikey demand, but at a price…more inventory.

Any thoughts or war stories?

Related posts: Does Your Cycle Time Have a Weight Problem?, Musings About FIFO Lane Sizing “Math”

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