Posts Tagged time observations

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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Time Observations – without Rigor, It’s Just Industrial Tourism

It happens way too often. Folks who are ostensibly conducting time observations frequently:

          • don’t appreciate the full importance of the exercise,
          • are not properly trained in how to conduct time observation methods (and the the related spaghetti charts, percent load charts and standard ops forms), and/or
          • are  just too lazy to do a thorough job.

The first two conditions are more straightforward in nature, the last, well…that’s a behavioral issue.  In any event, insufficient rigor will hamstring the effort to identify waste within a given process. A prior Gemba Tales post, Time Observations – 10 Common Mistakes, covers a lot of relevant ground here.

Lack of rigor and technical know-how can yield some very bad things – not the least of which are marginally useful time observations. This means that individuals and teams can come up with a stilted understanding of the studied process, miss or incorrectly identify the waste and opportunities, develop a less than least way post-kaizen future state standard work or…even worse, create new standard work that is going to go through tremendous adjustment during the PDCA process because it does not square with reality. Think “rework ” here.

So, what drives me absolutely crazy? Lazy observers! [By the way, here we assume that the time observation is worth doing in the first place (right scope, worthy target,  appropriate tool, etc.)]

We cannot be proponents of industrial tourism. Time observations require hard work and a good dose of stamina.

Hey, stopwatches are much more difficult to operate than one would think and breaking down the target process into the smallest observable elements is a pain in the neck. Observing multiple cycles, so necessary to getting a handle on variation (and thus opportunity), means more time on your feet, more writing and attention firmly directed on a process which may be as exciting as watching paint dry…in perhaps extreme heat, cold, noise, whatever. Following the operator or worker EVERYWHERE can also be a drag. And observing a process that has varied work content based upon different factors (such as warehouse picks from high bay versus low bay locations)  … can make it even more maddening.

My answer? Suck it up! Grind it out! Man-up (not really politically correct, but you know what I mean)!

It’s not that I am without empathy. I have personally conducted countless time observations of cycles that were many hours in duration, sported crazy variation and permutations, etc. It was at times, very, very painful. But, you really can’t get the proper insight into the waste and opportunities within a process without such a personal investment, and without going to the gemba. In fact, genchi genbutsu, “go and see for yourself” …and help facilitate that seeing with the rigorous application of a time observation form.

Don’t be a tourist! You owe an A-plus effort to yourself and most importantly, in the spirit of humility and respect for the individual, you owe it to the other stakeholders – the person(s) that you observe,  teammates, customer, etc. You must pragmatically conduct the best time observations you possibly can.

What do you think? Am I too demanding here?

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Guest Post: Beyond Toast Kaizen – Lean Breakfast Concepts, Circa 1937

I was in Boston this weekend with my wife and we were told the best place for breakfast was Paramount’s. As we waited in line to order food, I noticed their sign told us to “Please Order and Pay before being seated”.  They claimed not saving a table “ensures all customers will have a table when needed” and although “it may seem hard to believe, it’s been working well since 1937”. Like much in lean this seemed counterintuitive. I decided to do a few time observations while we waited in line. Fortunately, my wife puts up with my curiosity.

Customers came out of the breakfast line and cashier every 90 seconds. So, customers needed a table every 90 seconds (Takt Time). I watched several tables that were filled before we sat down and the time to eat was about 18 minutes. (This is not the type of place where you bring the paper and the server keeps filling your coffee. )

If customers were sitting down at a table every 90 seconds and it takes 18 minutes to eat, the restaurant would need 12 tables to balance the seating capacity with customer requirements (Cycle Time/Takt Time). The restaurant has 14 tables. So, the overall system Cycle Time (think “drop off rate”) was less than Takt Time. I convinced myself, and my wife, why their seating policy worked.

I am confident that Paramount’s system works and that now…and in the future, we will not have to save a table. One should always be available (assuming no substantial change in Takt Time). I wonder if when they started in 1937 they fully understood why it worked. Oh well, perhaps all that really matters is that their breakfast is outstanding and customers keep returning.

John Rizzo authored this blog post. He is a fellow Lean Six Sigma implementation consultant and friend of Mark Hamel. John also enjoys a good breakfast!

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Time Observations – 10 Common Mistakes

Stopwatch picUnderstanding the current reality within the context of time and space is extremely critical. The time observation form is a powerful tool to facilitate direct observation. The form is instrumental in the identification and understanding of waste elimination and variation reduction opportunities.  It’s a staple of kaizen and feedstock for standard work combination sheets and process capacity tables.

If the time observation form is so important, then everyone knows how and when to use it, right? WRONG. Unfortunately, there are a bunch of common mistakes that practitioners regularly make. In no particular order, here’s an incomplete list of time observation mistakes:

  1. One form for multiple operators. It doesn’t get much more confusing than this. The individual operator’s work sequence and work content can’t be discerned.
  2. Component tasks not broken down into the smallest observable elements. Summary tasks like, “assemble part” or “room patient” does not give the observer usable insight.
  3. Incorrect or missing cumulative times. The lap button is on the stopwatch for a reason. And don’t pretend that you’re accurate enough to use decimal points.
  4. Insufficient number of cycles observed. Unless we’re talking about multi-hour cycles, the observer(s) should observe and document as many as 7 to 10 cycles. How else can you identify variation and understand most repeatable times?
  5. “Interviewing” operators during the observation. Not a good way to conduct accurate, real-life observations…unless their work normally includes responding to interview questions.
  6. Improperly determining component task times. No averages and throw out abnormal values (but try to understand them and the reasons for them). Make their sum equal to the lowest cycle time observed. Above all, use common sense.
  7. Not communicating the what, how and why to the operators and other stakeholders BEFORE the observations are conducted. This is respect for the worker and helps ensure that the observed cycles are reflective of reality (no rushing by someone out to impress the observer, no slow down to taint the observations, etc.).
  8. Not following the operator. If they leave the immediate area, go and follow them. How else will you directly observe?
  9. Not using the “Points Observed” column. This is the place on the form where you can record the reasons for abnormal times, variation and capture improvement ideas. These are pearls.
  10. Not completing the form header. Without this information, later on it may prove difficult to determine who made the observations, what process was being observed and when the observations were made.

So, do you have any additions or corrections to this list of common mistakes?

Related post: The Truth Will Set You Free!

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The Truth Will Set You Free!

truth will set you freeLean thinking may not have been big in the first century, but there’s at least one quote that can be applied to Lean, “…you will know the truth, and the truth will set you free.” So, in a Lean context how do you know the truth and how will it set you free? Here are three steps.

1. Identify the waste through direct observation. Start with genchi genbutsu, Japanese for “go and see for yourself.” Go the gemba. Improvement begins with a deep understanding of what is called the current condition, current situation or current reality. In short, the truth. Truth can be obtained through personal direct observation. Anecdotal evidence is typically incomplete and often just plain wrong. It allows for the introduction of bias, whether purposeful or accidental.

In Lean we often employ the use of certain tools (and methods) to better force and focus us in our direct observation. They also facilitate the identification of waste and help uncover the root causes of that waste. The tools, depending upon the situation,  include current state value stream maps, time observation forms, standard worksheets, standard work combination sheets, % load charts, operations analysis tables, etc. When properly applied, their format forces a presentation of the data in such a way that waste and related issues are more easily identified for the observer and for others (the more, the merrier!).

2. Acknowledge the waste. Easier said than done. Direct observation can identify the truth, but it does not mean that everyone will acknowledge it. In other words, identification is largely a technical exercise, acknowledgment is mostly behavioral in nature. While the truth is the truth whether known or acknowledged, waste can’t be eliminated unless it is both identified AND acknowledged. As such, effective Lean cultures repudiate problem hiding. No problem is a big problem…heck, can anyone find a place where there are no problems? In order to facilitate the right environment there must be a large measure of trust where the focus is on fixing processes and not targeting people for blame. The principle of respect for the individual and a data-driven mentality must be front and center.

3. Eliminate the waste. Well, if you’ve identified the waste AND acknowledged it, then you know the truth.  You are now free to act upon it. Of course, this is a mixture of both technical (how) and behavioral (willpower, aggressiveness and stamina) elements. The truth has helped lead you to the PLAN, now it is time to DO!

What do you think?

Related posts: CSI Kaizen – When Forensics Supplement Direct Observation, Time Observations – 10 Common Mistakes

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