Aravind on TED - World Class Eyecare in India

As a follow up to my last blogpost, "Healthcare Modeled after McDonald's," TWI Blog reader Jason Yip provides this link to the fantastic website TED - Ideas Worth Spreading. The "talk" is by Thulasiraj Ravilla and the title of his talk is: How low-cost eye care can be world-class


Several clips in the talk feature the creator of the AES, or Aravined Eyecare System, by Dr. Venkataswamy. Yes, I just acronym-ed that! - Now, there were three things that struck me as significant about Dr. V's comments:

Dr. Venkataswamy: "I used to sit with the ordinary village man because I am from a village and suddenly you turn around and seem to contact his inner being, you seem to be one with him. Here is a soul which has got all the simplicity of confidence. Doctor, whatever you say, I accept it. An implicit faith in you and then you respond to it. Here is an old lady who has got so much faith in me, I must do my best for her."

Dr. V has been to genba and he knows what it will take to solve the problems of blindness, and he knows how to do it.

"See, McDonald's' concept is simple. They feel they can train people all over the world, irrespective of different religions, cultures, all those things, to produce a product in the same way and deliver it in the same manner in hundreds of places."

His dilemma was not necessarily the problem of blindness, he knew how to treat that. His problem was how to deliver high quality, consistent treatment to the people who needed it. He saw the problem of making burgers in the same light. Just about anyone can make a killer burger if they try hard enough, but how many can do it consistently, in quantities of billions?

"Supposing I'm able to produce eye care, techniques, methods, all in the same way, and make it available in every corner of the world. The problem of blindness is gone."

He adapted the concept of McDonald's efficency and production concepts to eyecare and saw that as the means to tackle the problem of blindness. Admittedly, he is doing many things differently than McDonalds would, like giving away services for free and still making a profit.

I think there is a lot to be learned from this organization, but I have a lot of questions. For one, are the costs kept down mostly through volunteerism? When Ravilla says they are comparing apples to apples with the U.K. system, the element of volunteerism is overlooked by the laughing audience. I don't know anything about Indian government or politics - how much of this organization's services are subsidized by the government, if any at all? This would be another point of comparison that can not be lost as Mr. Ravilla suggests we desire seeing "Obama's ratings go up again." Answers to these questions may reveal that the Aravind Eyecare System is an orange to our apple.

Healthcare Modeled After McDonalds?

Watch the video and see for yourself...

Some keywords to listen for...

"assembly line surgery"
"open up our intellectual property"
"reducing wait times"

...and a whole lot more!

Job Instruction Will Save Your Life!

Well, o.k., technically, the JI manual won't save your life. But a person may try to save your life someday! Are they ready? Today, TWI guest blogger, Sean Jordan shares his experience of how we can be better prepared for emergencies:

I recently attended an American Red Cross First Aid and CPR certification classes and all I could think about was Job Instruction.

First, this program was another example of a very personable content expert with shortcomings on instructional skills. Like many trainers in any environment, he did his best using the typical instructional paradigm: Talk, Demo, Use a Video, Student Tries, and move on to the next topic. Perhaps the root cause is the Red Cross trainer that certified this person as a trainer was not completely skilled as an instructor too.

Second, there is a lot of information to cover and it is set in a tight time requirement. How many times have we seen someone want the best of two worlds: complete training on content in the shortest amount of time?

Third, this seemed more like a cram session and the ability to thoroughly retain the information for more than one week seems doubtful. This is information that can potentially make a difference in an injured person’s life.

[Note, our instructor pretty much told us that the odds of us actually using these skills to save someone’s life are extremely low. Also, no matter what we do, we really can’t make things worse. REALLY?! Then why the heck am I here for the night classes?]

Hopefully, many of us will not need to use these skills until the next certification exam but it would be nice to retain this knowledge. I will be working on ‘refresher sessions’ with the team. Perhaps I’ll have them write some Job Breakdown Sheets of the training activities. It will certainly increase their knowledge retention by making a JBS as well as assist in the next class. Maybe it will motivate the instructor?

Fourth, the only way to understand the reasons for what we were doing was to ask probing questions.

Finally, there wasn’t a class survey or discussion about how to improve the course. Every training event has an opportunity for improvement, no matter how many times you have done it!

My actions are to follow up with the American Red Cross and share why I think they should consider apply Job Instruction. The good news is that they already have outstanding standardized procedures for applying CPR and First Aid. Also, most people probably want to follow those procedures exactly. You may hear in your assembly shop: “Yeah, but I like to build it this way.” I don’t think I have ever heard someone say “The Red Cross claims CPR should be done like that, but I like to do CPR this way.”

Don’t worry, if I see you in need of immediate care, I will be adequately prepared to assist.

Sean Jordan is Training and Development Manager at Biotek Instruments, Inc., in Colchester, Vermont.

Lean Healthcare - Voice of the Customer

Well, it has been an interesting week...

About 3:00p.m. on Monday, I was in the genba and had a twinge of pain in my abdomen. My co-worker asked if I was alright, to which I jokingly replied, "Probably just appendicitis." About four hours later, I was in the hospital emergency room as doctors poked and probed right around the area where that vestigial organ resides.

By 11:00p.m. I was calling Megan, who is pregnant with our fourth son, due any day now, was having labor pains, and couldn't believe what she was hearing: I was going under for appendicitis. We were so thrilled with the timing of it all! By 2:00a.m., I was in my room recovering.

Overall, I am very, very happy with the level of care provided. And given the fact that appendicitis, left untreated, can end a life we are very grateful for Dr. Kennedy and professionals at Northwest Medical Center.

But, I'm a leanster, and little things just don't slip under my radar anymore. Plus, I was bored out of my mind for two days and was thinking about Lean. Here are a couple of things...small, very small things that I think would have made the experience even better.

1) When I first entered the ER, I couldn't turn that well because of the pain. They also put an IV in me and I hate needles. So, as I tried to put the johnny on, I faced two problems: a) I couldn't turn enough to grab the ties and b) I was afraid that if I bent my arm with the IV, it would poke through my arm or something crazy like that. (yes, I'm a big baby when it comes to needles) So, I sat around for quite awhile with an open johnny. Finally, the ER nurse said with a chuckle that I could bend my IV arm, so I quickly tied that darn thing in a straight knot. Apparently the OR nurse does not share my knot tying skills, she cut it with scissors during surgery. When I woke up, I couldn't get it tied back up again! Call me modest, but I wasn't prepared to ask for help with my backside open until I was feeling like a #8 on the smiley pain scale. Is velcro out of the question?

2) O.k., I'm a hairy guy. When the first IV went in and I watched the ER nurse wrap a 3 x 3 inch slab of clear flexible tape over the carpet of my arm, I felt a little piece of me die inside knowing the pain that was to come upon removal. (I didn't know I had appendicitis at that point, so you will forgive me for feeling this way.)

When I was wheeled into the operating room, and strapped down onto the table, the nurse informed me that they would be shaving me. "No problem", I replied as the oxygen mask was tightened down, thinking that at least someone was thinking ahead. The last thing I remember was that chemically sweet smell of anesthesia, maybe for a half second. I don't remember anything after that.

When I woke up, the pain from the laproscopic incisions was surprisingly not so bad. But whenever I moved for the next two days, the hair that they didn't shave on my stomach pulled because the iodine had dried it all in place. I was forbidden to shower for 48 hours. To give you an idea of what this feels like, go get some shellac and smear it all over your belly and let dry. Now, cough, turn, sit up, laugh, hiccup and breathe. As every hair that moves is pulled, it all hurts. Now, try washing it off. Yup, it doesn't come off immediately. You need to wait another day! In addition, the area shaved around one incision area wasn't big enough, so those band-aids did some damage yesterday when I finally could shower and take those off. Ouch!

Here is my small kaizen idea: why not shave the whole darn area? Yeah, those spots itch like crazy right now, but I can take it and it looks better than three bald spots on my stomach. The alternative is potential Band-aid carpet removal? I suspect that is second only to water boarding. No, thanks. Shave it all.

3) Here is a Lean Product Development idea from my hospital experience. This one isn't hard. I had to be carted out in a wheelchair upon discharge. When I sat down in the wheelchair, something hard was pushing into my left shoulder blade. It was really uncomfortable, forcing me to sit forward, which wasn't easy in my post-op condition. When I got out of the wheelchair later, I couldn't wait to turn around and see the little dastardly bracket or handle the nurse forgot to fold away. Imagine my surprise when I turned to see a the top of an oxygen tank in its standardized holder! At the entrance of the hospital, a small fleet of these wheelchairs are at the ready, with oxygen tanks in the same position. For those of you who design these folding wheelchairs, try sitting in them before you commit to manufacture.

4) Talking wrist bands. If I had a dollar for the number of times I had to repeat my name and birth date as a healthcare professional was reading said information on my wristband, riveted to my wrist, yes, I could pay my healthcare premiums for the year. The technology exists to make this go away! Hallmark uses it in greeting cards for crying out loud! Here is how it works. You check into the hospital and get your wristband: "State your name and birth date, Mr. Lund, speak into the wristband, please." There, its over. I never have to repeat those words until I call the insurance company over billing issues. Now, I know the objection you will offer: "Bryan, this is for your own protection." O.k. fine. What happens if I code and need emergency medical treatment? A doctor can't wake me up and ask me to state my name and birthdate can he? I don't see the point except for some crazy liability B.S. No, you mark my words. Talking wrist bands. Next healthcare innovation.

Well, there you go. Four, small, kaizen ideas that could lead to increased patient (at least this patient's) satisfaction: velcro johnnies, shaving standard work and wheelchairs that don't bruise the patients and talking wrist bands. We always have time to spot an opportunity for improvement!

The best news though is that I did not miss the birth! On the night of my surgery, Megan was having false contractions. What luck! I'm already back on my feet, albeit tenderly, and should be able to fully recover in time to be there for her and the baby.

And in all seriousness, we have the best damn healthcare system ever!

Coming Events - Vermont Lean Healthcare

On May 11, nationally acclaimed author Naida Grunden will be the guest speaker at the "Vermont Lean Healthcare Forum" events being hosted at Fletcher Allen Health Care in Burlington from 9-10:30 a.m. and at Blue Cross Blue Shield of Vermont from 1:30-2:45 p.m.

Grunden's book, The Pittsburgh Way to Efficient Healthcare, describes the work of the Pittsburgh Regional Health Initiative, a small nonprofit organization established by medical, business, and civic leaders to address health care safety and quality issues in southwestern Pennsylvania.

In 2001, PRHI began to pilot the use of Toyota-based principles (Lean) in health care. These are the same principles VMEC has been applying in manufacturing across Vermont for the past 13 years.

Go to http://www.vmec.org/workshops to sign up at no cost.

TWI Job Instruction Case Study

Mr. John O'Dwyer has graciously made this case study available to the TWI Blog. Please take a look at the experiences at Lake Region, a medical device manufacturer.

Lake Region Case Study

Protecting the Worker

This leader tried to put himself in the shoes of his people. Then, he asked them for their ideas. Then he did the opposite of what most businesses are doing now - he is protecting the workers before he protects himself. And he did it in a way that most managers and professionals we see in the papers lack the courage to do. Read on...

Beth Israel's CEO May Have Found an Alternative to Layoffs

Lean Book Review: Lean Hospitals by Mark Graban

Book Title - Lean Hospitals

Author - Mark Graban

Register now for the 2009 TWI Summit and hear Mark Graban speak on TWI in Lean Healthcare!
______________________

Bottom Line

At first, I thought, "this is another Lean Simplified book with hospital words" - lean concept after concept with extensive commentary. This isn't criticism of author Mark Graban, it is what I have come to expect of these days with Lean books. It seems everyone re-publishes the same thing about Lean, except the authors use the "Lean ___insert your industry technical jargon here___," approach.

Here in Lean Hospitals, we have a truly unique experience. I had to read this twice, because I was gliding through this like it was another lexicon remix. This caused me to miss the deeper insight that the author, Mark Graban, artfully inserts in example after example. Once I slowed my pace, Graban very quickly takes you deep into thought provoking examples about the healthcare industry – pushing the reader beyond the common Lean definitions and into the real world. How refreshing! No made up stories in somebody’s garden or garage or a skip-hop-and-a-jump through imaginary utopias; NO – Lean Hospitals is the real world application of lean with all of its successes and many lessons learned.

Jammed full of knowledge, testimonials, how-to examples, pictures and illustrations for anyone wondering how Lean could possibly apply to a hospital environment, this book follows a similar pattern of other well written Lean related books where a concept is presented, explanation of the concept is offered and then a host of examples follow to cement the concept in practical application. The real strength of this book is in unique adaptations of kanban and lean concepts which should give some hospital administrators the confidence to take that first step in an otherwise uncertain Lean journey. Bottom line: order several copies and organize a book/work study group with your staff, working out real problems as you make your way through the book. Hint: take your time.

What’s New?

Mark Graban, who has extensive experience in Lean Healthcare implementations, diplomatically chips away on the mainstream approach to 5S - housekeeping - something I have blogged harshly on for over a year now. He stresses the importance of taking 5S out of the narrow crawlspace of housekeeping and into the infinite world of daily idea generation, involvement and continuous improvement. My only criticism here, if you could call it that, is that we only get a glimpse of this alternate 5S universe for a brief period. My neediness aside, this book is unique; non-Japanese AND goes beyond what we know as 5S conventional lean approaches. Mark shows us how hospitals are adopting lean and adapting to their unique environment, the ultimate lesson we should all learn. This is not only rare but refreshing for those of us that have struggled with the way 5S and Lean was interpreted over twenty five years ago and subsequently (and superficially) taught to thousands over the decades. Kudos Mark, for daring to go there, but on this matter - I was hoping you opted for a surgical grade bonesaw instead of a scalpel!

Mark touches briefly on TWI and in particular Job Instruction while you are knee deep in the Standard Work for Hospitals section. Here Mark draws a clear picture of the need for Job Instruction in order for Standard Work to be useful on a daily basis. I believe that this is the only book I have seen that explains the need in a non-manufacturing setting – again, illustrating how hospitals can and are adopting and adapting lean concepts to a real world environment. This may be a good opportunity for readers to point other Lean/TWI skeptics to a real world example of how JI is an elemental skill for Lean leaders. Even more so, TWI and Lean zealots alike will see how this book is substantial, should be taken seriously, and certainly not a Lean “___insert your industry here___“ book.

In a previous book review of Managing to Learn, I reveal how John Shook presents a new "pull based authority" concept. In Lean Hospitals, Graban shows us how pull based authority is applied across hospital departments – here we get clear insight on the kanban “how-to” and the reasons why we should consider this approach in administrative situations. It is very important and worth every penny for this chapter alone. This and many other sections of the book take complex Lean concepts and present them simply and clearly for anyone at any level in a hospital setting.

How many Gold Rivets, Rosie? 4.5/5

Lean Hospitals is a great book, loaded with how-to and sharp insight that predicts the future of healthcare; those organizations that run business as usual and those that are customer-oriented. The style is straightforward - concepts backed up with know-how, but may require another read to fully grasp the full context. This is because the examples tend to chop up the flow of the concepts and I found myself going back a couple of times to tie it all together. Regardless of my minor observations, keep this fantastic reference handy; I have pulled it off the bookshelf several times already and I work in consumer goods manufacturing, so it should be extremely useful to anyone in a hospital setting.

New Book - Lean Hospitals by Mark Graban

Mark Graban of the Leanblog has released a new book available at www.leanhospitalsbook.com I'm ordering mine today, there are many lessons that can be learned by other industries as they face their problems head on. The common theme we all can relate to is continuous improvement and Mark does a great job of leading this effort in the healthcare industry.

Atul Gawande - "Checklist" update

Good news. Mark Graban of the leanblog points us to an article that reversed the decison that prevented checklist being used to prevent infections due to catheters in hospitals. The link is here:

http://www.leanblog.org/2008/02/feds-reverse-their-decision-on.html

Lean Healthcare Follow-up to "The Checklist" by Atul Gawande

If you didn't see this article check it out here....this is standard work 101 in healthcare, with phenomenal results:

http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande

Here is the extremely dissappointing conclusion of this pioneering work in healthcare process improvment:

http://www.nytimes.com/2007/12/30/opinion/30gawande.html?scp=11&sq=atul+gawande&st=nyt

Please note the following emphasis (mine) from Gawande's op-ed piece:

"this past month, the Office for Human Research Protections shut the program down.," Gawande writes. "The agency issued notice to the researchers and the Michigan Health and Hospital Association that, by introducing a checklist and tracking the results without written, informed consent from each patient and health-care provider, they had violated scientific ethics regulations. Johns Hopkins had to halt not only the program in Michigan but also its plans to extend it to hospitals in New Jersey and Rhode Island.

'The government’s decision was bizarre and dangerous,' Gawande adds. 'But there was a certain blinkered logic to it, which went like this: A checklist is an alteration in medical care no less than an experimental drug is. Studying an experimental drug in people without federal monitoring and explicit written permission from each patient is unethical and illegal. Therefore it is no less unethical and illegal to do the same with a checklist. Indeed, a checklist may require even more stringent oversight, the administration ruled, because the data gathered in testing it could put not only the patients but also the doctors at risk — by exposing how poorly some of them follow basic infection-prevention procedures.'"

Blinkered logic, indeed. I think the government has a tail-light burnt out.

The Great Divide

What is the great divide between “the art of management” and “the science of management”? We get a clue in the December 10, 2007 issue of The New Yorker. In The Checklist, Atul Gawande explains how one doctor is radically changing medicine by improving the processes that doctors, nurses and specialists are engaged in everyday. For example, a checklist used in ICU reduced line infection rates from eleven percent to zero. Think zero defects in manufacturing. Part of a study done in ICUs found that an average of 178 procedures are completed on a patient. Inserting a line is only one of those steps. What else could go wrong?

Read the entire article and get it in the hands of others. It is compelling. It also helps quell the riot of that standard work stuff doesn’t work here mantra. If standard work can be effective in hospitals where an ICU team will face 1 over 32,000 possible combinations of procedures for every patient with on average of 178 steps for each combinations, then it can standard work will work for us in manufacturing.

This article reads like it was plucked from the newest lean manufacturing book. Take for example the quote from the subject of the article, Peter Pronovost,

“The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government and academia. It’s viewed as the art of medicine. That’s a mistake, a huge mistake.”

How many people out there think that what they do is more art than science? The fact is, it just feels like an art when everything works well. We just don’t see the pattern of repeatability in what we do. Whether it is the nurse feeling for a vein, an artist feeling the correct brush stroke, an mechanic setting the right torque, or an operator lifting something safely, there is definite and correct technique that produces a unique result.

In management, how often have you heard that management is an art, not a science? Isn’t it time we put that old horse to rest? Is the great divide between art and science then the concept of process improvement thinking?

Job Methods New Materials Update - TWI Service Website

I'm doing my spring cleaning in the winter! A couple of days ago, I announced the Job Relations materials update. There is also some Job Instruction for Healthcare. Hospitals need as much standardization improvement today as they did during the days of Gilbreth, Mogensen and others recognizing the need for standardization and simplification of healthcare work.

Today, visit the Job Methods page for insight behind Toyota's secrets to Kaizen, TWI! Dig deeper into the development of Job Methods and Kaizen by exploring archival documents retrieved from the U.S. Archives.

Job Relations - New Archive Manuals and Materials at TWI Service Website

I just finished uploading the new Job Relations page at TWI Service. Check it out!

Also, I had nearly forgotten about the material I retrieved in the National Archives a couple of years ago, but stumbled across it last night. It is the material created by the original TWI Service so district representatives could convert their Job Instruction Manuals into a Job Instruction for Health care manuals. This is really interesting stuff.

Within the next week or so, I will upload the Red Cross files discovered at the files. This involves the work TWI did with the Red Cross and the only evidence that the so-called multiplier effect was a deliberate and effective plan that spread TWI like wild fire!

Bryan