Helping Schools Become Lean

Education is a field that is ripe for lean transformation, but there isn’t much happening yet in that regard.

However, I recently came across a consulting firm devoted specifically to lean education – that’s something new, at least in my experience.

The firm is Lean Education Enterprises, located in Shoreview, Minnesota. Its two principals are Joseph and Betty Ziskovsky, and they provide organizational assessment and coaching services for process improvement in student learning, teaching, and administrative support. Joseph is a business guy and Betty is an educator.

I don’t know them personally, and I’ve never worked with the firm. But they seem to have the right focus on their website.

I particularly like a page in the site on the “7 Wastes of Education,” which lists the wastes and provides specific examples of each one.

They also have several case studies on the site of the kinds of things they’ve accomplished, though the specific schools and districts involved are not named.

As I said before, so far there has been little application of lean in education. I wrote previously about one educator’s efforts to improve college courses.

Do you have any experience with lean in education? Where in education would you like to see it applied?

Technology is Not a Threat to Manufacturing

I’m frustrated by a column appearing on Forbes.com, which offers some valuable insights into manufacturing today while simultaneously putting forth some incorrect and misleading statements.

The column, written by Kevin O’Marah, chief strategist at AMR Research, is entitled “The Real Threat to U.S. Manufacturing.” O’Marah argues – correctly in my view – that free trade agreements, currently under attack by many politicians, are not the problem their critics make them out to be.

He focuses on BMW, and its “bustling” plant in South Carolina, and Caterpilllar, as examples of companies with U.S. operations competing successfully in global markets.

The difference is not really foreign ownership, or even non-union workforces, but rather strength in the face of competition. There is no need for protectionist policies when manufacturing sees itself as part of a global value chain…

Protectionism is rising as the economy falters and politics takes center stage. As companies like Caterpillar and BMW show, however, there is not necessarily a link between free trade and job losses…

All the ingredients are there for Americans willing to learn and change. NAFTA has nothing to do with it.

I agree with all of that. But O’Marah also talks about what he perceives as the true threats to manufacturing.

One, he says, is labor unions. I’m no defender of unions, and sometimes they can be an obstacle to implementing the kind of lean transformation necessary for competing in today’s markets. However, I think O’Marah may be going a bit far when he says that unions “are political bodies interested more in votes than wage increases.” You can draw your own conclusions.

My real beef with O’Marah is when he says the other major threat to manufacturing is technology. Consider his statements:

Twenty-first century manufacturing is about an automated, integrated manufacturing process. Manufacturing automation will take over one manual task after another--first in the United States, then China and then eventually everywhere…

The implication is clear: Old-fashioned factory work need not be done by people.

For supply-chain professionals and manufacturing engineers, decisions about jobs are all part of an equation, and the math often says robots are better than people. Where cheap labor offers a lower cost, jobs are created, but this changes as wages rise and technology replaces manual work. This dynamic holds true from Japan and Korea to China and Eastern Europe, all of which have seen huge capital investment gradually replace workers…

The threat to our traditional manufacturing employment base comes not from Mexico, or even China, but from a volatile mix of technology whose productivity beats human labor and unions who think more like political parties than economic agents.

First, it is clear that O’Marah is talking about manufacturing jobs disappearing, not the actual companies.

More importantly, he is, for the most part, wrong. Yes, technology does often improve productivity, so that fewer workers are needed to perform the same work. However, he clearly thinks we are coming closer to the “lights-out” factory, where virtually all work is done by robots. That has been talked about for decades, it hasn’t happened yet, and it’s not going to happen.

It seems to me that some of the information O’Marah provides undermines his own argument. Have BMW and Caterpillar thrived by replacing workers with robots? I don’t think so. Like most successful companies, they have developed strategies built on the skill and expertise of their workforce – as well as technology – aimed at providing value for their customers.

Technology and improved productivity need not be threats to manufacturing jobs. The best companies (which do make clever use of technology) maintain jobs, and even add them, by growing their business. And they do that by becoming lean, intelligent competitors who understand their customers and the marketplace.

Hospitals Need a Team-Based Approach

Much of what has been written about applying lean to healthcare focuses, appropriately, on the inefficient, error-prone processes at hospitals.

A good article put out by H&HN (Hospitals & Health Networks) offers a different but equally important focus, on the need to change the structure and culture of hospital operations.

The article is written by Dr. Charles Shaney, SVP and chairman of surgical services at William Beaumont Hospital in Royal Oak, MI, and by David Ellis, corporate director of planning and future studies at Detroit Medical Center and publisher of Health Futures Digest.

They begin by discussing another article, published in the January/February issue of Health Affairs, and written by a nurse involved in the treatment of a critically ill infant.

The baby’s doctor had left instructions for the infant to be weaned off a ventilator, according to well-established protocols. The nurse, Ray Bingham, thought the infant needed to be weaned more slowly than the protocols dictated. Bingham used subterfuge – such as bathroom breaks – to do it his way.

When the doctor returned in the morning, he was angry, though no action was taken against the nurse. The baby survived.

Shaney and Ellis, while agreeing that no healthcare professional should blindly follow instructions they believe may be harmful, take the position that Bingham was wrong. They note that the baby might have done just as well if the doctor’s instructions were followed.

More importantly, Shaney and Ellis see this incident as an example of what is wrong with the way hospitals operate.

As Bingham’s article illustrates, the physician-centric, hierarchical delivery model is seriously flawed…

Our challenge to Mr. Bingham is to share the steps that he has taken to ensure that a nurse in his unit will never again have to resort to a similar strategy to ensure effective communication and the best quality care for his or her patients…

The postmodern health care reality will require a cadre of physicians who not only recognize and value the judgment, skill and experience of other increasingly autonomous and interdependent health care professionals, but also physicians who willingly depend upon such skill to safely and effectively execute life-saving and evidence-based treatments in a patient-centered manner.

The postmodern reality also demands longitudinal and continuous professional evaluation and improvement processes, as well as meaningful incentives that recognize and reward physicians and other members of the caregiving team based on their ability to interact collaboratively. Much as will be the case for health care information technology, we argue that it may be only with a new generation of physicians and other care providers—educated in a team-based and contextual milieu, and for whom no other reality is logically consistent—that we will begin to see truly transformational change in health care delivery.

While the authors don’t use the word “lean,” their discussion of team-based operations and strong communication go to the heart of what lean is all about. I hope they are right that the new generation of professionals will embody this kind of thinking.

Does a Hospital Really Need a Pharmacy Robot?

Can a big, expensive machine prevent medication errors at a hospital? Maybe, but I’m skeptical.

The machine in question is a $1.5 million “pharmacy robot” that recently began operating at Loyola University Hospital in Maywood, Illinois. The hospital says the robot is “designed to eliminate the type of life-threatening human medication errors that injured actor Dennis Quaid's newborn twins.”

According to a hospital news release,

The robot places single doses of medication in small plastic bags. Each bag has a bar code that identifies the drug. When the system is fully implemented, the nurse will scan the bar code on the medication bag, along with the bar code on the patient's wrist band. If the computer detects it's the wrong drug or wrong dose, a pop-up warning will appear and the computer will sound an alert…

The system is 28 feet long and 13 feet wide. At the front end, a robot arm packages medications in single-dose bags. At the back end, a patient's medication bags are arranged in order of administration and attached to a plastic ring. A card attached to the ring specifies each drug, along with important patient information.
The robot packages 3,200 medications, including tablets, capsules, vials, ampules and suppositories. It works around the clock.

Sounds impressive. So why am I skeptical?

First of all, it sounds like a lot of diligent work is required by human beings to make sure the robot does its job properly. People have to place the medication in the robot so that medication can be dispensed, right?

More importantly, I wonder whether the hospital really examined the issue of WHY medication errors occur. Installing a machine like this seems to imply that hospital officials believe problems are caused by human errors that a machine won’t make.

And while that may be true to some extent, it is also true that a lot of factors contribute to human errors. When I wrote previously about the incident involving the Quaid twins, I noted the two medications that were mixed up came in identical vials with near-identical labels. When that is the case, isn’t it just as likely a pharmacy technician could put the wrong medication into the robot as it is a nurse could administer the wrong medication?

Further, the pharmacy is only one part of the process by which medications ultimately get to a patient’s room. Has Loyola looked at all the other steps in that process? The bar code system that is part of the new installation may help, but I’m inclined to believe there are other opportunities for mistakes.

I would be more impressed by Loyola’s announcement if, rather than focusing on the robot, they were describing it as part of a broader attempt at process improvement. And I suspect that any reduction in medication errors at Loyola will not be as great as officials there hope.

Lean Jobs: Still Many Good Opportunities

Problems in the economy aren’t having much of an impact on demand for people with lean expertise. And there are good opportunities for such people in a number of industries.

That is what I am told by Ted Stiles, director of executive search for Stiles Associates, a headhunting firm specializing in lean jobs.

In my last post, I discussed how Ted sees strong demand for lean specialists in healthcare. (At Productivity Press, we agree that interest in lean is strong in healthcare, which is why we now offer a growing line of books for that market.)

But healthcare is not the only field with lean opportunities. Manufacturing is still the primary market for lean job candidates. Ted said manufacturing will account for probably 75 percent of all searches done by his firm this year (though that is down significantly from five years ago, when virtually all of the searches were in manufacturing).

And while lean used to be the focus primarily in discrete manufacturing, there has been a lot of growth in lean demand in process manufacturing, Ted says, in a variety of industries: pharmaceutical, oil, metals, food and beverage.

Part of the reason for that, he adds, is that process manufacturers are not following discrete manufacturers in a rush to move to other countries. “The plants (of process manufacturers) tend to be enormous,” he explains. “They represent a great deal of capital investment. They tend to run 24/7. It’s not the kind of thing you can shut down and move overseas.”

Another big trend, Ted says, is that private equity firms – some of which tend to acquire manufacturers – like to hire lean experts to help turn around the acquired company, and in some cases to help with the due diligence before the company is purchased. (Adam Zak, another lean headhunter, also mentioned this trend when I spoke with him last year.)

And for the job candidate, Ted notes, working for a private equity firm can be a good opportunity because the compensation may include some equity in the acquired firm.

Ted also sees growing demand for lean specialists in service industries.

Stiles Associates saw “a bit of a slowdown” in job searches in the first quarter of this year, he says, but is now seeing improvement. “Overall, we’re not forecasting a downward trend on our total search load. It will probably be flat to last year,” he comments.

He adds, “In downtimes, we end up coming through just fine. More companies realize margins are getting thin, sales are down. They say, ‘we have to figure out some way to survive.’ It is pretty common for our phone to ring with people saying, ‘we’ve thought about this (lean) for a while. We want to dig into it fast.”

And for job-seekers, he advises, “It’s in market conditions like this that lean programs are really tested, and the commitment to programs is tested. If you are with an organization that is cutting back, that may be a pretty good indicator of their commitment (to lean). The ones that ramp up have kind of a refreshed and new appreciation for just how impactful a well-executed lean program can be. Now is the time to shine if you’re in a good program.”

Lean Jobs: Good Prospects in Healthcare

Demand is growing in healthcare for people with lean expertise, and now may be a good time to move from manufacturing to healthcare.

That’s the word from Ted Stiles, director of executive search for Stiles Associates, a headhunting firm specializing in lean jobs.

“We’re seeing a lot of activity in hospitals,” Ted said when I spoke with him recently. “They are really setting up to be a long-term home for lean. There are a lot of systemic issues that are plaguing the hospital industry that are forcing them to look outside the box.”

Lin Stiles, the founder and CEO of the firm, mentioned the start of search activity in healthcare when I spoke with him a year ago. Now Ted sees the trend growing rapidly. He said the factors driving the trend are clearly evident when he listens to speakers at lean healthcare conferences.

“All of them are basically saying the same thing: Quality of patient care is going down, the cost of delivering that care is going up, and the amount the government is going to refund us for some of these avoidable mistakes is about to come off the table,” he comments. “A lot of these folks are feeling pretty desperate. Sometimes a burning platform is all we need to plant the seed for a lean transformation.”

Hospitals that decide to begin a lean journey typically do so in one of three ways, Ted says. The first approach is, “they take someone from the nursing staff, designate them a lean champion, send them to a seminar and get them some books. A lot of people are doing that.” He notes that at lean healthcare conferences, most attendees “tend to be lower-level administrative managers, or maybe the director of nursing, or in some cases the CNO (chief nursing officer). It’s rare you see the audience full of CMOs (chief medical officers) or CAOs (chief administrative officers), folks who can really be influenced at the top level.”

“And that’s a shame,” he adds. “If it works at all, it’s going to take such a long time going that route.”

The second approach is to hire a consultant. And the third, least common approach, is to actually hire someone with lean expertise (who then might be responsible for also hiring a consultant).

Typically, a hospital going the third route will hire a lean expert to be an internal consultant. One exception was ThedaCare, which actually hired a lean expert from manufacturing to be chief operating officer. “That was really unheard of, and near blasphemy,” Ted comments. “It was also a symbol of how serious they were.”

More commonly, he says, hospitals are “developing special segments of the org chart, creating brand new positions and teams, internal folks who act as consultants.”

And hospitals don’t want those new hires to speak in manufacturing terms. Virginia Mason is one of the few hospitals that openly acknowledged they were basing their approach on the Toyota Production System, Ted says. (Productivity Press will publish a book about Virginia Mason later this year.)

It is much more common to avoid manufacturing talk, which will “shut people down,” Ted says, adding “The healthcare community, and really almost every industry shares this to some level, says ‘You don’t understand our industry. We’re different.’ The healthcare community has that times a thousand.”

Someone moving from manufacturing to a job in healthcare will typically see a 10 percent to 20 percent increase in salary, Ted says. However, once in healthcare (where you often are working for a nonprofit organization), salary increases will be incremental, without the bonuses that would be part of a manufacturing job. “You may be jumping into slower growth in the long run,” Ted says.

But at the same time, he adds, a switch to healthcare can be a good career move. His view is that the hospitals that are giving lean responsibility to someone on the nursing staff “in about five years will probably realize, ‘man, we’re really moving slowly.’” At that point, he says, demand for lean folks – particularly those who already have a few years in healthcare – will be “pretty significant.”

However, he also notes that many of the candidates he has dealt with who are seeking to move from manufacturing to healthcare are doing so not primarily because of the money.

“A lot of people are just drawn on a personal level to fixing the system,” he says. “They are passionate about it, typically because they have been through some horrific experience (in healthcare).”

In my next posting, I’ll describe what Ted said about markets other than healthcare.

Military Projects: A Case Study in How Not to Be Lean

While I’m sure there are many areas of government operations ripe for lean transformations, I’d like to nominate one in particular: The design and development of new military technology.

An article in The New York Times today focuses on construction of a new combat ship for the Navy. The headline is “Costly Lesson on How Not to Build a Navy Ship.”

A project heralded as the dawning of an innovative, low-cost era in Navy shipbuilding has turned into a case study of how not to build a combat ship. The bill for the ship, being built by Lockheed Martin, has soared to $531 million, more than double the original, and by some calculations could be $100 million more. With an alternate General Dynamics prototype similarly struggling at an Alabama shipyard, the Navy last year temporarily suspended the entire program.

The program’s tribulations speak to what military experts say are profound shortcomings in the Pentagon’s acquisitions system. Even as spending on new projects has risen to its highest point since the Reagan years, being over budget and behind schedule have become the norm: a recent Government Accountability Office audit found that 95 projects — warships, helicopters and satellites — were delayed 21 months on average and cost 26 percent more than initially projected, a bill of $295 billion.

Ouch.

Reading further, it appears the problems have a lot to do with product design as well as the development process.

In a narrow sense, the troubled birth of the coastal ships was rooted in the Navy’s misbegotten faith in a feat of maritime alchemy: building a hardened warship by adapting the design of a high-speed commercial ferry. As Representative Gene Taylor, the Mississippi Democrat who leads the House Armed Services Subcommittee on Seapower and Expeditionary Forces, put it, “Thinking these ships could be built to commercial specs was a dumb move.”

Behind the numbers in the Accountability Office study, experts say, is a dynamic of mutually re-enforcing deficiencies: ever-changing Pentagon design requirements; unrealistic cost estimates and production schedules abetted by companies eager to win contracts, and a fondness for commercial technologies that often, as with the ferry concept, prove unsuitable for specialized military projects.

At the same time, a policy of letting contractors take the lead in managing weapons programs has coincided with an acute shortage of government engineers trained to oversee these increasingly complex enterprises.

We’ve published several books having to do with product design, which is clearly one part of the problem. These include The Toyota Product Development System by James Morgan and Jeffrey Liker, and the just-released Value Stream Mapping for Lean Development by Drew Locher. (Copies of the new book should be available next month.)

It sounds like a good number of people involved in these military projects could benefit from reading them.

Lean Thinking at Google

I don’t know whether Google operates as a lean company, but I was pleased recently to read evidence that the people at Google try to think in a lean way.

Popular Mechanics recently posted an interview on its website with Udi Manber, who is Google’s vice president in charge of search quality.

While the interview focused on trends and directions in search, the comment I found most interesting was when Manber talked about how Google reacts when a search doesn’t produce the results it should.

At Google we do not manually change results. For example, if we find for a particular query that result No. 4 should be result No. 1, we do not have the capability to manually change it. We made that decision not to put that capability in the algorithm—we have to go and actually change the algorithm. That is, we have to find what weakness in the algorithm caused that result and find a general solution to that, evaluate whether a general solution really works and if it’s better, and then launch a general solution. That makes the process slower, but it puts a lot more discipline on us and makes it more unbiased.

In other words, when there is a problem, don’t create a workaround; identify the root cause and solve the problem.

A good lesson for all of us.

Lean and Green in Hospitals

I’ve been writing recently about lean in healthcare, and I’ve also been writing about how well lean fits with issues of sustainability. Therefore, I was delighted to come across a recent article about how hospitals in the Seattle area are trying to embrace a green approach.

This is important because, as the article notes,

Hospitals have long been seen as one of the top waste-producing industries. In 1998, the American Hospital Association and the Environmental Protection Agency agreed on goals to reduce the effect of health care facilities on the environment. The goals included nearly eliminating mercury-containing waste by 2005 and reducing hospital waste 50 percent by 2010.

The article begins by looking at Evergreen Medical Center in Kirkland, and the efforts there by a nurse, Jim Overton, to make the center more environmentally responsible. It then focuses on other hospitals as well.

Overton's "Green Team" expanded the hospital's battery recycling program and collected 1,200 pounds of batteries during the past year. The hospital also collects used and unused-but-opened medical supplies, such as oxygen and blood tubes considered "contaminated" under U.S. regulations. The supplies are sent to Third World countries where they are sterilized and reused for patients there.

The team put up more recycling signs and bins and got the hospital's recycling container emptied three times a week instead of two. Containers for used needles are sterilized and reused, instead of being thrown away with the needles.
Overton started an internal Web site so staff could learn to become more environmentally friendly.

The team gives a monthly "Green Stewardship Award" to a staff-nominated co-worker who gives extra effort to the hospital's environmental progress. Local restaurants donated gift certificates as prizes.

Other Seattle-area hospitals are improving their bottom line by going greener.

Virginia Mason Medical Center's cafeteria has no garbage cans, since 100 percent of the cafeteria's waste is recycled, said Steve Grose, administrative director for process improvement. The hospital composts 750 pounds of food a day instead of grinding it in garbage disposals, which had needed 4,000 gallons of water a day. The water savings pays for the bags and composting, he said. In January, Virginia Mason began recycling 70 percent of the plastic used in about 70 surgeries a day.

The hospital hopes to eventually eliminate garbage cans throughout the hospital and recycle everything.

(Note: Later this year, Productivity Press will publish a book about how Virginia Mason Medical Center is applying lean methods to its operations.)

The University of Washington Medical Center recently started a paper-shredding program with Weyerhaeuser that the hospital estimates will save $70,000 a year. Surgical instruments are now disinfected with a less hazardous chemical. In 2006, the medical center began buying 100 percent renewable energy from Seattle City Light, which cost the hospital an extra $40,000 a year, but was worth the added expense, said hospital officials.

In two years, a water reuse system at UW Consolidated Laundry has saved 12 million gallons of water for a cost saving of $140,000 in water and $79,000 in natural gas.

Swedish Medical Center estimates saving more than $ 1 million since 2001 by recycling, said Michael Smith, the hospital's waste compliance manager. Swedish eliminated blood pressure monitors containing about 180 pounds of mercury -- and recycles all paper, cardboard, metals, batteries, lamps and printer toner cartridges, he said.

Food composting will begin at the end of March. It is working on a better way to dispose of expired medications and chemotherapy waste.

Children's Hospital and Regional Medical Center recycled more than 40 tons of computer monitors in 2006 and composts food, saving about $8,000 on water a year. Using new technology for cleaning and sterilizing surgical instruments, which uses more high heat and steam, Children's saves 4,100 gallons of water per day and more than $18,000 per year.

The article does not say specifically that lean tools or strategies are being used to accomplish environmental benefits. But at the very least, reducing environmental problems is elimination of waste, a key lean benefit. I hope we see more of this soon, and I expect we will.

Finding the Root Causes of Emergency Room Overcrowding

Identifying the root cause of a problem is a fundamental lean principle. That is the reason we ask “why” five times. Knowing the root cause is critical to achieving true improvement.

A new survey by a group of researchers, published in the Annals of Emergency Medicine, does an excellent job of looking at the root causes of emergency room overcrowding.

The ER is the focus of many current improvement initiatives in healthcare because of frequent overcrowding and long delays in patients being seen by doctors. Many initiatives focus on streamlining processes and improving patient flow, or patient throughput, so that there is less waiting time, and more patients can be seen.

That is all well and good. But the new research takes a step back to ask why ERs are overcrowded.

It is already well-known that demand for ER services has increased significantly in recent years. Conventional wisdom tells us that the cause is growing numbers of uninsured patients using the ER as their primary source of healthcare.

However, the new research demonstrates that conventional wisdom is wrong. The researchers used data from the national Community Tracking Study Household surveys for four different time periods between 1996 and 2004. They connected ER (or ED, for emergency department) visits to insurance status, family income, usual source of care and other factors.

Their findings: The proportion of visits by uninsured persons has not increased. However, there has been an increase in the proportion of visits by people whose usual source of care is a doctor’s office. The authors comment:

Our results provide strong evidence that visits by uninsured persons during this period were not a major cause of the overall increase…

These findings suggest that the rise in ED use is disproportionately due to non-poor individuals who have a usual source of health care. These findings have significant implications for current policy discussions because they suggest that the provision of health insurance will not, in and of itself, address issues of ED crowding or the more general issues of access to, and appropriateness of, health care services…

There are many factors contributing to the rise in ED visits, including population increases, the aging of our population, the increased numbers of time-sensitive interventions requiring state-of-the-art hospital care, larger numbers of patients with complex medical problems requiring evaluation in a setting in which sophisticated testing and consultation are available, and complications from medical and surgical treatments.

Another reason for increased ED use may be difficulty obtaining timely appointments from one’s usual source of care, or physician referrals to EDs because of their diagnostic and treatment capabilities.

Thus, the uninsured are not primarily responsible for the increase in ED utilization. Instead, the increase in ED use may be attributable to lack of ready access to primary care and other structural problems in the health care system.

The next step is to identify and come up with ways to address those structural problems. Now the real work begins.