What is the problem with drawers in the LEAN world?

What IS the problem with drawers?

According to LEAN Hospitals author, Mark Graban,  "Before Lean, most supplies are kept in closed  cabinets or drawers, which create waste as employees search for items and cannot see what is located where.  With improved organization, employees will no longer waste time opening multiple cabinets or drawers, searching for what they need.  When determining storage locations, LEAN leaders challenge the need to store items in closed cabinets or drawers.  Well-organized departments are not afraid to keep supplies visible and in the open, since we will no longer have the piles of disorganized supplies we used to hide behind doors, as pictured in figures 6.1 and 6.2.  Hiding the old mess behind closed doors was often a workaround to the problem of not keeping things organized."

LEANster tells the problem with drawers

Are you kidding?  Really?  This sounds so dumb.  Fo real.  'Nuf said.

Efficiency vs. Quality - LEAN goes for efficiency at the expense of quality (and the morale of workers)

Here is an example of the emphasis that LEANSTERs can place on efficiency.  When you are in a healthcare setting, sometimes quality trumps efficiency.  If the  method looks  like it has been LEANed, and is more efficient, but underneath the quality of the process has been sacrificed, then there has been a threat to patient care.


This is a danger of the LEAN intruder in hospitals.  

The article 3/15/2008:

To build a better hospital, Virginia Mason (Medical Center) takes lessons from Toyota plants

http://www.seattlepi.com/health/355128_lean15.html

"Virginia Mason said overall benefits include an 85 percent reduction in how long patients wait to get lab results back, and lowering inventory costs by $1 million. They've redesigned facilities to make patient and staff work flow more productive. The hospital reduced overtime and temporary labor expenses by $500,000 in one year and increased productivity by 93 percent. While direct cost savings aren't passed on to patients with the new system, less waiting, increased safety and more efficient care are." (Bold added).

LI comments:  

85% reduction in wait for lab results 

$1 million lowering of inventory cost (for today yes, for the year maybe not)

redesigned facilities to make patient and staff work flow more productive (more productive but at what quality level?  LEAN can mean higher productivity at lower quality levels for the patient - this must be accounted for)

reduced overtime and temporary labor expenses by $500,000 in one year

increased productivity by 93% (Huh?)

direct cost savings not passed on, BUT 

less waiting, 

increased safety, 

and more efficient care. (a measurable benefit or a Hawthorne affected opinion?)

The LEANSTERS would always tell you that care is more efficient, however, in a healthcare setting efficiency and quality may not always be equal.  Let's not choose efficiency over quality.

http://www.seattlepi.com/soundoff/comment.asp?articleID=355128

Posted by FirstHillResident at 3/15/08 12:26 p.m.

"Yeah....I left Virginia Mason because of this system. It has completely ruined morale among workers. I was in the accounting office, but when they implemented this system I literally had a guy with a stopwatch standing over me for two days timing my every move, looking for ways I could accomplish more in less time. I can't tell you how demeaning that felt. There's also such a thing as being too lean. This system has actually caused problems at Virginia Mason, most notably the death of an elderly female patient because they had gone so lean that a certain chemical wasn't properly labeled and she was injected with it. Workers there really hate this system, and if patients are ultimately going to get good care, their healthcare providers needs to be happy to be there." (Bold added).

Have a good read - that's all I can say

Virginia Mason in Seattle goes LEAN (the article)


The comments from employees - woo hoo (the comments)


DRACONIAN measures on where to put the stapler are IN PLACE and spreading!  See readers comment:

"So far, our use of Lean seems to be confined to administrative aspects--for example, can we reduce the time it takes to process a medical claim. If we go as far to implement draconian productivity measures like where to put a stapler, I can envision a similar exodus of medical staff like the one VM appears to be facing."

5S Audits and LEAN in Healthcare - a technique for the controlling micromanager

Let's take 5S and Audits to mean that you have identified a checklist of criteria that can be observed showing that a workplace is being maintained to standard, monitored with results posted in the workplace.

Definition of 5S:

5S – (Sort, Shine, Set in Order, Standardize, and Sustain) A method of creating a clean and orderly workplace that exposes waste and errors.  

http://www.mayomedicallaboratories.com/about/quality/framework/glossary.html

Now, let's look at TheLeanThinker's blog entry on 5S erosion:

http://theleanthinker.com/2010/08/03/5s-erosion-continued/

"Note that I am not questioning the value of having a standard for workplace organization. I am not even directly challenging audits, measurements, etc. However these things must have a clear purpose, or we are just blindly implementing tools and repeating mantras. And if we cannot articulate the core purpose of these things to each other, how can we ever ask others to do these things with any more authority than “because I said so” or “because it is in this book?”

The LEAN intruder could not agree more with the LEAN thinker.  This makes sense, doesn't it?  Let's not "blindly implement tools" without clear purpose.  This is LEAN Intruder's main bone to pick with LEAN - BLIND IMPLEMENTATION of TOOLS.  Now, more on the story with a response to the LEAN Thinkers blog entry with LEAN Intruder's (LI) comments:

Jim Fernandez wrote:

OK, I’ll give you the simple answer. I can tell you what the purpose of the audits have been here where I work. Not in any particular order of importance:

1. Audits provided a score that was posted in the cell area. It was supposed to create some healthy competition between cells. And thereby, hopefully, some motivation to maintain the 5S condition.

LI comment:  Not sure what group of employees engages in healthy competition between cells.  Haven't found it to be the case with cells of nurses or cells of laboratorians.  Maybe the cells of surgeons would respond (ha!) - they are a competitive bunch. (smile).  Healthy competition between cells huh?  Sounds like a white man's game to me- healthy competition (perhaps another oxymoron)  Right?    Not sure the female dominated health care fields will hunker down for this one.

2. Audits were a means to a free lunch. The audit score was used to give awards (a free pizza lunch) for the cell with the highest score.

LI comment:  This is an epidemic in our schools - the pizza party as reward.  The elementary kids may buy this approach, but once you get past middle school it's not the reward that works for the masses.  Let's offer the neurosurgery cell vs. the othopedic cell a free pizza lunch for the best performance on their audits - yeah!

3. Audits provided at’ta boys. They provided feedback to the workers telling them that management, or other cell leaders, thought they were doing a good job.

LI comments:  Intrinsically motivated health care workers aren't much for the at'ta boy.  

This sounds so paternalistic, and again appealing to the white male hospital management club.  

4. Audits provided feedback to the workers to tell them which area of 5S needed more work. And which area was “good enough”.

LI comment:  The workers can't figure that out for themselves?  Are you kidding?  It's their workplace isn't it?  Aren't they familiar with expectations and the critical needs for the job to be done well and the area to be neat?

Most people went to school and are used to getting grades. If they get a B+, they can be proud. If they get a D, they know they need to try harder.

LI comment:  And some people give up with the D, especially if what they are being asked to do is stupid, pointless, and instituted by a manager who wants to show off audit sheets to tour groups.

The problem that the audit was supposed to solve was a lack of adherence to 5S principles.

LI comment:  Lack of adherence to 5S principles.  Take a look - that's some serious cult talk there - it's a piece of jargon that cannot stand alone.  Sad.

We observed the problem by noticing that the work areas were falling back into a pre 5S condition.

LI comment:  And this is defined in LEAN terms as the human element as resistant to change. 

Posted 03 Aug 2010 at 11:19 am ¶

5S and Audits provide a very neat platform for controlling micromanagement in Healthcare. The more micromanagement, the less likely the team is to perform at peak levels.  So wake up all you controlling micromanagers and get back to finding something else to do with your excess time at work.  

Lean Intruder - Hide your drawers, hide your doors!

It won't make sense but they'll take them away!  You are so dumb!  You are really dumb, for real!


HEADLINE:  LEAN TECHNIQUES INCREASE VISUAL CLUTTER


I stand strong AGAINST unnecessary visual clutter in the workplace.


We had a huge laugh when a friend told us that she worked in a new laboratory where the VP had been trained in what I will call "LEAN techniques."  


LEAN techniques mean that the white man has heard about some techniques that he hopes will make him look better to upper management, who he hopes will then reward him, give him a raise, a pat on the back, and a new title.  He is going to implement the techniques without a true understanding of the effect of the techniques on the workplace, the workers or the outcome on the customer/patient.  In other words, he hasn't captured the true essence of LEAN. He grasped couple straws to show off with and this makes workers/nurses/etc. MAD. ANGRY.


Back to the friend in the new laboratory where the VP had LEAN  techniques...
 When she told  us  "then they took all the drawers away" with the most incredulous tone and look on her face, we busted out laughing.  


We have the same incredulity to this day when the LEANSTERS swoop in on a drawer removal mission.


What's the harm in a drawer, you wonder?


Why would you build a new nice lab facility and then remove the drawers, leaving the supplies that were organized and out of view to sit out all over the benchtop, increasing visual clutter and inability to clean and dust easily?


Well, let's go to the LEANSTERS to find out...


"Also make things easy to put away.  Having to open a drawer to put something away might not seem like a big deal, but if you do it five times a day, that's 1,250 drawer openings and closings a year.  Can't you do something more useful than that with your time?  Part of this phase is storing similar items together for logical consistency.  Some places color code things to make them easier to identify and pick up.  Label items and storage locations so you know where everything is at a glance."
from LEAN Six Sigma Secrets for the CIO:  ITIL, COBIT, and Beyond, by William Bentley and Peter T. Davis.


IS THAT WHAT THIS IS ABOUT?  1,250 seconds per year?  One second to open, one second to close?  That is 20 MINUTES per year!  WAKE UP.  That makes NO sense.  ZERO.  


You mean to tell me you are taking away the organized clutter free look of drawers in the workplace to save 20 MINUTES per year?  


Can you see why we think these people are out of their minds?


And the author asks if I can find something more important to do with my time than spend it opening and closing a drawer?  Well, here is what I CAN find that is more important -  doing the job that I am paid to do, rather than having to dust around supplies that are now kept out in the open.  


Keeping supplies/papers, etc. that are utilized once per week, or even once per day in a drawer that can be opened and closed in 2 seconds makes sense.  


Hello.  Is anyone listening?  Common sense here please?


But NO, they come in and remove drawers without study or question.  And they remove them with the narcissistic authority of one who is not to be questioned.  If you do question the logic, you will be treated like a sub par human being who is questioning the obvious.  Thus, the cult label that I have applied in a previous blog entry.  The cult leader is not questioned.  Don't forget.


The LEANSTERS are removing the drawers without checking with the worker to see if the drawer is opened 50 times per day (agreed upon possible waste- a LEAN term), or 5 times per day (10 seconds per year savings), or even 1 time per week (let's see, that's 2 seconds per week, or 104 seconds per year or a grand savings of 1.733333 minutes per year.  Wow. We need to worry about that drawer, hmmm.)  




Read the following review of LEAN Six Sigma Secrets for the CIO:  ITIL, COBIT, and Beyond (OMG, it's so incriminating- why?  see bullets below)


This complete resource for CIOs and IT managers provides effectivestrategies to address the human element that is so fundamental to success and explains how to maximize the voice of your customers while keeping in touch with the needs of your staff. And perhaps most importantly—it provides the evidence needed to build your case to upper management. http://www.dl4all.com/e_books/100600-lean-six-sigma-secrets-for-the-cio-itil-cobit-and.html


-"effective strategies" ---- jury is OUT on this.


-"address the human element"-----there are humans involved here?  thinking humans?


-"keep in touch with the needs of your staff"-----this is big counsel, anyone listening?


-"Perhaps most importantly (hee, hee), PROVIDES EVIDENCE TO BUILD YOUR CASE TO UPPER MANAGEMENT"-----yeah, that's right, the big consulting fees paid out and big monetary rewards promised to your hospital/workplace mean that you are going to look BIG. Even though the workers will see that you are LITTLE due to your lack of common sense application.


So would you look at the number of seconds you are trying to save and please listen to your workers and please not blindly remove drawers just because LEAN says to do it?
Thank you.


Coming up:
Hawthorne effected numbers and LEAN http://www.q-skills.com/Lean6Sigma.pdf).

Seattle Children's and Hospital language for "the best"

Seattle Children's Mission from the website:

http://www.seattlechildrens.org/about/mission-vision/

Our Mission

We believe all children have unique needs and should grow up without illness or injury. With the support of the community and through our spirit of inquiry, we will prevent, treat and eliminate pediatric disease.

No arguments with that mission....

Our Vision

We will be the best children's hospital.

• We will provide patients and their families excellent care with compassion and respect
• We will provide superior, accessible, cost-effective service
• We will attract and retain the best talent at all levels of the organization
• We will be one of the top five pediatric research institutions
• We will be the nation's premier pediatric educators
• We will achieve worldwide prominence by integrating patient care, research, education and advocacy

BUT, the Vision?

We will be the best children's hospital.   Why?

We will be the nation's premier pediatric educators.  Why?

We will be one of the top five pediatric research institutions.  Why?  Does top 6 mean you stink?

We will achieve worldwide prominence by integrating patient care, research, education and advocacy?  Why?

WHY, WHY, WHY?

the best, premier, top five, and then worldwide prominence?   What for?  So that outside sources can signal that you are doing a good job while your patients and employees see deficits in patient care?  Does that make sense?  The LEAN and continuous improvement  Healthcare initiatives are like sparkling fool's gold.  Catching to the eye, boastful at first, but then when you pick it up and really examine it, it's worth nothing.  

The parade continues, people are impressed as they walk through, as they hear about the initiatives.  And yet, the people on the scene and in the trenches know the truth - it's just a show, fool's gold, the emperor has no clothes.  The real story is beneath but no one is listening - the sparkle has caught their eye.  LEAN Healthcare initiatives do not necessarily improve patient outcome and in fact can be detrimental.  Emperor, where are your clothes?  Oh, no one close to you will tell you that you are naked.

More wisdom from the NYT article

Let's take another look at some paragraphs from the NYT article on LEAN in Healthcare:

http://www.nytimes.com/2010/07/11/business/11seattle.html

At Seattle Children’s Hospital, Dr. John Waldhausen, the division chief of pediatric general and thoracic surgery, acknowledges that he and other doctors weren’t initially very enthusiastic about C.P.I. (continuous performance improvement) because they thought it would take some decisions about patient care out of their hands.

Over time, he changed his mind, and he is now a vocal advocate of C.P.I. “When you look closely, C.P.I. is the same scientific method we learned in medical school, including hypotheses, data collection and analysis,” he says. “It is not opinion and conjecture — it is data-driven.”

TEN years ago, Seattle Children’s set a goal to become the top hospital of its type in the country, and hired Joan Wellman & Associates, a process improvement consulting firm in Seattle, to help it get there. Ms. Wellman, who had worked with Boeing on its lean-manufacturing processes, suggested that the hospital apply similar principles.

Mr. Hagan says he became enthusiastic about lean manufacturing and C.P.I. after doing research and visiting local manufacturers. He directed the hospital staff to examine the “flow” of medicines, patients and information in the same way that plant managers study the flow of parts through a factory.

Commentary from LI:

Seattle Children's set a goal to become the top hospital of its type in the country.   Similarly, our organization set a goal to become the top hospital of its type in the country.  A LEAN or process improvement healthcare consulting organization was hired.  Other hospitals that had made LEAN improvements were visited or targeted as having "must have" processes.

It didn't matter one bit if these processes fit our particular hospital, setting, population, staff, patients, etc.  The administrators simply saw cookie, and reached for the cookie cutter.  If Seattle Children's, or another top hospital of its type is doing this, then WE MUST DO THIS.  That's ??sane?? 

The issue:  Who states a goal that a hospital become the top hospital of its type in the country?  The patients?  The staff?  The administrators?  The Board of Directors?  The CEO?  If you detract from the goal or experience of providing top patient care, then who cares if you are a top hospital in the country?  If you take away from the experience of working in a hospital that cares about providing for the needs of it's patients, then who cares if you are a top hospital in the country?

The U.S. News BEST Hospitals have inspired this type of competition.  See http://health.usnews.com/best-hospitals/rankings.  Why?  Who is putting on the competition?  Read about who votes, how these ratings are created, how votes are bought.

Here they are - the honor roll hospitals and do you want to know who wants to get on this list?  And what they will do to get there?

http://health.usnews.com/health-news/best-childrens-hospitals/articles/2010/06/02/best-childrens-hospitals-2010-11-the-honor-roll.html

Best Children's Hospitals Honor Roll
Children's Hospital Boston
Childrens Hospital Los Angeles
Children's Hospital of Philadelphia
Children's Hospital of Pittsburgh of UPMC
Cincinnati Children's Hospital Medical Center
New York-Presbyterian Morgan Stanley-Komansky Children's Hospital
St. Louis Children's Hospital-Washington University
Texas Children's Hospital, Houston

 

NYT Factory Efficiency (LEAN) Comes to the Hospital

What do you see when you read the article from the NYT on LEAN in hospitals?

http://www.nytimes.com/2010/07/11/business/11seattle.html



Here is one paragraph:


"The system (refers to supply system for ICU) is just one example of how Seattle Children’s Hospital says it has improved patient care, and its bottom line, by using practices made famous by Toyota and others. The main goals of the approach, known as kaizen, are to reduce waste and to increase value for customers through continuous small improvements."


Note the following sentences from this paragraph:
1)  "Improved patient care, and its (Seattle Children's Hospital) bottom line."


2)  "Main goals...are to reduce waste and to increase value for customers through continuous small improvements."


What are the main goals of a hospital?


Reducing waste and increasing value for customers?  Does that mean cutting costs and what for customers?  Increasing value?  What does that mean in a health care setting?  "Improved patient care and its bottom line."  Which comes first - the improved patient care or the improved bottom line? 


 Was there any or check in place to catch the fact that the enthusiastic LEANsters in the hospital were convincing Hospital administration to do something that would degrade patient care?


If not, why not?


“It turns out the highest-quality care also is the most cost-effective because we make fewer mistakes and create better outcomes,” says Patrick Hagan, the hospital’s president."


Not true based on Seattle Children's second child death due to drug overdose in a year.  Sad,but a wake up call?