Who knew Honda made Tofu?

When people think of Lean they often think of the tools associated with it: 5S, kanban, error proofing, visual controls, etc. But the tools alone are not what lean is. Lean is basically finding creative solutions to management problems (or engineering problems).

John at Curious Cat Management has a great example of creative problem solving from honda:
"Of all the bizarre subsidiaries that big companies can find themselves with, Harmony Agricultural Products, founded and owned by Honda Motor, is one of the strangest. This small company near Marysville, Ohio produces soybeans for tofu. Soybeans? Honda couldn't brook the sight of the shipping containers that brought parts from Japan to its nearby auto factories returning empty. So Harmony now ships 33,000 pounds of soybeans to Japan." - Forbes

That's just elegant. In addition Honda has never suffered layoffs or an unprofitable year. Hmmm.

Photo- Jwinfred

Standard work is for everyone: even the CEO

Continuous Improvement starts and ends with standard work. It is much easier to improve a process when everyone works the same way. And the only way to maintain the gains of an improved process is to standardize it. This is fundamental for front line workers, but is often missing from the leadership of many "Lean" organizations. In order to improve how you lead or manage you have to standardize the processes you use to lead and manage. The CEO is not exempt. Here are a few ways that the folks in the C-suite can apply standard work.

The employee safety rate in healthcare (my industry) is abysmal. The injury rate is three times that of most manufacturing industries. Nurses and techs tend to focus on patient care and safety while ignoring their own personal safety. This is not an accident, it is a direct result of the way that most hospitals are led from the very top, and up there employee safety takes a back seat to patient safety and care.

Leading a safe organization starts with making safety a priotity. Do this by putting safety first, literally.
  • Make it the first item on the agenda for leadership and operational meeting.
  • Start every day by reviewing and following up on injuries from the previous day.
  • Make your recordable injury rate the first item on you operational dashboard.
Insist that your directors and managers follow this example and put safety first in their daily meetings and interactions with frontline employees. Putting safety first at the very top creates a culture of safety. It is not the only thing need to improve safety, but without it nothing else matters.

Go to the Gemba

In Lean, gemba means "the place where the work is done." We talk about "going to the gemba" to see what is actually happening with our employees and customers. This is also called management by walking around. When the CEO or or VPs go to where the work is done and talk to front line employees amazing things happen. Trust starts to build. The leadership will understand what challenges are employees face in getting their work done in a way that they wouldn't otherwise.

This is something that makes sense to most leaders, but is still done much too infrequently. How can that change? make it part of standard work.
  • Schedule part of every day to visit some area of the organization and talk with the employees.
  • This should not be a formal meeting, just observe the work being done and talk with them about any challenges or frustrations they have. (And remind them to work safely.)
  • Make this a part of your routine, and set the expectation that VPs, directors, and managers make it a part of their routine.
If it is important, measure it everyday. Enterprise software makes it easy (or at least possible) to track financial metrics by the day, and most executives do this already. But financial metrics are often too far removed from the processes we manage to be a real guide. Identify what process have the most impact to meeting your goals, find a way to measure them, and track those metrics on at least a daily basis.

Every organization I've worked at has had at least some metrics that they looked at monthly, and caused hysteria when the numbers were out of line. By the time the metric is actually reported it was too late to investigate the problem, much less fix it. If a process is important enough to report monthly, then it is important enough to measure daily. This is how you make sure that you stay on top of those things that are important, not just urgent.
  • Inventory: Have your supply chain manager or each department manager report inventory days on hand on a daily basis.
  • Staffing: If you flex your staff based on demand, measure your staffing ratios on a daily basis and tweak your flexing process.
  • Clinical results: Any clinical activities that have a standard process associated with them should be measured daily. examples include: medication nomograms, glycemic control, and time from lab order to result reported.
Standardize the process of getting these metrics so that you know that the right people are also looking at the numbers. The IT department shouldn't just write a report that for the CEO that does this automatically. The process owners need to be responsible for collecting this data and reporting it up.

Meetings at most companies are a mess. There are too many of them getting too little done with too many of the wrong people attending them. Leadership can go a long way toward fixing this by setting some standards.
  • Agendas: Every meeting needs an agenda. Short, simple, and in the body of the email (instead of an attachement) is best. Give your people the option of declining any meeting that doesn't have one.
  • Time: Keep them to fifty minutes. By ending ten minutes before the hour folks can get to their next meeting on time. We should have learned this in high school. See if your IT folks can make this the default in your calendar software.
  • Publish the decisions made and next actions the same day.
The further you get from actually serving the customer or making your product the easier it is to get distracted from what is really important in your organization. Use standard work to keep the important things first.

Photo: indexed

Improve Your Dessert

This blog is mostly about process improvement, but it is generally about everything improvement, and today it is about dessert improvement. Here it goes: throw out your Cool Whip right now! Wired magazine has a very informative article on what is actually in Cool Whip and guess what, cream is nowhere to be found. In fact the ingredients are pretty disgusting. Go ahead, Read it.

Now I understand using concoctions like this for the sake of convenience, but th
e truth is that making real whipped cream is so cheap and easy there is almost no reason not to. Here's how you do it :
  • Buy heavy whipping cream
  • put in mixing bowl with some sugar (and maybe a dash of vanilla)
  • whip with electric blender
  • Its done when it looks and feels like whipped cream.
if you are too lazy to do that, use Reddi Whip instead of Cool Whip. At least the first ingredient on the Reddi Whip can is actually cream.

Photo by 91RS

Correcting Errors Early: Source checks, Self checks, and Successive Checks

The Lean Healthcare Exchange has an excellent article about source checks, self checks and successive checks. This concept needs to be incorporated into standard work procedures in healthcare whenever other error-proofing methods are not in place. And that would be most of the time.

The need for these checks stem from the fact that there is so much opportunity in healthcare to cause great harm from simple mistakes: fat fingering a medication order in the EMR, transposing two numbers in a lab result or medication dosage, or confusing left and right when performing a procedure on a patient. Smart people can easily make these kinds of mistakes. Source, self, and successive checks prevent these errors from harming the patient.

The classic example of this is the surgical time-out. The nurses, surgeon, and anesthesiologist stop what they are doing and review the procedure and location on the consent. This successive check ensures that they are doing what the patient and physician intend.

Unfortunately this assumes that everything leading up to the written consent is correct. The recent example of a surgeon removing the wrong kidney from a patient illustrates the problem with this. It turns out the wrong kidney was reported as cancerous in the medical record. Lets look at how source checks, self checks, and successive checks can help prevent this type of error.

  • The radiologist performs a self-check to ensure the film is not backward before reading it.
  • The radiologist reads the film again (source check) just prior to reporting the result.
  • The physician double checks the radiology report before ordering the surgery (successive check)
  • The physician looks at the film himself before ordering the surgery (source check)
  • After ordering surgery the physician compares what he just ordered with the radiological report (self check)
  • The surgical team checks the consent before starting surgery (successive check – this is standard practice, and is what the team did)
  • The surgical team checks the original film before starting surgery (source check – this is the new procedure instituted at the hospital in question)
All of this checking and re-checking seems like wasted activity. But eliminating the defect early on is much less costly than letting the defect get to the customer. This is true in manufacturing, and it is even truer in healthcare.

Real Reference Material vs Back Breaking Binders of Slideuments

In most six sigma training the students get several big thick binders filled with the PowerPoint slides used in class. This is a huge waste: a waste of trees, a waste energy carrying the things back to the office, and a waste of shelf space. The problem is that good presentation materials make horrible documents and good documents make horrible slides. When you try to do both you get slideuments, and slideuments stink.

So when I had the opportunity to develop Green Belt training from scratch I committed to making the PowerPoint slides support my message without being the message, and to giving my students decent reference material instead of useless slideuments. Since the organization is saving perhaps a quarter million a year by doing the training in house instead of hiring one of the big consultant firms, we can spend a few bucks on books.

Here is a list of the books I use in my Six Sigma Green Belt training.

Getting Things Done by David Allen

A very good book on personal productivity, it also has a chapter on project planning that I used as a basis for project management training material. I think Everyone should read this book.

The Six Sigma Handbook by Thomas Pyzdek

A big fat reference book. I don't think I like this any more than Implementing Six Sigma by Forrest Breyfogle (another big fat reference book I've used for many years). But it is cheaper.

Improving Healthcare Quality and Cost with Six Sigma

A nice application of the tools to healthcare. I've gotten good feedback on the book from the Green Belt candidates.

Measuring Quality Improvement in Healthcare: A guide to statistical process control applications

An excellent book on using SPC in healthcare. It has a lot of examples, many of which were directly applicable to processes the students work with every day. Chapter 5 has almost everything a Green Belt needs to know about SPC. In fact, this is probably the best book on SPC for non-statisticians that I've seen.

The Lean Healthcare Pocket Guide XL - Tools for the Elimination of Waste in Hospitals, Clinics and Other Healthcare Facilities
This has nice, concise description of most Lean tools. The XL version is much easier to read than the pocket size version.

Rath & Strong's Guide to Minitab: Release 15

I gave the students this guide as an alternative to writing my own guide to Minitab. I may have to write one myself anyway.

Start Projects Right: the Problem Statement, the Project Objective, and the Business Case

Projects that get off track are often not defined well in the initial meetings. Team members will have different ideas about the purpose, goals, and scope of the project. If those are not reconciled and agreed upon at the beginning, the result will be conflict and misunderstanding later on. A project charter will get the team on the same page right from the beginning and keep them there as the project moves forward.

One of the first meetings you have as a team should involve a discussion of the purpose and goals of the team. This discussion plus some data should give you everything you need to write a problem statement and a goal statement.

Problem Statement

A good problem statement will have the following items:

  • What the problem is
  • Where it is occurring
  • When it occurred
  • The extent of the problem
  • How you know it is a problem

Here is an example of a bad problem statement:

“The hospital has too many patient falls.”

A good problem statement will contain the five elements above:

  • What the problem is
    • “Patient Falls…“
  • Where it is occurring
    • “Patient Falls on the inpatient floors at the hospital…
  • When it occurred
    • “Patient Falls on the inpatient floors at the hospital during FY 2005…
  • The extent of the problem
    • “Patient Falls on the inpatient floors at the hospital during FY 2005 averaged 20 per month…” (Not bad)
    • “Patient Falls on the inpatient floors at the hospital during FY 2005 averaged 20 per month resulting in one death and $500,000 in uncompensated treatment… (Now we’re talking)
  • How you know it is a problem
    • “Patient Falls on the inpatient floors at the hospital during FY 2005 averaged 20 per month resulting in one death and $500,000 in uncompensated treatment. This rate is 50% above ministry average.”

The problem statement is short, concise, describes why and to what extent this is a problem. It should never contain causes of the deficiency or likely actions or solutions. And it also won’t contain all of the detail that came out of the conversation about the purpose of the team, but it will give a powerful reason of why the project is necessary.

Project Objective (Goal Statement)

The team should already have a list of goals for the project team. These will include all of the ways the team sees their work and the process improved at the end of the project. The goal statement will not include this detail, but achieving it should have the result of meeting all of those individual goals. For six sigma projects, a good goal will be SMART: Specific, measurable, aggressive, realistic, and have a time-frame.

A note about the realistic aspect: goals can be very aggressive and still be realistic. It often means that you will have to be more creative with your solutions. A SMART project objective might be:

· Implement a patient falls prevention strategy for inpatient areas that eliminates patient falls by January 1, 2009.

The word “eliminates” might raise some eyebrows. Naysayers will tell you that achieving zero defects is unrealistic. But for patient safety issues what is the alternative? How many patient falls are acceptable? We do not want patient falls to be an outcome of our standard way of doing business.

Business Case

It is also a good idea to establish a business case. The project objective and problem statement get the team on the same page. The business case gets the buy in of leadership. The problem statement establishes the extent of the problem, while the business case ties that in to the organizations key business objectives. This is fundamental to getting the resources and support you need to complete the project. If your project is not related to senior management’s goals, then you are going to have difficulty getting commitment from them to provide people and resources for the team.

· In FY 2006 the hospital provided 1.5 million dollars in uncompensated care to patients injured during the course of their stay. Patient falls accounted for $500,000 dollars of that uncompensated care.

Now that gets the attention of even the bean counters.

Leading projects is not always easy, but making sure that the team is on the same page regarding the problem and objectives, and that senior management supports the goal, goes along way toward ensuring success.

Keep Projects on Track with the Natural Planning Model

We have all been on project teams that flounder. The brainstorming sessions seem vague and unfocused. The action plan doesn’t address the problem. Or nobody seems to really understand what’s going on in the first place. This is all a result of poor project planning.

When people think of project management they usually think of Gantt charts, pert charts, and MS project. These can be useful tools when used appropriately, but most projects don’t need them. Since most people know these tools aren’t needed for their project, and that is what they know of project management, they end up doing no planning at all.

David Allen describes the Natural Planning Model in his book Getting Things Done. I have had excellent success applying this model to all kinds of projects. The key is to follow each step in order, and to be constantly aware of where your project is within the model

The five steps are:

Define your Purpose and Principles

It is very important that everybody on the team knows exactly why the project is necessary. Revenues are short of budget and the team needs to figure out what to do about it; the defect rate on a particular product is too high; or the CEO is in town and we need to roll out the red carpet. If people on the team are not in agreement with what the purpose is from the start, then it is very difficult to keep people working toward the same thing

In team leadership training you are taught to establish ground rules in the first meeting. ‘Be Respectful’, ‘stay on topic’, and ‘start and stop on time’ are common ground rules, and can also be thought of as the principles of behavior the team agrees to work by. These are great, but you also need to establish more concrete principles as well. ‘Stay within budget’, ‘cut expenses without laying people off’, and ‘spare no expense to solve the problem’ are the sort of principles that need to be stated up front so that everyone understands the constraints the team is working under.

State the Goal

If you don’t know where you are going, you will never get there. It is not enough to understand the purpose of the project team. You also need to have a vision of project success. What will be the benefits? How will it feel to work with the new process? When will these goals be met? This is the opportunity to envision “wild success” and set aggressive goals. As David Allen says, “‘wouldn’t it be great if?’ is not a bad way to start thinking about a situation.”

Most formal problem solving and project management methodologies sum up the purpose and the goal in the project charter. The purpose might be called the business case or problem statement. The goal might be called the project objective


After setting the goal for the team, it is now time to figure out how to get from here to there. There are dozens of ways of doing this. From very loose mind mapping and idea generating tools, to well structured problem-solving methodologies. No matter how you go about it, generate as many ideas as possible. This is not the time to evaluate or pre-judge, just get every idea on paper. The evaluating will come later.

“The best way to get a good idea is to get lots of ideas” – Linus Pauling


Now that we have all of these ideas, we need to organize them. Separate the good ideas from the bad (based on whether or not they will get us closer to out goal). This is where data collection and statistical analysis come into the picture if this is a six-sigma project. Figure out what needs to be done first. Organize by department. The goal is to decide which of the ideas to actually do and organize them in a way that makes sense to get them done.

Next actions

The last stage is to answer the question “what can we do now to get the project moving.” Many projects get organized well only to sit in limbo because nobody takes any action. Defining what can be done right now, who does it, and when it will be done by goes a long way toward actually getting you action items completed. When it is time to move on these things do not leave any doubt as to who owns each piece and what the expectations are.

Traditional project management training focuses on organizing the action items. Complex projects may need complex project management tools. Most projects do not. Even when they do it is still necessary to define the purpose, principles, and goal and brainstorm all possible ideas. MS project does not do that.

Many projects get to this point and stall because the team members see little association between the action items and the purpose of them project. This is almost always because the purpose and/or the goal were not well defined. Following these steps well from the beginning is key to getting things done at the end.

Applying these five steps to every project you have will result in greater clarity of purpose and better results. If you wonder whether or not to use the Natural Planning Model with a particular project, ask yourself this: “will it take two or more steps to complete?” If the answer is yes, then you should take some time to think go through all five steps.

Vote Early Vote Often

What better innaugural post for Improvement in Practice than a supercute reminder to vote?  Now go Vote!

About Me

I help people make their processes better. In manufacturing process improvement is old hat, In health care its not. This is due to the fact that most health care is not delivered through well defined processes. It is usually delivered by nurses and physicians doing what they must to get the job done. But the industry is starting to realize that having standard processes for health care delivery leads to improved patient care and improved employee satisfaction. This is where I come in.

As a continuous improvement evangelist I preach the gospel to all levels of the organization.

As an educator I train nurses and managers to use lean and six sigma to improve their processes, and help them develop process thinking.

As a leader I mentor trainees through their improvement projects, and help floundering project teams get back on track.

Education and leadership require curiosity beyond the technical aspects of the my field. In order to become a better teacher and leader I study presentation design, communication, and management as well as graphic design, typography, story telling, entrepreneurship, time-management, and marketing. I incorporate all of these into my training to improve the skills of my students, I incorporate it into my work to improve the hospital, and I incorporate it into my life to improve myself.