GA 114 | How to Apply Lean to Healthcare with Mark Graban

You're listening to episode 114 with Mark Graben. Welcome to the Gemba Academy Podcast, the show that's focused on helping individuals and companies achieve breakthrough results using the same continuous improvement principles leveraged by companies such as Toyota Del Monte and the U.S. department of Defense. And now, here's your host, Ron Pereira. Hey there. This is Ron Pereira with Gemba Academy, and I'd like to welcome you to another edition of the Gemba Academy podcast. As always, thanks. Thank you so much for taking time out of your day and your week to listen to the show and for watching our Lean and Six Sigma training videos over at Gembacademy.com we definitely appreciate each and every one of you. Now today, I'm excited to welcome my friend Mark Graben back to the show. Now, this is the fourth time that Mark's been on the show, and in this show, what we're gonna we spend a lot of time talking about Mark's new book. Well, it's actually not a new book per se, but it's the the third revision to his Lean Hospitals book, which if you're in the healthcare space and you haven't read Lean Hospitals, you really are missing out. And so I would definitely encourage you to pick up the third revision to the book, which is now available. Mark mentioned it was, I think, shipped last night or released to the to the world last night as I'm recording this. So by the time you're hearing this, it's going to be definitely be available. So if you want to download a free chapter to the book and learn how you can get the book, all you have to do is go to lean hospital book.com and now there's no S in hospital. So it's not Lean hospitals book, it's leanhospitalbook.com I made that mistake myself putting an S in there. So during this show, Mark and I spend a little bit of time talking about some of the misconceptions about Lean. And one in particular is Mark's extremely passionate about, and his topic is, just to give a little hint, is that Lean is far more than just a set of tools to improve productivity. So we spent some time talking about that. We also talk about the role of systems and why errors and defects aren't caused by bad people. Instead, they're almost always caused by bad systems. And then we spend some other time talking about things like the VA issues that we've had heard about in the news with waiting times and so forth. And we talk about what needs to be done to improve situations like that. So the show notes for this particular episode can be found over@gembapodcast.com just look for episode 114 or 114. So again, that's gemba podcast.com and look for episode 114. Okay, enough for me. Let's get to the show. All right, Mark, well, welcome back to the show. How's it going?

It's going great. Thanks, Ron. Thanks for having me on.

Yeah. So I was telling you this is the fourth time that you've been on the show. So you were. And I don't know if you remember way, way, way back in like 1998 or. No, episode seven was your first time on. You talked about just lean healthcare in general. Episode 46, we explored your recent trip to Japan talking about lean in Japan. And then 71, episode 71, you talked about Practicing lean. So here we are now. And I don't know where we're at 100 and something or other. So. Yeah. Well, thanks for coming back on.

Well, sure. Thanks for having me. Hopefully I'll have something different and interesting to say.

I know. Well, it gets more challenging. We're not going to do the reflection section, the end. But I can't let you off the hook with the quote. We got to do a quote, man. So let's start there. Do you have one?

I do. And I think this is different than what I've used before. I always like to go back to the work of Masaki Amai on Kaizen and continuous improvement. And the one quote I think is particularly meaningful in healthcare. Mr. Amai said, progress is impossible without the ability to admit mistakes.

What's that mean to you?

Well, I mean, I think it's something we can all take to heart. I mean, I think last time we talked about the book Practicing Lean, and I think that's one of the themes there. I've made mistakes along the way. Mistakes are going to happen in people's lean journeys or organizations. Lean journeys. But I think it's also meaningful. There's a related Toyota ism that says no problems is a problem. And one of. I think that just the challenges in healthcare with the typical healthcare culture is getting people to admit that there are problems. And that can be difficult for executives to admit that there are problems. It can be difficult for staff to admit that there are problems that they have been involved in. Mistakes that are quite often systemic mistakes. People don't want to speak up because they're afraid they'll be blamed. And I think all improvement starts with the realization that we're not perfect, things can be better. And I think Mr. Amai has always said and written a lot of really inspirational things to that effect.

Yeah. Now, just in case somebody hasn't listened to the previous episodes, I guess we should maybe start at the start, if you will, and tell us a little bit about your background and kind of how you came into working with Lean Healthcare.

Yeah, well, I got into Lean Healthcare as really a sole focus of mine back in 2005. Before that, I mean, like a lot of people, I'm involved in Lean. I'm an industrial engineer. I started my career, I had about 10 years focused on manufacturing. So, you know, degrees in engineering and business. And I thought my career was going to go in a very different direction. But I think what I was fortunate to have the opportunity to get into Healthcare in 2005. I learned that these methods apply because it's about people. I think people in healthcare aren't that different than people in manufacturing and the work that they do in healthcare is so important. I think that's all the more reason why Lean is necessary in healthcare, because the stakes are so high in so many different ways.

Yeah. A defect in a hospital is a little different than a defect on an assembly line, right?

Yeah. And health and manufacturing, there's sometimes this Lean dogma where people might repeat this could be a quote from Ono or Shingo. It's probably Ono. Overproduction is the most dangerous form of waste. Well, in health care we tend not to have overproduction because it's all a build to order environment. Build to order manufacturing might be. We don't tend to over produce in health care. But I think the waste of defects is quite literally. When we talk about the deadly wastes, sometimes that's overstating it. But in healthcare it's really true because people get harmed and quite often die as the result of preventable errors, process problems, systemic errors, as opposed to being a problem with individuals or bad people or poor training.

What about over processing?

Well, over processing can be a real problem. Doing things that aren't necessarily the most helpful to the patient. I think of examples of people in healthcare trying to reduce over processing. There are a lot of good reasons to try to avoid CT scans unless they are really truly necessary. A CT scan is really helpful for diagnosis, but it also exposes the body to radiation and excessive CT scans can cause cancer. So there are times where people are, let's say someone comes into the hospital with back pain. Well, instead of just putting them in the CT scanner because that's force of habit. There are hospitals that have tried to do more effective, less expensive things such as first starting with physical therapy and doing things to treat the problem instead of overdoing it with certain diagnostic work or just ordering lots and lots of blood tests that can even if it doesn't increase risk the way CT scans might. Excessive diagnostic testing just increased costs maybe without having any benefit. So yeah, over processing, you know, doing things that aren't necessarily helpful, maybe because they're force of habit, that can be a problem in healthcare. Yeah.

So I understand that we're about to have access to the third revision of Lean Hospitals, which is pretty exciting. So what's new in the book and when's it going to be available?

Well, you know, we're recording as we're recording this books supposedly hit the publisher's warehouse yesterday.

Oh wow.

The supply chain is marching along and those books I believe are being shipped out to people who pre ordered them through the publisher. It should be available on Amazon. It'll take another week or so usually for it to kind of lurch along into the Amazon supply chain for people who ordered that way. But it's funny, in publishing, if you go through traditional publisher, traditional printed books, there really is no concept of kaizen or continuous improvement. I had the opportunity, so you take the opportunity to do a big batch of improvement. It's been five years since the second edition and there's things that have changed in the healthcare landscape. So the book we're trying to reflect that there's a focus not just on the boundaries of the hospital, but the boundaries of an integrated health system. And trying to deliver the right care in the right place at the right time, even if it's not within traditional inpatient hospital settings. I try to take advantage of the opportunity to really comb through the book and update it from COVID to cover, trying to clarify explanations of things, adding new quotes from hospital leaders, different examples and stories, in some cases updated data compared to five years ago. So there's a lot of updates. Hopefully more book means more value that I wasn't just over processing. But there's additional content. There's a brand new chapter on Lean design kind of writing about the trend of hospitals renovating or building new facilities using a quote unquote lean approach of engaging the staff, working in a closer partnership with architects and the construction companies.

Is it kind of like a 3P thing or.

Yeah, it's sort of an expansion. Yeah, it builds upon 3pm methodologies. What others? It's a topic. There's a Great book called Lean Led Hospital Design, which is really a fuller discussion of Lean design. But there's examples in the book from what are called critical access hospitals. So I had a chance to Visit one of ThetaCare's smaller 25 bed hospitals to see how they're applying Lean. That, yeah, Lean applies even in a smaller hospital hospital setting. There are examples and stories from the Baylor, Scott and White health system here in Texas. So there's, I think, hopefully more helpful value to the reader. And then I also put in a section about trying to kind of column A, column B. What are some misconceptions about what people think Lean is sometimes or what Lean is not, versus a column of what's arguably closer to Lean? Trying to dispel misconceptions that are floating around out there or have gotten maybe created problems in people's attempts to understand and practice Lean.

Well, it's funny you mentioned that because I saw that and I was towards the end of chapter two, and I want to spend some time talking about that. I mean, there's several of them, so we don't have time to go through all of them. But there's one in particular that I know you're especially passionate about and I am as well. But it's actually the first one that the misunderstanding is that Lean is only for speed or efficiency or cost. And if you want quality, then you need Six Sigma, right? Or you need some other methodology. So what's the truth there?

Well, I mean, I think the truth. And if you go back to Toyota's own explanation of the Toyota production system, they talk about the dual pillars of just in time or focusing on flow and the idea of jidoka or building in quality at the source. So whether it's illustrated as a Toyota house or just as those two pillars. And even if you look at the history of Toyota, when you look at methods like mistake proofing, there are methods and a culture of quality that is part of the Lean and Toyota approach. When people say, and unfortunately I hear this a lot, I don't think they would have gotten the idea from the first two editions of my book. People will really solely focus on cost cutting or they'll focus on efficiency, which sometimes I think gets misunderstood as keeping everybody busy all the time. Where in the lean approach, we're focused on flow, we're focused on preventing delays, we're trying to improve flow through the entire value stream. And sometimes that means you have some slack or buffer capacity in the system. And it's probably first on the list because I think that's the most widespread misconception about Lean. And I think part of the challenge, I think either people are taught the wrong things because there are people who run around saying Lean is for speed and Six Sigma is the only thing that improves quality, or I think there's old habits in healthcare where the traditional approach to healthcare management is very cost focused. So I think executives who view the world through a cost cutting lens might learn about Lean and say, oh, here are new methods for cost cutting, even if that's not really what's being taught.

Right. Another one that jumped out to me was, and I've seen this myself, is that the misunderstanding is that Lean's just a bunch of events or projects. What do you think about that one?

Yeah. Well, and more hospitals and health systems are coming around on this to realize that you can't just teach a bunch of tools to frontline staff. You can't just do a bunch of week long projects. You need to also focus on ongoing, continuous improvement. That's why Joe Schwartz and I wrote our Healthcare Kaizen book. You also need to focus on the management system and the culture of the organization. And that starts with executives learning about Lean, trying to practice some different behaviors, trying to lead by example. Where I think there's a related misunderstanding where people say, well, okay, yeah, Lean is about fixing my employees and you just need to train them and they will become Lean. Instead of looking at the role that executives play in creating a culture, the role of executives and setting atone for a culture of safety, a culture of quality, and then with that tends to come a culture of excellence which can include a culture of efficiency, a culture of patient flow, a culture of employee engagement. It all goes hand in hand. It's a system. And I think there's a related misunderstanding where people think, well, I can just kind of cherry pick a tool here and there instead of trying to understand and embrace Lean as a more holistic system.

Yeah. Now, so speaking of systems, I want to kind of dig in a little bit about, you know, errors and defects that we talked about. And many times the headlines say something to the effect of, you know, bad doctor caused the someone to die or something horrible like that. Right. When clearly I don't think that's accurate. So let's, let's bring it back to what are the role of systems?

Well, there are, I think we build on the old lessons of W. Edwards Deming, who would always say most vast majority of defects or problems are caused by the system, not by bad individuals. He would throw around a number something like 93%. And that's an unknowable number, but it's something on that scale people in health care, and this includes people in the patient safety movement. And medical experts have been saying for a long time the problems are not caused by quote, unquote, bad apples, but by badly designed systems and disconnects and miscommunications and much more systemic factors. And I think it really gets illustrated when you see instances where many people are making the same mistake that screams systemic problems. So you have some circumstances where the headline might say, surgeon operates on wrong side of patient. Well, even that surgeon is part of a system. They're part of a team. They're part of an organization in an environment. And sure, you'd say the surgeon has a certain level of professional autonomy or professional responsibility, but they're human. Instead of just throwing up our hands and saying, what can we do about human error? We try to put in place better systems and processes that help protect against human error. Or you have situations where multiple nurses are giving the wrong medication to a patient. Well, again, the fact that multiple nurses are doing this screams systemic problem. And you see the headlines. Society, I think, often asks first, who screwed up? Organizations tend to blame and punish individuals when there's medical errors. Or even if you look at the VA scandal where waiting times were excessively long, people were managers in multiple VA offices around the country were being given targets. And setting targets doesn't necessarily improve a system. The office in the Inspector General said these were unrealistic targets, but yet people were being offered rewards or threatened with punishment for not hitting those targets. So you know what? People start fudging the numbers. They start gaming the system. And the fact that this was happening at dozens of locations around the country says, well, they didn't just hire a bunch of unethical managers. There's systemic problems here. And the VA needs to focus more on actually increasing capacity, actually improving throughput so they can get waiting times down instead of just trying to make the numbers look better. And it seems like they're still struggling with that. Unfortunately. If it were only so easy to punish and blame, get rid of the bad individuals or bring it back to quality. I often say somewhat tongue in cheek, like, well, it's just, why don't you identify all the people who are going to make errors and then fire them in advance? Yeah, and that's not a really realistic approach to quality either.

You know, I guess it's been, well, almost a month now. Time flies. We spent a week or so, my gaming Academy colleagues and I at CMS in Baltimore, the center for Medicare and Medicaid, and just really exploring their journey. And I gotta say I was, and I know I've shared this with you off microphone, that I was extremely impressed with that group of people and just their passion and they didn't pretend to have it all figured out. And I know it's easy to pick at people, but I tell you, I left with a lot of hope for our country, really, that there was people like that who are really genuinely trying. And it's not what we would call lame lean or fake lean or whatever. I mean, they're really getting after it and they're really trying. So I'm curious, like, what is your overall perception of just lean healthcare here in 2016?

Well, I'll comment first on CMS, the Center for Medicare and Medicaid Services in the federal government. I've never had a chance to visit there, but I have met some of their leaders. When Dr. Don Berwick, who very famously founded the Institute for Healthcare Improvement when he was the head administrator for cms, he continued to be an advocate for lean in healthcare and for the application of lean practices within CMS operations. And Dr. Patrick Conway, who's deputy administrator, is going to be speaking again this year at the Lean Healthcare Transformation Summit event later here in June. They're not just advocating for Lean, but it seems like they're really trying to practice what they preach in a lot of different ways. I think that sets a good example. That is, I think, a reason to be encouraged. You know, if you're asking about the broader. You were also asking about the kind of. The broader landscape of lean in healthcare.

Yeah, yeah. Like, I mean, you're obviously deeply involved in it. I mean, is it, is it going well, do you think? I mean, obviously it could be going better. Anything could be better. But what's your overall feel?

It's, it's, it's a mixed bag. It's almost, I would almost say, you know, if you look at kind of success with Lean, however you would gauge that or quantify that. I don't think it's necessarily a bell curve. I think there's more of a bimodal distribution out there of organizations. And I'm not even a Six Sigma person, but I know what a bimodal distribution is. But.

You are a six. No, no, no, no. You're not only a Six Sigma person. You are a six Sigma plus person, aren't you?

Yeah. When I worked at Honeywell, I was certified as a Six Sigma plus Lean Expert. Yes, yes, it was on the lean side of the house.

I even have a picture to prove it.

I have a plaque hanging in my office. But it's not a belt, it's a plaque. Okay, but anyway, back. But this bimodal distribution. You have healthcare organizations that are making great progress because they're embracing Lean as a management system. They're trying to change the culture. Their executives are participating, not just sponsoring Lean or not just endorsing Lean. And then you still get a lot of organizations that are struggling for different reasons. They've put people in the unenviable position of being hired in as the one Lean person and being expected to change the organization from this just middle layer without the right executive support. If people are just doing projects, if they're just using tools, if they've been busy certifying Lean Sigma belts, but not letting people put those methods into practice. There are people who. Organizations that are struggling. Some of these organizations have disbanded their formal Lean initiative. And that's really troubling because, well, what else are you doing to improve quality? A lot of these organizations fall back on just their kind of traditional cost cutting, financial management type approaches. And it's disheartening to see where people would draw this conclusion. Oh, we tried Lean, but it didn't work. Here there's a much deeper discussion to be had about that. What did they really try to do and what did they mean by it didn't work? I mean, that sort of passive language there, Lean didn't work. As opposed to saying, we weren't able to make an impact doing what we were doing. It's easy to blame the methodology kind of the same way people might have said, well, we tried Six Sigma and that didn't really work. And we tried TQM and that didn't really work either. At some point you got to look and say, well, why do none of these methods work? What's the common theme?

But they're different, Mark. Of course they're different. Right.

Well, I was reading the other day, people say, okay, man, get a life. You need to find some more fun summer reading. I was reading a book published in 1994 called why TQM fails. And I tell you, in some ways it's history repeating itself. Where 22 years later, a lot of the stuff in that book, you could replace the letters TQM with the word Lean. And they're very familiar stories. So we're at this point, I think after about 12, 15 years of people in healthcare practicing Lean Lean, it's proven that it works. At this point, but sort of like what we see back in manufacturing. It doesn't mean that it's guaranteed the work or that it's easy or that every organization and its leaders can really make the type of changes required to become a lean organization. Health care, I think, is starting to get to that point where the thetacares and the Virginia Masons and others in that category, they wouldn't stop doing lean because they're a lot more successful in basically every dimension. They're going to keep going. Some people might stop doing lean, sort of like in manufacturing. Some people say, well, we tried just in time, inventory, and that didn't work, so we stopped doing lean. And then maybe five years later they learn, oh, wait a minute, there's organizations that were going about this differently. We're more successful. Let's try again, but do it better. I hope those organizations in healthcare that have stumbled or given up on this get a second, second attempt to try to do it better.

You know, so along those lines, let's assume that there's a hospital administrator listening right now, and maybe they're just getting started with their Lean journey. What advice do you have for that person?

I'd say make sure the learning starts with yourself. You know, don't just sponsor Lean. Get involved. Learn, read, take training classes. Don't. Don't ask your VPs or directors to do anything you wouldn't do in terms of trying to adopt new behaviors, learning new ways of looking at work. And I would also recommend to get involved. I think there's the one common and classic piece of advice that would say get out of the office and go participate in some rapid improvement events or Kaizen events. I think that's great advice. I would also suggest that they need to have a more active role in applying Lean principles or Kaizen and continuous improvement to their own work, to their own office, to their board meetings, to the processes that they're a part of. Improve their own work so they can learn by doing. And again, I think so they can set an example for the organization. Lean needs to be a participatory sport, not a spectator sport.

Yes, very good. All right, Mark. Well, as always, it was awesome talking with you, and I'm excited to get my own copy of Lean Hospitals. I think I've got all the other revisions on my bookshelf over here, so I'll look forward to finally getting my third revision.

Thank you. It would be great if we could publish it with the Microsoft Word track changes feature so people could see what was different.

Did you have any typos in revision two that you found later?

Oh, gosh. There was a. I think it was just in the first edition. There was a typo, a spelling error on page one of the first edition. Wow. Now again, when you talk about systemic problems or good people in a bad system, or you say, well, Mark, why didn't you catch it? Well, it's really hard to proofread your own work. And then there's the systemic factor of publishing software, at least as what I've been told, not having spellcheck built in. Because why? Because they have professional copy editors. Well, professional copy editors are human. They miss things.

What was it? What was the word?

Oh, gosh.

Do you remember like you're and supposed to be.

No, it wasn't wrong word. It wasn't a wrong word typo. It was just. It was a spelling error. And one of Jeffrey Leiker's books on Toyota had a typo on the first page as well. That makes it hard to do continuous improvement if there are errors. And if anyone who reads the book finds a typo, please email me. Because they can make small changes when they go back and do additional printings when they print another batch. But that's not really continuous improvement either. It's killing me what the word was. But I believe it was just in the first. First edition.

Yeah. All right, very good.

There's a defect in every book that's ever been printed, I think.

Yeah. I was actually reading my kids a book last night and it was like a missing word. I'm like, oh my gosh. It's like this famous kids book.

And what I fear the most is a missing word. Like, I've done this in blog posts where somebody will post a comment and say, I think the word not is missing from that sentence because that could change the meaning of what you say dramatically. So if I was trying to write, you know, something like it's important to not blame employees for system and that word not is missing, I would want to recall those books. Oh, I remember now. And I pulled this up. The second edition was spelled properly, the word prestigious. Oh, so there's a line. It just first paragraph even. It said, hospitals do many wonderful things. But a senior leader at a prestigious university hospital summarized their internal challenges by lamenting that we have world class doctors, world class treatment, and completely broken processes. Well, there was an I missing the second I and the word prestigious was missing.

That is a hard word, though, in fairness. Yes.

I should write using simpler language perhaps. Yeah.

Awesome. He's awesome. Or something.

It's this awesome hospital. Yeah, they're all awesome. That's part of the challenge of. Again, back to admitting that we have gaps and problems and opportunities for improvement. But we'll keep at it.

All right, well, how can people connect with you, Mark?

Well, people can number of ways. Markgrabin.com if they want to, email me markgrabin.com whether they find typos or they have other reasons to reach out. I'm on Twitter Ark Graven. The lean hospital's book website islean hospitals book.com, so I would invite people to go there. You can download the first chapter for free. You can look for typos or hopefully get value.

I get you nervous now, don't I? Yeah. I'm gonna go back and power read it real fast.

Well, what's printed is printed.

Yeah, exactly.

But I hope people enjoy the book and that it's helpful and that it adds, that they find value in it.

Yeah, I'm sure they will. All right, my friend. Well, let's go have a coffee soon, all right.

Yeah, look forward to that, Ron.

All right, take care.

All right, you too.

Thanks for listening to the Gemba Academy podcast. Now it's time to take a free, no strings attached, fully functional test drive of Gemba Academy's School of Lean and Six Sigma. Over@gembaacademy.com Gain immediate access to more than 500 Lean and Six Sigma training videos free of charge at gembaacademy.com. Sam.