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Guest Post: Libby Zion

Today’s guest post is by James Lawther.  James gets upset by operations that don’t work and apoplectic about poor customer service.  Visit his web site “The Squawk Point” to find out more about service improvement.

On 4th March 1984 Libby Zion (an 18 year old known to be using anti-depressants) was admitted into a hospital in New York with a high fever.

That night, Luise Weinstein, a medical intern 8 months out of medical school, was on call. He discussed her case over the phone with a senior doctor, and then prescribed two drugs, a pain killer and a sedative.

The next morning Libby was dead.

The subsequent inquest found that a reaction between the two medicines and her anti-depressants was the cause of Libby’s death.

Why was she prescribed those drugs by the medic? Didn’t he know what would happen?

It transpires that like all medical interns he had been working a long shift. He was over worked and sleep deprived and made the wrong decision.

How long do you work?

How long can you expect somebody to work? In the UK and US there are laws that prevent lorry drivers from working more than 11 hours without a 10 hour break.

11 hours is also the time it takes to fly from London to Los Angeles. Would you get on a plane flying the return leg if you knew that the pilot had just flown the outbound trip?

That shift, Luise Weinstein had worked 36 hours.

A change in the law

Libby Zion’s father happened to be a journalist and he did what all good Journalists do. He created a story, a mass of publicity. In response the governor of New York set up a committee to look into the case and in 1989 the law changed in New York State forbidding Medical residents to work:

  • More than 24 consecutive hours
  • More than an 80 hour working week

Remember that plane trip?

Ten years later the New York State Department of Health conducted surprise inspections at a number of hospitals. They found that over half of surgical residents work in excess of 95 hours a week .

Why do the hospitals flout the law? Simply because it would cost them a lot of money to obey it.

The problem with focusing on cost

Lean thinkers talk about purpose, they say you should always focus on purpose first and foremost. If you do that efficiencies and cost savings will come as a by-product.

Hippocrates is often quoted as saying “first do no harm”.

Perhaps that would be a good purpose for the hospitals to focus on.

James writes about process improvement at www.squawkpoint.com

Learning and Leaving

The other day I was listening to a speaker discuss manufacturing jobs in the the U.S.  The speaker hit on a reason why there are fewer and fewer people with the job skills needed for the manufacturing shop floor.  The reason was employer paid training is being cut.

Manufacturing has a lot of technical based jobs.  People need to run equipment and know about machinery in most industries today.   In order to get training and stay up-to-date on the latest technical training, the employers pay for people to go to training.

In the past, this wasn’t an issue.  Employers were happy to pay for the training.  They expected people to be with the company for a very long time, so it was an investment in the employee.  Today, the expectation that a person will stick with a company for a long time isn’t accurate.  I think of myself.  The automotive company I worked for paid for me to get a lot of training on problem solving skills and techniques and some in lean, but as soon as my growth potential topped out I left the company.  That was within a year of completing my training.  The plant manager was upset but he was the one that told me my growth opportunities were topped out.  What did he expect?  I was 29 at the time.

What makes manufacturing unique is the fact that employers do pay for the training.  In healthcare, legal, or IT the individual pays for their training on their own time.  So the individual has more responsibility to not waste that training by using it wherever it fits best.

I know technology is changing fast and keeping up with it can be hard.  This doesn’t mean it can’t be done.  And the ones that do keep up with be rewarded with better paying jobs and more opportunities.

Would manufacturing skills be more plentiful today if the individuals had to keep up with it on their one?  I don’t know.  I’m not saying that is the right answer, but it is something to think about.

What are you thoughts?  How can manufacturing skills of individuals keep up with changing technology and employer and employees feel good about the training that was done without the fear of an employee leaving once they have developed their skills?

Standardization Enhances Innovation

Fast Company Design has a great article about the importance of standardization in leading to innovation.  The article mentions 5 ways that standardization can help.

One way is the standardization of processes.  Having everyone doing the same thing the same way.  Baptist Healthcare System in San Antonio, TX had physician led improvement councils around their hip and knee replacement procedures.

Where previously each one of the system’s 40 orthopedic surgeons had their own particular way of doing things, the Council developed a single model of care for all five of the hospitals in the system. New standards included everything from pre-operative tests, radiology, operating room instrumentation, supplies and other equipment, to post-surgery medication, food and nutrition, physical therapy and physician consults. Within a few months the results were dramatic; BHS cut its readmission rate in half, and infection rates dropped.

Standardizing the process led BHS to new and innovative care reaching quality levels not before acheived.

The article also talks about how Black and Decker’s tool division made a turn around by standardizing the parts used to make their various tools.

By 1970, Black & Decker’s consumer power tool portfolio was a hotchpotch of 122 different models, which between them had 30 different motors, 60 different motor housings and 104 different armatures. Each of these variants required separate tooling.

The results were amazing.

A concerted effort by the business over the next three years saw a massive reduction in variants, leading to just one motor, a huge reduction in space, facilities, resources and time needed to manage parts and equipment, faster production cycles and retooling times. Motor production labor costs were cut by 85%, armature costs by 80%, and failure rates fell from 6-10% to 1%. New products were introduced to the market in weeks rather than months and prices to the consumer were slashed by as much as 30% while maintaining 50% margins.

Not only the reduction in cost and space, but the standardization led to improved time to get new innovative products to market.  This breaks the dam open on innovation because ideas aren’t sitting around like they might have before because it took so long to get to market and out of the innovation pipeline.

Innovation can happen when parts become standardized like on a rifle.  The Picatinny Rail was part of the rifle that became a hot spot for rifle innovation.

The Picatinny (Pic) Rail allows soldiers to attach and detach weapon accessories like optics, lasers, bipods, and other hardware to the M-16A1 assault rifle. Since its introduction in 1995, it has helped to more than double the longevity and functionality of millions of the Armed Forces’ standard issue weapons. The common interface provided by the rail has reduced the costs and simplified the logistics of equipping and supporting 1.5 million soldiers and 1.5 million reservists, and increased the rate of innovation and growth in the small arms and accessory industries. For example, Aimpoint Inc., a manufacturer and supplier of high performance optics to the U.S. Army and Air Force, has seen a fifteen-fold increase in revenues since 1997, since the rail makes it possible for more soldiers to be deployed with, use and service advanced optics and other accessories in the field.

Without standardization these innovations may not have happened or may have not reached as many people as they have.

Standardization is not a bad thing, but like anything else when it is not used properly or with the right intent it can cause people to fear it.  Standardization is not put into place to turn people into robots.  They are there so we don’t have to waste our energy thinking or reacting to the basics.  We can spend our energy thinking about new and better processes, products and ideas to improve our company or our life.

One Reason Our Healthcare Costs Are Increasing

One industry that lean is starting to penetrate is the health care industry.  After experiencing a story of a relative last week, it made me sick to hear how insurance companies don’t help the situation of increasing cost.

The person is on a medication that is extremely hard to get approved for by the insurance companies.  Approval from the insurance companies is a must because most people can’t afford the medication without it.

A few years back the person was approved for the medication after a 4 month process.  When they started the medication the expectation was they would be on it for at least 15 years or so.  It basically is part of their life at that point.

Fast forward to present day.  The person has responded incredibly well to the medication.  In fact, they responded so well, there is thought that the person may not have to take it anymore, but the doctors can’t take the patient off of the medication because if they do and the patient does need the medication the doctors will not be able to get the patient approved a second time.  At least it has never happened yet.

Because of the pain and inflexibility of the insurance companies, the patient and the doctors are in a tight spot.  Do they keep the patient on the medication even though they may not need it or do they go a few months without the medication but still filling the prescriptions and holding on to the medication so the patient doesn’t loss eligibility?

Either way, it is money out of the patient’s pocket that could be saved.  Plus, additional cost to the insurance company of a VERY expensive medication.  In either of these cases, more costs will be added causing insurance premiums, medications, the whole health care system to increase.

This just isn’t right.  The system has made it nearly impossible to do the right thing and extremely easy to do the wrong thing.  As a country, we have a long way to go to fix some deep rooted issues with our health care system, which I believe is still one of the best in the world.

An Acceptable Range Does Not Equal A Baseline

When solving problems the first thing a person needs to understand is where they are starting from.  To do this they have to create a baseline.  A set of data for the current process and situation.  Without a baseline, a person will never know if they improved the process or made it worse.

When I say a baseline, I mean an understanding of data of the current situation.  I do not mean a range of what is considered normal.  A range does nothing but tell a person where they might expect the data to fall when creating a baseline under normal conditions.  A range can hide problems under the guise of being acceptable.  What if something is at a high end of an range and drops to a low end of the range?  This can still create problems.

For example, two parts have to fit together.  If both parts are at the high end of the range of their part variation they snap in perfectly.  Then one part drops to the low end of the range, while the other is at the high end of the range.  Now the parts don’t fit together and people are confused because both parts are within their acceptable range.  The issue is there never was a baseline created to understand both parts were at the high end and this condition created a good result.

The area I have the most frustration with this is in health care.  A person can go to the doctor wondering if they have hearing loss or damage.  The doctor tests you and says you are fine there is no damage or loss.  How do they know?  They never had a baseline from before to understand the person’s hearing is any different.  The doctors just tells the person they are fine because they are in the “normal” range.

The assumption is the range is built on lots of data over time and covers the 80-85% of the normal distribution of data, again assuming the data fits a normal distribution curve.  What if the person is someone at one of the extremes of the curve?  Doesn’t this change things?

I understand doctors need some tools to help them out.  That is what a range is a tool.  If a patient says something is not normal for them, the doctor can’t say they are normal because their test falls in a certain range.

Ranges are nice and can be helpful, but they are not a substitute for a baseline.  The baseline gives a more detailed picture.  Baselines help to problem solve and improve. So before judging if there is a problem, a person should ask, “Where did I start from?” or “What is my baseline?”

Lack of Handoff Integrity and Empowerment

A couple of weeks ago, my wife was dealing with a mess between our health insurance provider and our flex plan provider.  This is our first year of using a Flex Plan that pulls money directly from my paycheck (before taxes) into an account to be used on medical visits, prescriptions, etc…  Everyone mentioned how wonderful this is.  It is kind of like level loading the payment for doctor visits and prescriptions we would need during the year.  This is suppose to be a seamless process for us.  The insurance company is suppose to automatically send processed claims through to the flex account provider.  At that time, the flex account provider is suppose directly deposit the money into our checking account for us to pay the bills.

If you noticed, I used the word ‘suppose’ a lot above.  There is a good reason for that.  The process is not working like that at all.

After a few months, my wife had noticed that we hadn’t received our reimbursement from our flex plan for several doctor visits.  She keeps meticulous records, so she knew exactly what the amounts were, what doctor, and for what.  My wife called our flex plan provider.  It didn’t take long before the flex plan provider pointed the finger at the insurance provider.  I think it was put this way, “We can’t reimburse you if we haven’t received any notice so it is their fault.”

That led to a call to our insurance provider.  My wife spent almost an hour on the phone with them.  The insurance provider said they sent it.  Their system showed it was sent on a specific date.  My wife asked how often do they send claims to the flex plan provider and do they get a confirmation of receipt back?  It was explained to her that all claims are sent out electronically to the flex plan provider on Wednesday (weekly batch and queue method) and they do not get any confirmation back of what was received.  The woman that my wife spoke with was very nice.  She very politically said they know there is a problem and there was nothing she could do about it.  Basically, we have to now re-submit for reimbursement the manual way.  Send a fax to the flex plan provider with the Explanation of Benefits.

How much of this sounds like the place you work at?  A very common failure point is at the handoff point.  Passing information and work from one person to another.  This is exactly where the failure is happening in this case.  Could the handoff errors be caused by the batch and queue method of sending claims all over at the same time on Wednesday?  Could this overload the computer system and cause claims to disappear?

Does the insurance and flex plan providers really have the consumer in mind?  If they did, I would think they would be more willing to work together to solve the problem and help consumers.  Instead, they point the finger at each other and the problem continues, causing headaches for the consumer.

Finally, the woman working for the insurance provider is the closest to the problem because she hears from the consumers directly.  She told my wife they know it is a problem but they aren’t going to do anything about it.  The insurance provider does not even have a stop gap or rework loop.  They put it all on the consumer to manually refile directly with the flex plan provider.  Would you agree that she is not empowered to make change or even suggestions?  If the woman was empowered to make change she would have mentioned what action was being taken.  Instead, she made it sound like she can’t take action because the company won’t let her.

Wouldn’t the insurance provider’s cost be less if this problem was fixed?  Wouldn’t they need less call center people answering phones?  Maybe they could be working on other improvements to the system?  Maybe the benefit pre-approval area is swamped and could use the resources to help out?

The biggest thing that irritated me wasn’t the existence of a problem, but rather they knew it was a problem and sounded helpless to do anything about it.  That sounded like the sentiments I hear every time I go to a new area to conduct a kaizen event and try to engage a new set of employees.  They can say the industries are different but the problems look the same to me.

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Collaboration Paradigm

I am a big fan of Fox’s TV show HOUSE.  As I was watching, I couldn’t help but think the medical team was participating in a kaizen event.  The concept that struck me was watching the doctors collaborate in the diagnosis of a patient and how this is just like breaking down the functional silos in a business environment.

Reaching across functional silos and collaborating has become more prevalent in today’s manufacturing world.  Manufacturing must collaborate with procurement and transportation in order to create a better total cost system that delivers value to the customer.  It has not been easy and it has not been the norm in the past, but there is still an abundance of examples to point to showing the benefits.

Why don’t more doctors work in collaborative teams?  The team on House all have different backgrounds and specialties.  This gives them all different perspectives on the situation (like transportation, procurement, and manufacturing) with one common goal……..save the patient (deliver a quality product to the customer when they want it).  At some point, if you put different doctors in one room and have them discuss the issue with you, it would seem that you would get to a true root cause quicker and I would suspect the cost would be lower instead of doctors working in their specialty silos.

Have you ever gone to the doctor when something is wrong and they sent you to a different doctor that is a specialist?  Then Specialist A runs all his test and claims nothing is wrong, so he sends you to Specialist B.  Specialist B runs his test and says your are fine and this goes on for what seems like an eternity.  Finally some doctor tries something and it maybe it works and maybe it doesn’t.  Is it just helping the symptom or is it the root cause?

Having doctors work in collaborative teams would seem to have the patients best interest in mind and create a stronger health care system.  I know we wouldn’t want to set up the  health care system to do this for every problem.  We could develop standardized work that would state when to call together a team of doctors and when to have doctors work individually.

We have torn down a part of the collaboration wall in manufacturing.  Can we start to tear down that wall with doctors?

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