NC State of Business

In this blog, Marianne Jackson, a physician that has recently emerged herself into the Toyota Production System (TPS) or ‘lean’ philosophy for continuous improvement, explores a very important subject of engaging physicians into lean transformation. Specifically, she focuses her thoughts around the subject of standardization and its meaning to physicians. Not only this subject is relevant and important, but it challenges us to search for common ground to exchange and share knowledge with physicians in one industry in serious operational crisis – healthcare.

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Immersed as I am now in Lean literature and methodology, it is sometimes hard to recall my first reactions as a physician to the words Standardization and Compliance. I am reminded, however, of my negative reflexes when I see the responses of physicians who attend Lean educational sessions. Those who are following along contentedly through Value Stream Mapping and A3s suddenly throw up walls of defensiveness when they hear Standardization and Compliance.

The response of Quality Assurance staff and facilitators often is to become frustrated and critical of us physicians for being too conservative and wedded to our autonomy. They may proceed with improvement efforts without physician participation. I’d like to explore the physician context and in so doing, suggest means for introducing Standardization and Compliance in ways that physicians can accept because physician engagement is critical to the success of the majority of Lean Healthcare transformations.

Lean has only been aggressively adapted to the healthcare market for about a decade. We promoters understand it to be an integrated approach to improving processes and systems using the innovations of all of the workers who touch the process, top to bottom and bottom to top. Prior to Lean, quality initiatives came strictly from the top and often from outside the hospital walls. Regulatory agencies developed and imposed “standards” and only negative indicators of poor outcomes such as infection rates, low APGAR scores and returns to OR without the input of those who provided the care.

Enforcement of “standards” or compliance was given to the Quality Control Officer (intimidating language) whose job it was to comb through charts finding the omissions, failures and faults in order to display them for the Medical Staff for review and report to the Board. Such statistical methods applied to very small sample sizes and minimally meaningful indicators created anger and rejection of the process among medical staff. For example, a physician who had saved a life by diagnosing a post-operative bleed, who took the patient back to the OR was “dinged” and judged as culpable by the indicators. Many of these practices continue today. If an error is caught in a non-Lean regulatory environment, what are the incentives to identify and disclose it if you are going to be penalized?

Physicians work with many sharply competing incentives. Reduce costs, see more patients, make no errors, document to satisfy even the harshest malpractice lawyer, be compassionate, spend more time with all patients, screen for seatbelt or tobacco use, complete required authorizations for HMO’s, coordinate care with all providers, and be prepared to respond to any emergencies. We will resist Standards if they feel like another burdensome injunction to “remember to do” one more thing that is going to be measured.

On being introduced to Lean, physicians are likely to think of it is a means of meeting current reporting requirements while we know it can have much greater impact. I saw a recent example at Scotland Memorial Hospital in Laurinburg. Surgeons began using Lean to investigate why they had deficiencies in meeting SCIPS DVT prophylaxis indicators and why orders for heparin were omitted. When they went on a Gemba walk they discovered the many wastes in their whole pre-operative admission process. They discovered how Lean methodology could be used to simplify, not burden their practices. They discovered how standardization is about having resources, routines and safeguards in place that protect their practice of medicine. Simple examples of standards and routines include having laboratory results reported in an accurate and timely manner, for having outside records available prior to consults, for medication refills ready for signing after checking for allergies, for check lists for pre surgical authorizations and registrations. These examples and others can demonstrate how standardized work can avoid errors, redundancy, waiting, and rework while simplifying medical practice but not constraining it.

To engage physicians, emphasize that Lean Methodology is devoted to establishing processes throughout an organization that reliably support the physician’s efforts. Demonstrate how standardization links the physicians’ work to those who come before and after in the sequence. Compliance with standard work is a means of confidently controlling the mundane work and focusing the physician’s efforts on the exceptional and unusual cases. Physicians will see that the processes associated with standard work assist them to provide individualized care and responsiveness to unpredictable need.

For assurance, we should emphasize what Lean is not – it is not a means of controlling, policing or punishing. It is not a set of Do’s to remember. It is not a denial of individual patient or physician needs. It is not strictly an efficiency tool. And it is not the enemy of innovation. Atul Gawande, MD, in his outstanding book “Better” examines several stories of clinics and practitioners whose outstanding outcomes are many percentage points above the expected. He challenges us to look at that variability for the sources of true excellence. Compliance with standards by everyone in the workflow is not going to eliminate all variability or stifle innovation but it will provide an unprecedented level of support and stability to highly competent physicians who will be able to focus on excellence.

We physicians are not necessarily resistant or obstructionist when it comes to Lean or quality improvement efforts. The Lean transformations of Virginia Mason and Theda Care were led by physicians. Engaging physicians is critical for success in Lean Healthcare. As a facilitator, sensei or change agent, success will be when you find the ways to align the Lean principles with the physicians’ goals – they are not incompatible. The true transformation in the medical culture will be achieved when this alignment results in trust and cooperation among all providers of patients’ care.

Written by Marianne Jackson, MD, MPH
Forwarded by Lukasz Mazur, Ph.D.

Nine Eleven. 9/11. These two words, this date, will always remind me of the acts of heroes and the coming together of the American public. Today is the first officially-designated September 11 National Day of Service and Remembrance. It is marked by service projects in all 50 states as a way to honor the victims and heroes of 9/11 and to rekindle the spirit of unity and compassion that followed the attacks.

Today is a good day to remember that Tuesday eight years ago, and commit to service in your community. Many organizations pursuing sustainable strategies already recognize the triple bottom line approach of protecting people, the environment and the economy. Community involvement is a great way to engage your employees in socially responsible activities.

Where do you start? Conduct a search for volunteer opportunities in your city, remember and act!

Undoubtedly, the challenges for manufacturing are great. Global competition places enormous pressure for companies to survive. The job loss is painful! However, when is the last time you saw these facts in the national headlines:

• U.S. manufacturing produces more goods than any other country and is 21% of the world’s total.

• Manufacturers account for two-thirds of all private research and development in the United States.

• Twenty-two manufacturing occupations have expectations of “average” to “much faster than average” growth nationally.

And I suspect you have not seen these North Carolina manufacturing facts in the headlines:

• The seventh largest manufacturing state in the nation.

• Manufacturing is the largest contributor to the gross state product at 18.6%.

• Manufacturers provide 98% of all state exports, or $21 billion.

• Average annual manufacturing earnings per job is $59,964 - 46 % higher than the statewide average.

Indeed, productivity enhancing technologies are eliminating routine work positions while simultaneously increasing the required skills for the remaining positions. Consequently, companies become more competitive and we have the results above. Note that certain occupations are anticipated to be high growth jobs. We regularly hear about job loss in manufacturing but rarely do we hear the message that good job opportunities will continue to be in manufacturing.

So, the next time you hear manufacturing is going away, share some of the facts above. And turn the conversation into how we can help manufacturing become even more competitive and successful.

Let’s not forget that manufacturing matters. It matters a great deal to all of us!!

Many companies develop an Environmental Management System (EMS) according to ISO 14001. To demonstrate adherence to these requirements – they get “certified” or “registered” by an accredited registrar. This is the best way to verify the company is meeting ISO 14001 – through the use of an external EMS audit conducted by “accredited” external auditors.

However, registration services/ audits cost a lot of money. For a small company, registration auditing services may cost $15,000-$25,000 / 3-year period, not to mention the drain on employee resources needed to answer the auditor’s questions (auditees). The less expensive solution would be for the company to “Self-Certify” / “Self-Declare” conformance to ISO 14001.

Clause 1 of ISO 14001 allows companies to demonstrate conformance to the standard by either
• Making a self-determination and self-declaration
• Seeking confirmation of its conformance by interested parties such as customers
• Seeking confirmation by external parties
• Seeking confirmation by certification/registration by external parties

The self-declaration simply implies that a company which has implemented ISO 14001 publically asserts that it conforms to the standard (without the involvement of certification bodies (registrars). So the question then becomes – how does your company self declare with credibility. Do you use external accredited RAB/QSA ISO 14001 auditors? Do you follow a protocol established for this purpose?

The US Army has done just that by developing a protocol for self-declaration audits as follows:

STEP 1: Determine Organization EMS Requirements
STEP 2: Planning the EMS Audit
STEP 3: Conducting and Documenting the EMS Audit
STEP 4: Determining Self-Declaration Status and Communicating the Results
REFERENCE - US Army Procedure for Self-Declaration on Compliance ….
This is very similar to the auditing guidance offered by ISO 19001. A step-wise procedure for managing and conducting EMS audits.

The NC State University-Industrial Extension Service (IES), could act as an external auditor – to assist companies in self-declarations. By auditing key personnel at all “functional levels” of the EMS, IES could provide the quantitative assessment to demonstrate conformance to ISO 14001. An example of a possible report format is shown below. This type of self declaration / external audit approach – especially makes sense for simple companies that have little or no – environmental issues (warehouse, office complex, etc).

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Figure 1. Example ISO 14001 Audit Report Which Could be Used for Self-Declarations

This past weekend I had to deal with a supplier that didn’t know how to communicate, and even though it was a bad experience because of all the time I had to invest, it was a good reminder of the importance of honesty with our customer even when we know we will not be able to fulfill all their expectations.

Why are we afraid of our customers? Do we really believe we will have their loyalty by lying to them?

The truth is that customers rather hear the truth about what they should expect, than for us to make them believe that they will get something that we know they won't get.

The bad experience of this weekend reminded me that we need to learn to communicate with our customers regarding any type of news, good or bad, if our customer is going to be affected, we need to let them know in a timely manner what to expect, and what is the plan to ensure their satisfaction, or at least to try to make things right. If we "hide" information from our customers just to try to look better, eventually the customer is going to notice, that we were not truthful to them, and this could destroy their trust in our product, service and ethics.

It is important that in our organizations we ensure we create a culture of open communication, with no fear, this approach will really enhance our ability to communicate internally and externally and as a result have a collaborative team and a happy customer.