Issue 25


Issue 25

The Scientific Method by Ron Bercaw

Many of you have been diligently using a plethora of tools to help see and eliminate waste. Indeed in this e-newsletter, dozens of articles have been written on the application of lean tools. Many lean practitioners are proficient in process mapping and applying the value added / non-value added principle to tasks along a workflow. Other lean practitioners also use the spaghetti map and standard work on a regular basis. These staples are helpful in identifying and eliminating waste.

To organize the team's activities and facilitate the identification and the elimination of non-value added activity, each lean leader should use a project management framework. There are many frameworks in existence including the Plan-Do-Study-Act framework (PDSA), the Plan- Do-Check-Act framework (PDCA), and the six sigma framework of Define, Measure, Analyze, Improve, and Control (DMAIC). The best companies in the world use A3 thinking to facilitate change and improvement within their organizations. More importantly, the best companies use a single framework. How many different frameworks does your organization use? Trying to learn all the different frameworks will take many years, and teaching the entire organization to learn the multiple frameworks will be mission impossible.

Let's review what is common in the various approaches. Each of the frameworks is based on the scientific method. Improvement and improving performance should be looked upon as creating a community of scientists. These scientists, the people that do work every day in your organization, should all be engaged in some form of seeing and eliminating waste. What the scientific method ensures is that we ground our improvement in data, and that improvements are tested before solutions are deployed in mass. The scientific method ensures that both the current state and the desired state are identified, and the gap between the two is quantified prior to developing solutions.

Many of you know the problem-solving A3 follows a common format. The key sections* include:

  1. Reason for Action (Improvement) - Defining why we need to take action
  2. Current Conditions - Data on how the process operates today
  3. Target Conditions - Data and Attributes on how the process should perform in the future
  4. Gap Analysis - Quantifying the variance between current conditions and target conditions
  5. Countermeasures and Action Plans (Solution Approaches) This section is where we create our hypothesis for testing. Action plans are the experiments.
  6. Follow Up Plans - Activities to implement the solutions, once the experiment validates that the solutions have closed the gap between current and target
  7. Measure Tracking - Here is where the data is trended to ensure the target conditions are met and sustained
  8. Lessons Learned - Organizational learning that should be shared with others that will want to replicate the solutions

*Note: there are different formats of the A3 in use. Some have 7, 8 or 9 sections depending on the format used. The lean community would benefit by standardizing the format 🙂

My call to action for the lean nation this week is to do a better job of teaching the A3 framework to our team members. Many of you do a fantastic job in teaching the discrete tools, but the A3 is frequently not taught well, or even referenced in improvement efforts. Having our community of scientists understanding the scientific method and its application in improvement is equally as important as understanding the individual tools used to see and eliminate waste. I encourage you to begin each team activity and to close each team activity with a discussion on where you are in the scientific method when working through a project.

The technique I find to be the most useful is put the working documents on flip chart paper on the wall around the room in the order of the A3. This way the flow of the room and the scientific method are one in the same. Everyone in the room, including the lead leader, will know exactly where they are in the problem-solving process using A3 thinking.

The ultimate improvement organization has all employees performing small experiments designed to eliminate wasteful activity. Tests of change can be managed through A-3 thinking. As a lean practitioner, it is your responsibility to transfer improvement knowledge to the organization. Be sure your team is building capacity while they are improving!

Get off the Sideline by Steve Newlon

Deploying lean to one organization, I noticed the lack of commitment from a mid-level manager. Following an improvement workshop, the manager completed all assigned action items, but items in the optional or in the “can do later” category were left undone. The manager demonstrated no enthusiasm for what was being rolled out, and outside of mandatory meeting discussions was frequently busy with “urgent matters.” The manager's boss provided coaching, yet the situation remained unchanged. This went on for months and over time the manager was able to "slow-leak" the program and ultimately contribute to its demise.

As a final intervention, we thought education, training, and discussion would help, but it only armed the person with a vocabulary to attack the effort instead of supporting the effort. As this person’s knowledge grew, the manager became more skillful at arguing against ideas using lean terms. It showed that the person understood the concepts, but failed to accept them.

This activity is commonly seen in lean circles and is titled the "frozen middle". Staff workers enjoy process improvement as they have a voice in changes necessary to create more value for customers. Senior leaders like the improvement as it drives real results and the corresponding numbers. Middle management is sometimes frozen as they are not always comfortable of the change they must now manage. In this specific case, the manager was a side-line player and side-line players can be very disruptive in the change process. Some leaders act as if they support the team, but passively undermine the effort or slow progress. Assuming positive intent, when we see this behavior we hope for the best and tell ourselves that they’ll soon buy in. While possible, it is not a guarantee.

Behavior, not words, will always tell us the values and beliefs of a person. Side-liners are difficult to spot because they wear the team uniform and even score a point here or there, but their heart isn’t in it to win. Lean systems and tools are designed to drive new behavior and when implemented correctly can change the behavior of a side-liner. At risk isn’t our pride or personal success, but better value for our customers, enhanced staff satisfaction and organizational health. The mission is far too important to be sidelined.

Optimizing Your Surgical Program by Felicia Gordon

Do you know one of the secrets to success for the O.R.? It’s the surgeon’s preference card. The preference card is the hub of much of the activity for the O.R. It is used when a case is scheduled, when the case is being prepared on the day of surgery and for supply charging while the case is underway. The preference card holds all the information about how a surgical case is performed for a specific surgeon. If the card is incorrect in any way, there is a real chance the surgical case will be frustrating for the surgeon and staff and also a chance for a negative quality issue related to patient care, as well as a delay in the case.

Why wouldn’t the preference cards be correct?

Surgical techs/nurses don’t keep them updated. Why?

  • An experienced tech/nurse for that surgeon may believe they know exactly how to do the case without the use of the preference card. And that may be true; however, not all of your nurses/techs have that same level of experience. So when the surgeon has a different crew than his experienced one, the case may have problems. Have you heard a surgeon say he only wants to work with certain people?
  • Updating the cards takes time.
    • The surgical staff are an expensive and limited resource. Most hospitals use some type of productivity standard and when there are no surgical cases being performed, the staff is sent home.
    • The surgical staff are required to take “call” and may be in the O.R. all hours of the day and night. They don’t place a high value on being there any longer than absolutely necessary. Taking care of a patient is a priority. Updating preference cards is not.
  • The cards are usually electronic and permission to create/update is typically restricted to just a few people in order to keep the process clean. Why?
    • Understanding the electronic dictionaries and the electronic structure of the cards is typically only known by a few people.
    • Often there is no standard work developed for keeping the cards “clean” so if everyone were allowed to update the cards as they choose, the cards could become chaotic.
    • Perhaps the dictionaries are incomplete and new items/item numbers have to be requested from central supply and billing before the cards can be updated.
    • And so on...

Surgical preference cards typically are not built systematically, don’t follow a standard layout, and not de-activated when no longer needed. Why?

  • It’s just not a priority and the job becomes overwhelming when the upkeep is not continuous.

Is there a rapid solution to this problem?

One of the fastest ways to resolve this problem is outsourcing the work. FGCS, LLC Healthcare Consultants has a team of experienced surgical techs and nurses who can work with you to quickly overcome this overwhelming task. They use LEAN principles to accomplish the work. For preference cards the same thinking used to create a high performing work area can be applied to cleaning up preference cards: 6S

Sort – Cull through the entire list of cards and eliminate those that are no longer used or needed.

Set in Order – Determine a layout for all of the cards to be most efficient and accurate for assembling the supplies and equipment for the case.

Standardize – Develop standard nomenclature, update item lists, develop generic options.

Scrub – Clean up all the cards that are on the list to keep.

Sustain – Create an on-going process with standard work to keep the cards clean.

Safety – Establish and monitor metrics to ensure that the cards are updated and issues during a case are not related to a poorly developed/maintained card.

Most organizations attempt this work on their own, however, the cleanup work is frequently piecemeal and can take many months, if not years. In fact, many times the update is never completed, let alone kept current. With FGCS, your staff will still be involved in the work, but the bulk of the labor will come from FGCS resources. FGCS can even remotely keep the cards updated for you so that the backlog of incorrect preference cards does not reoccur.

If you would like to know more about our services, please contact Felicia Gordon via e-mail at or call / text 806-789-2272.

Please click on the link to read an AORN document related to the importance of the preference card.

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