Lean and Operational Excellence

Grand Challenges…Here we come!

What comes to your mind when we say “grand challenge”? People think about big issues such as ending world hunger and curing cancer.  These are certainly big problems that takes several thousand people working every minute for the betterment of the society. We all want to be part of these grand challenges, but either have limited capabilities or the time, given our day-to-day schedule. What if we use these grand challenges as learning opportunities? Perhaps this may allow us to make some incremental contributions and also learn at the same time.

This was the main idea when we started our conversations with the Mid-Ohio Food Bank regarding a “learning lab” for our MBOE students. Mid-Ohio Food Bank is one the largest food bank in the United States primarily catering to the 20 counties surrounding the Columbus region. They are an amazing organization with great talent yet have really complex challenges in serving the community. Think about this for a statistic:

“There are over 400,000 people in Franklin community who live under 200% of the poverty line and miss over 15% of their meals. In other words, over 400,000 people are going without food for an entire day each week.”

This is not because Mid-Ohio Food Bank or their agencies have a shortage of food. It is because as Mark Mollenkopf – Strategic Solutions Developer – so eloquently puts – “Our problem is to get the right food to the right people at the right place and the right time”  

This is a perfect learning opportunity for our incoming MBOE students to scope down this larger complex problem into manageable problems in distribution, access, population health, nutrition and consumer behaviors. Our incoming class of students will spend time at the Mid-Ohio Food bank understanding and solving this problem over 5 months beginning November 2019.  They will first learn to break the complexity down to workable “chunks”, where to make impactful changes, how to measure and sustain these changes over 4 different learning sessions. Our students won’t be able to eradicate human hunger in 5 months, but they can certainly make a difference and make substantive improvements in this given time.

Our MBOE and Fisher Management Science team are really excited to use this amazing learning opportunity and help our community along the way!

Come and see what we do in our MBOE program at: https://fisher.osu.edu/graduate/mboe

Operational Excellence Systems – How to Create a Perpetual Learning Organization?

Have you ever worked for an organization that is always successful in its mission whose employees are highly committed to its purpose? Anyone reading this article would question the existence of such an organization. Through our research, teaching and outreach, we found that managers from various industries such as healthcare, information technology, manufacturing and hospitality services are constantly searching for the answer to the question on how to create a perpetual learning organization where everyone continuously learns, improve and remain committed to its purpose every day (similar to the perpetual moving machine shown below).

 

 

Think about the following example of a healthcare system that personifies such a learning organization where a small problem faced by one unit becomes a great learning opportunity for the entire system.

“In a Tier 6 daily huddle using visual management, the senior leaders (including the CEO, Chief Medical Officer, Chief Nursing Officer, Chief Financial Officer and Chief Quality & Safety Officer) of Apollo Hospital systems were informed on a “near-miss” caregiver fall injury that had happened in one of their regional surgical units previous day, 60 miles from their main hospital. The attending nurse almost tripped on a wire from a new computer terminal recently installed due a system wide rollout of electronic medical records. After a quick discussion, it was decided to prioritize this issue and offer support to the care team at the surgical unit to solve this problem. The next week, the CEO attended their tier 1 huddle at the regional hospital listening to how the team was planning on solving this issue. Thirty days later, the countermeasure developed and vetted by the team in the surgical unit was spreading all across the 24 hospital systems involving more than 30,000 caregivers to avoid similar near miss injuries. What is fascinating is that every unit in Apollo is adapting the solution to their appropriate unit needs, tracking them and improving them on a daily basis. Six months later, Apollo continues to maintains a zero-fall injury rate for both their caregivers and patients”

  • Information about a close-encounter from a regional unit within the hospital system percolates all the way up to the C-suite within 24 hours. It is important to note that action follows immediately after the reporting process.
  • The hospital system tracks caregiver outcomes (e.g. near-miss accident) and prioritizes them along with patient (customer) outcomes.
  • The CEO of the hospital system makes time to travel 60-miles to offer her support to the team in the unit the next week.
  • There are no specialists solving the problem at Apollo. Rather, the team who encountered this problem is tasked to come up with a countermeasure and report on the efficacy of this measure after experimentation.
  • The countermeasure developed in this unit (i.e. process of problem solving and not the solution) is rolled out across all 24 hospitals within 30-days. This process of problem solving results in customized solutions across other units adapted to their needs (i.e. there is no single silver bullet for problems).
  • The entire organization is learning every day and improving from smaller experiments that are happening throughout the system. These lessons are made available to those facing similar problems in a way that same problems do not get solved over and over.

Our research with several organizations, including Toyota, Mayo Clinic, Nationwide, Cleveland Clinic, Thedacare Systems, IBM, General Electric and 3M etc. reveals that creating a perpetual learning organization such as the one described in Apollo requires creating four distinct learning systems. They include Alignment & Adaptability Systems, People Development Systems, Problem Solving Systems, and Daily Management Systems. We refer to them collectively as Operational Excellence Systems.  See Figure 1 that describes these systems.

Figure 1: Operational Excellence Systems

Dimensions of the Operational Excellence Systems

  • Alignment & Adaptability Systems – Systems that allow everyone in the organization to understand the value and purpose of the work they do and how it relates to the higher level strategy. This allows them to guide their actions as well develop adaptive skills to change for the future.
  • People Development Systems – Extent to which the firm invest in practices that add skills and capabilities to employees at all levels that allows them to continuously experiment, reflect, learn and innovate and become change agents.
  • Problem Framing & Solving Systems – The approaches taken by everyone when a problem arises in way the problem framing and solving processes are standardized across all levels of the organization and the learning permeate through the entire organization.
  • Daily Management Systems – The practices leaders at all levels use every day to identify potential issues and ensure all activities are on track and create accountability and cadence to the functioning of their units.

It is important to note that these systems are leader independent and sustains even after the departure of the architect responsible for creating them. They are also independent of the processes and business functions and has to exist at every level within the organization.

Our findings are not only informed through our research but also through our experience developing 300+ change leaders through the Master of Business of Operational Excellence (MBOE) program at the Fisher College of Business. In this program, executives from various industries develop their own operational excellence systems over a year. Through this journey, they document some of their challenges and opportunities when creating these systems back in their organizations.

What became evident to us through this learning journey is that even exemplar organizations don’t have all four systems at all levels within their organizations. The answer to creating a perpetual learning system may involve creating “isomorphic” structures of these systems at all areas in your organization.

Interested in knowing how to develop these systems in your organizations? See how our students and organizations partnering in MBOE program do by visiting https://fisher.osu.edu/graduate/mboe

Do we understand Lean Deployment in Healthcare?

Patient Safety                                             Lean

Anyone who has taught lean principles grounded in the famous Toyota Production System (TPS) to organizations outside the manufacturing industry has – at least once – heard this common refrain: “(Insert industry here) isn’t cars on an assembly line. This doesn’t apply to my work.”

Leading lean thinkers, of course, have learned how to work with individuals and teams to move past this roadblock and garner buy-in – that’s why the practices and tools intrinsic to TPS have made their way into countless industries. Lean still can be a target for criticism, though, and one need look no further for proof than an article published earlier this year in the New England Journal of Medicine – and the debate it ignited.

The January issue of NEJM featured an article called “Medical Taylorism” where authors and physicians Pamela Hartzband and Jerome Groopman assert that lean principles “cannot be applied to many vital aspects of medicine. If patients were cars, we would all be used cars of different years and models …” This tipped off a flurry of rebuttals, including one from Lean Enterprise Institute CEO John Shook boldly titled “Malpractice in the New England Journal of Medicine.” In his piece, which itself attracted widespread attention, Shook writes that the foundational lean principles of continuous improvement and respect for people are critically important in the health-care system.

Shook is right, but I’d like to approach this discussion from a different angle, namely that this line of criticism has emerged elsewhere – and it’s rooted in a lack of understanding of lean deployment.

One of my initial research areas sought to understand how standardization and “smart application” of Design for Six Sigma (DFSS) principles can aid R&D and innovation efforts. I pursued this as a number of business press publications and industry practitioner blogs lamented the damage Six Sigma does to creativity and praised the need for variation for innovation. Several years of research1,2 at Fortune 500 companies with my colleagues in Fortune 500 companies made us realize such sentiments don’t hold much water. We found ambidex, in fact, that principles of Six Sigma/DFSS – when applied to the innovation process correctly (hence the “smart” in “smart application’) – can help reduce unnecessary variation and stop worthless innovation activities that consume R&D funding (shift).

I’ve more recently collaborated with researchers and physicians to tackle similar questions in health care. Once again, the findings – published in several academic and practitioner outlets – are very similar: The smart application of lean and continuous improvement principles can help develop a safe and patient-centric healthcare system.

In arguing that patients aren’t cars, the NEJM’s authors are absolutely right – but they’re dead-wrong in concluding there’s no place for lean in “many vital aspects of medicine.” As with our R&D research, we’ve found that lean deployment in hospital settings minimizes unnecessary variation that comes from care providers, not patients. In fact, it frees up time and effort to cater to the necessary variability in a population diverse in its illnesses, economic backgrounds, languages and more.

 

Huddle2

As an example, in a recent study, my fellow researchers that include physician leaders and I spent years looking at Ohio State University’s Wexner Medical Center, specifically a lean deployment effort in its kidney transplant discharge process (see right picture). Transplant recipients after discharge must drink at least three liters of fluid a day – failure to do so can spike creatine levels, elevating blood pressure and increasing the likelihood of readmission. This is an evidenced based fact well-grounded in the medical literature7. During our roundings, we found variations in how these instructions were delivered to the patients: One nurse, for example, nonspecifically recommended drinking “a lot of fluids” while another suggested 100 ounces. Interestingly, we found nurses varying instructions between patients and patients who received different instructions from more than one nurse. These nurses weren’t being intentionally deceptive but their inconsistencies confused patients as they took in a tremendous overload of instructions.

Overhauled through the lean deployment via standard work design, nurses in our medical center now clearly explain the specific volume of fluid, use a jug to visually illustrate, and discuss the consequences of not following the instructions. Preliminary findings show this approach soothes patients’ anxiety levels and has reduced the chances of readmissions in the first month after transplant.

This isn’t just a lean approach to a problem – it’s a smart lean approach. And in an environment that, yes, isn’t cars on an assembly line that matters more than ever.

References:

  • Chandrasekaran, A., Linderman, K., Sting, F., Benner, M. 2016, Managing R&D Project Shifts in High-Tech Organizations: Multi-Method Study. Forthcoming at Production and Operations Management
  •  Chandrasekaran, A., Linderman, K., and Schroeder, R.G. 2012. Antecedents to Ambidexterity Competency in High Technology Organizations. Journal of Operations Management, 30(1-2) 134-151.
  •  Chandrasekaran, A., Senot, C., Boyer, K. 2012. Process Management Impact on Clinical and Experiential Quality: Managing Tensions between Safe and Patient-Centered Healthcare. Manufacturing and Service Operations Management, 14(4) 548-566
  •  Senot, C., Chandrasekaran. A. 2015. What has the highest impact on Readmissions Rates? Harvard Business Review (A joint collaboration between HBR-NEJM)
  •  Senot, C., Chandrasekaran, A., Ward, P., Tucker, A., Moffat-Bruce, S (2016) The Impact of Combining Conformance Quality and Experiential Quality on Readmissions and Cost Performance. Forthcoming Management Science
  •  Chandrasekaran, A., Anand. G., Sharma L., Ward, P., Henry M., Pesavento T., Moffatt-Bruce. The relationship between Patient Anxiety, Quality of Discharge Instructions and 30-day Readmission Rates for Kidney Transplant Recipients. (Findings presented at the American Surgical Congress, Feb 2016)
  • Gordon, E.J., Prohaska, T., Gallant, M., Siminoff, L., (2009). Self-care strategies and barriers among kidney transplant recipients: a qualitative study. Chronic Illness. 5(2) 75-91.