So Want To Be A Member of the Healthcare Value Network? – Vancouver Style

As part of my work to support the Healthcare Value Network I have the opportunity to visit many great organizations that are applying lean thinking to health care.  I’ve written about being an HVN member before.

Yesterday I had the good fortune to visit our member organization in Vancouver, British Columbia – Vancouver Coastal Health.

Here are some of the things I saw.

This impressive team of 3 women have had a huge impact on the maternal unit at Richmond Hospital.  Laura is a midwife and facilitates the education process on the unit.  Lynn is the facilitator.  I asked her how she learned what she knows.  She told me that her dad worked at Toyota and that influenced her.  Wendy, the manager of the unit is a really dynamo.  She visited some other HVN organizations, got some ideas and made it happen.  She tried a lot of different things.  She and her team were not afraid to make mistakes.

photo 15

This team did not start simple or easy.  They tackled a big hairy audacious goal (BHAG) – the percentage of C-Sections done on the unit.  They wanted to work on something real – something that mattered to patients and to physicians.  This was their current state value stream map.


They involved the patients and asked them how they wanted to process to go.

photo 12

They worked on it, and worked on it and made some terrific improvements, including a protocol that everyone could agree on for when it makes sense to perform a c-section on the unit and not transport the mother to the OR.

photo 10


They developed these nifty “line of site” tools that show how the department is doing every day, as well as possible causes for not achieving the measures.  They borrowed the original idea from 2 other HVN member organizations,  then they went through lots of iterations of these, and will likely continue to revise and improve them.

photo 13


They use a kind of self-assessment to determine how they are doing.  The current state is on a spider diagram.  This is similar to the work we are doing with the HVN assessment team.

photo 14

They devised a way to audit key processes.  The current one is “documentation”.  This board is located where staff walk in to the department.  The red card shows how we are doing today.  There is also information to show why it’s a red card and not a green one.  The staff then know what they need to do.  No need to have a long conversation about it.

photo 16

Keeping staff up to date on clinical education is also important.  They have a simple method and board for that as well.  This board is also located in the hallway where staff come to work.  Anyone can stop by and read what’s new and then move on.

photo 17

They have also developed and documented lots of standard work.  They call it “standard operating procedures” or “SOP”.  The documents feature lots of photos.  Here’s an example of a draft of one of their SOPs.

photo 6

These documents don’t just appear.  It requires some teamwork and detailed-thinking to produced these documents and keep them up to date.  Here’s a team working on some of these SOPs.  Some of the team members are from another part of the organization (not on the maternal unit).  They are working on their green belt.

photo 7

In the intensive care unit, they are determining what to work on next.  There are lots of priorities (based on a study of their value stream).

photo 8

Everyone gets a chance to vote on the items they would like to see worked on.  The “top vote getters” go on a PICK chart to determine the “one thing” they are going to do next.

photo 9

On another unit I saw another approach.  They call it “releasing time to care“.

photo 19

photo 18

The unit has a vision statement and the photos of the staff are featured.

photo 21

They get lots of thank-you notes from patients.

photo 22

Part of a this approach is called a “well organized ward” (WOW).  This is similar to 5S in the lean world.

photo 23

This unit has accomplished a lot!  Here’s a running list for everyone to see.

photo 24

They also have a method to determine what they are going to work on next.  Everyone gets a chance to vote on the options to pick the next “one thing”.

photo 20

So one unit calls their improvement work “lean”, another calls it “releasing time to care”.  Is this a problem? (that there are two approaches in one organization).

I think the answer is “maybe”.  Improvement needs to be owned by the people who do the work, yet at the same time where there is variation there is potential for waste and duplication of efforts.  Top management needs to facilitate collaboration – win-win.  This can’t be mandated, but needs to happen.

I saw some other great things on my brief tour.

Here’s a flow diagram showing a family’s journey in the care system.


Here’s an example of some 3P space redesign work for a pharmacy.

photo 5

There’s good stuff happening in this organization!



People Develop, But Do People Develop People?

I don’t think so.  At least I think it’s more complex than that.  I’ve blogged about this before.

Muck of what I hear about “people development” seems to be based on some questionable principles of the prevailing style of management.   Dr. W. Edwards Deming had a term for this “the mythology of management” (referring to what he saw in the Western world).

In his 1993 book, The New Economics, he described “faulty practices of management with suggestions for better practice.  Here is a partial list:

Screen Shot 2014-07-27 at 7.26.25 AM

I like the contributions of Heero Hacquebord as well.  Heero is one of the people who worked very closely with Dr. Deming and would often participate in his 4-day seminars.  Heero provided a helpful presentation at the Ohio Quality and Productivity Forum years ago.  Here is a summary of Heero’s lists:

Screen Shot 2014-07-27 at 7.29.43 AM

I think that the prevailing style of management is described in the left-hand columns from Dr. Deming and Heero Hacquebord.  This style is not fixed.  It’s actually a relatively modern invention.  It’s not the kind of management we need now and in the future.

Yes we need for people to move from the prevailing style to a better style (they must develop), but we must not approach this in a mechanistic, reductionistic, formula-driven approach.  People are complex.  They have a free will.  For instance, we can use extrinsic motivation (one person trying to motivate another), but that approach is based on the left-hand world.  It will not only likely backfire, it will most likely make matters worse.  This s also well-supported in the peer-reviewed literature.  A useful article (Self Determination Theory and the Facilitation of Intrinsic Motivation, Social Development and Well Being) by Edward Deci and Richard Ryan can be found at this link.  Edward Deci has a helpful book titled Why We Do What We Do, and Alfie Kohn has written several books on this topic including Punished By Rewards.

These are my thoughts.  What do you think?

Dancing with the (lean) stars – and the CEO

When we welcome new organizations to the Healthcare Value Network, the usual orientation method is a webinar in which we provide information about the Network and how members can access the other member organizations and the systems and event offerings we have.

When I made my initial site visit to Tucson Medical Center, we talked about the orientation process and they asked if we could do something special – something in-person.  “Sure, let’s try something different”, was my response.

I returned this past week, and joined the managers and staff for a celebration.

tmcaz celebrate

Here’s a short video of my intro to the history-making orientation.   This group knows how to celebrate, and they also like to dance.  That’s me with the CEO, Judy Rich.  We were dancing at the end of the celebration, and if I get a video clip of that, I’ll update this blog.

mike & judy








They prepared a nice video that summarizes some of their work to date.  Take a look at this, and see the kind of great work they doing.

Here are some of the great results they have achieved thus far:

Screen Shot 2014-07-21 at 10.04.51 PM

Screen Shot 2014-07-21 at 10.05.06 PM

Screen Shot 2014-07-21 at 10.05.37 PM

Screen Shot 2014-07-21 at 10.05.48 PM

Screen Shot 2014-07-21 at 10.06.02 PM

Screen Shot 2014-07-21 at 10.06.15 PM

Watch for continued great contributions from this great (and fun) organization!  Welcome to the Healthcare Value Network.



OK, now get back to work

I took some time off from work.  I mean, I really took some time off.  But now the fun is over, and it’s back to work.  (That reminds me, I need to write a blog post on one of my favorite books “The Three Boxes of Life and How to Get Out Of Them“)

I had the good fortune to visit some of our Healthcare Value Network member organizations in the New England area almost immediately after my vacation was over.  There’s lots of good stuff going on, and here’s one example – a brief summary from UMass Memorial Health Care:

With the appointment of their new CEO and President, Dr Eric Dickson, the Lean journey at UMMHC has launched toward “Becoming Lean” from “Doing Lean”.  During the past year, Eric has championed Idea Systems, Executive Rounding, Leadership training opportunities, and Hoshin Kanri.  He has focused the organization on True North and has championed A3s like Flow, Access and other strategic initiatives to close the gap in the financial performance.  The summation of all these efforts and more have contributed to a predicted positive profit margin for FY14 instead of a budgeted loss.  The employees are looking forward to his continued leadership in making UMMHC “The Best Place to Give Care and the Best Place to Get Care”.

Screen Shot 2014-07-14 at 3.30.16 PM

I took a short video of a document that describes some of the improvement work.  Here’s the link to that video:

I think the real improvement came about because they realized that the advice they received from some consultants (experts in benchmarking, so they said) had led them down the wrong (and expensive) path and now they are recovering with some real improvement.  Unfortunately, I personally wasted years of my life in companies where there was this belief (based on faulty principles) that it was possible to divide the organization into parts, find benchmark numbers (productivity, etc.) on similar parts (departments) and then give people these target numbers and tell them to meet those numbers.  “If these organizations can manage to this level of productivity, then you can do it!”.  Total bunk!  Absolutely the worst possible approach that anyone could take.  I regret every minute of my time spent in that wasteful and destructive activity.  This has been a topic of my blogs multiple times (paper presented at Deming Research Summit, To Be List, Item #8, This is truth!, the case against performance appraisals, guiding principles, values & behaviors, rehearsing, life-long learning, lean in imaging.  I also posted some thoughts on our ThedaCare Center blog.  It’s a reoccurring theme.

But the good news is that we can find examples of organizations taking a better approach.  I plan to return in a few months to this terrific organization and better understand and document the improvement work thus far.  So, watch for that update.

All Work and No Play … Rende Mike Un Ragazzo Ottuso

I think there’s more to life than work (I also think there’s more to work than “standard work” … but that’s a different blog post).

I blasted out of orbit from the giant hairball and visited Italy with some friends.  Actually, we just found a different hairball to orbit.

These are some of our adventures (with random photos and links to videos in no particular order).


Peg takes a hike in montesssoro


weird wine museum


what to do when they close down alba?


il signore delle mosche


hike in italy (the glacier)


watching italy’s last world cup game 2014


italian yarn shop–Zbo


roaming the roman ruins


italian postal service


picnic near italian castle


some day all this will be yours


legolas’ steps & peg


we have no idea what’s going on


chllin at home base


storming the castle – part 1
part 2 of storming the castle
storming the castle, finale – the butt lift

italian manifestation marching band


recycling & trash day in italy


looks like “plan b”

plan b starts with wine


but I got this great parking spot


the meat is undercooked, but the water is well done


found another ancient roman theatre


we found something that was open in aqua terme italy


international incident – part 1
international incident – part 2

do you want your lunch with our without a helicopter?


Everyone in Italy is on our highway


Toll booth international incident – part 1

For whom the booth tolls


Iceman gift shop

Sprechen sie deutsch? nein


We made it.  It was a miracle!


Peg’s hiking advice


Four musketeers in Ortesei Italy


Austrian wild hogs


going up




Clean up crew


We thought we were on the canal bus


NOW we are on the bus



We thought we found our hotel



Let it be – on San Marco Plaza



Watching the world cup in Venice



Interpreti Vivaldi




Simulated gondola ride


Tina walking




Board of Directors Huddle – Lesson from Kitchener, Ontario, Canada

A few years back I heard John Shook (CEO at Lean Enterprise Institute) say that healthcare is doing some innovating things in their efforts to apply lean thinking.  He identified 3 items in particular:

1) Using white boards.

2) Using check-lists.

3) Stand-up huddles.

These may not sound that innovative for other industries, but for healthcare it IS pretty radical.  I saw one organization take the huddle process even further.  During a recent trip to St. Mary’s General Hospital in Kitchener, Ontario I watched a hospital Board of Directors meeting start with a brief huddle.  Here’s a very short clip of that huddle: 

Screen Shot 2014-06-16 at 9.18.18 PM


This is pretty impressive, and is rare.  I was at another facility a few weeks ago and the senior management team went on and on about how they were trying to “get teams to huddle” across the organization.  When they paused for questions, I asked, “do you huddle as a team?”  Their silence said everything.  Leadership is doing (trying?) different things, not just talking about how they want others to do different things.

Best Conference Ever! – Till Next Year (2014 Edition)

We just wrapped up the 5th Annual Lean Healthcare Transformation Summit in Los Angeles.  Based on my conversations with many who attended, it was one of the best conferences ever.  Of course I said that back in 2012.

There were lots of highlights.  We featured many Healthcare Value Network member organizations in a variety of ways: 20 Network members presented in our “Experiments Around the Network”; our CEO keynote panel featured three Network CEOs (Maura Davies, Kathryn Correia and Laura Easton); once again this year we hosted a CEO track with the majority those in attendance coming from HVN Member organizations; and we had a great networking at the reception with Live Jazz music from John Toussaint and Network member Terrigal Burn from Palo Alto Medical Foundation!

Screen Shot 2014-06-15 at 8.58.45 AM

There were lots of “favorite” presentations to choose from, and it is hard to select one that stood out above the others.  My primary responsibility at the Summit was to facilitate a series of presentations at a breakout session for CEOs.  I call it “the summit within the summit”.  These were all great presentations and discussions, but I’m going to feature one in this blog post that really stuck out for me.

Len Barry, PhD, from the Mays Business School at Texas A&M University presented on a topic that really grabbed my attention: “Common Success Drivers of  Three High Performance Health Systems in Wisconsin”


Of 306 U.S. Hospital referral regions analyzed in the 2012 Commonwealth Fund study on access, quality, costs and health outcomes, the Wisconsin regions of Appleton, La Crosse, Green Bay and Neenah rank overall 5,7,12 and 14, respectively.  So, he asked the question “what is going on in Wisconsin?”

Dr. Beery spent several weeks “embedded” in three health care organizations: Gundersen Lutheran in La Crosse, Bellin Health in Green Bay and ThedaCare in Appleton.

“Why are three independent health systems in one state doing so well?” he asked.  Dr. Berry found that Gundersen, ThedaCare and Bellin Health had several things in common that many hospitals across the U.S. don’t:

  • The core of success is stable, value-driven leadership by the management and hospital board. Each hospital has a CEO who has been there a long time. That gives other organization leaders confidence to be bold. The hospital board also works closely with leadership and is not seen as the enemy, as in some other organizations.
  • Each has core values like innovation, respect and excellence. “Many (other health care organizations) have the wrong ones,” Berry said.
  • Each has common cultures of focusing on accountability, collaboration and being unconventional.
  • Institutional self-confidence, which paves the way for unconventional thinking and high aspirations. “These institutions are better at controlling their destiny,” Berry said. “They make the tough decisions today to strengthen the organization tomorrow.”
  • A broad view of value. It’s not just a focus on lowering cost, but improving the patient service.
  • Teamwork and coordination between doctors and departments. “The language of team work — I heard it wherever I went,” Berry said.

“What drives the success is focus, but that doesn’t mean you’re perfect,” he said.

Each organization needs to work on a few things, like more of a local presence and engaging patients more creatively in being responsible for their own health, he said.

Screen Shot 2014-06-15 at 9.21.44 AM

If you want to learn more about Dr. Berry and his work, go to this link to obtain a copy of an article that he co-authored with Dr. John Toussaint, “The Promise Of Lean In Healthcare