Archive for category: Lean Six Sigma

Four Keys to Lean Problem Solving

Oftentimes, we see organizations struggle to sustain improvements in key areas of performance. Despite frequent training and supervision of staff, outcomes are difficult to obtain and continue over time, whether related to census and occupancy or incident investigation and prevention. The challenging piece is that staff almost always want to do good work, but, unfortunately, systems and processes get in the way. Lean is really about a systematized way of applying a philosophy and a set of tools to overcome barriers and produce lasting results. Here are four keys:

1) Go to the floor. (In Lean terms, we call this “the gemba,” or the place where work happens.)

You can’t solve problems by sitting in an office or a conference room. Yet, stubbornly, many quality improvement discussions occur in these places isolated from where the work actually occurs. Instead of falling into this common trap, go to the site of the issue. Be respectful of the workplace– don’t interrupt staff during busy times and let them know clearly why you are there. Use their wisdom to learn about the true nature of the work and to uncover both visible and buried barriers to the work.

2) Look across departments and focus on the resident experience (the “value stream”).

Most issues are rarely isolated to one department. Instead, we need to reach across department lines, gather diverse interdisciplinary teams, and look at challenges from the resident’s perspective. Look for ways to simplify processes, reduce barriers and deliver the right service to the right resident at the right time.

Process mapping, value stream mapping, critical to quality trees, and voice of the customer assessments are all helpful tools during this phase.

3) Find the root cause of problems and enact countermeasures.

Use the five whys, A3 problem solving, and other interactive methods to drill down to the root causes of issues. Too often, providers try to solve surface issues or apply band-aids, which wastes both staff efforts and morale. Sometimes, “solutions” even serve to further  hide problems, which leads to less value for residents. Resist the urge to come to simple conclusions.

When you do identify root causes, brainstorm countermeasures and then test them. Follow up after 30, 60 and 90 days. If the countermeasures fail, be sure to acknowledge the failure with staff and return to the problem solving process. Don’t blame staff for failures! If a countermeasure wasn’t implemented completely, analyze why and adjust the countermeasure as needed. Remember, most staff want to do good work!

4) Sustain results through standardized work.

Once you identify countermeasures, be sure that standardized work is created, staff are well trained, and there is clear and visible documentation. It shouldn’t be difficult for staff to find answers to common questions, and new staff shouldn’t be “thrown to the wolves” when they arrive on the floor. All too often, providers rely on decades-old policies and procedures (and update P&Ps constantly but fail to match them to actual work) and wonder why staff aren’t able to follow through.

Remember, standardized work is the current best practice for accomplishing work. When you know better, do better– but make sure you update the standardized work and ensure that staff are knowledgeable and trained!

EHR Implementation Lessons from the Long-Term and Post-Acute Care Health IT Summit

The LTPAC Summit, held this week in Baltimore, MD, featured dozens of incredible speakers on the growing place of Health IT and technology in the LTPAC space. A number of key leaders at the Office of the National Coordinator and CMS confirmed the importance of increasing attention to LTPAC providers, who were, to a large extent, unfortunately left out of early planning and funding.

An entire track of sessions were focused on EHR implementations and case studies, providing useful advice for providers contemplating an EHR or interested in optimizing a prior installation. I was pleased to present one of the sessions on using lean six sigma to improve implementation strategies. By combining lean analysis of processes and people with six sigma project methodology, I shared how providers can save time and money while reaping better EHR adoption outcomes.

Several themes were common through the track, including these three takeaways:

1) Project Management Skills are Fundamental

Several speakers noted the importance of strong project management skills in designing and implementing an EHR project. LTPAC providers typically don’t have project staff onsite and several providers shared how they benefited from the support of an outside implementation manager to assist with the transition.

An experienced project manager ensures an accurate project charter is developed, the project team is diversified and represents all stakeholder groups, project milestones are kept on track, and resources are deployed effectively to ensure a successful EHR adoption experience.

In planning the project, it is important to spend adequate time on initial project scoping and team selection. Providers noted that initial investments in the planning phase provided substantial dividends throughout the process.

2) Thorough Needs Assessments are Important (and You Can’t Rely on Your Vendor)

From examining IT needs to measuring the current capacity of line staff to use computerized processes, providers shared that an initial assessment is key to developing an accurate plan of the training and equipment that will be necessary for implementation. Vendors can provide some support in this process, but it’s important to not rely on them to drive the process. Oftentimes, vendors propose generic training plans that don’t uniquely address the facets of individual communities and systems.

I shared that one of the ways eSSee Consulting helps providers save money is by focusing training specifically on job routines rather than deploying mass, untargeted training. By creating training specifically for each job, tailored by the staff’s existing familiarity with computers, and deployed close to the time of implementation, providers can expect a 20-40% reduction in total training time needed.

3) Processes Will Change; Be Ready

Workflows and processes need to be updated for an electronic environment. Old workflows should be thoroughly mapped and examined to see how work will change, and it’s important to be willing to let go out old practices and habits. Many providers create trouble down the road by trying to keep old forms and habits that reflect a paper-centric way of thinking.

A great example is the SOAP note that most nurses are familiar with. Traditionally, the chart note is completed by documenting the subjective resident complaint, objective data collected, the nursing assessment of the issue and the plan of care to resolve the concern. Because EHRs store notes in reverse chronological order, and oftentimes truncate notes after a few lines, providers can reduce the time spent on gleaning needed information by promoting an APSO note instead. By charting the assessment and plan of care first, future readers will be able to more quickly identify a resident’s status and care needs, oftentimes substantially reducing the number of clicks needed to display the needed information.


Are You Considering an EHR or Still Struggling to Improve Your Community’s Adoption?

eSSee Consulting offers a range of solutions to assist you. Our deep experience in workflow analysis and process improvement helps us craft individualized solutions that will help your community reap the full benefits of an EHR, from improved resident care to streamlined billing to better business intelligence for decision-making. Get in touch today to learn more about how we can help you succeed.

Standardized Work: A Better Way to Approach Policies and Procedures

One of the most common problems in long-term care is around line staff not following correct work procedures. Long-term care communities have no shortage of policies and procedures, nor are they typically shy in disseminating them to staff over and over (usually after a disciplinary counseling or adverse event). Unfortunately, problems with compliance seem to reoccur, and significant time is spent fighting fires as a result.

So what can be done?

Lean uses a concept called standardized work to describe a more sustainable approach to process and work management. Standardized work is very different than a policy and procedure, and it creates a much different result, as well.

1) Standardized work is written by those who do it. I once worked with an Executive Director who hated writing policies and procedures. “Anything but that!” he would say. His biggest obstacle, however, was that he tried to sit in his office and write out what staff were supposed to do. This is a recipe for disaster. Standardized work is accomplished by having those who do the work write out the process. Managers need to be involved too, particularly making sure all regulatory requirements are addressed, but line staff should lead the exercise.

2) Standardized work is the best knowledge at the time and must be changed whenever improvements occur. Policies and procedures tend to last far longer than their usefulness, and it’s not uncommon for us to walk into a building and find P&Ps that haven’t been reviewed or updated for years. In addition, line staff view P&Ps as mandates from above that must be followed regardless of whether they make sense or describe the best way to accomplish work. Standardized work, on the other hand, is supposed to be improved upon. By tasking line staff with the primary responsibility to write the process, they are likely to be more empowered to change the work as they discover better ways to accomplish tasks.

3) Standardized work must be clearly displayed. Standardized work serves as both a guide for line staff and a tool for supervisors to ensure work processes are completed corrected. By communicating the information clearly, and placing the information in easily accessible places (NOT in a binder on the shelf that no one reads!), it’s much easier for employees to do what is expected of them.

4) Standardized work makes orientation much more effective and complete. How many times have you hired a new staff person only to find they are trained “the wrong way” by their trainer? With turnover between 30% and 75% in most communities, consistency of training is a huge concern. Standardized work helps ensure consistency because it represents the best way to accomplish a task. It also provides an easy to understand, easy to follow guide to the work expected of new staff.

5) When standardized work is not being followed, managers must ask why. In typical environments, managers respond to failure to follow work procedures by admonishing or disciplining an employee and requiring compliance. Lean requires a different approach. Instead, managers must ask the employee why the standardized work is not being followed. Employees rarely choose to do bad work for the sake of doing bad work. Instead, other problems (the root causes) such as not having adequate equipment or supplies, not having enough time, or an outdated practice are the reasons behind deviation. By asking why and finding the actual problems, we help to create better work environments for all staff, leading to better care and service to residents.


For more thoughts on standardized work, read Mark Graban’s post, where he summaries the main concepts from Lean Hospitals.

Root cause analysis in The Toyota Way to Lean Leadership

In Jeffrey Liker and Gary Convis’ book, The Toyota Way to Lean Leadership, Gary recounts the story of a young Toyota manager, Yuri Rodrigues, learning the lessons of root cause analysis while working at a Toyota plant in Brazil. A quality problem in the trim department was traced to the wrong torque being applied by technicians. Yuri suggested the plant purchase modern wrenches that would stop automatically when the right torque was applied. His leader replied, “Do you want me to buy new $400 wrenches for everyone in the plant? Because if you’re telling me that is your solution for the problem, that’s what I’ll have to do. I suggest you go back and observe the team members to really understand this problem.” Upon further research, Yuri discovered the ultimate root causes to be poor training and a lack of preventative maintenance.

I like this story for a couple of really important reasons:

Root cause analysis is hard

Purchasing modern wrenches would have been an easy solution, but another quality problem caused by the same lack of training and preventative maintenance would have occurred shortly down the line. In long-term care, fixes are commonly applied to a surface issue, but there is little work on the root causes, and the daily work is filled with a prioritization of firefighting activities.

Ultimately, a lot of unnecessary waste could be eliminated by uncovering the common root causes for many of the problems that plague the industry and addressing those instead of continuing to manage crises. Unfortunately, finding root causes takes tenacity, insight, and an engaged workforce that can critically examine work practices.

Error-proofing is not always the right (or only) solution

Error-proofing is an important part of building quality into processes, but it’s not always the best approach to a problem. In this case, an automatically-stopping wrench might make it easier to use for untrained technicians, but it would just push the problem into another area of the work. Creating “idiot-proof” systems rarely leads to sustainable quality. Rather, error-proofing goes hand-in-hand with expertise and fully-trained employees.

In contrast, solutions in long-term care oftentimes perpetuate the root causes of poor training and a lack of employee engagement by trying to make it difficult for line staff to influence the process. These bottom-line focused solutions might solve one issue, but the core cause is still there.

Problems are rarely caused by a single issue

When Rodriguez went back to the line to study the problem, he discovered not only the wrong torque being applied to the trim, but also that the preventative maintenance program was missing. This example demonstrates one of the most important– and sometimes overlooked– benefits of a rigorous root cause analysis process: the identification of multiple causes, each of which might need a different countermeasure.

Too often, we stop after identifying the first problem and miss other contributory factors, which only leads us back to quality issue. In most cases, we need to focus on root causes, not just root cause.

Workers are not the problem

An easy answer to the problem would have been to tell workers to stop over-tightening the bolts. Lean thinking, however, teaches us that this is mostly a wasted effort, and will have little lasting impact on quality. Instead, the point that lean makes over and over is that workers are not the source of problems in most organizations, systems and processes are. The lean value of respect for people demonstrates that with fair treatment and proper tools and resources, employees can actually solve most of the challenges confronting an organization– they just need to be unshackled from dubious mandates and ill-conceived systems.

Too often, line staff in long term care are blamed for poor performance and quality problems. Broad inservicing and rampant memos take the place of thoughtful training and effective communication, and the disciplinary process is quick to engage staff unlucky enough to be singled out by management. To drive sustained results, we need instead focused root cause analysis and a culture that supports long-term quality improvement and value creation.


Lean Bureaucracy

As organizations mature, bureaucracies tend to grow to provide support for large, system needs. In long-term care organizations, bureaucracies leans towards a coercive model of employee management, relying on strict rules, policies and procedures and hierarchies. In The Toyota Way, Jeremy Liker diagrams four styles of bureaucracy, modeled after organizational theorist Paul Adler’s research on Toyota:

Organizational Bureaurcracy


Organizations, when small and young, trend towards the bottom half of low bureaucracy. With little structure, organizations either rely on the empowerment of individual employees or the direction of strong executive leadership. As organizations evolve, rules and procedures become more complete and complex, and there is a natural drift to the top left quadrant.

What Toyota has done with lean management is create systems that provide support for people, invest deeply in individuals (through training and mentoring) and then promote ongoing learning to enable autonomous decision making. The result is an agile culture of continuous improvement that exists within a large, corporate body.

Contrast this to most long-term care organizations, where line staff typically has little ability to change or improve their own work. Supervisors and managers spend considerable time and resources ensuring compliance with rules and proper procedures. Think of the standardized checklists for paperwork that must travel an almost endless cycle of approvals or the trivial management of side work without regard to outcomes.Think of the effort spent on managing the few employees who struggle with non-compliance and the lack of investment in the rest of the team.

How can organization’s make the shift?

Instead of focusing most resources on the poor performers through a system of performance standards, focus on best practices and share information extensively. Support team learning and sharing of these best practices rather than individual assignment of blame.

Instead of creating forms and processes in closed loop circles (like HR or management meetings), actively engage employees in the process and listen to pain points in completing bureaucratic work. If forms require redundant work or excess approvals, involve the stakeholders in conversation and revise them.

Build systems and polices that support the majority of employees who will do good work, rather than for the small minority of employees who need to be proactively managed out of the organization.

Create a culture where policies and procedures are guidelines of the best current knowledge, rather than strict rules from above. Encourage staff to communicate opportunities for improvement through dialogue and challenge.


For a great related article, check out “How Netflix Reinvented HR” in the Harvard Business Review.

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