Wednesday, September 29, 2010


To follow up on yesterday's post about the CC6 Lean team, I had a few minutes today to drop by just as the group was getting engaged in fishbone diagrams. These are used to brainstorm in more detail the nature of major problems, looking at their components and then asking the "five why's" to conduct a root cause analysis.

As I walked into the room during a break, a couple of people mentioned to me that the morning session had been a lot tougher, emotionally, than yesterday's current state analysis. This is a common stage in the Lean process. It is relatively easy to map out the current state. When you start talking about why it exists, it is hard not to blame someone else in the room or someone who is not in the room. "If [name] only did this differently, we could solve the problem," is the common refrain I have seen in other rapid improvement events.

But, the idea of Lean is to focus on the problem and not the person. This is not about blame. It is about a workplace environment that has evolved over the years -- full of work-arounds and inefficiency and waste. By the time I left, the group was again smiling a bit more and collaborating on how to analyze the situation. Later, they will invent countermeasures to help undo the waste, setting goals and targets and timelines for the next steps.

Here is a short video about fishbones to give you a sense of the concept and how it progresses. Jenine Davignon from our business transformation group is leading the class. If you can't view the video, click here.


Anonymous said...

I realize this may sound like heresy, but is there a "diet" version of Lean which may be self-taught and implemented in, say, a single-physician practice, or a small independent laboratory? The process described here is of course critical for a large operation, but applying that amount of time and resources to a small operation seems daunting.

I confess I have not paid attention to this level of detail until it suddenly became personally relevant, but I bet my question applies to others also.


Alison Small said...


Just to recap our second day of Lean Rapid Improvement Event focused on cc6 work flow and communication.

We identified major opportunities for improvement and were able to prioritize action plans. We accomplished this by utilization of A3 process which created goals and target dates for our identified improvements.

Building off the work we did yesterday on our current state process map we developed a future state map for cc6 which had many less non valued steps.

Utilizing Fish Bone Diagrams we were able to take our agreed upon goals and identify barriers to these goals.

Our very engaged Lean Group was able to see the value in standardized work and the importance of standard work flow to create an environment for lasting and sustained improvement.

We wrapped up our two day event by creating timelines for Just-Do-It improvements. For example:
Standardize patient assignment sheet;
Redesign linen carts and location on unit;
Relocate supplies and location on unit bringing them closer to the patient and staff who use them;
Redesign Unit White Board to display geographical assignment locations;
Form Unit task group to develop cc6 staff expectations that outline role responsibilities and foster staff respect;
Developed cc6 Lean Steering Committee that will monitor progress and work to maintain sustainability.

I would like to thank everyone for their participation it was a great two days with lots accomplished. Stay tuned we have only just begun to improve work flow and communication on cc6 which will ultimately improve care of patients.

Mark Graban said...

@Nonlocal - There is a book published by the American Society for Quality called "Lean Doctors" that seemed pretty solid (I've read most of it) and it's targeted toward outpatient / ambulatory settings.

I've worked with a primary care office before (3 docs, a PA, nurses and front desk staff)... finding time to get people to look at their own process was a challenge. We certainly didn't/couldn't have a room full of people looking at their processes and workflow, but it was possible to drive change that helped the docs and improved patient flow.

Anonymous said...

Thanks very much, Mark!


Rich said...

From Facebook:

Very cool. We are starting our 5th RIE in a few weeks and our Sensei has yet to pull out the Fishbone to facilitate the elucidation of the 5 why's. It must be a personal preference.

It is amazing how powerful these events can be. I have had directors stare at me in amazement as I describe how we are getting our providers to switch office locations to allow better patient flow. Following the lean process allows us to show, in excruciating detail, why it is in everyone's best interest to redesign everything with the patients in mind.

We moved into a new multi-story, multi-million dollar facility a little over a year ago and quickly realized that the building was not designed well. Despite this, the RIE process has been nothing but positive and forces us to focus on how to act on the opportunities to improve rather than point fingers. I am glad you are having the same experience.

SuziCollins said...

Great entry and video. The work that your staff is doing is impressive. I hadn't seen the fishbone diagram before but I like that concept very much. Looking forward to seeing the results after the implement the changes. Thank you so much for sharing!

Suzi Collins