Tripp - your old cut and paste talking point was that Lean was "codified" in an extreme, unevolving way. You speak of Lean as this centrally-controlled monolith... but now you're trying to claim there is no consistent method. Which is it? Clearly, there is no "cookbook" for how to implement Lean. If there were, you'd criticize that. There are consistent Lean principles -- it's easier to define "what Lean is" and "what Lean is not" than it is to define precise roadmap that doesn't exist.

Many are "doing Lean wrong" because they don't understand or don't embrace core concepts like "respect for people" or they blindly copy tools. Neither Berwick nor Toussaint are advocating the blind copying of tools. They are being inspired by manufacturing quality, which is often at a higher level than healthcare.

Who is doing is right? Clearly, ThedaCare is one of those organizations (based on their peer-reviewed data) and yet they'd be the first to admit that they aren't perfect and they don't have it all figured it.

Tripp,
Please cite the data you are challenging and explain. I think it’s time for you to substantiate such an allegation or retract it.

By the way, re-read On the Mend pages 28, 52, 67, 71, 93-98, 135-136, 154, 171-174, where standardized work as applied to healthcare is fully explained. You’ll see that unlike your mistaken characterization of it as an inflexible one-best-way approach, standardized work is always being improved.

I’d like to point out that asking the “5 Whys” in Chapter 3, an exercise you questioned because it led to a team’s realization that a standard process was needed, was part of a very successful effort to reduce the waiting time for people suffering heart attack symptoms.

I’d argue that having an efficient standardized process for treating heart attacks is a good thing if every step in the process adds value from the patients’ point of view — immediate EKG in a dedicated room, all medication stored in a kit that a nurse grabs as she enters the room, immediate vital signs taken by another nurse, immediate paging of a catheter team if the ER doctor sees a heart attack on the EKG, etc. This is what ThedaCare did. And it is continuously improving the process, beginning from the baseline of the current standardized process.

You failed to note that on p.42, also in Chapter 3, that doctors believe that because a standardized process is now followed for every person complaining of chest pains, more people having heart attacks are being identified and treated, especially women and others having atypical symptoms.

Perhaps you haven’t gotten to page 112. The authors explain what can’t be standardized about medicine. They call it “middle flow” and it’s the time doctors actually examine patients and discuss treatment. Every patient is different so there is no attempt to make every doctor behave the same way. However, much of what happen before and after examination – making the appointment, taking vital signs, running follow-up tests, making follow-up appointments – can be improved by standardized work as well as other lean concepts.

In healthcare, the customer should not be viewed as merely “part of the delivery” as you imply; that’s a dangerous approach. The customer (patient) should be the focus of delivery processes. In fact, lean healthcare designs care around the patient as a true system approach should. (Full disclosure: I work at the Lean Enterprise Institute, publisher of On the Mend. You are invited to read what respected healthcare and process improvement experts have said about the book at:
http://www.lean.org/BookStore/ProductDetails.cfm?SelectedProductId=275&… )

Many different things and there are no perfect data . . . understood. Here are a couple:

1. An understanding that there was not any reward or incentive to manipulate the data. If executives or managers were rewarded for the numbers manipulation can easily come into play. I asked you this question and you said you didn't know. Yet you promote the book and all that is in it.

2. There are no data on control charts. The writers assail six sigma in the book, but the one useful thing that six sigma has in the SPC charts. The book itself, displays no knowledge of variation. Deming and Shewhart left us a great way to look at data. If you put the Theda Care employee satisfaction survey (page 170) on a XmovR chart you will see that there is no improvement is ee satisfaction all points with in the limits, chart it yourself. The lack of charts tells me a lot that is wrong with the approach. How do you improve a system without knowledge of special and common causes of variation and the importance in taking the right or wrong action?

You claim to know about Deming and his teachings and promote a book devoid of one of his most important contributions.

3. Operational definitions. How things are or aren't counted make a difference. I have no idea whether the same operational definitions that were used in the baseline data applied to the "improvement" data. I do know that when I get into the work that I usually find things mis-categorized, just by pulling them out does not constitute improvement. I would say that in most improvement efforts that I have been involved that operational definitions have a tendency to change.

4. These writers don't explain what is wrong with the data. Ever talk to a scientist? He can tell you what is wrong with his findings regarding an experiment. Same thing applies to data. I see some things like the footnote on page 3 that gives me a range of data results for a time period (not relevant to Theda Care's data and its timeline), but no chart indicating limits for the HHS data.

I suspect other problems but peer reviewed or not, most physicians don't work with data in this way. They may know medicine, but most don't understand variation or the use and misuse of data.

There are others but I can't and won't fix all that is wrong and suspect with lean manufacturing approaches in service industry.

Tripp - you are the only that lacks evidence that Lean is "dangerous" (as you say) or that it doesn't work.

There is countless evidence data and evidence published all over the place that Lean can work in healthcare, especially when it is treated as a philosophy and a management system instead of being just a bunch of tools.

If you had evidence or experience to share, I would listen. I'm still waiting.

Can we please have a rule here about stating your conflict of interest, since Howard (SYSTEMSTHINKER) works for John Seddon....

Did you even read Dean's piece? He talks about philosophy and management system... this is ridiculous.

SYSTEMSTHINKER - the notion that you and Tripp share that lean can be "dangerous" (your words) for healthcare -- is this a theory or a fear or do you have evidence and examples? If you do have examples, it's time to step forward with them.