June 19, 2013
Fast Thinking & Slow Thinking

gemba walk” (lean thinking term) to go to the actual place where value is added + “walkabout” (Australian aborigine) a short period of wandering bush life engaged as an occasional interruption of regular work . Mike Stoecklein . mstoecklein@createvalue.org . my employer gave me that e-mail address, but the ideas and opinions below are mine.

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I came across this from one of my favorite websites: http://www.youtube.com/watch?feature=player_embedded&v=yanow4fcYg0 
It’s worth watching.  Here’s a related one: http://www.youtube.com/watch?feature=player_embedded&v=0zMbtamP8_E 
The website I am referencing is: http://blog.deming.org
The topic of slow thinking and fast thinking makes good sense to me and is something I am trying to learn more about.  I found this book: Thinking, Fast and Slow by Daniel Kahneman (a Nobel Laurette – in economics)

Some excerpts from the book (so far, I’m not done reading it):

I adopt terms originally proposed by the psychologists Keith Stanovich and Richard West, and will refer to two systems in the mind, System 1 and System 2. System 1 operates automatically and quickly, with little or no effort and no sense of voluntary control. System 2 allocates attention to the effortful mental activities that demand it, including complex computations. The operations of System 2 are often associated with the subjective experience of agency, choice, and concentration.
When we think of ourselves, we identify with System 2, the conscious, reasoning self that has beliefs, makes choices, and decides what to think about and what to do. Although System 2 believes itself to be where the action is, the automatic System 1 is the hero of the book. I describe System 1 as effortlessly originating impressions and feelings that are the main sources of the explicit beliefs and deliberate choices of System 2. The automatic operations of System 1 generate surprisingly complex patterns of ideas, but only the slower System 2 can construct thoughts in an orderly series of steps. I also describe circumstances in which System 2 takes over, overruling the freewheeling impulses and associations of System 1. You will be invited to think of the two systems as agents with their individual abilities, limitations, and functions.
In rough order of complexity, here are some examples of the automatic activities that are attributed to System 1:
Detect that one object is more distant than another.
Orient to the source of a sudden sound.
Complete the phrase “bread and…”
Make a “disgust face” when shown a horrible picture.
Detect hostility in a voice. Answer to 2 + 2 = ?
Read words on large billboards.
Drive a car on an empty road.
Find a strong move in chess (if you are a chess master).
Understand simple sentences.
Recognize that a “meek and tidy soul with a passion for detail” resembles an occupational stereotype.
The highly diverse operations of System 2 have one feature in common: they require attention and are disrupted when attention is drawn away. Here are some examples: Brace for the starter gun in a race.
Focus attention on the clowns in the circus.
Focus on the voice of a particular person in a crowded and noisy room.
Look for a woman with white hair.
Search memory to identify a surprising sound.
Maintain a faster walking speed than is natural for you.
Monitor the appropriateness of your behavior in a social situation.
Count the occurrences of the letter a in a page of text.
Tell someone your phone number.
Park in a narrow space (for most people except garage attendants).
Compare two washing machines for overall value.
Fill out a tax form.
Check the validity of a complex logical argument.

In all these situations you must pay attention, and you will perform less well, or not at all, if you are not ready or if your attention is directed inappropriately. System 2 has some ability to change the way System 1 works, by programming the normally automatic functions of attention and memory.

June 16, 2013
Still “All In” … and could use some help

gemba walk” (lean thinking term) to go to the actual place where value is added + “walkabout” (Australian aborigine) a short period of wandering bush life engaged as an occasional interruption of regular work . Mike Stoecklein . mstoecklein@createvalue.org . my employer gave me that e-mail address, but the ideas and opinions below are mine.

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So, I met this by (by phone) and now I’ve met him on skype.  I wrote about him some weeks ago:

http://gembawalkabout.tumblr.com/post/48848011399/t-minus-41-days-until-the-lean-healthcare

He’s doing some amazing stuff in Tanzania.  Here’s a link to his latest work:
http://www.linkedin.com/groups/Using-Lean-thinking-reverse-Maternal-3880443.S.245123890?qid=a3a90646-ead7-40a0-928e-3fdb47172628&trk=group_most_popular-0-b-ttl&goback=%2Egmp_3880443

It’s from a Linkedin group he started - Lean4NGO 

This link will also connect you to this “Mentors For Africa” blog: http://mentorsforafrica.blogspot.com/2013/05/my-first-79-days.html?goback=%2Egmp_3880443%2Egde_3880443_member_245123890 

He also corrected me on the information I provided about him - he did not sell off all of his possessions … but, pretty darn close.

He’s doing amazing stuff, he’s still “all in” and he could use some help.  Any help.  What he’d really like is “boots on the ground” (people who have some lean skills and could help him in Tanzania).

But he’ll talk to anyone about any help they can give.

So . contact him.  I’m sure he won’t mind if I make a connection for you.  So, here’s my contact information.  mstoecklein@createvalue.org  If you reach out to me, I’ll help you reach out to him.

He’s “all in”.  We should all be “all in”.  He’s showing us what “all in” looks like. 

June 14, 2013
Optimize & Suboptimize

gemba walk” (lean thinking term) to go to the actual place where value is added + “walkabout” (Australian aborigine) a short period of wandering bush life engaged as an occasional interruption of regular work . Mike Stoecklein . mstoecklein@createvalue.org . my employer gave me that e-mail address, but the ideas and opinions below are mine.

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My job is to optimize a peer-to-peer learning network.  What does that mean?

We have member organizations all over North America.  Not everyone can get together all of the time face to face (we do our best once a year with our annual Summit - see last 50+ posts).  In order to optimize the experience for all, we design and redesign systems and processes that facilitate learning, sharing and connecting between all of the members.

Here’s an example.  Just yesterday, we sponsored a webinar that featured an organization in Indiana and one in New York.  They described their approaches to education and training around lean concepts.  During the webinar, one of the participants (from Pennsylvania) acknowledged and thanked one of the presenters for some things he and learned.  The presenter thanked the Pennsylvania guy in return.  As it turns out, the New York folks paid a visit to the Pennsylvania folks.  This would not have happened without the systems and processes that support the network.

After the webinar, the two presenters and I exchanged some e-mails.  Both presenters mentioned and expressed thanks for what they had learned from each other.  This would not have happened without our help (the webinar), and it will lead to future interactions and sharing.

The system works.  But what does “optimization” mean?  Sometimes, ideas are put forth by members to make things better.  We ask for these ideas all of the time and specifically during our advisory council meetings.  We try to act on as many of the ideas as we can, but we can’t act on all of them.  My job is to optimize the whole, not the parts.

Dr. Deming talked about this a lot.  And you can read about it in his books.  In The New Economics, he illustrates the concept of optimizing the system as follows:
image
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Dr. Deming proceeds to illustrate with a simple 3-part system (company).
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This is a simple (3-part) system.  The system I oversee has 50+ members, so the grid would be much bigger.

The table below shows the idea of optimization.
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This shows that, without thinking about impact on the overall system (all members), there are some winners, but also losers and the net effect for the system as a whole is a loss.
With some understanding of optimization of the system, the benefits are shared by all, even though (for some), they may not see it as a “win”.  By definition, optimization of the whole system means that some of the parts will be suboptimized.
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And the process continues with exploration of further ideas - for the benefit of all.
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June 13, 2013
Best Conference Ever! … till next year, It’s Thursday, not too late to start that experiment

gemba walk” (lean thinking term) to go to the actual place where value is added + “walkabout” (Australian aborigine) a short period of wandering bush life engaged as an occasional interruption of regular work . Mike Stoecklein . mstoecklein@createvalue.org . my employer gave me that e-mail address, but the ideas and opinions below are mine.

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One year ago, to the date, I posted this:

http://gembawalkabout.tumblr.com/post/24714920664/best-conference-ever-till-next-year 

I thought it was true, and turned out I was right.  Now the 4th Annual Lean Healthcare Transformation Summit was the best conference ever.

Some favorite tweets (more to follow in the days ahead):

“It might be a crappy standard, but let’s prove we can hit it 100% and then move to a better standard.” Craig from Packard

Lean’s place in strategic planning? Macfie:Not only in finance, quality or culture discussion; lean surrounds the entire process!

don’t treat patients as idiots, treat them as partners, with respect

In Sweden, surgeons are offering FIVE YEAR warranty on knee-replacement surgery. If ANYTHING happens, payer doesn’t pay.

“We have to change how we deliver healthcare if we want to stop impoverishing American families” says Francois deBrantes at

Toussaint - don’t just Plan and Do and Run - focus on Study and Adjust!

If you think your system is doing well today, wait a month. Reimbursement is changing

Toussaint: first question he asks on any Gemba visit: ‘How is your existing process working?’. Do you know?

We spend millions of $ on electronic medical record & what do we have? A system that produces faster crappy data

Can we at least thank people for what they do? Even if we thank them for great workarounds

“Most of what we call mgmt consists of making it difficult 4 ppl 2 get their work done.” Toussaint quoting Drucker

We are off & running

June 12, 2013
Best Conference Ever! … till next year, It’s Wednesday, How’s that Experiment Going?

gemba walk” (lean thinking term) to go to the actual place where value is added + “walkabout” (Australian aborigine) a short period of wandering bush life engaged as an occasional interruption of regular work . Mike Stoecklein . mstoecklein@createvalue.org . my employer gave me that e-mail address, but the ideas and opinions below are mine.

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One year ago, to the date, I posted this:

http://gembawalkabout.tumblr.com/post/24714920664/best-conference-ever-till-next-year 

I thought it was true, and turned out I was right.  Now the 4th Annual Lean Healthcare Transformation Summit was the best conference ever.

Some favorite tweets (more to follow in the days ahead):

RT : O’Neill: “Compare everything you do to what perfect looks like. It’s like draining the swamp.”

Why is it so hard to call a defect a defect?

Irony. RT : Paul Oneill: health care injury rates are highest of any industry in US

O’Neill: “You can’t get to zero safety incidents with cheerleading or writing it on the wall”

Yes. Events are episodic, not continuous. Events alone cannot create a “culture of continuous improvement.”

Reich: it’s exciting to see what’s happening in healthcare. What’s the ideal state for the culture of your HC organization ?

O’Neill Alcoa market value increased 800% in 13 yrs by paying attention 2 NON-financial measures… finances took care of self

Paul O’Reilly If God is not keeping you from doing it, do it! Just strive to be perfect with no waste

There will be a lot of quotes coming from this years summit. Amazing! Still love the Transparency analogy.

O’Neil: It takes 5 months to close our books at the treasury. It should take 2.5 days

Paul Oneill: It is fascinating to see how accounting view distorts economic view, creation of human value view.

Leader of Paul O’Neill’s stature (Secretary US Treasury, CEO Alcoa) working on HC improvement great sign. Wonderful presentation

O’Neill at “Working to do things perfectly leads to better financial results than any sort of financial engineering.”

O’Neill at “the goals [like 0 injuries] aren’t from on high, but from a discussion about what the aspirational goals SHOULD be”

Show me organization with a Vice President of equal opportunity & I’ll show you an organization without equal opportunity

O’Neill: Can your employees say: “I am treated with respect and dignity by every person I encounter every day”

paul o’neill . Belief we can’t afford to be better than we are . Don’t want to set goals we feel we can’t achieve

Paul O’Neill: Does your org really value its employees? Does your org publicly report real-time days lost to workplace injury?

Paul O’Neill: If you want to be best in the world at what you do, you must start by caring about people in your institution

Organizations are either habitually excellence or they are not paul O’Neill

Nice job by all the presenters at the ‘Experiments Around the Network’ afternoon track

June 11, 2013
Best Conference Ever! … till next year, keeping the buzz alive

gemba walk” (lean thinking term) to go to the actual place where value is added + “walkabout” (Australian aborigine) a short period of wandering bush life engaged as an occasional interruption of regular work . Mike Stoecklein . mstoecklein@createvalue.org . my employer gave me that e-mail address, but the ideas and opinions below are mine.

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One year ago, to the date, I posted this:

http://gembawalkabout.tumblr.com/post/24714920664/best-conference-ever-till-next-year 

I thought it was true, and turned out I was right.  Now the 4th Annual Lean Healthcare Transformation Summit was the best conference ever.

Some favorite tweets (more to follow in the days ahead):

CEO summit within the we need more experiments that manage across the silos avoid more problems like tish’s story

CEO summit within the it’s important to have access to a mentor . When you hit the wall

Healthcare Business Performance. Mindset, skill set, tool set. Analytics tools are only as good as your ability to analyze.

One persons waste is another persons revenue said Mark Hallet @ be respectful when asking questions.

Standard work is the best known way to do the work TODAY. Today being an important word. Always room for improvements.

we didn’t know what we didn’t know when you don’t know what you don’t know you need a consultant

A3 thinking is not an individual sport. It is a team sport that requires coaching.

established candor with respect use a3 thinking to make progress CEO summit within the summit

Hallett: “Quality is a process… but when there’s a problem, people don’t sue a process”

We have not established the competences for management . The standards . We need to change the way we train . Not to groups

The problem of deselecting - what we agree we will NOT work on the CEO summit within the . need a process & follow it

Teaching and coaching is an executive responsibility. CEOs should be CBRs (Chief Barrier Removers)

Wish I had gotten a pic of all the MD hands going up in air… about 1/3 of this breakout session audience. Great to see

Henry Hawthorne CEO @ carolina lean collaborative puts you in the baseball position to be ready for what is next

@ quality improvement without payment reform is shooting yourself in the foot. FFS payment is barrier to progress.

CEOs @ governance of a lean organization is different they need education too . Gemba visits for the board helping

Don Shilton CEO @ st Mary’s Kitchener Ontario 2 days with paul O’Neill like 2 days with Knute Rockne Working on board education

Alan Aviles CEO union environment not that different . Have discovered leaders we did not know we had

All 3 CEOs @ CEO panel have foundation of engaged employees to identify & remove waste

Henry Hawthorne CEO @ Carolina lean collaborative catharsis in truth telling with transparency on how we are doing

Shilton: we set & achieved goal of becoming safest health system in Canada

You can’t improve if you don’t know what your current state is

H. Hawthorne Columbus Reg. CEO: We had fallen into tolerance w mediocrity. We were ‘habitually good’ & we were ok w that.

Lean can be threatening to middle managers because they’re trained to be problems solver instead of coaching/empowering staff

alan Avila CEO ion the CEO panel not likely candidate for let 1000 flowers bloom to get engagement


June 10, 2013
It’s Monday Morning, What’s Your Experiment?

“gemba walk” (lean thinking term) to go to the actual place where value is added + “walkabout” (Australian aborigine) a short period of wandering bush life engaged as an occasional interruption of regular work . Mike Stoecklein . mstoecklein@createvalue.org . my employer gave me that e-mail address, but the ideas and opinions below are mine.

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One year ago, to the date, I posted this:

http://gembawalkabout.tumblr.com/post/24714920664/best-conference-ever-till-next-year 

I thought it was true, and turned out I was right.  Now the 4th Annual Lean Healthcare Transformation Summit was the best conference ever.

Some favorite tweets (more to follow in the days ahead):

It’s standing room only in the Shingo Scrimmage session with BJC Healthcare…WOW!

Reward & recognition system typically drives the wrong behavior - focus on results behaviors are leading indicators

Need to identify the behaviors that really matter CEO breakout

Mark Hallett MD: “MDs can be the primary saboteurs or turbo chargers of your initiative.”

Lean for Physicians: Unlock the scientific methods they(MDs) already have to charge your lean transformation

Business performance systems: “the ultimate arrogance is to change the way people work but not to change the way we manage.

Just heard Alan Gleghorn’s keynote @ in Orlando. Very relatable and great presentation!

Alan Gleghorn on Leading improvement: Focus on facilitating the passion for closing the gap or you’ll sabotage the journey

We need to develop a love of improvement . It IS about the snacks the storm

Gleghorn: Don’t show people this complexity until they first love the game.

“Big ole solution waiting for a problem to solve” what traditionally defines a successful manager.

I don’t know if 21 days breaks a habit but it sure breaks a spirit the storm

Tools + theory does not equal doing we got resistance from management the 8th wonder of the world x matrix

Only take advice from farmers with fruit on their trees the story the storm

: Hospital billboards celebrating their success. Read the fine print, “We still suck” -A.Gleghorn

Alan Gleghorn: “How many books about growing fruit trees do you think my farmer grandpa had on his shelves?”

Top 20 this, top 100 that, best place for this. Under all that fine print it says “we still suck”. Alan Gleghorn tells it.

- Gleghorn - manufacturing employees are motivated extrinsically - healthcare is intrinsically around the patient outcomes


June 9, 2013
Best Conference Ever! … till next year (ditto) day 2

“gemba walk” (lean thinking term) to go to the actual place where value is added + “walkabout” (Australian aborigine) a short period of wandering bush life engaged as an occasional interruption of regular work . Mike Stoecklein . mstoecklein@createvalue.org . my employer gave me that e-mail address, but the ideas and opinions below are mine.

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One year ago, to the date, I posted this:

http://gembawalkabout.tumblr.com/post/24714920664/best-conference-ever-till-next-year 

I thought it was true, and turned out I was right.  Now the 4th Annual Lean Healthcare Transformation Summit was the best conference ever.

Some favorite tweets (more to follow in the days ahead):

Womack at - no1 ever got a bill, said “woah that’s large, but OK since there was so much good mgmt in what I got”

Jim Womack no tool has ever been invented that cannot be misused

Womack says he’d like to take “Dr. Pokayoke” to the hospital with him to doublecheck every single thing that’s done :-)

Mgr can’t tell doc how to do his work but he can ask how he’ll do it &how he’ll collaborate w/others to get a repeatable result

Womack cautions attendees to watchful so Lean does not become falsely associated with cost (read head count) cutting

Womack: Said “no” when hospital CFO asked if could take out 25% of cost in 1 year. That’s not the reason to try lean.

Womack: In current U.S. government environment, “nobody is allowed to spend any money to go learn anything.”

Womack: Henry Ford lacked “a scalable management system” (it was all dependent on Henry)

Womack: W’re trying to get today’s healthcare up to the performance level of Henry Ford in 1908.

June 8, 2013
Best Conference Ever! … till next year (ditto)

“gemba walk” (lean thinking term) to go to the actual place where value is added + “walkabout” (Australian aborigine) a short period of wandering bush life engaged as an occasional interruption of regular work . Mike Stoecklein . mstoecklein@createvalue.org . my employer gave me that e-mail address, but the ideas and opinions below are mine.

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One year ago, to the date, I posted this:

http://gembawalkabout.tumblr.com/post/24714920664/best-conference-ever-till-next-year 

I thought it was true, and turned out I was right.  Now the 4th Annual Lean Healthcare Transformation Summit was the best conference ever.

Some favorite tweets (more to follow in the days ahead):

Sitting poolside with and the guy next to us is reading Managing to Learn!

RT O’Neill: Can your employees say:”I am treated with respect and dignity by every person I encounter every day”

“Most people are out on the floor because the floor is on fire. That’s not a jim Womack”

Thanks to all who tweeted from the . You helped bring a little of the Summit to all of us who wanted to be there and couldn’t.

“MDs can be the primary saboteurs or turbo chargers of your initiative.” ” Many MDs were doing QI before LEAN or QIPP !

- Monday morning, take on the gaps in the management system, thanks for an OUTSTANDING chance to recharge and share

All that ROI work for is Muda . No patient ever asked for the ROI

Womack on ROI: “If you add up all the projects, they’ve removed more cost than there is in all business.” :-) The work of improvement is not done by the improvement team, it is done by the line. - Jim Womack

“That’s impossible”, said the workers. “In that case we need to start immediatly” said the Toyota sensei. Thanks Jim Womack.

- Womack - to purpose, process, people add work, management, leadership - say this 5 times fast!

Lean Leader Goals = To eliminate on their watch the need for heroic leadership

Jim Womack senior management must create a legitimate role for horizontal thinkers 

June 3, 2013
T-Minus 1 Day Until the Lean Healthcare Transformation Summit - To Be List, Item #11

“gemba walk” (lean thinking term) to go to the actual place where value is added + “walkabout” (Australian aborigine) a short period of wandering bush life engaged as an occasional interruption of regular work . Mike Stoecklein . mstoecklein@createvalue.org . my employer gave me that e-mail address, but the ideas and opinions below are mine.

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Most everyone has a “to do” list.  I do.  The current list has 158 items on it, up 4 from yesterday.  Is that different?  Shouldn’t I be concerned? Isn’t that something to react to?  Maybe, maybe not.  I’ll mention something about that on “T-Minus 1 Day”.  

Wait a minute -that’s today. 

What about a “to be” list?  I was thinking that this is what the 10 guiding principles of the Shingo model are - a list of things to be.  It doesn’t have to be the principles from the Shingo model.  Other people have proposed their list of principles.  Dr. Deming had 14 points (really principles, I think).  Jeffrey Liker lists a different set of 14 principles in his book “The Toyota Way”.  Womack and Jones described 5 principles in their book “The Machine That Changed The World”.  In a recent article (http://bit.ly/12IFR0M) Toussaint and Berry describe 6 principles.  There are examples from other authors and thought leaders.  I could go on and on.  You get the idea.

Here’s the 11th item on the “to be” list using the Shingo model for operational excellence:

Wait a minute - there are only 10 guiding principles in the Shingo Model.  What’s this “11th item”?

I think the Shingo model is missing an important item.  It is something that was central to Dr. Deming’s teaching, but for some reason, it has been “lost in translation” over the years.  Maybe it is implied in the model, but not explicit.

The 11th item is - be a person who understands how to react to variation.  Sounds simple, but I see absence of this knowledge every day.

First - the basics:
1 Every process (or system) produces output in variation - variation happens.
2 There are 2 types of variation: from common causes and from special causes.
3 Common cause variation is the random variation that comes from the parts of the system and how they interact.  You cannot (and should not) try to find the “root cause” of common cause variation.  You won’t find it.  Chasing after this is a waste of your time (muda).
4 Special cause variation is something different.  Something that deserves study and action.  It can be a special cause that produces extra good results or one that produces worse results.
5 Knowing what kind of variation you are dealing with matters.  Traditional management thinks action is require and ends up tampering (making matters worse).
6 For those who DID learn this, they most likely think that it applies when you have figures.  Duh … that’s why you make control charts right? 
7 The most important applications of this knowledge applies when you don’t have figures - in the management of people.
Why do I consider this to be a guiding principle?  Because it has these characteristics:
1) It is a universal truth, a self-evident law of nature.
2) It governs consequences.  Whether you understand variation and how to react to it or not, you are governed by the consequences.  One of the main consequences are the losses (wasted efforts) due to tampering - reacting to random variation as if it requires action.

I’ve recorded some webinars on this topic, so go here to listen and watch:
http://bit.ly/12rSbXu
So …. I’ve been keeping track of the items on my “to-do” list every day and putting them on this blog.  I actually have been keeping track of it longer in order to make this point on this day.

Here is a control chart of the “number of pending to-do list items” over the last 23 days.  
 image
Every day on my blog post I’ve been asking questions - shouldn’t I take action on the last data point?  Shouldn’t I do something?  Anyone who understands the basics of variation can see that the answer is “no”.  It’s random variation.  No reason to react differently to the high points or the low points.

This doesn’t mean you do nothing.  If you want the process to perform at a different level (and with less variation), you would work on the process and test ideas for improvement using the PDSA cycle.  But the point is, you do not react to individual data points or even apparent patterns.

Here’s an example.  I was visiting one of our Network member organizations and they are doing some impressive work in a lot of areas.  I saw some data for tracking readmission rates that looked like this.

image
So, if the performance is above the target, it gets a red color.  If it is below, it get green.   If there are 2 or more periods of red, then management needs to put together an A3 to work on it.  I asked how they determined whether two is the right number.  They said “it just is”.

Here’s the same data using the same pattern from my “delinquent to-do list”.
image
Anything above the red line gets a red, anything below is green.  But it doesn’t make any sense.  It’s all random variation.  The result is “tampering” - making matters worse.
You may or may not hear about “understanding variation” at the 4th Annual Lean Healthcare Transformation Summit June 5-6 (http://www.lean.org/Events/2013_lean_hc_transformation_summit.cfm).  

More than likely, you won’t.  Like I said, I am not hearing a lot about this important concept.
I did hear it in a conversation last week and it gave me encouragement - for a while.  I was talking to some people about their lean efforts and they described how they put lots of effort into improving the patient experience and the patient satisfaction data measures actually went down (slightly), not up.

One of the managers said, “I wouldn’t worry about that.  It’s just common cause variation.”

“Sweet!”, I thought to myself, “at least one person gets it”.  But wait a minute … the person who said that was a physician who attended one of the 3-day courses that I provided more than 10 years ago.  Knowledge about variation has not spread that much. 

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