Azure Lamb
Hi, and welcome to Be The Flagship with our podcast host, Jeff Parsons.
This is where we tackle the day-to-day talent management challenges you face, particularly
in hospice and small healthcare organizations.
And now over to our host.
Take it away, Jeff.
Hello, happy new year and welcome to Be The Flagship.
I'm your podcast host, Jeff Parsons.
I hope you had a great holiday season and you're ready to get 2024 off to a great start.
I know I am.
So I've dedicated all of the episodes in January to topics related to process improvement and
healthcare.
So I hope we brought a notepad and a pen because you're really going to want to take notes.
And we're starting off with an exceptional guest speaker.
So let's take a quick break and I'll be back with the introduction.
Is your team in need of alignment?
Do you need to develop your team through a team building event?
If so, contact a team building expert today.
Contact Jeff at 1-800-530-4189.
Extension 101.
And take your team to the next level.
Okay.
Let's talk about our guest speaker.
And his name is Terry Norris, MBA and a Lean Certified Master Black Belt.
He is a full-time Lean Consultant, Speaker and author of the book, How to Make Lean Work
in Your Hospital.
He has trained over 1,800 hospital leaders and 150 plus hospitals on Lean concepts, principles
and specifically on how to lead a Lean transformation.
As a consultant, he's helped multiple hospitals develop a Lean strategic implementation plan.
He's led dozens of frontline rapid improvement events in all major hospital departments,
saving millions of dollars through efficiencies and significantly increasing revenue through
new strategic options.
Terry's Lean experience is diverse and extensive.
He's provided Lean consulting services for the federal government, the military and multiple
industries.
Some of these industries include manufacturing, healthcare, pharmaceuticals, airlines, construction,
public utilities, professional services and cellular services.
Terry also served in the US Air Force for 25 plus years.
Thank you for your service, Terry.
In his last role, he was the Lean leader for a complex organization with 5,500 people at
five locations in four European countries.
Terry established the organization's Lean structure and developed a strategic and tactical
plan that delivered 55 major improvement projects, saving millions of dollars through direct
savings and cost avoidance.
Terry has also taught graduate and undergraduate courses in Lean deployment, strategic management
leadership, operations management and project management for 18 years.
So again, we're privileged and honored to have with us today, Terry Norris.
So Terry, thank you for joining us today.
For sure.
Thanks for the opportunity.
So this episode is an introduction to Lean in healthcare.
So let's just start with Lean itself, Terry.
So can you briefly tell us the origins of Lean, where it came from?
Yes, and I will give you just that, a brief overview of it.
Because it's quite detailed and it goes back for centuries, the little nuances and the
tools and things like that.
But Toyota originated or Toyota, Lean originated with Toyota from the Toyota production system.
And that's really the origin of Lean as we know it today.
You can say Toyota production system or Lean and you're essentially saying the same thing.
There's been a few minor changes in America, especially with the Lean compared to that,
but it's very, very close.
It's again, almost the same.
Okay.
So again, with Toyota, so it sounds like a manufacturing concept.
So can you define Lean healthcare?
Yes, and I will say too, it definitely was a manufacturing concept.
It was used there and the ideas and the concepts came from there.
But the principles and the ability to solve problems and to make things better and all
that, that's very universal.
And I'd like to preface the definition of healthcare too by saying it this way.
When I got into Lean kind of full time, especially when I was on my own as an independent Lean
consultant and I'm talking to people about it, when I give the standard definition of
Lean, talking about a management system to eliminate waste and all that, most people
would, I could almost literally see them starting to yawn.
So I realized early on that in order for people to understand really what Lean should be,
I created a different description.
So anyways, this is the description that I came up with to help people understand Lean
healthcare and really Lean in general.
But it goes like this, Lean is a function of leadership, a secret weapon that will significantly
improve patient care and give your hospital an unfair competitive advantage.
Lean healthcare is a system-wide strategy for achieving excellence.
And then that's really the big part I want leadership to understand.
And then I go on with a couple of bullets or three bullets by creating value from the
customer's perspective, by creating a culture of continuous performance improvement and
working to eliminate all waste of resources and time, by creating high quality stable
processes and emphasizing respect for people throughout the organization.
So that definition is really more of a description, although it includes what you would generally
hear from the definition.
But it helps people see that it's much bigger than just tools and eliminating waste, which
is not really clear to a lot of people anyway when you first say that.
So hopefully it helps people understand what you're getting into when you say you want
to get into Lean healthcare.
Okay.
Yeah, I mean, I'm aware of healthcare professionals who have attended Lean in healthcare certification
workshops.
And one of their frustrations is that when they walk away, they're still in their mind
is not that link in terms of knowledge versus application.
So hopefully we can address that as we have our discussion.
So let's get into, I mean, Lean has numbers, right?
Two Lean pillars, five principles of Lean, eight types of waste.
So let's start with the two Lean pillars.
What are they?
The two Lean pillars are continuous improvement and respect for people.
And this is from the Toyota Way model house.
And within those two pillars, when I do Lean training, I tell folks, I say, listen, you
know, I realize that some of you guys are never going to become Lean zealots, but there
are things that you're going to listen to, you're going to hear, you're going to learn
that can help you no matter what you ever do.
And this is, these are a couple of those.
So the idea of continuous improvement, when I think of that and I think of the fifth principle
of Lean perfection, which we may get to, they're really interconnected.
And so to say continuous improvement, just one, the idea of the words kind of give you
what the idea is to continuously make things better and continue to do so over time.
But unless that becomes part of your culture and the mindset of the people that work there,
it's not, it's probably not going to happen.
And that's more the general idea of continuous improvement is changing the culture and having
a mindset where people think that way.
So the second pillar is respect for people.
And with that, it can make all the difference in the world with the first pillar, that the
idea of changing the culture.
But when you think of respect for people, people generally think of what's most common,
that you treat people like you want to be treated, that you're kind, that you ask for
people's opinion.
And all of that is true.
And things like schedule, work-life balance should all be taken into consideration.
But with Lean, the idea of respect for people is a bit different.
The idea of, it's more like, the best way I can describe it is think back in your life
when somebody, whether it's a parent or coach or music teacher or professor, somebody, they
pushed you to perform better than you are currently performing.
They didn't allow the mediocre or even just the normal good.
They pushed you.
Those are the people that we generally think about, that we respect, that we admire, that
they brought us along, that helped us become who we are now.
And that's more the idea of respect for people.
So when you have a culture where you're pushing people, you're challenging people, you're
pushing in a good way, but you're challenging them to become better and better and better,
those are, that's the type of organization, the culture with the continuous improvement
and respect for people that can really make all the difference in the world.
Okay.
That's interesting.
And it's certainly, when you describe it in that manner, it's certainly universal to all
types of businesses and industries and organizations.
It's a mindset and it's a cultural phenomenon.
Yes.
Absolutely true.
Most of the things that we will talk about, they work in the same way.
They would be applicable across industry.
So let's talk about the five principles of lean, Terry.
Okay.
With a quick summary, the five principles are value, value stream, flow, full, and perfection.
And I'll talk just a little bit about each.
So for me, value and value stream are easier to explain together.
But the idea of value is what's considered value from the perspective of the customer.
And we all think that sort of, you know, intuitively, well, that's kind of a norm.
However, when you look at it from a lean perspective, we go just a little bit deeper.
The idea of lean and the value, it's an emphatic about what's the customer understanding and
what the customer wants.
And then the value streams are all the steps in the process.
And because of that, it forces us, even if we have 150 steps, we look at each one and
say, does that add value?
Does that add value all the way through?
And then we have a much better picture of what adds value from the customer's perspective.
So value stream is simply all the steps in the process.
And the third principle is flow.
And the idea that that value flows perfectly without stop, without rework, it just flows
nicely.
And a matter of fact, all the tools that we use and everything that we do generally is
to help things flow, help processes flow by eliminating waste and all of that.
Then you have pull, which is probably one of the least understood, I would suppose,
especially outside of manufacturing.
But I'll give you a quick healthcare example.
And I will try to not get into the great level of details, but this actually happened and
the story isn't exaggerated to make a point.
But I was doing observations and surgery one morning, had a mid-size hospital.
And at eight o'clock in the morning, all the people that were having surgeries for the
whole day were already checked in.
And I asked the registration director there, the patient access director, I said, so where's
everybody at?
You know, and they were, they're like, they've all been checked in and the individual was
serious.
So I said, okay.
And even if they had a surgeon at 2.30, like, yes.
I went to the pre-op area and of course there was a lot of people there.
You know, I saw, I asked the people that worked there, I said, so what does your patients
think of this?
You know, and they were very nice people.
They're like, just smile and said, they hate it, you know, especially the one that have
later surgeries.
And then I went to the holding area, which where they repeated the same thing that happened
in pre-op and it was near surgery on another floor.
And there was a lot of people there, a lot of people there, people that were going to
be having surgery several hours later.
So there's much more to that story.
But the idea is that they, they pushed people through the system.
Registration wasn't ready to have all that, that many people come in at 5.30 or six in
the morning.
Pre-op wasn't ready to handle that many people in surgery.
It definitely wasn't.
So they pushed them through the system.
So if it was pulled, they would have scheduled the surgeries an hour and a half or whatever
the workup time was prior to surgery throughout the day.
Have people come in, do pre-op and go straight into surgery.
Straight into surgery throughout the day.
And that's more the idea of pull.
And then the last one is perfection that I've hit on a little bit already.
And that's the idea where your people, they start, they start thinking that idea of continuous
improvement and they're trained, they're taught, they understand how to do it and they're rewarded
for doing it.
And they're always looking and thinking that way.
How can I make something better?
And the technical definition is, you know, to continuously work, to eliminate all waste
of resources and time.
And that is correct.
But if you can't get that in the minds of the people, they won't go very far.
So in summary, it's value, value stream, flow, pull and perfection.
Thank you, Terry.
And that's a, that's a great example, by the way.
So you know, lean really focuses on waste elimination.
That's my understanding, at least correct me if I'm wrong.
So can you walk us through the various types of waste?
Yes.
And it's funny.
I feel like lean, one of the most well-known things, I suppose, even if you just take a
course on lean or whatever, you're going to say, well, lean is about eliminating waste.
Which is true, but I feel like waste gets all of the notoriety when it's really flow.
You know, why do we even bother eliminating waste and all that stuff?
It's because we want things to flow.
Victoria came up with something they refer to as seven deadly waste.
And one of the things that made them so successful is because they relentlessly go after these
seven deadly waste.
Now over time, there has been one added and I'll mention that when I get to that.
But of the eight types of waste are emotion, transportation, weighting, defects, inventory,
and it's really excess inventory, overproduction, over-processing.
And then the eighth one is underutilization of your staff, of your folks.
And I can give you just one or two examples that ease in a healthcare environment, like
for defects, it could be incorrect or missing information on forms, repeat visits, things
like anything that goes wrong.
Defects is probably the easiest one to explain.
For weighting, okay, I'll take it back.
Weighting is the easiest one.
We've all done that in all aspects of our life.
But weighting for results, weighting to see a doctor, weighting for transportation.
And inventory, again, excess inventory having more than what you need and there's a lot
can be said about that, but I'll leave it at that.
Overproduction is a little bit less understood, but it's really doing more than you're required
to do and doing it sooner than required to do.
And that one can be confusing, especially in a competitive environment.
So don't you want us to do more?
And the answer is we want to give the customer more than they expect.
Yes, but do we want to do more in our processes?
No.
For example, mixing 10 doses of medication when you only need seven, making multiple
copies of forms that are rarely used.
That's overproduction.
Overprocessing is doing more to something than required.
So let's say you need three signatures for something, but you really only need two, but
you have to get three.
That would be overprocessing.
Multiple reviews, approval, things like that.
Transportation is moving things.
Moving things are people unnecessarily so excessively doing more than required.
Moving patients, specimens, supplies, equipment, long distances, multiple bed assignments,
moving patients, things like that.
Motion is moving yourself, basically searching for patients, looking for supplies, reaching
across things in an unsafe way.
It's movement.
It's human movement.
And the underutilization of people is the one that's been added over time.
When Toyota was asked, well, why don't you include that, it was more like, well, that's
a given.
We're going to do that.
We're going to utilize our people.
So they think just a little bit differently.
So if you have people and there's no cross-training, there's no capturing best practices, no considering
suggestions, ideas, things like that, that would be considered some examples of underutilizing
people.
So let's talk about the standard work.
You refer to it as the heart of lane, so can you tell us more about that?
Yes.
So for standard work, in order to be lean at all or to even pretend to be lean, you
have to have standard work.
And I have over the years became, it's became one of my, I don't know, you hate to say passion,
but it's one of the things that I understand that if you don't do it, you're not going
to be able to be lean.
You're not going to have the highest level of consistent quality and things like that.
So the idea of standard work is simply everyone doing the same job the best known way.
And then when somebody makes it better, everybody makes an adjustment and makes it better as
well.
And that's really the most basic definition, but it's the one that I found that people
understand the most.
And it's funny too, as we just talk about standard work, people sometimes resist it.
They're like, you know, I'm not a robot.
You know, I have, you know, I'm a human, so I make different decisions and things like
that.
I don't want to do it this way.
And I understand that.
And honestly, I felt that way before in my lifetime, early in my life, in my career.
But when you think about it from a broader perspective, you want people to do things
the same way, right?
It reduces variation.
So if you show up for an appointment today, it doesn't matter who's working, you're going
to get the same level of service.
But if you don't have standard work, you're just hoping and praying that this other person's
working and not that one, because you know, they do things quite differently.
So we want people to do things standardized.
It makes it easier to train.
It makes you, it helps your quality go up, your safety is much better.
So standard work is a big, big deal when it comes to lean.
Gotcha.
So, Terry, let's talk about how lean applies to small healthcare.
When I say small healthcare, I'm referring to, you know, hospice and home health and,
you know, smaller hospitals and things of that nature.
So talk to me about how it applies to small healthcare.
In general, it applies the same in general.
And then we can talk about specifics as we think about what are some of the issues and
problems that people in small healthcare come up against, especially when you think of one
person going into someone's home or in the case of hospice or home healthcare, either
one.
So it helps people, you know, go back to those most famous words, eliminates waste in their
processes and things like that.
But again, that generally doesn't mean anything to people unless you look at what the process
is and what does that really mean?
Can I spend less time doing something that I do now, but actually make it safer and higher
level of quality?
So that elimination of waste, that looking at your processes like that is, you know,
is a way.
Again, very general.
Communication is improved in a lean organization.
So whether it's a small or large, how you communicate and how you communicate results
and things like that are looked at and that is improved.
Safety and quality, as I mentioned, is a big part of the improvement because of the standardization.
So I've worked in organizations where, and I've surveyed organizations where they've
had let's say 15 people go out in the home care.
They have 15 different nurses goes out.
And I'm pretty sure that the 15 different nurses did things 15 different ways, you know,
because that's just sort of human nature anyway.
There was no emphasis on standard work.
But if you train people in a certain way, and of course there were certain protocols
for each, but that basic type of training with all of the different nurses, that means
that that particular company would deliver the same level of care, ideally, throughout,
you know, with all the different people, 15 different folks, no matter who went out.
So standard work is pretty important in a small or large organization.
And when you start looking at things like metrics and a couple of things that say, okay,
did we do good today?
How do we know if we did good?
We look at those metrics and it helps us, it really starts uncovering problems and things
that we don't really talk about much.
We just kind of live with or do workarounds or whatever we need to do.
And when you can eliminate some of the things that waste time, it helps the nurses in particular,
people that are dealing with people, spend more time with the people, whether a nurse
or a staff.
It helps eliminate those, I don't know, things that frustrate throughout the day that just,
I'll share this, one of the things I've done survey work and some of it, you ask questions
like something that happens poorly.
How often does that happen?
People will say, I don't know, I never really tracked it.
What does it happen weekly?
Oh yeah, yeah.
Three or four times?
Yes, yes, for sure.
So you have something happen three or four times a week at least, every week, and it's
never dealt with.
In a lean environment, you would look at that and you'd say, that's a problem.
You would identify it and then you would take some action to make it better, make it go
away, make an improvement.
So you're not dealing with the same thing.
So just like in a big organization, you can use the same ideas, the concepts, the principles
to make things better, smoother, safer, higher quality for everybody that's involved.
Thank you, Terry.
So let's wrap up our discussion today, Terry, and we'll pick it back up next week on why
lean fails and what we can do about it in healthcare.
Let's go to a commercial, then let's come back.
I'll end this episode with a quote and we'll go from there.
Do you need to schedule a strategic planning session, but don't want it to waste your team's
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If so, you need an expert facilitator who knows how to make the most of your session
and give you the deliverables you need.
Contact Jeff today at 1-800-530-4189.
Extension 101.
Get your new year off to a great start with a great strategic planning session.
Okay.
I hope you enjoyed this episode and I would like to end it with a quote from a legendary
NFL coach by the name of Vince Lombardi.
The quote is, perfection is not attainable, but if we chase perfection, we can catch excellence.
And again, that's by the great legendary Vince Lombardi.
I hope that gives you some encouragement to move forward with your process improvement
initiatives.
I look forward to you joining us again next week when we continue our discussion with
Terry on lean and healthcare.
Goodbye, everyone.
Take care.
Thank you for listening to this episode of Be the Flagship with Jeff Parsons.
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