Maintaining inefficiency is a good thing? Seriously?

Leave it to the professors at Harvard Business School to demonstrate a complete lack of lean thinking. A recent HBS Working Paper points out that increasing ordering capacity of the ultrasound service in a hospital led to longer wait times for that service. It turns out that the increased capacity led physicians to order more ultrasounds.

This type of finding isn’t new – transportation experts have known for a long time that building more road capacity doesn’t ease traffic congestion. The extra road room encourages more people to drive, with the result that the new, wider roads have just as much gridlock as before.

What’s so utterly disappointing, however, is the authors’ recommendation: retain the inefficient step in the process in order to discourage physicians from ordering ultrasounds. They write:

to improve hospital performance it could be optimal to put into place "inefficiencies" to become more efficient.

The authors have correctly recognized that given the opportunity, doctors will order more tests. But their solution of keeping inefficiencies in the system is as absurd as saying that we should make cars less stable in order to keep people driving within the speed limit. Or that we should have smaller freezers so that we can’t keep as much ice cream in the house and get fat.

The right recommendation – the lean recommendation – would maintain the local level efficiency improvement, while also including a structured problem solving initiative to reduce the number of unneeded ultrasounds. As Dr. Deming pointed out, the system in which people work drives the vast majority of their behaviors. The doctors aren’t simply ordering more ultrasounds because they can, irrespective of the benefit to the patient. They’re doing so because the system rewards that behavior.

You’d think that a Harvard Business School professor would know that.

Mise-en-place, 5S, and why tape outlines on the desk are stupid.

Karen Martin, Mark Graban, and Kevin Meyer have been tweeting over the past couple of days about a hospital in New Mexico that -- sadly -- is putting tape outlines on people's desks in a misguided implementation of 5S. This nonsense has enraged the nurses who understandably see this as irrelevant to their ability to get their jobs done. Confusion about how to apply 5S in a knowledge environment is rampant, as these stories of "lean as misguidedly executed" (LAME) attest. I believe that's because people focus on the easily visible, outward trappings of 5S without understanding the purpose of the tool.

In his book Kitchen Confidential, chef Anthony Bourdain explains the function of a cook's mise-en-place. His description gets at the heart of 5S better than anything I've read by any lean consultant:

Mise-en-place is the religion of all good line cooks. Do not f**k with a line cook’s “meez”—meaning their set-up, their carefully arranged supplies of sea salt, rough-cracked pepper, softened butter, cooking oil, wine, back-ups and so on. As a cook, your station, and its condition, its state of readiness, is an extension of your nervous system—and it is profoundly upsetting if another cook or, God forbid, a waiter—disturbs your precisely and carefully laid-out system. The universe is in order when your station is set up the way you like it: you know where to find everything with your eyes closed, everything you need during the course of the shift is at the ready at arm’s reach, your defenses are deployed. If you let your mise-en-place run down, get dirty and disorganized, you’ll quickly find yourself spinning in place and calling for back-up. I worked with a chef who used to step behind the line to a dirty cook’s station in the middle of the rush to explain why the offending cook was falling behind. He’d press his palm down on the cutting board, which was littered with peppercorns, spattered sauce, bits of parsley, breadcrumbs and the usual flotsam and jetsam that accumulates quickly on a station if not constantly wiped away with a moist side-towel. “You see this” he’d inquire, raising his palm so that the cook could see the bits of dirt and scraps sticking to his chef’s palm, “That’s what the inside of your head looks like now. Work clean!”

Want to know what 5S is and why it's important, without resorting to all those difficult-to-pronounce Japanese words? It’s mise-en-place. (Of course, I’ve just substituted French for Japanese, so this may not be an improvement.)

Doctors and nurses (mostly) embrace 5S when it comes to the tools of their care-giving trade. Take a look at any surgical tray, and you'll see that's true. Physical organization -- 5S -- is essential to being able to deliver care smoothly and efficiently. Supply closets are perfect examples of places that benefit from 5S. But organizing the stapler and 3-hole punch on the desk? That's asinine and pointless. No one needs to find the stapler with their eyes closed.

When it comes to the office environment, it's more important to apply 5S to the information people manage, not the tools they use. The issue isn't where the stapler sits; the issue is where critical information resides. Can people find it quickly and easily on the file server -- or on medical forms?

Making information flow faster, with less waste and greater clarity -- that's how 5S should be applied in the knowledge workplace. The nurses at the Covenant Health System in Texas understand that. They didn't mess around putting tape outlines on their desks. But they did reduce the amount of time they spent filling out paperwork by 50% by simplifying, standardizing, redesigning, and eliminating all their forms. That's 5S intelligently applied to a real problem.

Tape outlines around the stapler? Diktats concerning the maximum number of pens a person can have at his desk? Please. They're not going to get rid of the mental equivalent of peppercorns, spattered sauce, bits of parsley, and breadcrumbs that litter the brains of knowledge workers.

The gemba for a knowledge worker is inside her head. Let's make sure that the information that goes in there is well-organized and easily accessible.

Cardboard boxes and common sense.

“Sorry about the mess. These are just the cases that came in the last couple of days. The big pile over there? That’s the research project that I’m supposed to be working on.” Megan sighed despairingly and waved her arm, indicating piles of unread slides stacked like ziggurats on every flat surface in her office. Megan is an experienced, talented, and very hard working pathologist at a major cancer hospital. Her days are spent with her face pressed up against the viewer of her microscope, examining tissue samples for evidence of malignant tumors. I was visiting her because she seemed to have lost her ability to read cases and turn them around rapidly for the referring physicians. Megan was caught in a bind: she was feeling pressure from her boss to work faster, but she was worried that reading the slides more quickly would increase the risk that she’d incorrectly diagnose a case.

Megan went on: “I used to be able to read more cases during regular business hours, but now I have to come in earlier and stay later just to keep up—and obviously, I’m not doing a particularly good job of that. Although to be fair, no one else in the department is either. We’re all feeling swamped.”

Frankly, I wasn’t sure I’d be able to help her. I’m neither a pathologist nor a doctor. (Which, since I’m Jewish, always made my parents very sad. They weren’t exactly cheering when I took a class in the Semiotics & Hermeneutics of the Mystery Story.) I know as much about interpreting tissue samples as I do about designing sub-atomic experiments for the Large Hadron Collider.

So I spent a couple of days watching Megan work. And what I saw reminded me of what Keith Poirier wrote on Jamie Flinchbaugh’s blog recently:

Lean is nothing more than the re-introduction of ‘common sense’ into our daily work lives.

I don’t know anything about interpreting biopsies. But it turns out I didn’t need to. What I saw was a doctor who seldom got more than eight uninterrupted minutes to analyze a slide. Practically every time she nestled up against her microscope, someone came into her office and interrupted her. Following each interruption, she’d turn back to the slide, and start re-reading it from the beginning to ensure that she didn’t miss anything. As a result, reading each case took three, four, five times as long as it needed to.

What’s worse, in the two days I watched her, none of the interruptions were urgent. In fact, the most common interruption was from technicians bringing her new slides to read. They’d walk in, say hello, tell her that they have new cases, and she’d tell them to just put them on the corner of her desk.

My solution? Put a cardboard box outside of her door with a sign telling the technicians to put all new cases inside it. Megan created a fixed schedule to pick up any cases every 90 minutes. Fancy, right? She cut interruptions by two-thirds, and cut the time it took her to process her cases by 40%.

We didn’t talk about takt time, pull systems, or kanbans. As Keith Poirier wrote, it’s just common sense. You’re not going to be able to do your work—whether that’s reading pathology slides, writing ad copy, calculating force vectors on bridges, or writing a patent application—quickly or efficiently if you’re always being interrupted. So we cut down the interruptions to help her do her work a bit better.

There’s still plenty of work to be done in that hospital’s pathology department. There’s waste all over the place. But by focusing on simple, small, and rapid improvements, we made a big difference in Megan’s performance—and her happiness.

Master the art of saying yes slowly.

Learning to say no matters. A lot. I've been thinking recently about what Michael Bungay Stanier describes as "Bad Work," "Good Work," and "Great Work," particularly as it relates to my wife. (Michael is the founder of Box Of Crayons and is the author of Do More Great Work.)

In Stanier's view, "Bad Work" is the brain-numbing, soul-sucking crap that drives you to drink -- stupid meetings, inane emails, pointless office face time, etc. "Good Work" is the work you do most of your time, the product or service that your organization provides to the world. Stanier says

There’s nothing wrong with Good Work—except for two things.

First of all, it’s endless. Trying to get your Good Work done can feel like Sisyphus rolling his rock up the mountain, a never-ending task. And second, Good Work is comfortable. The routine and busy-ness of it all is seductive. You know in your heart of hearts that you’re no longer stretching yourself or challenging how things are done. Your job has turned into just getting through your workload—week in, week out.

By contrast, "Great Work" is the stuff that makes a real difference to the organization and to the world. Great Work

is what you were hoping for when you signed up for this job. It’s meaningful and it’s challenging. It’s about making a difference. It matters to you and it lights you up. It matters at an organizational level too. Great Work is at the heart of blue ocean strategy, of innovation and strategic differentiation, of evolution and change. Great Work sets up an organization for longer-term success.

Now, my wife is a doctor at a major NYC cancer hospital. It's a teaching hospital, which means that while her days are primarily clinical, filled with procedures and patients, she also has a significant research and teaching burden.  I think that kind of work is both "good" and "great." I mean, helping to cure people of cancer is pretty damn meaningful and makes a real difference. But at the same time, it's routine (for her, not the patients); it's often not that challenging; and it's definitely Sisyphean.

Recently, she's been heavily involved with a major process improvement project. Even though it's administrative work, I think it qualifies as Great Work because when it's done, the hospital will be able to treat more people, more quickly, with less of a hassle for the patients. And if you're sitting there with a giant liver tumor, getting to see her more quickly with less of a hassle is pretty Great.

But here's the problem: the clinical, academic, and research burdens are overwhelming her. She has very little time to work on the process improvement project, because she has so much else going on. And she feels as though she can't say no to any of those other responsibilities. Partly that's self-imposed pressure. Partly that's due to preposterously high expectations set by the hospital. So she's got a ton of work that's not getting done, and she feels terrible about it.

Of course, even though she's accepted all the work, she's not getting to a lot of it. Her time is finite. So even though she says yes, she might as well have said no.

And if she had explicitly said no to some of the work -- by doing fewer procedures, teaching fewer residents, not reviewing any papers -- she'd be able to do more of the process improvement project. Frankly, she's not doing those other things in a very timely fashion anyway. And had she done so, she might be less stressed and feel better about herself.

I've written before about the importance of understanding one's own production capacity. It seems to me that if you understand your capacity, it will help you learn to say no (or as Stanier says, at least it will help you "master the art of saying yes slowly").

After all, your capacity is fixed. Saying yes or no will not affect the amount of work you can do. But saying no will make you feel better. And it just might help you do more Great Work.

Create a fast track for your work.

I spent a few days at the SHS/ASQ alphabet soup conference in Atlanta this week, learning about how hospitals are implementing lean to improve their quality and lower their costs. I was struck by the fact that all the focus is on hospital processes -- admission, discharge, nurse shift change, etc. -- but no one is thinking about how to use lean to improve the way people do their office work. The nurse supervisors and managers I spoke to, for example, were complaining about the difficulty of getting their administrative tasks done in any sort of efficient way. Like workers in any other kind of organization, they buried by email, paperwork, and meetings. There's no easy solution to these burdens, but there are lessons from the way hospitals manage patients that can be applied to the way that individuals manage their work. Consider the "fast track" that many hospitals have implemented in their emergency departments.

There's one pathway for the serious problems -- gunshot wounds, cerebral hemorrhages -- that need immediate attention. And there's a fast track for people who have non-life-threatening issues that can be easily resolved, such as stitching up a bad cut or splinting a sprained finger. These are high volume, fast turnover cases. If you've ever gone to an emergency department that doesn't have a fast track for a non-life threatening problem, you'll end up sitting around for hours studying People magazine's "Sexiest Man of 2007" double issue while the medics take care of the guy who's having a coronary.

What would happen if you created a fast-track for your work? As part of 5S, sould you set up a paper and electronic filing system that separates the high volume, fast turnover work from the serious, more complex issues that take time to process? That would make it easier and faster to access the information you need, and avoid those Howard Carter-like archaeological expeditions looking for stuff.

Going one step further, could you create blocks of time in which you only dealt with high volume, fast turnover work, and other blocks that were reserved for the big stuff? If you did that, you might increase the likelihood that you'd deal with everything more quickly, more smoothly, and with less stress.