Monday, December 1, 2014

Why and When Physicians should learn Lean

As I do the Green Belt course I’ve been asking myself when and why physicians should be interested in learning Lean? At first I struggled a little to find out how the physician’s mindset could fit in with what I was learning – it is hard to extrapolate from non-clinical material to a clinical world. I do think that Lean training for physicians needs to be clinical and to that end will help push that forward as my own agenda as best I can. But in thinking offhand as to why a physician should learn Lean I came up with two salient reasons.

First, in practicing medicine I’ve come to realize with such a demanding domain that everyone – yes, everyone - needs help. For example, in comparing the not-so-remote system of written orders versus computer order entry which can trigger one to remember more, I feel the latter is better. No one wants to acknowledge that they don’t know or remember everything – indeed there is a striking amount of cockiness in physicians when it comes to assessing what they think they know concretely – but having a standardized, computerized, evidence-based system in place which helps one’s thought processes be non-omittingly comprehensive helps non-threateningly alleviate this real issue. Expectedly, as good computer order entry implementation is really a “mini-Lean” process, Lean methodology mirrors computer order entry’s philosophy:  namely that clean standardization of processes due to an acknowledgment that what we think we know isn’t always what actually is, is imperative for error-reduction. Both entities refuse to rely solely on individual recall and perception for progress with the knowledge that these are inevitably, routinely incomplete.

Second, in conjunction with the above, I think that analyzing processes from the way one has always analyzed them is less than fruitful. To be in medicine and to assume that one has the answers to process issues because medicine is indeed different is false. Actually, processes are often processes and it frequently takes an outside perspective (not a consultative perspective, just an outside perspective) to understand what one didn’t before. For a physician to learn Lean is to currently step outside of the medical domain and learn something new which then can provide a novel approach as to what to do with standard process issues which have benefitted from Lean/Six Sigma elsewhere. Physicians above all should step outside of their domain to learn Lean because they deserve to be running the show of medicine, given how their sacrificial and hard-working existences are impacted by it.

And as to the question of when to learn Lean? Very possibly early on, in medical school. Lean appears to be catching on in medicine, from hospital to hospital but still, it is a piecemeal approach, one that largely hasn’t yet been embraced collectively by physicians but more so by many ancillary to the medical process. This isn’t bad but again as with so much in medicine, the power shouldn’t be given away – physicians need to be overseeing process improvement which impacts them directly. With this, it would be great if the thought process were already innate, and truth to tell, the earlier one learns a subject, the more time one has to incorporate it into his or her world experience. Medical school might be the optimal time to tie in Lean training into the world of medicine, to get the creative juices flowing.

So, those are the thoughts for now, why and when physicians should learn Lean. Yes, Lean will likely be beneficial for medical process improvement, especially if clinically oriented. And with this, physicians, who are caught by edicts from so many directions, would best be served by learning (at minimum) this one methodology, if not more, early on and comprehensively to be able to assert greater sensible control over their unique domain.


Saturday, November 1, 2014

Application of Knowledge - My first Capstone Event

We've gone through the first Capstone event, based on Department of Motor Vehicle inefficiency, and I thought it was good. As I said in my prior post, it was hard to wrap my head around foreign new terminology (and acronyms – oh, the incessant acronyms) but beginning to go through the material “live” helped clarify and solidify some of the ideas. I'm interested in more “live” application, as I think this is where (as with most concepts) the knowledge comprehension, retention, and transmutation (into wisdom-based experience) get tested out. In walking through the preliminary concepts actively, it was a bit more conceivable to me than before how one could eventually approach clinical issues and begin to tease them apart into manageable, solvable problems.

There was something nice about beginning with the affinity diagram. It’s an unassuming organization tool with a lot of potency. It’s appealing in its uninhibited, creative beginnings, brainstorming off of what one has to analyze, to figure out what the issues might be, the raw reality of a situation. It’s a starting tool for all of us, situationally assessing and then taking our assessments and grouping them together into relationships. The Project Charter was more challenging because of the foreknowledge required: it’s tough to know without prior experience what angle one should take with an objective. The SIPOC diagram was also a bit tougher to relate to, especially because it’s hard as a clinician to think in terms of suppliers and customers, inputs and outputs – even that terminology seems remote and out of our sphere (we’re used to conversing in specialized medical jargon which is highly remote to everyone else). We went quickly at the end through the CTX tree, and I’ll need some more time with that. We left things off with our project at analysis still, and it will be interesting at the next Capstone event to push our interim knowledge acquisition forward further.

“Live” application of knowledge over time is crucial to becoming wise. Medicine may be the ultimate field where this is tested out, as the stakes are high in getting things right. Doing an exercise like the Capstone event is a mini-scale way of reminding ourselves of the necessity of application of knowledge, of not presumptuously remaining in our heads but playing things out in a challenging forum. Process improvement, or likely any improvement, needs to be thought out and then brought to life. I’m looking forward to learning more study-wise and then seeing what edification the next Capstone event will bring.


Wednesday, October 1, 2014

Gaining a deeper understanding of Lean.

So far, so good with the course, but I haven't by any means internally captured the essence of Lean/Six Sigma. I'm usually a reasonably quick study over time, but after having been steeped in medical knowledge for quite a while, and my own pursuits, it's hard to switch gears and focus with a mind like an open book on something so new and foreign. I'm finding the introduction to be sensible, logical, and even - for someone devoted to basic organization - intuitive. Still, though, I know that acquiring a new set of knowledge takes time (months to years) and experience, and I know that one has to integrate it into one's mindset and life (one’s genetic material) - which may be where process improvement has failed in healthcare.

Process improvement in healthcare has been largely a “pet project” endeavor, somewhat akin to the haphazard development of land in the United States, with efforts of varying vision spurred largely by private motivations rather than collectivity - we’ll put a strip mall here and a housing development there and necessity or not, it’ll work itself out. Process improvement has similarly sprouted up in a non-unified, “siloed” fashion which is one likely reason that cohesive fundamental change in healthcare has not yet occurred. It isn’t that those attempting to improve the current culture aren’t top-notch, but there have been iconoclastic captains for each ship with each vessel running ship its own way, rather than a standardized fleet. Again, perhaps that’s been the American way in most things, but with external pressures (CMS and likely eventually other insurers) arising, forcing an alignment of remuneration with proven, replicable quality, and inevitable consolidation of organizations in the market, there will be a unspoken edict soon for everyone to be on a relatively equal playing field of quality.

So education to me seems to be the way – education such as what I’m attempting to learn now, true education to improve the insight and behavior of those very individuals who are instrumental to the vitality of a healthcare organization. It seems important to educate the involved masses as to how to go about changing the ways of an organization, and therefore its culture. Lean/Six Sigma seems like self-help for organizations, a guidebook for self-improvement. And just like any self-improvement, once you’ve incorporated balanced principles into your psyche – your DNA – you’re a different person.


Monday, September 1, 2014

Process Improvement in Healthcare

I've been working in medicine a fair amount of time now, and one of the main things I've noticed is how each hospital (even within a system) seems to be its own fiefdom, with its own territory, weighted political hierarchies, farming tenants, and roving populations. With such, the obvious corollary is that each hospital has its own way of doing things, for better or for worse, which may or may not result in great quality. As I am someone who enjoys the zen of simplification down to essentials, I have been wondering as a small cog in the massive wheel of the American healthcare system how to reconcile the obvious disparities between different healthcare providers into a more streamlined system? It is easy to get concerned about trying to do so, because many independent-minded individuals might have the fear that their power or choice would be taken away, but actually standardizing a system of inequities would probably be ultimately more wholly beneficial to more people collectively than it is now. Other industries have implemented process improvement globally, and no one is complaining about less product defects or airline crashes. Right now, depending on location, socioeconomic status, education, personality, basic values, and a dash of sheer luck, one could have a vastly different medical experience and outcome in one place than another. This isn't just on the patient side of things, but also on the provider side, which can be extremely frustrating and an impetus to the perceived quality of one's job. If we could even out the experience, standardize the quest for quality for all participants in healthcare - the crossroads for all extant humans as our lives are dependent upon our health which will fail at some moment in time - then possibly we could raise the quality of our health and perhaps even our happiness.

That's a lofty goal, something to keep in mind. For now though, the more immediate and pressing point is to begin learning a system which may help me/us in my/our quest for unified quality. As a physician, I have made a commitment to start learning process improvement and, hopefully, how it can help my medicine.  I'm beginning my journey here, with a course to become a Green Belt in Lean/Six Sigma. Like an intrepid explorer of yore, I will chronicle my journey and God-willing beyond through this blog. I'm excited for my departure, and will let you know my initial impressions in October.