Preventing Medical Errors

WSJ Published this cool article “Catching Deadly Drug Mistakes“. 

• The picture below demonstrates a lack of understanding of the human performance model. 
• We all do our best to work within the system of work, we are human and by nature make mistakes. 
• Error proofing (or mistake-proofing) could help prevent this from happening. 
•  The idea is to make it impossible to make a mistake by design.
• The picture below depicts four vials each with a different medicine or dosage:

Managing Customer Expectations

How do you assure on-time arrivals?  This is a difficult problem if you think about system complexity and variability, but what if you were to think outside of the box?

WSJ published “Why a Six-Hour Flight Now Takes Seven”

For some airlines, longer scheduled times for flights reflects inefficiency in the nation’s air travel system, which often can’t handle the volume of planes without delay,

For travelers, it can seem like airlines are cheating. “If you leave late, you know you will arrive late. But now you leave late and arrive early,” said frequent traveler Steve Edmonds, who works for the city of Austin, Texas.

So that explains why we keep arriving on time even when the flight leaves late.  All I really care about is getting to my destination on time to board a connecting flight in time, or get to my destination on time.  By managing our expectations, the airlines have solved the on-time problem.

Did the airlines in fact really solve anything?  I mean did they eliminate the cause for late arrivals, or just mask the defect? 

Can we copy these ideas to our own work?  How about starting with managing your boss’s expectations? 

• When given that new and totally cool project, we can hardly wait and get all optimistic. 
• We gladly commit to getting it done in two weeks, that seems like a long time. 
• How many times do we apologize for being late? 
• We tend to overestimate our ability to complete a task by underestimating its complexity and by underestimating our uninterrupted availability.

Airlines have worked hard to improve their service given unpredictable commodity prices and brutal competition.  Out of necessity, airlines have applied elements of the Human Performance Model  innovatively. 

For example most airlines now add a $15 bag handling fee at check-in.   I suspect the purpose of this was not to increase revenue, but to change behaviors. 

• Now hardly anyone checks their bag, which makes it difficult to lose since it’s not checked. 
• Fewer bags are now handled by the airport’s system which frees up resources (equipment, space, and time). 
• People who previously loaded baggage now have extra time and space for loading more cargo — which increases revenue.

WSJ Publishes “Strategic Plans Lose Favor” and “Where Process Improvement Projects go Wrong”

How about this for a dose of reality in the new year?

Strategic Plans Lose Favor

This article makes it clear how important being agile for companies in this chaotic world.  I kind of wished this article would have been published a year ago. 

• It gives great examples of how successful companies have looked closely at the frequency of the budgeting process, and how keeping in closer tune with the voice of the customer can result in more sales. 
• The example of Office Depot selling individual sized packages instead of bulk was awesome. 
• It also shows how little we really can know and predict about the future. 
• The solution seems to be just-in-time decision making which lends itself to glass wall value stream level metrics…

Where Process Improvement Projects Go Wrong

• This is a very good article that compares the life-cycle of six sigma and lean improvement teams to spring metal being stretched and broken. 
• It ties into the human performance model in several areas where a Director’s compensation was tied directly to six sigma team’s results. 
• Interesting how focusing on successful teams (and not reporting on the failed teams) prevented the company executives from dealing with the situation earlier. 
• I liked the four lessons learned, and agreed with the conclusions.  Sustaining lean or any other improvement process is very difficult, but it can be done.  

True Empowerment — Lean Sponsor

There are so many books written about “Empowerment”.  The first I remember reading was “Zapp! The Lightning of Empowerment: How to Improve Productivity, Quality, and Employee Satisfaction”.  

Still many people just don’t get it.  I met Managers who struggle with getting everything done in a day, and even so have a tough time letting go. 

Since it is the start of a new year here are some thoughts:

• Look for the problem areas (anytime people say “they” is a great candidate). Backlogs and customer complaints provide another source of information.
• Get a team together, and set a stretch goal (make the objective clear and measurable).
• Your job as a sponsor is to set the stage, run interference and know when to get out of the way.
• Let the team decide what needs to be improved first, and then transfer ownership quickly so the team feels the burden of accountability. 
• Your job is not to know the answers, instead know which questions to ask.
• Ask; “what do you think causes this?”  “Why?”  “What would tell you this is the reason?” and so on. 

Mentor the team without giving the answers, as you want them to grow and take on the responsibility.  When you are confident the team is on the right track, ask “what do you think will solve this?”  Let the team agree on potential solutions to try as a series of small experiments.

Then transfer ownership and accountability to the team.  This is done by asking; “Who wants to take on this part?”  Once everything is assigned, ask the team to report out in a week. 

During the report out, be very generous with praise and remember that this is uncomfortable for the team members.  Make the report out a positive experience, and then stretch the team with more challenges and questions.  Encourage your team to implement improvements rather than just pointing out problems.  Remember “improving the work is just as important as doing it”, and “the people doing the work know it best”.

Teams will look forward to reports outs and find solving their own problems to be very empowering!

Value Stream Workshop feedback from ATMAE

Association for Technology Management and Applied Engineering provided feedback on the last VSM simulation from my recent visit to Kentucky.  This feedback will provides an insight on how the Pizza Game is being percieved, and will help to make it even better:

Plus	Delta
The hands-on component is excellent.	Would like to see additional modules to be delivered separately.
Great video introducing concepts in a situation everyone can relate to in the real world. Thanks, Bob	Nothing I can think of but will let you know if I come to think of something
Best time spent in presentation in years.	If you deliver a workshop after lunch, you might want avoid video or keep the lights on.
Bob, you did a fantastic presentation.  If I can be of assistance, please call on me.	No pizza to eat.
Entertaining, concise, good tone	Improve clarity of objectives
Liked hands-on simulations, toast video, gas station and airport activities.  Liked the Pizza Game.	Well maybe software for doing VSM (Excel, other)
Great Presentations! Very Useful, Good pace, Hands-on!
Good overview that is paced just right
Good results and points, good visuals

Thanks for the feedback!

Bob

Presenting in Louisville on 11-12

Very honored to be selected to present at the ATMAE conference.  Details are here…

Update on Open Space experiment

Feedback from recent work with teams and coaching in a new field continues to be very good.  Early wins have created a more positive atmosphere between departments.  Most of the work was performed by my shadow.  Next step is publishing the results to recognize those creating new positive energy.  Interesting how bringing down walls and barriers seems to make people happier at work.  

Next challenge is to go after an analytical area with poor morale.  My mentee is going to use the proven template to open up dialog.  Still running into people wanting to take on too much of the work themselves.  My advice is to work on delegating and transferring the ownership or risk burnout.

Have a great one.

BP

Organizational Development, Lean, and Open Spaces

So we tried a new approach to jump-starting a “difficult” team.  The call came in an hour before an important 75 minute meeting and I was asked to run it.  The meeting would be a first for this team and there was reportedly tensions. 

So, I thought about what approach to use.  Using my favorite lean training tool (thanks Brian Maskell for showing “Toast Kaizen” to me in 2006), and using the principles of adult learning (thanks to Malcolm S. Knowles) I decided it would be a simple matter.

Starting with introductions (always respecting people), we formed a circle with nothing between us.  The idea was that everyone could make eye contact (thanks to Harrison Owen).  We went around the room with each person’s name, something that makes him or her unique as a person, and any improvement you noticed in recent history (in any industry).

Thanks to GBM for creating such a powerful training tool (Toast Kaizen).  We then reflected on how the person doing the work knows it best. 

The answer!   Open a space.  I asked; “what could be improved around here”?  Talk about the flood gates opening up!  Each team member was instructed to write down their idea (one per sticky — Thanks 3M), state their idea to the team and post it on the board.

At one point someone posted a sensitive subject, and I reminded the team that we should postpone judgment until later. 

Then we used multi-voting (thanks General Tire) to prioritize the issues.  We used triadic evaluation using simple color dots (5,3,1).  The only rule was the highest ranking person had to vote last.  So then I asked a team member to tally the votes, and there we had the top four items. 

I asked “who really wants to see … improve”, and then we had identified the first leader.   Then, I asked each person to help the leader with understanding the problem a bit better and make some suggestion for improvement by the next week.

Feedback was outstanding.  By the next morning word had spread, this was going to be different, “we are in control”!  It was awesome. 

And there you have it, open space with OD and lean!

Using Open Space Technology for Lean Transformations

Certain facets of Open Space Technology are used for creating and transforming high performing teams, and this can apply to lean facilitation as well:

• Once, when facilitating a value stream mapping team, we were called out of the room to participate in a survey. 
• Thinking this would likely end in disaster, an hour later the team had proved that thinking to be totally flawed. 
• The team had gone through the Storming stage and was already Norming!  We could not believe how quickly the transfer of ownership moved from the facilitator to the Team, and how well the team took charge of their own progress. 
• From that point on, we used this method each time a new team starts to create a value stream map.

Please share your thoughts…

System Dynamics — Uneveness caused by “Cash for Clunkers”

A sudden increase in demand was caused by the subject program, and systems in place could not deal well with this (Mura).  Increased paperwork and new delays combined to create aftereffects such as:

1. Title paperwork was delayed so my new vehicle license expired right before Labor Day weekend.  The dealer apologized and overnighted the paperwork, and promised to pay for any tickets that could result in driving on expired temporary plates.  (Safe bet because I didn’t dare to drive it that weekend).
2. The insurance process was also affected as a sudden increase in new policies delayed the billing process in my case.  When I received the bill from my insurance company it was already two weeks overdue.  So the insurance company is now threatening to cancel the policy.  So do I call them and get put through additional bureaucracy? 

At least I got a new truck…

Was anyone else affected on the plus or delta side from the cash for clunkers?