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Topic Title: Healthcare Stuck In Craft Production?
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Created On: 02/22/2016 01:32 PM
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02/24/2016 05:00 PM
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SetupGuy
Thomas Warda



Lean is not new to healthcare, but it sure seems to be foreign to many healthcare professionals. I wanted to share an observation I've made after many years of teaching and implementing Lean thinking first in various manufacturing environments, but then transitioning to healthcare institutions. I wanted to see if anybody else has come to the same conclusions.

When introducing anybody to Lean for the first time, I always go back to the first really good book I read on the subject - The Machine that Changed the World by Womack Jones and Shook. In that book, the authors review how manufacturing (specifically automotive manufacturing) has gone through three distinct evolutions over the years.

The first generation was Craft Production and this could be characterized as products produced by craftsmen who were individual experts in their craft. Methods were fairly secretive and closely guarded. New craftsmen only learned the trade through apprenticeships with Master Craftsmen over a long period of time. Products were produced one at a time and each one was unique due to the production methods used. Costs were quite high - also due to the production methods used - and outcomes / quality were highly variable. The focus of Craft Production was the task itself.

The next generation of manufacturing - Mass Production - was driven by Henry Ford and the product was his wildly successful Model T. The biggest differences with Craft Manufacturing were standardized gauging and measurement which led to the ability to have both interchangeable parts and assembly line production. And the assembly line could be run by workers of average skills instead of skilled craftsmen because everything was made to fit. Other hallmarks of Mass Manufacturing were large batches (for efficiency) and more product standardization. This standardization was good in that it drove cost and variability out of the system so quality improved - or at least variability was reduced. But quality was generally "inspected in" after the process too. The flip side was that individual customization was much harder to accommodate. The focus of Mass Production was the product itself.

The third generation of manufacturing described in the book is Lean Manufacturing - as driven by Taiichi Ohno and his Toyota Production System. Hallmarks of this system were smaller batches, shorter lead times, higher quality and much greater worker involvement - driven by continuous improvement and the goal of a batch size of just one. Quality was further improved through prevention of errors at the source and successive checks. Cost was further reduced and customization actually became easier to accommodate. The focus of Lean Production (finally) returned to the customer.

So why would I go through so much detail on manufacturing processes when introducing Lean to healthcare professionals? Could it be that I was trying to alienate the audience right away? (Sometimes I did.) No, I start with this discussion because I then ask the audience where healthcare is; Craft Production, Mass Production or Lean Production? Every single time - sometimes after lively discussion - folks reluctantly come to the conclusion that healthcare (in general) is stuck somewhere between Craft and Mass Production.

Why is that so important? Because the system used will drive the results achieved. Looking back to Craft and Mass Production and the results generally seen, most folks start to understand why healthcare has many of the problems it currently does. I also add that in my years of Lean experience, it's hard enough to get folks to make the transition from Mass to Lean Production - no matter what business we're talking about. But making the leap from Craft to Lean Production is harder still.

So I'd like to ask my friends here what their experience has been. Do you ever introduce Lean the same way? Do you see the same reactions? Do you find that some folks - notably the Docs - are actually proud that they're "craftsmen?"

Tom
02/28/2016 09:56 PM
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289160
Arnout Orelio



Hi Tom,

Thanks for sharing this. I've not yet tried it this way, but it seems like a good way to compare two 'totally' different industries.
02/28/2016 09:56 PM
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leanblog
Mark Graban



I think you're correct, but I wouldn't "introduce Lean" to people in healthcare that way.

They don't care about or relate to manufacturing history. They might take pride in being called "craftsmen."

It's better to focus on the issues of today... what problems do we need to work together to solve in the year 2016 rather than talking about manufacturing history.

That's my advice.
02/28/2016 09:56 PM
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DannyLuo
Danny Luo



Really good post, Tom!
Two questions on it:
1.Do you think the three-generation-model fit to all industry espercailly healthcare?
2.If yes, how to make healthcare to generation 3?
02/28/2016 09:57 PM
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DanielFleming
Daniel Fleming



Hi Tom,
Thank you for your post. I like the way you introduce automotive history when introducing lean in healthcare. You share it while making a valid connection to healthcare. This is why your healthcare students have accepted the history lesson. I also teach lean in healthcare after many years of teaching in manufacturing. I find it hard to ignore the history and have heard from some healthcare organizations that they do not want any mfg. examples or discussion. After working in healthcare for several years, I can easily do this but still find it interesting and inspiring to speak about the history - so I do without overdoing it.

I also find it difficult to eliminate all the Japanese words. Some words like kaizen and kanban are extremely common and should be used to distinguish lean as something different than what they've been introduced to in the past.

Clinicians have a hard time accepting that their practice or specialty can be improved. They've worked hard to achieve success in their professional lives and to suggest that they need to improve is very humbling. Also, they do not think they work in a processes or have a hard time thinking in terms of a process. Everyone else may work in a process but they help patients. Other more technical areas of the hospital, such as imaging areas and labs, have an easier time thinking in terms of a process as they are technical people and work a technical process.

Overall, my experience in healthcare has been very positive. I've met many smart, dedicated and passionate people that really do want to improve. They've begun to make great improvement. The difficulty has been getting to a critical mass of people and areas of the hospital to make a significant difference.

Lean people are eternal optimists. We do not give up easily and nor do I. The work continues!

Dan
03/01/2016 07:10 AM
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SetupGuy
Thomas Warda



First of all, thank you for all of your thoughtful responses. The real intent of my post was to get some people thinking - and talking - and it apparently did just that. Let me see if I can address some of your comments in no particular order of importance.

As for the way I've been introducing Lean to healthcare professionals starting with the automotive industry, I agree with Mark in that it may not always be the best way to start. However, my hit rate is above 70%, so introducing it another way might be required for the other 30%. What I struggle with is jumping straight into Lean / TPS without first explaining other theories that preceded it.

As for healthcare professionals having issues with thinking of what they do as a process, I absolutely agree. However Dr. Deming once said: "If you can't describe what you are doing as a process, you don't know what you're doing." That one would probably be really hard for healthcare professionals to swallow, but it too is absolutely true. Of course this might be a hint as to some of the problems in healthcare today.

As for the question around healthcare fitting the Craft, Mass, Lean progression, that's an interesting point. Most folks I've worked with reluctantly come to the conclusion that healthcare is currently stuck somewhere between Craft and Mass Production. That would say that they understand what Craft Production is and how it mirrors much of what they do. They also agree that there are elements of Mass Production (particularly batch & queue), so they understand that. And since a number of leading healthcare facilities have successfully embraced Lean, I'd say the progression does indeed apply to healthcare. I will add that when I have this discussion, I note how hard it was to get folks in other professions / industries to move from Craft to Mass Production. And getting anybody to even think about moving from Craft straight to Lean is next to impossible. This may explain some of the difficulty some of us are facing in healthcare today.

And yes, I agree that removing at least some Japanese words from use in most healthcare Lean journeys is probably a very good move. The concepts and tools are hard enough to swallow. Throw in a whole bunch of "foreign" terms and you'll really have your hands full.

Finally, I'd like to reinforce the fact that by and large, my experiences in working with healthcare professionals and Lean have been very positive. I'd like to single out the nurses and support staffs as being particularly receptive to Lean. Then again, in my experience, these folks are the least likely to be stuck in the Craft Production mode. Doctors however are the most likely to look at themselves as craftsmen - and are generally darned proud of it. As one doctor put it: "I save lives every single day and you're trying to tell me that I can do better? How many lives have you saved?" Ok, that's a tough one.
03/07/2016 07:01 AM
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leanblog
Mark Graban



The sad, but real, counterpoint to "how many lives did you save today?" is the question of "how many patients were harmed or killed as the result of preventable medical error today?"

That question and that reality is about systems and processes... but some people will take personal offense at the idea that patients are being harmed. Putting their heads in the sand is not exactly scientific behavior.
03/11/2016 06:36 AM
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SetupGuy
Thomas Warda



Mark, I absolutely agree with you on the sad truth about patients being harmed in today's healthcare system. I have personally been harmed by a "healthcare professional" due to what I consider a lack of mistake proof / failsafe techniques. (Unfortunately, I survived and continue to use my bad experience as both a symptom of a much bigger problem and a teaching opportunity.)

When I teach Lean to healthcare professionals, I spend an inordinately large amount of time on Mistake Proof / Failsafe techniques. What I find is that most of these folks consider what turns out to be "inconvenient to do wrong" as enough prevention. My definition is "Easy to do right, and hard or impossible to do wrong." When one applies that definition / test to something as simple as giving a patient a shot (injection), it's easy to shoot all sorts of holes in the current practice. And if somebody stuck in Craft Production mode, they believe that good training will prevent any mistakes. Words fail me.
02/27/2017 10:31 AM
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DanielMunoz
Daniel Munoz



Why do you believe it is nearly impossible to go from Craft production to Lean?

My experience managing a small Clinic is that Doctors are very "unique". What I mean by this is that each Doctor is a universe and each patient is a universe. Healing a patient is not a mechanistic process, but rather a holistic process, where the patient and the doctor somewhat unite to find a new equilibrium, which is healthier for the patient (and hopefully at least not less healthy for the doctor, and also wealthier!!!).

My big problem for the moment is not even standardizing or improving processes, but rather improving teamwork on a job that has been mostly a solo activity by the doctor.

By the way, doctors who have been very instrumental in mechanizing and improving patient flow, have also had the worst patient results in my clinic. Usually doctors more inclined to seing their work as a Craft, tend to be better than doctors that are more process-driven.

In my opinion healthcare should never pass through a mass production phase!! That would be a very bad phase to be in for the patients!

Thanks for getting me to think a little!
02/28/2017 10:49 PM
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pc2
P. Cartagena



Is healthcare built around craft production? Yes.

Why? Because it should be. It needs to be.

All of mass production and most examples you ever see of craft or even lean production are centered on repetitive volume manufacturing. Exactly what healthcare should never be.

Healthcare is the ultimate expression of high mix/low volume, where each and every customer is unique and each and every "product" should be uniquely tailored for that customer.

That's not to say that there's no repetition. Even the most highly customized product can't (and shouldn't) be 100.000% generated from scratch. But the trick to doing any sort of customized product is knowing what should be handled as routine and what should be individualized.

And I have to agree with Mark, starting off with a discussion of manufacturing history outside of tradition manufacturing organizations is never a good idea. All they hear is factory blah blah blah, Ford blah blah blah, Toyota blah blah blah and then dismiss you as having no idea who they are or what they do. (Actually, they do that in manufacturing organizations too.)

I would suggest starting off with what's-in-it-for-me. Explaining that lean is about delivering exactly what's needed, where it's needed, when it's needed, in the correct amount at the highest quality and lowest cost, and is based on the principle of respect for people, should gain you more traction with healthcare professionals.

To relate the idea of craft vs. mass vs. lean in healthcare, perhaps a hypothetical comparison based on principles would be a place to start....

Craft production:
Doctor. - "I need a 1cc syringe."
Nurse - "I'll see if I can come with one."

Mass production:
Doctor. - "I need a 1cc syringe."
Nurse - "There aren't any. The economic order quantity on syringes is 1000 units of each type, 1cc through 25cc, with re-orders triggered when stock on every type falls below 250 units. We're stocked out on 1cc and 3cc. We have less than 250 units each of 5cc and 10cc but we still have 312 units of 25cc. The ERP system estimates we'll hit trigger point on Thursday and flag a re-order during the system roll-up at midnight. It should cut the P.O. Friday and the vendor should be able to schedule shipment early next week....."

lean production:
Doctor. - "I need a 1cc syringe."
Nurse - "Here'ya go."
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