1 00:00:00,000 --> 00:00:02,430 The following content is provided under a Creative 2 00:00:02,430 --> 00:00:03,730 Commons license. 3 00:00:03,730 --> 00:00:06,060 Your support will help MIT OpenCourseWare 4 00:00:06,060 --> 00:00:10,090 continue to offer high quality educational resources for free. 5 00:00:10,090 --> 00:00:12,690 To make a donation or to view additional materials 6 00:00:12,690 --> 00:00:16,560 from hundreds of MIT courses, visit MIT OpenCourseWare 7 00:00:16,560 --> 00:00:17,744 at ocw.mit.edu. 8 00:00:26,325 --> 00:00:28,075 EARLL MURMAN: OK, the title of this module 9 00:00:28,075 --> 00:00:29,530 is Improving the Enterprise. 10 00:00:29,530 --> 00:00:31,600 And just to put it in context, we 11 00:00:31,600 --> 00:00:34,070 inherited a poorly performing clinic. 12 00:00:34,070 --> 00:00:37,390 We have applied lean, what we call local lean. 13 00:00:37,390 --> 00:00:39,970 But now we're going to look at, how 14 00:00:39,970 --> 00:00:42,950 do you handle issues that are outside the span of control 15 00:00:42,950 --> 00:00:45,310 of the clinic? 16 00:00:45,310 --> 00:00:47,840 And this is where you usually end up. 17 00:00:47,840 --> 00:00:50,360 That's the objective for the rest of the afternoon, 18 00:00:50,360 --> 00:00:51,777 with the exception of the very-- 19 00:00:51,777 --> 00:00:53,360 at very end, we're going to tee you up 20 00:00:53,360 --> 00:00:54,920 on a homework assignment. 21 00:00:54,920 --> 00:00:57,470 OK, so if you want to improve the whole enterprise, 22 00:00:57,470 --> 00:00:58,850 you can't just do it locally. 23 00:00:58,850 --> 00:01:01,280 You'll end up suboptimizing the enterprise. 24 00:01:01,280 --> 00:01:02,720 You may optimize yourself locally, 25 00:01:02,720 --> 00:01:04,910 but you'll suboptimize the enterprise. 26 00:01:04,910 --> 00:01:07,610 So we want to work through on how organizations 27 00:01:07,610 --> 00:01:11,180 can adapt to external constraints and implement lean. 28 00:01:11,180 --> 00:01:13,970 And the mode we're going to do this 29 00:01:13,970 --> 00:01:16,460 is something called a rapid process improvement workshop, 30 00:01:16,460 --> 00:01:19,280 which is one way to implement lean across a wider 31 00:01:19,280 --> 00:01:21,020 group than what you have here. 32 00:01:21,020 --> 00:01:23,270 We're going to look at including a daily management 33 00:01:23,270 --> 00:01:25,550 system, which is a little bit of an add-on. 34 00:01:25,550 --> 00:01:28,490 And then we're going to see we have some trouble doing that, 35 00:01:28,490 --> 00:01:30,110 and we'll discuss it. 36 00:01:30,110 --> 00:01:34,400 OK, so just to frame this, health care operations 37 00:01:34,400 --> 00:01:36,110 are often impacted by decisions which 38 00:01:36,110 --> 00:01:38,080 are outside the control of the clinic. 39 00:01:38,080 --> 00:01:41,390 I mean, this is regulations, insurance, 40 00:01:41,390 --> 00:01:43,190 resource constraints. 41 00:01:43,190 --> 00:01:46,070 We had something earlier this afternoon, 42 00:01:46,070 --> 00:01:48,560 where we had some change of employees. 43 00:01:48,560 --> 00:01:51,050 It was beyond the purview of the clinic. 44 00:01:51,050 --> 00:01:52,820 We had to adjust for that. 45 00:01:52,820 --> 00:01:55,460 That was a disruptive thing we had to handle, 46 00:01:55,460 --> 00:01:57,560 which is not unusual. 47 00:01:57,560 --> 00:02:00,115 And we need to optimize at the enterprise level, 48 00:02:00,115 --> 00:02:00,990 as I've already said. 49 00:02:00,990 --> 00:02:06,187 Otherwise, we may not optimize across our whole enterprise. 50 00:02:09,169 --> 00:02:11,540 OK, I think this has already been contained. 51 00:02:11,540 --> 00:02:14,450 What I'd really like to do is get some examples 52 00:02:14,450 --> 00:02:15,950 from your own experience. 53 00:02:15,950 --> 00:02:20,300 Or what are some external things that you've 54 00:02:20,300 --> 00:02:25,174 experienced that have disrupted your enterprises you work with? 55 00:02:25,174 --> 00:02:25,674 Yeah? 56 00:02:25,674 --> 00:02:29,390 AUDIENCE: Well, just patients showing up all in one bunch. 57 00:02:29,390 --> 00:02:32,990 Like when I was on triage as a medicine resident, 58 00:02:32,990 --> 00:02:37,400 all of our admissions would show up at 4:30 in the afternoon. 59 00:02:37,400 --> 00:02:41,400 Because everyone was coming to the ER in the afternoon. 60 00:02:41,400 --> 00:02:43,820 And then, by the time they got worked up, 61 00:02:43,820 --> 00:02:47,870 that load would hit the medicine admitting team at 4:30. 62 00:02:47,870 --> 00:02:49,160 So it's kind of the-- 63 00:02:49,160 --> 00:02:51,410 EARLL MURMAN: So yeah, this is a classic thing, 64 00:02:51,410 --> 00:02:53,658 isn't it, that the one department in the enterprise 65 00:02:53,658 --> 00:02:54,950 impacting the other department. 66 00:02:54,950 --> 00:02:57,470 And it's out of your control. 67 00:02:57,470 --> 00:02:59,100 And of course, yeah, exactly. 68 00:02:59,100 --> 00:03:04,295 And it can happen the other way, too, that the admissions, 69 00:03:04,295 --> 00:03:06,170 they're not being admitted into the hospital. 70 00:03:06,170 --> 00:03:08,990 So they're piling up in the ER and affecting the ER. 71 00:03:08,990 --> 00:03:10,900 OK. 72 00:03:10,900 --> 00:03:11,530 Other things? 73 00:03:11,530 --> 00:03:12,355 Yeah? 74 00:03:12,355 --> 00:03:13,585 AUDIENCE: [INAUDIBLE] 75 00:03:13,585 --> 00:03:14,460 EARLL MURMAN: Pardon? 76 00:03:14,460 --> 00:03:15,070 AUDIENCE: Funding. 77 00:03:15,070 --> 00:03:15,700 EARLL MURMAN: Funding. 78 00:03:15,700 --> 00:03:17,570 OK, so resources-- here's the thing, where 79 00:03:17,570 --> 00:03:19,780 you know you can do something. 80 00:03:19,780 --> 00:03:22,390 You want to do something, but you can't get the funding. 81 00:03:22,390 --> 00:03:24,400 Or maybe you get the funding, and then there's a reduction. 82 00:03:24,400 --> 00:03:26,275 I mean, that's happening in my local hospital 83 00:03:26,275 --> 00:03:28,390 now in Washington state. 84 00:03:28,390 --> 00:03:33,220 The state's grappling with a $2 billion budget shortfall gap. 85 00:03:33,220 --> 00:03:35,470 And they provide basic health coverage 86 00:03:35,470 --> 00:03:38,650 for underemployed people in the state. 87 00:03:38,650 --> 00:03:40,300 I live in a rural community. 88 00:03:40,300 --> 00:03:42,130 My hospital has a lot of these people. 89 00:03:42,130 --> 00:03:44,050 They're about ready to lose all that money, 90 00:03:44,050 --> 00:03:46,600 and they still have to treat the patients. 91 00:03:46,600 --> 00:03:47,907 OK. 92 00:03:47,907 --> 00:03:48,990 It's beyond their control. 93 00:03:48,990 --> 00:03:50,970 I mean, they can go down to Olympia and lobby a little bit. 94 00:03:50,970 --> 00:03:53,010 But basically, it's beyond their control. 95 00:03:53,010 --> 00:03:53,647 Yeah? 96 00:03:53,647 --> 00:03:55,980 AUDIENCE: So I've been working on a telephone operations 97 00:03:55,980 --> 00:03:59,190 improvement project recently with an ancillary department, 98 00:03:59,190 --> 00:04:01,170 where we only have three front desk staff. 99 00:04:01,170 --> 00:04:03,540 And our intervention was to separate 100 00:04:03,540 --> 00:04:05,550 one of the front phones in the back area 101 00:04:05,550 --> 00:04:08,133 and then have just the front desk staff locked 102 00:04:08,133 --> 00:04:10,050 at the front, directly interact with patients, 103 00:04:10,050 --> 00:04:12,480 and not have to worry about phone calls. 104 00:04:12,480 --> 00:04:17,310 And in doing our pilot, to the two-week PBSA pilot, some days, 105 00:04:17,310 --> 00:04:19,660 we only had one staff actually show up to work. 106 00:04:19,660 --> 00:04:23,625 So obviously, our plan didn't go as it would have, 107 00:04:23,625 --> 00:04:25,380 if we had the three staff. 108 00:04:25,380 --> 00:04:26,430 EARLL MURMAN: Yeah. 109 00:04:26,430 --> 00:04:28,170 So there you got an employee issue. 110 00:04:28,170 --> 00:04:29,880 Yeah. 111 00:04:29,880 --> 00:04:31,560 It might have unreliable employees, 112 00:04:31,560 --> 00:04:34,740 or maybe there are complications in their family life, 113 00:04:34,740 --> 00:04:36,240 that they couldn't come or whatever. 114 00:04:36,240 --> 00:04:37,430 AUDIENCE: [INAUDIBLE] sick. 115 00:04:37,430 --> 00:04:39,030 EARLL MURMAN: Sick, yeah. 116 00:04:39,030 --> 00:04:40,750 Any other examples? 117 00:04:40,750 --> 00:04:41,555 Yeah? 118 00:04:41,555 --> 00:04:43,180 AUDIENCE: The recession-- our economics 119 00:04:43,180 --> 00:04:45,820 and how it affects our patients [INAUDIBLE].. 120 00:04:45,820 --> 00:04:48,403 EARLL MURMAN: Yeah, I mean, we can't control the world, right? 121 00:04:48,403 --> 00:04:51,040 We're in an environment imposed on us, 122 00:04:51,040 --> 00:04:52,940 and we have to deal with it. 123 00:04:52,940 --> 00:04:54,150 Yeah. 124 00:04:54,150 --> 00:04:55,400 Any examples you can think of? 125 00:04:55,400 --> 00:04:56,510 AUDIENCE: Space constraints. 126 00:04:56,510 --> 00:04:57,843 EARLL MURMAN: Space constraints. 127 00:04:57,843 --> 00:05:01,490 AUDIENCE: When your capacity exceeds your [INAUDIBLE].. 128 00:05:01,490 --> 00:05:03,560 EARLL MURMAN: Yeah, just not enough facilities. 129 00:05:03,560 --> 00:05:06,680 OK, so these are not unusual disruptions. 130 00:05:09,520 --> 00:05:12,670 OK, so we say this is a statement. 131 00:05:12,670 --> 00:05:14,620 I suppose it may be more of a hypothesis. 132 00:05:14,620 --> 00:05:17,560 But the lean organizations, by their nature, 133 00:05:17,560 --> 00:05:19,870 are maybe more adaptable to change 134 00:05:19,870 --> 00:05:22,540 than other organizations. 135 00:05:22,540 --> 00:05:25,670 First of all, you're process-oriented. 136 00:05:25,670 --> 00:05:27,490 You think about processes. 137 00:05:27,490 --> 00:05:32,888 You think less about side or turfs or rice bowls, 138 00:05:32,888 --> 00:05:33,930 or those kinds of things. 139 00:05:33,930 --> 00:05:36,780 You get process-oriented and think about, 140 00:05:36,780 --> 00:05:38,580 how do you change your process? 141 00:05:38,580 --> 00:05:40,590 If you have standardization, which you should 142 00:05:40,590 --> 00:05:42,330 if you're a good lean organization, 143 00:05:42,330 --> 00:05:44,580 it means you're going to have fewer things to change. 144 00:05:44,580 --> 00:05:46,500 You have a stable base on which to change, 145 00:05:46,500 --> 00:05:49,650 as opposed to many things that have to be changed. 146 00:05:49,650 --> 00:05:52,080 You're used to thinking of things in rapid cycle times. 147 00:05:52,080 --> 00:05:54,870 And that's going to be really this whole rapid process 148 00:05:54,870 --> 00:05:58,345 improvement workshop, adapting to change quickly. 149 00:05:58,345 --> 00:05:59,720 And you just have a culture where 150 00:05:59,720 --> 00:06:02,420 you're accepting of change. 151 00:06:02,420 --> 00:06:03,202 Lean is a Journey. 152 00:06:03,202 --> 00:06:04,160 You're always changing. 153 00:06:04,160 --> 00:06:05,618 You're always trying to get better. 154 00:06:05,618 --> 00:06:07,500 So you're not fearful of change. 155 00:06:07,500 --> 00:06:11,960 So these are all things that, in terms of a lean organization, 156 00:06:11,960 --> 00:06:16,450 help you in dealing with these external constraints. 157 00:06:16,450 --> 00:06:19,510 Just to anchor this back in this process improvement framework 158 00:06:19,510 --> 00:06:23,080 we've been using-- and by the way, a copy of this 159 00:06:23,080 --> 00:06:26,130 is in your folders, just for your reference purposes. 160 00:06:26,130 --> 00:06:28,510 And why we put it there is to try 161 00:06:28,510 --> 00:06:35,710 to impart a thought process of structured approach to change 162 00:06:35,710 --> 00:06:37,690 and not ad hoc approach to change. 163 00:06:37,690 --> 00:06:39,708 So this is one structured approach. 164 00:06:39,708 --> 00:06:41,500 There are many other structured approaches. 165 00:06:41,500 --> 00:06:44,140 This is one that we adopted, just to give you one. 166 00:06:44,140 --> 00:06:46,390 And right now, we're in here. 167 00:06:46,390 --> 00:06:48,617 We're going to be doing another. 168 00:06:48,617 --> 00:06:50,200 We're going to have some changes we're 169 00:06:50,200 --> 00:06:51,700 going to introduce to you. 170 00:06:51,700 --> 00:06:53,548 They're going to be beyond your control. 171 00:06:53,548 --> 00:06:55,090 And we're going to have to figure out 172 00:06:55,090 --> 00:06:57,430 how to respond to them, develop an implementation plan, 173 00:06:57,430 --> 00:06:58,630 and try it out. 174 00:06:58,630 --> 00:07:02,095 And in doing this, as you go beyond your clinic, 175 00:07:02,095 --> 00:07:03,970 you're going to have to interact with a wider 176 00:07:03,970 --> 00:07:05,630 group of stakeholders. 177 00:07:05,630 --> 00:07:07,570 And that's part of the complexity of it. 178 00:07:07,570 --> 00:07:11,600 We've heard from Beau, for example, already about that. 179 00:07:11,600 --> 00:07:13,960 So let's talk a little bit about stakeholders. 180 00:07:13,960 --> 00:07:17,170 We had this slide up yesterday in a slightly different format. 181 00:07:17,170 --> 00:07:19,360 But a health care enterprise like yours 182 00:07:19,360 --> 00:07:20,890 has a lot of stakeholders. 183 00:07:20,890 --> 00:07:24,250 And let's just try to identify, in the interest of time 184 00:07:24,250 --> 00:07:27,880 and keeping this focus, for our clinics here, 185 00:07:27,880 --> 00:07:30,028 who are our major stakeholders? 186 00:07:30,028 --> 00:07:30,820 AUDIENCE: Patients. 187 00:07:30,820 --> 00:07:33,700 EARLL MURMAN: Patients, OK. 188 00:07:33,700 --> 00:07:34,330 OK. 189 00:07:34,330 --> 00:07:35,163 AUDIENCE: Suppliers. 190 00:07:35,163 --> 00:07:37,972 EARLL MURMAN: Suppliers, OK. 191 00:07:37,972 --> 00:07:38,805 AUDIENCE: Providers. 192 00:07:38,805 --> 00:07:41,080 AUDIENCE: Providers and doctors and the medical staff. 193 00:07:41,080 --> 00:07:43,505 EARLL MURMAN: Yeah, so you have the staff, medical staff. 194 00:07:43,505 --> 00:07:45,380 Why don't we just put all the staff together. 195 00:07:45,380 --> 00:07:48,670 There's the medical and the administrative. 196 00:07:48,670 --> 00:07:50,260 For now, let's just call it staff. 197 00:07:50,260 --> 00:07:54,650 Any other stakeholders in our simulated clinic environment? 198 00:07:54,650 --> 00:07:55,590 AUDIENCE: Investors? 199 00:07:55,590 --> 00:07:57,005 EARLL MURMAN: Investors, OK. 200 00:08:00,562 --> 00:08:03,010 AUDIENCE: The government. 201 00:08:03,010 --> 00:08:04,120 EARLL MURMAN: OK. 202 00:08:04,120 --> 00:08:06,640 The government is an important stakeholder, 203 00:08:06,640 --> 00:08:10,347 but probably not so much for our classroom environment here. 204 00:08:10,347 --> 00:08:11,930 But there is another important-- yeah? 205 00:08:11,930 --> 00:08:13,900 AUDIENCE: Oh, whoever's regulating. 206 00:08:13,900 --> 00:08:15,358 EARLL MURMAN: We've got management. 207 00:08:15,358 --> 00:08:17,290 It's called managers-- 208 00:08:17,290 --> 00:08:21,640 CFO or CMO, or whatever it is. 209 00:08:21,640 --> 00:08:23,560 You've got somebody you're reporting to. 210 00:08:23,560 --> 00:08:25,690 They keep imposing new things on you and saying, 211 00:08:25,690 --> 00:08:27,040 you can't do this, you can't do that. 212 00:08:27,040 --> 00:08:28,707 AUDIENCE: You've got the payers as well. 213 00:08:28,707 --> 00:08:30,760 EARLL MURMAN: Payers, OK. 214 00:08:30,760 --> 00:08:34,710 We haven't actually collected any money from them yet. . 215 00:08:34,710 --> 00:08:36,312 OK, this is a pretty good group. 216 00:08:36,312 --> 00:08:37,770 So let's just stay with that group. 217 00:08:37,770 --> 00:08:39,789 But you can imagine, in a more complex enterprise, 218 00:08:39,789 --> 00:08:41,039 you're going have more people. 219 00:08:41,039 --> 00:08:43,806 You'll have regulators. 220 00:08:43,806 --> 00:08:47,770 You might have partners. 221 00:08:47,770 --> 00:08:51,160 My hospital, for example, can't do a number of procedures 222 00:08:51,160 --> 00:08:52,000 as a small hospital. 223 00:08:52,000 --> 00:08:54,040 So partners with Swedish Hospital, 224 00:08:54,040 --> 00:08:56,500 in Seattle, and Harrison Hospital, in Bremerton, 225 00:08:56,500 --> 00:08:59,290 these are important stakeholders; EMS systems. 226 00:08:59,290 --> 00:09:01,960 They're all sorts of other partners. 227 00:09:01,960 --> 00:09:04,480 Now, we had this slide up yesterday, too. 228 00:09:04,480 --> 00:09:07,990 But each of these stakeholders expects some value 229 00:09:07,990 --> 00:09:10,010 from your enterprise. 230 00:09:10,010 --> 00:09:12,610 So let's just think, what value do patients 231 00:09:12,610 --> 00:09:15,960 expect from your clinic? 232 00:09:15,960 --> 00:09:16,710 AUDIENCE: Quality. 233 00:09:16,710 --> 00:09:17,627 EARLL MURMAN: Quality. 234 00:09:19,860 --> 00:09:24,890 OK, so remember, we've been doing that managements 235 00:09:24,890 --> 00:09:27,560 ask you, every so often, did some patient get 236 00:09:27,560 --> 00:09:29,240 treated incorrectly? 237 00:09:29,240 --> 00:09:31,140 That's a concern they track that. 238 00:09:31,140 --> 00:09:32,190 AUDIENCE: Affordability. 239 00:09:32,190 --> 00:09:33,250 EARLL MURMAN: Affordability. 240 00:09:33,250 --> 00:09:33,750 OK. 241 00:09:38,430 --> 00:09:41,880 Maybe we should introduce a pay for service, 242 00:09:41,880 --> 00:09:44,620 pay for performance option in this simulation. 243 00:09:44,620 --> 00:09:45,880 We haven't done that yet. 244 00:09:45,880 --> 00:09:46,380 OK. 245 00:09:46,380 --> 00:09:47,310 AUDIENCE: [INAUDIBLE] 246 00:09:47,310 --> 00:09:48,490 AUDIENCE: Quick access? 247 00:09:48,490 --> 00:09:49,590 EARLL MURMAN: Access, yep. 248 00:09:49,590 --> 00:09:55,080 Access-- they want to get treated. 249 00:09:55,080 --> 00:09:56,078 AUDIENCE: The time. 250 00:09:56,078 --> 00:09:56,870 EARLL MURMAN: Time? 251 00:09:56,870 --> 00:09:57,495 AUDIENCE: Time. 252 00:09:57,495 --> 00:09:58,580 EARLL MURMAN: Time. 253 00:09:58,580 --> 00:10:00,810 OK. 254 00:10:00,810 --> 00:10:03,000 That's a metric we've been tracking. 255 00:10:03,000 --> 00:10:04,530 AUDIENCE: Safety [INAUDIBLE]. 256 00:10:04,530 --> 00:10:05,250 Safety. 257 00:10:05,250 --> 00:10:06,818 EARLL MURMAN: Safety. 258 00:10:06,818 --> 00:10:08,610 Yeah, it's a little bit related to quality, 259 00:10:08,610 --> 00:10:11,350 but we'll put it here. 260 00:10:11,350 --> 00:10:13,000 OK, how about the suppliers? 261 00:10:13,000 --> 00:10:14,670 What are they? 262 00:10:14,670 --> 00:10:17,800 And by the way, also, this is a two-way street. 263 00:10:17,800 --> 00:10:22,170 I mean, they expect value, and you expect value. 264 00:10:22,170 --> 00:10:25,080 Suppliers-- what are some of the value considerations 265 00:10:25,080 --> 00:10:26,430 that come in with suppliers? 266 00:10:26,430 --> 00:10:28,336 AUDIENCE: Accuracy? 267 00:10:28,336 --> 00:10:29,940 You got the order accuracy. 268 00:10:29,940 --> 00:10:33,025 EARLL MURMAN: Accuracy, OK. 269 00:10:33,025 --> 00:10:33,900 AUDIENCE: Timeliness. 270 00:10:33,900 --> 00:10:36,024 EARLL MURMAN: Timeliness. 271 00:10:36,024 --> 00:10:38,160 AUDIENCE: Cost. 272 00:10:38,160 --> 00:10:38,952 EARLL MURMAN: Cost. 273 00:10:38,952 --> 00:10:41,580 And what do you expect from your suppliers? 274 00:10:41,580 --> 00:10:43,955 What value do you expect to get? 275 00:10:43,955 --> 00:10:44,830 AUDIENCE: [INAUDIBLE] 276 00:10:44,830 --> 00:10:45,310 AUDIENCE: Quality. 277 00:10:45,310 --> 00:10:46,227 EARLL MURMAN: Quality. 278 00:10:49,390 --> 00:10:54,970 AUDIENCE: Reliability, in both ways, I guess, 279 00:10:54,970 --> 00:11:00,010 that they rely on a steady stream of orders. 280 00:11:00,010 --> 00:11:00,903 EARLL MURMAN: Oh, OK. 281 00:11:00,903 --> 00:11:03,070 And you rely on them delivering it when you need it. 282 00:11:03,070 --> 00:11:03,700 AUDIENCE: Yeah. 283 00:11:03,700 --> 00:11:06,880 I mean, they don't want you to go to their competitors. 284 00:11:06,880 --> 00:11:09,582 EARLL MURMAN: Are you guys happy with your suppliers? 285 00:11:09,582 --> 00:11:10,540 AUDIENCE: I don't know. 286 00:11:10,540 --> 00:11:11,680 AUDIENCE: Generally. 287 00:11:11,680 --> 00:11:14,680 EARLL MURMAN: If you had to rate 0 to 10, how would 288 00:11:14,680 --> 00:11:17,240 you rate your suppliers, 0 to 10. 289 00:11:17,240 --> 00:11:17,740 AUDIENCE: 8. 290 00:11:17,740 --> 00:11:20,395 EARLL MURMAN: 8. 291 00:11:20,395 --> 00:11:22,020 AUDIENCE: Probably just a [INAUDIBLE].. 292 00:11:22,020 --> 00:11:22,520 5. 293 00:11:22,520 --> 00:11:24,120 [LAUGHTER] 294 00:11:24,120 --> 00:11:25,870 EARLL MURMAN: Our supplier just joined us. 295 00:11:25,870 --> 00:11:26,370 OK. 296 00:11:26,370 --> 00:11:28,840 [LAUGHTER] 297 00:11:28,840 --> 00:11:31,094 OK, what value do the staff expect? 298 00:11:31,094 --> 00:11:33,514 AUDIENCE: [INAUDIBLE] 299 00:11:35,450 --> 00:11:38,320 EARLL MURMAN: What do you want to get out of your clinic? 300 00:11:38,320 --> 00:11:39,730 AUDIENCE: Not feeling overloaded. 301 00:11:39,730 --> 00:11:40,630 EARLL MURMAN: OK. 302 00:11:40,630 --> 00:11:42,105 You want an acceptable workload. 303 00:11:44,670 --> 00:11:46,982 AUDIENCE: Just then value-added work. 304 00:11:46,982 --> 00:11:48,440 EARLL MURMAN: Value-added work, OK. 305 00:11:48,440 --> 00:11:50,657 Do you feel like they're doing value-added work now? 306 00:11:50,657 --> 00:11:51,240 AUDIENCE: Yes. 307 00:11:51,240 --> 00:11:51,680 EARLL MURMAN: Yes? 308 00:11:51,680 --> 00:11:52,180 Good. 309 00:11:52,180 --> 00:11:53,780 All right. 310 00:11:53,780 --> 00:11:58,070 Thinking back to the exercise in the people module yesterday 311 00:11:58,070 --> 00:12:00,390 about some of the things you value as employees-- 312 00:12:00,390 --> 00:12:01,790 you're the staff-- 313 00:12:01,790 --> 00:12:03,886 what are things that come to mind? 314 00:12:03,886 --> 00:12:06,520 AUDIENCE: [INAUDIBLE] respect. 315 00:12:06,520 --> 00:12:09,160 EARLL MURMAN: Respect. 316 00:12:09,160 --> 00:12:11,573 AUDIENCE: Cooperation. 317 00:12:11,573 --> 00:12:13,490 EARLL MURMAN: I know it's most the clinics are 318 00:12:13,490 --> 00:12:14,420 working overtime. 319 00:12:14,420 --> 00:12:16,180 Is that something you like? 320 00:12:16,180 --> 00:12:18,330 AUDIENCE: [INAUDIBLE] or something. 321 00:12:18,330 --> 00:12:19,930 [LAUGHTER] 322 00:12:19,930 --> 00:12:22,310 EARLL MURMAN: Yeah, salary was important, too, wasn't it? 323 00:12:22,310 --> 00:12:23,510 AUDIENCE: Communication. 324 00:12:23,510 --> 00:12:24,677 EARLL MURMAN: Communication. 325 00:12:24,677 --> 00:12:26,510 OK. 326 00:12:26,510 --> 00:12:28,760 I'll show you a little later on a slide. 327 00:12:28,760 --> 00:12:33,910 But my local hospital, what the staff picked is their measure. 328 00:12:33,910 --> 00:12:37,160 Their surrogate metric they track for their satisfaction 329 00:12:37,160 --> 00:12:42,040 is finishing work on time and not taking anything home. 330 00:12:42,040 --> 00:12:43,600 That was the one metric they track. 331 00:12:43,600 --> 00:12:44,970 And they tracked that metric. 332 00:12:44,970 --> 00:12:46,303 AUDIENCE: Safety to [INAUDIBLE]. 333 00:12:46,303 --> 00:12:47,680 EARLL MURMAN: Safety, yes. 334 00:12:47,680 --> 00:12:49,832 AUDIENCE: And [INAUDIBLE]. 335 00:12:49,832 --> 00:12:51,790 EARLL MURMAN: Oh, teamwork, teamwork-- got you. 336 00:12:51,790 --> 00:12:56,390 OK, so there's a long list here. 337 00:12:56,390 --> 00:12:59,726 OK, let's not spend too much more time on this. 338 00:12:59,726 --> 00:13:02,120 Let me just skip these two, because they aren't really 339 00:13:02,120 --> 00:13:03,570 too much players in our system. 340 00:13:03,570 --> 00:13:04,820 But what about our management? 341 00:13:04,820 --> 00:13:06,962 What are they looking for? 342 00:13:06,962 --> 00:13:09,220 [INTERPOSING VOICES] 343 00:13:09,220 --> 00:13:11,200 EARLL MURMAN: Perform [INAUDIBLE].. 344 00:13:11,200 --> 00:13:11,800 Performance. 345 00:13:11,800 --> 00:13:15,070 We've got some metrics up here they're tracking. 346 00:13:15,070 --> 00:13:18,650 We know they're tracking performance. 347 00:13:18,650 --> 00:13:20,660 We're measuring it in terms of patients served. 348 00:13:20,660 --> 00:13:24,590 We're looking at error safety, basically, or errors, 349 00:13:24,590 --> 00:13:26,440 like quality. 350 00:13:26,440 --> 00:13:28,020 OK. 351 00:13:28,020 --> 00:13:29,250 Legal reliability. 352 00:13:29,250 --> 00:13:30,360 EARLL MURMAN: Reliability. 353 00:13:30,360 --> 00:13:31,510 AUDIENCE: Legal liability. 354 00:13:31,510 --> 00:13:34,020 EARLL MURMAN: Oh, legal liability. 355 00:13:34,020 --> 00:13:36,342 AUDIENCE: Patient satisfaction [INAUDIBLE].. 356 00:13:36,342 --> 00:13:37,800 EARLL MURMAN: Yeah, they don't want 357 00:13:37,800 --> 00:13:40,090 to hear from angry patients. 358 00:13:40,090 --> 00:13:42,130 Luckily, our patients aren't talking. 359 00:13:42,130 --> 00:13:43,126 [LAUGHTER] 360 00:13:43,126 --> 00:13:44,620 AUDIENCE: [INAUDIBLE] 361 00:13:44,620 --> 00:13:46,220 EARLL MURMAN: OK. 362 00:13:46,220 --> 00:13:47,785 Patient satisfaction. 363 00:13:52,060 --> 00:13:53,548 OK, well, I just wanted to make-- 364 00:13:53,548 --> 00:13:55,090 we wanted to bring some of these out. 365 00:13:55,090 --> 00:13:58,270 And we're going to start addressing them. 366 00:13:58,270 --> 00:13:59,155 So let's move on. 367 00:13:59,155 --> 00:14:01,530 I'm going to skip the next slide, which is our discussion 368 00:14:01,530 --> 00:14:04,530 slide, which we just did. 369 00:14:04,530 --> 00:14:06,960 I'm going to put this up here. 370 00:14:06,960 --> 00:14:09,865 But we're not going to spend much time on ideal state now. 371 00:14:09,865 --> 00:14:11,490 Because we're a little behind schedule. 372 00:14:11,490 --> 00:14:17,110 But we have a value stream. 373 00:14:17,110 --> 00:14:19,600 We have an improved value stream. 374 00:14:19,600 --> 00:14:23,350 And we've talked before about thinking of the ideal state 375 00:14:23,350 --> 00:14:24,460 value stream. 376 00:14:24,460 --> 00:14:27,700 And this is a nice quote that comes from Sue's partner, Cindy 377 00:14:27,700 --> 00:14:31,250 Jimmerson, whose book I recommend to you, that this is 378 00:14:31,250 --> 00:14:32,500 what the ideal state would be. 379 00:14:32,500 --> 00:14:34,375 "Giving the customers exactly what they want, 380 00:14:34,375 --> 00:14:37,970 when they want it, is a core principle of an ideal state." 381 00:14:37,970 --> 00:14:41,513 OK, well, our customers, our main customers, 382 00:14:41,513 --> 00:14:42,180 are our patient. 383 00:14:42,180 --> 00:14:46,260 So this is what we would really like to do for our patient. 384 00:14:46,260 --> 00:14:47,760 So "as you observe work in progress, 385 00:14:47,760 --> 00:14:49,737 note the delays in care created by caregivers 386 00:14:49,737 --> 00:14:51,820 waiting for the necessities from their suppliers." 387 00:14:51,820 --> 00:14:53,640 Now, we don't have a lot of suppliers here. 388 00:14:53,640 --> 00:14:55,140 But we have had to wait for them. 389 00:14:55,140 --> 00:14:57,477 But that kind of delay is just passed on. 390 00:14:57,477 --> 00:14:58,560 So this is another reason. 391 00:14:58,560 --> 00:15:01,080 If you want to optimize the performance of your clinic 392 00:15:01,080 --> 00:15:02,580 or improve it, you're probably going 393 00:15:02,580 --> 00:15:05,860 to have to include your suppliers. 394 00:15:05,860 --> 00:15:07,740 That's very common. 395 00:15:07,740 --> 00:15:10,880 I'm going skip over this. 396 00:15:10,880 --> 00:15:13,325 OK, so that's just some sort of framing discussion 397 00:15:13,325 --> 00:15:14,450 for what we're going to do. 398 00:15:14,450 --> 00:15:18,140 Now, management's told me-- and the reason 399 00:15:18,140 --> 00:15:20,000 they had me come today to do some training, 400 00:15:20,000 --> 00:15:21,958 because management told me that there are going 401 00:15:21,958 --> 00:15:25,130 to be some disruptions coming soon from the enterprise, 402 00:15:25,130 --> 00:15:27,830 from these CXOs. 403 00:15:27,830 --> 00:15:31,080 And they wanted me to get you ready for handling those. 404 00:15:31,080 --> 00:15:35,150 OK, so this is going to involve working across clinics 405 00:15:35,150 --> 00:15:37,050 to handle these disruptions. 406 00:15:37,050 --> 00:15:39,170 By the way, in terms of access, and we 407 00:15:39,170 --> 00:15:43,520 have a problem with access here, some patients 408 00:15:43,520 --> 00:15:45,520 aren't being treated. 409 00:15:45,520 --> 00:15:47,640 We don't have the right diagnostic equipment. 410 00:15:47,640 --> 00:15:49,310 So we're sending them home untreated. 411 00:15:49,310 --> 00:15:51,510 And the management's not happy about that. 412 00:15:51,510 --> 00:15:54,800 The patients are unhappy about that. 413 00:15:54,800 --> 00:15:57,540 So how do we go about working across clinics? 414 00:15:57,540 --> 00:15:59,180 OK, a good way to do it is something 415 00:15:59,180 --> 00:16:01,790 called a rapid process improvement workshop. 416 00:16:01,790 --> 00:16:02,540 And what is that? 417 00:16:02,540 --> 00:16:05,510 Well, that's a focus on a specific improvement 418 00:16:05,510 --> 00:16:07,400 opportunity, as we're going to have 419 00:16:07,400 --> 00:16:08,630 coming up here in a minute. 420 00:16:08,630 --> 00:16:12,050 It's an event that's chartered by a sponsor 421 00:16:12,050 --> 00:16:14,990 in the organization, one of the managements, who 422 00:16:14,990 --> 00:16:18,440 sets the goals, the what has to be done, and the constraints, 423 00:16:18,440 --> 00:16:20,180 and provides the resources. 424 00:16:20,180 --> 00:16:21,198 And the resources are-- 425 00:16:21,198 --> 00:16:22,490 we'll get to those in a minute. 426 00:16:22,490 --> 00:16:23,573 But they're mainly people. 427 00:16:23,573 --> 00:16:27,690 They provide coaches and facilitators to help you. 428 00:16:27,690 --> 00:16:29,490 A rapid process improvement workshop 429 00:16:29,490 --> 00:16:30,960 never goes over a week. 430 00:16:30,960 --> 00:16:34,140 Most of them are a week long. 431 00:16:34,140 --> 00:16:36,750 Sometimes they're less, if it's a less complex problem. 432 00:16:36,750 --> 00:16:39,820 But it takes several months of planning to get ready for this. 433 00:16:39,820 --> 00:16:42,600 And what it does is it brings together, 434 00:16:42,600 --> 00:16:46,530 for the week, all the people who need to interact to address 435 00:16:46,530 --> 00:16:48,690 this improvement opportunity. 436 00:16:48,690 --> 00:16:52,940 And the opposite of that is that these people-- 437 00:16:52,940 --> 00:16:56,340 the contrast would be that these people are mainly 438 00:16:56,340 --> 00:16:58,500 doing their day jobs, wherever they are, 439 00:16:58,500 --> 00:17:00,270 and you're trying to do this improvement 440 00:17:00,270 --> 00:17:03,840 opportunity over a distributed group of people 441 00:17:03,840 --> 00:17:05,460 in time and space. 442 00:17:05,460 --> 00:17:09,180 And what might take six months to a year just to coordinate, 443 00:17:09,180 --> 00:17:11,265 you get done in one week. 444 00:17:11,265 --> 00:17:13,140 But in that week, that's all these people do. 445 00:17:13,140 --> 00:17:15,210 They're released from all their other activities, 446 00:17:15,210 --> 00:17:16,619 and they participate in this. 447 00:17:16,619 --> 00:17:18,732 And this is the kind of thing that Sue does. 448 00:17:18,732 --> 00:17:20,190 I presume you run these, don't you? 449 00:17:20,190 --> 00:17:20,670 AUDIENCE: Some of them. 450 00:17:20,670 --> 00:17:21,462 EARLL MURMAN: Yeah. 451 00:17:21,462 --> 00:17:22,619 Yeah. 452 00:17:22,619 --> 00:17:24,700 OK, so it involves all the stakeholders. 453 00:17:24,700 --> 00:17:26,417 It's a very data-driven process. 454 00:17:26,417 --> 00:17:28,500 We've been trying to emphasize you work with data. 455 00:17:28,500 --> 00:17:30,480 You get the value-stream data. 456 00:17:30,480 --> 00:17:35,010 The week ends with actually a beginning of an implementation 457 00:17:35,010 --> 00:17:37,140 and a plan for final implementation. 458 00:17:37,140 --> 00:17:40,110 And so this is how you get a whole enterprise together 459 00:17:40,110 --> 00:17:41,410 by getting the right people. 460 00:17:41,410 --> 00:17:43,980 This is an example of one I've drawn these slides from, 461 00:17:43,980 --> 00:17:45,660 where I sat through with this. 462 00:17:45,660 --> 00:17:47,980 AUDIENCE: [INAUDIBLE] you're actually implementing. 463 00:17:47,980 --> 00:17:49,730 EARLL MURMAN: Yeah, we actually implement. 464 00:17:49,730 --> 00:17:52,053 But we implement, but there may be 465 00:17:52,053 --> 00:17:54,470 additional training and other things that need to be done. 466 00:17:54,470 --> 00:17:56,778 And we'll show you that in a minute. 467 00:17:56,778 --> 00:17:58,320 Here's diagrammatically what that is. 468 00:17:58,320 --> 00:18:01,020 So we have a rapid process improvement workshop 469 00:18:01,020 --> 00:18:04,020 that's going to be three to five days, say. 470 00:18:04,020 --> 00:18:05,790 And it starts by understanding what 471 00:18:05,790 --> 00:18:07,740 is important to improve in the enterprise. 472 00:18:07,740 --> 00:18:10,240 And there's always more to improve than resources. 473 00:18:10,240 --> 00:18:12,120 So you do some kind of Pareto chart. 474 00:18:12,120 --> 00:18:15,150 We've done that informally with this kind of thing we had, 475 00:18:15,150 --> 00:18:18,490 which was, what were the big bottlenecks you had to address? 476 00:18:18,490 --> 00:18:20,040 So you pick some target. 477 00:18:20,040 --> 00:18:23,280 You make a strategic choice on what you're going to improve. 478 00:18:23,280 --> 00:18:25,620 And then you may take three months or so to get ready. 479 00:18:25,620 --> 00:18:27,120 You have to go out and get the data. 480 00:18:27,120 --> 00:18:28,770 You have to figure out who are the right stakeholders. 481 00:18:28,770 --> 00:18:31,710 You have to plan it so the stakeholders can be available. 482 00:18:31,710 --> 00:18:34,860 You're going to pour a lot of resources in for one week. 483 00:18:34,860 --> 00:18:36,750 But you'll probably pour a lot less resources 484 00:18:36,750 --> 00:18:39,195 than if you try to stretch it over six months to a year. 485 00:18:39,195 --> 00:18:41,820 PROFESSOR: And the agreement has to be that the stakeholders do 486 00:18:41,820 --> 00:18:44,340 not leave the room, turn off cell phones, 487 00:18:44,340 --> 00:18:47,058 and they're cloistered for the whole time. 488 00:18:47,058 --> 00:18:47,850 EARLL MURMAN: Yeah. 489 00:18:47,850 --> 00:18:50,023 And they don't arrive late, and they don't go back 490 00:18:50,023 --> 00:18:50,940 to some other meeting. 491 00:18:50,940 --> 00:18:52,980 That's it. 492 00:18:52,980 --> 00:18:55,970 And that's why you need this top level support. 493 00:18:55,970 --> 00:18:59,060 OK, then that group is given a charter. 494 00:18:59,060 --> 00:19:00,980 And they're given the resources they need 495 00:19:00,980 --> 00:19:02,690 and the data they need. 496 00:19:02,690 --> 00:19:04,520 And that's a really intense week. 497 00:19:04,520 --> 00:19:06,770 Has anybody participated in one of these rapid process 498 00:19:06,770 --> 00:19:08,510 improvement workshops? 499 00:19:08,510 --> 00:19:12,500 Sue, Sue and I, and Hugh. 500 00:19:12,500 --> 00:19:14,690 You think this course is maybe intense. 501 00:19:14,690 --> 00:19:18,005 These are much more intense than that. 502 00:19:18,005 --> 00:19:19,130 But the outcomes are great. 503 00:19:19,130 --> 00:19:23,130 So out of that comes your future state and implementation plan. 504 00:19:23,130 --> 00:19:26,720 And as Sue said, you actually do the prototype implementation 505 00:19:26,720 --> 00:19:27,780 in place. 506 00:19:27,780 --> 00:19:29,960 Sometimes you can't do the final implementation. 507 00:19:29,960 --> 00:19:32,535 And then you track it and make sure 508 00:19:32,535 --> 00:19:34,160 that it's performing the way you think. 509 00:19:34,160 --> 00:19:35,600 And oftentimes, you've misjudged. 510 00:19:35,600 --> 00:19:37,100 You made a mistake somewhere. 511 00:19:37,100 --> 00:19:38,210 Training is a typical one. 512 00:19:38,210 --> 00:19:39,835 You didn't get people trained properly, 513 00:19:39,835 --> 00:19:40,950 or something like that. 514 00:19:40,950 --> 00:19:43,430 And so you may have to do some follow-up action. 515 00:19:43,430 --> 00:19:47,420 And then you feed that back in and do the next rapid process 516 00:19:47,420 --> 00:19:48,215 improvement event. 517 00:19:48,215 --> 00:19:49,340 Who are these stakeholders? 518 00:19:49,340 --> 00:19:51,860 Well, you want to have the people actually doing the work. 519 00:19:51,860 --> 00:19:53,460 In this case, that's you. 520 00:19:53,460 --> 00:19:54,462 OK? 521 00:19:54,462 --> 00:19:56,420 You want to have some facilitators and coaches. 522 00:19:56,420 --> 00:19:57,900 That's Beau and me. 523 00:19:57,900 --> 00:20:02,320 And you might think of Hugh as our sponsor. 524 00:20:02,320 --> 00:20:04,480 If we were doing something where suppose 525 00:20:04,480 --> 00:20:06,850 we're going to implement some new protocol. 526 00:20:06,850 --> 00:20:10,600 Well, we need people from the training department to come. 527 00:20:10,600 --> 00:20:14,415 We may need some IT people to write some software. 528 00:20:14,415 --> 00:20:16,040 If we're doing something more physical, 529 00:20:16,040 --> 00:20:18,110 we might have facilities on board. 530 00:20:18,110 --> 00:20:20,140 They just saw down the walls and move them, 531 00:20:20,140 --> 00:20:21,250 right during the week. 532 00:20:21,250 --> 00:20:24,150 I mean, this is really action-oriented. 533 00:20:24,150 --> 00:20:26,530 OK, so you may need some support facilities. 534 00:20:26,530 --> 00:20:30,670 And you want somebody up there at the CEO level 535 00:20:30,670 --> 00:20:32,227 who's championing it. 536 00:20:32,227 --> 00:20:34,060 And here's what takes place during the week. 537 00:20:34,060 --> 00:20:37,860 So day one-- this is for a five-day-- 538 00:20:37,860 --> 00:20:38,610 you come together. 539 00:20:38,610 --> 00:20:39,693 You do some team-building. 540 00:20:39,693 --> 00:20:42,360 Make sure you're all being able to work with each other. 541 00:20:42,360 --> 00:20:45,610 You go to the Gemba and actually see what's happening, 542 00:20:45,610 --> 00:20:48,027 make sure you understand what the real problem is. 543 00:20:48,027 --> 00:20:50,610 You'll probably come in with a current state map already done, 544 00:20:50,610 --> 00:20:52,020 because that takes some time. 545 00:20:52,020 --> 00:20:54,150 And you do a lot of brainstorming. 546 00:20:54,150 --> 00:20:57,210 How are we going to address this improvement opportunity that 547 00:20:57,210 --> 00:20:59,010 is given to us in our charter? 548 00:20:59,010 --> 00:21:00,630 So day one is really getting started. 549 00:21:00,630 --> 00:21:02,700 Day two-- go home and sleep out. 550 00:21:02,700 --> 00:21:06,000 You come back on day two, and you say, OK, 551 00:21:06,000 --> 00:21:09,330 from our brainstorming, we think this is the way we can go. 552 00:21:09,330 --> 00:21:13,550 Here's going to be our draft future state map and strategy. 553 00:21:13,550 --> 00:21:15,680 And you have senior management come 554 00:21:15,680 --> 00:21:19,700 in the afternoon of day two and say, here's where we're at. 555 00:21:19,700 --> 00:21:21,560 And this is the direction we want to go. 556 00:21:21,560 --> 00:21:22,880 Do we have your approval? 557 00:21:22,880 --> 00:21:25,422 Let me give you the example I went through in this one, which 558 00:21:25,422 --> 00:21:26,630 the pictures are taken from. 559 00:21:26,630 --> 00:21:30,680 This was, how do we treat STEMI cases in our hospital? 560 00:21:30,680 --> 00:21:32,790 And our hospital can't do a catheter-- 561 00:21:32,790 --> 00:21:34,550 doesn't have a catheter lab. 562 00:21:34,550 --> 00:21:39,410 And the treatment time was from a presentation 563 00:21:39,410 --> 00:21:43,730 to when they were getting finally sent down to Bremerton. 564 00:21:43,730 --> 00:21:48,140 Treated was-- I've forgotten, something like several hours. 565 00:21:48,140 --> 00:21:49,065 AUDIENCE: [INAUDIBLE] 566 00:21:49,065 --> 00:21:49,940 EARLL MURMAN: Pardon? 567 00:21:49,940 --> 00:21:51,920 AUDIENCE: [INAUDIBLE] 568 00:21:51,920 --> 00:21:54,120 EARLL MURMAN: STEMI is S T Elevated-- 569 00:21:54,120 --> 00:21:55,520 AUDIENCE: S T segment elevation. 570 00:21:55,520 --> 00:21:56,618 It's higher tech. 571 00:21:56,618 --> 00:21:58,410 EARLL MURMAN: It's a blockage [INAUDIBLE].. 572 00:21:58,410 --> 00:22:00,202 AUDIENCE: A research pattern that shows up, 573 00:22:00,202 --> 00:22:03,312 a leakage [INAUDIBLE] right now. 574 00:22:03,312 --> 00:22:04,020 EARLL MURMAN: OK. 575 00:22:04,020 --> 00:22:06,120 So we gathered on day one. 576 00:22:06,120 --> 00:22:10,602 And we immediately found out, on day one, 577 00:22:10,602 --> 00:22:12,310 there was a constraint that was so great, 578 00:22:12,310 --> 00:22:13,590 we couldn't solve the problem. 579 00:22:13,590 --> 00:22:15,690 And that was, we simply physically 580 00:22:15,690 --> 00:22:17,700 couldn't get the patient to my town, 581 00:22:17,700 --> 00:22:20,730 to Bremerton, within the 90-minute window that you 582 00:22:20,730 --> 00:22:22,210 use for STEMI treatment. 583 00:22:22,210 --> 00:22:24,530 And so actually, we were stuck. 584 00:22:24,530 --> 00:22:27,590 And then what happened, we got the cardiologist on the phone 585 00:22:27,590 --> 00:22:29,270 and said, we're stuck. 586 00:22:29,270 --> 00:22:31,610 And he said, well, if you're stuck on that, 587 00:22:31,610 --> 00:22:34,160 the next best thing is to get him the thrombolytic drugs as 588 00:22:34,160 --> 00:22:38,060 quickly as possible and then get him to Bremerton. 589 00:22:38,060 --> 00:22:42,578 So we came up with plan B. And plan B, 590 00:22:42,578 --> 00:22:44,870 put together that Monday day-- this all happened Monday 591 00:22:44,870 --> 00:22:48,020 morning, Monday afternoon-- 592 00:22:48,020 --> 00:22:50,210 was to focus on the patient. 593 00:22:50,210 --> 00:22:52,700 And the patient was the organizing-- 594 00:22:55,655 --> 00:22:57,780 everybody organized around focusing on the patient. 595 00:22:57,780 --> 00:22:59,280 By the way, he had six organizations 596 00:22:59,280 --> 00:23:02,310 involved in this workshop-- two hospitals, two EMS drivers, 597 00:23:02,310 --> 00:23:04,400 and two cardiologist groups. 598 00:23:04,400 --> 00:23:06,050 And decision was, the best we can do 599 00:23:06,050 --> 00:23:09,230 is give the patient the thrombolytic drugs in the EMS 600 00:23:09,230 --> 00:23:11,530 vehicle on the way to Bremerton. 601 00:23:11,530 --> 00:23:13,780 OK? 602 00:23:13,780 --> 00:23:16,270 And basically, we put the hospital where the patient was, 603 00:23:16,270 --> 00:23:17,860 is what we did. 604 00:23:17,860 --> 00:23:21,850 And the big hangup was, who pays for the thrombolytic drug? 605 00:23:21,850 --> 00:23:24,002 Because it's $3,000. 606 00:23:24,002 --> 00:23:25,460 They've never gone to the hospital, 607 00:23:25,460 --> 00:23:27,085 so the hospital can't be billed for it. 608 00:23:27,085 --> 00:23:31,467 The EMS company has no authority to bill for drugs. 609 00:23:31,467 --> 00:23:33,050 They can only bill for transportation. 610 00:23:33,050 --> 00:23:35,860 So we had a solution, but a complete blockage. 611 00:23:35,860 --> 00:23:37,720 We brought in senior management. 612 00:23:37,720 --> 00:23:41,330 And the CEO, right there, Vic Dirksen, 613 00:23:41,330 --> 00:23:44,480 said, this is the right solution for the patient. 614 00:23:44,480 --> 00:23:44,990 Do it. 615 00:23:44,990 --> 00:23:47,970 We'll figure out how to pay for it. 616 00:23:47,970 --> 00:23:49,100 And we really needed that. 617 00:23:49,100 --> 00:23:51,788 Without that commitment that he would pay for the drug-- 618 00:23:51,788 --> 00:23:52,580 that happened here. 619 00:23:52,580 --> 00:23:56,630 Then the team put together the new protocols. 620 00:23:56,630 --> 00:23:58,700 Here's the mock-up kit for the thrombolytic drug 621 00:23:58,700 --> 00:24:02,500 that's going in the ambulance, training materials, and so on. 622 00:24:02,500 --> 00:24:05,210 And by Friday afternoon, we got by everybody 623 00:24:05,210 --> 00:24:06,780 we needed to do this. 624 00:24:06,780 --> 00:24:09,860 And by Friday afternoon, the protocol was established. 625 00:24:09,860 --> 00:24:13,520 But it took about two or three months to train the medics 626 00:24:13,520 --> 00:24:16,700 and to make sure that the hospitals were ready for it, 627 00:24:16,700 --> 00:24:17,447 and all that. 628 00:24:17,447 --> 00:24:19,280 And that's now the protocol in my community. 629 00:24:19,280 --> 00:24:21,110 And there are articles about how many lives 630 00:24:21,110 --> 00:24:24,350 it saved in my community. 631 00:24:24,350 --> 00:24:29,720 OK, that would have taken two years to do by any other way. 632 00:24:29,720 --> 00:24:31,050 So that's one way to do it. 633 00:24:31,050 --> 00:24:32,900 I just want to ask, how does change 634 00:24:32,900 --> 00:24:36,470 take place in your organizations compared to this? 635 00:24:36,470 --> 00:24:37,700 You're mostly students. 636 00:24:37,700 --> 00:24:40,865 But how about-- 637 00:24:40,865 --> 00:24:41,740 AUDIENCE: [INAUDIBLE] 638 00:24:41,740 --> 00:24:43,240 EARLL MURMAN: Jennifer, I could ask. 639 00:24:43,240 --> 00:24:45,020 OK, good, and I'll Jennifer, because she-- 640 00:24:45,020 --> 00:24:47,530 AUDIENCE: In our resident, internal medicine residency 641 00:24:47,530 --> 00:24:52,300 program, we were pretty active in [INAUDIBLE] going along with 642 00:24:52,300 --> 00:24:57,070 lean thinking, maybe not the formal process on how much 643 00:24:57,070 --> 00:25:01,400 the interns and residents were walking out each day, 644 00:25:01,400 --> 00:25:04,460 going back and forth between floors, caring for patients, 645 00:25:04,460 --> 00:25:08,770 and then trying to move towards a more geographic lean system-- 646 00:25:08,770 --> 00:25:13,660 so things like that that affected our work [INAUDIBLE].. 647 00:25:13,660 --> 00:25:17,162 So it was kind of doing some trials and then going back 648 00:25:17,162 --> 00:25:18,120 and see if [INAUDIBLE]. 649 00:25:18,120 --> 00:25:19,180 EARLL MURMAN: Not as focused as this. 650 00:25:19,180 --> 00:25:20,470 AUDIENCE: Not nearly as focused as this. 651 00:25:20,470 --> 00:25:20,800 It took a long time. 652 00:25:20,800 --> 00:25:23,133 EARLL MURMAN: It probably took a long-- that long, yeah. 653 00:25:23,133 --> 00:25:24,370 Yeah, Martha? 654 00:25:24,370 --> 00:25:26,480 AUDIENCE: I was just going to say, 655 00:25:26,480 --> 00:25:28,480 working in a lot of under-resourced areas, 656 00:25:28,480 --> 00:25:32,650 the way it really seems to work in real life is that it's based 657 00:25:32,650 --> 00:25:37,270 on a branch, or a regulation, or a staff shortage, 658 00:25:37,270 --> 00:25:40,550 or a work-around, is how change happens because it has to. 659 00:25:40,550 --> 00:25:42,290 EARLL MURMAN: [INAUDIBLE] 660 00:25:42,290 --> 00:25:44,741 AUDIENCE: Catastrophic event [INAUDIBLE].. 661 00:25:44,741 --> 00:25:47,840 EARLL MURMAN: Yeah, or a catastrophic event, yeah. 662 00:25:47,840 --> 00:25:50,330 Laura, what about the [INAUDIBLE]?? 663 00:25:50,330 --> 00:25:52,080 AUDIENCE: Well, I'm at the medical school. 664 00:25:52,080 --> 00:25:55,580 And I teach a course with first and second year 665 00:25:55,580 --> 00:25:56,330 medical students. 666 00:25:56,330 --> 00:25:59,840 And that course, is constantly evolving. 667 00:25:59,840 --> 00:26:03,050 So they do a lot of real-time changing based on feedback. 668 00:26:03,050 --> 00:26:05,360 But I'm not so sure that that's always-- 669 00:26:05,360 --> 00:26:08,570 it was maybe a little bit too rapid, with not enough-- 670 00:26:08,570 --> 00:26:11,072 enough real evaluation of what's going on. 671 00:26:11,072 --> 00:26:13,280 EARLL MURMAN: But this is still a fairly small group? 672 00:26:13,280 --> 00:26:15,110 I mean, how many people-- 673 00:26:15,110 --> 00:26:16,550 AUDIENCE: The class is-- 674 00:26:16,550 --> 00:26:21,180 well, there's about 100 students in a class. 675 00:26:21,180 --> 00:26:24,250 And the class manages both first and second year class. 676 00:26:24,250 --> 00:26:28,370 So about 200 students total are managed in the class. 677 00:26:28,370 --> 00:26:30,440 And then, when there are other problems that 678 00:26:30,440 --> 00:26:32,273 need to be changed, it does take a long time 679 00:26:32,273 --> 00:26:34,460 to actually change the facilitator's manual 680 00:26:34,460 --> 00:26:39,150 to actually institutionalize some changes. 681 00:26:39,150 --> 00:26:40,700 So in some ways, some of the changes 682 00:26:40,700 --> 00:26:43,370 take place in a rapid fashion, based on the student input. 683 00:26:43,370 --> 00:26:46,190 And then some of them, actually, because the process 684 00:26:46,190 --> 00:26:49,020 has to go through the dean and whatnot, 685 00:26:49,020 --> 00:26:50,742 it actually doesn't get done. 686 00:26:50,742 --> 00:26:52,700 EARLL MURMAN: And well, it sometimes just dies. 687 00:26:52,700 --> 00:26:53,870 AUDIENCE: It just dies. 688 00:26:53,870 --> 00:26:56,520 There's a lot of talk, and then it kind of fizzles-- 689 00:26:56,520 --> 00:26:57,020 a lot. 690 00:26:57,020 --> 00:26:58,645 And I even think, in residency, there's 691 00:26:58,645 --> 00:27:00,438 a lot of ideas that come out. 692 00:27:00,438 --> 00:27:01,730 And then they just fizzle away. 693 00:27:01,730 --> 00:27:05,600 Because nobody has a real time to actually dedicate 694 00:27:05,600 --> 00:27:07,028 to seeing the process through. 695 00:27:07,028 --> 00:27:07,820 EARLL MURMAN: Yeah. 696 00:27:07,820 --> 00:27:09,080 So you can't do this for everything. 697 00:27:09,080 --> 00:27:11,150 Because this takes a real focused application 698 00:27:11,150 --> 00:27:11,790 of resources. 699 00:27:11,790 --> 00:27:13,915 So you have to do it for the most important things. 700 00:27:13,915 --> 00:27:17,870 AUDIENCE: Dartmouth has a really complex and wonderful quality 701 00:27:17,870 --> 00:27:18,830 department. 702 00:27:18,830 --> 00:27:20,630 AUDIENCE: Yes, so the TDI can handle it. 703 00:27:20,630 --> 00:27:23,742 AUDIENCE: A TDI that can handle a lot of these kinds of things. 704 00:27:23,742 --> 00:27:25,700 If you go to them and with a proposal, and they 705 00:27:25,700 --> 00:27:27,825 can put a team together. 706 00:27:27,825 --> 00:27:28,700 AUDIENCE: Yeah, yeah. 707 00:27:28,700 --> 00:27:31,075 So I'm speaking specifically about at the medical school, 708 00:27:31,075 --> 00:27:33,020 what I'm working with at the hospital. 709 00:27:33,020 --> 00:27:35,540 Yeah, the TDI works closely with Dartmouth Hitchcock. 710 00:27:35,540 --> 00:27:39,027 And they do a lot of some lean and some other. 711 00:27:39,027 --> 00:27:39,860 You would know more. 712 00:27:39,860 --> 00:27:43,290 But they incorporate a lot of continuous quality improvement, 713 00:27:43,290 --> 00:27:43,790 methods-- 714 00:27:43,790 --> 00:27:45,590 AUDIENCE: [INAUDIBLE],, things that are, 715 00:27:45,590 --> 00:27:48,100 I mean, for many years, before they call it lean. 716 00:27:48,100 --> 00:27:49,850 EARLL MURMAN: We had an interesting thing. 717 00:27:49,850 --> 00:27:52,370 And I keep drawing on my health care system, 718 00:27:52,370 --> 00:27:55,190 because it's my base of firsthand knowledge. 719 00:27:55,190 --> 00:27:58,430 But we had an urgent care clinic and a regular clinic 720 00:27:58,430 --> 00:27:59,305 in the system. 721 00:27:59,305 --> 00:28:00,680 And for financial reasons, it was 722 00:28:00,680 --> 00:28:04,520 decided to co-locate them and physically move them 723 00:28:04,520 --> 00:28:08,190 and that they would share examination rooms. 724 00:28:08,190 --> 00:28:10,850 And these are two groups which had never worked together. 725 00:28:10,850 --> 00:28:18,690 And the groups were not happy about this, this new one. 726 00:28:18,690 --> 00:28:21,910 So they had a three-day rapid process improvement workshop. 727 00:28:21,910 --> 00:28:24,570 And I was fortunate to go to the final report 728 00:28:24,570 --> 00:28:27,040 out on the third day. 729 00:28:27,040 --> 00:28:31,570 And the nurse from the clinic started by saying, 730 00:28:31,570 --> 00:28:33,045 Sunday night-- 731 00:28:33,045 --> 00:28:35,170 the thing started Monday and finished on Wednesday. 732 00:28:35,170 --> 00:28:37,090 She said, Sunday night, I didn't sleep. 733 00:28:37,090 --> 00:28:39,393 So I came into this Monday morning just 734 00:28:39,393 --> 00:28:40,810 knowing this wasn't going to work, 735 00:28:40,810 --> 00:28:42,340 that the whole thing was just going to break down, 736 00:28:42,340 --> 00:28:44,048 and we wouldn't be able to work together, 737 00:28:44,048 --> 00:28:47,140 and that there was no way we could share examination rooms. 738 00:28:47,140 --> 00:28:52,600 And she came in totally convinced this wouldn't work. 739 00:28:52,600 --> 00:28:55,930 By Wednesday afternoon, she and the staff 740 00:28:55,930 --> 00:28:58,630 in the urgent care clinic were the best of friends. 741 00:28:58,630 --> 00:29:00,560 They had worked through all their issues. 742 00:29:00,560 --> 00:29:02,410 She said, this is just remarkable. 743 00:29:02,410 --> 00:29:03,993 Now, can you imagine how long it would 744 00:29:03,993 --> 00:29:06,035 have taken for that to happen, if they didn't get 745 00:29:06,035 --> 00:29:08,110 this intense environment, with the facilitators 746 00:29:08,110 --> 00:29:09,220 and the objective? 747 00:29:09,220 --> 00:29:11,423 It probably would have died. 748 00:29:11,423 --> 00:29:13,840 Or either that or it would have been dictated by the CEO-- 749 00:29:13,840 --> 00:29:14,830 we're going to do it, in which case, 750 00:29:14,830 --> 00:29:16,840 they would have not had any ownership in it. 751 00:29:16,840 --> 00:29:20,090 And it would have always been a burr under the saddle. 752 00:29:20,090 --> 00:29:23,450 So it's really amazing how these things work. 753 00:29:23,450 --> 00:29:25,580 AUDIENCE: I think that the times that I've really 754 00:29:25,580 --> 00:29:27,236 seen change work in our department 755 00:29:27,236 --> 00:29:29,870 is when, unfortunately, it's mandated. 756 00:29:29,870 --> 00:29:31,880 Because we have a lot of people who 757 00:29:31,880 --> 00:29:37,040 come with particular interests and establish relationships, 758 00:29:37,040 --> 00:29:38,880 people who have decided not to get along, 759 00:29:38,880 --> 00:29:41,380 people who have decided that they don't want to collaborate, 760 00:29:41,380 --> 00:29:43,970 who have just created their own separate worlds that 761 00:29:43,970 --> 00:29:46,530 spin in parallel laws of duplication. 762 00:29:46,530 --> 00:29:49,435 And it really wasn't until the chairman of the department 763 00:29:49,435 --> 00:29:51,560 was sitting at a table in a meeting that was called 764 00:29:51,560 --> 00:29:54,020 and basically said, this division of labor 765 00:29:54,020 --> 00:29:56,720 is unacceptable, and we all have to change, 766 00:29:56,720 --> 00:29:58,400 that change actually happened. 767 00:29:58,400 --> 00:30:00,710 And then, once that mandate was there, 768 00:30:00,710 --> 00:30:03,070 people decided that they were going to try to get along. 769 00:30:03,070 --> 00:30:06,530 But unfortunately, the top-down-- 770 00:30:06,530 --> 00:30:08,030 the bottom-up approach didn't work, 771 00:30:08,030 --> 00:30:09,745 and it had to be a top-down. 772 00:30:09,745 --> 00:30:11,120 EARLL MURMAN: You're lucky you're 773 00:30:11,120 --> 00:30:13,220 in an organization where the people eventually 774 00:30:13,220 --> 00:30:14,180 decide to get along. 775 00:30:14,180 --> 00:30:16,597 Because there are a lot of organizations where people say, 776 00:30:16,597 --> 00:30:19,620 we'll just wait till that guy moves on. 777 00:30:19,620 --> 00:30:21,270 There really is no bonding. 778 00:30:21,270 --> 00:30:22,770 So you're very fortunate on that. 779 00:30:22,770 --> 00:30:23,970 Yeah. 780 00:30:23,970 --> 00:30:28,080 OK, so anyway, this is a proven way 781 00:30:28,080 --> 00:30:30,030 to implement change, where you've got 782 00:30:30,030 --> 00:30:31,470 multiple stakeholders involved. 783 00:30:31,470 --> 00:30:33,180 But you've got to do it right. 784 00:30:33,180 --> 00:30:37,860 And there's a lot of dynamics going on this week, 785 00:30:37,860 --> 00:30:41,940 that you have to have somebody skilled to see. 786 00:30:41,940 --> 00:30:46,620 OK, so what we're going to do is we're 787 00:30:46,620 --> 00:30:49,590 going to do a mock RPIW for your next change. 788 00:30:49,590 --> 00:30:53,742 We're going to do this five-day in about an hour and a half. 789 00:30:53,742 --> 00:30:55,200 But we're going to get to the point 790 00:30:55,200 --> 00:30:59,197 where you're actually going to implement your new system. 791 00:30:59,197 --> 00:31:00,780 You'll see in a minute what management 792 00:31:00,780 --> 00:31:02,040 is going to tell you to do. 793 00:31:02,040 --> 00:31:04,983 But we're going to do it like a mock RPIW. 794 00:31:04,983 --> 00:31:06,400 The other thing we're going to do, 795 00:31:06,400 --> 00:31:09,210 which is really not as much of an enterprise thing, 796 00:31:09,210 --> 00:31:12,160 is we're going to implement a daily management system. 797 00:31:12,160 --> 00:31:15,160 Now, a daily management system is an approach 798 00:31:15,160 --> 00:31:21,170 where-- in this case, one of our clinics at 7:55 each morning, 799 00:31:21,170 --> 00:31:25,140 the entire clinic staff meets for five minutes. 800 00:31:25,140 --> 00:31:27,500 And they go over the status of the clinic 801 00:31:27,500 --> 00:31:28,880 and what's coming up for the day. 802 00:31:28,880 --> 00:31:30,350 They have a board prepared. 803 00:31:30,350 --> 00:31:32,780 This is prepared by the clinic administrator. 804 00:31:32,780 --> 00:31:36,200 So it would be like the scheduling person. 805 00:31:36,200 --> 00:31:37,733 Here is the previous days-- 806 00:31:37,733 --> 00:31:39,650 just like in the New Balance chart, basically, 807 00:31:39,650 --> 00:31:41,780 the New Balance thing-- the previous days 808 00:31:41,780 --> 00:31:45,440 by provider, how many people they were expected to see, 809 00:31:45,440 --> 00:31:48,390 how many they actually saw, all the way down. 810 00:31:48,390 --> 00:31:51,472 And this part is the upcoming day, 811 00:31:51,472 --> 00:31:53,930 how many people are scheduled and how many open spots there 812 00:31:53,930 --> 00:31:54,770 are. 813 00:31:54,770 --> 00:31:57,020 This is feedback from the patients. 814 00:31:57,020 --> 00:31:59,480 This is feedback from the workforce staff. 815 00:31:59,480 --> 00:32:03,320 I mentioned they track, did everybody go home on time 816 00:32:03,320 --> 00:32:04,430 with no work to do? 817 00:32:04,430 --> 00:32:06,821 If not, why? 818 00:32:06,821 --> 00:32:09,020 And there's some quality metrics they track. 819 00:32:09,020 --> 00:32:12,020 So the clinic administrator gets this all prepared. 820 00:32:12,020 --> 00:32:14,720 There's a stopwatch here somewhere. 821 00:32:14,720 --> 00:32:16,910 At 7:55, she punches a stopwatch. 822 00:32:16,910 --> 00:32:18,050 The meeting starts. 823 00:32:18,050 --> 00:32:20,597 At 8 o'clock, it goes off, and the meeting's over. 824 00:32:20,597 --> 00:32:21,680 It's not really a meeting. 825 00:32:21,680 --> 00:32:21,950 It's-- 826 00:32:21,950 --> 00:32:22,760 AUDIENCE: [INAUDIBLE] puddles. 827 00:32:22,760 --> 00:32:23,965 EARLL MURMAN: Yeah, yeah. 828 00:32:23,965 --> 00:32:24,590 I've heard it-- 829 00:32:24,590 --> 00:32:24,980 AUDIENCE: [INAUDIBLE] 830 00:32:24,980 --> 00:32:25,772 EARLL MURMAN: Yeah. 831 00:32:25,772 --> 00:32:27,170 And here's the staff. 832 00:32:27,170 --> 00:32:30,920 And this gets everybody in line for the day. 833 00:32:30,920 --> 00:32:32,583 And many times, we'll come out as-- 834 00:32:32,583 --> 00:32:34,500 find out, well, we've got a patient coming in, 835 00:32:34,500 --> 00:32:37,400 and we don't have all the paperwork ready, or something. 836 00:32:37,400 --> 00:32:42,570 So they get on top of that right away and get that done. 837 00:32:42,570 --> 00:32:44,750 So we're going to, I believe-- 838 00:32:44,750 --> 00:32:46,930 am I right? 839 00:32:46,930 --> 00:32:49,150 See, we're going to try to implement daily management 840 00:32:49,150 --> 00:32:50,460 system here, too? 841 00:32:50,460 --> 00:32:51,370 OK. 842 00:32:51,370 --> 00:32:58,120 So right now, the people in the clinic don't see what's coming. 843 00:32:58,120 --> 00:32:58,930 Right? 844 00:32:58,930 --> 00:33:01,070 Only the scheduler knows what's coming. 845 00:33:01,070 --> 00:33:02,380 OK? 846 00:33:02,380 --> 00:33:05,440 So we didn't know had three gray bodies coming in. 847 00:33:05,440 --> 00:33:06,610 OK? 848 00:33:06,610 --> 00:33:09,340 We're going to get that up where it's very visually 849 00:33:09,340 --> 00:33:10,900 available to everybody in the clinic, 850 00:33:10,900 --> 00:33:13,160 and you can track it in real time. 851 00:33:13,160 --> 00:33:17,020 So the wrap-up is that optimizing lean 852 00:33:17,020 --> 00:33:19,640 at the local level is a good place to start. 853 00:33:19,640 --> 00:33:22,270 But you can only get so far. 854 00:33:22,270 --> 00:33:24,802 And the biggest problem we have right now 855 00:33:24,802 --> 00:33:27,010 is that some of your patients aren't getting treated, 856 00:33:27,010 --> 00:33:29,320 and there's nothing you can do about it. 857 00:33:29,320 --> 00:33:31,895 So we need to solve that problem. 858 00:33:31,895 --> 00:33:34,270 And I think there are going to be some other disruptions, 859 00:33:34,270 --> 00:33:37,590 that management is thinking about, we have to implement.