A machine, or merely Lean?

In the past, I’ve written about lean manufacturing concepts in the context of the film industry (and CIA) and in one’s home life. Lean (in my context) can be roughly defined as the effort to eliminate anything that doesn’t add value for the customer.

I recently had a surprise case of appendicitis, resulting in an appendectomy at a Kaiser Permenente hospital. I was admitted to the ER at about 0500. I was discharged the same day at about 2100. My surgery was performed by a surgical resident, under the close supervision of a scrubbed-in, experienced surgeon. It was the resident’s 100th or so appendectomy. It was about as close to routine as one could get.


Kaiser claims to be a ‘lean health services provider’, I’ve heard objections to the machine-like process of the Kaiser HMO. Machine or not, I find it to be a fairly comprehensive implementation of Lean/5s principles.

I understand how being the object of a lean hospital process could be unnerving to some people. Things move quickly. One is bar-coded, scanned, analyzed, scanned, medicated, scanned, measured, and prodded in an extremely efficient, clinical way. This gives rise to an inherent conflict: Is it respectful to treat people this way?

I think so. The medical staff was extremely communicative, but things did happen quickly, and according to strict procedure…Even if it was an unfamiliar process to me, it was driven entirely by the need to create a positive patient outcome (i.e, get me healthy).

The people who treated me always had a smile, time for some questions, sometimes a joke, and occasionally time for a brief moment of conversation. However, they didn’t dawdle or dwell, and kept their interactions brief.

Perhaps the root of the objection to the Kaiser process is that getting a person physically healthy quickly isn’t necessarily compatible with taking the time away from medicine to address their anxieties, fears, and mental state. That’s a tough contradiction to manage in a Lean process. Perhaps this is an area for Kaiser to improve, especially for those patients not versed in process and flow management…Those that can’t geek out at what’s happening around them.

Observations on 5s and Lean:

There were a few specific examples that popped out at me during my stay. Lean was defined above. 5s is an organizational methodology that is often implemented to support lean processes.

Poka Yoke (Mistake-Proofing)

My bracelet had a QR code (or similar 2D barcode) on it. Every pill or saline bag given to me, every piece of entered data about my health or physical state started with a scan of my bracelet. The computer recorded everything given to me, and would have alerted at prescription contradictions. The computer also prompted the RN to ask specific questions at specific times, regarding my pain levels, nausea, etc.

At every step, there were checks to ensure mistakes weren’t made. The RN, the ER doc, the resident, and the surgeon all double-checked my physical condition, my chart, and me. They all (I suppose as a matter of procedure) actually bothered to talk to me. Needlessly repetitive?  Well, getting prodded at McBurney’s Point that many times wasn’t fun, and answering the same questions several times was repetitive, but better that everyone actually verify my condition before surgery…

My journey from ER to OR was approved as soon as an OR slot opened up, but paused until everything was in order, including discussions with the bartender (anesthesiologist). My move out of the OR recovery room to a regular patient room didn’t happen until I met certain criteria…The process was set up not only to prevent mistakes, but make sure I was in the right place with the right equipment, were a problem to appear, or a mistake to be recognized.

Andon (White Boards for Visual Organization and Status)

Kaiser was big on white boards. There were several at every nurse’s station. There was one by every patient bed. The ER patient whiteboards had spaces for the patient’s name, attending doc, RN, charge nurse, and actions to be taken. The recovery room whiteboards had slots for the RNs by shift, CNAs by shift, the name I preferred, immediate issues, etc. It was a fast way to communicate important data. Notably, prognosis was kept off the white boards.

Muda (wasteful activity)

When in the ER, the doctor discussed several paths forward. I could undergo a CT scan, confirming the appendicitis condition. Or, given the presentation of classical symptoms, I could move straight to a laparoscopic appendectomy. The CT scan would have ensured that surgery was the correct path, but at the cost of a fairly heavy radiation dose. It would have covered the hospital’s proverbial arse, but at a long-term risk to me. They could have protected themselves, and externalized a longer-term cost on me.

Kaiser ultimately gave me the option of a CT scan, if I wanted it. But that they didn’t jump to a CYA mentality and immediately order the scan spoke well of their effort to root out waste in the process of getting me healthy.

I should note that some people have been Kaiser patents for over a half century, so the basis for certain process decisions and improvements come from an analysis of a remarkably huge datapool, and an expectation that many current patents will be Kaiser patents for well into this century. Kaiser doesn’t want to treat cancer caused by a needless CT scan 50 years from now.

Seiketsu (Standardization)

There was identical equipment in the wall manifold above each bed. Vacuum pump, O2, medical air, isolated outlets for sensitive equipment, code buttons, etc. There was an identical computer interface in each room…No searching for little things, or having to jump amongst rooms to find things. This is typical in hospitals, but is often not recognized.

Seiso (Cleanliness)

Important for a hospital…Waste receptacles were clearly marked. Sharps to the sharps bin, biological waste to the red bin, basic trash to the trash bin, linens/washables to the stainless cart…The room cleaning started as soon as I left, which brings us to:

Shitsuke (Sustain: The hard one)

The hardest part of a 5s or Lean scheme isn’t getting there, it’s maintaining it. Having the self-discipline to keep improving is important. Kaiser seems to be fairly good at this. Hopefully, they can sustain in.

Post Process:

There was no rush to shove me out of the hospital in fact, the RNs, CNAs, and surgical resident were very insistent that I meet certain criteria before I was allowed to even think about leaving. When the criteria were met, I was sent home with prescriptions in hand, and comprehensive discharge instructions. The RN discharging me went over the instructions, and expressed surprise at some additions. This was a good sign, it indicated that continual improvement was happening, and the instructions weren’t some 20 year old stale document.

I got a call a couple days later asking about my condition, with follow-up questions. They verified my appetite was normal, and my body was more or less functional, then the scheduled a post-op visit.

On my way out of the room, the RN suggested that I take the box of tissues to have in my car, because they had already been opened and would have to be thrown out otherwise. How’s that for minimizing waste?

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