Posts Tagged ‘lean’

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?

Poka Yoke


So, this is a wonky post, inspired by my time in some of the largest factories in the world. They all claim to be ‘Lean’…And all are, to a certain extent. Instead of writing volumes of NDA violating prose about those experiences, I want to write about some specific lean concepts that seem to be second-tier.

There are many mixed feeling about lean manufacturing, it’s risks, it’s benefits, and the usefulness of the whole concept. I understand the criticism, especially when companies focus on inventory/tooling reduction while ignoring process improvements, or  while ignoring their employee’s input and call it ‘lean’.

There are, however, two pillars of the Lean process that I feel are indisputably important, and often neglected. The first is a general respect for people. People are not only human, but the source of innovation, improvement, and thus profit. Treat humans humanely, and reap the benefit…Companies that don’t are, in essence, investing in a capital asset and only using half of its capabilities. Humans aren’t just a pair of hands. They have brains too. Why not use them? After all, you are paying for them.

The second is concept Poka-Yoke, or ‘mistake proofing’. I will write a little bit about Poka Yoke, because writing about respect for people would require my not ranting.

A simple Google search shows the (anecdotal) neglect of some lean concepts:

  • Search: “Lean” (“poka yoke” OR “Mistake Proofing” OR “mistake proof”) –414,000 results.
  • Search: “Lean” (“respect for people” OR “respect people” OR “respect workers”) –130,000 results
  • Search: “Lean” (“inventory reduction” OR “inventory management” OR “inventory cost”) –2,000,000 results
  • Search: “Lean” “inventory” –16,000,000 results.

Inventory reduction is, perhaps, the logical outcome of other Lean concepts/efforts…Not really the best starting place, even though that is where the effort is, since inventory is so easy to measure. People are the starting place, and their tools are things like Poka Yoke.

On Etymology (A Digression)

First, the term ‘Poka Yoke’ is Japanese in origin. It roughly translates to ‘error avoidance’. The term originally was ‘Baka-Yoke’, or ‘fool-proofing’, but if you look back a few paragraphs, respect for people is important. To paraphrase Shiego Shingo: Since everyone makes mistakes, the only true fool is the one that doesn’t learn from mistakes. Hence: Mistake-proof, not fool proof. Not Baka-Yoke, because we all err.

Back to the Point

Poka Yoke might mean using the key (or key fob) to lock your car, instead of the interior lock, thereby ensuring your keys are in your hand, and not in the ignition when locking your car.

It means minimizing risk through process.

In the film industry, we often used high-wattage lighting, and there were basic processes to protect ones-self…Touching a high voltage Bates connector with the back of your hand, so if you are shocked, your contracting muscles close your fist on empty air, not on the un- or badly-grounded connector.

On a related note: Bates connector was designed (decades ago), so it could only be attached in one orientation, preventing live and ground legs from being crossed.

It’s any process or mechanical implementation designed to prevent mistakes.

I saw it applied in the film industry, I see it applied in manufacturing, and one can generally see it everywhere. From plugs that can only go in one way to cars that won’t start unless they are in PARK…People called it all sorts of things, but it can be boiled down to a simple concept:

When possible, eliminate the possibility of mistakes.

 Poka Yoke at Home

The interesting thing is applying this concept to one’s home life. As mentioned with the key fobs, there are ways to improve even the simplest of daily routines.

Do you keep your coffee mug to the left of your laptop, even though you are right-handed? Prevent a spill, switch it up.

Do the garbage and recycling buckets in the kitchen look the same? Do they need to? Does this ever cause confusion?

Do shoes end up everywhere in the front hall? Huge factories lay tape down to define where pallets sit and people walk. Maybe a nice square of dark carpet would suggest a place for shoes to call home.

It’s the little stuff that makes a difference, but there is room for improvement everywhere.


Data management and the CIA


Since 2003, I’ve worked for a number of media companies, ranging from a company with 16 networked HD edit suites, two online suites, audio suites and an archive going back decades, to individuals working on a single computer. One thing that most of them understood was the need for robust backups: The equity is in the intellectual property. It must be protected. There must be a process to protect it.

Legal issues aside, the CIA procedurally screwed up, and mistakes are things beast learned from.

The CIA:

The CIA has tapes of 9/11 plotter Ramzi Binalshibh being interrogated in a secret overseas prison. Discovered under a desk, the recordings could provide an unparalleled look at how foreign governments aided the U.S. in holding and questioning suspected terrorists.

Well then. I guess they missed some of the tapes that they had intended to destroy in 2005. Oops.

How is it that virtually every media company I’ve ever seen can do a better job of data management than the CIA? Even the sole proprietorships. There is a lesson to be learned from this: The brief version is don’t be like the CIA. The long version is procedural:

Multiple Backups: Many companies use a 3 tier concept at a minimum: Aside from the working dataset, On-line backups and offline backups create a decent system. In the case of something like an Avid Unity, the working dataset and online backup are the same thing, and contained in a networked RAID (The ISIS uses RAID 6). Individual hard-drives can fail, RAID cards can fail, but there are multiple copies of the data.

Backup offsite: Facilities get damaged. The offline backup isn’t enough. The offline backups could theoretically be moved offsite, but if not, a separate facility with it’s own extant dataset might be prudent. The Universal Studios fire in 2008 comes to mind as an example of why this is important.

Love the WORM: Write Once, Read Many. A DVD-ROM can only be burned once…or for the people who can afford it: AIT cartridges can set up for write-once operation. This removes the temptation to recycle, and forces the creation of physical media with a single purpose: backups. I’ve seen people lay off media to DVD-ROMs, D5s, Any number of other HD tape formats…They all work, and one will fit your needs well.

Access/Metadata: Who gets to access the backups? How is that logged? Are there check-out procedures? Is the location of all media known? This is where the CIA messed up. They didn’t have decent records of the location, access, or use of their backups.

A little bit of thought can go a long way towards preventing major problems…The CIA gives us a teachable moment. Again, legal issues aren’t my point here. My point is data management. Had they practiced good backup procedures, they would have known where all the copies of the tapes were, and would have succeeded in their end goal:

The destruction of the tapes and suppression evidence potentially relevant to the Binalshibh case.

Backups. With Procedures. It’s good for you. It’s even Lean (for those into that sort of thing…)

More me…