Cancer Center Sterilization

This prominent Los Angeles-area cancer hospital was one of my first exposures to healthcare delivery as a consultant. By the time I got there, my firm had thoroughly indoctrinated me on Lean principles. Of course, I had spent a career in innovating solutions. I now had a portfolio of experience that included both the operations and design worlds. Previously, I had worked at a medical device company, and now I was where the nurses, doctors, and surgeons were doing their job. Ready, set, go!

Our operations consulting delivery model was to place a consultant at a client with a team, in a conference room for an entire week. I shared in the Navy A.D.D. moment that the first three days can be quite difficult, typically because we uncover a significant amount of procedural waste. Despite the fact that employees can feel the pain, some leaders have trouble admitting their existing process needs to change and that they weren’t leading the team in the optimal direction.

The task here seemed simple: redesign the area and the process used to sterilize the surgical equipment. Things did not go smoothly. The amount of push back we received from the new department manager and the “sterilization expert” was so high that they tried to cancel the engagement after just one day. As consultants, this experience isn’t out of the ordinary. We have to have an escalation path. In this case, it was the Chief Nursing Officer. Magically the new manager and team aligned with our method and findings.

As we were digging into the details of what was currently occurring with sterilization, the main problem became readily apparent. Each surgeon had their own set of requirements, based on what procedure they were doing. However, the department providing the surgical instruments wanted to have a standard kit for all surgeons. As you can imagine, we were re-sterilizing many instruments that surgery didn’t use. In fact, about 70,000 a year that were never used were re-sterilized. Each had been exposed to the atmosphere of the surgical suite, thus contaminating them.

We defined the challenge as “putting the correct instrument in the surgeon’s hand when asked for during the procedure.” From there, we were able to come up with a process to do just that. As a result, we drastically reduced the number of instruments in a kit as each surgeon got their own custom kit. It required a bit more coordination on the sterilization department, but it saved the hospital a lot of money. Annually, tens of thousands of instruments avoided the destructive process of repeated sterilization-without-use. There were savings in both the process and purchase budget. That savings could fund treatment for the patient instead of repeat sterilization of an unused instrument.

USN Ordnance Team

In my previous post, I mentioned I wanted to be a fighter pilot. As a child of the ‘80s, I was captivated by Top Gun. I researched anything military, whether it was bombers, ICBMs, nuclear-powered submarines or aircraft carriers. As a military brat, I visited Navy stations, Army bases and Air Force runways just to catch a glimpse of an aircraft, but it was almost always from afar. The closest I got was during air shows. Sometimes I was part of a crowd surrounding stunning, military jets or part of a group of onlookers as we gazed into a roped-off hangar further away.

When I got to work with the US Navy, I was up close and personal with fighter planes. It wasn’t cockpit-close like the F-15, but these jets were on an active runway and in use. When the F-18 Super Hornets took off, you could wait and hear the faded booming of distant bombs falling on the desert range to the east, pounding the ground with 500 lb. of explosives on each drop.

My job was helping the naval ordnance team to be more efficient in the entire process from bunker to fighter and return. I worked with a small group of E2s to E4s, with an E6 to keep them in line. Their language was enough to make a sailor blush. Oh wait, they were sailors. Enough to make me blush. They pushed each other hard, they didn’t let any mistake remain unfixed or poor performance not be corrected, and they called each other out on anything and everything that kept them from achieving top level results.  I loved it.

The process I apply at clients can be very demanding. We pull aside a team of about ten people for a full business week to drive significant improvements immediately. Every day can be draining. They have nicknames for each hard day: Margarita Monday, Tequila Tuesday, and Whiskey Wednesday. By Thursdays, the team has made it past the tough part and has to implement the defined work.

These soldiers did a fantastic job. Their Chief had created a team that could perform under difficulty. I pushed them hard too. They came together, fought, talked it out, argued, cursed and came up with a great new process that improved mission readiness and performance. They were proud of their motto and shouted it with pride: IYAOYAS!

USAF Medical Clinic Redesign

My mission, if I should choose to accept it: Design a new, medical clinic that will keep the airmen mission-ready for decades into the future. The medical group commander responsible for the project was a full Colonel that wanted the best for her troops but insisted on the optimum use of the designated funds for the project. The Lieutenant Colonel (Lt Col) that she assigned the work to wanted to do it the typical Air Force way. We began the work and quickly identified they could reduce the new clinic’s footprint by fifty percent. We were still meeting demand, working faster, and meeting the target of having no waiting rooms. The Lt Col didn’t believe it could be done.

As always, there was some pushback. The Lt Col became an active resistor to the new possibility. We pushed with data. Ultimately, it was a compromise between our capability and their comfort level with the approach. Although they ended up adding some space back for their peace of mind and comfort, it was a great result. The output thrilled the Colonel. I earned a commander’s coin for that work. That clinic now serves as a model for the Air Force. What happened with the Lt Col? He was unceremoniously pushed on to his next role.

I loved this project, not because we were achieving our mission to improve the accomplishment of their mission, but because it was a base with fighter jets. In junior high, I had dreams of becoming a fighter pilot. I wanted to fly the F-15 Eagle. It was the premier fighter jet during the ‘80s. I had models of it, drew pictures of it, and stood in awe at its performance at the annual air show. However, my dreams died when I got glasses to correct my nearsightedness. Although, the F-22 replaced the F-15 and the F-35 is replacing the F-22, there were still some F-15s around on this base.

During my training runs in the evening, there was a road next to the airstrip that the F-15s would use. One run allowed me to “race” an F-15 as it taxied down the runway. I shared my story with the Colonel and the next day I was standing in a hangar, climbing into the cockpit of my childhood dream. We didn’t go out for a flight, but I was sitting in the jet, looking at gauges and controls of this once-elite fighter. I loved it.

VA Cardiology Suite Redesign

The task seemed relatively easy to me: design a new cardiology, surgery suite that can provide world-class care while simultaneously keeping up with future demand for our veterans. This project was at a major, regional VA hospital. I had done similar work before, but not for a government agency. Apparently, it was a big deal. The local press was at the kick-off event for the work. I was partnered with a high-powered, architectural firm. Our goal was to develop and finalize the design to build.

We established a team of stakeholders and subject matter experts. They conducted interviews with patients, surgeons, nurses, and staff. We began the process and analyzed existed demand, procedures and available technology as well as budget. We discovered great information. The government building-requirements binder was as thick as I had ever seen but despite the significant number of rules and regulations and requirements for cardiac surgical suites, we made them work for us.

The team created an optimized layout for the entire department, with specific attention to where clinicians delivered the medical care, the surgical suite. We used a Lean tool known as Process Preparation (2P). For this, we made small-scale, “paper doll” cutouts for everything that might go into a surgical suite. Then we moved things around on an architectural blueprint until we found a good solution for the suite itself and the entire floor. Eventually, we mocked-up an actual suite with surgical tables, full-scale cardboard cutouts, and auxiliary equipment until we finalized a solution that would work for everyone at each stage of use: before, during and after surgery.

We had created the goal. From there, it was figuring out how to make it happen. A team took our work and delivered it. It was a great plan with great teamwork that yielded great results. Our veterans are receiving better care, at a lower cost, because of it.

Solving Children’s Food Insecurity with Innovation

The goal was to help feed the 50,000 children who don’t get meals on a regular basis. Not getting enough to eat is called food insecurity. Police, educators, public policy makers, industry, and nonprofit food pantries would have to partner together. Although I have worked with several federal agencies over the past several years, my first foray into the local public domain was in Indiana. They asked me to play the process expert and facilitator for a project that could have a significant local impact to urban residents. In setting up the team, we included execs from the police, public policy, food pantries, donors, healthcare and local media.

Secondary research indicated 20% or over 50,000 children in the identified area were food insecure. This number was a significant gap, and we needed to understand what, besides food, was necessary to fix the issue. Reporters conducted our primary research by interviewing dozens of food insecure families. The core team visited multiple food pantries. These combined efforts gave our team the necessary information to make informed decisions. After several months of preparation, the team spent a week together thinking about what solutions would be effective. Several great project ideas came out of our session: police delivered food, food pantries at every school, and an app for information. We named project leads for each idea, and the teams began their work.

It took a while to build some momentum. Sometimes, it looked like it was over before it started. There was a great dream but it faced some obstacles. Fortunately, months after the initial session, the effort is making serious progress. They are delivering meals to hungry children across the entire metropolis in new ways not previously imagined. It took a strong realization to get this effort started, continue it through some tough times and start to impact actual lives. The project is positively affecting people’s health and future.

Nearsightedness Kills Innovation

This system became famous in its industry for its original implementation of lean in the early 2000’s. Following their heyday, the CEO went on to be quite famous and started a consulting firm helping implement lean in other healthcare organizations. However, they were still not achieving the breakthrough level of performance improvement they needed or wanted. They called me in when they were looking to redesign their care model for their high-risk patient population. By definition, we included the top five percent of these patients. It would require a new way of thinking about things.

Per my typical requirement, they named a leader and set-up a cross-functional team to successfully execute this massive project. We established stretch goals and began work. The team developed an in-house, risk stratification method to define the patient population for the new care model. This patient population was then studied to determine their barriers to care and better health. The insights were staggering. One patient traveled over 5,000 local miles annually to get to all of their appointments. Another patient had 66 physician interactions in one year; more than one per week!
Patients were interviewed, observed at home and brought into focus groups.

We studied their engagement with the healthcare system. Their needs and pain points became evident, and the brainstorming of solutions began. Soon, a new model of care began to coalesce. It was different than anything this healthcare network had done before. Every patient would have an interaction with a patient care team that acted as an extension of the primary care provider. The team included all critical elements determined during research: a pharmacist, a social worker coordinator, a behavioral health counselor and a triage nurse. The experiments began. The team saw multiple successes in medicinal accuracy, blood pressure control, blood sugar reduction, physical activity and patient engagement.

My involvement stopped when they were expanding the patient cohort. It was then the Operational Excellence team swooped in and almost destroyed the efforts. This company struggled the entire length of the project despite years of Lean implementation and associated subject matter expertise. Eventually, the COO disbanded the effort, even though the health outcomes were outperforming even the best physicians in their network. This organization struggled with many of the Becoming Endurance principles outlined in this book and the results have become obvious.

If you talk to the former CEO of this organization, he will say he wonders why they only came up with two “new” things during his tenure. My analysis and involvement made it clear that they were expecting the operational excellence tool kit to innovate. It is unable to do this; you need innovation techniques. Teams can’t innovate when you’re staring at the bottom line every month. Executives have to be 100 percent committed to the project once they decide to do it. The project should keep going until it’s time to stop it altogether. Why? Because nearsightedness kills innovation.

Priceless Gems

I was standing in a heavily secured room in the diamond district of Manhattan. In the palm of my hand was a large, pink diamond worth hundreds of thousands of dollars. I then held a smaller, yet more valuable, blue diamond worth millions of dollars. The value of those diamonds was legitimate, but their value wasn’t always known. A few decades ago, diamonds were worth whatever a salesperson could get for the diamond, often not even selling an actual one, but a knock-off gem. That doesn’t happen much anymore, or ever if the stone is certified. Why? In the early twentieth century, founders started a non-profit organization with the distinct purpose of protecting consumers from jewelry con artists.

The most, publicly famous output of this non-profit organization was the 4 Cs of a diamond: color, cut, carat, and clarity. Diamonds could now be valued based on criteria established by each of the Cs. This judgment is what determines how much a diamond is worth. Diamond owners can, for a small fee, have their gemstones assessed by expert graders, giving confidence to buyers and sellers about its quality. This organization created criteria not only for diamonds, but also all types of gems as they expanded their protection of consumers. They trusted me to hold the blue diamond in my hand, and they also trusted me to help them on their next part of the journey.

The biggest gap in the jewelry world then became the jewelry itself, not the jewel that goes in it. Most of us don’t think about it, but the shape of prongs has specific best practices that hold and display the stone forever and can be disastrous if done poorly. Cutting, polishing, soldering, casting and many more techniques can be done well or done poorly too.

Ring mold
Mold for platinum ring.

Under the leadership of their VP of Education, they hired a Director of Jewelry Design. He was responsible for growing and teaching tomorrow’s bench jewelers using world-leading, best-in-class techniques. This direction meant a complete overhaul of a specific certification program from the ground up. We recreated the entire program using innovation processes and visual management techniques. We interviewed instructors and students and identified pain points for each. Brainstorming began.

The team gutted the hands-on focused, outdated classrooms so students could easily interact with the instructors during praxis. We threw away the educational, paper-based study material and recreated in an electronic, interactive, tablet format for all classes. The response was overwhelming. Both students and instructors raved about the changes. Attendance grew, and the company was back on track to better protect and inform consumers in another area, jewelry design.

At the same time, I was able to successfully have my wife’s twentieth anniversary ring designed and built. I relied on contacts made while working there. With certified diamonds, the right precious metal, and a recommended bench jeweler, I was confident of what I was getting would last forever. It all came together, and I was able to present her with the ring during our anniversary trip to Alaska. She gets compliments all of the time, and I’m confident in what she wears everyday is worth what I paid.

anniversary ring
Ring I designed for my wife on our 20th anniversary.