Improving Healthcare with Lean: An Interview with Mark Graban

We’re pleased to present to you this interview with our good friend, Mark Graban. Mark is the guy you want on your team when it comes to improving healthcare. As you read this interview, you’ll learn the following:

• What led Mark to read Deming’s Out of the Crisis while he was on Spring Break from his university studies instead of partying at the beach like other college students.
• How Mark went from being an engineer to focusing his Lean improvement efforts on Healthcare.
• Why your hospital should call Mark for help if your nurses are overloaded and patients are being harmed.
• What he would say to the Secretary of Health and Human Services if he had an opportunity to have lunch with her.

Enjoy the interview and read more about Mark in his bio section after the interview and be sure to check out our other interviews with leaders in lean.

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Thanks for joining us Mark. Can you please introduce yourself and your work to my readers?

It’s probably easiest to start by saying I wear a lot of different hats, professionally. Since 2010, I’ve worked under the banner of my own company, Constancy, Inc., as an independent consultant, an author, and a speaker. I work primarily with hospitals and healthcare organizations to better understand, implement, and sustain “Lean” methodologies and the “Kaizen” approach to continuous improvement. Since 2011, I’ve been part of the team at KaiNexus, a startup technology company with a software platform that helps organizations in multiple industries better manage their improvement work.

Educationally, my undergraduate degree is Industrial Engineering (Northwestern University), so I started my career in manufacturing, with a stint in another software company. After two years at General Motors right out of college, I had an amazing opportunity to do a dual master’s program at MIT, studying mechanical engineering and business in a program now called “Leaders for Global Operations” or LGO. I had a fortunate opportunity to shift into healthcare work in 2005 when I joined Johnson & Johnson and their consulting group that did Lean and Six Sigma work with healthcare organizations. People can read more about my background via my bio or LinkedIn.

Mark, can you share with the audience how you got started on your Lean journey? Was there a specific event that sparked your interest and lifelong journey in Lean?

I started college a chemical engineering student, and then materials science, but realized that I was more interested in business and people than I was about how the world works at a microscopic level. Before I was introduced to Lean and the Toyota Production System in college, I was fortunate that my father (who spent all 40 years of his career at GM) was able to attend one of the famous four-day seminars run by the late, great Dr. W. Edwards Deming.

In my I.E. classes, we learned about pull systems and just-in-time materials management (and how that was better than push systems and complicated computer scheduling approaches), but it was a pretty limited view of Lean. We weren’t taught about the Lean culture and management system. Over one break from school, I borrowed my dad’s copy of Deming’s Out of the Crisis and that book was very inspiring and transformational.

My passion for Lean comes from the lessons that Deming taught Toyota and other Japanese companies that the most successful companies have leaders who create an environment where people can have “joy in work” and where everybody wins. I guess I’m an idealist in thinking that people should have great workplaces and shouldn’t hate being at work.

You’ve written several books on Lean for Healthcare. Can you share with the audience how you came to focus your efforts on healthcare?

My move into healthcare is what I’d call a “happy accident.” In 2005, I was an internal Lean consultant for Honeywell, in Phoenix, and my wife had a new career opportunity in Texas, which put me on the job market. In a classic case of “right place, right time,” I got a call from a J&J recruiter about their consulting group. I wasn’t driven to get into healthcare because I had any bad first-hand experiences in the healthcare system or anything beyond long waiting times in a primary care physicians office (the type of thing you accept as “normal,” until you realize there is a better way). While in Phoenix, in early 2005, I had the chance to do a gemba walk at a hospital in Scottsdale to see some of their early Lean improvement work in the emergency department, which piqued my interest. I was reading what I could about Lean healthcare online (which was a limited literature at that point), so the call from J&J might have been fate.

When I took that job, I thought it would be an interesting experiment, not knowing if it would be a temporary detour or a major career shift. Over nine years later, I guess I’m now “a healthare person.”

Tell us about your consulting work.

At J&J, I was part of a 25-person team that worked together and ran relatively long 12- to 16-week projects. As a consultant today, I either work independently on smaller projects or I partner up with other consultants when it makes sense for us and the client.

In the past few years, I’ve been involved with some “Lean design” efforts, working with hospital staff, leaders, and architects as they plan the construction of new space. My role is to help them understand their existing processes to see 1) how those processes can be redesigned or tweaked and 2) how the space needs to be designed to work with those processes.

I’ve also help launch formal Kaizen initiatives in many organizations, including coaching their leaders as they learn approaches to ongoing daily continuous improvements. I occasionally will help an organization with value stream mapping or other Kaizen events, but I’m more interested in helping organizations create and nurture a “culture of continuous improvement,” instead of just doing a project here and there. I’ve also done some work recently, partnering with Karen Martin, to help a health system start a formal “strategy deployment” process.

I’ve also done some pro-bono consulting and coaching for a few non-profit organizations, which is how I like to try to give back to the community.

What type of challenges might a healthcare organization be facing for which your services is especially tailored to assist?

Some of the challenges include:

• “We’ve been doing Rapid Improvement Events, but want to also incorporate ongoing continuous improvement into our workplace.”
• “We’ve been using Lean tools, but need to start managing and leading in a Lean way to really affect change and better performance.”
• “Patients are being harmed and nurses are overloaded¦ we need to figure that out and fix that.”

If you had the chance to have lunch with the Honorable Sylvia Mathews Burwell, the current Secretary of Health and Human Services, what would you like to talk to her about?

Oh, many things, but one topic I’m really interested in is whether different financial penalties (for things like high readmission rates) or performance incentives based on patient surveys (like HCAHPS) create more dysfunctions than they solve. Many of the incentives or penalties from Washington seem to be overly simplistic “solutions” to complex problems. If these approaches actually do work, then maybe we should consider fining a hospital $1 billion (spoken like Mike Myers’ Dr. Evil) each time a patient dies as the result of a preventable medical error. If penalties drove the right improvement, would that eliminate things like wrong-site surgeries and hospital-acquired infections?

On a less tongue-in-cheek note, I’d want to talk about the one part of the “ObamaCare” law that’s received the least attention. The formal name is “The Patient Protection and Affordable Care Act,” but there’s been far more talk about the “affordable” aspect. Medical harm is a national catastrophe (now estimated to be the third leading cause of death in the U.S.) and we aren’t having a meaningful national discussion about that.

You spent a few years as a Senior Fellow at the Lean Enterprise Institute. What was that experience like?

I worked out of their Cambridge, Massachusetts office for a year when my wife had an opportunity to also study at MIT and worked from Texas as a half-time employee for another year. The timing was great in that LEI was starting to get really interested in Lean healthcare. I was part of the team for the launch of the Healthcare Value Network, a collaboration with the ThedaCare Center for Healthcare Value. Instead of consulting, our role was promotion and sharing of Lean practices, mindsets, and success stories. I was able to visit many hospitals across the U.S. and Canada as the organizations who were members of that Network shared their experiences, successes, and struggles with each other. LEI’s founders and leaders have humility and a hunger for learning that I find to be inspiring.

Can you share with the audience some results from your healthcare engagements? If you could, it’ll be instructive tell us about the problem or opportunity (generally), the steps you took – especially steps that were informed by Lean, and the results. Generally, of course, without divulging any client privileges.

One of my favorite projects is something that’s disclosed in the 2nd edition of Lean Hospitals. Children’s Medical Center Dallas had a problem where children would have to wait 12 to 14 weeks for an outpatient sedated MRI. We pulled together a full-time team from different disciplines and functions, including nursing, scheduling, and an MRI technician. They analyzed the current state, including scheduling policies and practices, the patient flow upon arrival for the appointment, and the relatively low utilization of the MRI machines. The MRIs were actually only actively scanning a patient about 33% of the working hours. So, we had this strange conundrum of patients waiting for months, but machines sitting mostly idle.

The team proposed and tested a number of changes, including new scheduling policies (making sure scheduled MRI procedure slots were the length of the actual procedures), adding a third anesthesia team (so the next patient could be prepped while two patients were being scanned in the MRIs), and a number of other small changes.

The MRI machine utilization rate went from 33% to about 60% on a daily basis and the backlog of patients was quickly worked down to the point where patients waited only two or three weeks (which was half the waiting time of a competing hospital) for an appointment leading to better and more timely patient care.

To me, some of the key lessons were to involve the people who actually do the work, given them time to analyze and understand what’s broken, and let them work on fixing it not needing artificial constraints of week-long Rapid Improvement Events (since some changes were much bigger and some were smaller). Because the team owned their new process, the results were sustained from 2008 through 2013 (the last time I talked with them).

You have accomplished much in your career. What’s the one thing you still lack and are actively working on?

I lack patience! I want to see healthcare transformed to a point where patients aren’t being harmed, employees are happy and engaged, and healthcare organizations success financially at prices that are fair and reasonable. That doesn’t happen overnight. We have pockets of great success in healthcare, so it’s frustrating that meaningful Lean management systems aren’t being adopted more widely (instead of just tools and projects).

I am pretty serious about trying to continually become better at everything I do, so there’s no lack of things to actively work on!

You are an influential voice in the Lean community. If you were to list 3 things that the Lean community is focused on but shouldn’t be, what would they be?

First, the Lean healthcare community, specifically, needs to be more focused on improving patient safety and quality. If patients (and staff) are being harmed on a regular basis due to process problems and bad systems, that has to be our first priority, not trying to tweak the number of office supplies that are in the nurse’s station. Lean mindsets and methods have so much to offer to improve safety and quality¦ even if our organizations are not asking us to work on these things, a responsible Lean professional should be pushing to work on safety first.

Secondly, the Lean community needs to study the lessons of Dr. Deming more and put these ideas into practice. We put Toyota leaders like Ohno and Shingo on a pedestal but far too often ignore Dr. Deming. I encourage Lean professionals to read a book by Dr. Deming or about him instead of reading yet another Lean book. Or, read a book by people who worked with him, like Fourth-Generation Management by Brian Joiner or Understanding Variation.

Thirdly, I think it would be helpful to think of Lean less as a set of events, projects, and certifications, and more about engaging everything in Lean thinking and continuous improvement. As Masaaki Imai says, improvement is something for everybody, everywhere, every day.

Is there anything else you’d like the audience to know?

Thanks for interviewing me!

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About Mark Graban

Mark Graban is an internationally-recognized expert in the field of Lean Healthcare, as a consultant, author, keynote speaker, and blogger. Mark is also the Vice President of Customer Success for the software company KaiNexus, helping further their mission of making improvement happen in healthcare organizations and other industries.

He is the author of the book Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement (Productivity Press), which was selected for a 2009 Shingo Research and Professional Publication Award, the first healthcare book to win this award, and is being translated into eight languages. A 2^nd revised edition was released in November, 2011.

Mark has also co-authored a second book, titled Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvements, which was released in June 2012 and also a Shingo Research Award recipient in 2013. A newly revised and condensed edition, The Executive Guide to Healthcare Kaizen: Leadership for a Continuously Learning and Improving Organization was released in August, 2013.

He is the founder and lead blogger and podcaster at LeanBlog.org, started in January 2005.

Mark earned a BS in Industrial Engineering from Northwestern University as well as an MS in Mechanical Engineering and an MBA from the MIT Sloan Leaders for Global Operations Program (previously known as Leaders for Manufacturing). Mark has worked in automotive (General Motors), the PC industry (Dell), and industrial products (Honeywell). At Honeywell, Mark was certified as a Lean Expert (Lean Black Belt).

Since August 2005, Mark has worked exclusively in healthcare, where he has coached lean teams at client sites in North America and the United Kingdom, including medical laboratories, hospitals, and primary care clinics. From 2005 to 2009, Mark was a senior consultant with ValuMetrix Services, a division of Johnson & Johnson and he currently consults independently for healthcare organizations.

Mark’s motivation is to apply Lean and Toyota Production System principles to improve quality of care and patient safety, to improve the customer/patient experience, to help the development of medical professionals and employees, and to help build strong organizations for the long term.

From June 2009 to June 2011, Mark was a Senior Fellow with the Lean Enterprise Institute, a not-for-profit educational organization that is a leading voice in the Lean world. Mark served as the LEI’s Chief Engineer for healthcare activities, including workshops, web & social media, and other publications. Mark also served as the Director of Communication & Technology for the Healthcare Value Network, a collaboration of healthcare organizations from across North America, a partnership between LEI and the ThedaCare Center for Healthcare Value.

A member of the National Speakers Association, Mark is a popular speaker at conferences and private healthcare meetings. Mark has spoken across the U.S., in multiple provinces across Canada, and other countries including Finland, Holland, and Sweden. He has guest lectured at schools including MIT, Wharton, UT Health Science Center, and Ohio State University and has served as a faculty member for the ThedaCare Center for Healthcare Value and the Institute for Healthcare Improvement. He has been quoted and interviewed in many publications, including Health Affairs and the New York Times.

Mark and his wife live in San Antonio, Texas. Mark serves on the board of the Louise H. Batz Patient Safety Foundation, the board of the AME Southwest Region, and on the advisory board for the Michigan Lean Consortium. Mark is also an advisory board member for the startup technology company Homeward Healthcare.

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