Jun 22, 2007

Real data about hospitals - a start

At least 32 newspapers jumped on today's news that the US Department of Health and Human Services has published comparative statistics on quality of care in hospitals across the nation. The actual data was given to hospitals, but the consumer can select hospitals and find out how they compare in treating certain conditions. At the moment, you can see some things about treatment of heart attack, pneumonia and prevention of surgical infection. Go here to check out the process: http://www.hospitalcompare.hhs.gov/Hospital/Search/SearchCriteria.asp?dest=NAV|Home|Search|SearchCriteria#TabTop

I found some surprises. Around Detroit, the hospitals I picked were all above average (sounds like Lake Wobegone), but comparing the details to find out which are better and which are best offered some surprises.

The osteopathic hospital that word-of-mouth says is poor actually had better scores than University of Michigan and Henry Ford Hospital on many measures. Now, U of M and HF might have determined that these actions (how long antibiotics were continued after surgery, for example) were not indicated in the patients surveyed. Not surprisingly, Detroit Receiving, where most indigent patients end up, fared relatively lower on most of the scales. Still and all, Detroit is a pretty good place to get sick in.

HHS says it will collect and publish more data, and perhaps someday make a point of showing which hospitals are dangerous to your health, but this is a start.

Jun 18, 2007

An innovation in value stream integration

To paraphrase Graham Richard, mayor of Fort Wayne, Indiana, 95% of what you need to know is outside your usual field of experience. I say that because last week I attended a portion of a conference on lean construction, at the invitation of Greg Howell of the Lean Construction Institute (LCI). Since I usually hang out with manufacturing people, this was new stuff to me.

Lean construction is not just the Toyota Production System applied to installing mechanical systems or hanging drywall. Construction as a whole – the system composed of the building owner, the architects, engineers, contractors, subcontractors, project managers, superintendents, and workers – involves a different lean approach. In construction, the work tends to stay put while the processes move in and out, whereas in manufacturing the work moves according to the physical locations of the process steps.

Those with a high-level understanding of the Toyota Management System will already see the big picture the lean construction people are painting. A product starts with an idea, becomes a concept defined according to the value the customer is ready to pay for, is transformed through collaborative product and process design and validation, goes through a preproduction phase where the production system is laid out, and only then do all the plans culminate in what people usually think about when they encounter lean manufacturing.

Project-based work, such as product design and construction, happens through transactions – accepting work, performing it, and handing it off. Any of us who have worked on projects know how that simple idea fails when a large project involves a massive number of such transactions. They all have to take place at the right time and the work performed correctly, or you might as well forget about your budget and project completion date.

The Project Management Institute (PMI) model uses a highly developed cascade of projects and sub-projects with work broken down into whatever units the manager deems proper, the duration of the work and dependencies analyzed, and resources assigned. This can all be done now in something like Microsoft Project that will render you a set of planning charts in living color and great detail. Somehow, life never works out like it should. Thus you get chaos, finger-pointing, replanning, negotiating for more time and money, and sometimes, financial liability pushed onto whoever loses the argument that lands the parties in in court and makes lawyers wealthy.

LCI and the construction professionals who participate in its activities have evolved a number of tried and tested tools to rethink the way projects are done. These include what they call the “Last Planner” system, conversations, reliable promises and self-assembling teams. More about those later. First, let’s visit the real foundation of a building’s construction – the contract.

Both lean manufacturing and lean construction are best seen as extended value streams with a series of suppliers and the suppliers’ suppliers and so on. Between the upstream and downstream entities are contracts of some form or another. Think about it – the number of contracts must rise exponentially with the complexity of the project. Furthermore, it means that various downstream entities have no idea what entities in other streams are going to be doing.

Some poor soul is going to have to keep all these activities aligned. Which is impossible, so you have the electrical guys standing around because the plumbing guys aren’t finished because a supplier was late delivering parts of the water system. Then the electrical guys are guessing at where to install outlets, so that during the final walkthroughs, the drywall guys are cutting holes to let the electricians can engage in rework. Then the painters have to repaint where the drywall guys had to cut and patch the holes. Ad infinitum.

Here’s where the construction industry has come up with an innovation I have not heard mentioned in manufacturing – the integrated relational contract. That was the subject of the two-day LCI conference I attended, led by Will Lichtig, the attorney who was a key partner with the construction business leaders involved in LCI.

OK – my disclaimer – the following description is going to be as flimsy as the description of lean construction I just gave you. You’re welcome to clarify and elaborate, but don’t jump in and gleefully point out blatant stupidities in my explanation. One keyword I learned was “conversation.” Players in the game have conversations, they don’t need to argue, negotiate toughly, or belittle. The conversations probably become lively or even heated at times, but they are among people who want to solve a problem or satisfy an “underlying concern,” another phrase that Will used. Let’s move on…

What the LCI has developed is a proposed standard called the “Integrated Agreement for Lean Project Delivery between Owner, Architect & CM/GC” (CM/GC is basically the general contractor). This is meant to be one contract that lays out the agreement among all the key parties for how the building will be designed, built and paid for, as well as how risk and reward will be apportioned. It’s 40-some pages long, so obviously I’m condensing greatly.

In addition to starting off with shared knowledge and understanding among the players, the contract itself is meant to support the lean construction philosophy. (Various architecture and contracting associations are developing integrated contracts too, but not with any basis in lean.)


An empowered core group – a team – makes all the necessary decisions throughout the project. An executive group oversees the core group, but does not get in and run the project.

The agreement describes things like the participant roles in weekly planning meetings, how communication will be conducted, and how trade subcontractors and suppliers will be selected and added to the project.

The budgeting phase includes the target value design and a cost model. The idea is to design to a detailed estimate – starting with what the owner can afford and really needs, instead of architects blue-skying a bunch of nifty technical features.

A whole section of the contract sets out a shared understanding of what collaboration means, and how it will be used to integrate preconstruction services.

The engineering phase includes provisions for value analysis, value engineering and constructability.

The construction phase includes requirements for 5S plans, safety plans, a definition of excusable and inexcusable delays, how change orders will be handled, how quality will be assured, and so on.

The conversation that leads to the document tends to identify where “contingency” money – some call it “padding,” which we have all done to protect ourselves from screaming fights with our accounting people and managers. The pockets of contingency, if added together, are likely to exceed any reasonable estimates for the system as a whole. The whole contingency is then apportioned by agreement among the key parties, with the owner retaining some significant part of the risk. Agreements are reached on the amount and type of insurance the parties will purchase to cover adverse events. This is completely unlike the typical contract, where the owner’s goal is to push all the risk on the contracting partners, to the point of frequent and lengthy litigation after the project itself is over.

Surfacing the underlying concerns that caused parties to include unrevealed contingencies in their bids requires and helps develops trust, the basis for a successful project.

Among the leaders in lean construction that have been testing the relational contract is Sutter Health, which is rapidly expanding medical services in California and investing in new hospitals and medical centers. DPR and Turner Healthcare are firms that have executed a number of the projects, with Skanska coming in to handle some others. Will Lichtig has helped guide the process as special counsel to Sutter Health.

These companies, along with many subcontractors and suppliers, have learned how to trust each other and genuinely collaborate. Little wonder that those firms who have become good collaborators want to work together on later engagements. This is leading to “self-assembled teams” that collectively bid on a major project in the offing. Experience with the relational contract is another piece of knowledge that enhances the competitiveness of their teams.

Many thanks to Greg Howell, and to his partner Glenn Ballard of LCI, for allowing me the chance to learn what’s happening in this field that’s outside my general scope of experience, and to Hal Macomber, author of the Reforming Project Management blog, who got me started.

Jun 9, 2007

How change happens

If you had asked me a year ago whether I wanted to spend $1,000 on a large white purse, I would have thought you were crazy. A white purse doesn't last long before it's irreversably dirty, and a big purse doesn't work that well for a small person. But lately I've had a hankering after one, and if I had a spare grand around, I'd go to Nordstrom's today.

So what happened? As many have said before me, people don't resist change, they resist being changed. If people resisted change, shopping wouldn't be one of the fastest growing hobbies. (And men, before you scoff, let me say just two words - "Best" and "Buy." If you don't feel inclined to read the rest of this post, substitute mp3 player or game-blasting PC)

I love accessories, so I'm more predisposed to paying attention to new ideas about purses than many people.

Notice I say ideas about purses. Fashion is about ideas, just like business or manufacturing is.

Being predisposed to ideas about purses, I tend to put myself in the way of exposure to them. I read fashion magazines, go through mail order catalogs, hit the handbag departments when I go shopping, and I have visited the handbag website that comes up in the web ads. (That service lets you lease fancy purses.) I know big purses have been the thing, especially with lots of hardware - buckles, rivets, chains, charms, etc., because I've seen images of bags like that over and over again.

I've seen the picture of variations of this purse over and over again for the past several months. That's just the color. I've been seeing the size and type of bag for the last couple of years. Repetition is important.

I don't just want any white purse. The idea includes supple pebbled leather, overlapped seams with an exposed cut edge. Not a white white, but half a shade on the gray side.

I'm sensitive to quality - good leather, even stitching, fine finishing. I look at where the bag was made. It's probably made in Italy, maybe France, and possibly in the U.S. Generally this level of quality is $800 or more - much more for the big purse that's part of the idea in my mind.

So I'm predisposed to a new idea in an area of interest, I do things that leave me open to encountering the new idea, I have preferences that affect the new idea I'll begin to accept, and I have a definition of value.

Change happened. I did say earlier that I want the bag, not that I'd buy it. $1,000 is still more than I feel comfortable spending on a purse that will be usable for one season and is going to be too big to be practical. Aha, there's an answer. I'm on the lookout at Target for a good fake. It will bother me that it's not a good bag, but it will look good enough. If I still want one next year, I'll be looking for a used one, if it's cheap enough. I've been checking Ebay.

See, I also have the opinion that the white bag is just a passing fad. It's almost the middle of June, and summer will be over soon. By August the bag's appeal is going to be over. No one's going to still be using one. Unless the idea of the white bag becomes style, not fashion. If I see it used through the fall and winter, the $1,000 investment may seem more worthwhile.

And add to the other factors then that I am "resisting" change. If you really thought I ought to embrace the change, you'd have to find my point of resistance and how you to overcome it. If you were Fendi, Dolce, or Gabbana, you'd have leverage. If you were Target, you'd have an opportunity. Even better, if I were popular or influential, you'd have a trend. If you really wanted change in a larger group of people, you'd give me or lend me a really nice large white handbag.

So I'm thinking that lean is like that. Someone who's going to change has to like change in work routine, be predisposed to the change in question, be exposed repeatedly to the idea, have a sense of value for the idea, believe it will last for a reasonable period of time, perceive the right price (effort, if not dollars), and find it available. Perhaps the source of the idea is important, and the person will be influenced by seeing someone else using it with pride. It's likely to take a long time before the person wants to buy the idea. And the point of "resistance" has to be "overcome." Ideas sometimes have to be sold, and sold in subtle ways. It then has to be persistent - the way things are done for the long term, not for a quarter's press release.

So if you still see that white bag in next Fall's fashion mags, send me a Nordstrom's gift certificate, don't send me a purse. The bag has to fit my ideas well. Don't send me your idea of the perfect white bag.

Jun 6, 2007

Stop raining on parades

This will be brief. I know language changes, but there is one set of words consistently confused with each other: Damp and dampen.

Examples: Dampen the market rise, dampen the excitement, dampen the fluctuations in defect rates.

The word is damp! Oscillations are damped, not dampened!

Does your fireplace have a damper, or dampener? Probably a device to damp the flow of oxygen, that also closes the chimney altogether. It's possible that you also have a dampener if there is a device to spray water on a fire that's out of control.

There's an odd logic to word substitutions like this. Rain does tend to dampen spirits at a picnic, but most of the time when people use the word, there's no water involved.

Jun 3, 2007

Plastic brains and individual differences

Jon Miller discussed memory, learning and Taiichi Ohno’s reputation for yelling at people a few days ago, drawing on the work of Eric Kandel, a giant in the field of brain plasticity. I want to expand on Jon’s post with a story...

It’s raining hard in a Midwest suburb, and the street is beginning to flood, for the second time in a month. As the water level rises to the curb, you observe the following behaviors:

Person A runs out to the water, wades in and starts jumping around and laughing. Person A hears a loud voice and goes back in the house, grumbling.

Person B goes to the garage, puts on some rubber boots, takes a rake, and wades into the water muttering.

Person C watches from the house, shudders at the loud voice directed at Person A, but continues watching Person B.

Person D rushes to the garage, gets an axe, rushes up the stairs to the second story of the house and climbs into the attic. Person D starts whacking a hole in the roof in a panic.

What just happened in the brains of these people?

Person A is a small child. The loud voice is the child’s mother, yelling at the child to get back in the house, saying “I don’t care what your father let you do last time! You’re not going out in that water!” The child was just following a learned process, and was being yelled at for doing it the wrong way. The yelling caused emotional and cognitive changes in the brain, with some resistance, but a bit of fear as well.

Person B is muttering, “If I’d cleared the debris out of the storm drain after the last flood, this wouldn’t be happening now.” Person B starts raking sticks and leaves out of the gutter and the flood rapidly drains away. Person B had noticed an opportunity for improvement, the need for better preventive maintenance, and was now learning from experience about the inconvenience when you don’t engage in continuous improvement.

Person C is a child. Last time the street flooded, the child’s father dragged the child into the house and beat the child for playing in the water. The child re-experienced the trauma when the other child’s mother expressed anger. Continued abuse over time, is systematically changing the child’s brain to respond with fear to any number of emotional triggers in everyday situations.

Person D moved into the neighborhood last week, and was a survivor of the hurricanes in New Orleans. Person D had been trapped, helpless, in an attic for two days before being rescued. The floodwater covered the floor of the attic itself and Person D had had to pile up old furniture to stay above it. Person D had suffered extreme situational trauma and the sight of the rising water and the sound of the rain created a panic that hijacked the brain and caused what seemed like a bizarre action.

I’m leaving out a lot of science here, and encourage you to read Kandel’s work along with that of Joseph LeDoux and Martin Seligman. But think about change in the workplace.

One person grumbles when a new rule is imposed. (Let’s be really unfair and propose that this is a man whose wife always says you have to hit him over the head with a verbal 2x4 to get him to listen.)

Direct experience teaches another person the commonsense aspect of changing maintenance and housekeeping processes.

A third is frightened of almost any change, as well as of the loud noises of the factory and gruff interactions among other workers. He or she has learned to hide the symptoms and needs the job, but has to feel emotionally safe in order to learn to do something different.

The fourth may have witnessed a severe workplace accident, been in a tragic car accident, or faced another strong and immediate threat to life and limb. People are aware of the person’s distress, but aren’t sure what to do about it. They see that the person has difficulty learning or even paying attention, but they remember the excellent work the person did before the event and hope time will take care of the problem. This person is going to feel better as any unsafe conditions in the plant are found and remedied. Helping the person get professional PTSD treatment would be warranted.

You can imagine other scenarios for yourself.

The point is NOT that we should play amateur psychiatrist, but to keep in our own memory that people respond to change differently. No matter how many “Managing Change” seminars we go to, each of these people will learn in a different way and take a different amount of time to do it. Following Dr. Deming’s rule to “Drive out fear,” may be a better general policy than Mr. Ohno’s yelling. (Except for Person A, that is, and we all know one.) Consistency of message, reinforcement by example and experience, attention to safety, and time all work together to change neural connectivity in people’s brains. Think about it.

Jun 1, 2007

What if there really is a US apparel and textile industry?

I don't visit Kathleen Fasanella's "Fashion Incubator" blog as much as I should, and I missed an April post, "Emerging Textiles" about the international textile and apparel industries. Kathleen reports on a report that says the Mexico is rapidly losing apparel industry jobs to other countries, while China and India are preparing to duke it out. This post is doubly worth reading because of the intelligent comments of her blog readers.

One prediction is that rising prices could make apparel manufacturing in the US more attractive for buyers, but that unwise plant closures could make that impossible. Plants in deteriorating condition, machinery sold off, employees moving on, all take away capability in an industry that once played a huge role in the economy.

Another reason to visit Kathleen's blog regularly is the insight she brings to an industry that remains under the radar. That is the world of the designer-entrepreneur (DE) and a constellation of related services that actually represent an apparel industry within the borders of the US right now. One of their problems really represents an opportunity for somebody. Designers offering small boutique collections don't use hundreds of yards of fabric.

Fabrics have to be different from other designers' and they have to fit the vision of the designer. Fabric merchants won't deal in what to them are small lots. So c'mon you lean guys - take a look at an industry you never thought about and see what you could do better than the old-style managers who lost the businesses. Small lots, delivered just-in-time, flexibility, and value-stream partnerships could build on what's already going on in Kathleen's world.
Copyright @ 2005-2014 by Karen Wilhelm