When the Gemba is an ER

As any student of Toyota knows, going to the gemba is step one when investigating a problem.  This principle is often referred to as genchi genbutsu, and lean thinkers know why it's such a powerful and almost mandatory concept.

But what about when the gemba is an Emergency Room?

My first thought is that all workplaces are different, but what we're looking for pretty much stays the same.  In other words, a gemba is a gemba.  But, having spent enough time in ER's recently, I think there are a few differentiators that we can take into account:

1. The doctors are the touch labor.  Whereas in manufacturing, we sometimes see the problem of the touch labor employees not being respected and their voices not being heard, we sometimes have the opposite problem in healthcare.  Doctors are so well-respected, and sometimes so feared, that they can have an almost unwieldy amount of influence.
2. Everybody is at a computer.  No, they're not playing solitaire or checking Facebook.  They're working extremely hard to enter their patient encounter information into the system.  In modern healthcare, it feels like everything is dependent upon electronic information management.
3. Flow is hard to see.  Many ER's were not designed with one-piece flow in mind.  Or cellular flow.  Or pull systems.  Or level loading.  Or visual management.  Or any of the other concepts that help improve flow and make flow visible.  The structural design of many ER's can make it almost impossible to see the flow of patients through the system.

If you're a lean thinker looking to make the move to healthcare, these are just a couple of thoughts to keep in mind.  But, if you're a lean thinker, you've probably been to many gembas and you probably know that each one has their own set of differentiators.  An ER is still a gemba, just one that maybe requires a little extra patience and finesse.

Top 3 Insights from Jim Womack on the Lean Blog Podcast

I just listened to Jim Womack's interview on Mark Graban's Lean Blog Podcast.  Really good stuff, especially the part where Mr. Womack talks about healthcare.  Here are the ideas/concepts that really resonated with me...

1. Healthcare is not scientific.  Mr. Womack says we think of the practice of medicine as a scientific endeavor, but when you go to the gemba of a healthcare organization, you often see a highly craft-oriented culture.  Process variation between physicians is sometimes the norm, rather than the exception.   The decision to perform a process differently is often not based on outcomes data, but rather on the way the process was taught to the physician by her mentor.  Scientific, this is not.
2. Physicians are the front-line workers.  Whereas in manufacturing the "touch labor" employee might be an entry-level blue collar worker, Mr. Womack discusses that in healthcare this role is performed by highly-trained, highly-compensated physicians.  This creates all sorts of unique situations that we must be aware of when trying to promote kaizen in a hospital setting.
3. Nurses are the main ones thinking about process.  When I came to healthcare as a newcomer less than a year ago, I was surprised that the nurses are pretty much the ones running the show, from a process perspective.  As previously mentioned, the physicians are the touch labor employees.  Mr. Womack indicates that his leaves the nurses as sort of the stewards of the horizontal flow of patients across our processes.  Of course, nurses are also touch labor employees, so horizontal flow often gets pushed aside when the nurses have to focus on performing a touch labor task.

I highly recommend listening to the interview with Jim Womack.  He talks a lot about his new book, his approach to walking the gemba, and other insightful tidbits.  Check it out.