Yes, there is a connection between a lost set of false teeth and lean!
A few days before Christmas, my sister took Molly to the hospital emergency department from her care home. During the admission process, Molly’s false teeth went missing. I imagine that having no teeth would be stressful enough at any time of year but made worse by the thought of having to eat Christmas lunch out of a blender.
The nurses could not have been more helpful once they had realised Molly’s teeth were missing. They tried to work out what had happened and spent a lot of time looking for them.
In the Lean world, time spent looking for teeth is ‘non-value added’ time or ‘waste’. And it feels like a waste of time. Nurses’ time is valuable and better spent on nursing. Lean coaches help people look at processes from the customer’s point of view and how waste can be found and removed.
So how do false teeth go missing? Judging by the reaction of the nurses, it wasn’t the first time they had had to look for teeth. Problems usually occur when ‘things fall through the cracks’ or there is no clear process or responsibility for a task. All the individuals involved in a process may be doing their part exceptionally well, but something gets missed on a handover or when one person makes an assumption about what others might be doing. In most organisations the staff are good in their areas of expertise. In a hospital, the doctors, nurses and other staff are generally well trained, knowledgeable and experts at their job. Keeping false teeth safe does not require any technical expertise.
Value vs Waste
Most workplaces involve many processes. In manufacturing, the product moves through the plant from raw material from suppliers through to finished product delivered to the customer. We often call this process the value stream. Value is added along the way when the product is changed in a way the customer wants. There is also usually a lot of waste in the process, when the product is waiting, or being moved, or something is missing, or has to be reworked. This waste is all the stuff that normally happens which the customer is either unaware of or wouldn’t appreciate paying for. Customers are usually happy to pay for value. Wastes are the opportunities to improve.
In a hospital it is the patient who is the value stream. Value is added when the patient is being treated. Lots of professionals interact with the patient and do their part of the job well. That might be taking a temperature, administering drugs, assessing what to do next. But each time a patient moves from one person to another there is a risk that something gets missed. Which is why everything gets documented on the patient charts, the risk of mistakes being made is minimised.
Safety – quality – delivery – productivity KPIs in that order
In most workplaces, people are measured through KPIs (Key Performance Indicators).
Safety should of course be the top priority, and that would be equally true in a hospital as in a factory. As loose false teeth in a patient’s mouth is a hazard, then the teeth should be removed.
The next most important KPI is quality. Removing mistakes and the chance of mistakes being made. Hospitals are good at minimising the risk of a mistake causing medical harm. Keeping false teeth safe is perhaps not an urgent medical issue, but you could argue it could become a medical issue over time, so it’s important to keep them safe.
Delivery means shortening the time of the value chain. How can we get the patient through the admission process, through any treatment and back home in the shortest time. Often this is interpreted as needing to do work faster, but instead focussing on removing non-value added steps, or waste, can improve delivery times without sacrificing quality.
Productivity is the one measure that will improve on its own if quality and delivery are focussed on first. An example of this is the lost teeth. It might take an extra minute to bag and label Molly’s teeth when she was admitted, which if you’re being measured on how productive you are and you have some more urgent medical issues to address it might not be seen at the time as a priority. But how much time did the nurses spend looking for the teeth after they had gone missing?
There is a rule of thumb that if a task that takes 1 minute gets missed and goes to the next stage it takes at least 10 minutes to fix later. Keep multiplying by 10 as the problem goes further along the process. Getting it right first time and improving quality therefore directly improves productivity. But if you focus on productivity first, then quality can suffer. If an individual is measured on productivity and the KPI doesn’t include the time spent fixing up an error, then there is no incentive to do it right first time. Even if you know it’s the right thing to do, people will often do what they are measured to do, which is be ‘productive’.
Root Cause Analysis
There are two types of problems. Those you have seen before and those you haven’t. Typically when we ask people in their workplace about which types of problem they have the most, it’s the former. Molly wasn’t the first patient to have lost her teeth, so this wasn’t out of the blue, but a repeat problem. Family members who visit hospitals regularly know to take teeth home with them so they can’t get lost. Even a big sign in the waiting room saying “there is a good chance we will lose your loved one’s false teeth – please take their teeth home with you” might reduce the number of lost teeth. A sign like this would be what is generally called a quick fix to a problem. It’s a band aid solution until you investigate the root cause and come up with a countermeasure.
Why? not Who?
When something goes wrong, there should be an investigation. Unfortunately, this is often when everyone dives for cover so there’s no chance of them being blamed. There is no incentive for anyone to be open about what had happened and it’s hard to get to the bottom of what occurred. Instead of asking who did something, try asking why something occurred. Typically you ask why 5 times as you dig deeper to find out what has happened. You know you’re getting somewhere when you get past a person’s involvement and start looking at changes to processes to stop recurrence.
Go easy on the person and hard on the process
In getting to the root cause of the problem you have to go past blaming someone. It’s not the nurses’ fault, or my sister’s fault. If you keep asking why a problem occurred you will eventually come up with one of 3 causes:
1. No Process
Is there are process for managing false teeth? If not, create a process, document it in a procedure and train everyone on the procedure.
2. Ineffective process
Is the process any good or does it need to be modified to prevent teeth from getting lost? Auditing a process to see whether it is followed, and if not why not, can determine if the process actually works.
3. Process in place but not followed
If there is a good, well documented process, why was it not followed? Does everyone know about it? If not check how people are trained. Does it need to be included in an induction training program?
If there is a good process, everyone knows about it but it was still not followed then you need to ask what is driving that behaviour. Often it’s because someone is pushed for time and it’s not seen as important. Realigning KPIs can help modify behaviour. For example if the nurses have a KPI around how fast they can admit a patient there may be incentive to take some short cuts that have no impact on the medical outcome, but may have an impact on the quality of the patient’s experience (such as losing false teeth).
Most people (me included) are in awe of what doctors and nurses do. It’s much closer to rocket science than keeping a set of false teeth safe. Which is why patients and their families are particularly frustrated with something like lost false teeth. Keeping teeth safe is not a hard thing to do on its own, but there are so many things that doctors and nurses need to do to keep their patients safe, keeping false teeth safe needs to fit into the overall process of caring for patients., with a process to follow.
It seems like there is a simple solution. Whenever you go into hospital they print lots of labels with your name and details on them. Why not have a ziplock bag for false teeth, hearing aids and other items and stick one of those stickers on it. Then have a safe place to put the bag. At least with a label if they did get lost, you’d know who to return them to.
On this occasion, Molly’s long hospital stay was remembered more for her not having her teeth than for the excellent medical care she received. The good news is that one of Molly’s sons found an old pair of teeth in time for her return to her care home, which made the move back a bit easier for Molly.