‘Medical device supplier regrets poor service’ – Skipr.nl, Skipr Editorial, June 13, 2014 [Anonymized]

“A medical device supplier regrets the poor service it has provided in recent months. The company writes this on its website. It was raining complaints.

The supplier attributes the poor service to the changing healthcare market. The government is making substantial cuts. Due to budget pressure by municipalities and fierce competition in the market, prices have fallen sharply recently. As a result, unfortunately more things are going wrong than usual at the moment and serious situations are occurring.”

What to do about it?!

Adding more staff

“In the coming period, the supplier will focus solely on improving the service to its customers. For example, more staff have been deployed, additional support points have been opened and the opening hours have been extended.”

Just another article of an event in the healthcare sector and how it has been responded to by those involved.

The problem for the customers of this supplier is the lack of service. In the words of their customers and clients, this means that the supplier did not live up to its agreements. They were far from delivering the right equipment, at the right time.

If we look at this article through a Lean lens the following stands out:

1. It is nice that the supplier acknowledges the problem and looks for the cause in himself, instead of in the customers or the environment.
2. It is, of course, a very good idea that the supplier wants to improve service delivery.
3. However, the measures proposed by the supplier are all different ways of expanding capacity: “For example, more staff have been deployed, additional support points have been opened and the opening hours have been extended.” The solution is thus sought in doing more of the same and putting more time and resources into it.

However, in my experience, these measures do not lead to sustainable improvements in the process of service delivery. None of these measures change the way we work, while (not) delivering the right stuff, at the right time is clearly a process problem.

My experience is that ‘if you do more of the same, you get more of the same outcomes’. But then again, what’s the alternative? Surely the problems require a lot of time and manpower?

If you, as a supplier, really want to help your customers, like providing patients with equipment, then it is better to focus on investigating and eliminating the causes of your service problems. You do this by taking the following steps:

1. Investigate the problems extensively, at the place where they occur; i.e. with and at the customers
2. Find out the root causes of the problems
3. Use the creativity of your employees and customers to devise measures, which remove these causes.
4. See all this as a way to learn and therefor as a way to develop and grow people.

This example of an equipment supplier that solves its problems by expanding its capacity is, for me, a symbol of a common way of handling problems in health care.

The boat in the canal

Let’s apply this approach to a boat in a canal. If the boat is in danger of colliding with something on the bottom, we fill the canal with more water to cope with the situation. This solves our problem at that moment, but leads to additional costs, without adding any more value to your customers. You can’t keep this up for long, because at some point you run out of money. Customers are generally not willing to pay for these extra – unexpected – costs, I like to call waste. Especially not if the money is to correct your own mistakes.

So, adding resources to solve your problems, leads to adding costs, without adding value.

The approach taken by the healthcare provider in the example is clearly also about adding resources: “… more staff have been deployed, additional support points have been opened and the opening hours have been extended.” But, does this also lead to more value? (Read: do more customers, get better help?). There seems to be an assumption that the cause of all the supplier’s service problems is “not enough capacity”. But, is that really the case?

To answer this question, I use the following – Lean – definition of capacity:

Capacity = value-added activities + non-value-added, but necessary activities + waste

According to this formula, it makes sense to view capacity problems as symptoms of a problematic process. Before you expand your capacity examine how you are using your capacity. Is capacity wasted? This is almost always the case.

Therefore, before you expand your capacity, try to eliminate any wasteful activities, such as correcting mistakes or searching for items, and reduce non-value-added but necessary activities, such as checks. You do this by identifying and eliminating the root causes of your problems. In doing so, you get closer to your goal of providing safe health care, right the first time.

For “the boat in the canal,” this means asking yourself, why is it that you need so much water? To answer this question, you dive into the canal and analyze what obstacles (causes) prevent you from sailing and thus “force” you to add extra water.

5x Why?  5x What is the reason?

To address problems sustainably, you will have to solve them at the source. You will need to identify the root causes and develop countermeasures to eliminate them. For this purpose, a tool has been developed called: “5x Why?”. This tool teaches you to ask why a problem occurs and then ask again why that is. The “5x” stands for the fact that you need to keep asking why, sometimes as many as 5x (or more) to get to the root cause of your problem.

The disadvantage of asking “why?” is that people can easily feel attacked or accused by it.They might get defensive. To avoid that, it’s more effective and less threatening to ask (5x) “how come?” or “what’s the reason?

Imagine that the supplier had used this approach. Then he would ask, “what exactly is the problem?” The possible answer: “the walker was too small.” Then he might ask, “how could that happen?” To which the possible answer is: “our client is quite tall (2.00m) and the walker is for average people of 1.80m (6ft).”  To which he may follow up with: “how could this happen?” A possible answer is then: “the client’s height was not asked for, when taking his order.”

So, to eliminate waste and solve your problems, keep asking “why” until you find the root cause of the problem. In the example, the waste (the symptom) is the incorrectly delivered walker, which means another one has to be brought in. This wastes the time of the technician and the client, after which the client also has to wait for the correct walker to be delivered. The problem, from the patient’s perspective, is “the walker that is too small’. The root cause of this problem is that the length of the client, was not used as input during the ordering process.

Based on this discovery process and understanding the problem, very different countermeasures would have been devised. No need for more staff or extra support points. For example, the supplier could have adjusted the order form so that deviating sizes could be listed and thus ordered. This way of improving would have had many advantages, as it would have led to simple, staff-developable and cheaper countermeasures that would have solved the problem permanently.

An extensive version of “the story of the boat in the canal”, helping you to change your thinking about how to solve your problems you’ll find in my of my book “Lean Thinking in Health Care. Safe, compassionate, zero waste, no struggle”.

Make sure you get a personal copy . Download the teaser.

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