When written in Chinese, the word ‘crisis’ is composed of two characters. One represents danger and the other represents opportunity.John F. Kennedy
The worst time to prepare for a crisis is once you find yourself amid one. With the United States now surpassing China with over 86,000 Coronavirus (COVID-19) cases, too many healthcare executives are coming to terms with this. And although this virus is an anomaly, the fact is, healthcare systems in this country also fail under normal conditions. The Centers for Disease Control and Prevention estimate that nearly three-quarters of a million Americans develop healthcare-associated infections each year, 75,000 of whom die during that hospitalization.  Furthermore, more than 12 million patients each year experience a diagnostic error in outpatient care, half of which could cause harm. The media has harped on the lack of N95 respirator masks as a failure mode for hospitals. Hospitals are in such shortage that they must reuse masks from one patient room to another; a practice that is known to increase the likelihood of infections spreading from patient to patient. However, this is too narrow of a focus. Even with the proper number of masks to equip healthcare staff, the virus would continue to overwhelm our healthcare system. Why? Because healthcare systems are poorly designed, allowing for waste, a burden on workers, and, as a result, human error. The late Dr. W. Edwards Deming described this as the 85/15 rule: 85%  of a worker’s effectiveness is determined by the system they work within, while only 15% by their own skill.
If you’ve ever been in a medical unit, you may have seen clinicians working on what-are-referred-to-as Workstation On Wheels (WOW). These workstations allow healthcare staff to be mobile while charting, encouraging real-time data entry on a patient’s condition. At a client site where The Kōhei Group was leading a Lean transformation, we conducted what is referred to as a Genba Walk to notate waste and opportunities for improvement. On our walk, we noted that nurses would sanitize their hands prior to entering a patient’s room, but did not clean the WOW machine, even in cases where it was previously in a room whose patient had an infectious disease such as C. diff. This was an opportunity for improvement as the lack of cleaning put both patients and staff at risk for contamination. So, were the nurses to blame? No; not at all. When we approached the unit manager and asked them what the standard was for cleaning a WOW, we came to learn that there was none. How could the nurses be accountable for something that didn’t exist? Even the mention of cleaning the machines caused the unit manager to panic: our nurses are already overworked and now we are going to add one more thing to their plate! She was right. Making nurses clean the WOW, in-and-of-itself, wouldn’t solve the problem. We needed to go beyond that.
If 97 percent of a worker’s effectiveness is dependent on the system they are working in, that begs the question, what does the right system look like? Although there is no one-size-fits-all system, in my book, Sacred Workday: How to Create an Awe-Inspiring Business, I offer a useful model as seen in the image below that guides the process of designing one.
In the case above, our first step was to define the Standard Work, the expected way for employees (in this case, nurses and technicians) to work that would provide a baseline for continuous improvement. The leadership provided direction to focus on the evidence-based practice of hourly rounding which has demonstrated “moderate-strength” in increasing patient satisfaction, reducing patient falls and call light use.  Using a program developed in World War II called Training Within Industry (TWI), top performing nurses and technicians helped develop the way to do the work using a tool called a Job Instruction Breakdown Sheet (JIBS). Their JIBS for rounding consisted of four important steps: 1) checking pain, 2) asking to use potty, 3) repositioning the patient, and 4) gathering possessions. Each important step had key points and reasons why to reinforce doing the step in a specific way. For example, for step four (gathering possessions), the key point was arms reach and the why was to prevent fall and reduce call light use. This why would prove key in gaining peer buy-in later when we would later train the entire staff. If staff were to spend more time than they typically did rounding, they needed to know what the return on their investment would be. In this case, fewer trips to patient rooms and reduced falls.
After setting up the work environment with everything the staff needed, in a way that reduced their motion, we began to conduct a time-study and found that we could perform one round for a moderate acuity patient in five minutes. Since a nurse and technician pair had to cover five patients in one hour based on their assignments, we had sufficient time to incorporate post/pre work as well, including documenting in real-time, sanitizing hands and sanitizing the WOW prior to moving onto the next patient. In total, our target for both the round and post/pre work would be ten minutes (50 minutes of total work to be completed in 60 minutes by two staff members).
Once the work was defined, we leveraged another tool in the TWI toolbox to train staff called Job Instruction (JI). Each staff member was trained and confirmed that they could do the work to standard in the patient room. If they could, they would be checked off on a skills matrix indicating they were competent in the skill. If not, they would receive feedback and coaching on how to improve towards the standard.
Although defining Standard Work is a good first step, it’s not enough. If we continue to use the Lean Management System model, we see the need to incorporate Sensory Management and Self-Accountability. Sensory Management is any sensory tool that assists staff in following the standard work and/or signals when the standard work cannot be followed. Self-Accountability is the act of a worker attempting to follow the standard work and signaling their performance to the team using Sensory Management. For example, in our case, nurses and technicians were given smart wearables that would buzz on the top of each hour to signal the start of rounds. At that point in time, both the nurse and technician would gather at a Rounding Hour-by-Hour Board as seen on the diagram below where they would plan out their next hour. Upon completing their rounds, they would update the board to indicate whether they were able to perform the standard work, i.e. leave the magnet red if they could
not, or flip it to green if they were able to so. In this case, red was not bad. To the contrary, red represented an opportunity. In the case a staff member could not perform the standard work, they would fill out a Pareto chart with the reason why. These reasons would allow leadership to problem solve and eliminate obstacles so that, over time, the standard work would be achieved with more reliability. From the initial buzz to the last flip of the magnet, staff would practice what Deming referred to as PDCA (Plan Do Check Adjust). At the end of each shift, the team would tally up the score and see what % of rounds they were able to complete to standard. 
With Standard Work, Sensory Management, and Self-Accountability in place, it is important to add two more tools to complete our system. Go and See is the act of leadership going to the workplace to ensure the first three tools in our system are working properly. The role of the leader is not to go to the work and tell the staff what to do. In our system, the staff have already defined how to work and, thankfully, since they are the closest to the work. However, leadership does have a role: ensuring employees attempt to follow standard work, interact with Sensory Management, and take ownership through Self-Accountability. When employees do not, it is leadership’s responsibility to coach and develop employees, ensuring all staff understands the why behind the Lean Management System.
With all these elements in place, the Lean Management System can now do what it is intended to do: make problems (the gap between actual and expected performance) visible in order to enable continuous improvement. By expanding this model to include all healthcare roles and critical jobs, hospitals will become better equipped to provide a better patient experience in normal times and abnormal times.
So When Should You Start?
Even during the chaos that currently exists, the time to start is now. Too often, continuous improvement initiatives are viewed as “nice-to-have.” But as you can see, a Lean Management System is fundamental. As Taiichi Ohno, the father of the Toyota Production System, said, where there is no standard there can be no Kaizen [improvement]. Without a Lean Management System in place, the complexity of healthcare will be too much to handle for those on the frontlines. So many healthcare workers are willing to risk their lives, not only now, but during normal times too. They are owed the best systems to help their chances of providing the care that we would all expect for ourselves and for our loved ones should they ever need it.
 He would later adjust the ratio to 97/3
 Hourly Rounding to Improve Nursing Responsiveness: A Systematic Review, Matthew D. Mitchell, PhD, Julia G. Lavenberg, PhD, RN, Dr. Rebecca Trotta, PhD, RN, and Dr. Craig A. Umscheid, MD
 When we started, this number was in the low 20%s. It progressed to the high 90%s and had dramatic impact on Press Ganey scores, length-of-stay, and incidents of harm.