Featured On The Minitab Blog



Disclaimer:  I’m not affiliated with Minitab in any way…except for the fact that I find their product very useful on a daily basis!


Our friends at the Minitab blog just posted part one of a two part series involving how to create (and validate) a new measurement tool.  Look here for the post on this useful technique from the Minitab blog, and for more coverage on this important skill look here.

Do You Use This Antidote To Painful System Issues?

By:  DM Kashmer MD MBA MBB FACS (@DavidKashmer)


Healthcare colleagues:  have you ever felt like you’re running in mud? We have a term for when multiple small elements create resistance to inhibit you from getting done the work that needs to be done. That term is “friction”.  Friction is the accumulation of all those little things that add up to slow you down (or stop) you from imposing your will upon the disease process.  Well, colleagues, here is the antidote:  poka-yoke.


What Does Poka-Yoke Mean?


Poka-yoke is a design philosophy that, simply put, means “make it easier to do the right thing”. Want the physician to get charts done on time?  Make the computer work.  Make it accessible from anywhere.  Make the charts not come to his/her inbox in the eleventh hour with only one minute remaining before they expire such that they violate hospital staff bylaws (!)


Charts aside, want doctors to be on time for trauma?  Make a call room (and work hours) so attractive that they’ll want to stay there.  Make it physically harder to make a mistake.


A related description of poka-yoke is “poka-yoke as error-proofing”.  At its heart, the concept is the same:  make it more difficult to make a mistake.  This means either setup the system for success (as above) or create a better way to detect defects before the next step in a process.  Add inspection to a step before moving onto the next step.  Create a device that beeps if the water level in the tank I’m filling gets too high, etc. etc.


Error detection and inspection seem, to our team, to be somewhat more challenging to implement in healthcare than the “make it easier” approach described above.  We joked around at a process re-design meeting recently:  hire someone to stand outside the call room and knock or yell “beep” if we don’t wake up to the pager.  Possible?  Yes.  As practical as other choices?  Not really.


Each of the cases above may remind you of challenges with your own system, and (by no means) is the list above representative of what will work for you or all your unique factors involved.  Your data will guide you to your issues (if you let it).  However, the point here is that a workable solution is often not:  “doc work harder and just get it done”, penalties for not working hard enough, or chastising a colleague or entire service line at a meeting.  In fact, a healthy, workable solution may involve some poka-yoke type thinking that is very different than those other listed (more pathologic) interventions.


It boils down to this:  when I’m on the administrator side of the table, and when I need a system to function, I try to make sure it is easier for the person at the tip of the spear (the person awake at midnight, etc.) to obtain the desired outcome.  It needs to be as easy as we can make it given our available resources and what is within the realm of possibility for our system.  In other words, if there is a certain outcome that we want to obtain in quality control, we must make it easier to do the right thing.  That’s the poka-yoke design philosophy that accompanies Six Sigma and, often, Lean.  When was the last time you saw that used in healthcare?


Friction Is So Common & Overwhelming That We’re Trained To Accept it…Yet We Shouldn’t


For physicians, and particular trauma surgeons, we have all experienced that running-in-mud feeling of daily friction. When issues come up that are minor, additive, and problematic, I often jokingly ask “is this just the routine level of friction?” meaning is this just the routine level of friction we see every day or somehow even more than the norm. The facts about friction are so common and known that, well, friction has become a joke…but it shouldn’t be one.


People who speak up are often worried they’ll be labelled as “complainers”.  The truth is (as we all know in healthcare) if we started complaining we may never stop, so it’s easy to try and avoid falling into that bottomless pit.  Training seems to teach some that there’s no upside to complaining.  However, sometimes (just sometimes) the person who has the (often minority) viewpoint of the complainer may be a sign that something is amiss.  Collecting some data about the system can show whether that person’s view is trying to help signal you that there’s an issue or whether the system feels bad to them yet works just fine.


Although we may joke about it, the routine level of friction is often completely unacceptable and mis-aligned with the outcomes we want. Again, in quality control, if we want a certain outcome we need to make the design of the system line up with that desired outcome. That means it greatly helps the person performing the action when it’s easier to do the right thing.  That’s where poka-yoke is so valuable.  Magically, when the system makes it easier to get a desired outcome that’s often what you get.


The poka-yoke design philosophy helps grease the wheels, or gets the wave moving in a way so as to make it easier to surf to shore.  Imagine an environment that makes it easier for us to surf along and achieve a great outcome.  Think of that environment that actually supports our ability to be effective.  There aren’t many that I’ve seen in healthcare, yet the ones that do function that way are truly amazing in terms of quality and provider satisfaction.


Caution:  clearly we can’t spend millions of dollars on each project.  Resources are limited and constrain available poka-yoke solutions.  However, often, the costs associated with poor quality (the COPQs) are MUCH higher than we realize, so some reasonable expenditures on the preventative measures seen with poka-yoke may often work better for our system.  By the way, prevention (as you recall) is the only type of expenditure on quality that has a positive return on investment.  More here.


Have You Ever Seen A Healthcare Quality Project That Decreases Paperwork?


Consider more about how poka-yoke finds its application in healthcare. Have you ever been part of a quality control initiative or similar healthcare project where your paperwork burden is decreased? Probably not, because it just doesn’t seem to happen.  (It can, my colleagues, be done!) Maybe, after reading this entry, you’ll start to look for ways to reduce forms at your next quality improvement meeting.


Next time you are in a quality improvement meeting, remember to look at what the improvement would look like (and how it would feel) to the person on the front line. (Maybe even get the end user’s input in designing the solution!  Dare we ask the residents how to design the specifics of the solution we choose?) Consider how the job of the people on the front line can be made easier and more aligned with the outcome you want. Involve them in the decision making.


Creating alignment may involve removing obvious obstacles, improving resources available, or implementing a solution that just works better for everyone. The bottom line, in any event, is that you should remember “poka-yoke” to make it easier to get the outcome you want. Remember, in the next quality improvement meeting, the idea of friction and its antidote:  poka-yoke.

Top 10 Tips For Writing Good English In Your Blog Posts

By:  David Kashmer MD MBA MBB FACS (@DavidKashmer)


Sometimes you read something so useful (and clever) that you just gotta share.  For those of who who post on LinkedIn or other social media outlets, this one’s for you.  I found these Martin Garnder’s 1975 book Gotcha:

Below is a list of ten rules compiled by Harold Evans,
editor of London’s Sunday Times:

  1. Don’t use no double negatives.
  2. Make each pronoun agree with their antecedent.
  3. When dangling, watch your participles.
  4. Don’t use commas, which aren’t necessary.
  5. Verbs has to agree with their subjects.
  6. About those sentence fragments.
  7. Try to not ever split infinitives.
  8. It is important to use apostrophe’s correctly.
  9. Always read what you have written to see you any words out.
  10. Correct spelling is esential.

Yes, it’s easy to see the English run amok in the sentences above.  Much more challenging to see them in our own writing!  (Ut-oh, there’s a number 6 in my very own sentence!)

Hope you find this magical top ten list to be a useful reminder of how to write good English in your professional posts on LinkedIn and beyond.

Do You Know About Boston Snow & Special Cause Variation?

By:  David Kashmer, MD MBA (@DavidKashmer)

Lean Six Sigma Master Black Belt



Extreme Weather & The Six M’s




This is a recent photo of my car. Yes, I live and work in the greater Boston area.  Guess what–after this latest snowfall things only got worse.  That car is really buried now!


This latest snowfall gave me the opportunity to consider some of the interesting points about statistical process control and how to create systems in healthcare that work no matter the hour or condition–even when that condition is so bad that it spawns Twitter hashtags like #BosNOW & #bostonsnow.





Talk About An Organization Dedicated To Patient Safety (!)


During this latest winter storm, the organization in which I work has done remarkable things. Every morning, there is a group meeting which focuses on safety.  This daily meeting is built into the system, and happens even when there isn’t snow or some “hot topic” issue.  Lately, the meeting has included what we are doing to get our patients into and out of the hospital despite their comorbidities and the extreme weather. Every morning, as part of this safety huddle, each department reports off any safety concerns.


This focus on safety made me spend some time applying quality tools to how I get to work in the morning.  (Yes, you can do that!) Let me share with you some of the techniques I used to try to make sure I could effectively, and safely, get to work.  Let’s use these tools from the Six Sigma toolbox to highlight how they relate to extreme weather as a cause of variation.


The FMEA Highlights Things We Wouldn’t Have Thought About


First, I used the failure mode effect analysis (or FMEA) to figure out what all the ways were in which I could fail to get to work. The FMEA pointed out to me several ways in which I could be unable to do my job right at the onset of my time with the organization.  (I’m new to working here.)


As you know, coming into a new organization is a key time to build a team and quickly learn about the how and why regarding why things are the way they are. My personal failure mode affects analysis showed me that extreme weather was going to be a significant consideration.  Months ago, when I planned where to live, the FMEA made me recognize that weather was a significant concern that could impact my ability to perform.  Although snow was infrequent on a day to day basis, it could be severe.  The FMEA told the story.


How did I respond?  I made sure to find a place to live that had covered parking. I chose a place that was as close to the hospital as was practical. I also changed my car & purchased a used (pre-owned always sounds so much nicer but let’s call it what it is) four wheel drive vehicle. The FMEA really pointed me toward some key changes to make sure that I could even get to work. So, to sum up my personal portion of the story, the FMEA was very useful in pointing out to me some things that were necessary for me to even be able to get to work in the first place.  I wouldn’t have thought of these without the tool.


The Ishikawa, 6M’s, & Snow (!)


The FMEA is not the only useful tool of the component that can help us to design quality systems in health care. (And make sure we get to work!) Consider, again, the six sources of special cause variation. These are often called the six M’s or five M’s and one P. The six M’s include man (or people), materials (in the world of healthcare these are often patients with their attendant comorbidities), machine, method, Mother Nature, and management. Previously, I have discussed the six causes of special cause variation here.


Now, let’s take a moment to focus on Mother Nature. When we do a root cause analysis or similar quality meeting, we often make an Ishikawa or fishbone diagram. (More about those here.) The fishbone encompasses each of the factors in special cause variation. Again, one of these is Mother Nature. As mentioned previously here, we described (that once we’ve completed a fishbone diagram) we usually go back and label parts of it that we can and cannot influence. Parts that we can influence we label as C for control and parts that we cannot we label as N for noise (non-controllable). What is useful about this is that we can make a multiple regression analysis, and it can show us how much of the variation in the system we can directly control. (More on that here.)


As interesting as that may be, we should take a moment to describe that, even if we can’t control the weather, we can definitely plan for it. For example, throughput in the hospital changes greatly when people are unable to enter (and exit) the hospital.  This organization’s patient safety focused response plan is to be commended.


These Tools Answer Important Questions


Additionally, we may look to data and see how often we have weather extremes such as snowfall, heat, and other extreme variations in temperature and climate.  Important questions, such as “Does the hospital fill up with backlog?” or “Do patients not show up?” or even “Do both happen, and, if so, which effect wins out?” can be asked and answered with historic data.


We can then plan accordingly and make intelligent choices about what to do exactly when weather strikes. Again, I take a moment to compliment the organization of which I am a part. The team has a clear, patient-safety focused initiative to help patients enter and exit the hospital safely.


Utilization of a Y=f(x) (aka fishbone or Ishikawa) diagram may help us learn how weather impacts things such as hospital throughput. Insights like these come about when we take the time to understand how things like weather often lay behind other things we want to measure in our system.  A broad focus on all six causes of special cause variation yields insight that can allow us to help decrease outliers for issues like throughput.


I am confident that this health system and I will remember the impact of snow on throughput for a long time to come. For your organization it may be worthwhile, depending on where your organization is geographically, to focus on seemingly uncontrollable influencers that contribute to special cause variation.  Again, we may not be able to influence the weather, but we can definitely plan for it and see its effects in our models.


So, greetings from the greater Boston area and hope you are warm and safe wherever you are in the country. For questions, comments, or thoughts let me know beneath.

3 Great Articles From The Generation Y Surgeon’s Reading List

By:  The Generation Y Surgeon (@GenYSurgeon)


The internet is littered with articles about doctors and medicine…some good, some not so good.  I enjoy reading them, regardless of quality.  With the growth of social media and the prevalence of internet-based communications in medicine, the web has quickly become a new voice for physicians.  Most importantly, it’s a better way of communicating with the non-medical public.  Much of medicine remains a mystery to laypeople, especially when it comes to the daily life of physicians (and all other providers and ancillary medical staff for that matter).

Informal articles are frequently damaging to providers; however, some can actually be quite revealing to the public. With the constantly changing landscape of healthcare, it’s becoming more important to tell our side of the story.  Below are a few of the articles that recently caught my eye.  Enjoy!


(1) How Do Clothes Influence What Patients Think About Us? 




This article is symbolic of the many hats physicians are required to wear in modern medicine.  It also very clearly identifies some of the hurdles we face.  I sympathize with female physicians, as their wardrobe and image situation is much more complicated than that of male physicians.


(2) Where Does The Physician’s Responsibility End?



This article really strikes a nerve.  I’ve wondered for a long time, where is the line between my my responsibility for patients and their responsibility for themselves?  What do you think?


(3) Feel Like You’re Struggling Against The System?




Great article.  Period.  Every provider I know can sympathize with this article.  When you feel as though you’re struggling against the system…it’s because you are.

Do you have any articles to share with the group?  Please reply with links to anything you’ve found interesting.  I look forward to hearing your thoughts!

3 Reasons Why Great IP Doesn’t Get Developed – It’s NOT Always About The Money


By: James Kashmer (LinkedIn Profile here.)


For a product person like me, walking through a research institution is like a kid going through a candy store. Visiting with brilliant people and listening to them talk (while they show their life’s work) is an uplifting and motivating experience for me. So how do people like me choose with whom to work?


Personalities And Assembling A Team – What Is The Personality Of The IP Generator?


Personalities play more of a role than they should (and I do admit it). I, for example, do not waste time trying to get someone who has been working his or her entire life in pure research to sit down and prepare a detailed 100-page business plan. It’s NOT that they can’t do it–it’s that they choose not to. I also recognize it is not usually the best use of their time.


The same can be said about getting “researchers” to help get their “product out the door”. Recognize that implementation is not usually what interests (motivates) these people, and the person who created the IP (basis of your company) might not be the best person to do this.


In a startup situation, everyone needs to wear many hats and minimizing time to complete tasks is of the important for success. Some people can “flex” to do tasks they do NOT enjoy. It has been my experience a person who actually does (is able to) “flex” is a rare bird.


Greed – Drinking Your Own “Kool Aid” – Rewarding Those Who Actually Contribute To The Company Moving Forward


I have written previously “your IP is not worth much until you start eliminating unknowns” .  Another way of putting it is that your IP becomes more valuable when you are able to answer questions, and replace assumptions, with facts.


So how much do you compensate (with salary and equity) the IP Generator on day one of your NewCo? What’s the idea premium really worth? Usually going through this exercise on (or before) day one of your NewCo tells you everything you need to know about the people who you are choosing to start working with. Even though it is true that you would not even be talking about NewCo without the IP Generator, the IP IS NOT WORTH VERY MUCH until things start to get accomplished and the unknowns have answers. Shouldn’t the people making the contributions and enhancing the value of NewCo be as generously rewarded as the IP Generator? I think so.


Getting The Message Out:  Be Pro-Active


Just because you think you have a better “mouse trap” does not necessarily mean people will be “beating a path to your door”. Often the answer to fulfilling your funding needs is getting your succinct and targeted message out to where the people that can help frequent. Kudos to the present generation for creating and using powerful networking tools to help get the message out.


Getting the message out also implies people will respond. Critically analyze responses to see that the message that you thought you sent is being heard and / or understood by your targeted market (people). If your targeted market is responding and engaged to your message it is an excellent opportunity to choose “early adopters” willing to work with you to refine your initial product offering.  This, in part, is the basis of that well-described strategy of “getting out of the office” to create the Minimum Viable Product (or MVP).  For more on the MVP, look here.


Questions, comments, or feedback?  Let me know.  And keep the ideas coming!