People who take the lessons of Toyota’s production system to heart know that it is vital to go to the place where value is produced to learn what is really going on—the Gemba.

The advice is to “Go See,” not just once but repeatedly, especially if you are responsible and accountable for organizing people and resources to accomplish something. You “Go see” to get clues to solve problems as well as to have a sense of typical performance, so unusual changes will be easier to spot. That’s the essence of quality control.

One reason to have an organized and clean organized workplace is to make it easier to see if something is out of place; things out of place are signs of one or potential problems that deserves attention.

Go See is not limited to sight. I was reminded of sound as a trigger to problem identification a couple of weeks ago. My wife and I heard our dog Andy drinking water, enough to ask each other “Is Andy drinking more than usual?”

We didn’t have a control chart or any other formal measures of water consumption, just the sense that the sound of living with our dog was different--we’re in year 13 of living with Andy so we have a lot of sound memories stored in our brains. It was the sound of lapping up water that seemed special, noticeable, maybe more than usual.

This sound and the question it prompted started us on a diagnostic journey to determine a cause. There was more observation of Andy, cause analysis, development of countermeasure(s).  The scientific inquiry matches the steps in standard problem-solving methods like A3 or QC Story. 

It turns out Andy has lymphoma and we’re now treating him to make him feel better.

I’ve been to several vet visits since January 1. I’m always interested in how vets examine patients that can’t use words to describe what’s going on. When veterinarians do a physical exam of an animal, they complement looking with hearing, touching, and even smelling before they extend their senses with modern lab tests of blood, urine and tissue and the range of imaging techniques that match what’s available in human health care.

That brings me back to what people should do when they are caring for a work system. Go see but also go hear and apply all your other senses to understand how the system is performing. If you go regularly, then you have a reference set of sights, sounds, maybe even smells, against which to compare new events that may signal a change in performance that invites your intervention.

Value Streams

Two weeks ago at the IHI annual Forum, I helped Brian Maskell present the basics of value stream management. The half-day session provided the context and walked through the details of a value stream management tool that Brian calls a Box Score.

Brian shared a picture that shows how to apply value streams.

What’s a value stream? It’s a family of patient care processes with similar flows that includes all the people, equipment, and facilities that support patient care within that family of care processes. The value stream has few or no resources--machines, equipment, people, and departments—that need to be shared with other value streams. The value stream starts where the patient first enters the care process and extends through to when the patient exits the care process.

Once a value stream is defined and planned, you have to operate and improve it. How do you do this? A value stream manager is appointed and is accountable for cost and quality performance. Weekly review of performance measures and a disciplined approach to standard work, problem-solving and targeted improvement projects provide the means to control and improve performance.

In Brian’s view, the Box Score is the fundamental measurement tool for value stream management. The table at left is an excerpt from a Box Score developed for an elective hip and knee replacement value stream.

Typically, it has three batches of measures: operational measures (five to seven quality and efficiency measures); measures of capacity for key resources; and a value stream profit and loss statement. Brian has used the Box Score in six ways with his manufacturing and service clients:

  • A basis for weekly performance reporting and monitoring
  • As adjunct to value stream mapping
  • To assess impact of kaizen events and continuous improvement projects For decision making (choosing among alternatives)
  • To understand implications for major long-term projects
  • For monthly planning

Integrated Practice Units

Michael Porter’s work on improvement of health care value starts with a key proposition: care should be organized around conditions or patient characteristics in primary care. See for example Porter and Lee, “The Strategy that will Fix Health Care”, Harvard Business Review, October 2013 (available here)

Porter refers to the core organization of care as an integrated practice unit (IPU). An IPU has specific attributes, as described on the Institute for Strategy and Competitiveness’s website, accessed 18 December 2016:

  1. Organized around the patient medical condition or set of closely related conditions (or patient segment in primary care)
  2. Involves a dedicated, multidisciplinary team who devotes a significant portion of their time to the condition
  3. Providers involved are members of or affiliated with a common organizational unit 
  4. Takes responsibility for the full cycle of care for the condition, encompassing outpatient, inpatient, and rehabilitative care as well as supporting services (e.g. nutrition, social work, behavioral health)
  5. Incorporates patient education, engagement, and follow-up as integral to care
  6. Utilizes a single administrative and scheduling structure
  7. Co-located in dedicated facilities
  8. Care is led by a physician team captain and a care manager who oversee each patient's care process
  9. Measures outcomes, costs, and processes for each patient using a common information platform
  10. Providers function as a team, meeting formally and informally on a regular basis to discuss patients, processes and results
  11. Accepts joint accountability for outcomes and costs

The IPU and the Value Stream Organization

IPU attributes 1, 4, and 5 describe attributes of a complete value stream, with attention to comprehensive care. Attributes 2, 3 and 7 align with the principle that resources should be dedicated to the value stream and are not shared with other value streams. Attributes 6, 8, 10, and 11 address management practice and accountability. Only attribute 8, a specific recommendation about care management, is not immediately apparent in the value stream organization proposed by Maskell.

I conclude that IPUs look a lot like value stream organizations. If so, the methods of value stream management apply directly to IPUs, providing specific ways to operate and improve IPUs.


John Beasley, MD and his colleagues at the University of Wisconsin Department of Family Medicine and Community Health and the Department of Industrial and Systems Engineering recently completed a research project. They investigated the burden of electronic medical record (EMR) systems on family practice physicians at the University of Wisconsin. This burden is one factor driving physician burn-out and dissatisfaction with medicine as a profession.

They used logs from the EMR, validated by direct observation of physician computer use. The researchers found a consistent pattern of “work after clinic”--time spent during evenings and weekends.

Physicians averaged about 10 hours a week in EMR work after clinic over the three-year period of the study.

This research is notable for two reasons. First, it made novel use of EMR logs to quantify the extent of the work after clinic phenomenon.

Second, it described three specific ideas that could reduce primary care physician EMR work by as much or more time than 10 hours per week of work after clinic :

• Transcription with human assistance (Save 6+ hours each week).

• Paper/verbal order entry (Save 3+ hours each week).

• Automatic Log-in (Save 1+ hour each week)

What’s the prospect for successful adoption of these change ideas?

Dr Chris Hayes has made the case that changes in health care practice are more likely to be adopted if they have relatively high perceived value to patients and providers and at the same time don’t add workload (See Chris’s web site and this 2015 article in BMJ Quality and Safety, )

The perceived value and impact on time depend on each other—changes that reduce work seem likely to have more value to providers than changes that are work neutral or worse, add work.

Chris summarizes the situation with this picture:

By Hayes’ theory, the change ideas proposed in the UW research appear to be highly adoptable and sustainable once adopted. However, the two changes with the biggest impact requires other people to do more work and be paid to do so.

In the current situation, physicians are working after clinic “for free.” Longer-term effects like fatigue and burn-out, which lead physicians to seek less than full-time positions or leave the profession altogether, are diffuse and don’t show up in a regular bi-weekly cost statement. Adding cost for support staff, on the other hand, is easy to recognize and resist in a world of cost management.

So administrators and physician leaders will have to convince themselves of the business case for the package of changes.

How to make the business case?

Use the Model for Improvement:  Run tests, starting on a small scale—involve one physician, over one or two days, to iron out logistics. Then test the changes for longer periods of time, with more providers. Measure the impact on physician time using the EMR logs, costs for support staff, and physician perception. Have the administrators and physician leaders observe the tests themselves to inform their decisions.

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