Thomas L. Jackson's Blog

  • The lean science of waiting room design Part I: flow, push and pull

    As we learned from Womack and Jones in their book Lean Thinking:

    • Value the patient.
    • Map the process.
    • Flow the process, so patients never wait for clinicians—and clinicians never wait for patients.

    But, if you can’t flow, pull. 

  • Time or inventory; inventory or time?

    Between each process in a clinical value stream, we find patients waiting…and waiting…and waiting. At the Rona Consulting Group, we use hot-pink sticky notes to represent patient wait times on value stream maps. Stopwatch running, we sit down and wait with the patient and then record the number of minutes waited on a time observation form. We compare patient observations to identify the mode or most frequently occurring wait time and post that time on the hot-pink sticky note on our value stream map.

  • What does it mean to be “on the gemba”?

    What is the “gemba” anyway? You read about it all the time in books and articles on lean healthcare.

    Gemba is Japanese for “the real place.” Let’s say I am a reporter in Japan covering the nuclear power plant meltdown in Fukushima. The camera scans the wreckage and then focuses on me, standing in front of the mess. I deliver the latest bad news and then, as I’m signing off, I say, “This is Tom Jackson, reporting from gemba.”

  • Lean vs. six sigma: a pointless fight

    Healthcare leaders are looking for ways to change their organizations and their industry. In the search for solutions to help them, they encounter information, education, and consulting services that tend to fall into two camps: lean and six sigma.

    Lean and six sigma are often taken to be two different systems that are at odds, with experts and practitioners touting the superior benefits of one or the other. I myself once made a dramatic public presentation in which I described six sigma as a heartless robot. But this is a pointless fight. Lean and six sigma are fraternal twins.

  • Inputs, outputs, and human beings

    Within Rona Consulting Group, we debate how to refer to patients in the context of clinical value streams. Always with respect, of course. My partner, Patti Crome, a former nurse executive, speaks of having “a patient on her shoulder.” But there is a real dilemma when transposing the industrial method of value stream mapping to healthcare.

  • What does it mean to “meet takt time”?

    Clinical value streams are consciously designed to match patient demand with the supply of clinical services, in a management exercise known as “meeting takt time.”

    The word “takt” is German for “tempo” or “time.” (Insiders refer to takt time simply as “takt” to avoid redundancy.) Mathematically, takt is defined as:

     T = t/d,


  • Flow, push or pull?

    The language of value stream mapping describes a collection of processes in one of three physical states: “flow,” “push,” or “pull.” These three little words can cause much confusion. With the help of a little economics, I will attempt to clarify these terms for healthcare.

  • What is a process?

    One of the fundamental building blocks of value stream mapping is the simple concept of a “process”: “a series of actions or operations conducing [i.e., leading] to an end” (per Merriam-Webster To succeed in building clinical value streams, let’s get a little more detailed. 

    In the language of value stream mapping, a process is a sequence of  “operations,” where an “operation” is defined as a sequence of “tasks” performed by an “operator.”

  • Mapping clinical value streams

    In this blog we’ll explore the method of value stream mapping as applied to the clinical operations of the healthcare industry. Originating within the automotive industry—at the Toyota Motor Company—value stream mapping naturally raises questions in the minds of doctors, nurses, and healthcare executives: