Charts and graphs that indicate at a glance what is happening are essential to the success of this cooperative approach. When people are making progress, they need to see it. When they aren't, they need to see that also. Computer spreadsheets make it easy to contrast and compare, but if there is no spreadsheet expert on the team, it's fine to use hand-drawn charts. Just keep them current.

In a spaghetti diagram we draw a layout of the work space. This can be as simple as one room or could include multiple buildings. We place our pen on the paper and walk through the process we're studying with the pen making a line as we go. When we are finished, we see the path work is taking. We can enhance spaghetti diagrams by adding the dimension of time. If the process takes two minutes at points A and B and takes four hours at point C, we have enough information to ask some good questions.

The spaghetti diagram shows in very clear terms exactly how much time and distance we cover in the completion of a task.

The act of just watching, not judging, not fixing, but just watching is a real eye-opener.

1. Pick a place to stand and watch
2. Plan to take notes as you stand
3. Let people know you are just watching
4. See what you see
5. Share it with others

Standing and watching the work go on around us can be very educational. If we are in the right position, what we learn can be profound. For example, standing in the emergency room between patient triage and the treatment rooms, lets us see patients, doctors, nurses and technicians along with family members, offering a powerful perspective For a quick story on the use of this technique, click here.

A clean, well-ordered work space with everything we need where we want it and when we want it is the mark of a true professional. By removing junk and clutter and making supplies and equipment easy to get to at any time, we reduce cost, waste, frustration and exhaustion.

A 5-S project employs five distinct steps to produce a workplace that holds only the equipment and supplies necessary for the job and creates a simple way of keeping the area useful and orderly.

Here are the five steps as we use them in simple Lean.

1. Sort We make a wholesale sweep of a workplace or part of a workplace. We determine what we need to do the job. If we don't need it we remove it from the area. If we need it but have too much of it, we return inventory to supply. If we're not sure, we use the RED TAG approach that gives people time to weigh in on occasionally used items.

2. Shine Before moving things back into the space we do a complete cleaning and refurb. We wash floors, scrub and paint where needed and generally make the foundation of the workspace a clean and pleasant place to be.

3. Set in Order When re-staging the work or storage area, we organize the workspace in a way that supports the most efficient way to do the work. Parts are placed in a logical order (i.e., most used in the handiest area), equipment is placed where it is used or re-charged.

4. Standardize We make it easy to see where equipment and tools are supposed to be. We make re-ordering simple and as automatic as possible. We design the space so it serves the needs of the people who work there. The cleanliness and order adopted in steps two and three make it easy to see when something is dirty, broken or out of place.

5. Sustain Once everything is back in place, we'll need a way to keep it looking and working like that. In this step the team who has done the work decides on a cleaning and replenishment schedule. Photos are posted of the way it looked before and the way it looks now. Any team member can ask for a meeting to discuss problems with the upkeep.

This approach is also known as PDCA or PDSA and comes from the scientific method of create hypothesis, plan test, run test, measure results and plan and test again. It goes like this:

1. Determine what needs to change
2. Measure the present situation
3. Design the test
4. Predict the outcome
5. Carry out the test in a controlled way to protect safety and quality (for example, one patient, one day, one time)
6. Measure actual outcome
7. Design new test using collected data
8. Repeat

The key is to keep the test small and simple. Resist the temptation to try to fix everything at once. Keep testing, measuring, fixing and testing until the new approach is proven under many different circumstances. Use the data and the experience to implement the change.

Too many meetings get nothing done. In the simple Lean philosophy every meeting has a purpose that all attendees understand.

1. What is the purpose of the meeting? (decision, information, relationships, idea generation, etc.)
2. Why is each person there?
3. Is everyone there who needs to be? (for a decision meeting especially)
4. How long will the meeting be? (These can occasionally be long, but most meetings benefit from having a true deadline to reach a defined outcome)
5. Is there an alternative that will avoid a meeting?

A Small Test of Change meeting is designed to produce a test for change. It has a few useful rules.

1. The meeting lasts no longer than an hour
2. There should be an active representative of every group that is involved in the problem
3. Start by defining the problem on a surface everyone can see (flip chart)
4. Only make changes in an area that's represented (for example, if there is no one from IT in the room, the solution can't assume a re-written program)
5. If we don't have a workable plan within an hour we schedule another meeting and adjourn

There is an example of this kind of meeting in the Blogs here.

The Five Why tool is deceptively simple. We just keep asking "why" until we get to the root cause of the problem. For example, in the blog post Just Seeing I look at a problem where the emergency room backs up as soon as a serious case arrives. We began solving that problem using the Just Seeing approach. That gave us enough information to use the Five Why tool.

1. Why does the ER workload back up when we have a serious case? Because everyone is working on that case instead of working with other patients.

2. Why is everyone working on the serious case? (You could answer "Because that case is more interesting," which is neither charitable nor useful. Good healthcare professionals don't drop patients in need because something else is more interesting.) Because they have nothing else to do. (You could see this because treatment rooms remained empty waiting for a doctor to call them in.)

3. Why don't they have anything else to do? Because they have not been assigned a patient from the waiting list.

4. Why haven't they been assigned a patient? Because the Senior Doctor is the only one who hands out assignments and is also the one most likely to be needed on a serious case.

5. Why is the Senior Doctor the only one to hand out assignments? Root Cause reached.

There is no magic in the number five. We could have reached root cause in three or seven questions. What we can see at the end of the questions is something that causes the problem that we can get our arms around. The next step is to do a small test of change. Changes in such a critical area have to be done with absolute focus on patient safety.