We have just passed the half-way point for our trip to Japan. Following our visits to Yamatake already discussed by the General Surgery team, this week we visited two Yamaha plants (motorcyles and pianos) and two Aishin plants (automotive parts and mattresses).

The most interesting visit this week was to the Yamaha piano factory where we most clearly saw the answer of "How is learning about manufacturing going to apply to health care?". This is a question we commonly receive and we have asked ourselves. Health care is both a science and an art. Where in manufacturing can we find room for art or craft?

At the piano factory we saw highly skilled artists and craftspeople using "lean" principles. In this factory, specific people are chosen to complete work that requires a very high level of skill. The piano tuner is one of the most skilled roles in the factory. The work is manual. This piano tuner is selected to tune because of his or her exceptional 'ear.'

These craftspeople or artists work to a defined timeline, however - craft to a production takt time. If the piano tuner runs into timeline problems which could delay the delivery of the piano, there is a signal called an andon that goes on. This enables the piano tuner to easily receive help. It was very easy for us to imagine the piano tuner as a surgeon in the operating room practicing the art of medicine to a takt time. The analogy to health care was the best we've seen yet.

We arrived in Kyoto this morning after riding the bullet train. Tom Hansen has joined us for the remainder of our trip. We spent today presenting our first week's key learnings as well as discussing implications of our learnings for Children's and the orthopedic, general surgery, and ICU value streams. We've had multiple team-based debriefings throughout the last week. It was very powerful to be able to present and discuss summary conclusions with the entire group and Dr. Hansen.

A significant conclusion of the group is that we have to focus on standard work as foundational to everything that we do. We need to have a process defined in order to effectively improve it. The physicians in the group all agreed that creating standard clinical guidelines for patient care is essential. Every factory we have observed has standard work that they are continuously improving.

We look forward to developing standard work for clinical care in Orthopedics. We also hope to focus this next year on using andon visual signals throughout our clinical sites of care to assist with 'craft' timing and patient flow. We feel very privileged to have this opportunity to learn!