This is the 6th blog in my series on organizational transformation. We have organized these blogs into three categories based on the important components of Purpose, Process, and People. We are still exploring the category of process and this week are focused on kaizen.
Kaizen is from the Japanese symbols meaning “change” and “good.” It is usually translated as “change for the better.” Kaizen takes many forms from simple projects to week long improvement events. At ThedaCare we have used Rapid Improvement Events(RIES) as the way to improve complicated processes and to build effective teams. The action of an RIE is focused on a single week in which a cross-functional team studies a problem and makes immediate changes to the process. The full event is actually a seven-week cycle. Prior to the team week, a manager in the targeted area and the project sponsor establish quality, productivity and throughput goals, pick a team, collect existing data and/or conduct new time studies. Teams usually have a dozen or so members, drawn from front-line staff such as doctors, nurses and clerks, plus support staff such as pharmacists, radiology and EMS technicians, and then others who work nearby, or in upstream or downstream procedures, plus an outsider. The outsider might be from a different department or hospital, or from another company. Teams also try to include patients whenever possible, to ensure everyone stays patient focused. Day one of the RIE week includes a brief orientation period, with training in lean principles and details of the project at hand. The team then goes to the department or clinic area, maps the existing state and conducts time studies as staff members work through their usual routines. Day two, the team develops maps and timelines describing the current and ideal states. From this, members design the future state – taking into account practical realities while improving the process. The goal is always to pursue the ideal state, while improving what can be improved immediately. If machinery needs to be moved or roles need to change, team members often spend part of the day hauling equipment and briefing staff in the area. The difficulty of coming to consensus and then making real changes in areas where habits may be deeply entrenched has led staff to dub this Prozac Tuesday. By day three, the team watches and assists as staff in the target area runs and tests the new process. By day four, team members write and implement new standard work for the process. Day five, the team reports on early results during a company-wide Friday morning report-out meeting that includes up to six presenting teams and more than a hundred people in a local junior college auditorium. The report-out is part teaching session, part evangelical lean revival. As senior leaders, we make it a point to attend as often as possible. Kaizen is one of the core components to the improvement methodology and without it it is very difficult to make substantial change. Efforts to improve with 6 month improvement activity have met with little sustainability. We experimented with something called 90 day workouts which, frankly, by 90 days most people had already moved on to another issue which resulted no organizational benefit. The key learning with kaizen is that it needs to be rapid. Rapid experiments with focused energy deliver better results because it allows teams to experiment with more than one countermeasure, PDSA that countermeasure, and improve it until an effective solution emerges. If this isn’t done rapidly(in the kaizen week) ideas and experiments lose momentum and change doesn’t happen. Having said all this, however, Kaizen doesn’t stand on it’s own. Without standard work and rigorous audit and management of the standard work most improvements revert back to the original state. In my next blog I plan to discuss the role of standard work and auditing standard work as a key component of the methodology of continuous improvement.
The TV cameras captured the Acute Heart Attack Value Stream designed by ThedaCare doctors and nurses.
This is an interesting look at how lean has collapsed time for an acute heart attack patient. The remarkable thing is as the time has collapsed state of the art therapy is now available for patients that wasn’t before this team of doctors and nurses took the waste out of the acute heart attack process.
In the past if a patient in rural Wisconsin came to a small hospital emergency room with a heart attack he would be given clot busting drugs instead of the gold standard balloon therapy. This happened because the diagnosis and transportation took longer than the 90 minutes required to have a good outcome. The ThedaCare professionals have taken many of the wasteful steps out of the heart attack process and in so doing patients from 70 miles away now have the same chance for life saving therapy that urban dwellers have. Click on the link below to see the video of this remarkable work.
In blog 4 we covered Hoshin Kanri otherwise known as strategy deployment which is an important senior management tool in the lean methodology of continuous improvement. In addition we defined what an A3 was and how it is used to cascade strategy and create dialogue throughout an entire organization.
In this week’s blog I want to describe another critical component of this methodology which again comes under the rubric of Process and that is value stream mapping.Before we can describe a value stream we must first define the word value. The goal of every lean practitioner is to find what is of value to the customer and deliver it reliably, while removing all extraneous acts and materials from the process. In the strictest definition, everything that is not of value is waste.
But how does one identify what is truly of value for the customer? Many healthcare professionals probably think having blood drawn is of value. In fact, most people do not enjoy being stuck with needles and would avoid it if they possibly could. They place a value on being accurately diagnosed, but not on the diagnostic tests, per se. Diagnostic tests fall under the category of “necessary non-value added,” which can be a kind of holding pattern for waste – it is reluctantly accepted as necessary until some innovation comes along in this case, analyzing blood results without actually drawing the blood. This innovation is actually on the horizon now for diabetics who must check their blood sugar regularly. A sensor has been developed that is able to monitor blood sugar through the skin without needles. But for most, the non value added step of using needles to obtain a drop of blood is still the norm.
The most reliable way to determine value is to simply to have the customer answer one question.” Will you pay for this”? We have asked thousand of customers this question over the years and they have all been brutally honest that most of what we do is waste.
Identifying the existing state of a care delivery process is done by identifying each step in the process of delivering that service to the patient. Once completed the caregiver has a map, which we then can ask the “will you pay for it “ question of the customer. For example I was on a team that created this value stream map in obstetrics. We studied the time from when a baby is born to when the baby goes to the doctor for the first visit. This process had 140 steps many of which the customer on the study team said she wouldn’t pay for. For example she was not willing for the nurse to run out to the nurses station to get the baby’s medication but she was willing to pay for the nurse to the deliver the medication to her baby. This led to that team deciding to put all medications in the delivery room so the nurse would not have to perform that non value added step of retrieving medication. At the end of the week long improvement event (I will discuss these events in the next blog) the original 140 steps had been reduced to 70. In other words seventy steps of waste, from the customer’s perspective, had been removed. It is these steps then that make up what Toyota calls a value stream map. These maps originated at Toyota as a tool to help people see the flow of material and information as a product moves through a factory, a value stream map identifies every task required to make a product or deliver a service. In healthcare, these maps document and analyze every move made during a procedure, helping people pinpoint value and waste. They are created in two or three day sessions where front line workers and managers are taken off of their regular jobs to focus on the existing state of the care process,identify waste, and create a new future state value stream that becomes the new standard for delivering care.
A value stream map changes based on the changing understanding of the work.Typically, a new map is developed every few months as the team delivering care becomes more aware of waste and continually removes it. I have heard many staff and physicians say “we can’t believe our initial understanding of the future state was so flawed now that we have had a few months to really see the waste”..
Value stream mapping is one of the key components of the lean methodology of continuous improvement. Next week I will cover Kaizen and it’s role in the methodology.
For more reading on value stream mapping I recommend John Shook’s book “Learning to See”.
I have also included a value stream map in the link below – Value stream map1
In the end after the T.V. cameras had been turned off have we gotten any closer to real healthcare reform with President Obama’s health care summit?
Our politicians were cordial with each other and the Thursday summit was civil.But did it do anything to change fundamental flaws of the original discussions on health reform? The answer is a resounding no! Neither the democrats or the republicans are talking about the fundamental components that will improve our dysfunctional and under performing health care delivery system. As I have written and blogged for the last year the debate is fundamentally flawed and continues to be.
Unless we get serious about changing the way we deliver health care and the way we pay for care in this country, costs will only continue to escalate exponentially.
There was no serious talk about that on Thursday. At the end of the discussion incentives were brought up as a potential important concern but that was about it. No talk of re-designing care delivery, transparency of performance, or changing Medicare to reward health care value.
The following three fundamental principles are required for any health reform to be successful:
1. Mandate that each state establish consumer reports for health care cost and quality. It must report measures that are meaningful for patients such as medication errors and infection rates. Allow existing regional public reporting collaboratives to publicly report the data such as the Wisconsin Collaborative for Health Care Quality for this state.
2. Change government payment processes to reward better quality and lower cost. Medicare and any other public plans should be in the business of stimulating competition among providers to achieve what The Health Care Value Leaders Network members have achieved using the lean methodology. That competition needs to be based on who treats the patient condition best in terms of cost and quality.
3. Any new insurance plan should be paid for by taking cost out of the existing health system and it should be administered at the state level. The federal role is to assure all state residents are covered and quality performance is met but administration should be local like is already happening in so many states in the U.S.
These recommendations are based on years of experience working with many providers and insurance companies.
This is the 8th in a series of blogs devoted to organizational transformation. We have covered Purpose, Process and now are going to cover the hardest part, People.
In a system wide transformation the most challenging part is transforming the way people think. Coming from a top down autocratic environment (which is the current condition of most healthcare organizations) we are actually rewarded based how much “control” we have over decision-making. We ascend higher in the organization because we are able to get things done, our way as individuals not as a team. With more responsibility comes more resources, we can choose our projects our subordinates will work on (without their input) all along building our individual personal portfolio so that we are considered indispensable by the organization. In other words, we are rewarded for being heroes.
The traditional organization chart, showing who has authority over what activities, was once celebrated as a triumph of rational thought. But we now know that it has two major flaws: the rigid grouping of people vertically by function and the hierarchical top-down command structure. The problem with this structure is that it focuses vertically on the needs of the departments and their employees, instead of looking horizontally at the needs of the customer or patient. The challenge in a lean transformation is to focus on the patient when structure is designed as a series of silos. A patient wants a seamless care experience, with a team of knowledgeable people caring for him and treating his disease or injury from start to finish, instead of being handed off between caregivers in different – and sometimes rival — camps.
Using this logic, lean management emphasizes creating cross-functional teams that are gathered around a product – or, in the case of healthcare, around a patient’s condition or journey through the hospital or medical office. The patient becomes the organizing focus. When a company structure is viewed through the lens of this more collaborative, team-driven style, the hierarchy of the organizational chart – in which the boss bosses and everyone else obeys – suddenly appears unworkable. And yet, the vertical org chart is so embedded in the idea of how healthcare is conducted that it is very difficult to replace.
After all, think about those who are drawn to top management jobs. They tend to see themselves as born leaders with superior judgment and management skills. In healthcare, many of those leaders are also medical doctors, who have been trained to be firmly autocratic. Once all those leaders are clustered at the top in positions of authority, getting them off their hierarchy is a true challenge. What can we possibly do change this? Our experience suggests a few things are critically important.
Leaders must go to the gemba. The gemba is where the work is actually done. In other words where the value is created for the customer in this case the patient. By going there leaders begin to understand the barriers their staff face each day. We have an example of a leader going to the gemba on video at the end of this blog. You will notice that she is actually following a standard work sheet.
Leaders must follow standard work. The leaders need to establish what they actually do each day when they go to the gemba. What are they looking for? How do they make decisions? How do they prioritize resources? If these processes aren’t codified and followed by all leaders in an organization mixed messages are sent to the doctors and staff performing the actual value adding work which leads to distrust and cynicism.
Leaders must participate on teams. That means take a week off and do a kaizen event with front line staff or participate in a three-day value stream analysis. In order to begin to deeply understand the problems in the organization the leader must take the time to study the problems. This also sends a message that leadership is serious about lean and that it’s not just another management project of the month.
Leaders must learn the tools and philosophies of lean so they can mentor, facilitate and teach. They learn this by doing not by reading a book so getting the “hands dirty” on events and daily problem solving is the way to get educated.
Define the problem before jumping to solutions. We are rewarded in today’s environment in healthcare if we have all the answers. We rarely step back to really understand the problem. One of the most powerful processes a leader can learn is how to effectively identify the problem to be solved. The team members on the front line usually have the answers if the leader will let them speak.
These are a few of the traits of the lean leader. My next final blog on the subject of organizational transformation will be regarding the change of behaviors necessary for a new lean culture to take root.
This peer reviewed article was published by the Indiana University Business school in “Business Horizons”.
The article explores mistake proofing techniques in healthcare. We pay particular attention to the Collaborative Care Unit at ThedaCare where we describe both Jidoka and poka-yoke. Both concepts involve stopping the process.Jidoka involves stopping the line in order to solve problems. Poka-yoke stops the process in order to restore the process to it’s proper running parameters,or to remove the causes of defects.
John Grout gives us some fascinating real life examples of how health care organizations have implemented error proofing techniques. We hope this gives you some new ideas on improving safety at your institution.
The following article by the Toyota CEO Akio Toyoda outlines the renewed focus Toyota has on quality. It’s called “Back to Basics for Toyota” and was published in the Wall Street Journal opinion section today.
Toyota is testifying in front of congress today for quality missteps that have rarely happened before. The quality of their product has been second to none for decades and clearly is what differentiated them in the market place. Mr. Toyoda apologizes for these missteps and outlines what is in store for the future at Toyota.
This is a great example of how flawed strategy can lead to disastrous outcomes. Toyota still has the best quality improvement system in the world(The Toyota Production System). But when senior leaders at Toyota decided a few years ago to become the biggest car company in the world they abandoned their core principles according to Mr. Toyoda, “When my grandfather brought Toyota into the auto business in 1937, he created a set of principles that has always guided how we operate. We call it the Toyota Way, and its pillars are “respect for people” and “continuous improvement.” I believe in these core principles. And I am convinced that the only way for Toyota to emerge stronger from this experience is to adhere more closely to them.”
Because of the strength of the the Toyota culture and the Toyota Production System methodology the company will survive and prosper again but the lesson for the rest of us is that strategy not consistent with an organization’s core principles can have markedly negative consequences. The real question is what is the standard work necessary for leaders to avoid these types of culturally inconsistent decisions in the future?
The 4th entry in this blog series on whole system organizational transformation is under the rubric of Process and is the Methodology for continuous improvement.This is the Toyota Production System applied to healthcare.
The methodology of improvement could be a blog series in and of itself. The first of several upcoming blogs on methodology involves understanding Hoshin Kanri a core component of the Toyota Production System .
Hoshin Kanri . Developed in a few major Japanese companies during the quality movement of the 1950s, hoshin kanri is a discipline used to focus the work of senior executives. It was created by lean executives who saw many initially enthusiastic companies fail to become lean because, even when everyone’s eyes were opened to waste in the processes and the power of lean improvements, leaders would all rush off in different directions, pursuing different ideas of the most important problems to solve. The impact was often too diffuse to hit the bottom line and soon the lean initiative looked like nothing more than frantic action without direction.
At ThedaCare, we used hoshin kanri techniques – including a visual matrix diagram to identify key objectives and clearly deselect others — to focus our top leaders. Identifying key objectives came out of repeatedly asking the question, “What is most important?” Then leaders asked, “How do we measure that?”
We asked the questions repeatedly over six years, sometimes arriving at different answers and always striving to determine the most important needs of the entire organization. As we narrowed down the list of critical needs, we winnowed our major projects each year down to three or four initiatives that could be accomplished in a reasonable time frame and easily explained to the entire organization.
Although we started our Hoshin Kanri learning with the visual matrix we changed after we realized that the matrix was not allowing us to have the dialog necessary to deeply understand and solve problems. We converted to an A3 process for strategy deployment in the hopes that we would become more strategic in our thinking and less focused on the specific numeric results which were very important but crowded out any other discussion. The A3 process is based on the scientific method of proposing, implementing and studying changes in a process. This method has been referred to as PDSA (or PDCA), Plan-Do-Study (or Check)-Act. Some have referred to this as the Deming cycle after W. Edwards Deming, although he credits Walter Shewart with its development. Deming introduced the method to the Japanese in the 1950s. This powerful method is the foundation of A3 thinking and was widely adopted within Toyota.
The PDSA cycle has four stages:
Plan – Determine the problems with current conditions, goals, and the needed changes. This is the hypothesis.
Do – Try out the changes. In other words, experiment or trial.
Study – Analyze the results of the experiments and reflect on the learnings.
Act – Incorporate the new learning or knowledge into the new process and work to standardize the change.
The A3 method assures that the PDSA cycle is followed and the changes are monitored. The process steps can be documented in a variety of formats, but it typically includes the following elements, on a single piece of paper. A3 refers to the standardized paper size of 11” x 17”.
Title – Names the problem, issue, or topic
Owner/Date – Identifies who owns the problem or issue and the date of the latest revision
Background – Why is this important? What background information is important? What have we seen in gemba?
Current Conditions – Show the current state using pictures, graphs, data, etc. What is the problem?
Goals/Targets – What results do you expect? What are the key measures? (quality, cost, morale, delivery, access, etc.)
Analysis – What is the root cause(s) of the problem? If you work to eliminate this root cause, will you make progress toward solving the problem?
Countermeasures – What proposed actions do you intend to take to reach the target condition? How will you show how your countermeasure will address the root causes of the problem? What is the new standard process?
Implementation – What needs to be done? Who will do it? By when? What are the performance indicators to show progress? How will people be trained in the new process?
Follow Up – What issues can be anticipated? How will you capture and share learning? How will you continuously improve or begin the cycle again (PDSA)?
Wide adoption of A3 thinking through all levels of the organization will create a community of problems solvers. People will begin to think of every activity as a potential learning activity, rooted in everyday work.
Using the A3 tool to cascade key strategies and metrics from the CEO level to front line worker is the end game. Along the way, much dialog occurs which inevitably changes the A3 so that a system A3 for a key initiative may look different after it has been reviewed and talked about at every level of the organization. In this way each business unit of the organization can make the system A3 meaningful to their area. For example, a quality target of reducing falls by 50% might be appropriate for a hospital or a nursing home but inappropriate for an ambulatory clinic.But a system quality target of reducing medication errors by 50% could easily be applied in both settings.
In this way, through trial and error and long discussions ThedaCare’s leaders struggled to find true north metrics – the few, critical metrics to steadily guide everyone in the organization toward the same purpose and ideal. With the A3 process which is iterative, true north metrics were developed and changed based on the changing environment. Instead of waiting until the next year to develop the strategic plan, strategy changed real time based on these regular discussions with the A3. Leaders rethink metrics all the time, and nobody really believes the true north metrics will remain fixed forever. As the environment changes, what we measure needs to adjust. It is a dynamic world and, as Wayne Gretzky said, you have to skate where the puck is going to be, not where it’s been.
I would recommend reading John Shook’s book Managing to Learn published by LEI press if you want to learn more about the A3 process.
Last week I discussed the importance of purpose and making organizational purpose perfectly clear to everyone. This week I will cover one of three topics under the rubric of Process:True North Metrics.
Purpose, process, people.
Once purpose is clearly defined we need a process to actually achieve it. Part of that process is knowing how to measure success. Determining how to measure success is one of the most difficult problems on the lean journey. I struggled with my team over the years in defining metrics. I think this was hard because there were so many possibilities and so many perspectives. This struggle is what creates deep understanding though, and ultimately thats what true north metrics should reflect, the core of what the organization is in business to do.
When we first started on this journey our consultants initially challenged us to get our core measurements to the two or three things that really mattered. We argued about this for three days. How could we possibly distill the complexity of the business to only three things? We were quite proud of our first attempt. We decided there were three things that were really important on our journey to transform ourselves. The three things were meeting budget, achieving 95% performance in the country on all quality indicators and having all our staff members on Kaizen events (Kaizen is defined at ThedaCare as 5-day activities during which staff are taken off of their daily work to study their work and make suggestions as to how to improve and then these improvements are rapidly implemented over the next week).
As the years went by and we better understood our business we were subsequently embarrassed by our first attempt at True North. Meeting budget for example, had nothing to do with year-over-year improvement because the budget was re-set every year with higher expense levels than the year before. 95% performance on quality indicators left our patients still receiving many defects as the entire industry was poorly performing on medication errors, infection rates, and other defects. Having people on improvement events was a good idea but were we instilling the culture of continuous improvement by only doing events?
Thinking more deeply about this and using a standardized problem solving tool called an A3 (see attachment below for a description of the A3) we realized some important lessons. The key driver to our financial well being was labor. 60% of our expenses were in labor. Shouldn’t we focus our activity on this? We had established a no lay-off philosophy years before to help differentiate us in the market place for health care workers so how could we reduce labor costs without jeopardizing this core value? As we learned more about the methodology of continuous improvement called lean, we understood that taking waste out of the work process could make workers do more value-added work and improve the productivity of each staff member. We could improve productivity and simply not hire new people. The turnover rate in the first few years of the journey was over 10% so that was our opportunity. We also knew that each 1% of productivity improvement led to millions of dollars of operating income improvement. We now had the true north metric for organizational financial performance. Productivity, defined as gross revenue/FTE with price increases removed year over year is still the key financial indicator at ThedaCare.
The same deep understanding that led us to the productivity measure being true north can also be applied to quality performance. 95% of performance in the country still left us with many quality defects.The danger with comparative performance measures is that they can create a false sense of well being.95% may mean compliance 85% of the time with a quality measure. 85% compliance is 150,000 defects per million, certainly not what would be considered good quality. A simpler example is mortality rates in surgery. A 3% mortality rate in heart surgery means nine patients die each year if there are 300 surgeries. 3% seems reasonable but nine people dying doesn’t. As we considered this we came to the conclusion that it was the absolute number of defects that were important. The nine people, not the 3%. We moved from 95% to 50% reduction in defects as true north. That would take us from nine deaths to four or five the next year and so on. ThedaCare’s heart surgery team had one death in 2009 while doing 350 cases, still too many but by reducing defect rates 50% year over year they have moved very close to zero.
Finally, the third metric regarding staff engagement was initially flawed as well. We wanted staff to have hands on experience doing kaizen as that was important for them to learn the continuous improvement principles but number of employees in Kaizen was not the best way to measure engagement. As we visited other lean companies and began to deeply understand what impacted staff morale the most it became clear that engaging staff in problem solving and implementing their ideas for improvement was the true north for engagement. Toyota workers implement 69 ideas each every year.
I hope these these examples have been helpful to show how continued dialog and deepening understanding over time lead to the best true north metrics. This is dynamic, the metrics will continue to change as the organization changes, the market changes and the people change. Please click here to read more about A3s – A3 Summary5
Next week we will tackle transparency, the second core topic under the rubric of Process.
I just returned from a two week visit to many cities in China. The visit confirms that the U.S.has a new and powerful competitor that has 1.3 billion people focused on economic success.
Reading about China and imagining isn’t enough. You must go and see.China is a series of contrasts but one thing is certain, it has been ,it is, and it will be a major shaper of how the economy of the world evolves over the next generation and beyond.
I had the good fortune of visiting China for two weeks during the Chinese lunar new year holiday in 2010. My wife and I visited my son who is volunteering in the Hunan province as an English teacher. Hunan is one of the central states in China near where the ancient philosopher Confucius in 550 B.C. taught the core philosophical principle of “do not impose on others what you do not desire” which has been passed down as part of Chinese values for centuries.
We had the opportunity to visit the “real” China. Many foreigners have visited Appleton and ThedaCare over the years and I tell them the real U.S. is not in New York and Los Angelo’s but in places such as Appleton and Elkhart and Cedar Rapids. Taking the pulse of a country requires going to the gemba and seeing where the real work is done.
In Zhuzhou, and Changsha and Yongzhou we visited the Chinese people and we saw their life. It is changing rapidly. Cranes towering over freshly constructed buildings for as far as the eye can see. New roads, sparkling airports,and 5 star hotels. But the middle class is emerging too. A small family business every 10 feet of store front space in two and three story buildings housing the families of the business owners in the upstairs apartments. In the poorer areas four or five people sleeping in a loft above their business each night.But no matter whether they are selling one dollar scarves or three hindered dollar refrigerators they work. They work really hard,every day,14-16 hours a day.They work so their children,all 400 million of them can go to more competitive schools realizing that the competition for college is fierce and that the only way for a better life is to get a college education.Education is a highly valued commodity by this people.
China is clearly coming of age. The financial center of China is Shanghai and it is like no city in the U.S. it is better.Better mass transit,better architecture, better infrastructure,and a thriving business environment. I had the chance to meet a project manager from a Chinese engineering firm. His firm is regularly beating out the likes of GE and other American companies because they deliver a quality product at a better price. This publicly traded engineering firm in Shanghai has seven major power plant projects going on in the middle east and India. They competed for all these jobs with American companies and won. The major reason? Price! This company has many power plant projects to show for it’s work.All these plants work very effectively so why should the Indians or others pay more? The point? America is pricing itself out of the world market.
In Zhuzhou we ate a fabulous dinner including 5 separate terrific Hunan dishes and drinks for twelve dollars. In Shanghai the project manager from the engineering firm doing work in the middle east sees his private physician for 10 juan or about a dollar and a half per visit. When people get sick they arrive at the emergency room and are seen with short waits(two hours would be unusual). Contrast this to a Chinese friend who described her experience in a Los Angeles hospital E.R. while visiting her sister; hours of waiting and many thousands of dollars later no accurate diagnosis was made.Maybe the quality of Chinese medicine isn’t very good. We don’t know, but we do know what our system delivers, about 100000 deaths per year due to medical mistakes.
My experience in China re-confirms that as healthcare leaders we must redesign American healthcare now. The cost of our healthcare is contributing to our lack of competitiveness in this new world order where price and quality really matter and where companies like the Shanghai engineering firm can provide a quality power plant at a price we can’t match. Wait until they embrace lean!.
