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Quality management in a lean health care environment
First Edition Collins Digital Instant Download
Author(s): Collins, Daniel.; Mannon, Melissa
ISBN(s): 9781606499795, 1606499793
Edition: First edition
File Details: PDF, 11.05 MB
Year: 2015
Language: english
THE BUSINESS Quality Management in a Lean Healthcare Management Collection

COLLINS • MANNON
EXPERT PRESS Health Care Environment David Dilts and Lawrence Fredendall
DIGITAL LIBRARIES
Daniel Collins • Melissa Mannon Editors
EBOOKS FOR Quality in a lean health care setting has one ­ultimate
BUSINESS STUDENTS goal-to improve care delivery and value for the p
­ atient.
Curriculum-oriented, born-
The purpose of this book is to provide a blueprint
digital books for advanced

Quality
business students, written to hospitals, healthcare organizations, leaders, and
by academic thought ­patient-facing workers with tools, training, and ideas
leaders who translate real- to address quality within their organization. ­Examples

Management in a
world business experience from health care an other industries are provider to
into course readings and ­illustrate lean methodology and learn their application
reference materials for in quality. The reader can learn how other organizations

Lean Health Care

QUALITY MANAGEMENT IN A LEAN HEALTH CARE ENVIRONMENT

students expecting to tackle
improve quality, what their roles are, and what they
management and leadership
challenges during their do daily. By the end of the book, you will have learned
­actionable concepts and have the tools and ­resources to

Environment
professional careers.
start improving quality.
POLICIES BUILT
BY LIBRARIANS Daniel Collins earned his MBOE from The Ohio State
• Unlimited simultaneous University-The Fisher College of Business and his
usage BSN from The University of Wisconsin Green Bay. Dan
• Unrestricted downloading
is c
­urrently the directory of quality for ­
ThedaCare
and printing
• Perpetual access for a in ­
Appleton, WI. Dan has been with ThedaCare for
one-time fee 16 years working and leading lean improvement in the
• No platform or ­emergency services, intensive care, ­cardiovascular, and
maintenance fees ambulatory services. Dan is passionate about ­improving
• Free MARC records both the care that is delivered and the experience for
• No license to execute
the patient in that delivery.
The Digital Libraries are a
comprehensive, cost-effective Melissa Mannon is a research assistant at the ­American Daniel Collins
way to deliver practical Institutes for Research in Health and ­Social Develop-
treatments of important
business issues to every
ment division within the Health Policy and ­Research Melissa Mannon
­division. Her concentration at AIR is in ­Delivery S
­ ystems
student and faculty member. ­Improvement and Quality ­Performance Measurement.
She studied lean in healthcare at the ThedaCare Center
for Healthcare Value and studies public policy at George
For further information, a Washington University.
free trial, or to order, contact:
[email protected]
Healthcare Management Collection
www.businessexpertpress.com/librarians
David Dilts and Lawrence Fredendall, Editors

ISBN: 978-1-60649-978-8
Quality Management
in a Lean Health Care
Environment
Quality Management
in a Lean Health Care
Environment

Daniel Collins and Melissa Mannon

Quality Management in a Lean Health Care Environment

Copyright © Business Expert Press, LLC, 2015.

All rights reserved. No part of this publication may be reproduced,

stored in a retrieval system, or transmitted in any form or by any
means—electronic, mechanical, photocopy, recording, or any other
except for brief quotations, not to exceed 400 words, without the prior
permission of the publisher.

First published in 2015 by

Business Expert Press, LLC
222 East 46th Street, New York, NY 10017
www.businessexpertpress.com

ISBN-13: 978-1-60649-978-8 (paperback)

ISBN-13: 978-1-60649-979-5 (e-book)

Business Expert Press Health Care Management Collection

Collection ISSN: 2333-8601 (print)

Collection ISSN: 2333-861X (electronic)

Cover and interior design by Exeter Premedia Services Private Ltd.,

Chennai, India

First edition: 2015

10 9 8 7 6 5 4 3 2 1

Printed in the United States of America.

 Abstract
Quality in a lean health care setting has one ultimate goal—to improve
care delivery and value for the patient. The purpose of this book is to
provide a blueprint to hospitals, healthcare organizations, leaders, and
patient-facing workers with tools, training, and ideas to address quality
within their organization. Examples from health care and other industries
are provided to illustrate lean methodology, and its application in quality.
The reader will learn how other organizations can improve their quality,
know what their roles are, and know what they do daily. By the end of the
book, you will have learned actionable concepts and have the tools and
resources to start improving quality.

Keywords
lean, lean health care, quality improvement, quality management
 Contents
Acknowledgments�����������������������������������������������������������������������������������ix
Introduction...........................................................................................xi

Chapter 1 Foundation: Quality at the Source Gemba.........................1

Chapter 2 Pillars: Coaching, Improvement Process, and
Data Measurement..........................................................41
Chapter 3 Roof: True North, Sustainment Culture...........................77
Chapter 4 Conclusion......................................................................87

Appendix 1 RCA Standard Work.........................................................89

Appendix 2 Huddle Board Standard Work............................................99
Appendix 3 PICK Chart Standard Work............................................101
Notes..................................................................................................105
References............................................................................................107
Index..................................................................................................109
 Acknowledgments
The authors would like to thank the following colleagues who ­generously
donated their time to help edit and provide guidance for this book: Wendy
Blezek-Fleming, Shana Herzfeldt, Michael Radtke, Katie ­ Roseman,
John Toussaint, and Kimberly Wildes.
 Introduction
Quality is a singular word that means many things to many people. In this
book, quality will encompass all components of the patient experience,
which includes but is not limited to the registration, building cleanli-
ness, wait time, food, health outcome, communication, and care delivery.
Additionally, the book will provide background knowledge on lean—a
problem solving methodology—and tools, other helpful resources with
real examples of how these tools and methodologies are employed in
a quality department and integrated across an enterprise. Ultimately,
­quality cannot be done in a vacuum. That means that each category, unit,
department, and segment of the process flow cannot be divorced from
one another. This book will walk through the foundational components
of lean and how quality management, tools, methodologies, and people
fit together in health care quality.
Quality in health care can be defined by many entities—the health
care system, the payers, or the patients. In 1999, the Institute of Medicine
released a report that indicated nearly 98,000 people died of ­preventable
medical errors each year; these deaths are preventable and speak to larger
quality issues that exist in health care.1 A more recent assessment in the
Journal of Patient Safety suggests that the number of people who die
from preventable errors could be 4.5 times higher based on analysis of
other reports of medical errors and an examination of medical records
for indications of adverse events.2 In other industries, the quality of a
product is determined by the customer; customers then choose whether
or not to like or dislike an item, recommend it to friends, write an online
review, and so on. In this book, quality is also defined from the cus-
tomer’s ­perspective. The patient is the person that ultimately should be
happy with the health care they received. The patient wants to know
they received the health care they needed and wanted, and that they did
not overpay or get unnecessary tests or acquire additional illnesses. From
a provider or health care system perspective, this means that quality is
defined by providing the best-known current practices of care, promptly,
xii QUALITY MANAGEMENT IN A LEAN HEALTH CARE ENVIRONMENT

and without error. Ultimately, what the customer is concerned with is

the quality of care they receive divided by the cost they incur—otherwise
known as the value. The equation determines value as perceived by the
patient. It shows whether a patient paid for a Chevy and got a Cadillac,
or if they paid for a Cadillac and got a Chevy. In the end, whether the
consumer is shopping for a car or health care, they expect to get the best
for the least amount of money. In order to provide the value that patients
want, need, and desire, the quality component of the equation must be
a critical focus.
Quality has to be inclusive of every part of the process which con-
tacts the patient, because all of those instances are places where quality
can be improved. Health care is different from other industries, like the
manufacturing industry. Car manufacturers have to be concerned about
the quality of part production, assembly, and safety so that the consumer
is pleased and feels like they got a good value for their dollar. In health
care, the patient is the item that receives services, but the patient is also
the consumer that pays for the services. The patient plays dual roles, and
in health care, the services can literally be the difference between life and
death. This is not to dehumanize patients into products moving through
an assembly line; this distinction is made to show how important and
unique the patient’s perspective is in health care and why, when talking
about quality, the patient should be the focus.
Items as simple as the cleanliness of hallways, corridors, stairwells, and
patient rooms do impact the perception of quality and patient satisfaction,
and could impact health outcomes if the lack of cleanliness is extreme.
Every patient comes with different expectations for their care, clinicians,
facility, and more. For as many patients that come for treatment, there is
the same number of differing perceptions of quality. From the health care
clinical side of the continuum, a lack of cleanliness could cause injury
due to falls, contamination of samples, or the spread of infections. When
you view cleanliness from the patient’s perspective, it adds another layer
to the quality picture. If there is dust accumulated on the baseboards or
full trash cans in the waiting rooms, how can the patient trust that you are
getting the important things like completing the correct procedure, infec-
tion prevention, and providing the right medications at the right dosage?
They cannot and that will cause anxiousness and dissatisfaction. The first
 Introduction xiii

thing we all do as patients when we are sitting in an exam room is to start

looking around the room. We quickly notice if there are cobwebs in the
corners or on the windowsills, or we see that something was spilled on the
baseboard and not cleaned off, or that the trash is overflowing. To really
champion health care quality you have to look at all aspects and causes
of satisfaction and dissatisfaction. To really provide value to the patient,
you have to be concerned with providing the highest quality possible at
the lowest cost.
You will not see a chapter or a subsection that only discusses lean
leadership. Lean leadership is about being involved, engaged, and visible
within your organization. To describe lean leadership without the contex-
tual background to understand their role and interactions with employees
would be a disservice; a valuable resource to consult on this topic is David
Mann’s book Creating a Lean Culture. Leadership is the glue, nail, screw,
or nut and bolt that holds the house of lean together. It is not one singular
part of the structure; it is spread all through the large pieces and holds
them together. This is a hard concept. In the early years of ThedaCare,
leadership and the role they should play was a struggle. There was great
work happening across the organization, but the teams lacked vision and
did not know how to align their local improvements with the organiza-
tional vision. Kim Barnas, former senior vice president at ThedaCare, and
a small team created a plan to close this gap by developing a management
system to learn skills, and how to develop a plan to train and educate
other leaders. A management system is very important for the success of
lean and quality endeavors, but the detail and depth it deserves surpasses
this book. Much of what accompanies lean leadership is how leadership
interacts, is involved, and coaches employees on a daily basis.
Lean leadership is about doing things differently. John Toussaint,
MD, says in his book, On the Mend, that leaders who think they know
all of the answers, or are most comfortable leading from behind a desk,
struggle with emotional capacity; this is not the right work for you.3
Lean leaders are involved and engaged with their employees, floors, and
units. Lean leaders go, see, and support their employees’ needs, and they
facilitate problem solving rather than running to the problem with a list
of solutions for others to do. With a lean organization, you really have
to flip the pyramid, where the executives are on the bottom and your
xiv QUALITY MANAGEMENT IN A LEAN HEALTH CARE ENVIRONMENT

Patients, customers, and community

Caregivers, employees, and volunteers

Provider
Physician
Medical centers Systems of care strategies and
services
systems of care

Employer and
HR and talent Improvement Strategy and
payer
development system marketing
strategies

President and
CEO

Figure I.1 An inverted organizational chart that has patients,

customers, and the community at the top with the CEO and President
at the bottom, demonstrating the ideological shift from a top-down
approach to leadership

patient-facing workers at the top (Figure I.1). That way of thinking really
changes how leadership functions within the organization.
The scope of this book is narrowed to quality management, but the
quality department is a resource for every department in a health care
system. We will discuss the essential components of quality management,
which will include examples from other departments. Lean—includ-
ing lean leadership—and quality have a symbiotic relationship that is
­essential for improvement and sustainment; quality work is focused on
improving the current process to deliver the highest standard of care, and
lean methodologies develop an environment that can sustain improve-
ments. For the symbiosis to occur, organizations must understand how to
build that environment. A house is not built from the roof to the foun-
dation, and neither is a lean environment. The house of lean in Figure I.2
shows how you start from the foundation with standardized work and
other processes that will be discussed in depth later in the book, then you
build the walls with coaching and improvement processes, and, finally,
you build the roof, which is what and who your organization is. The roof
is called True North because, like True North on a compass, this should
be the guiding force for the organization. The left pillar supports True
 Introduction xv

Who and what you are

True North

Development of people
Improvement process
Kaizen
RCA Coaching
CDI

Management system

Standardized work
5S, kanban, culture
Foundational

Figure I.2 The house of lean that shows the foundation of

standardized work and culture with improvement events and coaching
as the walls and True North as the roof

North through improvement processes; these processes can be kaizen,

which is daily improvement work; a root cause analysis (RCA), which
is really a tool to help a team determine the true cause of a problem; or
continuous daily improvement (CDI), which is striving for an improve-
ment each and every day to the work flow. The second pillar that supports
True North is about developing people through coaching and mentoring.
All of these tools, processes, and methodologies are supported by the
foundation, which is composed of standardized work. This has to be at
the base because you cannot improve processes without first having a
baseline or standard for employees to work from. Standardized work is
supported by activities such as the 5S is a process that helps create orga-
nization and structure in the work environment to improve productiv-
ity in the work place. ­Standardized work is also supported ­kanban—an
­organizational and inventory system that promotes efficiency by stan-
dardizing stocking, ordering, and reducing waste—and culture. Now,
culture is included because people have to feel comfortable, safe, and
supported in identifying errors. Activities such as gemba, which is the
process of observing standards, can help support an open and transparent
culture of problem solvers. This book does not give an exhaustive list
of the tools and methodologies that compose the ideas of the house of
lean, but serve as examples of the activities that support improvement
processes or standardized work. The items and activities outlined in this
book are those that directly support quality; however, there are many
more tools used in lean.
 CHAPTER 1

Foundation: Quality at the

Source Gemba
The imagery of a foundation is usually built from a strong sturdy mate-
rial such as concrete, cinder blocks, or brick and mortar. These things
are there to provide a solid, supported structure that is intended to be
supportive for life. During the lifetime, the structure could have many
environmental influences that could compromise, degrade, and erode the
foundation. Poor drainage can erode a house’s foundation, a shift in the
soil could cause the foundation to crack, or a storm could bring destruc-
tive damage. These environmental influences mean that the foundation
has to be firmly built to withstand the challenges that could lie ahead, but
there must also be diligent and responsible people who are there to mend
the damage—to reinforce the once strong structure. All structures need
maintenance, whether it is a physical building with a concrete foundation
or a health care organization.
ThedaCare is an integrated health care delivery system in Wisconsin,
with 5 hospitals and 27 physician clinics. ThedaCare has been on their
lean journey for more than a decade, and former CEO, John Toussaint,
founded the nonprofit organization—ThedaCare Center for Health-
care Value—to educate and spread lean through collaborative learning
with other health care organizations. The hospital uses a collaborative
care model developed through lean transformation and improvement,
and they are also a pioneer accountable care organization (ACO). ACOs
are a federal pilot program that reimburses based on quality and care
management rather than fee-for-service (paying for everything done
­
­similar to how we pay for items in a grocery store).
ThedaCare has built a strong and solid foundation, but the organiza-
tion must be careful as environmental factors like policy and technology
2 QUALITY MANAGEMENT IN A LEAN HEALTH CARE ENVIRONMENT

changes, outdated facilities, employee turnover, and market competitions

are all factors that could erode the organization’s foundation, as well as the
cultural, managerial, and organizational foundations that are needed to
support the changes that have occurred and are yet to come. For this rea-
son, foundational components like 5S, kanban, standardized work, and a
culture of problem solving will be detailed in this chapter to help explain
the necessary components of a strong foundation.
Gemba is defined simply as where the work is done. Lean terms are
Japanese terms because lean is based on the Toyota Production System
(TPS). Toyota developed this model of problem solving through empow-
ering employees and by focusing on quality, the customer, and the respect
for people. The term lean was coined by Dr. Jim Womack in the 1980s
after studying Toyota’s model of management and quality while at MIT.1
This means that the gemba can be anywhere—the patient room, the sup-
ply room, the waiting room, and the pharmacy. The phrase going to the
gemba just means to go and observe where the work is done. The purpose
of gemba is not only to see but also to ask questions and learn what is
done, how it is done, why it is done, and to identify waste. This chapter is
intended to provide tools, training, and guidelines to help leaders under-
stand what happens in gemba, what to do in gemba, and how to get a
leader to go to gemba, so they can see the impact on quality at the source.
For example, at ThedaCare there were complaints that the stairwells
were not being cleaned as often as they needed and that the doors were
slamming and disturbing patients and employees. Leaders and employees
observed the use of the stairwells to understand the current state and
­document their observations. They watched to see how often they were
used, how dirty they were, if anybody came to clean the stairwell, how
loud the doors were, and so on. After observing people’s daily interactions
with the issue, they would look for the root cause. Asking why does this:
Why aren’t the stairwells as clean as we would like them? Why is trash or
dust accumulating? Why are the doors slamming? They would also ask,
why is a very common tool used for uncovering root cause; this tool is
usually referred to as the 5 whys. It is important to ask more than just
why; you must delve into the issue.
Anyone, and that means anyone, can go to gemba and observe.
In fact, fresh eyes can be helpful to see issues, or concerns, from a different
 Foundation: Quality at the Source Gemba 3

perspective, which can be very valuable. The role of the leader during
gemba is to ask thought-provoking questions of the workers to probe
them and further develop their problem-solving skills. Leaders should not
point out errors or defects and immediately tell them what they think the
solution is. It is not the role of leadership in gemba to point out defects
or waste or to give solutions for current problems. Leaders should just
observe and ask questions that spur thought around potential improve-
ment areas, and the questions should guide employees to develop their
own solutions.

Checklists
Standardized work and process improvement are fantastic ways to
improve items or tasks that are completed routinely, and they help pro-
mote standardized practice across the organization. Checklists are uti-
lized as a complementary tool to standardized work, because they walk
employees through the steps of a process. There are many tools people
and organizations can use to search for root causes, improve work flow,
and sustain improvement. All of those tools are not directly listed in the
house of lean. Checklists are a great tool for the foundation: standardized
work. Checklists are not intended to be for every single task, and should
not include every step of a process. This could quickly create a 10-, 15-,
or 20-page checklist, which would be ignored and would not benefit care
quality. When you give directions to someone driving a car from point A
to point B, you do not include steps such as get into your car, close the
door, put the keys in the ignition, and so on. The same is true for check-
lists. Every miniscule step wastes time, because employees do not need to
be reminded how to do things that they do daily, and it runs the risk of
negatively impacting quality because employees may disregard the check-
lists due to the length—not to mention the morale impacts of walking
employees through what to do daily.
Checklists are best used as a reminder that supports best practice.
Labor hours are used to develop standardized work, and it must be eval-
uated and updated. Frequently missed items or items that are not rou-
tine are included in checklists to remind employees of the important
steps that need to be completed. To extend the car example, the nurses,
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THE BIG SINDY VALLEY. +li^topy oF tlie people §^nd

Qounti^y I PROM THE EARLIEST SETTIJ-MENT TO THE PRESENT
TIME. By WILLIAM ELY. llla^hpabesl' CENTRAL METHODIST,
CATLETTSBURG, KY. 188T.
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 F^RKKACE. Almost all writers of history dwell on the
actions of men in their collective capacity. They describe the political
and other machines set up by nations, states, or counties. The
author ignores that method in his book, and chooses to follow
families and single individuals from their entrance into the Sandy
Valley to ' the end of their career, and tell what they have added to
the history of the country. The annals of almost every family noticed
in this book have been furnished to us by a member of the family
whose deeds we chronicle. We have guessed at nothing; and where
necessary to give dates, have freely done so. We trust our book Avill
be a valuable addition to the many books and periodicals treating on
East Kentucky aifairs, and that the people will appreciate our eiforts
to keep green in the memory of the rising generation the
 4 PREFACE. great deprivations which their ancestry were
compelled to undergo in order to rescue the Valley from the clutches
of wild men and ferocious animals, and make it the abode of peace
and plenty. THE AUTHOR. Catlettsburg, Ky.
 / INTRODUCTION. I HAVE written the history of the Big
Sandy Valley and its people with a view of being useful in my day
and generation, by rescuing from oblivion many incidents of great
moment, which, unless gathered up in book form, w^ould be
forgotten in this now fast, feverish age. The history of a people is to
tell who they are, from whence they came, and their characteristics,
public acts and tendencies. The land wearing out in the old Colonial
States, the people there began to look about for better land and
cheaper livings. Kentucky, once a county of Virginia, was the nearest
territory of unoccupied land to move to from Virginia, part of
Pennsylvania, Maryland, and the WM. ELY, Author of this Book.
 6 INTRODUCTION. Carolinas. As early as 1789 the
emigrants began to come to Sandy, and settle in the valley from
those States. They knew that mountains and hills an'd streams
would impede their progress ; it dismayed them not, for most of
them had, from near or far, looked upon the craggy peaks of the
Alleghany, Blue Ridge, or Cumberland Mountains. On the point of
land where the Sandy and Tug form a junction was the first
settlement attempted, in 1789. Soon after, near the mouth of
Pigeon, was the next; next at Pond Creek, on the Tug. All the
inhabitants from these places were driven away by the Indians. Not
until 1790 was it safe to stir up the redskins. Block-houses were built
by the Damrons, and others, near Pikeville ; by others near Prater
Creek. The Aucstiers, or Auxiers, as now Avritten, had built two,
near the mouth of John's Creek. Over at Licking Station, now
Salyersville, was a large fortification. At other places on the waters
of the Sandy, similar forts had been erected to protect the early
settlers from the tomahawk of the Indians. Our old pioneer
ancestors were so well skilled in the use of the rifle, and were so
brave, as to make it very hot for any red man to show himself in the
valley. The Indians ceased troubling our forefathers and mothers in
1790, while they were murdering the whites, and stealing horses in
the Scioto Valley as late as 1802. Yet game was much more
abundant in the Big Sandy Valley than in the Scioto. It failed,
however, to
 INTRODUCTION. 7 tempt them over. By 1806 many of the
old families, whose descendants are now our foremost people, had
taken up their abode in the valley. As the reader progresses along in
this volume, the doings of those pioneers will be chronicled. The
majority of the early settlers belonged to the best families of the
older States. They, it is true, brought their household goods on the
backs of horses, for no roads had been opened up. Many families
brought with them their slaves, and for many years after the
settlement of the country more slaves in proportion to the
population were found on Sandy than in the Blue Grass region. They
soon had pay-schools established in every neighborhood, to teach
the young. Churches they did not have, nor did they need them ; for
on large occasions they used the shady dells to worship God in,
according to the sentiment of one of America's great poets, that the
woods were '' God's first temples.'' They did not forget to honor the
great Creator, however, in neglecting to build churches, for every
householder saw to it that one room in his great log mansion was
dedicated to the worship of God. And not only did they open their
houses to the preaching of the Word, but one family would often
support a big meeting of a week's duration, sleeping and feeding all
who came to worship. This primitive custom has not died out yet.
Especially does it still prevail among the primitive Baptists in the Tug
 8 INTRODUCTION. Valley, where churclies are few. The
early pioneers ground their corn on hand-mills, or beat the grains to
meal in a mortar. They used bear's-oil in place of lard to shorten
their johnny cakes. It was many years before they had much hog-
meat or beef; but bear, deer, turkeys, and other game and fowls
were abundant, which more than supplied them with meat. Honey
was almost as plentiful as sorghum is to-day ; and every Spring they
made of maplesugar and treacle enough to run them through the
season. In a word, they lived at the fountainhead. The skins of the
bear, the deer, buifalo, and other fur-bearing animals, aiforded a
revenue of wonderful proportions, and when the reader takes into
account the vast sum added by the countless wolf-scalps at five
dollars apiece, and the ginseng crop, he feels that his ancestors
were engaged in a more lucrative business than saw-logging. As to
clothes, the thrifty housewife worked up the flax and cotton raised
by the men, and prepared it for clothing for the family, and coverings
for the beds, as well as table-cloths and towels. Even handkerchiefs
were woven from the flax, and served on many occasions as
wedding-gear. Many of the men could sport breeches made of
dressed deer-skins, and shoes made of the same material were
found on the feet of both sexes. When the wolves became less
troublesome, sheep were raised, and supplied the people with
another article of clothing, both for man and woman. Every house
had a spinning 
 INTRODUCTION. 9 wheel, a reel, and a loom, and the
wholesome damsels of that day knew well how to use them ; while
the mother spun the flax and wool into thread, the old grandmother
knitting the hosiery for the family, and the little girls filling the quills.
Those were busy days. No idlers then. The amusements of the
people were adequate to their wants. House-raisings, log-rollings,
corn-huskings, were engaged in by the men ; wool-pickings
quiltings, and flax-puUings by the women ; the latter participated in
by the beaus and lasses. Many of those gatherings wound up at
night with a play, and sometimes with a big dance. The morals of
the people were good. The men were brave, and the women
virtuous. That handy little imp, the modern pistol, was almost
unknown then. When men fell out, they generally very coolly fought
it out with their fists, and ended the matter by shaking hands all
round. No feuds then. Of course many drinkers to excess were found
in that day, for men everywhere partook of the fiery beverage. But
intoxication did not prevail as alarmingly as it has since the apple
has become so large a factor in potent drinks on Sandy. We should
say, however, that a great reformation has been going on for twenty
years, and the sale of liquor is, in the Kentucky counties, outlawed
by the people. Christian progress and esthetic taste bid fair to raise
the people of the valley to a higher plane than
The text on this page is estimated to be only 22.83%
accurate

10 INTRODUCTION. is attained in any other part of the

State. The somewhat isolated location has kept the valley exempt
from the grosser vices of the age. It is a good place to move to.
 The Big Sandy Valley. FIRST SETTLEMENT ON SANDY. The
following certificate so kindly put into the author's hands by Mr.
Richard F. Vinson and Dr. Milton Burns, would at first thought seem
to leave no doubt that the neck of land lying between the Levisa
Fork and Tug, in sight of where Louisa now stands, was the first
place where a permanent settlement in the Sandy Valley was
attempted to be made. The very same year, 1789, the Leslies
attempted to make a settlement at the mouth of Pond Creek, on the
Tug River. They, likeVancoover and others at the Forks, were driven
back by the Indians, who were at the time prowling around in the
valley. The Leslies returned in 1791, but instead of stopping at Pond,
they went on to John's Creek, and formed what to this day is known
as the Leslie Settlement. The Leslies must have been the earliest
permanent settlers in the Sandy Valley, yet immediately after their
coming, the Damrons, the Auxiers, the Browns, of Johnson ; the
Marcums, on Mill Creek ; the Hammonds, the Weddingtons, the
Pinsons, Justices, Walkers, Morgans, Grahams, 11
 12 THE BIG SANDY VALLEY. Williamsons, Marrs, Mayos,
Lackeys, Hagers, Laynes, Borders, Prestons, and others, followed
closely on their trail. AFFIDAVIT OF JOHN HANKS. I WAS employed
by Charles Vancoover in the month of February, 1789, along with
several other men, to go to the forks of Big Sandy River, for the
purpose of settling, clearing, and improving the Vancoover tract,
situated on the point formed by the junction of the Tug and Levisa
Forks, and near where the town of Louisa now stands. In March,
1789, shortly after Vancoover and his men had settled on the said
point, the Indians stole all their horses but one, which they killed.
We all, about ten in nupaber, except three or four of Vancoover's
men, remained there during that year, and left the next March,
except three or four men left to hold possession. But they were
driven off in April, 1790, by the Indians. Vancoover went East in
May, 1789, for a stock of goods, and returned in the Fall of the same
year. We had to go to the mouth of the Kanawha River, a distance of
eighty-seven miles for corn, and no one was settled near us ;
probably the nearest was a fort about thirty or forty miles away, and
this was built may be early in 1790. The fort we built consisted of
three cabins and some pens made of logs, like corn-cribs, and
reaching from one cabin to the other. We raised some vegetables
and deadened several acres of ground, say about eighteen, on the
point, but the horses being stolen, we were unable to raise a crop.
[Signed,] John Hanks. This deposition was taken in 1838, the
deponent being in the seventy-fifth year of his age. PIONEER
CLOTHING. What did they wear eighty years ago in the valley? The
men wore buckskin breeches and hunting-shirts of same material,
home-made linen
 WHAT DID THE PEOPLE EAT f 13 or cotton shirts made by
their wives and daughters. They generally wore moccasins made of
buifalo hide. Their hats were either made by a local hatter out of the
abundance of fur at hand, or made at home out of fur skins. The
ladies of the valley dressed well and comfortably in those good old
days. They spun and wove the cotton and flax into cloth for the
family wear, out of which they made handsome dresses and other
female wear. They bleached the cloth at the spring branch until it
was spotless white. Another part they would color with barks, and
make the most handsome stripes. And Avhen made up in the latest
style of that day, and worn by the belles, the beaux were as much
struck with the beautiful decoration of their sweethearts, as the
beaux of to-day are when their girls appear in silk. Sometimes they
wore deer-skin slippers, which were very nice. The old men who
linger behind say that the women not only dressed comfortably, but
looked handsome in their homemade wear. WHAT DID THE PEOPLE
EAT? This question is sometimes asked at the present time. Their bill
of fare was a very good one. A more tempting one could hardly, to-
day, be furnished by the best livers on Sandy. Bear-meat boiled, or
roasted before the fire, or on wooden bars over a furnace made for
the purpose. Venison
 14 THE BIO SANDY VALLEY. broiled on the coals, or boiled
and eaten cold. Pheasants hung up before the fire and roasted to a
fine brown. Johnnycake made of corn-meal beaten in mortars or
ground on hand-mills, shortened with bear-fat, Avith some stewed
dried pumpkin put in the dough. Wild honey in the comb, or strained
; maple molasses in abundance in its season, and plenty of maple-
sugar to sweeten their spice or other domestic tea. Huckleberries,
services, and other wild fruit as relishes. The epicure of to-day would
delight in such a meal. Hog-meat and beef soon followed along, with
a little flour, and after 1820 coifee was used quite often. The old
pioneer did not lack for plenty to eat, and that of the best. THE
STORE DRESS. An elderly lady living on Peter Creek, in Pike County,
related to us an incident in which her grandmother, when a young
lady, Avas one of the actors. She and a young lady friend were the
first in the settlement, seventy-five years ago, to own a store dress
each, and a pair of store shoes. The goods was of the brightest
colors, and made in handsome style, ready for the approaching
Sunday religious service in the neighborhood. The young ladies all
rigged out in their showy gowns, with shoes and stockings in hand,
when Sunday morning came, started on foot to meeting. On their
journey they came across a herd of cattle
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