DailyKaizen

Yesterday I spent some time talking with my new neighbor that moved in down the street.  We were making small talk and our conversation ended up moving to the economy.  As I listened to his powerful story I thought about how lucky I have been to work for a company that so far has avoided major layoffs in 2009,  but I also left feeling a heightened urgency.  The urgency coming from the knowledge that in the near term our company will face significant economic challenges (like all healthcare organizations) and yet it seems like we are not doing everything we can now to soften this impact.  We could learn a lot from what my neighbor shared with me (I asked permission and he read this before I posted) and I hope we take many of the actions they his company has. 

My neighbor works as a production manager for a family owned manufacturing company.  In a three month period in 2008 they had their revenue drop by more then 40%  and stay there after several years of record growth.  While the company was unable to avoid layoffs after a big initial reduction he told me the owners have done everything possible to save jobs.  He said that in the past cost improvement in the company was the job of management and there were usually a couple of big cost improvement strategies, usually focused on improving productivity in production areas or by outsourcing.  Most workers were kept in the dark about these improvements and would only be involved when they were asked to do something differently.  He said that once the initial layoff was completed management got together and tried to figure out where they could take out additional costs.  He said it became clear very quickly that management did not have any “new ideas.”  The way the company went about cost reductions activities in the past would not work into the future. 

At the same time staff were frustrated and fearful of what was coming in the future and management was not doing a good job communicating.  This weighed heavily on the President who in the past has a very good and trusting relationship with the workforce and he was frustrated that the workers did not understand how bad the situation was and why decisions were being made.  Given these conditions and not knowing what to do the President decided to set up a series of “townhall meetings” to educate the workforce on what was happening in the business.  The purpose of these meetings was basically to prepare the workforce for additional layoffs coming in the near term as the company burned through its cash.  The President and his team (including my neighbor) prepared a presentation and pulled together the first group of workers.  Once the management got done their presentation they asked for questions.  One of the workers raised his hand and asked “what can we do to help?”  This was not something the managers were expecting to be asked and they did not have a good answer.  While the management team was fumbling around for an answer someone else raised their hand and said “I have a couple of ideas”  And so it began…

Over the last year the company has created a “bottom up” cost reduction strategy that is called “No cost is too small.”  The focus of the strategy is to save jobs by engaging the workforce in reducing costs.  So far it has worked and several million dollars in saving have been identified.  Ideas have included:

• Reducing energy costs by more the 10,000k a month by simply turning machines off when they are not being used and by turning lights and computers off at night
• In-sourcing facility maintenance costs including production workers once per week bringing their law mowers to work to take care of the facility grounds
• Better using space in their facilities and reducing inventory that have allowed them to sell two warehouses
• More then a 50% reduction in scrap, because works are focused on making sure that every cost is accounted for
• The sales team has figured out ways to reduce travel costs by more then 50%
• etc.

What was most compelling to me was that the fact that the company had made the cost problem everyone’s problem.  When I think about my company as leaders we often communicate about the cost challenges of the future.  Yet, at the same time we don’t ask people to become involved in helping solve this problem.  We have all grown use to the small luxuries that we probably should be going without.  It is hard to believe that we will be successful with the big cost reduction strategies if with our actions we don’t treat the small cost opportunities with equal importance.  It time for us to make every cost a big deal and get everyone in the company involved in helping find ways to reduce them.

We are in an interesting place right now as an organization.  Over the last couple of years we have made a great deal of progress with our Lean work in helping the organization improve at a much faster rate then in the past.  The company is growing and we are doing okay financially, but all indications point to significant challenges on the horizon.  There is a lot of uncertainty about what will happen with policy changes in healthcare and there is no doubt that we, like all healthcare organizations have costs that are too high and rising. 

 These challenges have been recognized by our leadership and most of the 2009 strategies are focused on making the organization more affordable.  Many of these strategies are making good progress, but conditions are changing all the time.  It is becoming clearer every day that everything we are doing is necessary, but also insufficient.  We may be improving faster then we ever have, but it still is not fast enough to meet the demands of the changing marketplace. 

 So how should the organization respond?  Should leadership begin the process of identifying a new list of strategies that are focused on affordability?  This is exactly the action that we have taken in the past and I am hoping it is not the direction we go now.  Our current system has asked a small group of critical managers to again and again carry the weight of strategic improvement forward.  These managers are already struggling with the pace and number of improvements that are underway.  Asking these same people to add additional improvements to their inventory does not seem like the answer.  Thus, I don’t think a group of senior leaders in a meeting room defining a new set of strategies is the answer.

 So what do we do differently in order to get a more substantial result?  I believe the answer is not in focusing on adding additional strategies, but instead getting more people in the organization engaged in the improvement process.  We need to focus on improving and making more robust our management and improvement systems.  As an organization we have used the Hoshin process to identify a handful (some may say a couple too many) of strategic improvements that need organizational resources and support to be achieved.  In addition to keeping these improvements going we need to make it the responsibility of every manager and all employees that they also need to contribute to the organizations success and then we need to provide them the methods and process to make this happen.

Taking this approach is what Toyota calls the Daily Management system where each day teams work to improve their routine processes a little bit and over time it adds up to much bigger improvements.  This system is based on platform of standard work and will also allow us to sustain the strategic improvements we make.  There are several places in the organization where we have a good start in putting this system in place, but most of the organization is either just getting started or not started at all. 

In order to get moving there are several things we can do now including:

• Making sure that we set improvement related goals for every manager in the company that relate to affordability (i.e. 1% improvement on run rate per quarter, 3% productivity improvement per quarter, etc.)
• Make sure that clear expectations are set for level of performance that is expected by all management and that there is consequence when it is not reached and there is a reward when it is! 
• Make sure we develop a robust redeployment process and policy and require that the highest performing team members be redeployed to a centralized pool of resources to support further improvement.  This means taking people out of the process once it is improved. 
• Standardize the definition and requirements of what is required to put a Daily Management system in place.  Ensure that we are ready to bring together all of the following elements into a succinct system:
  • Linked measurement
  • Visual Management
  • Manager standard work
  • Process standardization and improvement, etc. 
• Make sure that our Finance, Lean and HR resources are organized and ready to support managers throughout the organization in putting this system in place and that we have a programmatic approach. 
• Finally, reinforce the organizations standard calendar and make sure that all leaders are getting out of the conference room and into the gemba to make sure that the appropriate checking and coaching activities are taking place.

 Anyway, that is my advice.  Anyone have additions or advice?

This weekend I was doing my best to explain to a friend what my job was as a Lean Sensei.  Not an easy task to explain to people that don’t understand Lean what it is I do, but I gave it a try anyway.  Much of our conversation revolved around what I do to help make leaders throughout the organization more capable.  How I focus on teaching them the Lean principles and techniques in order to make them more capable across the organization and within their function.  While this is not all that I do, it might be the most important work. 

My friend is an external consultant and told me that he felt sorry for internal consultants, because they had to work with the same people over a long period of time and they just couldn’t “walk away” from those that were not engaged.  I told him this is one of the things I like best about my job, because changing thinking is really challenging, but it is also really rewarding.  It takes trust and the ability to develop strong interpersonal relationships.  Yet, being an effective internal consultant also takes good judgment and perception.  You need to be able to see quickly if the leaders you are working with are engaged in the process and advancing or you risk wasting a lot of time.  As I reflected on this conversation I began to formulate a list of things I need to look for to determine if a leader is making progress at the beginning stages of our engagement.  I thought I would share my thinking and would love to hear from you if you have additional items.   

First, I think the easiest thing to measure at the early stages of an engagement to determine progress is how leaders are choosing to spend their time.  I can’t tell you how often I hear leaders talk about how dedicated they are to the process of improvement, but they continue to spend all their time in meetings away from the work.  Basically, they view their role as “a sponsor of Lean” and Lean is something “others need to do.”  Leaders that are engaged in the process will:

Ø      Begin to spend more and more of their time in the gemba seeking to understand what is happening and helping teams become more capable.  They protect their time in the gemba and meetings are a second priority.  They are constantly looking for ways to free up time to spend more time in the gemba

Ø      They don’t become what I call “victims to their calendar.”  When problems arise they swarm them.  They don’t wait until it is convenient for their calendar.  They show how serious they take problems with their feet not just their mouth. 

Ø      Many of the most effective leaders I know have given up their offices completely!

Second, leaders that are engaged in the process take their learning seriously.  They have a learning plan and they are good students.  These leaders are quick to sign up to participate in Lean improvement events, they visit other organization and they are constantly reading the newest Lean literature.  I know I am making progress with a leader when the process transitions from me as the consultant always having the list of questions when we meet to the leader having an equally complete list of questions for me. 

Third, leaders that are making progress should become more humble and transparent.  The more they learn the more they realize not only how much they don’t know, but also how many problems they have created within their areas.  They become more honest about their challenges and they are more willing to seek others help.  Additionally, they begin to see and understand process.  This shows them how their work connects with the work of other parts of the organization.  They know that their processes create problems for others and vice versa.  Thus they begin to reach across the lines to partner more cross-functionally with others to solve bigger system issues. 

Finally, I like to watch how effective the leaders are becoming with how they manage those that report to them.  There are three things I look for:

Ø      Are they always prepared for every interaction?  Have they gone to the workplace to see problems for themselves?  When the call a meeting to the have a purpose and a desired outcome?  Are they clear about what they expect and when they expect it?  These leaders no longer tolerate spending an hour in a meeting without and clear outcome.  They take everyone time serious and make sure it is used effectively. 

Ø      Have they begun to coach their teams?  Do they ask questions as opposed to give answers?  This is a challenge for anyone to learn, but are they trying. 

Ø      Do they have a system to follow-up in place?  If they ask a team member to get something done by a specific time are they consistent in following up.  Are they showing that they take their own expectations seriously?

Anyway, this list is by no means complete, but it is a set of things I look for.  For consultant out there reading this posting what would you add? 

As our organization has moved forward on our Lean journey we have begun to integrate PDCA into much of our improvement related work.  In many parts of the organization we have moved out of the Plan, Do mindset and people have learned how to define the problem, identify root causes and then to check often to make sure they are on the right track.  It is exciting to see the progress we have made.  Yet, this progress has been mostly limited to improvement related work that is most often managed through a project mindset and mostly driven by our Hoshin process.   As we move forward it is important to begin to transition this learning into our routine processes so that every task we complete is an experiment that we are looking to learn from. 

At Toyota and other advanced Lean organizations you often hear them talk about PDCA being part of everything they do.  In other words, every product they make and every process along the way is managed through a PDCA mindset.  Thus the learning process is built into everything they do.  This is the foundation of what people call continuous improvement and in Lean terms is the Daily management system. 

Below I have given some thoughts on how to integrate PDCA into routine processes.  I hope this is helpful to those of you getting started on your Daily Management systems. 

Plan:  The plan for routine related processes is the standard we have established for the process based on customer requirements.  Basically, it is what we are expecting to happen if the process is completed to the appropriate level of expectation.  For a pharmacy it might be the amount of time it takes to fill a prescription.  For an office visit it might be that all of the opportunistic care is provided.  

Do: The Do is what happened as we completed the process.  How long did it take to fill the prescription?  Did all the appropriate care get provided?  In Lean this is where we focus on developing standard work in order to reduce variation and make capable our processes.  By putting in place standard work we are then able to compare the Plan with the Do to see if what we thought would happen did happen.  Was our hypothesis correct?

Checking: Checking is the process by which on a regular cadence (often every hour or several times an hour for routine processes) we check our Plan (standard) vs. the Do (what we accomplished) in order to determine if we have a gap.  Checking is where the learning and improvement opportunity is identified.  Checking is also the part of PDCA that is most often not completed on a consistent basis, because managers don’t have standard work.  Without checking your teams will not engage in the improvement process.  For pharmacy the checking process might take place every hour to determine if the team is meeting the wait time targets so that there is a chance to respond before it is too late. 

Adjust: The adjust come in effect when during our checking activity we determine that we either are not meeting or we are not going to meet our Plan (standard) and we now must adjust to get back on plan.  For pharmacy this might mean taking quick action to move people in or out of the process to respond to changes in demand for prescriptions.  As we gain more experience with adjusting teams will begin to develop standard adjustment depending on why the plan is off track.  As teams become more engaged they will move away from waiting for mangers to check and they will check themselves and adjust without being prompted. 

Overall, as we begin to integrate the PDCA into our daily processes we will greatly increase the number of people that are scientist within the organization.  Each team member is really testing a hypothesis with each task they complete and they will constantly be asking “why” something did or did not happen.   This is really the foundation for how you create a culture of continuous improvement. 

As we continue to define and transition into a Lean management system one of the most challenging problems we are trying to solve is how to balance organizational and customer needs for consistency and performance with the engagement of frontline teams in defining improvement. When improvement is brought to a team defined and ready to implement it is difficult to engage that team in the process. Even if the improvement was designed by their peers (the old “it was not invented here” challenge). When improvement work is left completely up to teams based on a achieving a standard you may get the same outcome on paper, but in a service organization the customer experience may be so different that many complexities and problems are created.

This is particularly difficult when:

• Multiple locations provide the same services like we do with many of our clinics, pharmacies, labs, and specialty services.
• You are working through a sixty year hangover of improvement being 90-100% top down, management defined and specialist (project manager or consultant) implemented. 
• You are early on the journey of implementing a daily management system and managers are very uncomfortable in turning over improvement responsibility to their team members. This is because they don’t know how to engage their teams in PDCA and thus they don’t want to turn over control. This is often expressed by them comments such as, “there teams are really busy and I want to protect their time.” 
• You are using event driven approaches to improvement like rapid improvement workshops where only a small sub-set of those eventually impacted by the improvement are directly involved in defining the new process

Across our organization we are in the midst of trying to manage through these challenges. So where do we start and what should we do? I don’t claim to have all the answer on this, but we are working hard now to try and figure some of them out. Here are some suggestions:

• Simultaneously work on improving your management system from the top and from the bottom. While building the system from bottom up might be the best way in the long-term the realities of the short-term (political and business) often mean that we need to focus on both. Improvement work that is being driven “top down” will be disruptive no matter what. Yet, this disruption can be “softened” if teams have the opportunity at the local level to influence and PDCA parts of the process once it has been implemented. The trick is defining parameters for what can and cannot be changed. Consequently leaders who are driving work down in the organization need to be very clear about what these boundaries are and for items that are not “critical to quality” they need to get out of the teams way in allowing them to improve. 
• Related to above it is especially important that teams begin to implement a Daily Management system from the very early stages. Without this system teams will not be able to sustain improvement over the long-term. Not only will the reinforcement and checking systems not be in place, but teams will not be engaged if they cannot see the effects of their work. If improvement is always pushed on them they will eventually grow frustrated and either rebel or passively resist. I believe that the most powerful aspect of Lean is when teams fully engage around improving their daily work. This is the heart of the Daily Management system.
• Once a large scale change has been made “top down” it is wise to turn over the PDCA process to a local team. Again within parameters. This means pushing down the responsibility for improving the now stable process to those that are doing the work. Leadership should set the new standard and ask the frontline to come up with the next generation of improvement for the process. For a system with multiple locations it might be advantageous to rotate this responsibility among the different teams or reward it to the highest performing unit. Over time, teams that get a chance to improve processes that others must adopt will be more willing to adopt processes that other teams designed.
• Rotate as many people into Lean events as possible. As most of you know, people that participate in rapid improvement events often have a light go off and become big supporters of change. Many organizations have relied on this as their only method, which we don’t believe would be sufficient here, but it is a great tactic. 
• Finally, create every opportunity possible for teams to share learning’s and promote lateral improvement. If you can create systems that frontline teams are engaging with and pulling from each others improvements it becomes far less necessary for leadership to push improvements down in the organization.. Leadership sets the standards, creates the system for lateral learning and defines the parameters for improvement. Parameters might look like: “teams are free to pilot improvements, but in order to change the process permanently they must demonstrate an improve result with data” or “all teams much adopt a minimum of two processes a year from another work team.”

Anyway, this struggle will continue for us. I hope some of these suggestions help others. Please share your ideas!

Please find below the lastest guest blog posting by Connor Shea.  Connor is a Lean consultant at Grou Health that is always got a set of great ideas and never seems to not have a smile on his face.  In the post Connor shares some of his learning’s from a recent project he worked on.  Enjoy!

Situation:

A recent consulting engagement with many area leaders, each owning a component of a larger process, resulted in a situation that can be simplified into the following example:

Leader decision making factors:

A)    Facts and data

B)     Personal emotions / feelings

C)    Collective emotions / feelings of staff

D)    Political implications

E)     Personal like / dislike of stability vs. change

Decision making prioritization (key component of mental model):

Leader 1:  B, D, C, A, E

Leader 2:  D, C, E, B, A

Leader 3:  C, A, B, E, D

Etc

Goal: improvement based primarily on A

Outcome: Improvement based equally on A – E

Target:

Long-Term:

Every person is made unique by their upbringing, education, peers, and experiences. This uniqueness brings depth to an organization and should be valued. However, just as we ask front line staff to take their same uniqueness and decide on a best practice, should we not have the same expectations of our leaders? It seems that until an organization has a shared mental model that is explicitly understood and rigorously adhered to, we will have tremendous variation in the lean improvements that are taken on, the quality of their execution, and their sustainability.

Short-Term:

Create a micro-culture that had consistent goals, methods, and decision making priorities, even if the larger environment does not.

Proposal:

As the organization takes on the long-term target, a colleague and I focused on the short-term. Not all were tools I had in my toolbox prior to this work, as many were learned through trial and error, but they are all tools I will carry forward. I hope you one or two are helpful to you as well:

• We made sure that we remained consultants to the improvement, and not drivers of the improvement:
• 1 on 1 we attempted to understand and treat individuals as individuals. To do this we:
  • Observed and talk to them directly – why do they come to work everyday? What do they do on the weekends? etc.
  • Sought out input on personality, hobbies, history, etc from colleagues, senior consultants and others we had a working relationship with
• With the large group we set clear expectations with all members & held all members to the expectation equally:
  • We contracted with the senior leaders up front around a clear / explicit decision making process as well as working guidelines that team members would be held to.
• We learned to not solve a consulting problem with a technical solution
  • Early on, I believed that if I just explained the technical concept in a slightly different way, etc., that the light bulb would go off, and we’d move forward. Often however, understanding wasn’t the root cause holding the individual from moving forward. 
• To the best of our ability we made problems visible
  • Once visible, we were careful to ensure the issue was still about the process and not the people.
  • We used our consulting hierarchy to raise issues and barriers. Senior consultants were helpful in providing ideas and to help judge the situation to see if higher level actions were necessary.
• Finally, if working directly with an individual wasn’t working, we learned the informal power structure of the group and use it to our advantage:
  • To someone they listened to and/or reported to we focused on making visible how that’s individual’s behavior / actions impacted the overall success.
  • When we engaged someone’s manager, we tried to do so as fairly and explicitly as possible. The person always found out, and when they did, we wanted to be able to explain why we needed to engage their manager to ensure the success of the work.
  • Over time, all involved, began to understand and respect that we weren’t being unfair or playing favorites, but simply doing our best to ensure a successful improvement. Amazingly, we actually joked and laughed about these situations later in our engagement.

This last week I spent some time with a couple of colleagues of mine that are internal Lean consultants.  They are working in a large operations area within the organization that is just now getting started on applying Lean tools and concepts.  The leadership in the area has limited Lean experience and the management processes of this operation are very traditional.  All of us were somewhat frustrated, because it was very clear that Lean was being viewed through a project lens with a discrete oversight group, a set of experts coming in to facilitate the improvement work on behalf of operations, etc.  The work was being planned and organized around the existing structures and management constructs.  There was no view among leadership that this work was an opportunity to not only improve the frontline processes, but also to challenge and improve the management processes.   It was a classic case of Lean tools being applied within a system with no Lean management.

After getting some time away from this meeting I realized I should not have allowed myself to get so frustrated.  This case was simply a reflection of where the organization is on its Lean journey.  Across the organization we have a wide level of variation in how far and how fast different operations have embraced Lean.  Many parts of the organization are still holding out that this work will go away (although there are less each week).  Other parts of the organization are early on the path and they are focused on the Lean tools.  They us the traditional management system of using projects as the means for improvement and facilitate Lean events to improve processes.  Finally, in a couple of large operations like the Model Line and Primary Care we have leaders deeply embracing a Lean management system.   In these areas leaders have learned to view improvement through the process as opposed to the project lens.  Improvement is happening mostly through small changes being implemented daily across hundreds of teams, often being facilitated during daily stand up meetings called huddles.  In these areas Lean is used to not only improve the operational processes, but also the processes of management system.  Overall, in these areas Lean is not something separate that allows us to get the work done, it is the way that work gets done. 

So is it bad that we still have areas within the organization that are treating Lean as a set of tools or projects?  I don’t think so.  This is because through the application of the tools and the implementation of the projects an opportunity is created for learning.  Leaders involved in these projects with see first hand how the current management processes do not allow for sustainability of results.  How their own behaviors and actions often lead to negative impacts on the frontline and engagement, etc.  In other words, through the involvement in Lean projects leadership will see all the management problems become visible.  If they are good students and have good teachers they will then naturally begin to see how Lean applies not only to projects, but also their own processes (management system). 

The Model Line, Primary Care and all the other areas in the organization that have made this transition started with a focus on projects and then extend into a management system.  This did not happen overnight and it was often frustrating for those of us that were involved.  It was simply part of the maturation of our Lean system.   As consultants we need to make sure that we don’t get ahead of our leaders and expect them to master concepts without experiencing them first.

Below please find the latest guest posting from Greg Burnworth.  Greg is a Lean consultant at Group Health and he has spent the last couple of years working within our Health Plan to support our Lean transformation.  Recently, Greg has had the chance to pioneer some really impressive work within our sales and underwriting functions that we are all getting the benefit of learning from.  Enjoy!

One of the most challenging aspects for leaders in our aspiring lean organization is how to effectively role model lean leadership. I find this also particularly difficult as someone not only trying to coach and support these leaders, but also difficult in my own daily behavior as a role model for them and others. So when I was approached by Lee about contributing to the blog, I was impressed with the quick, direct nature of his request, and how effectively he modeled “taking initiative” with just a one sentence question. I guess it worked, because it has driven me to action!

I like to remind myself that the lean leader’s job on a daily basis is to create change. Creating change means engaging people to take initiative to solve problems that improve the work they and others do. While this sounds simple enough, it does not come natural. It isn’t natural because often managers (and most everyone else) don’t want to be seen stirring the pot, and increasing the accountability of others. Second, many managers have been promoted by nurturing relationships and being well liked, and in their minds, challenging others could impact them unfavorably down the road. This couldn’t be further from the truth; taking initiative with a critical mind builds respect, it doesn’t diminish it. In fact, in working with one leader recently on preparing questions to ask in a gemba walk, this leader’s question to staff in this particular role play was,” are you feeling OK with this change?” While empathy is important, a better question to a team member would be, “how is your daily work different now than from before?”

Another compelling job of the lean leader is to shift the workplace focus to where value is created. Ideally, all staff should be in a position to provide more customer-focused value to our members than what is typically written in their job description. This is a more difficult proposition because it involves asking people to change roles. Incidentally, there are plenty of staff who are ready to learn new skills, gain experience, and support value added processes outside their own routine work.

It is often said it is easier to act your way into a new way of thinking than the other way around, but often we have no basis on which to know how to act! So how does an aspiring, if novice manager begin the lean journey and model the right behaviors? Perhaps the first thing to do is to honestly assess the style of their current management behavior, and then introspectively evaluate its effectiveness and all its shortcomings using a scientific approach. It requires the manager to personally see and recognize the limits of how he or she manages, and acknowledge and commit to a different approach. It requires humility and seeking help from a trusted mentor, and a willingness to make oneself vulnerable to acting differently every day. It is really rewarding to see managers, who initially met lean head on with distrust and discomfort, shift to a mental model of introspection, curiosity, and initiative.

It is most often the case that when I first introduce Lean principles and tools to a group of staff and leaders that have no Lean experience that most people in the room are either skeptical or start from a negative place.  This is understandable.  For years people in the organization have been introduced to the latest and greatest program and they often disappear as quickly as they arrive.  When I first started doing this work I would often waste a lot of my time and the time of others in conference rooms trying to explain Lean and sell it to folks.  This was a bad strategy, because Lean in not about Lean.  Most people don’t get excited by the principles, tools and concepts.  Instead, they get excited and engaged when their lives and the lives of their patients are improved through the use of the principles, tools and concepts.    So instead of spending time trying to teach Lean upfront it makes a lot more sense to engage people in the improvement process and allow them to see how much better the end can be through the proper use of the right means.  In 95% of the cases once people experience the Lean process they are no longer skeptical or resistant.  Especially if they can see the direct impact on the care of their patients. 

What is far more difficult is trying to engage people that have been through a Lean implementation, but walked away with a negative experience.   Over the last couple of years I had heard rumors of “Lean gone bad” in the Seattle area, but I just figured it was noise associated with change.  This last week I have had the opportunity to spend time with several leaders and staff that have worked in organizations applying Lean in the local area.  Many of these folks have a really bad taste in their mouth from their experience.  (depending on the organization many have had great experience as well!) Several of the folks really believed in the Lean principles, but were very frustrated with the way the principles were implemented in their organizations.   Stories that included:

• Lean implementations that took management out of the gemba as opposed to focusing them in the gemba
• An organization that required all staff to sign a “Lean oath”
• Managers being encouraged to provide false data in order to make the Lean work look good
• Surgeons being “dinged” because they did not put the trash can in their office in the right place
• A divide among staff where 80% of people where labeled “concrete heads” and 20% as performers
• Staff members that got in trouble for bringing into their office more then the one allotted picture of their family

My intent of engaging in these conversations as well as writing this post is not to promote the negative side of  Lean work that has happened at other organizations.  Instead, I want to understand the mistakes that have been made elsewhere so that we don’t repeat them. Walking out of the room I had to reflect on some of my own behaviors and actions.  How quickly I have written off leaders that seemed to be resistant to Lean work.  How I have been dismissive in the past when leaders have suggested that I don’t use Japanese words while training our medical staff.  How I have focused on the ideal at the expense of getting improvement today. 

As I think about these cases it is not hard to see how these organizations may have gotten off track.   How easy we can mix up the ends with the means.  How easy Lean became about Lean as opposed to being about improving patient care.  Anything can be taken too far and turned into a religion and as a result you lose the very people you are trying to engage in the process.  In many ways this experience has made me think deeply about the approach we are taking and I will move forward with a greater awareness about ensuring we stay focused on what matter most: improving patient care.

 Below please find the newest guest blog posting.  The author, Dr. David McCulloch is an incredible Lean leader as well as a nationally respected physician.  David has been on the front lines working with our physician teams to implement our Medical Home model and Lean Management system.  In this posting, David warns us that we need to focus on what the patients need as opposed to just adding new technology.  Enjoy!

There’s an old joke that goes like this:

I was walking home late one night when I came across a man crawling on the ground under a lamp post.  When I asked if I could help him he looked up in bleary-eyed frustration.  “Lost me keys… hic… my house keys.”  For the next half hour I got down on my hands and knees to help him look for his keys.  We turned over every rock, combed through the gravel, and examined every crack.  It was my turn to get frustrated.  “Are you sure this is where you lost your keys?”  The drunk man shook his head sadly.  “I dropped them over there… hic… in the bushes, but it’s too dark to see anything over there.  This is where the light is brightest.”

In the ongoing debate about how to fix our irrational, unsuccessful and bloated healthcare system the blazing light of the media’s streetlamp is focused firmly on electronic medical records.  They are the “key” to unlock the door to a more rational and affordable healthcare system!  Every facet of their brilliance is being examined and debated.  Which ones are the best?  Can they talk to each other? How can we make sure that only friendly and helpful people have access to them?

And yet if we took the time to stroll over to the dark bushes we would find the consumers of the healthcare system hunkered down in frustration trying to hold on to their wallets.  If we asked them to describe what their ideal healthcare system would look like I doubt if you would hear them extolling the virtues of electronic medical records.  Instead, here are some of the things you would hear – I know because these are the things that I hear when I ask my own patients:

“When I have a health care concern I’d like to get answers from my healthcare team right away.  If I call I’d like to get through to a human being, preferably my own doctor.  I don’t always want an appointment either.  If I could get my questions answered by phone or e-mail that’d be great.  But if I do need to be seen in person I’d like to be seen on time, by people who are friendly and respectful, who listen to what my concerns are.  They’d understand how my health issues affect the rest of my life and would help me get the most out of it.  I don’t want dozens of unnecessary, dangerous and expensive tests.  I don’t want unproven or dangerous treatments.  When necessary, I want to know that I’m getting the right tests to diagnose my problem and treatment that is safe and effective.  And when I leave the visit I want all my treatment written down in words that I can understand so that I can remember it, and share it with my family and friends.  I want to know what to look for as I take the treatment, who to call if I have concerns, and I want a plan for my follow up.  And if I’m sent to another doctor I’d like him or her to know all about my medical condition from the health care team who knows me best.  Oh, and one other thing, even if I’m feeling perfectly well I’d like it if my healthcare team knew me well enough to let me know when I should consider getting immunizations, or cancer screening or other things that will keep me healthy.  Is that too much to ask?”

I don’t think that this is too much to ask.  What these “patients,” these customers, these consumers of health care are asking for is a rational, friendly, safe, effective, and affordable system that is designed to meet their needs.  It is well within our capabilities to design and implement this in the USA.

Don’t get me wrong.  I think that having sophisticated electronic medical records could be a tremendous asset in helping to design a rational health care system.  But if we simply apply cool technology to make our current irrational, unsafe, and overpriced healthcare system more “efficient” then we will have achieved nothing. If applied to a rational system then electronic medical records could be the key to unlock the door to a warm, inviting medical home, a place where customers would feel safe and well cared for.  But if applied to make our current chaotic mess more “efficient” then the electronic medical record will simply be the key to a drunk man’s junk closet.