DailyKaizen

Hi everyone, I’m still around, admiring the great work of Lee and colleagues at Group Health, and also applying my knowledge at a different level, working with the California Healthcare Foundation, based in Oakland, California. What I’m experiencing in this work is a very different view of health and health care - a societal one, as opposed to one that is based at the level of a health plan / delivery system.

The specific medical issue we’re looking at is the control of blood pressure, which has been really interesting to look at from a societal perspective. Why? Because the health system sees a slice of the impact - expenditures on drugs, office visits, and eventually the devastating outcomes of cardiovascular disease. It does not see the other impacts, on patients’ time, their costs, or the time and costs of their employers and families, which frames how a society might look at managing this condition (which right now is done poorly, with only 35 % of Americans with adequate control, and a third unaware that they are at risk).

This is very tied into LEAN for me, because it’s taught me to look at every problem as one impacting society, whether I am seeing it in an exam room or a board room. I am also using everything I’ve learned to date to help make an impact with this organization and its partners. This includes visibility - I asked if it would be okay for me to publish the plan “in the making” on the public Internet, and the answer was “yes.” I have never done that before.

With that in mind, feel free, if you’re curious, to take a look on my other blog and offer myself, and Californians, some advice on improving a plan that will make a difference for patients managing chronic conditions.

Also feel free to answer this question - why doesn’t every health care organization post its A3’s in progress for community comment? Should patients and their families be part of the nemawashi process? Should we create a forum where that happens?

(I’ve been spending a lot of time studying patient and family involvement in the care system, also thanks to LEAN..)

Finally, something to energize us about all that we have left to do:

A guest in my home who is from Germany told me today, “Ted, I saw that book (“Overtreated,” by Shannon Brownlee) on your table, and it brought a smile to my face that you were reading it. Why is health care here all about money? When I compare health care to Europe to health care in America, it’s like first class compared to tenth class.” I told her I was doing my best along with others to make a difference, but I felt as disappointed as I ever have at what we’re accomplishing with the $2 trillion we spend each year.

Tom Morgan asked Lee and I about this and we’re doing the natural thing, asking fellow experts for their input. Here’s the question, and Tom, you might want to flesh out a little bit about what the situation is. I’m sure many people here have experienced this lovely challenge:

Hi, Firstly thanks for the great blog.

I am considering the mechanics of implementing Quick and Easy kaizen (ala Norman Bodek) where I work. However I am not sure how it works where an idea involves a change to a key business process that spans several unrelated projects and in some cases geographically dispersed sites.

Any ideas how I might approach this?

I recently returned from Medical College of Georgia, in Augusta, which is nationally known for involving patients and families in their care. The work is very impressive, and I posted a summary and pictures on my other blog.

There is a story that I was told that is worth posting here:

Pat Sodomka, Vice President of Patient and Family Centered Care, and Bernard Roberson, Director of Family Services Development explained to me, Patient and Family Centered Care means a lot of little changes. They told me about patient Nettie Engels who asked for longer straws in radiology. Why? Because when patients were flat on exam tables and asked to drink contrast, short straws meant that contrast was more likely to spill on the patient, and due to the requirement that they be still, this resulted in unnecessary discomfort throughout the procedure. As a result, the hospital purchased longer straws, so that patients can now have the dignity of clean and dry clothing while undergoing an exam.

As we talk about leadership at all levels and the ideas of staff, how do we incorporate ideas from patients and their families? What is our mental model about the ideas of patients and families - do we see the problems that they bring to us as gold, or do we tally them in databases somewhere?

How many short straws are there in your institution that you don’t know about?

The title of my post is a corollary to Lee’s previous post, which I loved, because besides talking about the issue of going to see things, it also alludes to the idea that LEAN creates leaders who are able to reflect on to themselves what they reflect onto others.

My little add is to always go see as part of what I do. Now that I’ve been working this way for 3 years now (and I can’t believe that it’s been 3 years), I realize that I am more and more uncomfortable hearing about anything in the absence of seeing.

This has really hit home in the last two weeks, actually, as I wind down some of my sabbatical work, and schedules have gotten a little tighter. I found myself about 3 weeks ago having a conversation with a great group of physicians about their launch of a patient portal….in the conference room of their headquarters. It just wasn’t the same for me, and at some level I felt I was being disrespectful by offering any advice at all in the absence of seeing the care that these physicians provide.

Last week, I spent time in California, and I was able to get close to the work, but I didn’t actually shadow the patient process of care, and that still felt a little uncomfortable. Same feeling - what do I have to offer someone who experiences a set of facts that I did not see? At the same time, I saw more than I did in the experience above, and it was very important and meaningful, judging by the fact that my blog posts on them were much richer with information.

Fortunately, no communication is ever over in life, and I asked for the chance to go back and shadow the first set of providers. They said sure, and I really want to do this.

If there is anything from this experience that I could impart, it would be that your approach to where you do your work will change with LEAN. You will feel more natural being close to the patient, and more unnatural being farther from the patient. What used to seem like the easiest, most comfortable thing, going to the same conference room watching Powerpoint slides, connected to your iPhoneBerry, will begin to seem like the hardest, least comfortable thing. And you’ll love what you do more than you ever have.

While Lee (and many of you!) were in Orlando, I was in San Diego for the Health 2.0 Conference. I posted something of a play by play on my regular blog (they had tables reserved for bloggers, I had to earn my keep!).

What was eye opening about the event is/was that as much as we work to move our health systems further and faster toward a patient centered reality, there is a whole industry springing up that is already there, and creating their own reality in the void that still exists. They are both exasperated with mainstream health care and restless at the same time. The result is that our platforms will burn brighter and our relative biases toward inaction will melt away. I was reminded last week that we do have biases toward inaction. I needed that.

At the same time I engaged with a real consumer-centered world, I also visited some very well regarded medical groups and co-facilitated my first ever strategy deployment session with a group not-affiliated with our health care organization.

On the medical group visit, I had the sensation of meeting another American in Europe, when while doing the planning, I indicated that I wanted be as close to the patients as possible. The response was, “Oh, you want to come to the Gemba.” It was a wonderful thing to hear because the conversation instantly changed. Later on the week, though, with a different audience, though, I was asked about using the Japanese terms in mixed audiences and whether that enhanced or degraded understanding of LEAN. I need to watch myself a bit more, to prevent jargonization and some of the concerns Lee mentioned in his last post.

On the strategy deployment session, I was definitely on the nervous side as a non-affiliated outsider. I’m sure this is a feeling that many of the readers here have had in their careers! I saw how the process itself and the stage set by leadership allowed people to leverage the ideas to their maximum. I walked the group through my own experience transitioning to a hoshin process from 2004-2007. I had actually never compiled our story together with photographs, and it was great reflection for me to create a story reminiscent of Atlas Industries in Pascal Dennis’ book. If any of our readers are not documenting your stories through photographs (and maybe a blog…? :)), please do it. It will help you and those who come after you.

There were many things in the last week, and in the last 5 months that make me believe that we could reach critical mass for respectful continuous improvement methodologies in health care as a standard. The consumer movement in health care, technological advances, and the mixing of generational experience (Boomer - GenX - GenY) in leadership make it possible. When that happens, we’ll all be world citizens and it won’t be like meeting another American in Europe anymore.

Do others agree? Could we make this the standard across medical education and health system leadership in the next 10 years? How about the next 5?

Application of the Toyota Management System across the Group Health Cooperative System Slides compressed for Web delivery (2/26/08)

Slide: Appointment calendar, before and after standard work, Group Health Cooperative

Yesterday, Karl Hoover, Lee Fried, and myself led a national Web event sponsored by the Alliance of Community Health Plans about Group Health’s enterprise deployment of the Toyota Management System.

I asked Karl and ACHP if they wouldn’t mind flipping the switch to make the presentation open not just to ACHP members, but the entire public, and they both said yes, so it’s now available to this audience (and anyone else who would like it):

Application of the Toyota Management System across the Group Health Cooperative System slides compressed for Web Delivery (2/26/08)

I pulled out one slide here to show an example that I think a lot of you will recognize as a challenge in your work lives. Look what is happening to appointment calendars due to standard work.

A byproduct of the work that I alluded to in my part of the presentation has been partnership. It was remarked by our host at the end of our talk that we ran exactly on time, which is often a challenge for a talk with three speakers. The fact is that we work very well together because we have seen so much (double underscore) through this journey together, even though we are very different people. Right before the talk started, with me in DC, and Karl and Lee in Seattle, I asked how their stress level was. I think they paused for a bit and then began laughing together. I know what that laugh means. We are working hard and having fun. I hope that comes across in the talk. Enjoy!

Feel free to post your comments and questions below. Thank you again to our employer, Group Health Cooperative, and Alliance of Community Health Plans, for hosting the session and supporting our interest in sharing with every health care system.

Thanks, LEAN, for allowing me to recognize this.

I was reminded of this when I finished reading Pascal Dennis’ book (see my review here), and two recent events. Dennis says:

Detachment is a core Planning School assumption; the idea that we benefit by “abstracting” management from day-to-day operations.

Recognition #1

On my sabbatical project recently, working with other key leaders, we arranged to have two very important stakeholders come to the Gemba, many for the first time, to talk about providing for patients served in a leading-edge care system (see this post for the debrief and pictures).

The planning for the event was not straightforward, with lots of questions about how and why to do this, but the result was that the facts on the ground were obtained, and the conversations were rich throughout. How would I know about the epidemic (asthma) that was affecting families of this community disproportionately compared to the surrounding city? How would a payer and provider know where to collaborate to help these patients if not by being where the patients are?

The next day, when I visited with colleagues of one of the attendees, a comment was made by one that they have been meaning to visit this care site for a really long time. I think the attendees who were with me will make the case that it’s worth the trip. Not only that, but people are happy to show others what they do for patients.

As I have been spending time in the “abstracted” world of our nation’s capital, I realize how important these events are.

Recognition #2

On a recent trip to a invite-only workshop, I arrived to my hotel to discover that I had forgotten to pack dress pants. 30 minutes later, I found myself in a hotel van on a late night ride to Target, driven by one of the hotel’s managers.

He was in his 20’s and we were talking about his management approach. He said he preferred to work alongside his teams and help them solve problems directly. As an example, if a staff member felt that something was hard to clean, he would work with them to clean together, so they could see success. He said that he had been told to separate himself from those he managed to be a good manager and be respected.

The conversation made me think about how people learn how to manage and how it’s possible that we remove people’s ability to truly be respectful and be respected when we perpetuate the Fallacy of Detachment. It seemed like he was being taught the Fallacy of Detachment. My comment from the back of the dark van was, “You’ve got it right. Don’t change a thing.”

If I could at least throw a little doubt on the idea that detachment is appropriate (which is what I was taught when I was his age), I was up for it. That and the fact that I could get some very nice wool slacks at Target for a reasonable price.

As I have alluded to in the past, I think LEAN in health care will continue to get traction as more organizations tell their stories candidly. It is in the spirit that I post some excellent questions from one of our readers, in the hope that fellow experts here will provide their experience. If you are able to in your comments, let us know what organization you are either coming from, or where you got the experience that you did (as appropriate).

As I post this I remember contemplating heavily any mention of my organization or the people within it in this format when we first started. It’s a process to go through, in and industry that’s challenged by the concept of transparency. One outcome here is to hopefully normalize sharing for more organizations, as I have on the other blog I co-run (http://www.pchit.org).

Thank you, and comment away, please!

I am involved in the very early stages of a lean implementation in healthcare. Maybe you have addressed this on your blog, but one our struggles has been defining the best process for implementing lean. We are establishing a model line in food
services and are looking to begin spreading to other departments.

Our model line is still in a very early stage of development and we have only 2 engineers (as the major lean advocates) to support the hospital. Our focus has been to use a lean management system as a starting point. Some of the questions we have are:

How far to we take the model line before moving out?
How much training should we do beforehand?
If we start with the lean management, how developed does this need to be before
it is self-sustaining?
At what point do we need complete buy-in from senior management?
What should our implementation process look like?
And the inevitable question of how much is too much change? (Rhetorical)

Our approach so far has been to implement based on need. When the model line has an issue, we implement as much as we can to support that issue. The only constant has been a lean management system that I seem to be implementing with everything. We really have not done much training, but are now rethinking that to include much more. Our resources are limited, so my hope is that with education and a “push start” from us, the department will be able to realize success to keep things sustained. Past experience says this may not be realistic.

My thought is, that if we are going to do this, we should do it right. The thought has crossed my mind of value stream mapping the transformation process, but I would like a more experienced perspective on what the value adding steps are. Thanks again for your thoughts.

I’d like to ask for a little help with this one. Some of the work I am doing involves bringing leaders to the gemba for the first time, in the background of a non-LEAN environment. In what I do, this means shadowing a patient visit. I remember when I brought my boss to the gemba (see : Take your boss to the Gemba with you ) that I provided some guidelines to make things as appealing as possible. I felt I needed to do this because pre-LEAN, going to the place where work happens meant a lot of things to different people.

So here’s some of the guidance. I appreciate additions or changes:

Ideas about what this is for:

• To observe. Listen and Watch.  Notice 10 areas of potential improvement every 10 minutes, or use a template like “Stand in the Circle“
• To be as close to the customer as possible.
• To get the facts as to what is happening in the organization.
• To learn a little bit frequently (one patient visit every week is better than 22 in one day every year).
• To be visible to staff (who enjoy seeing you and showing you how they serve the patient)

Ideas about what you do not have to do:

• Come with prepared comments
• Solve problems on the spot
• Stay the entire day
• Act on every single potential improvement you observe

In the above, I don’t want to imply that a leader should erase the experience from their mind. It is assumed that the facts will have an impact on understanding problems and solving them - as they are laid out in a strategic planning process. This is to get away from a behavior where every visit should result in requests for action on what was seen. When this happens, people begin to dread the Gemba visit, because they will see it as expansion of their workload, and those who report to them will feel the same. A good strategic planning process should bring problems (which are gold) to the forefront and the Gemba visit supports that.

If it helps, I suggest that someone who is a CEO or Division Head pretend that they are not the CEO while they are shadowing. Better yet, pretend that  the CEO is the patient (and…just pretend that they are all the time anyway). If there is concern about their comfort or privacy, it will be respected, because the patient is the boss. Every visit will involve explicit consent from the patient, and there will typically be a break if a physical exam is involved, or at any time at the discretion of the physician or patient. (If this is truly the CEO/Division Head’s first time, I will accompany them throughout the experience until they are comfortable. One executive told me with some humor, “Don’t worry, I know how to talk to people.”)

The goal is for visits to become routine and not have tremendous amounts of what I call psychological overhead attached to them. Leaders lead best when they have access to the facts. And the facts exist as close to the patient as possible.

How does this sit with the audience? if you were a CEO would this make you feel comfortable about engaging in this activity? What else would you need to know or what questions would you have?

As part of my journey to understand LEAN in different environments for the purpose of growing it everywhere, I was invited to tour the Regional Laboratory at Kaiser Permanente Mid-Atlantic, one of the regions of our national affiliate, Kaiser Permanente.

As I posted previously, I have been observing the leaders and staff of this organization begin to embrace LEAN, and have been looking for more examples of LEAN practices in our nation’s capital. Luckily, I am finding them now, and this was a terrific example.

A case study about the lab’s transformation has been posted online.

I know many of the readers here have worked in lab medicine in LEAN transformations, so I am going to start by admitting a very naive perception that I have had of lab services as a family practice physician:

Whenever I have walked by a clinical lab, I have assumed that all of the big machines meant that everything was standardized and automated. The sample goes in the machine. The machine reports it. The patient and I use the data. Compared to primary care, what could be non-standard about laboratory processes?

(end naive perception)

Outside of the big machines there are huge potentials for variation and waste, and the impact is incredible. We started our tour with the story as told by the lab’s leaders. A decision was made to regionalize lab services, and the new facility came with a templated version of lab layout, which included walls, pillars, and separation of staff and machinery. The team knew they needed LEAN (more on that later) and started on a journey to build an operation that incorporated LEAN philosophy throughout.

For a service organization that performs about 5 million reportable tests a year, the impact is significant. The case study lays this out well, so I will focus on what I saw.

Pictures, click on any to see in gallery format

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