DailyKaizen

I hear what you are saying about the Gemba.

I had a similar experience yesterday, when the Executive Director of Quality/Informatics and I visited one of our contracted medical centers, in Vashon, Washington, to explore the issue of “information continuity” with them.

What we had heard was that there were challenges in providing this affiliated medical group with data about their patients who received some services in their system. After reading e-mails and other communications about the problem, I had formed a fairly good conclusion of what I thought the key issues and fixes were. However, when we went to the actual site and talked to the care providers, a completely different picture emerged. I got a much better sense of the experience for the customer, the patient, and we were able to put a very significant fix in for this group, using technology that we are currently rolling out.

Our course of action was almost completely changed after going to the Gemba. I feel much more confident in supporting these physicians and the members they care for. Sometimes, e-mail is the wasteful modality and a ferry ride and a morning of time are the valuable ones.

Not to mention that the bumper stickers are much more interesting at the Gemba!

Typically, in the organization where I work it is the job of consultants and project managers to seek out improvement opportunities and to build a case for change.  Leadership picks a project area and the consultant/project manager is expected to collect data, analyze the data and develop a set of recommendation based on what they find.  Leadership then reviews these recommendations and either makes a decision or more likely asks for further analysis to be completed.  As a result, leadership is often uninformed about the work, decisions are made slowly, and staff doing the analysis becomes frustrated because they are unable to build a strong case in isolation of leadership involvement. 

I am currently working with a group of mid-to-senior level Executives to map a Value Stream and we are doing things differently.  Rather then having the consultant do the analysis work, I am instead facilitating the process.  For the next two weeks I will be spending upwards of 50% of my time with a group of Directors and Managers collecting data and observing the work within our Health Plan Operations Area.  Although we are only two days into the “actual work” I can already see the value of this approach.  This experience has really highlighted for me the value of going to the Gemba and why the process of discovery is as important as what is discovered.  Without understanding the work it is impossible for leadership to make good decisions about how to change the work. 

While two weeks may seem like a lot of time to take Directors and Managers out of their regular work, I believe in the long-term it will prove to be a valuable investment.  By participating they will see how the work flows horizontally across the vertical “silos” that they manage.  The will understand why shifting resources from one area to another makes sense for the organization and the patient.   They will understand how their work impacts others and how other’s work impacts theirs.  I predict this insight will allow us to make much more drastic improvements then without it, because through involvement we have already begun the change management process.  These leaders will not need to ask for more analysis because they will have witnessed first hand the reason for a change and the opportunities for our patients. 

David Kauff, MD, and I were talking about what it would be like in a true LEAN world to have a well adult visit, one that had as little waste as possible. We both know that most of the physical exam performed (such as listening to heart and lungs) in most adult physicals does not have any basis in evidence. In other words, we don’t know that using resources to perform this service on every patient is cost effective.

So what we talked about was a true “waste-free” visit. Patient wouldn’t say a word, we would ask for an arm to take some blood, get their cholesterol results, and provide them with the data and send them on their way. How would that doctor visit be like?

We then realized, it wouldn’t be LEAN, because it is not wasteful to touch a patient if that is what a patient is paying for. We know as physicians that both physicians and patients find it valuable to listen to heart and lungs and provide a healing touch. Value is whatever the patient is willing to pay for. LEAN is not designed to dehumanize the patient-physician relationship. It will enhance it by freeing up the physician and care teams to do what the patient is willing to pay for, to be healed.

I thought it would be usesful to tell a story about a Kaizen I experienced recently in our rapidly growing Central Pharmacy.  New technology has allowed our organization to provide such services as online prescriptions and pharmacist HelpDesk, which have been embraced by our patients.  Additionally, we have added a Medicare Part D drug plan.  While these services have been great for our patients they have also meant a dramatic increase in the volume and complexity of work.  In fact, our pharmacy call center is taking more calls then our customer service center!

 
In the past the answer to increased workloads was simple: just add more staff.  This is no longer a viable option as the organization strives to remain cost competitive, not to mention how impossible it is to recruit a pharmacist these days.  In August, pharmacy leadership contacted the LEAN team and after a thorough analysis a future state for Central Pharmacy was designed. 

 
Last week I had the pleasure of helping facilitate a Kaizen in our Central Pharmacy that was led by two of my teammates.  This was the first of three Kaizen that will take pharmacy from the current to the future state.  Over the course of the five-day event we were able to standardize the work, reconfigure the work environment and establish a work leveling system.  It is early to tell, but it looks like we will be successful in achieving the Kaizen goals of cutting cycle times by half and freeing up 10 FTE.  That is a huge improvement for patients, since they will be getting their medication quicker; and for the organization, since 10 FTE can be reapplied to more value added activities resulting in nearly $750K in cost avoidance. 

 
The Kaizen in pharmacy was successful because of strong management support and participation, good facilitation, and excellent staff engagement. 

This article appeared on the Harvard Business Review, and relates to a central tenet of LEAN: Respect your staff.

Why Your Employees Are Losing Motivation : HBS Working Knowledge
Participative managers continually announce their interest in employees’ ideas. They do not wait for these suggestions to materialize through formal upward communication or suggestion programs. They find opportunities to have direct conversations with individuals and groups about what can be done to improve effectiveness. They create an atmosphere where “the past is not good enough” and recognize employees for their innovativeness.

This experience by a former General Motors employee made me wonder about how we handle employee suggestions in health care. I have asked many managers in the last few months how many suggestions per employee per month they receive. The most common response is zero.

The managers I speak to are ones that have good relationships with their staff and are good managers. I do not get a lot of suggestions either. I don’t think it’s a matter of putting up suggestion boxes. One thing a colleague and I talked about was the idea of requesting one suggestion from each staff member during the first week of each month. What are other ideas?

Welcome to the first of many posts for the Daily Kaizen, a blog that is dedicated to telling the story about one Healthcare organizations LEAN journey.  The journey began more then a year ago, but the pace we are traveling seems to grow faster every day.  What started as an experiment in frontline improvement conducted in our laboratory has evolved into Value Streams spanning throughout the organization.  With each step we take further the incline becomes steeper.  Kaizen is no longer viewed as a “tool”, but instead as alternative way that we can run our business that puts our patients first!  Kaizen challenges the status quo, because it requires staff to work differently and leaders to lead.  We are not sure where this journey will end up, but we welcome you all aboard.