DailyKaizen

On Friday, I was a guest lecturer for a class my boss is teaching at the University of Washington Executive MHA Program: “Process Quality Management.” The name of the class makes me laugh a bit because I think of my training as a physician and ask myself, “what does a doctor know about process quality management?”

Rather than me answering that question, I’m going to ask the students in the class to answer it here, by commenting on this post. One thing I think I didn’t do as well as I wanted to during the session was to get input from these health care leaders about our approach. Luckily, through the technology of a blog, the conversation doesn’t have to end. I have to say I was impressed that several of the students had read this blog or were reading it before I walked into the room. Class prep now includes reading the lecturer’s blog as well as readings…times have changed!

My presentation technique aside, there were two concrete things that we’ve done based on LEAN philosophy that I discussed that struck me as transformational:

1. The “emergency response team” we have created, based on Toyota principles, to democratize the action of alerting the organization to patient safety issues. In much of health care, there’s a sense of hierarchy that can prevent quality problems from coming to light. Earlier this year, we changed our processes to allow anyone to “pull the andon cord” for a suspected patient safety issue involving our electronic systems. During my talk, my cell phone vibrated several times. I checked in after the session and learned that these calls were an emergency response team alert, fielded by one of the physicians on my team. A potential issue had been discovered and acted on immediately, no questions asked.

2. Involvement of the customer. I am going into a kaizen event with several teams this week. This is the first kaizen where we will have one of our patients there the entire time. It will affirm that we can do our work on behalf of members with them “in the room” figuratively, and literally. We are here because of them. Let us learn in real time how we can provide the best value for their time and money. Both the LEAN philosophy and our organizational heritage (we were founded by patients) fully support us in doing this. It’s terrific for it to come together in this way.

Maybe there were others…comments are open…

Yesterday, our organization was visited by leaders from one of our “partner-suppliers,” from an organization that we have had a long and productive relationship with.

We demonstrated some of the work we are doing in the information technology space, and of course, or work on our LEAN transformation came up. Because the visit was short, I found myself weaving LEAN concepts into the conversation throughout.

It was brought to my attention that the word “respect” kept coming up in my descriptions. In my thumbnail description of “5S” in the workplace, I talked about respecting the work environment. I my description of process improvement, I talked about respecting staff by supporting them in examining the way they do work and changing it to reduce waste.

Since I read and hear again and again that LEAN is not about what you do, it’s how you think, would “respect” be the one word used to describe the way of thinking if there were only a few seconds to describe it? I know I didn’t use this word as much before we started on this journey. It was interesting to get the feedback that this was a recurring theme in the conversation.

One thing I have enjoyed throughout this process is talking with other people who are innovators about LEAN, whether they know a lot or don’t know a lot about it. They are the best sounding boards because most of them are already there in terms of “how you think.”

This week, we’re doing a rapid process improvement that is near and dear to us, clinical quality.

There are lots of way to talk about quality in health care. One way is by looking at HEDIS, which is what we are doing this week. The exciting thing about this week is that we are leveraging all the work we have done to build our world-class electronic medical record / clinical information system to improve quality. For an informaticist in our organization, it’s the equivalent of taking the jet into flight, because informatics doesn’t exist to implement technology. It exists to support members’ health.

Wikipedia defines Informatics as “the structure, behavior, and interactions of natural and artificial systems that store, process and communicate information.”

We don’t define informatics or health informatics that way. We define it as “information storage and processing that improves the care experience, clinical excellence, and affordability of health care (for our members).” Health care exists to support people in achieving their life goals.

It reminds me of the story in The Toyota Way where the IT manager of a factory presents the IT plan to the factory manager, and the response is, “I don’t see any cars on this diagram. Show me how technology supports the building of cars.”

I can see from this week that it’s not the LEAN tools that provide benefit (even though they really help move the work faster), it’s the way we think that does. As we go over quality measures and think about how we exercise the power of the tools we have, we are thinking about how each impacts the member’s experience. If we stray and focus on the technology or the staff supporting it, we can get right back to the member by asking, “where are the cars (our members) on this diagram?”

I recently received a fascinating new book called Training Within Industry (TWI) by Donald Dinero. The book explores a program called the TWI that was developed during World War 2 to quickly bring non-skilled worker up to the status of being productive. The program is a standardized approach to training that focuses on the “daily management” skills necessary for supervisors to perform their tasks with minimal waste and maximum speed. After the war the United State government through their reconstruction efforts of Japan trained thousands of Japanese managers in TWI, which was quickly adopted by companies like Toyota and became the core of what is now the Toyota Production System. In the United States, once the threat of war had passed the programs were placed on the shelf and rarely used by industry. The TWI tools and methods are simple to understand and extremely useful. Their focus is to provide frontline supervisors the skills necessary to standardize their processes, improve their processes and to stay connected to larger objectives.
As a LEAN consultant one of my greatest challenges is helping supervisors and managers sustain change after an RPIW. In healthcare most managers are promoted for their technical ability, but we have not done a great job a building their skill set in process or daily management. Thus, we often have to teach as we go leading to a lot of rework and an inability to manage change without support. I think that some of the methods and tools that TWI provides could be extremely powerful in helping solve this problem.

I am in the process of setting up the sponsorship group that will oversee the “Model Line” project that I will be supporting.  One of the challenges is helping leaders understand how different LEAN sponsorship is from “traditional sponsorship” that is the norm in most organizations.  In the traditional model of sponsorship leadership designs the plan for change, sets the vision, and then delegates change management to a support team.  On a regular basis the support team reports out on progress and challenges.  Typically, the sponsorship group rarely or never is involved or present in the work areas where the changes is occurring.  This method for sponsorship is neither adequate nor effective in supporting a major LEAN project.  Many of the techniques and solutions will seem counterintuitive to leaders who are not experienced in LEAN application.   In a LEAN project, sponsorship needs to actively participate in the process of change so they understand the “what”, “why” and trust the staff on the “how” of the change.  Additionally, a LEAN project requires flexibility and responsiveness from a sponsorship group and decisions cannot and should not be batched up for a progress check.  

I like this quote because I really believe that it speak the truth.  I believe that the most important thing I do for the organization is to help others lead by giving them confidence and new knowledge.  Lately, I have been excited to see that my efforts are paying off and people that have been neutral in the past are stepping up and leading others toward improvement.

“I start with the premise that the function of leadership is to produce more leaders, not more followers.”

–Ralph Nader

This morning on the news I watched a disturbing story about a hospital in Florida.  The story was not disturbing because of something the hospital was doing, but instead because the press thought it was news worthy in the first place.  The story was focused on a program that the CEO had initiated that required all senior administrators to get this: “spend one day a month rounding on the hospital floors.”  The story accredited this strategy with turning around the “culture of the hospital.”  I wonder what the administrators are doing the other 30 days a month?  Just think what would be possible if they doubled their rounding time!  I guess LEAN has not caught on at all hosptials, or in the media. 

I read Lee’s post below and think there is a risk of flavor of the month, every day, with everything. I think it takes a concerted effort to draw parallels in what we do in health care with what has been successful in a system like LEAN.

Lee recently gave me the article Decoding the DNA of the Toyota Production System. As I read it, I realized what a long way we have to go in health care. This is a good thing - we have a lot to strive for.

I was especially interested in the piece about standardized communication, which we are working on right now within our Medical Group. In medicine, we are definitely trained to “present the patient” to each other in a standardized format, and we reach into that skill every time we ask for a consultation on a case. I think LEAN will allow us to further standardize in a helpful way, in terms of the help we are asking for and what is needed. I also relate to what I have heard about in terms of the “inverse pyramid” hierarchy, where the worker that’s closest to the patient is at the top, and leads are beneath them, making sure they are productive. I think that the primary care physician could be at the top of the inverted pyramid, and consultative specialists could be there in support whenever needed, to level course of care and keep the patients healthy. Our system can support that model.

That is where the benefit will be - the content of clinical care. Our members will notice it because it will be directly tied to their care experience, rather than to the support systems around them.

A manager I am working with that has been with the organization for a long time sent me a manual from the early 1990s that was created by the Quality Department to promote an internally branded TQM strategy.  A strategy that lasted only a couple of years and was abandon as leadership lost focus.  As I have worked with different departments skeptics often refer to this manual as evidence of why LEAN will not be successful and just another “flavor of the month.”   Flipping through the manually I am impressed with how professionally it was put together and how useful many of the tools are that are described.  So what happened?  Why did the program disappear?  What can we learn so that we don’t repeat the same mistakes? 

Since I was not here during the 1990s I can only guess what happened.  In the manual there is a lot of discussion on tools, but not much on strategy.  Basically, it describes the organizational approach as train as many people as possible and then turn them loose to “improve their departments.”  I can imagine this approach consuming a lot of energy and good will, but not leading to much improvement, as systemic problems remain untouched and improvements remained scoped with departments.  Without focus the organization might be able to make a whole bunch of improvements to small parts that add up to very little for the end customer.   I wonder if others have these manuals lying around their offices and can make better guesses then me?

Once again it is Friday and the week has flashed by.  I would say it was a mixed week, with a lot of successes, but also some set backs.  Overall we are on the right path, but often we stray a little.  I like this quote, because it describes where my work is right now and what I have to do.  To bring others with me I need to be clear about our destination, yet concrete about each step we need to take on the way.

“The secret of getting ahead is getting started. The secret of getting started is breaking your complex overwhelming tasks into small manageable tasks, and then starting on the first one.”

–Mark Twain