DailyKaizen

Our Informatics team has been spending a lot of time at the Gemba for the last year. In our non-profit health system, the Gemba is not a manufacturing plant. It’s a medical center where real people tell their stories and go through the healing process. And I now see that the time there has been transformational far beyond what we did to help the individual patients we met.

Every day, our work designing and supporting health information technology systems brings a new challenge. some of them quite incredible. Very recently, when confronted with a challenge, I found myself in a room with managers who had been there (to the Gemba), and I found myself working with people who knew the impact of what we are doing. No arguments about what should be done - we did what a patient would want us to do. It was actually remarkable for me to see.

If there is ever talk about physicians not being systems thinkers, there is talk from physicians about non-physicians understanding the content of care. The people I work with understand the content of care, courtesy of many patients, physicians, and nurses who selflessly invited them into exam rooms to learn during our transformation. We have MD’s on the team that serve important roles, of course. The entire team, though, understands that everyone provides care.

So here’s my hypothesis: Time spent in the medical center with patients is like time exercising at the gym - it conditions and creates biological reserves for future body stressors. The gemba seems to do the same thing, conditioning and creating reserves for future stressors. The caveat is that regular conditioning is required!

To provide care, I don’t think you have to do surgery, read an x-ray, write a prescription, or have an M.D. You just have to know what it means to be there for a patient.

When you can provide health care, you can improve health care.

How quickly we get caught up and frustrated by the limitations of our IT systems. This was my key learning from last week after spending many hours walking through a maze of Administrative processes. Almost every staff member and manager that I talked to had a wish list of IT fixes and a longer list of IT problems. In this age of computer technology we have layered over almost every one of our Administrative processes with automation and work flow software. So much so that the associates doing the work are often unaware of the true nature of the work that they are doing or what connection it has to our members and patients.

As I sat with staff they would constantly point out the flaws of the system and describe how much more productive they would be if the system only allowed them to do something. We get so used to following the work flow that the computer lays out for us that we have forgotten to ask why are doing much of the work in the first place. Rather then question the work itself, we end up questioning the way that the system is designed and when no IT resources are available to make the fix we simple get frustrated and stop questioning all together. As we begin to redesign our processes around Value Streams it will be interesting to see how much of this software that primarily exist to pass work between departments will no longer be needed. I hope all of it….

I found these quotes in the newspaper this morning.  Since they fit so well with Ted’s quote I decided to pass them along.  In the article it talks about how most great companies had a “defining decision” that shaped their success moving forward. That the difference between these great companies and those that have gone into decline is that they were willing to take great risk at a time when it was required while their competition continued to take baby steps. To be successful these companies not only made the decision to change course, they also did not waiver from the new path.

“Don’t be afraid to take a big step if one is indicated. You can’t cross a chasm in two small jumps.” — David Lloyd George

“There is at least one point in the history of any company when you have to change dramatically to rise to the next performance level. Miss the moment, and you start to decline.” — Andrew Grove, Chairman, Intel

Taking a slight detour into the philosophical realm (part of my training in LEAN, to understand the “why”? of what I am doing), I was fascinated by this weekly podcast by Jack and Suzy Welch on the topic of this post.

The most important reflection for me was the way the question was interpreted. It was broken down into the possible options:

• It belongs to the shareholders?
• It belongs to the employees?
• It belongs to the customers?

It missed one option for me:

• It belongs to society?

Jack does refer later on in the podcast to companies supporting healthy societies. I think this is important, and an underpinning of LEAN - respect for, and interest in helping society. I believe that’s a general characteristic of most health care organizations which is one reason there is a fertile ground for LEAN here. Lee and others know that one of my most favorite quotes is the following. I use it to illustrate that there are parallels between the calling that medicine is, and car building:

Everyone should tackle some great project at least once in life. I devoted most of my life to inventing looms. Now it is your turn. You should make an effort to complete something that will benefit society. — Sakichi Toyoda to his son Kiichiro, founder of Toyota Motor Company

The work has been moving forward at a brisk pace within the Model Line. I thought I would take this opportunity to share our approach.  In order to break the work down into manageable pieces we have started with four Work Streams all working toward a common milestone in February when we hope to implement our first product line.  The four Works Streams are as follows:
 Operations:  To systematically transform current structure and processes from vertical to horizontal alignment through the application of LEAN principles

Demand Management:  To systematically capture data on the cost of variation, quality, and system limitations and over production in order to make informed decisions on how to reduce overall demand within operations. 
 IT throughput: To significantly improve the throughput of IT improvements and changes.
 Customer Focused Management Training: To develop a new management system that will result in standardized process that under control, measured in real time, visually displayed and improved on an ongoing basis in collaboration with staff members
 
Our Operations Work Stream will be the pacer for our transformation.  With the Demand Management Work Stream we are looking to reduce type 1 muda so that we can free up our best and brightest that will lead our change efforts.  The IT Work Stream is focused on changing the process by which we make changes in our IT system so that we are faster and more reliable.  Finally, the Customer Focused Management Training we are currently developing in house and will be training all 650 associates over the five months.  

Lee gently reminded me that I hadn’t posted in a bit. I have been on the road (and not that one can’t blog on the road, I am actually doing this one as I walk….technology is empowering) which has the impact of removing me from the gemba and therefore reducing the learning opportunities. Interesting - in the past I might have thought that time away would be where the learning happened.
Despite not working alongside Lee lately, I share the same feelings (the organizational nervous system transmits energy well across physical space, I suppose). Where will we go next? Deeper into information technology products - the support system, or into the content of care, the true support system.
My vote is for the latter.

Over the last couple of months I have found myself caught up in the excitement of the huge changes that we are leading and have had little time to pause. This last weekend I had the chance to get away and went on a hike by myself and for the first time had the opportunity to really reflect back on the work we are doing. I have so often found myself in situations over the last year where I had no idea what to do next. We have been working in unchartered ground and there are no benchmarks for us to follow. Often we have made decisions based on data and just as often we have made decisions based on principle because there was no good data. We have made mistakes, slid backward several times, but are still far ahead of where we were a year in the past. Most importantly, we are getting better, more knowledgeable and are pushing harder then ever. Getting out of one’s comfort zone, taking risks and learning from mistakes has treated us well and will continue to be our game plan moving forward.

I chose this quote to challenge those that are comfortable in their healthcare jobs, because I believe it is their obligation to try new things. This weekend’s Sunday newspapers were packed full of articles discussion how “broken” the US health system is. How many people are uninsured. How many medical errors are happening. Many of these problems are systemic and out of our hands, but just as many occur within the boundaries of our control. These articles frustrate me because there is so much opportunity, but only if people are willing to try new things. We need to stop focusing on what “we can’t do” and what “we can’t control” and instead get busy on making improvements in the areas that we do have control.