DailyKaizen

Last night I had dinner with a family member who is in town for cancer treatment. For hours we talked about the challenges of the current healthcare system. Although he is a stock broker by trade he has more experience and knowledge about the healthcare system then most people I know. Why, because he has been an active patient for a long-time, having fought off cancer many times. He has become an expert in cancer treatment and councils patients from around the world. It was fascinating to hear his observations and point of view.
One part of the conversation stuck with me in particular. A couple of weeks ago he spent a week in the ICU of a large east coast hospital. While there he became very close with two traveling nurses that were working on staff and he spent much of the week talking with them about the Quality of healthcare. These two nurses have been travelers for more then fifteen years and have worked in more then fifty different hospitals. One would assume that they would be an incredibly valuable resource for any hospital. They could come in and provide a fresh set of eyes, share best practices and transfer knowledge to the permanent staff. This was not the case. After observing the nurse work for a while my family member noticed inefficiencies in the process and began to ask why. Very simple challenges like why were the most commonly used supplies not stocked in the nursing stations.
The travelers agreed with the efficiencies, but said they were unwilling to pursue improvement. When asked why, they replied that to do so would mean that they would be blacklisted by the staff and end up in undesirable shifts doing undesirable work. They told several stories about how they had attempted in the past to bring best practices from high performing hospital to lower performing hospital without success and lots of hardship. I wonder why this is the case? I wonder why change is so hard in healthcare? This is a cultural challenge that will need to be overcome.

An entry Mark Graban’s LEAN Blog (one I read regularly), talks about an objection sometimes made by medical audiences about LEAN and its reference to manufacturing.

To phrase it as a question, I’ve heard “Is this assembly line medicine?” or “Are we building cars?” The answer to both is very obviously no, to anyone in medicine or supporting the improvement of medicine using LEAN. We are taking care of people. And we are not just taking care of people, we are helping them achieve their life goals through optimal health.

Those questions are not the ones that doctors (like me) want to ask. I’d rather ask, “What are we building?” than “Are we building cars?” That answer has more than a word or two to it, and it’s one that patients and doctors have plenty of time and energy to talk about. So let’s talk about that.

If there is something that I can do in every situation that helps every patient, like disinfecting my hands, like preventing heart disease using certain lifestyle and pharmaceutical therapies, or like reconstructing the process of care to maximize the patient’s time, my time, and their health, I want to know about it.

And I don’t want to only know about it, I want to help create it. We know there are some things that every patient should get reliably in health care. Let’s figure those things out.

Then after that’s done, let’s spend our time individualizing each unique experience and making it meaningful for every person we serve. How’s that for one piece flow….

Over the last month I have engaged in some colorful and constructive debates with a group of my colleagues about strategies and approaches to change management. For any change there is a hard (Process) and soft side (People) that needs to be effectively understood and managed. Many believe that focusing on the soft side upfront is the best approach and promote practices such as staff focus groups and conflict management training. I believe that leading with the process or the hard side of change is the best approach and when soft issues arise you have countermeasures well thought out and ready.

So what is the difference? In my view by focusing on the soft side we often build in a lot of waste, slow our efforts down and in the worst cases actually create more issues then would have been encountered without these efforts. I have often watched consulting groups and internal experts conduct studies on areas such as how effective is the communication process or how prepared is the frontline managers to handle change. Of course, each one of these studies comes back with the same results: the organization is not ready and we need to do a whole bunch of upfront work to get prepared. When ever you go looking for a problem you are going to find one and as a result we end up investing time and resource in soft interventions and trainings. Line managers that were often ready for change find themselves starting to question if they should be worried.
Our approach is to understand the current process and then working with the right people design the vision for the future process. We then decide the best implementation plan for the process, which includes countermeasures for potential people and process issues. When problems arise we deal with them, we don’t treat exceptions as the norm, but we are prepared when they come up. We are open and transparent with our communications. When managers start to struggle we support them. Whether it is a hard or soft problem we deal with it in a scientific way through PDCA.
I wonder what approach other consultants favor?

An exciting aspect of this journey is visiting with other organizations who are thinking about or transforming care using LEAN. It is a bit like traveling internationally and running into someone from your home country. There’s a feeling of commonality and community instantly with that person. There are also interesting differences in communication and custom at the same time. I am very impressed with the openness of organizations that allow someone like me to watch and listen. It’s great for the members I serve because I am learning more and more about the approaches that are most successful.

I won’t tell the stories of organizations I have visited on this blog because they own those. However, what I thought about when I last told our story was whether the next Art Byrne was in the room with us. I reflected on the fact that I started exploring LEAN based on an e-mail message from my boss, so my answer is that she/he probably is/was.

We may not meet her/him for 1 month, 6 months, or 2 years - and that’s just fine. I think the transformation needs to come from within, out of respect for where people are at in their journey.

On top of that, the great news is that I still have not met a care team that doesn’t want to take great care of patients.

Yesterday I got a call from the Director of Quality of a very large health system. I had originally met this Director about eight months ago when I presented at their annual quality conference in Colorado. At that time almost nobody in the audience had ever heard of Lean, but our presentation was received well. After the talk a small group came up to me including the Director of Quality and we talked a while about how to get a Lean Department started. They were really excited about the potential of Lean. They had been dabbling in Six Sigma, but had begun to run into some of the systemic barriers that can not be overcome by simply applying process improvement tools. I sent them some of our standard materials and toolkits to help get them started. Since that time I have talked with the Director occasionally when he needed a consult. It has been fun to watch an organization follow in our foot steps, and it has been equally fun to provide consultation to someone that I really respect.

When I picked up the phone yesterday I could tell he was really excited. They have been working on two large Value Stream transformations in their lab and pharmacy ancillaries. After some initial success senior leadership had begun to take notice. Over the last month their CEO has participated in three separate Kaizen and has become a zealot. The Director was excited because he had just left the CEO’s office where he was just told that the organization would be committing to making significant investments in Lean and wanted to take the next step. The Director had been reading this blog and wanted to know more about how to start a Model Line in their organization. He sincerely thanked me for sharing our work in this medium. It felt good to know that our efforts at Group Health have helped influence good work at other organizations that will lead to better and safer patient care for thousands more. I hope others are also taking advantage and find these pages useful.

I am back after a quiet week off spent with family and friends. During my time away I did a lot of reading, both for business and for pleasure. I have been on a Peter Drucker kick lately. He was truly one of the great minds of management thinking and was somebody highly regarded by Japanese companies including Toyota. In most of his books Drucker talks about the need for leaders to take the time to reflect and assess. To study where they have been and where they still need to go. What has gone wrong and why? What has gone right and why?
During the past week I did just what Drucker recommends. I thought a lot about what I need to do to get better at what I do and what the organization will need to do. I am energized from my break and ready to get back to work, and hopefully I will be more effective.
“Follow effective action with quiet reflection. From the quiet reflection will come even more effective action.” –Drucker

It was a real treat for myself and work colleagues to attend a community luncheon where one of our senior operations leaders talked about our organization’s work with LEAN. I am always ready to tell our story and what it means for the work I do. This time, I was the audience rather than the speaker. The “top down” part of “top down / bottom up” really hits home when your leaders are talking about the importance of LEAN to what all of us do. It is more than just the area of the organization that I work in now, and there is more demand for knowledge and learning about LEAN than the organization can supply. Cool.

Also during the luncheon, I happened to sit next to a gentleman who used to work at Boeing Aerospace. I asked him about the stories I had heard about Boeing being a leader in LEAN. He told me that his experiences corroborated this and shared knowledge about their success in significantly reducing the time it takes to produce a 737, in part by working with suppliers. I wondered when Boeing might turn to its health care suppliers for similar assistance. Maybe they already have. In any event, it will be great to know that if they have and if they do, that an organization like ours will have the ability to help this and other organizations achieve their goals for their customers.

I have recently been reading about plane building, from the 747 to the Airbus 380. The story of the 747 is an amazing one. So many contingencies were studied and managed to produce the marvel that the 747 is, and it wasn’t even intended to be “the” next generation transport (that was going to be the 2707, the never-launched supersonic transport).

With all of the processes that go into supporting healthy patients, it feels like we are building a 747 every day. I think we can build one that is as safe and of high quality as the one we get to fly around in….

Lee, wait, one more quick consult….

Yesterday, we met with some of our operations leaders about our work for 2007. We have stopped rotating our teams through our medical centers, temporarily, and planned, to support a major software upgrade that we must complete.

I mentioned to these leaders that I have noticed slight degradation of our performance in terms of understanding problems and acting on them quickly during this time period. I said I can’t wait for us to begin working again as close to our patients as possible. The response impressed me. It was that our care providers didn’t realize that our time with them “on the line” actually improved, rather than reduced our productivity. The perception was that being “on the floor” with them prevented us from doing “real work.” This was a nice perception to work with.

And I can’t wait for us to go back. Very shortly.

I am ready for a needed break and so is the leadership team that I am working with. On Friday I am going to get that break as I venture back home to the woods of northern Vermont for a week with my family. I hope most of the Model Line leadership team also gets some Thanksgiving time off. For our Hoshin planning we have clearly separated improvement work (strategic) from maintenance work (day-to-day). Being the benchmark for the organization has given us ambition and optimism, which in turn has led us to take on a lot of improvement work. At the same time we have not yet had the opportunity to standardize all of our core processes leading to instability in our maintenance areas. This combination has been tough on the leadership team, but they are doing great. Yet, again it is obvious that we need a break.

I didn’t know when I would use the skills I got in Hoshin Management training. I knew I would use them sometime. But not the very next day. It turns out that I joined an oversight team for an important project with tight timelines. Of course, I know that important projects typically don’t have loose timelines, so that’s expected and understood.

What wasn’t expected for me was that I could talk colleagues (hopefully) through the concepts I learned in Hoshin and proceed to develop a plan using an A3 as the “storyboard,” to define what we had tried before, and what our action plans would be. I think there was interest in the approach, so so far, I have not been voted off the island as it were.

One of the ideas I introduced was trips to the place where the work happens for our patients. My colleagues enthusiastically signed up for these. I did too - to areas that I have never been to. People asked what should be done when they shadow people serving patients. I said, “Watch and Listen.” Actually, this was advice given to me by a senior leader a few years ago, and it was right on.

I am honestly a little nervous about introducing a change in planning like this since deviations from the norm mean more accountability for the result. On the other hand, I consider myself 100% accountable for everything everyone does to serve our members. So I’ll tolerate being nervous. And enjoy the enthusiasm of my colleagues in trying something new to help our patients with me.