DailyKaizen

The readers and fellow LEAN bloggers always emphasize that LEAN is not about applying tools, it’s about philosophy. I enjoy seeing tools used as part of the work, rather than the focus of it.

This past weekend, in snowy Seattle, our team did an entire nervous system transplant of one of our core I.T. systems. It went very well. I woke up early on Sunday to visit the team and help out.

One of my colleagues showed me the visual system they had created as part of the work. It listed each task required to complete the night-long event, with projected times and outcomes. A red marker was used to write the actual time the task was completed.

As Edward Tufte might say, the visual had many dimensions of information contained within it. I could tell, at a glance:

• If the project was on schedule
• What percent of the project was complete

Which is what one would expect from such a display - things about the technical task. However, I could also learn things about the people and the process:

• The anxiety/excitement level of the staff, by the way they marked off each task - for example, several of the items were completed ahead of schedule. The red marker sometimes was used to cross out the projected time and replace it with the actual time. In other places, an exclamation mark was added for emphasis
• The fatigue level of staff members, by noticing how many hours they had been on duty, from the number of tasks crossed off and at which time(s) they started

This view of the work coupled with my watching and listening of those doing it, definitely made an impact on how I supported the group. They did a great job doing the work, and a great job leveraging tools we’ve observed to make it happen better.

I received a question from one of the blog readers yesterday that I thought would make a good entry. Also, I think there are others out there with far more experience then me that might be able to provide more thoughtful insight. Here is the question:
I would like to know to begin with how would you have a Lean transformation get started in a healthcare organization and to be successful will there be a particular area that we should first concentrate on, so we have buy-in with the management?
I am going to answer this question based on the approach that we took at Group Health and then reflect back on what has worked well and not so well. First, I would warn anyone against thinking that transformation is going to happen quickly, especially in the minds of management. Lean is all about embarking on a journey and the first couple of steps taken, unless you have a zealot CEO should be small and well thought out. To win over management you will need to show results which will lead to a pull for your support. Once this happens you will be able to contract with more leverage, which in turn will allow you to require leaders to invest more time in participation, which in turn will allow you to change the way they think–meaning “buy-in”. But first you need to get started.
There are two factors that we considered when we chose our first set of Lean “projects.” First, what leader would be open to new thinking and would be a good sponsor for this type of work. Second, what process is visible, has a big opportunity, but not overly complex. Based on this criteria we were able to find a couple of good areas to work with. We started in our laboratory service and pharmacy. Both these departments are led by strong leaders, they have processes that are easily made visible and there is always a big opportunity. I would caution anyone from trying to tackle a more complex healthcare process upfront like patient flow or OR scheduling. These types of processes will take a high level of technical sophistication, more advanced consulting skills and more importantly high levels of active sponsorship.
Once we had demonstrated success in lab and pharmacy we began to take on more complex, cross-functional work which has increased in complexity, scope and depth. Often we have made mistakes and gotten ahead of our leaders. I can think of one particular project that Ted and I worked on that took months to recover from, because we led our excitement get ahead of what the organization was ready to absorb. Management buy-in has quite literally come one RPIW or Value Stream event at a time, not as a big bang. The good news is that we have built a critical mass of supporters that is growing everyday.
So start small. Work with solid leaders that are open to new ideas and pick visible, easily scoped projects.

Over the next five months we will take the first step in reorganizing our Model Line processes around product lines (value streams). This means breaking down the current department centric structure and transitioning it instead into fully resourced, fully functional work cells. This includes not just production departments, but also supporting services like training and IT. I am very excited to begin implementation. For the last four months we have worked hard in developing a “master plan” that details each of the product lines from a process, people, technology and work environment perspective. We have developed our ideal system and will now work backwards to achieve it.
Through this planning it has exciting to identify just how much opportunity there is in making improvement in cost, quality and delivery. Yet, I am a little nervous that the larger organization may not completely understand what we are trying to accomplish and will get stuck in judging the work in through current paradigms. Being the Model Line we have had the benefit of a significant amount of resources being invested into this effort. With these resources comes a lot of exposure, high expectations and lots of noise. There is no doubt in my mind that we will be successful, but success needs to be measured over the appropriate amount of time. Additionally, success needs to be measured not through “big bangs” and “silver bullets”, but instead through small improvements made every day by every team that add up to huge improvements over time.
In fact, this is why the Model Line is different from the organization is used to sponsoring. We are not a project or an initiative with a specific end date. Instead, we are primarily focused on changing the way people think. We are reorganizing processes and creating a new system that will clearly allow staff to see cause and effect relationships and then have the authority to act on them. We are trying to create 700 improvement agents that will deliver results, not just a handleful of project managers and consultants.

Yesterday I had the privilege of watching members of my team present a plan for 2007 work, using a visual system, to senior leadership. The elements of the plan were taped around the walls of an office, requiring people to physically walk the room to see what was prioritized and how. There was also a discussion of the process and the way we would interact with business units, who really depend on the functioning of the systems we manage to serve patients.

I was, overall, very impressed with the interaction. It allowed the team I am on to demonstrate that they are aware of organizational priorities in a visible and tangible way. There was also healthy tension/discussion around the elements of the plan and the way they would be communicated to business units. What if a requested project wasn’t prioritized this time? How do we indicate relative importance of each in an objective way?

One key feature of the plan is that it extends 90 days, in a cycle. Formerly, we would plan for a year, and hope that the priorities of the business would be the same at month 11 as they are at month 2. From the experiences we’ve learned about in organizations that have done LEAN, we’ve changed the time horizon to 90 days. This allows senior leaders the opportunity to pursue a shift in strategy, and for us to be able to support it without excessively rearranging commitments. I was pleased that one of our leaders picked up on this and saw it as an opportunity, at the same time they provided guidance on representing the plan to their team(s).

The issue of a commitment is challenging for everyone. I don’t know that I/we have it right (and maybe some of the people in that room don’t think that I do). The best I know to think is, “My commitment is to do the right work for our members, as we know it today. I will make that same commitment tomorrow, based on what’s important to them then, even if it means changing the direction we set today.” I assume that those who we collaborate with will make sure we are all aware of organizational priorities and will shift with us, in the interest of the member. I feel (and hope) that this is a realistic expectation!

This is not an attempt to take over Lee’s Quote of the Week syndicate, just a handy addition.

I ran across this article in The Economist (subscription required to access), about “modesty” and the Supreme Court, which prompted me to review Chief Justice Roberts’ judicial philosophy and quote from his confirmation hearings.

John Roberts said,

Nobody ever went to a ball game to see the umpire.

My thinking immediately departed from the political sphere (and this post is not intended to take people there) and into the world of LEAN and leadership. In our environment, I would say, “No one ever went to the medical office to see the Chief Medical Information Officer.” They went to see nurses, doctors, and other people who care for them.

In the Economist article, it said that modern day justices conduct themselves like “philosopher kings.” This is what we are working to get away from, where people sometimes think they know what’s best at the level of the patient and their care team without physically being there.

With the understanding that we are what we are, support, we can be as modest and as humble as possible in our work with those closest to the patient.

This is why I thought the quote, extracted from the political realm, made sense here.

I am currently reading The Elegant Solution by Matthew May a book that describes how Toyota has created and maintained it’s culture of continuous improvement. I just finished a chapter where May describes Toyota’s methods for fostering employee creativity and ingenuity. In this chapter the author talks about how great companies avoid having victimism becoming embedded in their cultures and instead promote and reward those that are willing to take risks. I thought this quote from the text was interesting:
“The root meaning of ingenuity means free thinker. In a world run by powerful bosses and inflexible systems, rarely if ever is creative license granted freely. It’s taken. And that takes basic courage. Or at least a soldier’s bravado. It’s the obstacles that make the achievements so impressive. If it was easy, we wouldn’t me talking about it. No challenge, no creativity.”

In the midst of multiple planning adventures I am involved in right now, there has been a natural “fit” for the concept of Hansei (self-reflection). There’s a nice description of Hansei here. As in other work, I think we do this to an extent, but LEAN allows us to make it more explicit.

In one instance, I was asked if a group that met regularly in 2006 should continue to meet in 2007. I really didn’t have an answer for this. I didn’t want to provide one, either, because I don’t sit on the group in question and would be conflicted in providing input into a decision that affected colleagues without having their perspectives. I would imagine that these feelings might result in a lot of groups being supported in continuing to do good work for the organization. They might also result in more groups continuing on past the point at which they offer benefit. What’s right?

In this case I got unstuck by asking the question back (after being stumped for a bit, honestly), “Well, think back to why this group was created. What were the problems you were trying to solve, and what was the environment like in which you got together to solve them?”

I think there is fear that we could look back and say, “the problems still exist despite the work done.” This could drive continuation of the same manner of effort, maybe with more, maybe with less effectiveness. What if we weren’t afraid? Then we might say, “We did what was right for its time. Let’s do more of the same. Or let’s not.”

I’ve seen various flavors of the discomfort of self-reflection in the last few weeks. It’s required for hoshin planning (and it’s the “C” in PDCA, as Lee pointed out to me), luckily, which encourages its practice.

I have also been reading about structured models where this happens. One is the “After Action Review” practiced in the U.S. Military. There’s a formal guide to it, but also a very simple guide: “What was supposed to happen? What happened? What accounts for the difference?”

I have recently been challenged to work with a large group of mid managers to redesign their processes to go from being reactive to proactive. Since we are working within our model line department we have the luxury of providing this group with an extensive amount of education and support. Rather then helping them fish we are teaching them to fish. In this administrative area for many years process improvement has not been the norm and as a result the processes have become more and more complex. This has meant that it has become harder and harder to get accurate data and to be able to find the route cause of problems. As a result, most of the processes are more focused on catching problems then they are on solving them.
In order to simplify these processes and to develop these managers we have used many different tools and techniques. Two of the tools we have been using extensively and effectively lately is a simple fishbone diagram and a Pareto chart. These help managers prioritize opportunities and also help describe the cause and effect relationships, typically related to finding the route cause of problems. Quite simply, they allow managers to pick and own the best tactics for improvement and to be able to see first hand how their interventions are making a difference. It has also helped demystify many of the previous beliefs that have existed to explain why problems were occurring in the first place. Sometimes simple tools can make a big difference.

This quote describes perfectly most of the processes I have encountered in healthcare. So often I find myself wondering how some of the processes that I have worked to improve have ended up becoming so complex. Processes that started simple, but over the years have not been properly invested in with improvement resources. The result, complexity that is ever growing and more difficult to overcome. This is why Lean is so valuable, because it gives us some simple tools and principles to follow that allow us to quickly reduce complexity and if done correctly, build competency and discipline in our teams so it does not come back.
“A complex system that works is invariably found to have evolved from a simple system that worked….A complex system designed from scratch never works and cannot be patched up to make it work. You have to start over, beginning with a working simple system.” –J. Gall