DailyKaizen

In the Model Line we are currently implementing a Daily Management System which I have dicussed in many of my previous posts.  The foundation of this system is standard work and a standard method for improvement.  Most of the eighty five managers in the Divison have completed their training, standardized and improved their first process and many have started on their second process.  Walking the floor you can feel the excitement from the teams and you can see how much their confidence has grown.  At the same time, there are several managers that have had a real hard time with this change in work and more specifically the change in their role.  They are not used to empowering their teams to make decisions and improvements.  Most of this work they have owned in the past.  Most are committed to the principles and the method, but they are challanged by having to extend so much trust.  Having the standard method for improvement allows us to empower teams to make improvements with very little risk, yet, it will take time for the managers to get away from the security they are used to when their job has been primarily to tell people what to do.   The following is a quote from John Shook that speaks to this very subject:

“Provide the method for improvement and hold people accountable to following it, but don’t tell people the answers.  The answers will come from the method.”

A couple months ago we had a consultant that came to the organization and taught us some of the tools and thinking behind Strategy Deployment (Hoshin Planning).  One of the key success factors he talked about was the ability to get leadership to the point where they no longer were “talking Ford talk.”  In other words, getting leadership to be honest and upfront about the problems they are facing, the business conditions they are dealing with and their own departmental weaknesses.  Its all about treating problems like they are gold so you can actually do something about them.

In the Model Line we have been working to learn this thinking and to adopt these practices and I have to say it is very hard.  We have made progress, but trying to change many years of well established, functional thinking quickly is an uphill climb.  Leaders here are used to protecting their departments politically and economically.  They are used to solving problems independently and cross-functional projects are typically bogged down by lack of standard improvement and deployment processes.

So next week we are conducting an all day strategic planning session where we are going to do our best to “stop the Ford Talk.”  Over the last six months we have removed probably three years worth of work off from our one year strategic plan.  In reality, we all knew that there was no way even a fraction of the things would get done, but we always left them on the plan for some reason I cannot explain.  Some sort of confirmation I guess.  The problem is we still have far to much work to accomplish with our current levels of resources and time.  So next week we are going to challange the group to make hard choices.  For us to be successful many of the leaders will need to give up a lot of what has always been considered theirs.  It will be facinating and hard.  Stay tuned…

In in the Information Technology sphere, we’re doing a lot of great things. We are also receiving a lot of great ideas. We cannot act on all of them, and our way of dealing with this issue is challenging to some - giving access to build tools in our system using standard work.

In most Information Technology Divisions, there are appropriate “change controls” on systems used by practicing providers. We have those too. At the same time, we realized that once we completed successful rollout of our system and began studying LEAN, there could be a different way to maintain system stability while supporting innovation.

Instead of requests being passed to Department members here to be acted on, from idea through to production, we have established standard work for building updates to our system, that allows a much larger pool of talented individuals to grow the tool.

On the one hand, it might seem convenient and less challenging to pass a request on to an expert builder, at least in the short term. In the long run, however, I think it is less challenging to be sufficiently empowered to build the tools yourself, because you’ll see the impact of them being built well or not.

In deciding what is a candidate for standard work and decentralized building, a key criteria is whether the builder will feel the impact of the quality of the work. If they need to access a portion of the system that could create impacts on others but not themselves, then this is not a good candidate for standard work. If they access a portion of the system that creates impacts on the services they provide only, this is a good candidate.

There are certainly negotiations that take place around this and we are doing this slowly and deliberately. The numbers so far show that a significant portion of our physicians report being engaged in tool building of some kind since we created standard work.

I have really liked the part about LEAN philosophy that focuses on each individual seeing the impact of what they do for our patients. It taps right into the primary reason we are all here - we are here because of them, not the other way around.

I really enjoyed Ted’s post from this morning and thought that I would build on the topic.  During the Lean conference I heard a great story from one of the presentors.  He talked about a company that was taken over by a zealot Lean CEO and the first thing that the CEO did was forced all plant managers to train supervisors in the basics of standard work.  He would then make surprise visits where he would walk the floor with the plant managers in order to demonstrate their knowledge.  The CEO was not doing this to support the learning of the supervisors.  He was doing it to change the thinking of the plant managers who when he began had a very different idea about what it meant to be management. 

I have said this many time before, but going to the Gemba and seeking to understand really changes one’s perspective of what is important.  Leaders so often get caught up in the image of what they think it means to be a leader that they forget to lead.  Chairman Cho of Toyota says that there are three keys to leadership.  First, go see for yourself.  Second, ask why.  Third, show respect for your people. 

The CEO of HOKS that Ted mentioned in his last entry is not on the floor to save the company money, he is on the floor demonstrating leadership.  He is not asking anyone to do something he would not do himself.  He is there to understand the work and more importantly to teach.  He is a leader that I would follow!

I was taken by the image of the HOKS company president on his his hands and knees cleaning the floor, from Got Boondoggle?: Japan Day 4 - HOKS Part I, and reposted by Lean Six Sigma Academy.

As I have been describing the concept of “value = what the customer is willing to pay for,” to others, I have at times stated that if a patient was willing to pay for their physician to clean their hospital room, I would do it.

It might be that if patients paid physicians to clean their hospital rooms in addition to all of the other services they expect of us, the cost of health care would be even more prohibitive than it is now.

It also might be that having a physician clean the hospital room during an admission might increase the patients’ confidence in their ability to get well, or the physician’s understanding of the unique impact of the care experience on each patient, and would therefore improve the accuracy of the history and diagnosis.

I have found it useful for me to think in terms like this. We often make assumptions about what patients are willing to pay for, both by stating that a patient isn’t willing to pay for something when they actually are, and vice versa.

From the HOKS experience, I appreciate that there’s a president of a $50 million company out there willing to rethink assumptions about what his customer is willing to pay for. We’re being supported in thinking that way here, too.

This last week I had the opportunity to spend a lot of time on the production floor observing work in progress.  It was a long time past due.  I spent several hours on process walks following insurance claims and I also got the opportunity to listen to phone calls from our customers.  Over the last month I seem to spend most of my days in a daze of back to back meetings, trainings, etc.  It was about time that I re-calibrated and reminded myself what is important. 

What I found on the floor was encouraging and daunting at the same time.  Managers and staff are far more upbeat then when we first started.  Most have now been touched by our training efforts and are now in the midst of using their new tools to create standard work and make PDCA improvements.  The inital noise and fear for the most part has been replaced by excitement.  At the same time I felt overwhelmed by the task at hand.  Our organization is a complex one, but everything is connected.  By going to Gemba in one part of the organization it is easy to get a reading on the whole and what I felt was a real urgency for us to demonstrate success and to do it fast.   The organization is looking to the Model Line to show it “how” to succeed in an every more difficult business climate, yet, success does not happen over night in a Lean transformation.   Will will move as fast as we can this year and hope that this is sufficent.

Here is a quote from someone unknown at Toyota that describes very much my experience in the Gemba:

“You can understand everything about a company that is important by observing from a good spot on the plant floor.”

One of the big lessons I took away from last week’s conference was the discipline and rigor that is required to be an effecitve Lean leader.   Lean leaders manage by data and they manage by facts.  They are careful to not jump to conclusions and solutions, but instead ask their five whys.  Lean leaders are careful not to tell people what to do, but instead ask them the right questions that lead to the right answers thus keeping the responsiblity with the right people.  A Toyota motto is to “never talk about a problem unless you go see.”

This is a powerful lesson for me and for the organization that I work for.  I am someone that loves to solve problems and I often do so at the expense of my clients learning.  At my organization I see this behavior displayed with most of the managers that I work with.  At most meetings I hear managers talking about “them” in the context of other departments having to stop doing something or needing to be fixed.  I hear solutions thrown around every day with little or know data to support them.  Worse, I hear solutions being thrown around by people that have not even gone to the Gemba to see.  Worst of all, I am a Lean consultant that often display this behavior.  Time to reflect and change.

Speaking with my mentor they encourage me to always ask why “five” times and then have those that I am supporting bring three options for the “how”.  In order to bring three options for the “how” they will have to spend the time to really understand.  For my own behavior I need to stop making statement and ask more questions.  I need to learn that solving the problem for others is a short-term fix with no long-term payoff. 

The organization recently launched a pretty incredible Web-based reporting system for understanding key quality metrics in the populations we serve. It brings together so much of what we are good at.

The data and presentation (which is aggregated, secure, and protects privacy by not identifying any patients specifically) is helpful, but I needed help understanding how to use it to inform strategy. Each trend chart needed an a bit of explanation of what to do next, so I asked my medical director of quality for help. Each time I asked, he said, “Come see the wall in my office.” Yesterday, he asked for my help with something and I mentioned that I would be in his neck of the woods. He wrote back: “Perfect! Then you can see my WALL”

So I went.

On his wall, he had all the relevant measures posted, trended over time, with a target, and a single point showing the medical center with the highest achievement. He then told me “the story” from the big picture perspective, and then more detailed “chapters” at the level of individual measures. He reminded me that the measures parallel high quality care - we are not working for the measures, we are working for patients.

It was such a different experience than looking at the data on a Web browser - I could tell much more quickly how all the measures related to each other, got ideas where we should focus efforts, and saw a presentation of a population who we care for, rather than a series of numbers. We could toss ideas back and forth about how we could support our system best. He told me what he was most interested in and what the opportunities were. There was a story for each situation. It was great.

My colleague is actually a seasoned clinical improvement expert, so the telling of the story is really second nature to him. I think he had the idea to present the work this way before we began our LEAN transformation. Either way, it came together nicely. One wall was better than 100 e-mail messages.

He enthusiastically blogged his thoughts on how this system is working for our team, and gave me permission to repost part of it here:

… for this grey-haired middle aged guy the data are no longer hidden. Every morning when I walk into my office I am reminded of what I am here to do; to help us improve the care we give all our members so that the quality of their lives will be improved. Please feel free to swing by my office anytime and take a look at the wall for yourself. It’s a beautiful thing.

Having management responsibility over part of Group Health’s centralized Lean consultancy I had a lot of questions for other Lean leaders at last weeks conference about how they structure and support their own Lean resources.  I spoke to several leaders, all of which had different models that they deploy.   Some of the organizations had large corporate teams of internal consultants while others had few to none.  Some tied their programs to their leadership development track while others used primarily external resources.  The one thing that was common to everyone I talked to was that no matter how you organize and support Lean there was never sufficient consulting support.   One thing I found interesting was that the companies that seemed to be the most successful actually had a very small ratio of consultants to employees.  Actually, the company I was most impressed with is massive, multi-national, has successfully been deploying Lean across the world and only has a handful of internal and external consultants.

 How can this be?  The answer is simple.  These companies believe that the responsibility for improvement and change rests with line management, thus they expend their resources in developing line managers.  This means taking a long-term approach and investing a large amount of time in taking managers off the production lines to learn.  I believe this approach is far more challenging, yet in the long term it is the only way to make Lean sustainable. 

In the Model Line we are taking these learning’s to heart and are designing a very aggressive learning plan for our leaders.  On top of nintymanagers and supervisors going through our Customer Focused Management Training Program (similar to TWI) we are also going to train all nine Directors and fifteen managers on how to facilitate and lead an RPIW.  Each of these leaders will participate in one RPIW and then lead two.   Our goal is to have this completed within the next twelve months which will require a major investment in time and energy.  Once completed we will have a critical mass of Lean leader that are technically competent and are ready to lead change throughout the organization.   

This last week I had the opportunity to attend the LEI conference in Atlanta Georgia.  Over the next couple of days I will share with you some of my key takeaways from this event.  Overall, I thought the conference was excellent and I learned an incredible amount.  Most valuable, was the opportunity to network with many great Lean minds about their experiences on their journey.  I had expected that most people attending would be from manufacturing and this was really not the case.  The conference had a very diverse set of atendees from every industry including healthcare, high tech, financial and government. 

The theme of the conference was creating a Lean Management system.  Most speakers talked about the challange of moving away from a tool driven approach toward creating an environment that promotes Lean thinking at all levels.  This was exciting to me, since it confirmed out approach we are taking with the Model Line.   The one thing every speaker and attendee agreed about was the importance of leadership involvement and modeling in the success of a Lean transformation.  Below are two of my favorite quotes from the event:

‘There are three kinds of leaders.  Those that tell you what to do.  Those that allow you to do what you want.  And Lean leaders that come down to the work and help you figure it out.’ –Shook

‘A Lean transformation is a long-term process.  To be successful you will need to change the thinking of one leader at a time.’–Balle’