DailyKaizen

In the Model Line area for most teams the rate of demand of incoming work varies greatly by day of the week and day of the month.  As a countermeasure we have developed a toolkit and training program for implementing heijunka boxes and have put in place three thus far.  Applying these tools has effectively leveled demand for these teams, but this to my surprise is only one of the many improvements that have resulted.   

Perhaps the largest change has been in how the team has begun to work differently together.  Prior to implementing these tools the teams were really more a collection of individuals then teams.  Work in most of these areas was hidden in the computer systems, each job type only had one or two people trained in how to complete it and performance management was focused almost exclusively on individual productivity.   As you can imagine this was not very compatible with a Lean culture.

In just a few months it is amazing to see how different these teams have changed.  Each day the team now meets to discuss improvement opportunities.  All work is visible and loaded in one hour increments with the work rule that everyone will stay until the work is done.  Batches are smaller, productivity is way up, inventory is way down and quality is up in each area.  When ahead on their work a team member that barely new another a month ago gladly jumps in to help another that is behind on their work.  The first few weeks were hard on the teams, because it was so drastically different then what they were used to.   Yet, when you talk to them it is evident how excited and how much pride they have for their progress I doubt they would ever go back!

Today I had a great dicussion with two leaders from a department that develops software in our organization.  These two leaders have been deeply involved in the Model Line work and have been on a steep learning curve with the rest of the leadership team.  They shared with me a model for cross-functional planning that was well thought out and innovative.  It was a model that was focused on optimizing the whole business and not just the department.  It was a model that led with operations and not with IT.  It also was a model that demonstrated that these leaders had reached a new level of Lean development that was no longer just about learning the tools, management system and principles, but unlearning much of their professional discipline. 

To unlearn is probably harder then learning.  In order to unlearn one must leave the comfort of what they know and what is most likely safe.  It might mean having to take apart something one has built.  It often means breaking with tradition and moving away from years of well established practice.  In most healthcare organizations it means learning how to lead with the needs of the patient/member and not the function/service line or supporting department.   I can think of countless examples of unlearning that have taken place in just the last six months in the Model Line.  We have redesigned long standing performance management practices, moved professional training into operations teams, eliminated many batch and queue processes, etc.  Each one of these changes/improvements were made by a team that had to unlearn a practice often within months of when it was put into place.  It is kind of interesting to think that in many ways Lean is as much about unlearning as it is about learning. 

We have reach the point in our Lean journey where the pull for Lean support is coming from every corner of the company.  A goodproblem to have, but one that can be costly if not managed correctly.  We have been cautious up to this point in the way that we have supported Lean efforts in the organization in order to avoid doing a whole lot of Lean poorly.  We have also become more ambitious with our Lean efforts taking on more and more complex value streams with a goal of deeper learning.  This presents a challenge for the organization, because this more strategic level work requires talented Lean leadership.  Thus one of the keys to success will be our ability to align and integrate our Lean efforts with our leadership development and succession planning programs.  Here is a quote from Bob Emiliani about this very subject:

“Top managers often say that Lean is critical to the company’s future.  If Lean is truly critical, then the leading candidates for advancement should be the people that understand Lean management best.  And the talent pool with be among those who regularly participate in kaizen.  Promoting the right people will motivate others who don’t understand Lean to learn and improve.”

I finished the week not with 1 or 2, but 5 different examples of exciting improvements in what we’re doing.

Monday: Talked off the ledge

As we were about to go into another rapid process improvement event, and I realized that one of our work cells appeared backed up, I called our Director of Consulting Services and explained my worry. Would we fall further behind and should I help reduce workload? She very calmly reminded me that a different work cell was going into the next day’s event, with a clean slate, and ready to perform, and in our new way of doing things, we did not have to worry about spillage from one cell to another, like we used to:

From: Eytan, Ted A.
Sent: Monday, April 02, 2007 1:00 PM
Subject: Thanks…

For talking me off the ledge - imagine, that with LEAN we can do more
than one thing at a time. I will blog this later on, a
great illustration.

And you do have the coolest job in the world.

-Ted

Tuesday: The DNA is changing

Said event started (with said donuts served at the beginning). I was in the role of observer as our team leads introduced a medical center team to the week’s activities. The introduction and discussion was clear and flowed easily out of the mouths of the physician and consultant leader (both our staff). This is not a big deal anymore.

Wednesday: Focusing on spread of innovation

I met with senior leaders about the spread of a new reminder system we are putting in for preventive care. Our last production of these encountered some bumps and I relayed what I learned from digging in deeper to the root causes and doing things differently:

1. This set of tools was developed with nurses and physicians at the local level, they dramatically improved usability
2. I reached out personally (by phone, no e-mail) to management at each medical center where we planned to roll out. I learned at least 2-3 important points of advice from each about how best to communicate and support the new functionality
3. I sat with our technologists to understand how the system worked to be as prepared as possible for any questions
4. On my way back from a meeting, I dropped in to one of the medical centers where we would be doing the work, and was briefed by one of our nurses on what I could do to be supportive. She pulled a laminated set of national guidelines out of her drawer and handed it to me - I ended up using that guide many many times throughout the week - 20 minutes of time where the care happens = 200 minutes of enhanced knowledge discovery of what the right thing to do is.

Thursday: Launching a product powered by LEAN; Reminder system launched

I attended a celebration for a new web platform product created by the organization. A huge banner was visible that said, “Lean processes powered by state of the art technology.” First time that I’ve seen LEAN included in official company communications. It was reminiscent of the first time I saw a web address on a billboard (that was for a very successful airline flying out of Oakland, CA, in 1993). Both events made me think that something was catching on…

Reminder system that I have been working on the team with is launched. We are in PDCA mode, reviewing feedback and making changes on the fly, in the production system. I see experts from across our State collaborating on what they are seeing in the system. They aren’t talking about what they are seeing in the system, though, they are talking about the patients they are taking care of and how the system can best support them.

Friday: Site visit and some juicy data

We were visited by staff from an innovative health organization, who I brought to the event that started on Tuesday. Visiting used to mean a stop at headquarters; now it means going to a medical center, where the care is delivered. All were on the same page; this has reduced friction, increased participation, and sped improvements. LEAN concepts are discussed as second nature.

Data delivered at the end of the day that our work backlog has gone from over 1,000 items in 2005, to 116 now. 44% of items completed in the last three months were completed by local staff, rather than being pushed to a central queue.

Happy First Birthday

DailyKaizen.org started on April 10, 2006. I wish everyone out there a year as interesting as ours has been, with a week so full of inspiration at the end of it….

Like most organizations we started our Lean journey by buying from a consulting group a set of tools that we quickly put to use on improving primarily functional processes.  After several successful projects we expanded our effort into value stream mapping across departments and began to connect our improvements.  This further increased our rate of return. 

With the Model Line we have taken the next step on our journey and boy is it a big one.  As on senior leader puts it “we are looking for sustainable cultural change.”   This is when Lean becomes really hard.  So why is it harder?  Mainly because we are no-longer just trying to change the process, instead we are trying to change the entire system.  We are not looking to just use the tools to eliminate process waste we are looking to put in a management system. So what does that mean and how it is different?  I guess the simplest way to describe our objective is that the elimination of waste in now no-longer focused on just the front line.  Leaders are being asked to eliminate waste in their own processes, which means standard work for management work and a new management system. We are asking leaders to not only sponsor, but to own, role model and participate in kaizen.  This is hard work, because as any Lean practioner can tell you it is a lot easier to change practice and behaviors at the front line then it is in mid or senior management.  Yet, without having the change in the way senior leaders behave and think we can do nothing more then apply the tools. 

I returned from being on the road last week to hear about a rapid process improvement event last week that went well. Really well. So well that everyone says so without prompting, from multiple clinical and business units. Considering the complexity that comes with health care, and the many stakeholders involved in improving an entire system, this is really remarkable. I visited the site where the event took place yesterday, and the feelings were still present. Most importantly to me is that I wasn’t there, and I don’t need to be - they did this on their own.

I then received a message from a staff member later in the day about their experience at another event (also one where I was not present) that is worthy of remembering whenever we ask ourselves, “why are we doing this anyway?”

I’m deciding not to post the entire note here, but I will quote one of the things that was said

I believe it is everyone’s dream who works for GHC [Group Health Cooperative] to be asked to part of the process and development of changes or upgrades…… My experience with QIST [Quality Improvement Support Team - our name for these events] was amazing. At QIST we all met as a clinic before the QIST event even took place. We got to discuss as a clinic what was important to us. Then we all got to vote on it- MD’s, RN’s, LPN’s, MA’s, and management.

And the response from our LEAN process owner back to me

Thanks for passing along, this is exactly what we hoped to accomplish with QISTs.

It is great to not have to dream about this anymore….

The work that is underway in the Model Line is quite literally massive both in depth of learning and number of people involved.  We have four large work streams all of which are challenging both the way that we do the work and the way that we think about the work.  As we move forward in transforming the work fo 675 people it can often feel overwhelming.  During the LEI conference everyone we talked to about our work told us were going farther and faster then we should.  Yet, most of the critical change requirements are in place.  We have a zealot leader that both trusts the process and leads by doing.  We are well supported in the areas of people, process and technology.  We also have very little choice.  The organization has invested a lot in this effort and we need to define the “way” for the rest of the organization to follow.

I often am asked how we are able to keep it all together.  Like with any large change process there is lots of noise.  There are always competeing priorities and more problems then resources and time to solve them.  Mainly we hold it together by asking the question “what does operations need?”  Toyota might be able to plan five years in advance, but us new to this world focus on what is need this week and next and the priority is always set by what we need to do to continue progress in our operational areas.   While all functions might be equal in importance we all exist to support operations.  If we focus on the needs of operations it helps us keep it all together.

In the past few weeks I have been interacting with leaders at peer organizations in the area of health information technology, and I have been surprised to find that we’re still a bit of a zebra when it comes to the application of LEAN philosophy in this area. Despite all the hype around LEAN (even Newt Gingrich drops the “L” word in speeches now), it’s as important as ever to have the elevator speech ready about it, because for the few that are transforming along these lines, there are many who are not.

Given the amount of resources that the health care industry is putting into information technology ($17-42 billion in HIT expenditures in 2004, growth of 5-18% per year), this is one of the most important levers we will have to improve quality, safety, and affordability. At the same time, we won’t improve these things by implementing technology, we’ll do it by critically rethinking our processes when implement the technology.

Rather than this being bad news, it means that the story will have plenty of relevance to those who are looking to get the right things done more efficiently. In some of the interactions I have had, there’s almost a feeling of discomfort that one institution would offer to assist another in improving. I guess that’s a sign that we like doing things this way, because we’re comfortable recommending them to others, even our competitors.

I had an interesting conversation with a leader that I respect on Friday about leadership participation.  I have been coaching this leader through the Model Line work and she has made great strides since we began.   Recently, this leader has become far more involved in the details of the operation that is under her in order to “seek to understand what is really going on.”   She now spends many hours a week observing work, coaching staff and problem solving.  She remarked on Friday that she has been blown away by how much she did not know about the work that she is responsible for.  More specifically, she was amazed by how little cooperation there was across teams that reported up to her.  She told me that six months ago she believed that she “did not need to know the work” she just had to have “technical experts under her that she could trust.”   She also mentioned that it has taken a lot of discipline to spend time on the floor and to stay out of her office.  It also has been hard on some of the managers that work under her because some of them feel that she is “micro managing” their work.

As we move forward with the Model Line work the role of all of the leaders in the organization is changing.  Leaders need to know the work under them and they will need to have a strong understanding of the technical matters they oversee.   Participation of leadership in the work is one first steps of cultural change!

“A lot of managers preach total participation, but don’t participate themselves.  Total participation is fundemental for breaking through sectionalism and the tendency to sub-optimize.”–Shoichiro Toyoda