DailyKaizen

In the Model Line area we are currently in the process of planning and executing multiple Rapid Process Improvement Events (RPIW) to transform the environment from batch and queue to continuous flow.  One of our major focuses is working down backlogs and getting to the point where we can complete today’s work today.   Other departments are focusing on the same goal and I believe this will be a huge win for our members and patients as cycle times come down and problems become more visible. 

Each of the teams I have been working with tend to run between a five and ten day backlogof work.  When you study the data over time these backlogs tend to stay consistent in size.  In other words, on average they get about as much done as comes in.  So why the backlog?  There are many reasons, but the root cause is a result of our tendency to set up a specialist model of staffing where staff become highly skilled in doing a small number of complex tasks very productively.   Having specialists leads to two major problems: first, it is very difficult to be flexible to changes in demand or staffing leading to bottlenecks.  Second, with a specialist model we tend to focus on individual productivity which leads us to establish systems where we try to always have work available for staff to work on (backlog). 

In order to reduce backlogs and get teams to a point where they are doing today’s work today we are applying many of the Lean tools.  We are building workcells, implementing hejunika, putting in place standard work, simplifying work and cross-training like crazy.  All of these efforts are begining to show drastic reductions in cycle time which will lead to increased member satisfaction.  In addition, we are beginning to see improvements in quality as well as reductions in work.  Quality has improved because we are breaking down our focus on individual specialists and implementing highly trained work teams.  Reduction in work, because when there is no longer a back log problems become much visible and since most of our processes are exception based we are able to determining root cause and prevent the work from coming in, in the first place. 

I’m still filling in for Lee, so I’ll try for the quote of the week. I’m doing this one from the lovely community of Burlington/Montpelier, Vermont, where I was invited to talk about patient activation and empowerment through Information Therapy. As part of the way I do things in the era of LEAN, I asked to visit medical practices where care is provided to patients, instead of just coming to show what I’ve done. I learned an incredible amount - 10 things every 10 minutes, easily. The graciousness of the patients and physicians who I observed is a reminder that everyone is interested in quality improvement - when we ask.

The quote is from a book recently published called “How Doctors Think?” by Jerome Groopman, MD.

The book does a nice job of pointing out the way physician thought processes are shaped and the impact that it has. Here’s the quote:

Does acknowledging uncertainty undermine a patient’s sense of hope and confidence in his physician and the proposed therapy? Paradoxically, taking uncertainty into account can enhance a physician’s therapeutic effectiveness, because it demonstrates his honesty, his willingness to be more engaged with his patients, his commitment to the reality of the situation rather than to resorting to evasion, half-truth, and even lies. And it makes it easier for the doctor to change course if the first strategy fails, to keep trying. Uncertainty is sometimes essential for success. - Jerome Groopman, MD

This quote talks about a patient’s diagnosis, but I’m applying it to the diagnosis of a system. Physicians are trained to resist uncertainty. When we learn to accept uncertainty it allows us to experiment with different ways of providing care. If a new way isn’t better, then we’ll try something else. If it is, then we keep doing it. I think it’s okay to tell our patients that we’re trying new things, just like Lee and I are doing on this blog.

I thought the book itself was excellent and is worth a read. It includes an action plan for patients. I would add an action plan for physicians - visibly diagnose and treat the system, too. It will increase a patient’s sense of hope and confidence in health care.

Yesterday I had the opportunity to spend two hours with Pascal Dennis, a Lean consultant that is currently working with our organization to develop a strategic planning and deployment process.  It was a humbling and informative discussion.   Six months ago Pascal taught us the basics of A3 thinking and after the training we adopted most of the methods that we learned.   During our consult we told our A3 stories and then got feedback on how we can improve.  What was very clear from the discussion is that we have made good progress, but we are far from mastering the thinking and the practice .  This became very  apparent when Pascal could not tell “what experiment we were running” by looking at our A3.

Reflecting on the conversation there are several changes that we will make for this coming year’s planning cycle that will result in further refinement of our management systems.  Most importantly we need to focus on developing more effective measurement systems that transcend our organizational silos.  Our biggest challenge right now is our inability to get cross-functional data, which means that much of our plan is built on intuition and not analysis.   Additionally, we need to greatly expand our efforts around developing standard work for management.  Until we have effective checking processes in place it will be hard for us to establish the level of organizational learning necessary to make breakthrough improvement. 

I will look forward to Pascal returning in a few months.  In the mean time I will work hard to make sure we have a strong hypothesis and clarity around what experiment we are running. 

In a recent post, I spoke about the experience of care teams designing a specific care experience for our patients about depression.

This got even more interesting for me. After that post, I received a message from the team’s leader (who I don’t think saw my post), and allowed me to share her message here:

We … believe the product the team produced (Caring for Patients with Depression) will be very valuable in improving patient care through out the State. We will be testing the developed processes next week and will update workflow documents appropriately.

What is impressive is that I compared it to what I wrote about this very same piece of work, given to a companion medical center about a year ago, on this blog.

The difference in approach is huge.

A year ago, our care teams expected that the work of improving care would be done before we arrived, and they would spend time understanding it. That was 2006.

In 2007, a companion team feels comfortable with the idea that they are leading the improvement, testing it, and making it better for everyone. Could it be that the culture is changing?

Last Thursday and Friday I had the pleasure of leading a group of the top fifty leaders of our health plan through two days of Lean training and discovery.  It was an exciting two days with excellent dialogue and many colorful debates.  The first day was spent discussing the three management systems of Lean and the WIIFM (whats in it for me) for any leadership team that decides to embark on a Lean journey.  The second day we taught the lean concepts of waste, quality, steady flow, and leveling.  We concluded by talking about Lean leadership and implementation approaches. 

As a Lean consultant I have led several leadership teams through training in the past, but this one was very different for several reasons.  First, the entire Model Line leadership team was there and co-lead each of the agenda items.  This meant that the training was peer to peer, which is far more powerful then listening to a consultant.  It also meant that discussion wasrich with stories that brought a lot of credibility to Lean and took away the ”that’s fine in manufacturing, but healthcare is different” thinking.   

Second,  it was very evident by the sophistication of the discussions that in just two years the organization has come a long way in it’s Lean journey.  Of the fifty leaders in the audience almost all of them had in some way participated in a Lean event.  Nobody was asking for 101 clarification.  In addition, nobody seemed to question the value of Lean, but instead asked questions about “how far, how fast.” 

Finally, the level of honesty and openness of the group was refreshing.  People spoke their minds, were open about problems and did not hesitate to challenge each other.  There was no selling of Lean and no sugar coating what it will take us as an organization to make the type of changes that would be demanded if we continue on our journey.   Overall, it was evident that Lean has taken the organization to a different level of thinking. 

 Two years ago when I first started teaching and leading Lean events most teams that I worked with struggled with the concept of using our minds first and not our money.  Most managers had long lists of ideas for improvement all waiting for either specialist support, more staff or funding in some future year’s budget.  It was always hard work to convince managers and staff that there was an opportunity for improvement that did not involve new technology or additional staffing.   For example, when I first started working with the leadership team from the Model Line area there was a strong belief that until we made significant investments in IT changes there was little room for improvement.  

As the organization has continued to become more mature in it’s Lean thinking I have heard far fewer requests for large investments.  I see more and more teams working with the equipment, facilities and staffing that they have and getting more out of it.   Its been a long time since I have heard one of the leaders from the Model Line area complain about the limitations of the IT system.   Just recently we were able to make changes to the work environment for a few thousand dollars in contrast to an outdated plan that called for nearly a million dollars in change over costs.   In that spirit here is my quote of the week:

 “Obviously, the highest type of efficiency is that which can utilize existing material to the best advantage.”  –Nehru

This is part quote of the week and part memorable statement, made by our hosts at Genie Industries, when we toured the facility in July, 2006. We were being shown a workstation in the plant, and various modifications that had been made over time by individual contributors, given time each day to make the work go faster, safer, and with better quality.

The words came to mind many times this past week, when I participated in a workshop to improve depression care in one of our medical centers, using the power of our clinical information system and our knowhow regarding workflow and care experience. Prior to my first visit to the actual medical center where we would do the work, I was given several ideas regarding the best way to implement our information system tools. I let my clinical experts know that their insight was very valuable, and that I was also looking forward to see what care teams in the medical center would come up with.

Sure enough, the care team did come up with something simple, elegant, and transferrable to other teams in our care system, as well as across the various medical conditions we support. It got better. Throughout the week, each idea kernel put on the table by our visiting team was refined and made workable in short order. At one point, I asked to be shown one such change / improvement - thumbs up, much easier to use for the same amount of effort.

Thank goodness we get to build our clinical quality improvement system this way now….

How do you explain to a member what 4 strategic divisions employing almost 800 people are working on on their behalf? This image is posted with permission of the Executive Vice President of Strategic Services and Quality, and shows the progress being made in using the discipline of the Hoshin process for these groups. Prior to these, there wouldn’t have been a wall where you could go and see what was happening quickly. This is huge progress.

At the same time, the A3’s fill a wall, and they are a mosaic pattern of approaches. This wall was setup intentionally to demonstrate the next step of our work, which is the linkage and creation of a consistent story about what’s being done and how it’s being done. The team I serve on is represented in just one of the A3’s, but like everyone else in the room, I have a role to play in executing to all of them.

This demonstration was part of a session where we began the conversation. For me it was phenomenal, because we began talking about product lines and each Division’s contribution to them. I had not been in a room where this conversation was happening ever before. That was remarkable. The other thing that was remarkable was that I was one of three physicians in the room, representing the disciplines of Informatics, Quality (Clinical Improvement and Education), and Prevention, and we were all engaged as strong supporters and champions of the work. This is definitely a sentinel event in our journey. I am imagining what it could be like if our entire health care system functioned like this.

First, I want to apologize to all of the readers for having the time to add some posts over the last two weeks.  And thanks to Ted for holding down the fort while I have been gone.  I promise that I am out in the Gemba gathering all kinds of good experiences that I will share over the next month.

So why have I been missing?  Mainly because right now there are many moving parts and their all driving full speed ahead.  Believe me, I am not complaining.  In fact, I have never had so much fun at work, but it is overwhelming.  Over the last week we have had three RPIWs in process, move then eighty teams in process of putting in place Daily Management systems, the entire Senior Leadership or our Health Plan going through Lean Management Training and numerous other improvement events nearing implementation.  It is awesome!   In just a couple of months the work environment has changed drastically.  Walking the floor you can feel the buzz from all the learning and improvement taking place.  Yesterday, I spent some time with several of the line managers and they had just experienced their first RPIW and it was amazing to me how far they came in a single week. 

The next couple of weeks will continue at the current pace before it will slow down with summer.  I will do my best to keep everyone in touch with all that is going on.