DailyKaizen

Since my last post seemed to be popular I thought I would write more on the subject of measurement.  In the Model Line area we have been working very diligently to improve the processes by which we adjudicate our member’s benefits.  The largest and most complex system we are working on is our claims production system.  Basically, our production system is made up two components: the Information Systems that runs a series of checks in order to process our members benefits and the processor teams that manually work the exceptions.   Both components are necessary in order to get the job done and if either has limitations or problems it impacts the other. 

As we break down the silos and reorganize around product lines we are making a lot of problems visible.  One of the largest problems we need to solve is to figure out how to keep our information systems groups and our processing teams in alignment.  Both teams are very dedicated, hard working and focused on improving their processes.  The challenge is that often the priorities of the two teams don’t match which results in a production system that is not running at it’s optimal performance. 

So why don’t the priorities match?  By asking five whys the root cause is mostly because we don’t have shared measures and accountabilities.  Our processing teams are focused on getting today’s work done today and that is how they are measured and held accountable.  Our systems teams are focused on adding new features, increasing automation, etc. and that is how they are measured and held accountable.  So when problems arise with bad data coming in, system related production issues, etc. there is not the same level of urgency to get them fixed across both teams.  On the other hand, when new features and enhancements are requested by processing teams there is no formal accountability for the opportunity costs of the resources required.

The fact is our teams are operating exactly as any rationale team would and they are responding to the system that management has designed for them to work in.  Moving forward we need change the system and the first step needs to be a focus on gaining agreement around the same set of metrics that both teams will be held accountable against.  If both teams are accountable for reducing cycle time, improvement in FTQ, and reduction in cost we can really begin to make large improvements to our Production System.

In the video, “Hitting the Wall,” Dr. Dave McCulloch talked about visiting with one of our Medical Center leaders in Burien, Washington. Here are the photos, and her explanation. What would it be like if you saw this data as a patient?

Here is what she said about this work:

This is our large bulletin board at Burien - it is in an area where small meetings take place, where folks eat and pass by multiple times a day.

We have designed our own one pager on access/supply/demand in the middle - with our priorities below - Continuity, access, quality and service in that order. The left side has the quality information. With a ring holding each teams individual providers quality scores. The right side has the same for the service information. On the opposite wall are two small bulletin boards with just information and decisions from previous all staff meetings.

To be honest the design of the board was for our IHI/Kaiser collaborative last year - but it was in the basement. When I came to Burien - admin moved out of the trailer in back and into the clinic - this near the admin wing so lots of traffic and high visibility.

Yesterday after pictures were taken (a few weeks ago), while putting up the new service information - we have one cluster that has much better scores. We put up stickers and arrows pointing this out and we’ll have conversations about what they are doing that is making the difference….

I chose the following quote for its timeliness.  Like most healthcare organizations we have very strong silos.  Within these silos we tend to have measurement systems, but they typically outcome focused and primarily in support of the silo and not the larger process.  As a result we don’t have a very good view of how we are performing for our customers and when things go wrong it is often hard to identify the root cause. 

In the Model Line area we realized this limitation from the very beginning and have taken steps to begin to create a value stream measurement system.  It has been hard work, but we have made a lot of progress and now have a far great understanding of the “whole” then we ever have in the past.  Recently, we have run into some additional challenges that will take some hard thinking to overcome.  Because we are rapidly reorganizing work teams and processes across the Division we also need to be re-designing our measurement systems as we go.  Our goal is to connect our Hoshin planning system with the Daily Management systems that are being implemented at the team level.  This challenge is compounded by the fact that most line-managers have little experience putting in place measurement systems and the leadership team has little experience with Hoshin.  Overall, to be successful we need to teach everyone how to manage with data and facts.

“The only man I know who behaves sensibly is my tailor; he takes my measurements anew each time he sees me.  The rest go on with their old measurements and expect me to fit them.”  —Shaw

Over the last couple of months I have found myself in the position of facilitating several planning and deployment events.  Like most organizations we have many challenges when it comes to focus, coordination of resources and keeping alignment across silos.  In the past during planning events we have used many different frameworks to try and gain alignment, but none as effective as STP (Situation, Target, Proposal).  I was taught STP about six months ago by one of our Sensei and I have continued to use it with success ever since and thought it might be useful to share with the readers of this blog.

The STP framework and process is very simple which makes it easy to explain and to learn.  The premise behind STP is that if a group of leaders is given the same situational information and they agree to the same targets then coming up with proposals should be simple.  In other words, the root cause behind disagreement on solutions (proposals) is typically a lack of understanding on the current situation or a lack of alignment around what the targets should be.   In my experience thus far I have found that in most cases leaders that disagree do not have a common understanding of the current state, thus they jump to solutions about what the future state should be.

By using STP it helps the consultant begin to make visible the root cause behind mis-alignment and then take countermeasures to ensure that leaders can gain agreement in the future.  During my last event it became very obvious that some of the support service leaders did not have a good understanding of the situational information relating to the production system, thus they had a different solution then the operations teams.  In this case, both groups had agreed on the same targets, but could not come to the same agreement on the methods to achieve them.  In the past it may have been hard for me to see where the mis-alignment was coming from and I may have addressed a symptom of the problem as opposed to the real problem itself.   As a countermeasure in this example we were able to beef up our current state information as well as bring one of the leaders to the Gemba.

For those of you that find yourself struggling to gain alignment I would highly recommend this method.

Imagine having a Medical Director of Clinical Improvement and Education who is so passionate about improvement, about being transparent, and always reflecting on his own process to be the best for his patients. Here’s David McCulloch, MD, in action. Dave also happens to be a nationally recognized patient-centered diabetologist; a mentor to a whole medical group of patient-centered physicians.

With thanks to our leadership for allowing us to try this approach. Please let us know what you think of it! As I mentioned in our last post, LEAN is changing our culture in many ways.

Enjoy. Filming and production credit go to Martin Stabler, MSW, another improvement champion.

The first part of this post comes from a comment made to me by one of our nurses, who I was shadowing today. I asked to see how she cares for patients because of the specialized support her team provides for patients admitted to the hospital - making sure that every day is useful and that they depart safely.

She made the comment as I observed her because I asked a few questions about why things are done a certain way. A few times, she stopped, showed me a few examples of how things worked, and then brought me back to the task at hand. When I observe I am clear that I am not there to critique or suggest a better way; I am there to watch and listen. I think that in the course of asking why things are a certain way, she began to ask why as well. I guess it is possible that it is an intervention just to pay attention to what is happening in your system. That makes my time twice as productive - learning about an important part of care that is provided that I didn’t know about, and supporting others in learning about the care they provide, too.

The second part of my post involves the aspect of LEAN that covers the acknowledgment of opportunities to improve. Health care organizations are sometimes reticent to do this in a public way. Our journey has opened up our thinking a bit to the point that when we reflect internally, we now do it with the idea that we are reflecting for our members, too.

With that in mind, we just filmed a video podcast of my colleague, David McCulloch, MD, discussing his use of a visual system to track our progress in improving quality. Before we filmed, I asked that we would film it with the intention of sharing it with our members. After we filmed, I asked my leadership to share it publicly. They said yes. It’s in the next post. Our culture is changing. Enjoy.

Last week I read Jon Miller’s Lean book reviews and decided I needed to re-read Jamie Flinchbaugh’s The Hitchhiker’s Guide to Lean.  For those of you that have not read this book I would highly recommend it.  It is very easy to read, practical and gives an excellent perspective on how Lean can be adopted successfully.  I read this books several months ago and found it valuable, but on a second read now that I have a couple of months more experience I found the book even more valuable. 

This morning I was reading through a section that provides the “Five Leadership Moves for Lean” and all five I found to be accurate and timely for the work I am doing.  Lean is all about leadership and your lean efforts will live and die by the effectiveness of your leaders.  I am not going to tell you what all five moves are, you need to get the book for that, but I will share with you Jamie’s thinking on “Leadership Move Three:  Eliminate Fear and Comfort”:

“For people to learn, they must step outside the bounds of what they currently know.  They must change the conditions and rules under which they operate.  This does not mean chaos and unorganized change.  Stepping out of the comfort zone should be purposeful, continuous and mulit-dimensional.  The leader must force people out of the comfort zone by setting clear goals and providing mechanisms.  It is not simply about setting higher targets.  It is requiring individuals and organizations to experiment purpose-fully.  A leader should not reward those who hit the number by merely repeating everything they did the year before…If a leader asks a worker every day about the experiments he or she has performed toward improvement, the worker will eventually have to conduct some experiments to answer the questions.”

I returned back home to participate in a rapid process improvement event in one of our specialty care areas: cancer care. After a focus on primary care earlier in the week, a focus on specialty care later in the week was a perfect balance. In our technology / business process innovation work, I think specialists (and the patients they care for) are vital in extending our expertise because they often take care of patients at times of greatest need.

Our cancer care group shares the same leadership as another specialty group we worked with a year ago, and the comment made was that a year later, our team was now noticeably tighter in its execution. This comment was made to me as I was looking at a projected image of the patient care tool the team created in just 2 days - I had not seen us create anything that sophisticated before, and it appeared to be something well within our comfort zone now. Amazing.

I think the team really had no choice but to get this good. There is no better impetus to improve the way you serve than to be continually exposed to those who you are serving. If our team had not been making regular trips to the Gemba, would their techniques have advanced as quickly?

What about the specialists and care teams? They were fully engaged and brought as much compassion to improving the system as they do to their individual patients, even spending time before and during very busy days to be available to help. It is remarkable to me after these experiences that anyone feels that improvement can only happen in spite of doctors, rather than in partnership with them.

What about patients? One of the folks I caught up with this week was Susannah Fox, Ph.D, from the Pew Internet and American Life project. Her team just launched a new web site, e-patients.net (because health professionals can’t do it alone).

This post from that blog provides great context for the idea that everyone has a role in improving the system. Consumer empowered health is not scary in a LEAN environment, because we support leadership at all levels and in every role.

And when we do, good things happen. One of the most impactful moments of this week was when a member of our team told us that she specifically requested that her work cell be assigned to this event. Why? Because she’s a cancer survivor and wanted to give support back to those who supported her. From seeing her work this week, I know she will impact many many patients who come after her.

I think this is the key strength of LEAN in health care, that it unites everyone around the needs of the person we serve, the patient.

At the tail end of my vacation last week, I had the great fortune to sit in and also present at the Patient Centered Primary Care Collaborative (Patient Centered Primary Care Collaborative Web Site) (My Slides) meeting in Washington, DC.

“The Patient Centered Primary Care Collaborative is a coalition of major employers, consumer groups, and other stakeholders who have joined with organizations representing primary care physicians to develop and advance the patient centered medical home.”

The basic components of the patient centered medical home are: Patient engagement, clinical information systems, transparency, and feedback.

What is exciting about this concept to me, originally proposed by the American College of Physicians, supported also by American Academy of Family Physicians and American Academy of Pediatrics, is that it has a nice fit within a LEAN framework that supports absolute focus on the customer, the patient. It think this represents a potentially significant and fundamental shift in the way health care leaders conceptualize the American health care system.

There is a very compelling video presentation on the site hosting the materials by Barbara Starfield, Ph.D., a recognized expert in health services, on the impact of supporting primary care models in health care. You can access it here.

In my comments, I suggested an additional component of the medical home model: the continuous improvement system. I asked the audience if they had heard of the Toyota Management System or The Toyota Way - about 60 percent raised their hands, which was very positive. I then showed a few images of our improvement events and pointed out that most of the individuals in the pictures were non-physicians, but all were involved in improvement efforts.

The impact of a national health care system that is funded around the holistic needs of the patient AND includes regular reflection and participatory improvement by all of its professionals is something that we would all welcome. I enjoyed learning from this accomplished group that we are not alone in moving in this direction, and that LEAN can gain acceptance as a system in getting us there faster.

I think it is worth following the work of this group and developments around the creation of advanced medical home practices. IBM announced that it will likely launch a pilot of an advanced medical home practice in January, 2008. Our organization has been piloting an advanced medical home since January, 2007.

This last week we had our first big problem become visible in the Model Line area and boy was it a good opportunity to learn.  Over the last four months we have been very busy pushing forward rapidly with implementation.  In are largest production area every team in in the process of being reorganized with the goal of taking us from a specialist model to generalist work cells.  At the same time we are redefining our management systems and putting in place a Daily Management system with a focus on standard work and visual controls.

As you can imagine there are a lot of moving parts.  Because we have to keep the production line moving at the same time we make the changes it is often challenging to keep everything in alignment no matter how much you plan.  Every team is going through cross-training, Kaizen events are happening across the division and managers are learning how to integrate PDCA thinking into their management practice.  The best analogy to decsribe our task at hand is that it is like changing the tire on your mountain bike as you are rushing down a steep hill. 

So getting back to the problem.  With all hands on deck and focused on the tactical changes we lost visibility of what was happening at the macro level.  Each team was falling behind a little bit, which we expected because of the training and improvement which resulted in increased inventory.   While the problem was not to large at any given team, when you add it up across the teams the levels were not acceptable.  The problem really became visible when our IT system had some challenges and our inventory levels suddenly jumped.  Managers that knew there was a problem found themselves in a situation where they did not know where to turn to raise the issues.

It was clear that we had a flawed management system and in the spirit of PDCA it was time to adjust. We had defined escalation paths within teams, but we had not adequately defined them across teams.  As the teams were pulled together this week we made many corrections and it was an amazingly rich learning experience.  It was a very hard couple of weeks on the management team, but it was amazing to watch them problem solve and learn together.  Moving forward we are implementing a new dashboard, we are re-defining our escalation paths, designing “rings of defense” and we are adjusting our checking processes.  Already our inventories have begun to drop.  In reflection I believe this will turn out to be a very good mistake to have had happen, because sometimes it take a mistake this large to really make the changes that are needed.