DailyKaizen

Over the last week I have begun to pull together a strategy for our expansion efforts of the Model Line work.  We are going to begin the process of value stream mapping with a group of leaders the upstream functions from where we began last year.  The scope of the work is daunting, yet, it is very exciting.  When we started the Model Line work we focused almost 100% on redesigning the operational areas and we purposely decided to avoid the design process (I will discuss our rationale in a future posting).  In this new effort we will focus on both the operations as well as much of the design process, which will offer all kinds of new learning’s. 

At the risk of being vague I will do my best to share my thinking on the functions we will be exploring and what we are planning to do differently then change efforts in the past.  In many ways these functions are a crossroad between the financing and the delivery of healthcare.  For those of you that know healthcare there are many challenges that not only our organization, but all healthcare organizations are facing in these areas.  As a result of these challenges the organization has continuously wrestled with the purpose and design of these functions.  

Many change efforts have been kicked off, but few have gained much traction.   Why?  I believe it is because as an organization we have not viewed these processes through the eyes of our members.  Instead, we have tried to design them around the needs of internal functions and regulatory agencies, which puts us in a situation of gridlock.  Caught, like all healthcare organizations in a world where financing and delivery are not in alignment.

So we are going to try something differently this time.  I ran off to Barnes and Noble the other day and purchased a couple copies of Womack’s and Jones new book LEAN Solutions.  The book shares a methodology that if followed allows you to map the provision, consumption and production processes together so that you are clearly bringing the needs of the center front and center.  We plan on following this process and our hope is that we can move the conversation away from what we need and transition it to what the member and patients needs.  I am confident that we can be successful, because every leader I am going to have on the team is committed to providing the best experience possible for our members.  They just have never been given the opportunity to see the entire experience through the eyes of the member and this is exactly what is needed to bring organizational focus in defining purpose of the process in the first place. 

I have written a lot about the Model Line area over the last couple of months and our focus on creating transformational and sustainable change.  During the week I got in a very exciting email exchange with one of the line managers and process owners from the Model Line area who is in the process of leading her team through this transformation.   She has been doing an excellent job leading her team through a roller coaster of change and it has been exciting to watch her develop her leadership skills. 

My concern is that we might focus more energy on RPIWs (rapid process improvement workshops) and less on our daily management system (standard work system based on the Training Within Industry program).  If we don’t understand how to create metrics to measure our status and progress toward “what our customers want” and learn to create visual systems to help us manage our business, what difference does it make…RPIWs get us big reorgs and major breakthroughs, but they are here today and gone tomorrow.  Our daily management system gives us a solid foundation to fall back on.  —Debra Moore

There are many reasons why I love this quote.  It demonstrates to me through its sophistication how far and fast the learning has progressed in the Model Line area.  A learning that can only occur through application and PDCA.  In her role as a line manager, Debra is currently in the position of balancing transformational change, which is the outcome of the RPIWs and sustaining that change, which is the purpose of the Daily Management System.  This is often a tricky balance to strike, because you can only go so far before you outpace the speed by which you leaders can learn.   Because of the hard work of Debra and her team we have put much of the foundation for improvement in place, but boy it has been very heavy lifting. 

I saw the aforementioned VP at a leadership meeting last week. He lived up to Lee’s description in his comments during the day - and he did read Lee’s blog post, so we’ll leave it at that.

One thing he said to me that related to the work I was doing was something to the effect of, “Before I spent time doing Gemba tours, if I walked into an area where staff was working, they would stop working. Now, they continue working because it’s normal for me to be among them.”

It made me think again about the culture and training of physicians. A few weeks ago, I arrived with a colleague to shadow a physician who I had talked to previously about seeing them practice. When we arrived on the appointed day, there was a concern, stated explicitly by this talented doctor, that they must be in trouble for something, otherwise they would not receive this attention. I explained that this was exactly the opposite - that this physician had a great reputation and had asked me previously for tips on using our systems and that I would be happy to oblige.

Last week, I was speaking with another very talented specialist about the way another department was using our systems. She asked, “Ted, do you know what their workflow is around this issue?” I know backwards and forwards how the system is wired, but admittedly, I don’t know how this work unit actually interacts with it at the level of the patient. So I said,”I don’t. Do you want to walk over there with me right now and ask?” She said yes and we did. And it was a great conversation. The physical presence of the layout said so much about their workflow and what was best for their patients. However, at the same time, it felt like there was an implicit assumption that there was a problem with a person or persons, otherwise we wouldn’t have come in the middle of the day to observe.

In each one the implicit “I’m in trouble” was wiped away quickly - the clinicians involved readily understood why this valuable and dug in - kudos to both physicians for not hesitating one moment to do something different to look at a problem. It was great. We all have the aforementioned VP in all of us. We just need the chance to be him/them. For physicians, who as I often state, spend 84 cents of every health dollar, their role in being the great VP cannot be understated.

I would imagine the employees in the model line will, through their experience with their VP, alter their management approach over time and come to expect this behavior from each other when they become VP’s. I hope the same for our medical group, and one day, for all physicians.

I think this is a good place to start talking about the role of medical education. Anyone out there interested in creating a 4th year medical student elective on LEAN? I’ve got the curriculum in my head…..

I thought I would spend some time today telling the story of the VP who has been my client for the last year.  We have been through a lot of learning together and he is a good friend and mentor.   I hope sharing the story will give hope to others that are working in organizations trying to gain executive support.  I am going to try and be as honest as possible and hopefully this does not turn out either critical or fluffy.  I am not sure if he will read this posting, but if he does I hope he comments. 

I decided to write this entry after I overheard a couple of front line staff talking about him the other day who did not know who I was.    The conversation went like this:

‘I did not used to like ____ (the VP)very much, he always acted like he knew everything.  I always thought he cared more for the claims departments and did not pay any attention to us.  I was really surprised a couple of months ago when he came to our area and started asking us questions about our work.  I figured something must be up, but he was asking good questions.  I was even more surprised when he showed up again and remembered almost everything we told him and then started asking more questions about our improvement.  Last week when he came by the entire team was so excited to show him how far we have come.  I really like him now.’

Our paths crossed about a year and a half ago when I assigned to a project that was primarily in the VPs area.  The project was being pushed from top down and the VP acted like most would in a similar situation and was not very engaged at first.  I am very persistent and nagged him (with help) to become more involved.  Over time the VP warmed up to our approach and began to take interest in learning more about Lean.  What stared as a trickle of interested turned into a waterfall as the VP began to ask for more and more books to read as well as becoming more and more involved in the details of our project.

After about four or five months I had to start getting out of his way, which I often had a hard time doing.  I was playing the role of the teacher, but was only months ahead of my student.  And boy had he become a student of Lean and spent a lot of time reflecting on his own management practices as well as the systems he had created within the organization.  He realized that he was in fact responsible and that if things were ever really going to change he would have to change first.  Thus, the concept of the Model Line (with others help) was born.   

Over the last eight months we have driven ahead with a goal of changing the culture and nothing has changed more then the VP himself.  Like an ungraceful Art Byrne marching into Wiremold our VP has dedicated every single hour of his day to changing the culture of his organization and helping those around him learn.  I can give you countless examples of when the VP has stumbled, demonstrated poor judgement, reverted back to old ways and made other blunders.   Yet, each time he has recognized his mistakes, dusted himself off and stepped back onto the path he has set for himself.  His lack of experience has not slowed him down at all and he is focused on learning by doing.  He is on his horse, intends to ride it and whats more important is that almost everyone in his organization will follow him anywhere!  The change in him is incredible by all measures.  For example, a year ago the VP spend 90+% of his time away from the Gemba in meetings.  Now he spends probably less then 40%.  Every week is visiting teams, teaching and helping them improve.   His energy and efforts are paying off and teams are really starting to respond as demonstrated in the opening discussion I overheard.

Anyway this is a kudos to our VP.  Now I can only hope I can find more of him, because pretty soon he won’t need me any longer.   

I had a good first day back from vacation and am excited to jump back into things.  Before I left for vacation as well as today I had a couple of conversations that worried me a little.  My worry is that management may be getting so focused on the application of Lean tools that they may be in some incidences loosing sight of the purpose of the effort in the first place.   For example, I had a discussion with a line manager who is pushing to have a rapid process improvement workshop (RPIW) in their area, but when I asked what problem they were trying to solve I did not get a very clear answer.    The manager had heard about others success with the tools of Lean and wanted their chance to put in “rings of defense”, steady flow and a heijunka even though they did not really understand the underlying reason for applying the tools.

I was not surprised by this conversation, and believe it is just an outcome of where we are as an organization on our Lean journey.   In the early stages of our Lean efforts we put a heavy emphasis on training and deploying various Lean tools with moderate improvement.   Our primary vehicle for improvement was events and they have served their purpose well.  At first we needed the exposure, sponsorship and focus on the RPIWs in order to make cross-functional change happen quickly.  The high profile nature of the events as well as the visibility of many of the tools have created a lot of energy and excitement that have caught the attention of leadership across the organization and the pull is very strong.  Moving forward we need to make sure we shape the use of tools and events in a way that leads to deeper learning.  Learning the context in which the tool is applied and not just about the tool itself.

Recently, with the start of the Model Line work we have begun to be more strategic with our training and deployment activities.  We have begun to shift away from a tool driven approach to one more centered on improving our management systems.   This makes the work far more difficult, yet far more rewarding.  Difficult, because it means that leadership needs to significantly change their behavior and roles.  Rewarding, because its no longer just about following the steps in applying a new method.

Tools and events will continue to be important components of our strategy, but they are simply tools and they should only be applied when system changes will result.   My worry is that as an organization we will need to get all 10,000 employees to understand this difference. 

Because Lee’s on vacation, I should try and approximate him a little…

Adults are always asking kids what they want to be when they grow up because they are looking for ideas - Paula Poundstone

I visited with a physician colleague about a week ago who sent me a note about an aspect of workflow involving our medical record system. I asked, “Can I come watch you practice?” Yes, she said. I came to meet her team and I observed a few patient visits. She asked me to also watch the flow of her support team, which I did. I didn’t have an answer because her setup is slightly different than the one we use at the medical center I practice, but I did capture some photographs of our team to inspire and give ideas.

A week later, I went back to the same medical center pick up another physician colleague who was being honored as student in an entering class of a very prestigious community leadership program (which is inspiring in and of itself - an organization that embraces LEAN does great things for society). On the way out, I ran into the colleague that I shadowed last week and we talked for a bit.

Then she said, “Come over here and see what I’ve done.” She had created laminated cards in various colors as a signal to her team which allows them to know which patient needs to be discharged. She said, “It’s better. I just need to remind myself to allow my team to handle discharging so I can tend to the next patient.”

I never would have come up with something like this, not knowing the nuances of her practice environment. Whether or not the new system takes hold, I was so impressed at this self-directed mini-Kaizen, which actually incorporated a visual system and reinforced synchrony of her team, for the benefit of the patient.

As I left the building to join my other colleague, I was marveling at this very busy physician’s creativity. She did it herself, with a mixture of intelligence, caring, and humility. I have never doubted that nurses and doctors know what good health care is. They will try anything to make it better - we just need to replicate this experience for every care team in every care system. What would it be like if we unleashed their creativity a little every day to improve one process they perform?

So now I know what I want to be when I grow up - a person who watches people solve problems. Not a bad aspiration!

I spent the last week away from work on vacation so I apologize to all that were looking for new content from me, but did not get any.  It was great to have a break to re-energize and I also got to spend a lot of time with my parents who were in town from the East Coast.   Because of the Quote of the week I am always looking for quotes I can steal.  In Vancouver, British Columbia I saw this quote on the back of someones backpack and thought it was timely for me. 

 “The time to relax is when you don’t have time for it”

Since I have been gone for a week I don’t have any new content for the blog, but I am looking forward to getting back to work and continuing to tell my story here.  So stay tuned…

I was very excited to read this study just published in Harvard Business Review Working Knowledge. Why? Because the authors compared work teams who were involved in process improvement and ones that weren’t in the Neonatal Intensive Care Unit and used an outcome that matters, “standardized mortality ratio” to test whether there was improvement.

Our local sensei cautions me that the definition of “Daily Management” that the authors use is not the same that’s used in the LEAN world. In fact, the article doesn’t really refer to LEAN at all, but the concepts and philosophy the authors are studying are the ones I think we all care about.

Please take a look if you haven’t and let us know what you think.

A long awaited journey was completed today, to the NUMMI plant in Fremont, California, by myself and the 3 business partners I work most closely with. Lee did not accompany us, unfortunately, due to a conflict (even though I did get clearance from his boss!). There is a no-camera policy in place in the interest of protecting the privacy of staff, so no pictures will accompany this post.

Our company is not one that has sent people to Japan as part of our journey, and I don’t know that this is a good use of our members’ dollars. Traveling to NUMMI, though was exciting. I consider it a gift to be supported in learning what we can from other successful businesses to help our members be healthier. And so we made this journey.

We began the tour with a short video of NUMMI’s history, followed by a Q&A session, followed by a tram tour. There were big signs on the wall with words like “Kaizen” and “Jidoka” which were of course familiar to us. The video was a lot about the people of NUMMI and less about the machines and the accomplishment is impressive. I remember the NUMMI announcement in the 1980’s and what a big deal it was - Toyota and GM working together? It was explained to us that GM was the landlord and Toyota ran the operations.

Before the actual tram tour, we were shown the training area, where mock cars were on a belt with andon cords over head. It was explained that some of the parts in the kits were purposefully defective, and the exercise was a training in pulling the andon cord whenever defects were seen.

What would it be like if we trained nurses and doctors to work in mock operating rooms or exam rooms where there was a quality issue or complication and they had to ask for help? What a great way to learn to solve the kinds of problems our patients face - problems of clinical excellence, care experience, and affordability. This approach was definitely not the one used in my (or most MD’s) training, by the way. The goal in my training was always to be self-sufficient - I have worked to unlearn this learning, but the attitude that spawned it still exists (do I really want to stop someone else’s flow to help this patient? YES!).

We were then on the tram tour, and I would say it most resembled a theme park ride. This particular plant builds Corollas, Vibes, and (UPDATED: Tacomas). I could not help but wonder at the amazing choreography of the building of these machines. It must have put together by a genius somewhere - or by a lot of smart people collaborating together to make things better every day.

What was really special, though, was the staff who ran by the trams to wave hello, and the spontaneous applause of the tour participants as an engine was bolted in or a worker crossed the tram path. People are excited by the idea that workers are empowered to do great work and take care of themselves and their families doing it. It’s what we want for ourselves, and what our patients want for their caregivers - they want to clap for a care team empowered to take the best care of people.

We were told at the end that one tour is not enough - 3 or 4 would be more useful. I would do it again. A parting request of mine was that the staff ask their doctors and nurses to come to their Gemba the next time they went for a health care visit. These are patients who have a lot to teach their teachers!

I thought I would piggyback off of Ted’s post from yesterday and tell my own Gemba story.  Yesterday I had the pleasure of leading a tour of leaders from a Seattle coffee company through the Model Line area.  Their goal was to see visual management systems in action and to share stories of implementation.  It was fun to have these new friends join us, especially because they are in nearly the same place we are in their Lean transformation.  It is amazing to me how the challenges in implementing Lean in a coffee company are almost exactly the same as implementing in a healthcare company.  Once again confirmation that it is all about the people.

It was an honor to have a team come and visit us for this purpose since we are so new to this world ourselves.  Over the last six months we have been developing and refining visual systems to support standard work, communication, leveling and problem solving.  The staff and managers have worked hard on their systems and their work is beginning to show fruits of their labor.   Having groups come visit, especially from companies held in high esteem is a great way to both recognize staff for their great work as well as to reinforce the work they are doing. 

I love leading benchmarking groups, because it provides me an opportunity to see just how far teams have come in terms of the learning in such a short-time.  As we moved from one team to the next we were met by staff that were excited to tell their before and after stories.  In front of one our hejunika’s we encountered a staff person that was in the process of pulling his hourly work.  I have known this person for over a year and in the past he was always reserved and shy.   Without preparation or forewarning he excitedly agreed to walk us through the story of his team’s transformation as well as the improvement he was working on personally.  The sophistication as well as the enthusiasm that he demonstrated made me walk out the door last night beaming with pride.   While my friends on the tour would not have recognized this transformation it was a big deal to me.

Its great to have friends come to the Gemba!