DailyKaizen

In my last post I mentioned our discussion last week in regards to human resources and how it is viewed differently in a Lean organization.  Well that discussion has gotten stuck in my head and I have thought a lot about it over the last couple of days.  When I think about what makes great organizations stand out from good organizations the answer is simple: the engagement of the people that work there.  I believe that almost all organizations are collections of very smart, good intentioned individuals that desire the opportunity to provide a meaningful contribution.  Yet, few organizations have figured out how to put the right management systems in place to create this type opportunity for their employees.    Instead, they are mired in their traditional management practices that look at people as costs, and like with all costs the need to be tightly controlled. 

In the Model Line area we have been working hard at shifting our management systems to align them with the principles of respect for people.  It has been hard and often slow work, because you cannot build trust overnight and employees have learned to maneuver many changes in the past so they are cautious of anyone saying that this will be any different.  Still, it is beginning to take hold in almost all of the teams that we are working with.  Managers and staff are far more vested in improving their work then they ever have been before.  Capable employees are being allowed to not just use their hands, but also their minds to make a difference and as a result their engagement is creeping upwards.  By continuing to tap into the thinking of our employees we have a great opportunity to create a competitive advantage that none of our competitors could copy.

I believe our work and learning’s in the Model Line area is beginning to influence the larger organization as it moves forward in developing it long-term strategic plans.  Our organization, like most is searching for ways to reduce cost in order to remain viable.  As a result there is a lot of discussions on how to cut back on resource allocations, which may be appropriate, but not complete.  I think there are some short-term resource decisions that need to be made in order to cut costs.  More importantly, as the Model Line has taught us the only sustainable strategy is to invest in the right resources: our people.  And to do it with a long-term focus.  All other resources are scarce, but human resources if tapped are limitless.

These were my words to a colleague sitting next to me at our Division’s annual meeting today. Our Divisional teams were showing off their daily management and cross functional team and strategy management (very cool), and at one point, someone asked what happened if a dependency existed on a team that was not yet part of this management system. Our presenter said this is a challenge, and then I said my words, because I was in this session with all of the senior leaders from the Division.

I then said something to the effect of, “Now that this issue is out in the open, the leaders are going to need to respond to this and fix it.” And that’s when my colleague turned to me and said, “The front line staff are fixing problems. The leaders’ job is to acknowledge it.”

I loved this and the conversation after, where we shared the fact that we have both been in front line positions in our lives, and what it felt like to be fixing problems all day. I will remember this - to find out what problems are already being fixed.

‘Human resources in a Lean organization is the responsibility of all management and not a function.  Since human resources are the most important resource of an organization it is important that all manager feel accountable for them.’ 

–Kris Box

As Ted mentioned I spent the last week participating with as well as training a group of leaders from our health plan Division.  It was a fun week and exciting to to me how each time we do another training it seems to become more effective, sophisticated, and system not tool driven.  For the first three and a half days of the week we focused on technical training in such areas as steady flow, leveling, pull systems and quality assurance.  During the last part of the final day we devoted the afternoon to talk about People systems, which was taught by our Sensei.  It was a fascinating discussion about how the People systems of Lean organization are far different then those in a traditional organization.  Not unexpected the discussion quickly moved to the role of Human Resource functions in a Lean organization and I stole the above quote from this discussion.   

This week I have been invited to participate in a consultant training that Lee and our Sensei are conducting in our Health Plan Division. Many here are not doing this for the first time. There’s a lot of new things for me, as well. Besides the learning that I am engaging in myself, it’s great to see colleagues from another division go through the process, as they apply what they are learning to what they do for members. We are all connected.

We prepared a control chart as part of an exercise today, the first time I have done this. To create this chart, a group of 5 of us was responsible for hammering a nail into a board to a specific depth, drawing the histogram (pictured), and calculating the process capability. Ours had a bit of an uneven distribution. Can you tell why? (Hint, there were 5 people on the team)

Our sensei walked by and said, “It looks like there is good process control, but not capability.”

As usual, I see many correlations to what we can do in clinical medicine….

If you could have a leader participate in a planning process for 10 hours once a year, or for 2.5 hours four times a year, which would you recommend?

I have a feeling the answer to this one won’t be controversial for the LEAN community!

I was on a walking meeting with my boss yesterday and he asked me how he (and the organization) could be engaged in and confident of the planning process for our clinical information system as my sabbatical looms very near (more on that tomorrow).

Well, I said, we have converted from a yearly planning horizon in 2004, to a pseudo-quarterly planning process in 2005, to a true 90 day planning process in 2006 and 2007. Each 90 days comes with a set of predictable steps for involvement of the stakeholders for the electronic nervous system for our health care processes. He wondered if we were getting it right, if we would provide enough bandwidth and input to folks who wanted to implement improvements in all of the clinical areas we support.

I felt the answer is in the cadence of the planning event, rather than in the accuracy of any individual one. Everyone gets a chance to make it better if they do it enough times. With frequency, conversation never really ends, it just continues on a schedule.

I ended my appeal with, “It really is our accountability to deliver on the cadence of this process, and if we don’t, then we are not living up to the expectations we’ve set and we should be in trouble.”

He asked how we’ve been doing so far, and I told him - we’ve completed three cycles, each with “greater” success than the one before it, and the next cycle would start soon. I did not know the exact day it would start, just that I was confident that it would start. What I worried about just a little was the fact that we are about to do a major software upgrade, and whether that would throw the schedule off. That would be hard us to experience.

As it so happens, just a few hours later, stakeholders received a well crafted message from our clinical information system manager, announcing that the 4th quarter process was beginning anew. She included a reminder of the steps involved in the process, down to the day, and even a full accounting of the number of work units available for the team to work on. She also announced that through the creation of different sized work cells, the number of work units has increased from the previous quarter, allowing the team to do more work than expected outside of the major upgrade.

And so the cycle did start, on time, and without any special prompting or worry on our part. Great managers (as this one is) know the value of a predictable process, and we will enter into a fourth cycle of planning in the time that we used to only have one cycle. Everyone gets a lot better doing something 4 times instead of 1 time. Thanks, Hoshin strategy planning!

If you could have a leader shadow a physician for 18 visits in one day, or 1 visit a week for 18 weeks, which would you recommend?

Physicians acquire information on behalf of their patients to reduce uncertainty, which eases discomfort and promotes healing. We like predictability.

All people need time to process new experiences, and when they spend a little bit of time out of their comfort zone to start with, they can expand it.

I invited two of our organization’s leaders, from our Governance Services and Community Benefit Departments, to shadow our excellent family medicine physicians last week. They asked me, “How long should we plan on staying?” I said, “One patient visit (with proper consent from the patient) would be just great. Frequency is more important than duration.” So they came, and then split up and each spent time with one patient being cared for by one physician.

I sat in on one individual’s debrief with the physician she shadowed and debriefed both afterward. I think both individuals really felt the impact of the experience. In the debrief with the physician, one observer told him very positive things about his ability to connect with patients that he did not notice in himself. Both told me things about their visits (sans any personal details about the patients) that I or any other physician would never be able to describe in words to them, while adding the important perspective that they have as leaders so connected to our member governance and community interactions.

I then shadowed an additional family medicine physician myself for a few visits, and she was also terrific.

When I completed my shadowing and thanked the other physicians for their time, each of them said a variant of, “I’m not sure how useful that was for you, but I hope it helped.” My truthful response was, “More than you know.”

I hope the leaders I invited (and any leader) experienced learning 20 things in 20 minutes by being as close to the customer as possible. I hope they will feel comfortable coming back regularly. Even for just one patient visit.

I hope the physicians and patients who volunteer their time know that they can teach 20 things in 20 minutes. I hope they’ll feel comfortable hosting other leaders regularly. Even for just one patient visit.

If this experience becomes standard work, physicians can predict that organizational leaders will see the impact of the support they provide when they make decisions, and organizational leaders will be comfortable in seeing the impact as they work to improve the health system.

Sponsorship is a topic that I have been spending a lot of time thinking about as well as discussing with various leadership groups in the organizations.  Like most organizations we are project and initiative heavy.  Chances are if there is an improvement effort underway in the organization there is also a project plan and a traditional sponsorship structure.  A formal structure of regular report outs, committees and decision making being consolidated in the hands of the few.  Our management system is designed around this project mentality and I have found lately that it creates many cultural paradigms that we will need to find ways to work our way out of.  

Even our initial Lean efforts were integrated within this system.  We would find a “Lean sponsor” and put together an event driven improvement plan.  We would report out to the sponsor on a regular basis and occasionally they would attend an improvement event.  As we have progressed with our Lean thinking in the organization the role of Lean sponsorship has drastically changed.   We have several engaged and zealot leaders now that are on the floor leading improvement on daily basis.  As Lean thinking continues to deepen in the organization the tension will between these two worlds will only intensify.

Possibly the most challenging paradigm that will have to change has to do with sponsorship and what the role of leadership is in relation to improvement.  In the current management system senior leaders act as sponsors for a vast number of “projects” or “initiatives.”  On a regular basis these leaders will convene at sponsorship meetings were teams of specialists bring them reports on progress and requests for resources.  The sponsors ensure that decisions are made, that stakeholders are aligned and that the work progresses forward.

There are many problems with this form of sponsorship/leadership.  First, executives are distant from the work meaning that the real opportunities to make lasting systems changes are never made apparent.  Second, sponsors tend to have many projects underway at any given time making it very difficult to coordinate resources.  This leads to all kind of waste and a lack of focus.  Finally, decision making and improvement is consolidated into the hands of the few, meaning that not everyone is responsible for improvement, thus a missed chance at creating a culture of continuous improvement. 

The good news is that leadership is aware of these challenges and behaviors are beginning to change.  We are making great progress and to put it in perspective it took the organization sixty years to build the current management system and will take many more years to adjust it to one based on Lean principles and practices.