DailyKaizen

As I have dicussed recently I have a new role working with the leadership team in transitioning the organization from our current planning system that is a classic MBO (management by objective) to a Hoshin Kanri system.  The challenge is huge and its not as many articles characterize simply a exercise of changing to a new set of tools and methods.  Hoshin Kanri is a management system that will bring discipline, new thinking and most importantly a new set of behaviors to our organization. 

If we stay the course and continue to hold leaderships engagement it will eventually result in a very different culture, but loosing this engagement is also our greatest risk early on.   Our countermeasures are fairly straight forward to ensure we balance the short and long-terms needs of the organization so their is a willingness to stay the course: 

1. We will need show results quickly.  Thus we need to focus the organizations energies on only the most important few areas for improvement.  This means that in many parts of the organization improvement needs to be strictly limited to stabilization and standard work in order to properly support the Hoshin changes.
2. We need a heavy dose of Lean leadership, technical training and Sensei support for our Executives to continue to learn lean thinking and behaviors.  We need to work very closely with our CEO and his team to help them guide them in determining the “how”
3. We need to organize our consultancy in order to best support the behaviors and thinking that we are trying to create.  It will be our job to always help, but never do!
4. We need to treat this work as one of the pillars of the Lean Management system and thus it needs to be implemented with all of the other parts to work effectively.
5. Finally, we need to communicate, communicate and communicate so that everyone in the organization comes along on the journey with us.  In order to engage staff we also need to communicate primarily through story telling, a very different way of communicating then how it is currently done.

Any one else out there want to add to the list?

I was allowed to observe a group receiving this (the training) yesterday, courtesy of the aforementioned sister organization, that is letting me watch their journey. This was in the afternoon. In the morning, I was invited to sit in on a problem solving discussion about an important clinical issue, one that in fact we had had a discussion about back in Seattle not too long ago. A reminder to me that if some issues were easily fixed, they would have been fixed already - everyone wants things to work for the patient, always. We do this work because it’s hard, not because it’s easy.

In the training, I picked up some useful knowledge about sampling populations. I was mostly interested in observing the training process and seeing what cross section of the organization is involved. I learned that the instructor actually came from the financial services industry where he had applied LEAN and Six Sigma Techniques. Very cool - yet another industry where we can look to for knowledge about improving the care experience. I was allowed to provide a little context for a few minutes from the things I’ve done back in Seattle, which I turned into a sort of “LEAN is not a fad” speech. My thinking is that if I have five minutes to talk about LEAN, it is to say that it reinforces philosophy that we bring to health care - respect for the people we serve (our patients, our staff, society), and because of that, it can transcend the potential buzzword/jargonization that comes with any unknown. It’s the right thing to study, and it’s worth the effort.

It’s a good question for this audience, though - if you had 5 minutes to talk about LEAN to individuals new to the field, what would the theme of your discussion be?

I appreciate the time and experience of the group(s) I was able to meet yesterday. I continue to appreciate the fact that an organization committed to LEAN is one that wants to share and learn more, always.

“We are what we repeatedly do.  Excellence, then is not an act, but a habit.”  –Aristotle

I chose this week’s quote in response to a management report-out that I attended this last week in the Model Line area.   The report-out marked the conclusion of a five day, intensive, design workshop where the team of managers and supervisors were charged with designing standard work for the Daily Management system.  More importantly, it was the first time on our Lean journey where we have been able to design standard work for supervisors, managers and directors.  In my opinion this event represents a very important milestone for our organization on it’s Lean journey.  Let me try and provide some background information and explain why.

Over the last eight months we have been focused on implementing standard work across all 85 work teams in the Model Line area.  As we have implemented standard work processes within teams have realized significant improvement in quality, cycle time and reliability.  At the same time we have begun to shift the culture from one focused on individual accountability’s and results to one focused on team accountability’s and root cause finding. 

Most team have embraced this new way of working, but supervisors and managers throughout the organization have struggled with the requirements of their new roles.  In the old world they spent most of their time in their offices making decisions and coordinating cross-functional problem solving.  In the new world their job is to manage improvement from the Gemba, empower teams to make decisions and to teach team members standard work and problem solving.  They are the owners of the check and adjust cycle. 

The role changes have been so significant it has taken its toll on the leadership team and we needed to make some adjustments.  Our countermeasure was to focus on applying the same principles and methods of standard work as we have with the front-line teams.  We needed to create standard work for the entire leadership team right down to level of detailed that they now will be able to know exactly what they need to do every hour of the day to ensure that their operation is running smoothly and continuing to improve. 

During the report-out the team shared their new visual management systems, including a “Daily Kaizen” board to monitor and promote improvement; a Kamishiabi board to facilitate the hourly checking process; as well as a production board to monitor plan vs. actual on an hourly basis.  Additionally, the team has designed an Andon process that was very cleaver for a administrative environment.  All the standard work was recorded on job breakdown sheets and easy to follow as well as spread to other teams. 

As the end of the report-out the team role played for the entire management team a “day in the life” scenario for managers and supervisors.  It was a powerful display of what is possible if management applies the same principles to their work as they ask front-line teams to do.  

I got to connect with the first LEAN consultancy on the East Coast yesterday. It’s based at our national affiliate / sister organization, which is as world-class as ours, in my very humble opinion. I think much of their greatness comes from the fact that they are member-centered also, which is a core requirement of being successful with LEAN (and in health care in general) also, in my opinion (don’t you agree, though? :)).

From what I was shown, the group started relatively organically as we did. They referred to the strategy as “Middle Out” which on reflection is close to what ours was. They are combining LEAN and Six Sigma together which appears to me to add good analysis and statistical controls to the methodology. In my own training at Group Health, I was just beginning to learn about this. They have made improvements in strategic areas just like us, including the laboratory and the pharmacy. They did something that we also did - showing members and staff real improvements in the everyday care experience by making things happen, and then coming around to have the conversations about methodology. Seeing and feeling results is a great way to have the dialog, isn’t it.

The great thing about an interaction like this for me, though, is the observation of the enthusiasm that comes from being able to do better for members/patients. It’s the same feeling, different coast. We don’t want to do it the same way, but we want it to feel the same way. “You just saved your members’ time, money, improved their satisfaction, and the satisfaction of those who care for them, are you going to continue to champion this?” - The question that’s easy to answer because it answers itself.

If I am lucky I will get to report on what they do, or maybe they will do it themselves….

I am double dipping here, as I reviewed this same paper in the context of patient centered health information technology elsewhere. However after the fact, I remembered this piece of the article that really struck me. The paper is a nice study of the use of electronic mail communication between physicians and patients that supports its use in practice. Excellent.

Look at this description of workflow:

Although our consent form indicated that e-mail responses would be sent within 72 hours, almost all physician responses were sent within 24 hours. In addition, many responses during regular business hours were sent within 2 hours. At the same time, our telephone triage system routed patient calls from patient to secretary to nurse to physician. The routing process could take several hours depending on the workload of each staff member. Our e-mail process bypassed the support staff, leaving the physician response time as the only bottleneck. The patients who used e-mail instead of telephone to communicate urgent concerns may have believed that the message would get through faster than through our telephone system. Thus, our efficient e-mail system may have emphasized inefficiencies in our telephone triage system; therefore, our short e-mail response times may have encouraged inappropriate communication of urgent concerns.

What I liked here was that the study, an objective evaluation of a “new” technology (e-mail), really became an evaluation of the established “gold standard” technology. The gold standard is shown to be (a) maybe not so efficient after all (b) not so valuable to patients who are paying for the service and (c) not so defining of what inappropriate communication of urgent concerns is. I found this last point especially interesting, because inappropriateness seems to be based upon inability to respond to the request quickly enough, not on the patient’s need. Since they discovered that “physician as the only bottleneck” is actually more efficient and results in a reduced response time, the definition of inappropriate communication changes. When we have a system that is transformed to respond at the speed expected by the patient, every communication of urgent concerns is appropriate, right?

I thought today I would tell a story about a Lean experience I had outside of the workplace for a change.  I was a great experience given the circumstances even though I wish it would never have happened.  Yesterday, I was munching down an apple for lunch when I felt something hard in my apple.  I looked at it closely and I found a whole bunch of small pieces of metal.  Running down to the bathroom I confirmed my greatest fear: two of my fillings had fallen out and there was a giant hole in my two of my teeth.

So I picked up the phone and called my dentist hoping that I might get in sometime in the next couple of weeks.  I was really surprised when the receptionist actually remembered who I was.  I must confess, I have a pretty bad phobia of going to the dentist and have not been very proactive with my oral care over the last couple of years.  I was even more surprised when she told me that there was an opening first thing this morning.  I asked her if somebody had cancelled and she said no and that they always hold a certain number of spots per day for emergencies. 

Arriving this morning I checked in at the front desk where I was handed a sheet with all of my insurance and personal information already filled out.  My job was to simply confirm that it was accurate.  The office was very busy, but I did’nt even get a chance to sit down when I was met by the dentist who asked me how I was doing and how my new house was holding up.  I have no idea how he remembered that I just got a new home.  He took look at my tooth, let me know that things were on time, the work I required was not complex, and that I would be out the door within thirty minutes.  Five minutes later I was in his chair and he was explaining in very clear terms why my tooth had broken and how to prevent it from happening again. 

I walked out of the office twenty minutes later with the least amount of anxiousity that I have ever had leaving a dentists office.  As I drove to work all I could think about was if we could only take when my dentist did for me today and replicate it across all healthcare organizations.   What if we could:

• Accurately understand demand and plan accordingly
• Be responsive to the pull of our patients
• Not waste any time of anyone we serve
• Take a big office and make it have small office feel
• Standardize the product we deliver, but customize the experience to make people feel comfortable and cared for

I may go to the dentist more often.

Now that Lee and I are both back from our respective holidays, comments on posts are now turned on again. The comment spam filter on this blog system is very robust, but sometimes a few make it through.

Thanks to Lee for keeping things going as I continue some searching around the East Coast for LEAN excellence…

“For the first time I feel like we are starting to really work as a team and not just a collection of individuals.  I had no idea how little I knew about what the others on my team do.  There is so much opportunity and redundancy.  If we all focus together as a team we can do so much more.”  –Director

This weeks quote came from a hallway conversation I had with a Director after we had just completed a catchball session this last Friday with a group of forty managers.  This session is a big milestone for this team that I began working with about four months ago.  When we began the process the team was struggling with focus and they asked me to come in and help them think about how they could align the departments in a way that would make them more effective. The team represents a group of functions that manage the organizations communications, branding, governance, government policy and many other intangible processes.   Working with a group that was non-operations focused was exciting to me, because I don’t have a lot of experience working with these types of processes.   It would be a great opportunity to learn so I signed up.

For the first few sessions I taught them the basics behind the A3 process and A3 thinking.  I then facilitated a series of sessions where the team reflected on their current situation, defined their “True North”, developed a small set of targets and then created a set of Hoshins to guide teams in creating the how.  Overall, the team has grown tremendously since we started and it is very clear that they are becoming far more focused on what they need to do moving forward to improve results.  We have struggled the most with idenfitying in-process measures for non-transactional processes, but even in this area we are making progress. 

Our next step will be to work with the next layer down to identify the “how” of our work-plan that will allow us to achieve our objectives.  I have no doubt that the team will make big improvements this coming year.  I will also now have a great example to share with future teams when I hear the infamous “lean sounds great, but we are not making cars.”

I had an interesting talk today with a Lean leader from another organization about how best to structure a Lean consultancy within an organization.  They are a couple of years into their Lean journey and are now at the point where they need to become more disciplined and strategic.  It seemed to me that their organization is where we were about a year ago when senior leadership began to become engaged and the demand and sophistication of work surpassed the ability of our consultancy to support it. 

In my opinion there is no single answer on the best way to organize a Lean consultancy.  It really depends on a lot of different factors including:

• The level of senior leadership engagement
• Is Lean still just a set of tools or is it a management system
• The organization’s culture
• The organization’s structure and geographic distribution
• Etc.

In our organization we have had to adjust our Lean consultancy’s structure several times over the last couple of years and we have learned a lot.  Recently, we have begun to move toward a centralized/decentralized model.  In this model the centralized consultancy supports the overall setting of the organizations Lean strategy, supporting the executive team’s development, ensures that standard methods and language is being followed and acts as a catalyst to get Lean improvement started in our Divisions.  The decentralized consultancy’s are assigned to each value stream and are in charge of developing people and executing tactical change.  Our goal is to have small centralized consultancy and the right size decentralized consultancy’s.  We believe this is the best way to deliver on our goal of building the thinking back into the teams doing the work, but it might not be the right model for others to follow.

 I am wondering if others can share the models that they have found effective?

Hi everyone.  I am back from a wonderful trip to Italy and trying to ease my way back into work and sort through an incredible backlog of emails.  Thanks to Ted for holding down the fort while I was gone.

I thought I would take today’s post to set some context.  As I mentioned before I left on my trip my job has changed.  As a result a lot of what I will be discussing and seeking advice on in this blog will also change.  I have been asked to support the senior leadership team and the organizations Lean champion in the process of implementing a Hoshin Kanri (Policy Deployment) system to replace our current budget driven planning system.   This is a big change for me having spent the last year “starting up” and helping drive the work in our Model Line area which has been the primary topic of my blog entries.  I have mixed emotions about this change having developed a lot of ownership for the Model Line work, but overall it is the right move for me and hopefully the organization.

In reality, I believe that this work is far broader and more exciting then just implementing a new planning system.  As most of you  know, you cannot implement a Hoshin System without simulatiously embedding Lean thinking into all employees.  Without both you will simple create a system of management by objective, which is more of what we already have as an organization.  Thus in order for us to be successful in putting in an effective Hoshin system it is my belief that the organization is going to be forced to make a decision about the definition and future of Lean. 

• Is Lean simply a set of tools and methods or is it a management system? 
• Will we effectively be able to integrate Lean thinking and behaviors at all level of the organizations? 
• Will the rest of the organization follow the Model Line’s lead and drive toward enterprise level Lean transformation?

I have no idea where the organization will end up on these questions, but I do believe that we have the right process in the mix that will lead to an answer in the near future.   As readers I hope you can help provide guidance as we move into our next Lean chapter as an organization and I hope our journey helps others that are on similar paths.