DailyKaizen

When you make an appointment with your own doctor, do you always try to get the first one of the day to stay on schedule?

The year of KaizenHappiness is not quite over yet, Lee!

As I have mentioned previously, I have been looking for a LEAN practice on this side of the U.S. since I arrived here. My visit to the Lean Enterprise Institute confirmed that it would be a bit of a hunt in the Mid-Atlantic area; however, it is here and it is helping patients (and if readers know of other examples in DC/Maryland/Virgina, let’s have them).

This particular practice is at our sister organization, Kaiser Permanente, who, independently of Group Health, have begun a Lean-Six Sigma program. I was invited to a training session, and learned that they had completed a very successful project in one of their clinical areas, involving first appointment starting times. This is really interesting to me because in my work at Group Health, we had not yet entered clinical operations in our LEAN transformation. Since physicians ultimately control spending of 84% of every health care dollar in our nation’s medical centers and hospitals, I think this is where LEAN ultimately needs to transform. This group is there.

The location where this happened is the Woodlawn Medical Center, in Baltimore, MD. My problem is that I am not facile with a car here in DC (because you don’t really need a car here, sorry Toyota). However, there’s no replacement for the Gemba, so I asked if I could go, and they said yes. So I rented a car and went.

When I arrived, I was asked what I wanted to see. I said I would like to stand where patients arrive as the medical center began its day and watch. So we did - no chalk circles, though!

The words in the title of the post came from the Medical Center Administrator, when she asked members to participate in time-motion studies to learn about starting medical appointments on time. She said the patients said yes, and when their contribution was complete for the day, she said they came back to her and said, “Wow, this is a different place.” It’s a reminder that involving your customers in your transformation only makes you look better, and a finding that I have discovered in my travels - observation by itself is a powerful intervention.

Images - click on any to see full size:

The MCA talked about what they learned when they did the studies. 91% of patients arrived at or at least 1 minute before their appointment start time, ending the erroneous belief that late start times was because of late patients. There was also a belief that patients with more complicated check-in processes (e.g. cash collection, demographic updates) took longer, ended by the data showing that each patient requires about 60 seconds. More data showed key root causes that were not going to be solved by simply adding more staff in pre-medical center prep. The impact: 8% of appointments started on time, with about 44 appointment times, or 10% of physician capacity lost to delays in meeting patients on time.

We watched the new process unfold as patients approached the desk for their first appointment. The check in desk was prepped and ready, with computers booted because of a slight shift in work hours ($0 net cost) for one clinical assistant. Check-in staff were trained with scripts in waiting room management to bring first appointments forward. A stop in a triage room was eliminated for first appointments - patients were taken directly to the exam room. This in and of itself was interesting to me - thinking about the impact of a patient with limited mobility needing to go from room to room to see their doctor. Nursing backup was readily available for clinical issues brought up - the patient-physician relationship was prioritized.

As we stood there, physicians walked in to the office before the first appointments started. It seemed that a virtuous circle was created. I did not see a queue in the check in area, as patients were brought back to rooms at the medical center start time.

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It was great to connect with Ted and catch up on each other’s stories the other day.  Both of us are working harder then we ever have in the past, but having more fun as well.  The more we understand about Lean, the more we realize just how much possibility for improvement there is in healthcare.  Looking back I think we would both say that the organizations we work with have made tremendous progress, but the challenges have only grown in scope and depth.  Yet, for the first time I think we are both feeling like there is a wonderful opportunity to be part of something really big.  A window to truly transform heathcare and create the first, really great health systems.  Guess my optimistic side is showing itself.

Connecting with Ted is a great way to end the year.  I wanted to let folks know that I am going to take a break from the computer and spend some time up in the mountains on my snowboard.  Please check back right after the new year for the next year of adventures. 

Thanks to all for reading and Happy New Year!!!!

I just got off the phone with Lee and we decided that I’d write a post about our check-in conversation (with Lee adding his thoughts, of course) about Lee and LEAN. The news is good - Lee is working hard and enjoying it, and LEAN is being led at the Executive Leadership level, most notably by CEO Scott Armstrong. I asked what Group Health might be like in 3-4 months or so. He said not to expect that the “how” of everything might be different, but that there would be alignment around the “what.” Lee sounds excited, he is seeing engagement from senior leaders, and they are developing standard processes to do their work. When Lee sounds excited, I am excited. One of the most important measures I consider is Lee’s happiness factor.

As for me, I am still out there in the rest of health care, and I’m learning that there’s no less of a commitment to patients in other environments, and further, that people want to learn and do better. I’m continuing to blog everything I do, as a bit of a stimulus to increase the transparency of every improvement effort in every care system (why not?). A new addition to the concept of this blog on the PCHIT blog is that I am inviting the organizations I visit to come blog with me, so that they join the discussion as authors. All have been open to coaching and learning about a new openness in what they do for patients. Maybe we should have that happen here, too. Where are the other DailyKaizen blogs, and shouldn’t a blog be a documentation requirement for a LEAN transformation?
Lee’s going to the LEAN Transformation Summit in Orlando. He’s going to present with Group Health colleagues, a huge honor. I’m going to the Health 2.0 conferencewhich is happening at the same time. All of us need to create a light onto the rest of health care in what we do, and create community around it at the same time. I think Lee and I will do our best to cover those bases. I know everyone here is, too.

In the meantime, we both wished the best for our Executive Leadership Team, and all that they do to serve our members and communities, as they write a new chapter for the organization.

And as I finished writing this post, I received this E-mail, which Karl gave me permission to include. These are the messages that arrive in your inbox sent when transformation is happening.

From: “Hoover, Karl M.”
Date: December 18, 2007
To: “Ted Eytan”
Subject: Studio 3A

Yes that’s right; we now have 4 focus areas with pacesetters (ELT’ers) assigned, sensei’s assigned to them and getting ready for the real mother A3 development work in January.

- Karl
____________________________
Karl M. Hoover | Executive Director
Group Health | Quality & Informatics Division

Way to go, team.

I have spent a lot of time over the last couple of weeks talking with various leaders in the organization about capacity.   As an organization we do not have a very good understanding of how to measure and manage capacity. In our operational areas where services are provided directly to our customers we do a fairly good job, but often have access buffer.  In our supporting service areas like Information Systems, Finance and Human Resources we really struggle.  Stepping back and taking a systems view of our organization it is not surprising that we are challenged in this area.  We have very strong silos and we are primarily budget driven.  Thus shared services are caught in the position of having to manage the competing priorities of many different operational areas.  Because we are not organized around value streams (yet) there is always and unlimited amount of demand, a high level of work in progress and a high difficulty in measurement.  All of which make the question of capacity a difficult one to manage.

These discussions are timely, because for the first time I believe the organization is positioning itself to be able to better manage and understand capacity as we begin to put in place a Lean Management System.  The first step will occur during our Strategy Deployment process over the next couple of months where through the process of catchball we will for the first time make explicit decision about priorities at a strategic and not department level.  We will also for the first time explicitly define and organize around our value streams.  Allowing us to measure and make decisions in alignment with the way that our customers experience us.  Both of these changes will allow us to make capacity issues more visible. 

In the mean time in preparation for the Strategy Deployment process most of our supporting services are beginning to take steps toward better understanding their internal capacity.  This will be a useful exercise.  When asked I always tell teams that their first step is to separate the maintenance work from the improvement work.  A challenge in itself, but necessary in order to be able to measure how capable the department is in supporting the demands of the organization.

I was honored to appear on National Public Radio’s Talk of the Nation program last Thursday, along with another physician and a researcher from the Pew Internet and American Life Project, here in Washington, DC.

I’m cross posting the links to the show here (a) to prove that I am still around doing stuff and (b) because an interesting conversation point among the panelists was the topic of “respect,” and the way we choose to value it for all of the participants in our health care system. I thought the way it was brought up was fascinating, and the opportunity to speak to it after we have done so much thinking about it is really an exciting one for me (and you may notice it in the pace of my speaking, I’ll work on that for next time :)).

Feel free to take a listen and see what you think. The discussion, which was about “Do It Yourself Diagnosis on the Web,” is first up in the pod/webcast:

Link to iTunes Podcast, Talk of the Nation, December 13, 2007

Link to Webcast, Talk of the Nation, December, 13, 2007

Blog Software Upgrade

It was time to bring this blog system up to the most recent version of Wordpress. Most notably, you’ll see support for tags at the top of posts. I’m mentioning it here in the hope that you’ll notify us if you notice that something isn’t working quite right. Thanks again for your support.

A year or so ago the organization decided to make a commitment to using A3’s to support planning and improvement in the organization. At that time I was a big proponent of this change. I was fully convinced that if we only had a standard tool for planning we could be far more effective in not only developing the plan, but also executing to the plan. Like most organizations our’s had a high level of variation in our planning and deployment tools and formats. Primarily, long and boring PowerPoint’s were the primary tool of choice. Far from compelling.

Now it is a year later and A3’s are being used widely across the organization, but I would say that the change has led to moderate improvement at best. Yes, we have cut down on the over production of long status reports and planning PowerPoint’s. Yes, there are some teams that have embraced the A3 process and it has led to improvement. But overall the change has fallen short.

Why? The answer is simple, the A3 is a tool and without the process and thinking behind it nothing really changes. In our organization in most cases leaders and more often staff took the plans they had already developed and translated them into a new A3 format. As you can imagine, there are a lot of A3’s floating around with size 8 font in order to fit all of the content into a single page. In most cases PDCA was not applied, nor was the basic root cause and Pareto analysis.

Please don’t get me wrong, I am not trying to be critical. We learned the tool, but were not yet ready to learn and embrace the the thinking. Now that the organization has made an enterprise wide commitment to implementing a Lean Management system things have changed. Leadership is very vested in learning the foundational thinking that underlies Lean and the A3 process. We are developing a standards and a process around how the A3’s should be used and more importantly we are now capable of coaching leadership in the thinking. Just this Friday I spent a couple hours with one of our physician leaders as he worked to develop an A3. He was very excited by the process and how close the thinking is to how physicians approach their work every day through the scientific method.

I guess sometimes its okay to learn the tool, but like everything, its all about the thinking!

The VP over the Model Line and I had the pleasure of hosting Jon Miller, a friend and Sensei from Gemba Research join us for a Gemba walk this last Monday. If managed correctly having regular site visits can be a valuable opportunity to recognize staff and gain feedback from an outside set of eyes. In this case we were able to achieve both objectives and hopefully added some value for Jon as well.

We started out with our standard process of providing a high level overview of our journey as an organization thus far as well as a more detailed discussion of our objectives and tactics with the Model Line. We then spent two hours on the floor where we visited two different teams as part of the VP’s standard work on gemba walks. It was a great opportunity for me to get back out on the floor with the VP and witness firsthand how far he and his organization had developed. Almost a year ago we began the process of gemba walking and neither of us had a clue what we were doing, but we went out any way and did our best (with support from our Sensei). During the early walks the VP was always uncomfortable with both being in the gemba and attempting to teach and the teams were uncomfortable with him being there. By the time I was redeployed he had come a long way and the teams were responding very positively. This Monday he showed how much he had advanced since then. I had to stop and reflect that here is a VP over 650 employees who has made it his number one priority to teach all of his employees PDCA thinking. He has mastered the content and gained their confidence and the results are speaking for themselves. How foreign to traditional management, yet, how powerful.

At the conclusion of the visit we gathered for a debrief and exchanged ideas and feedback. I was impressed by how much Jon was able to pick up during the brief exchanges we had with team. He pointed out that the VP needed to provide a standard for each team in advance so that they could hold him accountable to his process. In other words, the VP needed to practice what he was out to teach and share with teams his purpose and process and then have them evaluate if he was able to hit his intended outcome. Additionally, Jon pointed out that the teams seemed ready for a suggestion system and that we should benchmark Toyota to understand their processes around empowering employees to PDCA their work. Both great ideas that we will move forward with implementing.

Its always fun to have friends come to the Gemba!

At the risk of being abstract I am going to write this post on the subject of defining purpose.  Purpose is defined by wikipedia as “an anticipated aim that guides action.”  Webster defines it as an “anticipated outcome” or a “function of what something is used for.”  During his visit to our organization a couple weeks back James Womack asked each team we visited the question: “What is the purpose of this process.” This is the same question my Sensei asked me each time I would bring an improvement idea to the team.  So what is all this talk of purpose and why is it important?

The more I have gained experience the more I have learned just how important it is to define purpose for everything you do or would like to do.  Whether you are trying to set the direction of the organization, questioning why a process exists, trying to define why an action should be taken, or just simply stating the reason a group of leaders are being pulled together for a meeting it is essential to first define the purpose.   Given how important defining purpose is you would expect that it would become common business practice to take care to make sure it is defined.  Yet, in my business experience this is not the case.  As I work with leadership teams it is fascinating how little agreement there typically is around purpose, primarily because we often skip the step of defining it and jump to action.  Thus the purpose is assumed and not until later do we realize that assumptions have been made or expectations are not being met.  Just as often you will find long purpose or objectives statements at the top of team or project charters.  These statements are suppose to define a piece of work or function, but they are so diluted they often say nothing with meaning.  How strange. 

Without first defining purpose we run all kinds of risks as well as miss some of the greatest opportunities to promote alignment and make improvement.  Recently, we have had several proposals for improvement that when we questioned the purpose of the process in the first place we realized that rather then improve the process we should just stop doing it in the first place, because it has no purpose to support our customers.   Another good, simple example is our work with leadership teams to put in place standard work for meeting.  Part of this work is that every meeting must have a clearly defined purpose.  Sound simple, but you would be amazed at how many meetings just happen with no purpose and how much time can be saved, by making leaders first define why a meeting needs to take place before they ask for others time.

 Lean organizations take care to define purpose for everything they do.  Purpose needs to be explicit and measurable.  As an organization we have a great opportunity to follow their lead.