DailyKaizen

Yesterday was a great day.  Not only did I get a chance to host a webinar with two of my favorite people in the world, which Ted described in the last post, but I also got a chance to visit the Model Line area to see their progress since I had transitioned out.  As I walked the floor of the Model Line stopping to talk with all the folks I had worked so hard with over the last year I was energized.  It made all of the hard and stressful days worth while.  It really has become a different culture and the progress is so impressive.   The knowledge had deepened so quickly across all of the teams. 

Standing in the gemba I replayed in my head many of the questions asked by the audience during the webinar.   Everyone in the audience worked in the healthcare industry and many of whom are just getting started or interested in Lean.  During the webinar I described the strategy behind the Model Line and I spent a lot of time talking about our focus on standard work to build a stable foundation.  When we began the process we knew it was important, but I don’t think we grasped just how important.  For several years we had been applying Lean tools and principles through rapid improvement events, but we had never been able to integrate them into our management system.  Nor had we figured out how to integrate Lean thinking and behaviors into our daily work. 

With the focus on standardizing all processes, including the process of management in the Model Line we had unlocked a powerful force.  If applied correctly standard work gives teams the foundation for innovation and improvement.  It makes visible the opportunities and it quickly separates facts from ideas.  It breaks down barriers between teams by encouraging sharing.  It provides a common language and method for improvement.  And finally, it allows you to apply all of the other Lean tools and principles in a way that can be measured, sustained and the effect understood. 

So to all of you that listened to the webinar and are now here reading this post the best advice I can give you is to focus your Lean efforts early on in implementing standard work.  Study the TWI methodology and read about the Daily Management system in the Total Quality Management literature.  You don’t need to worry about all of the other Lean tools to start with, those can come later.  Invest in putting the stable foundation in first.

Application of the Toyota Management System across the Group Health Cooperative System Slides compressed for Web delivery (2/26/08)

Slide: Appointment calendar, before and after standard work, Group Health Cooperative

Yesterday, Karl Hoover, Lee Fried, and myself led a national Web event sponsored by the Alliance of Community Health Plans about Group Health’s enterprise deployment of the Toyota Management System.

I asked Karl and ACHP if they wouldn’t mind flipping the switch to make the presentation open not just to ACHP members, but the entire public, and they both said yes, so it’s now available to this audience (and anyone else who would like it):

Application of the Toyota Management System across the Group Health Cooperative System slides compressed for Web Delivery (2/26/08)

I pulled out one slide here to show an example that I think a lot of you will recognize as a challenge in your work lives. Look what is happening to appointment calendars due to standard work.

A byproduct of the work that I alluded to in my part of the presentation has been partnership. It was remarked by our host at the end of our talk that we ran exactly on time, which is often a challenge for a talk with three speakers. The fact is that we work very well together because we have seen so much (double underscore) through this journey together, even though we are very different people. Right before the talk started, with me in DC, and Karl and Lee in Seattle, I asked how their stress level was. I think they paused for a bit and then began laughing together. I know what that laugh means. We are working hard and having fun. I hope that comes across in the talk. Enjoy!

Feel free to post your comments and questions below. Thank you again to our employer, Group Health Cooperative, and Alliance of Community Health Plans, for hosting the session and supporting our interest in sharing with every health care system.

Thanks, LEAN, for allowing me to recognize this.

I was reminded of this when I finished reading Pascal Dennis’ book (see my review here), and two recent events. Dennis says:

Detachment is a core Planning School assumption; the idea that we benefit by “abstracting” management from day-to-day operations.

Recognition #1

On my sabbatical project recently, working with other key leaders, we arranged to have two very important stakeholders come to the Gemba, many for the first time, to talk about providing for patients served in a leading-edge care system (see this post for the debrief and pictures).

The planning for the event was not straightforward, with lots of questions about how and why to do this, but the result was that the facts on the ground were obtained, and the conversations were rich throughout. How would I know about the epidemic (asthma) that was affecting families of this community disproportionately compared to the surrounding city? How would a payer and provider know where to collaborate to help these patients if not by being where the patients are?

The next day, when I visited with colleagues of one of the attendees, a comment was made by one that they have been meaning to visit this care site for a really long time. I think the attendees who were with me will make the case that it’s worth the trip. Not only that, but people are happy to show others what they do for patients.

As I have been spending time in the “abstracted” world of our nation’s capital, I realize how important these events are.

Recognition #2

On a recent trip to a invite-only workshop, I arrived to my hotel to discover that I had forgotten to pack dress pants. 30 minutes later, I found myself in a hotel van on a late night ride to Target, driven by one of the hotel’s managers.

He was in his 20’s and we were talking about his management approach. He said he preferred to work alongside his teams and help them solve problems directly. As an example, if a staff member felt that something was hard to clean, he would work with them to clean together, so they could see success. He said that he had been told to separate himself from those he managed to be a good manager and be respected.

The conversation made me think about how people learn how to manage and how it’s possible that we remove people’s ability to truly be respectful and be respected when we perpetuate the Fallacy of Detachment. It seemed like he was being taught the Fallacy of Detachment. My comment from the back of the dark van was, “You’ve got it right. Don’t change a thing.”

If I could at least throw a little doubt on the idea that detachment is appropriate (which is what I was taught when I was his age), I was up for it. That and the fact that I could get some very nice wool slacks at Target for a reasonable price.

I thought I would take the opportunity to respond to our readers questions about a Model Line given that I have spent a lot of time working with leadership to start and support one over the last year.  I would also recommend readers to Jon Miller’s excellent post and my reply at the following links:  http://www.gembapantarei.com/2008/01/the_pros_and_cons_of_model_lines_for_lean_implemen.html

http://www.dailykaizen.org/archives/498

How far to we take the model line before moving out?

We began transferring learnings within the first three months from our Model Line to the larger organization.   Most of this transfer in the early stages was in our supporting services like Quality, HR, Leadership Development and IS.  After about eight months we began to expand the improvement efforts up and down the value stream.  Most importantly we made sure at first that areas where we “spread” learnings were connected in some way to the Model Line areas operations so that the improvement was not spread to thin and unsupported.
How much training should we do beforehand?

We struggled a lot with this question, mainly because of capacity.  We adopted a teach to fish model which included identifying resources from within the operations of the Model Line area to be redeployed to support training.  We then taught leaders to teach managers to teach staff.  We also focused our Lean training efforts around the areas where we wanted to see breakthrough improvements (identified during our Hoshin process).  At the same time we rolled out a TWI based program of implementing standard work to all 85 teams. 
If we start with the lean management, how developed does this need to be before it is self-sustaining?

Not sure if I understand this question.  If you feel confident that your managers are capable of standardizing processes and improving them on a daily basis you are close.

At what point do we need complete buy-in from senior management?

This is a tricky question.  We did not have “complete” buy-in from senior management at first, simply because they did not understand what we were trying to do.  We did get agreement for regular involvement by having them check our progress and come to the gemba.  If you don’t have regular involvement I don’t think you will be successful.  If you are adopting a Lean management system it will not take you long to begin to run into the barrier of your traditional system and without involvement and sponsorship you will run out of steam and lose engagement.
What should our implementation process look like?

This depends a lot on your organization.  We started with three strategies:  Implement Hoshin Kanri to create focus and involvement.; focus Lean tools in one area to drive results; implement a daily management system by training all managers to implement standard work and improve their processes on a daily basis

And the inevitable question of how much is too much change?

Others may argue with me, but I believe that the pace of change is primarily determined be the capability of leadership.  More specifically at first, the leader that is in charge.  The VP we partnered with rolled up his sleeves, jumped right in even though it was new and led from the front.  Kaizen became his way of life and most of the 650 people that worked for him quickly lined up.  I often hear others talk about resources being the biggest limiter, but I don’t believe that is the case.  At first there is so much opportunity to get improvement if you engage the minds of those that work in the process. 

Other please jump in and share, argue and provide other advice!

As I have alluded to in the past, I think LEAN in health care will continue to get traction as more organizations tell their stories candidly. It is in the spirit that I post some excellent questions from one of our readers, in the hope that fellow experts here will provide their experience. If you are able to in your comments, let us know what organization you are either coming from, or where you got the experience that you did (as appropriate).

As I post this I remember contemplating heavily any mention of my organization or the people within it in this format when we first started. It’s a process to go through, in and industry that’s challenged by the concept of transparency. One outcome here is to hopefully normalize sharing for more organizations, as I have on the other blog I co-run (http://www.pchit.org).

Thank you, and comment away, please!

I am involved in the very early stages of a lean implementation in healthcare. Maybe you have addressed this on your blog, but one our struggles has been defining the best process for implementing lean. We are establishing a model line in food
services and are looking to begin spreading to other departments.

Our model line is still in a very early stage of development and we have only 2 engineers (as the major lean advocates) to support the hospital. Our focus has been to use a lean management system as a starting point. Some of the questions we have are:

How far to we take the model line before moving out?
How much training should we do beforehand?
If we start with the lean management, how developed does this need to be before
it is self-sustaining?
At what point do we need complete buy-in from senior management?
What should our implementation process look like?
And the inevitable question of how much is too much change? (Rhetorical)

Our approach so far has been to implement based on need. When the model line has an issue, we implement as much as we can to support that issue. The only constant has been a lean management system that I seem to be implementing with everything. We really have not done much training, but are now rethinking that to include much more. Our resources are limited, so my hope is that with education and a “push start” from us, the department will be able to realize success to keep things sustained. Past experience says this may not be realistic.

My thought is, that if we are going to do this, we should do it right. The thought has crossed my mind of value stream mapping the transformation process, but I would like a more experienced perspective on what the value adding steps are. Thanks again for your thoughts.

As I have dicussed many times over the last couple of months we are in a transition year.  The organization is moving from a system of Management by Objective (MBO) to a Strategy Deployment System (Hoshin).  For all of you familiar with Strategy Deployment you know this commitment and change is far more extensive then just learning to apply a new set of tools and processes. in order to develop and deploy a strategy.  Strategy Deployment is a management system that challenges traditional leadership models, leadership behaviors and probably most drastically when it is applied correctly it will it challenge the belief systems of an organization. 

Strategy Deployment has a management cycle where each year the organization stops and reflects on the past activities before it sets direction for the next years.  As a result each year the organization gets more focused on where it’s biggest problems and opportunities are and the causes that are associated.  The focus and understanding of the organization’s business should improve each year and so should the business results. 

Additionally, one of the most powerful aspects of the Strategy Deployment system is that each year senior leadership takes time to reflect and improve the management system itself.  This is a powerful and unique concept that is foundational to continuous improvement.  Not only do we focus on improving the results of the business, but also the means by which the results were achieved. 

This year I believe this reflection is even more important then it will be in future years for our organization.  Unlike in future years we will not have a years worth of data and intuition captured as a basis for us to learn and develop our next years plans.  Nor will we have a years worth of leadership experience in working in this new way and practicing these new mental models.  As a result, we will make more mistakes this year.  Problems will seem bigger and scarier then in the past, because we will know more about them.  This is why the reflection will be so important this year as we build this new management system.  We need to stop often to understand why challenges are arising and to adjust.  We need to capture our learning often and improve our system so that next year we don’t repeat the same mistakes. 

Additionally, we need to provide an outlet for leadership to release the pressure of the challenge of this transition.  This last Thursday we stopped to reflect with the senior leadership team who is wrestling with many of the challenges of this transition.  The entire team is working really hard to learn and do at the same time and it can be exhausting.  This reflection was an important moment for the team to stop and recognize how far we had come so quickly.  And more importantly, it was a chance for the team to realize collectively that it was okay that we were making mistakes.  Things were not going to be perfect and better is the focus not best.  Very powerful…

Over time an organization applying Lean principles and practices learns to adjust how it views and approaches it human resource strategies.  The traditional view of career paths up through functions, specialized skills sets and narrow job descriptions is no longer practical or sufficient.  These are replaced by career paths that value cross-functional experience, generalist skill sets,  a flattened heirarchy and flexible job classifications. 

The transition from these old practices to this new view of human resources is a difficult one and it requires time, practicality, consistency in practice and a lot of change management.  In many ways this is the greatest challenge we face in our organization moving forward with our Lean transformation.  This transition challenges decades of management practice and doctrine and makes void what for so many years people have been taught is important.  For employees that have been working their way up the career ladder the next step may not be in the same direction.  For long tenured employees with deep functional skills the new, generalist requirements of the job may seem overwhelming.  And for the star on the team that is always coming to the rescue when a new fire pops up the reward and the recognition may no longer be the same. 

Yet this new way of working offers many advantages over the old.  Associates are supported to learn new skills, practice experimentation and problem solving.  Career paths offer the excitement of change and broad experience.  The work can be more interesting, more challenging and less mundane.  Associate will be provided a broader view of how their work makes a difference to those that they serve. 

As the organization begins its transition it is important that leadership is able to describe these advantages in a compelling way.  At the same time it is also important that leadership is open, transparent and forthcoming with staff about how their jobs and roles will change.  Leadership must describe in detail, often what the future world will look like and reinforce why the change is so important to improving the ability of the organization to serve it customers.  Its patients.   What the change settles down, most employees will like the challenge of the new world.  In the Model Line area I have heard several managers say “they would never go back” to the old way of working.   Sadly, some will not make it through the transition, the new way of working does not match where they want to go or they hold on to tightly to where they have been. 

I’d like to ask for a little help with this one. Some of the work I am doing involves bringing leaders to the gemba for the first time, in the background of a non-LEAN environment. In what I do, this means shadowing a patient visit. I remember when I brought my boss to the gemba (see : Take your boss to the Gemba with you ) that I provided some guidelines to make things as appealing as possible. I felt I needed to do this because pre-LEAN, going to the place where work happens meant a lot of things to different people.

So here’s some of the guidance. I appreciate additions or changes:

Ideas about what this is for:

• To observe. Listen and Watch.  Notice 10 areas of potential improvement every 10 minutes, or use a template like “Stand in the Circle“
• To be as close to the customer as possible.
• To get the facts as to what is happening in the organization.
• To learn a little bit frequently (one patient visit every week is better than 22 in one day every year).
• To be visible to staff (who enjoy seeing you and showing you how they serve the patient)

Ideas about what you do not have to do:

• Come with prepared comments
• Solve problems on the spot
• Stay the entire day
• Act on every single potential improvement you observe

In the above, I don’t want to imply that a leader should erase the experience from their mind. It is assumed that the facts will have an impact on understanding problems and solving them - as they are laid out in a strategic planning process. This is to get away from a behavior where every visit should result in requests for action on what was seen. When this happens, people begin to dread the Gemba visit, because they will see it as expansion of their workload, and those who report to them will feel the same. A good strategic planning process should bring problems (which are gold) to the forefront and the Gemba visit supports that.

If it helps, I suggest that someone who is a CEO or Division Head pretend that they are not the CEO while they are shadowing. Better yet, pretend that  the CEO is the patient (and…just pretend that they are all the time anyway). If there is concern about their comfort or privacy, it will be respected, because the patient is the boss. Every visit will involve explicit consent from the patient, and there will typically be a break if a physical exam is involved, or at any time at the discretion of the physician or patient. (If this is truly the CEO/Division Head’s first time, I will accompany them throughout the experience until they are comfortable. One executive told me with some humor, “Don’t worry, I know how to talk to people.”)

The goal is for visits to become routine and not have tremendous amounts of what I call psychological overhead attached to them. Leaders lead best when they have access to the facts. And the facts exist as close to the patient as possible.

How does this sit with the audience? if you were a CEO would this make you feel comfortable about engaging in this activity? What else would you need to know or what questions would you have?

As part of my journey to understand LEAN in different environments for the purpose of growing it everywhere, I was invited to tour the Regional Laboratory at Kaiser Permanente Mid-Atlantic, one of the regions of our national affiliate, Kaiser Permanente.

As I posted previously, I have been observing the leaders and staff of this organization begin to embrace LEAN, and have been looking for more examples of LEAN practices in our nation’s capital. Luckily, I am finding them now, and this was a terrific example.

A case study about the lab’s transformation has been posted online.

I know many of the readers here have worked in lab medicine in LEAN transformations, so I am going to start by admitting a very naive perception that I have had of lab services as a family practice physician:

Whenever I have walked by a clinical lab, I have assumed that all of the big machines meant that everything was standardized and automated. The sample goes in the machine. The machine reports it. The patient and I use the data. Compared to primary care, what could be non-standard about laboratory processes?

(end naive perception)

Outside of the big machines there are huge potentials for variation and waste, and the impact is incredible. We started our tour with the story as told by the lab’s leaders. A decision was made to regionalize lab services, and the new facility came with a templated version of lab layout, which included walls, pillars, and separation of staff and machinery. The team knew they needed LEAN (more on that later) and started on a journey to build an operation that incorporated LEAN philosophy throughout.

For a service organization that performs about 5 million reportable tests a year, the impact is significant. The case study lays this out well, so I will focus on what I saw.

Pictures, click on any to see in gallery format

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Over the last couple of weeks I have begun to notice evidence of a new management system beginning to take hold in the organization.  It is subtle, yet, very exciting.  After gaining executive commitment for adopting an enterprise Lean transformation we no longer in the situation of having to gain agreement on the “what”, there is no longer resistance to Lean.  Instead, we now get to focus on helping leadership with the “how” in terms of making the transition.  Given that we are a large organization steeped in the practice of conventional management the “how” can be a real challenge.  You need to be careful to now overwhelm leadership by trying to move at a speed that outpaces peoples ability to learn. 

Our approach has been to support senior leadership in this transition by helping them make small changes to our management system each week.  We started with a two part strategy:  First, we would work with senior leadership to begin the process of reducing waste and variation in their own management practices, which I have talked about in several postings in the past.  Second, we have asked them to committ  a significant amount of their time for planning, kaizen, gemba and reflection with the purpose of supporting their learning about Lean and the business system itself. 

This second strategy has mainly taken the form of organized events, with purposes ranging from lean education, learning about the business to developing A3’s.  We had to use an event format to break out of the challenges of our current, conventional management system where available time was non-existent.  This approach has a negative side effect at first, basically, leadership would practices the new way of working during the event, and then go back to the old way of working once it was over.  Please note that I am not being critical, learning takes time and lots of practice. 

What is exciting is that over the last couple of weeks I have watched some of these learnings begin to take hold in daily practice.  I have watched many of the leaders break away from a reliance on the events to get things done.  I have seen a couple of the leaders out, in the gemba, engaging staff in the learning and teaching process.  This last Friday I talked with a group  of very excited mid-managers who had just walked out of a training, led by their executive, on root cause analysis.  Perhaps the best evidence of all of this transition will take place over the next couple days during a stratgic planning event with a group of top leaders.  The event starts with four hours of training on Strategy Deployment and PDCA followed by a day and a half of detailed planning.  Typically, it would be a Lean consultant leading the training and the sub groups, but not the case this week.  The Executives will be leading the training and leading the break out groups.  Leaders are becoming teachers, how cool!