DailyKaizen

As part of our transition to a new management system based on Hoshin Kanri it took the first three months of the year for us to define and deploy a strategic plan.  We are now in the DCA part of the PDCA cycle.  In order to support this part of our cycle we are in the process of developing dashboards at the top two levels of the organization.  The dashboards and good measurement is essential to our success moving forward.  By making performance visible and binary it will allow us to be flexible and nimble as an organization.  Without good measurement it very difficult for us to know how we are performing against our hypothesis (plans) and when their are deviation we would often not be able quickly identify the root cause.  Additionally, without a good measurement system it makes organizational learning very difficult, because we often lose track of the mistake of the past and thus repeat them again and again. 

This work as generated a whole host of new challenges and learnings.  What is very clear is that the measurement systems of the past are no longer valid moving forward into the future.  For the most part we have very few process metrics and almost everything we measure is end of pipe and results focused.  The outcome metrics we do track are often complex and unactionable.  For example we have several index measures that are very difficult to break apart.  We also spend a lot of effort tracking financial metrics that are retrospect in nature and tell you little about recent performance.  The few process metrics we have are mostly untimely.  At the team level our measurement systems are often focused on the individual performer as opposed to the process they are working on.  This adds a whole host of challenges that we will need to work through over time.

I am sure that our problems are not uncommon and many of you have been where we are.  It will take a lot of work over a long period of time to step by step redefine our measurement system.  The great news is that we have a very engaged CFO as well as several other executives that are deep in the learning process trying to think through new ways to deploy measures.   Our first step is to teach them to think and see the value streams of the organization so that we can begin to move from a silo based measurement to value stream measurement.  I am excited for the learning to come!

I recently returned from Medical College of Georgia, in Augusta, which is nationally known for involving patients and families in their care. The work is very impressive, and I posted a summary and pictures on my other blog.

There is a story that I was told that is worth posting here:

Pat Sodomka, Vice President of Patient and Family Centered Care, and Bernard Roberson, Director of Family Services Development explained to me, Patient and Family Centered Care means a lot of little changes. They told me about patient Nettie Engels who asked for longer straws in radiology. Why? Because when patients were flat on exam tables and asked to drink contrast, short straws meant that contrast was more likely to spill on the patient, and due to the requirement that they be still, this resulted in unnecessary discomfort throughout the procedure. As a result, the hospital purchased longer straws, so that patients can now have the dignity of clean and dry clothing while undergoing an exam.

As we talk about leadership at all levels and the ideas of staff, how do we incorporate ideas from patients and their families? What is our mental model about the ideas of patients and families - do we see the problems that they bring to us as gold, or do we tally them in databases somewhere?

How many short straws are there in your institution that you don’t know about?

I am currently in the process of working with a team to develop a series of Lean Learning sessions for our executive team.  It has been a challenging and educational process for me as it is the first time that I have worked with a top level executive team that is committed to transformation.  Over the last couple of years we have conducted several “Lean trainings” with this team, but is was completely different then our current approach.  Lacking the current commitment levels it was typically information only and it lacked connection to specific, strategic need and results.  Thus the overall effectiveness was never very solid.  With our new organizational focus this has completely changed and we have the opportunity to work for twelve full days over the next year to begin the deep and applied development process. 

There are a total of four sessions that we will teach this year:

1. Make problems visible  (waste, visual management, standards, 5S)
2. Reliable process through reliable methods (PDCA, Point Improvement and Daily Mgt/Std work)
3. Make Value Flow (Value stream improvement)
4. System Improvement

Our approach this time is to learn by doing and to spend more time in the gemba then in the classroom.  Thus our training will be based out of a medical center.  The following is a general outline of how we will conduct these sessions:

1. Define the overall organizational improvement system and supporting framework.
2. Teach a technical skill/principles of Lean (Flow, Standard work, etc.)
3. Practice skill/principle through case study
4. Go to the Gemba to see skill or principle in action or to determine how it could be applied
5. Reflect on how skill/principle fits into broader improvement system and framework

Additionally, each executive will have to take the learnings and apply them in their own functional areas.  At the beginning of each session each executive will report out in a standard format their improvement projects, results and learnings.  Our goal is to use this process not only as a primary driver of learning, but also as a mechanism to begin to build out and improve our management system.  For example, during the first session we will teach visual management and then each executive will for their homework develop a functional dashboard to display target/actual. 

I would welcome feedback!

As an organization we are just in the very initial stages of putting in place a Lean Management system which I have discussed in many posts over the last couple of months.  As of last week we completed our first strategy development and deployment process based on the Hoshin system.  The process took us two months and it was rich with new learnings and new behaviors.  Now that we are moving into the execution phase of our cycle it is critical that we begin the process of putting in place a linked checking process based on PDCA that needs to link all levels of the organization.  The purpose of the checking system is to ensure that at every level of the organization we are disciplined about checking our hypothesis to determine if we were correct and the plan is on target.  If we are not on plan then we will need robust processes to support putting in place adjustments (countermeasures) that will get us back on plan. 

For the first time last week I began to realize just how powerful this check/adjust system could be for the organization.  Our Sensei have repeatedly told us that the most dramatic change will come when we drive the checking process forward as an organization, but being caught up in the new way of planning I never stopped long enough to take in how big the change really is going to be.  The organization will be a very different place if we are successful in putting this new management system in.  Over time the system will move the organization:

• From unclear ownership of problems To clear lines of responsibility
• From thin knowledge required of a problem To disciplined problem solving based on facts and data
• From pushing due dates and giving up on projects To quickly implementing adjustments to ensure resolution
• From slow and inaccurate transfer or information between layers To clear standards and pathways for information to travel
• From problems being hidden To problems being visible
• From cumbersome committee structures that slow down decisions To clear standards that lead to rapid decision making
• From short-term organizational learning To long-term retention

This is just a partial list of what this new management system could do for the organization.  Even more dramatic and powerful is to think about the change in leadership that will be required in this new world.   A world where managers will be responsible for owning and making problems visible.  Where they will need to teach others to solve problems as opposed to solving them themselves.  Where deep thinking, deep understanding and hands on involvement is required to be effective. 

The title of my post is a corollary to Lee’s previous post, which I loved, because besides talking about the issue of going to see things, it also alludes to the idea that LEAN creates leaders who are able to reflect on to themselves what they reflect onto others.

My little add is to always go see as part of what I do. Now that I’ve been working this way for 3 years now (and I can’t believe that it’s been 3 years), I realize that I am more and more uncomfortable hearing about anything in the absence of seeing.

This has really hit home in the last two weeks, actually, as I wind down some of my sabbatical work, and schedules have gotten a little tighter. I found myself about 3 weeks ago having a conversation with a great group of physicians about their launch of a patient portal….in the conference room of their headquarters. It just wasn’t the same for me, and at some level I felt I was being disrespectful by offering any advice at all in the absence of seeing the care that these physicians provide.

Last week, I spent time in California, and I was able to get close to the work, but I didn’t actually shadow the patient process of care, and that still felt a little uncomfortable. Same feeling - what do I have to offer someone who experiences a set of facts that I did not see? At the same time, I saw more than I did in the experience above, and it was very important and meaningful, judging by the fact that my blog posts on them were much richer with information.

Fortunately, no communication is ever over in life, and I asked for the chance to go back and shadow the first set of providers. They said sure, and I really want to do this.

If there is anything from this experience that I could impart, it would be that your approach to where you do your work will change with LEAN. You will feel more natural being close to the patient, and more unnatural being farther from the patient. What used to seem like the easiest, most comfortable thing, going to the same conference room watching Powerpoint slides, connected to your iPhoneBerry, will begin to seem like the hardest, least comfortable thing. And you’ll love what you do more than you ever have.

Never speculate about problems you don’t go see first for yourself is a goal of mine that I am trying to integrate into both my teaching and my management practices.  I cannot tell you how hard it is to adopt this into daily practice.  Just the awareness of how often I talk about problems that I do not have facts to support has been staggering.  Yet, as I learn more and more about the principles of “Management is Responsible” and “Respect for People” I cannot understate how important this goal is.

So where did it come from and why am I trying to do this now?  I am not sure if there is a single answer to this question, it is more of a build.  Over the last couple of months I have spent a lot of time working with leadership teams helping them transition to a new way of thinking and behaving.  I came to this world after spending two years deep in the gemba working through major value stream redesigns.  I would often find myself in meetings where a group of leaders would be discussing a problem or situation that I new a whole lot about from my past experience.  It was always really frustrating when leaders would claim to have the solution or worse new just who to blame for this so called problem that might not even exists in the first place.  As information travels up through the organizational ranks it is amazing how quickly in becomes corrupted and fades from fact. 

Just recently I was in a coaching session with a Senior Executive who made some untrue comments about a specific project that I had worked on.  I knew the comments were coming so I was prepared to not be defensive and I challenge this person with a set of questions.  I asked them if they had gone to see the problem themselves and then admitted I knew a lot about the situation.  The executive who I respect very much did not get defensive at all and suggested we go together, which I am arranging.  About thirty minutes later we were talking about something completely different and I began to speculate on a problem myself.  BAM!  He called me on it.

Now back to the beginning where I began this post.  With my new awareness it is amazing how often I get caught in the trap of speculation and how hard it is to stop.  This is just one example of why companies struggle so hard with the principle of Respect for People, because it takes such discipline and awareness of behavior to be successful.  So the best way to change thinking is through a change in action, so I am going to continue to do my best to use my feet to see problems as opposed to my mouth to talk about them.

While Lee (and many of you!) were in Orlando, I was in San Diego for the Health 2.0 Conference. I posted something of a play by play on my regular blog (they had tables reserved for bloggers, I had to earn my keep!).

What was eye opening about the event is/was that as much as we work to move our health systems further and faster toward a patient centered reality, there is a whole industry springing up that is already there, and creating their own reality in the void that still exists. They are both exasperated with mainstream health care and restless at the same time. The result is that our platforms will burn brighter and our relative biases toward inaction will melt away. I was reminded last week that we do have biases toward inaction. I needed that.

At the same time I engaged with a real consumer-centered world, I also visited some very well regarded medical groups and co-facilitated my first ever strategy deployment session with a group not-affiliated with our health care organization.

On the medical group visit, I had the sensation of meeting another American in Europe, when while doing the planning, I indicated that I wanted be as close to the patients as possible. The response was, “Oh, you want to come to the Gemba.” It was a wonderful thing to hear because the conversation instantly changed. Later on the week, though, with a different audience, though, I was asked about using the Japanese terms in mixed audiences and whether that enhanced or degraded understanding of LEAN. I need to watch myself a bit more, to prevent jargonization and some of the concerns Lee mentioned in his last post.

On the strategy deployment session, I was definitely on the nervous side as a non-affiliated outsider. I’m sure this is a feeling that many of the readers here have had in their careers! I saw how the process itself and the stage set by leadership allowed people to leverage the ideas to their maximum. I walked the group through my own experience transitioning to a hoshin process from 2004-2007. I had actually never compiled our story together with photographs, and it was great reflection for me to create a story reminiscent of Atlas Industries in Pascal Dennis’ book. If any of our readers are not documenting your stories through photographs (and maybe a blog…? :)), please do it. It will help you and those who come after you.

There were many things in the last week, and in the last 5 months that make me believe that we could reach critical mass for respectful continuous improvement methodologies in health care as a standard. The consumer movement in health care, technological advances, and the mixing of generational experience (Boomer - GenX - GenY) in leadership make it possible. When that happens, we’ll all be world citizens and it won’t be like meeting another American in Europe anymore.

Do others agree? Could we make this the standard across medical education and health system leadership in the next 10 years? How about the next 5?

I got back to work on Friday fully energized from a great couple of days at the Lean Enterprise Institutes’s yearly Lean Transformation summit.  Like last year it was a great event and I left with a mind full of new stories and ideas to apply back in Seattle.  The last couple of Lean conference I have attended I always felt overwhelmed and somewhat behind at the conclusion of the event.  That was not the case this year.  As an organization we have advanced so far in a single year and as a Lean practitioner I feel so much more confident then I have in the past.  I have to admit that it feel pretty good to have folks come up to you and ask for consultation for an invitation to “come see” our gemba.

Myself and two senior leaders from Group Health had the opportunity to present twice during the event.  The focus of our session was Implementing Managers Standard Work.  Instead of having dozens of slides full of bullets and playing the part of talking heads we decided to just tell a story about what we are trying to do at Group Health.  Our slides were simple picture of the work place and the people we work with.  Overall, I think most found the talk useful and we got mentioned a couple of times by the keynote speakers.  I was surprised by how popular the topic was and how few organizations have focused on standardizing their management processes. 

The event concluded with James Womack giving the final talk.  I was very impressed by his thinking and his challenge to the group.  He told the audience that his greatest fear for the next couple of years as the country inches toward a recession is that so called “Lean Consultants” will begin to appear out of the woods and begin selling their head cutting expertise.  I hope this is not the case and Lean does not go the way of Process re-engineering.  In concluding this posting I will quote Dr. Womack who discussed the PDCA process at Toyota during his talk:

‘At Toyota there is no such thing as solutions there are only countermeasures.  This is because Toyota is smart enough to realize that by the very act of solving one problem you always introduce new problems into the system.’

I am really excited for this week and its not just because I get to leave the damp Northwest for a couple of warm days in Florida.  Myself and two of my co-workers will be presenting at the Lean Enterprise Institutes annual Lean summit.  The purpose of our session is to share out learnings on creating Managers Standard Work.  It is such an honor to present in front of so many great Lean thinkers with so much great experience.  My hope is that our story and materials will be of value and that folks walk away with not only a deeper understanding, but also with some learnings that they can apply immediately upon returning to the their organizations.

I spent a couple of hours this morning running through the presentation and I have to say I am proud of the work we have been doing and the progress we have made.  There is a really interesting story to be told.  In three years we have moved from applying Lean one tool at a time to an enterprise wide transformation anchored in improving our management systems.  Ever day the organization seems to be learning more and as a result we understand more about just how much more there is to learn!  I guess it is our turn to stop and share with others what we have picked up along the way.  So many other organizations have helped us out that it is probably about time.

I hope that some of you are also attending the summit.  If you are please swing by and say hello.  I will be back to blogging next weekend.