Daily Kaizen

My role over the last couple of weeks has evolved, on purpose, from one of doing work to one of coaching and teaching. It is a difficult transition for me to make and for those that I am working with. Why is it so difficult? Well mainly because I love to solve problems and so does those that I am coaching and teaching. When we first started out in the Model Line area in order to jump start the work we often assumed leadership since those they we are working with had little to no Lean experience. Over time we have gradually handed back over leadership to the line managers. Still I often catch myself leading and solving problems as opposed to supporting and coaching the line managers so they can effectively lead and help others solve problems. Overall, I am getting more disciplined and better at stepping back . It has been interesting to see that the line managers struggle with much the same challenges that I do, just in a different context. They too have a difficult time allowing others to make decisions and to solve problems. In the current management system it the norm for line-managers to make most decisions, which has been a real bottleneck for improvement. This problem is compounded when you consider that they are unable to track at the detail level. The Vice President that is leading the Model Line has been working very hard at changing his behavior to reflect this new system we are trying to create and it shows. He is now asking more questions then making statements. It has been very tough for him, yet in many ways rewarding. Yesterday he commented that he has been catching himself forty to fifty times a day giving people answers, which was down from more then a hundred. Moving forward the success of our transformation is contingent on our ability to teach managers how to teach. This means having the discipline to break old habits and the support to build new skills.

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On Friday I attended the annual manager retreat for the division that I work for. It was an exciting and educational day that proved for me just how far the organization has change for the better in a single year. The focus on the retreat was strategy deployment and catchball. Each of the line managers in the division told the story of their department in just twenty minutes using A3s and then gained feedback from the audience. Groups of managers rotated between the different departments so they could understand and provide feedback to six separate line managers. It was the first time that this large of a deployment activity has been attempted in the organization. In every single breakout room I witnessed first hand how powerful Lean Thinking has taken hold in the organization. Every line manager had Lean language, principles and tactics interwoven into their stories and their plans for the year. Lean is no longer viewed as just a process improvement methodology, but instead as the way we will achieve transformation. A year ago at the same retreat most people didn’t even know what Lean was.
For the last two years as a Lean consultant I have always questioned whether leadership will stay the course. I can’t count how many times I have heard the “flavor of the month” comment or been reminded that “we already tried this before.” At the end of the day the Executive Vice President concluded the event by make a statement that left me energized and left no doubt in my mind that Lean is here to stay. Standing up in front of over a hundred managers he made a simple pledge:
‘This is the horse that we are going to ride. As long as I am the Vice President of this Division this is not going away.’ -James Hereford

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Over the last couple of week’s Ted has shared several useful and interesting posting about different work teams that he is engaged with and their quest to make work more visual. Last night I had a very eye opening experience. After an oversight meeting that went late into the evening I was walking down the hallway with the CIO of our organization. It was late enough that nobody else was around. Out of the blue he asked if I minded giving him a tour of the production areas so that he could see some of the visual systems that teams have been putting in place.
Over the last couple of months all of the managers and supervisors have been going through our Daily Management system training where they have picked a process to standardize and bring under control. Part of their training is to build a visual system for their process. Over the last couple of weeks I have walked by many of these visual systems, but I have been tracking at a higher level of detail and have not invested much time in learning what each team is working on. Big lesson learned, I better know the details of the work!
So I told Ernie, our CIO, sure, even though I immediately felt stress, because I was not sure if I would be able to explain the Visual Systems to him not having the knowledge at the detail level. As we walked from one team to the other I became relieved. Each visual system is based on a standard format, that provide info on process flow, customer requirements, targets, in process measures and counter measures. Without knowing the process we were both still able to know exactly what the improvement goals were, where the team stood against these goals and what the team was up to next. It was very powerful. We went to four different areas and for each we knew the story without have to ask a team to explain. Simple, informative and exciting! The transformation has begun.

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As I follow Lee’s experience, it is fascinating to me how we arrive at the same analogy. Lee is engaged in a sponsored, organizational change effort, the Model Line, which is working within the larger organization.

I am engaged in more of a federation of sponsored, smaller efforts, without the clear organization of the Model Line. Yet, the experiences are similar. My day to day experience has been one of connecting teams and watching connections and conflicts happen between teams. The teams I am working with have not had a great degree of formal training, yet they are improving their work every day through the training of peers and real inspiration. The victories are small and steady, and they do not bubble upward and sideways or get connected with something with a label, such as Model Line. They just happen.

The image attached here is one – it’s a new visual system put up to guide large project work. Note the sign on the left – it says “Up for Grabs,” which empowers staff to choose their next piece of work. Also note the creative cost saving – discarded letterhead envelopes are used as the building blocks.

On the day that I saw this for the first time, I actually had just walked upstairs from the review of another visual system for a companion team. They are starting to link together. Eventually, we will link to the work of the Model Line.

I think this is a great place for a physician to be and I hope other physician leaders will join in this work – physicians bridge worlds all the time, between patient and optimal health, business and clinical, health care and community, and quality and affordability, too.

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I don’t know if anyone has seen the recent television advertisement for Quickbooks software. At the beginning, a gentleman is facing a wall of post-it notes and says, “This is my accounting system.” It looks eerily similar to the visual system I posted here recently.

The advertisement goes on as expected to tout the advantages of the product. I thought it was humorous in that we are doing exactly the opposite in our work and are getting great results – not using a software product and putting the post-its on the wall.

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As I have stated before one of our major focuses in the Model Line during 2007 is the implementation of a new management system based on PDCA. Different components of the new system include establishing a Hoshin Planning process, developing a new strategic deployment system, creating a dashboard at the functional and organizational levels and last but not least creating a Daily Management System. Implementing this new management system is challenging us all to think differently, plan differently and behave differently. This impacts no group more profoundly then the leadership team that I am working with. While these changes are very exciting, the accountability, the responsibility and much of the energy to put them in place falls directly on their shoulders.
Since the Model Line is out in front of the larger organization these leaders are having to operate in two management worlds: the one we are putting in place based on Lean principles and the one based on “traditional” management practices that rest of the organization is part of. This tension is most evident as the leadership team try’s to prioritize their time. The demands of the Lean system call on them to spend large amounts of time in the Gemba coaching and mentoring staff. It asks them to lead RPIW events and manage large scale change. The demands of the old world ask them to spend time with other managers in meetings building consensus, reacting to problems and facilitating handoffs between departments.
To be successful these leaders will need to find a balance. In order to not burn out they will need to remove themselves from many of the activities they participated in the old world. At the same time, they need to stay engaged enough to ensure our customers needs are met and to ensure that others learn from what is happening in the Model Line area. A great challenge.

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I’ve been involved in some improvement event planning where the question comes up, implicitly and explicitly : how much work do we do before we do the work?

The way I pose the question above reveals my inherent bias. I have to admit, I am a fan of “just-in-time.” I think some of this is bred into physicians when they train. A patient might experience it as, “Go ahead and make an appointment to see me and we’ll figure it out then.” It’s the way the health care system is set up – acute, episodic care.

When I am thinking of working with a cross-functional team on a project, I go to the same place – “Let’s get in the room and we’ll figure it out then.” At the same time, when those who get in the room are unprepared, there are negative impacts.

I predict that this will be a constant tension. I will predictably be in the “prepare less, focus more” camp. I plan to be proven incorrect more than a few times, and to adjust and learn accordingly….

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Over the last week I have had several conversations with various managers in the organization about standard work. It is amazing to me how resistant people are to the idea of having standards that all associates are required to follow. One group of managers argued that they ‘are not robots’ and that having standards would mean that they would have no opportunity to bring creativity to their work. Another IT manager told me that he believed that making people follow standards would mean that there would never be innovation or improvement. The fact is, standards are the basis for creativity and innovation. Without a common standard when one associates finds a new and better way to do something it is very difficult for anyone else to benefit from it.
Standards have a bad name in the organization mostly because they have been designed and maintained by groups of managers and supervisors that are not directly involved in doing the work. As we progress with the Model Line it will be important for us to teach people the value of developing and following standard work. In order to do this successfully, we will need to turn over the responsibility of designing and improving standards to those that are following them, this is the trust that will make the difference. The people doing the work know best how to improve the work!
I thought this quote below by Matthew May describes well what I have encountered:
“The thought of standards makes a lot of people cringe. That’s because they confuse standardization with uniformity. They think standards somehow discourage creativity. The perceive standards as a control mechanism to prevent individuals from performing the job in the manner they view as best.”

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The value stream of the Model Line area is an administrative process that is focused on adjudicating the benefits of the members we serve. Every day we receive on average almost 30,000 claims. Most of these claims travel through our information system and auto-adjudicate, meaning that the computer system does all the necessary checks and there is no manual work required. There are many exceptions that lead to claims “pending” out of the system for a processor to manually review them. In fact, we have somewhere around three hundred full time employees focused on working these exceptions.
There are many reasons that a claim can pends, but all of them are due to defects in either the system or the data. Over the years as we moved from a completely manual process to one that is primarily automated we have lost touch with what the work really is. Associates are very specialized and only work a small range of exception types thus they don’t see how their work is contributing to the whole. As the processes have become more and more distant from the meaning of the work so have the performance management and reward systems. Instead of rewarding people to find ways to error proof and stop the errors from coming in to the system in the first place we reward people on how fast they can process the errors once they have occurred. Thus, work is viewed as just work and not as opportunity. Our great challenge is working with managers and associates to help them understand the cause and effect relationships that drive the exceptions to them in the first place. We are teaching them problem solving skills, and how to work with data. We are also beginning to disassemble the current performance management and incentive systems.

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This week’s quote comes out of a Hoshin planning session that we conducted this last Friday with the Model Line leadership team. The quote comes from Hope Wiljanen our Sensei as she describes the PDCA process of Hoshin Strategy Deployment.
‘When we talk about PDCA it should be capital P, lowercase D, capital C, lowercase A. This is backwards from conventional thinking where organizations spend most of their time and energy on doing and acting. Moving forward we need to devote our time and energy on planning and checking. This is the discipline that will make us successful.’
Over the last three months we have been working to incorporate PDCA discipline into our Model Line planning process. We are quite literally building a new management system in the organization and it is fascinating. There are many attributes of this system including developing standard work for managers, redesigning the strategic planning process, developing a strategic deployment process and most important formalizing the checking process at all levels. It will take several years to fully put in place, but by year end I think we will show great progress.

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