Daily Kaizen

I am currently working with the leadership team to help them crosswalk our long-term strategic plan into an A3 format and process, which will be deployed over the next couple of months.  The team has been working for several months on understanding the market place, defining current state, shaping a vision and getting focused on the critical pieces of work that must be completed in the next five years.  I am impressed with how focused and thoughtful they have been during this process and believe we have great opportunities moving forward.  Most importantly, I am excited, because for the first time I think the organization has clarity and alignment on the few, most critical areas where we need to improve. 

What is surprising is that this might actually be the easy part of what still needs to be done in concluding the planning process and deploying the plan.  The real challenge will come over the next couple of months as we work with leaders and teams throughout the organization to deselect work.  As an organization we have a limited amount of improvement resources and to successfully achieve our breakthrough priorities we will need to use the vast majority of them.  This will be a big change in the organization where most departments currently have access to “their share” of support and resources.  Additionally, we have far to many improvement initiatives in progress.  There are literally hundreds of them.  Far more then can be supported.  Thus  to remain focused we will not  only need to set up a process to deselect improvement work, we will also have to kill many initiatives in progress. 

To manage this change it will be very important that senior leadership is able to tell a compelling story about what we are and are not going to do as an organization.  Additionally, it will be important to engage as many employees in the planning process as possible so they see for themselves.

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Here’s proof that you can bring LEAN into your every day work, even in a small (and vital!) 501(c)3 non-profit organization. Stimulated by my trip to LEI, I put together this very basic visual system with my colleague Josh Seidman, Ph.D. for the work we are doing. It’s hosted at the Center for Information Therapy, with a duplicate paper copy for me. Since every good visual system deserves a theme, I chose the Washington, DC Metro as my analogy, with work yet to be undertaken located at the Shady Grove station, active work located at the Bethesda station, and completed work at the Dupont Circle station (since that’s where I return to every day).

Related to this, I have been spending time with organizations that I would formerly consider the “Have Nots” – those without the relatively rich resources (mission, vision, as well as financial) of an integrated delivery system. And guess what, they are innovating in very impressive ways, using techniques that are very consistent with LEAN. There’s a write-up of a recent encounter I had with the American College of Physicians’ Center for Practice Innovation on my other blog. Almost every presentation demonstrated work that was directly related to components of LEAN philosophy. I was incredibly impressed.

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One of the interesting parts of my job is I get to work with teams in different states of their Lean journey.  Working at a large company with 10,000 employees the contrast is quite large given that some teams have been deeply engaged in Lean thinking for several years where others have had little or no experience at all. 

During my first two years of Lean work I was primarily focused on working with mid-managers and front-line teams.  As we began to change the daily work of teams we would go through a similar cycle of change management and then excitement as teams began to realize how much empowerment they had been afforded.  As measurement and incentives were changed the teams would begin to shift from individual to team focused management where peer pressure would become the primary driver of performance.   Additionally, with the application of Lean tools work would become more visible, more team focused.   Within months of changing their work the teams would be operating very differently then similar teams that had not begun their Lean journey.  Being at the front-line the contrast was very noticeable. 

Lately, I have been primarily working with teams of senior leadership and it has been interesting to view this contrast at a different level.   In fact, I would argue that the contrast may be even greater then the difference between front-line teams.   Here are a couple of my observations about senior leadership teams with more experience in Lean:

• They tend to have very different ideas of what is important.  This is most visible in how they spend their time.  Moving from conference rooms to the workplace. 
• They tend to ask more questions and make less statements. 
• They tend to be less reactive when problems arise.  They ask for data and cause as oppose to jump right into action.
• They tend to be more humble.  They realize how much waste there in in their areas and how much better they need to be.
• They are far more critical about their own work.  They are more open in talking about problems in their areas and there is less “happy talk.”
• They become more an more inpatient with the organization.  Its like they have stepped out of the box and not only are they no longer to step back in, but they want everyone else to step out, soon. 

It will be interesting to see if this contrast grows smaller as we work with more and more teams.

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Just and FYI to the readers: I have decided to sunset for a while the Quote of the Week posting.  I have exhausted my notebook of favorite quotes and will be rebuilding over the next couple of month.

Today I want to challenge you with a case study and am very interested in hearing your thinking.  I have a feeling that many of you are working  or have worked in the past through a similar challenge and am wondering what steps you have taken or took.  I will provide my current thinking as well for feedback.

Description of the current state:

• Twenty-six service centers (medical) across a two state region
• High variation in customer needs depending on geographic
• No two work environments the same: size of centers ranges from 20 to 100s of employees
• All centers provide basic services, but number of special services provided depends on center
• All centers utilize same information system

The question: How to build standard work and “Spread” improvements across a system with high variation?

This was the question that I discussed last week with several highly committed leaders that are looking to move from a manage by results to a manage by process model.  How can we possibly implement standard work across so many centers that are so different?  Possibly even more challenging is trying to figure out how once we have standard work in place across all of our center will we spread an improvement once one center has figured out how to do something better? 

I have done a lot of reading about how other companies approach this challenge, but have not been satisfied with what I have read.  Most cases and articles talk about the need for best practice sharing session, promotions for latteral learning processes or “meet it or beat” policies.  While I believe all of these strategies have merit they are not sufficient.  None of them go deep enough.  They all seem to be a single component of a much bigger system.

So here is my latest thinking of how to manage this challenge.  To try and identify and spread best practices across the system in the form of standard work is unsustainable.  We would be solving the symptom and not the cause.  I believe that variation is the result of non-standard management work.  Thus the best approach that we can take is to focus first on creating a consistent and standard management system that all centers, regardless of size, location or service mix would adopt.   In this system the role and the processes of management will be the same in every center.  All managers would follow the same improvement process, learn how to manage by data and facts, teach staff, follow a standard checking cadence, and focus on bringing processes under-control by implementing standard work within their centers.  At the same time the organization would need to work to redefine our planning and measurement systems.  Only then could we focus each team on the most important improvements and identify with relability best practices. 

So am I on the right track?

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This is how our day began yesterday as Dr. James Womack described why he was at Group Health for a site visit. For those of you that don’t know Ted, he is fearless, and it was not a surprise to any of us last week when we were contacted by LEI for a site visit. Like always, Ted is working magic, even from the other side of the country.

Images below, click on any to see full size:

Yesterday, James Womack the founder of the Lean Enterprise Institute and Helen Zak the chief operating officer spent the morning walking through the gemba of our Model Line area as well as providing us feedback and consultation on where we should be focused as we move forward. The word got out to the teams late last week that our guests were coming to town and there had been a growing buzz ever since. After the visit the teams were still buzzing and our corporate library has had a rush on demand for copies of Lean Thinking. Walking out the door yesterday it was so satisfying to see how proud the teams were of gaining such deserved recognition.

In attendance was our Lean Champion, a small subset of our Lean consulting group and the Model Line leadership team. We started the day out talking about our organizations Lean journey. Both James and Helen had a lot of excellent questions most focused on our efforts to adopt a new management system. We talked a lot about our transition from a strategy that was event (RPIW) focused to one that is focused on shifting the purpose, role and focus of the organizations management. There were a lot of take aways from this discussion, which will become the subject of future blog posting. Mostly I left the conversation with a confirmation that we were on the right track, that we are blazing a trail in healthcare, and that our success is contingent on our ability to adapt the thinking and behaviors of the organization into a new management system.

We then went out into the gemba and visited two teams. James and Helen quickly engaged the front-line managers and staff in dialogue about their experience with the changes in our management system. I was impressed how quickly both of them narrowed in on where the teams were from both a process and people perspective. The teams quickly forgot their nervousness as the opened ended questioning engaged their thinking. I was also nervous at first, and I am not sure why. The teams handle each question with honesty, and demonstrated just how far their thinking had advanced in such a short time.

After the walks we all met back in the conference room to reflect on what we saw and to gain feedback from our guests. During the walks I was curious why James and Helen asked so many questions about standard work. During the debrief the reason became clear that they were testing if our efforts were more show then real. Were we simply putting up visual management systems, running events and applying tools? Or have our efforts been deeper, more substancial? Overall, I think that they were impressed with how quickly we have been able to move. That being said they had a lot of valuable feedback to provide including:

• Our need to continue our focus on implementing standard work with a focus on shifting manager’s thinking and behavior
• Our need to carefully define purpose for each process so that we don’t fix work that should not be done in the first place
• Our need to redesign our work environment and break down the physical barriers that hinder teamwork and problem solving
• Finally, our need to engage senior leadership in their willingness to lead this journey, even though there are so many unknowns

The discussion continued for over an hour with the topics ranging from the current state of Lean Healthcare to the challenges of the United State education system. It was an opportunity that I will not forget. Thanks so much Helen and Jim!

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I have spent the last couple weeks immersing myself into our companies strategic planning process with the purpose of developing a transition strategy.  We are at a milestone for the organization where we will begin to shift from a management by objective system to a management by policy system (hoshin).  This first couple of years will be very difficult, because the changes in behaviors and thinking are so large.   Working with leadership teams we are often asked to describe how the new system will be different.  I find this question difficult to answer, because on paper the steps are the same, the difference is in how each step is performed and the behaviors required.   It is hard to explain leadership standard work to a team that has never experienced putting it in place.   So often our answers basically translate into “you will have to trust us and the process”.  As a consultancy we have enough experience now to know that we need to break the process into small steps and help a team get the experience and training through the work until they become more confident.  Soon enough we will be getting out of their way.

What is remarkable to me is how excited almost every leader is for taking on the challenges of putting this new system in place given the change that is required of them.  I believe this is mainly the result of the excitement our Lean efforts have created across the organization by engaging staff and leaders at all levels in improvement.  There is growing buzz across the organization as more and more teams engage in kaizen.  Leadership has thrived off this excitement, but they also recognize that without aligning efforts from the top down through the organization we will not sustain this engagement.  Thus, Hoshin is the logical next step.  In that spirit I chose the following quote:

“One premise of hoshin is that people who are charged with executing a plan should participate in the planning process itself…The benefit of such activity comes from the fundamental belief that people want to do what they believe is right.  Unless they participate in the broader dialogue of the company, they will not know what is right and will tend to sub-optimize, or do what is right according to the perspective of their own”egocentirc” process.”  –Akao

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Some people visit Paul Revere’s home when they come to Boston…

In case you were wondering how the Lean Enterprise Institute organizes its own work -

I happened to be in Boston on the project I was working on and honestly did not realize that LEI is based here, but when our sensei connected me with David LaHote, President of LEAN Education, I jumped at the chance to learn more. And I brought my digital camera (of course).

So, LEI is based here, and here are images of their “world headquarters.” As you can tell, the space is open and modular, and the components of LEAN that we think of are employed here. David tells me that they try as much as possible to emulate the philosophy they support, but they aren’t perfect. LEI participates in research and education and does not do hands on consulting, which is very useful for an organization like ours. They are participating more in health care issues and have partners beyond the auto industry.

I was lucky enough to come on a day when Jim Womack was in the office and was able to speak to him for a bit. We talked about what Group Health is doing in LEAN and about the mutual interest in producing portable knowledge (research) that come from process improvements. I remarked that I have not yet seen very much in the peer reviewed medical literature that I could use in my LEAN work. My other interest, as I have mentioned here, is in medical education, to train physicians before they become physicians about process improvement and patient-centered philosophies.

I came today to find out what might be going on in my new back yard (Washington, DC) that I could learn from while away from home base. I think the answer for now is that I might have look a little harder, or create some magic myself. No big deal. There’s definitely some work happening here in Boston, to be sure.

Enjoy the photos and thank you to Jim, Dave, and the staff at Lean Enterprise Institute for accommodating an inquisitive physician on their journey….

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We currently have a meeting problem!  Between oversight sessions, committees, planning events and other across functional coordination activities leaders throughout the organization don’t have time to spend in the gemba, participate in kaizen or develop their people.  I recently spoke with an executive that had collected data on the activities of their calendar and it was staggering how much time they were spending in meetings trying to coordinate across functions.  There are many causes for our problem including multiple layers of management, complex products, lots of silos, and a lack of management standard work.

We have begun the work of implementing a new management system and there is a great need to free up time on managers calendars to support planning, deployment, checking and improvement work.  The good news is that this problem is very visible to all of leadership and they are committed to starting to take some steps to improve the situation.  The first step will take the form of a design workshop that will include our most senior leadership team with the purpose of starting to build standard work for management.  The scope will be small, yet, still very challenging.  During the event we hope to be able to set email policies for the organization, standardize our meeting processes to make them more efficient and to standardized the checking process at the highest levels.  Most importantly, we are going to focus on standardizing the organization’s calendar so that “meeting free zones” are created, and a cadence for meetings links the top to the bottom of the organization. 

While many of these changes may seem small, I believe that if they are successfully implemented we will be able to free up a significant amount of time for improvement.  Additionally, since the standards will be set at the highest levels of the organization we will also be setting a great example for the type of behaviors that we want to promote moving forward. 

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This last Thursday I was stuck in Seattle traffic on my way home after a very long day from work and I was reflecting on our challenges to integrate PDCA thinking into all 10,000 of the employees I work with.  During the day I had met with several teams that are focused on breaking out of their current “aim from the hip” culture and looking to move toward one more based on discipline and scientific method.  But it is hard pushing, old habits die hard and many of these teams are feeling exhausted by their attempts to change.  Each time something goes wrong it is human nature to fall back on what you know.

In the background I was half listening to an interview on NPR with a young man named Chris Sharma who just had a movie made about his rock climbing abilities.  It suddenly dawned on my that the young man on the radio, who was sharing is philosophy on rock climbing was talking to my thoughts.   In the interview, Chris shares the importance of process thinking, setting standards, and rapid cycles of testing and improvement.  All of the points he makes in the interview are applicable to the challenges we face in trying to reshape our culture.  There is no doubt in my mind that Chris Sharma is a Lean Thinker.  When I got home I went online and listened several times to the interview several times and would recommend it to everyone.  Here is a couple of quotes on rock climbing that stuck with me: (Taken off the radio so might not be 100% accurate)

“The hardest thing is to do something for the first time.  Someone has to have the vision (to say), ‘oh, that’s possible.’  And once its done, others can see ‘oh yeah, it is possible.’  And it becomes easier for others to do it as well.”

“There are a lot of people that may be way to focused too much on getting to the top.  They just want to get to the top, and have the success, which is to bad, because so much of it takes place in the process of working on it.  That is the whole life of it.”

“Climbing is evolution.  Where the standards today are the combination of all the efforts of all of us who are climbing right now and all the people before us.”

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I was fortunate to catch up with Lee over the phone today, myself in Logan Circle, him in Seattle somewhere….I can tell that our experiences are bifurcating, in a very complimentary way. As he’s going to discuss, he’ll be involved in an organizational-level transformation to LEAN. I’m involved a journey of breadth, rather than depth, connecting with health care organizations that are very different than ours – the 97% of health care that is provided outside of model systems like ours. Instead of ready access to sensei, an Intranet with downloadable tools, and visual displays all around me, I’ll be self-teaching, searching for answers, and trying a bunch of new things that may or may not work in the majority of US Health Care. Hopefully, we’ll then meet in the middle, with enough breadth and depth to appeal to every patient and care provider in every health system. Only 5 months to do this, and if 5 months isn’t enough, then I’ll just think of a month being equal to 5 years. With an extra 5 year buffer.

One little self-teach for me surrounded the definition of “Plan” in “PDCA,” which I had to ask Lee about. Yesterday, I convened an advisory group for the work I’m doing here and was asked a great question. It was (I’m paraphrasing), “Ted, if you say that 80% of time in a Toyota Model is spent on Planning, and this is the majority of your PDCA cycle, you’ll be challenged to have relevance in policy, because without anything to point to as actually happening, your work will be less compelling.” I left the discussion with a discrepancy – diligent planning is good, PDCA cycles are good. Which is it?

Lee talked me off the ledge on this one by explaining that for senior leaders, Planning is actually a cycle, which includes the strategy, checking on the strategy, and adjusting it, continually. Within this, PDCA cycles are running, so that product is being created and improved. The point is that leaders in a LEAN world do not create a plan and then send it off to be acted on and check on it way down the line. They stay attached to it and adjust it, even if they aren’t “do”-ing the work. So “P” from “PDCA” is not the same as “P” from “Planning Cycle.” For my work then, I should be checking and adjusting frequently, and not keep doing things the same way based on a plan we created several months ago. Given the cadence of what I’m doing, 30 days is actually a good term. Comments on this question/dilemma are welcome of course.

In the course of writing this post, I also realized that I shouldn’t lament the lack of visual systems around me – I should create them for my project and put them up now. As it is said, “If you don’t like the news, go out and make your own.”

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