Daily Kaizen

Over the last couple of years of writing on this blog I have probably written three of four posts discussing the need for the organization to cut down on the amount of improvement work in progess and to focus on only those improvements that will be truly transformational for the patients we serve.  So what the heck, why not a fifth?  I am worried that this year we may repeat the mistakes of the past so I wanted to write this post to share some of my thinking.

So why is there a lack of focus?  Overall, we really are an amazing organization at coming up with innovative ideas and solutions.  Since we lack an organizational competency in developing improvement hypothesis based on data (although we are getting better) most ideas end up being good ideas.  Additioanlly, because it is a lot easier to say yes then it is to say no we end up with far more work in the pipeline then we can get done.  As a result, the same leaders get tagged with leading far to many improvements.  The same supporting resources have far to many number one priorities.  The work drags on slowly and we don’t achieve the results we all know we are possible of achieving.  I am sure that many of you readers know this story pretty well since I am sure we are not alone in having this problem. 

The good news is that over the last couple of years there have been a couple of times that the organization has taken a piece of work and really focused.  When this has happened the results have always been impressive.  Implementing our electronic medical record, rolling out the Model Line in our Health Plan, developing our five year strategic plan and developing our enterprise value stream maps are all examples.  In each of these cases there has been a razor focus of leadership and supporting resources on getting high quality work done very quickly.  In a relatively short period of time work moved forward rapidly and people lined up to support the work.  Why was this work successful?  It is because the entire organization focused on moving this work forward.  From the senior leaders to the front line staff.  The problem is that when we have been successful it has taken a huge amount of organizational energy to make it happen.   

The organization needs to look at these improvements as examples of what is possible when we focus.  What if we were able to put this amount of focus and energy into each of our strategies?  The results would be far better then the norm.  Yet, this will only be possible if we limit the work in the system.  Focus on three or four things at a time as oppossed to fifteen or twenty and get them done thoroughly and quickly.  An interesting challenge we will continue to wrestle with.

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Its been a long time since I woke up on a Saturday morning and had the energy to walk down my hallway and log onto my computer.  The last couple of months have been exhausting and to be honest I have felt removed from the work.  For the last year I have worked hard with our leadership team to define and implement a strategy deployment system.  While this work has been important it has meant I have been removed from the gemba for far too much of my time.  As the cloudy days of rain have come marching into Seattle I have gotten into somewhat of a “work funk” and its stuck with me for the last couple of months until yesterday, when finally, with a little help from a great team I broke out of it. 

For those of you that are not as familiar with healthcare there is currently a crisis happening in this country with Primary care based medicine.  Poorly designed incentives, long work hours, an over emphasis on throughput and a lack of financial reward have resulted in huge shortages of Primary Care physicians.  Many have burned out and students entering Medical School are choosing to become specialists as opposed to generalists.  This has put a huge strain on the the healthcare system with less preventative medicine, more expensive services, etc.  Being a Primary Care based system our leadership a couple of years ago decided that they were going to do something about this challenge.  They defined a set of principles that are patient centered, identified a pilot clinic and empowered a team of clinicians to help us define a new model of care that would be transformational.  Not just transformational for our clinicians, but also transformational for our patients.  This team has answered this charge and have created a new model for care that has resulted in improvement across almost every standard.  Now the challenge of the organization is to take this model of care and deploy it across all 26 of our medical centers.  Lean has provided the means by which the organization can make this happen. 

I have mentioned before in the last couple of posts that I would be transitioning my work at my own request and spending more and more of my time partnering with the leaders of our clinical teams.  Late Friday afternoon I drove out to hear a report out from a RPIW (rapid process improvement workshop) that had taken place all week in this pilot clinic.   The focus of the event was standardizing the process by which clinicians practice virtual medicine.  Allowing patients to get care in a convenient and timely way, clinicians to manage the chronically ill far more effectively and all around leveraging out model of care.  It truly would make a great case study in James Womack’s book Lean Solutions. 

As I sat in the back row and listed to the team of nurses, staff and physicians report out on the results of the five day event I could not help but think I was whitnessing an event with a far greater purpose then improving the systems of Group Health.  I have been to dozens of these type of report-outs in the past and as most of you know they are always exciting.  For me, this one was different.  There was a level of excitement in the room that I think can only be created when a team has figured out that they are onto something.  That something is a new system of providing medicine that connects back to the ideals that made them become caretakers in the first place.  An ideal that was lost somewhere along the way and was again awaken. 

Physicians stepped up and told story after story about how much more effective they are in taking care of their patients   They talked about how they intended to retire and now there was no way they were leaving.  They asked little of the senior leaders in the room, just thanked them for allowing them to have the opportunity to participate and urged them to continue to push this work forward.  The team was vested in the success of far more then the event itself.  They pledged to help spread the word to other parts of the organization and champion the change.  It was the definition of engagement in practice. 

While this might sound cheesy as I listened to the team tell their stories I could feel myself waking up.  My mind started to search for ways that I could join in and help move this system forward.  How I can help make this team successful.  Since walking out of the room I have been filled with energy.  Enough energy to get me up out of bed and in front of the computer on a Saturday morning.

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Lee commented to me that I hadn’t posted in awhile (a long while) so I thought I would jump in to let readers know that our paths are forking in a more sustained way.

I have accepted a position with The Permanente Federation, LLC, and have made Washington, DC my permanent home, leaving Seattle (“The other Washington”), and am still on the LEAN journey, now starting at a different level. This company supports the 8 medical groups of Kaiser Permanente and Group Health Permanente, the medical group associated with Group Health Cooperative, where Lee works. We’re still technically in the same family, luckily.

I’m a little bit of a Desi Porter (for those of you who have picked up John Shook’s latest book from the Lean Enterprise Institute), given a charge and pursuing the same steps that Desi is in the book, to create a strategy for improvement in a specific area. The improvement methodologies in this organization are dynamic and changing, which is an opportunity for me to start at the beginning, with a Gemba Tour, hosted by one of Kaisier Permanente’s regions. That’s where I am now in real life. I’m farther ahead in the reading in John Shook’s book – I work at a different level in this organization, so it is much more important to take the time to go through the steps of managing to learn. Publication of the book was great timing in that regard.

I’m being given license to blog about my experiences, as was the case at Group Health Cooperative. I will blog mostly about them on my professional blog at http://www.tedeytan.com, which integrates my interests in patient empowerment, the Washington, DC region, and LEAN, all together. There’s an RSS feed that can be subscribed to there, of course. I think all three things fit really well together, and in 2008 in this part of the country, especially so!

It’s worth pointing out that this blog has been going since 2005, establishing the value (I think) of health care organizations talking about their journeys publicly. Who’s next?

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I spent some time this morning working through some strategic improvement plans that our senior leadership team is developing.  I asked myself how do we know if this is the right work several times.  The answer was always the same, we don’t know.  While we know more now about the organization then we ever have we still don’t know enough so we are often having to make decisions based on intuition.  Our current measurement systems are not capable of helping us really understand our performance.  They are built to support the individual departments and divisions, but tell us very little about where we are and where we need to go.  With the exception of the areas where we have driven Lean thinking deeply from a strategic and from an operational perspective we don’t currently have sufficient measurement capabilities to really understand our business.

Having just finished our first enterprise value stream work this gap is really on my mind.  I understand very clearly that our current measurement systems are broken and drive the wrong and wasteful behavior and that a major focus of our value stream improvement work this year will be to begin to change these systems.  I can’t tell you how many times during this work we visited teams where measures were not used at all or if they were they were almost completely outcome focused.  In other words the measures were not integrated into the work nor were the used by the teams to focus improvement efforts.  In most cases the measures existed for one of two reasons: either we were measuring something for reporting to outside stakeholders or we were using measures to monitor individual performance (productivity) as opposed to process performance.  As you can imagine this led to all kinds of problems and sub-optimization. 

Even in areas where we have done a lot of Lean work we still have a long way to go.  Last week I was talking with a leader who is frustrated with the rate of improvement and struggling with why things are not moving faster.  When I reviewed their improvement plans it was clear that the leader had not changed the metrics of the area.  This leaders team was getting mixed messages.  The leader was asking them to work differently as a team, but measuring them as individuals.   The leader may say things are going to be different, but without changing the measures it is unlikely that people behaviors are going to change.  I pointed this disconnection out to the leader and they quickly realized that this was a problem.  The good news is that later in the week I got an email from the leader who had already begun to work with her team to change the measures. 

This last example I shared is exactly how we will put the measurement system in place that we need.  One team and one process at a time.  We need to change the thinking and then change the measures.  It will be hard work, but its the right work.

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