Daily Kaizen

It is most often the case that when I first introduce Lean principles and tools to a group of staff and leaders that have no Lean experience that most people in the room are either skeptical or start from a negative place.  This is understandable.  For years people in the organization have been introduced to the latest and greatest program and they often disappear as quickly as they arrive.  When I first started doing this work I would often waste a lot of my time and the time of others in conference rooms trying to explain Lean and sell it to folks.  This was a bad strategy, because Lean in not about Lean.  Most people don’t get excited by the principles, tools and concepts.  Instead, they get excited and engaged when their lives and the lives of their patients are improved through the use of the principles, tools and concepts.    So instead of spending time trying to teach Lean upfront it makes a lot more sense to engage people in the improvement process and allow them to see how much better the end can be through the proper use of the right means.  In 95% of the cases once people experience the Lean process they are no longer skeptical or resistant.  Especially if they can see the direct impact on the care of their patients. 

What is far more difficult is trying to engage people that have been through a Lean implementation, but walked away with a negative experience.   Over the last couple of years I had heard rumors of “Lean gone bad” in the Seattle area, but I just figured it was noise associated with change.  This last week I have had the opportunity to spend time with several leaders and staff that have worked in organizations applying Lean in the local area.  Many of these folks have a really bad taste in their mouth from their experience.  (depending on the organization many have had great experience as well!) Several of the folks really believed in the Lean principles, but were very frustrated with the way the principles were implemented in their organizations.   Stories that included:

• Lean implementations that took management out of the gemba as opposed to focusing them in the gemba
• An organization that required all staff to sign a “Lean oath”
• Managers being encouraged to provide false data in order to make the Lean work look good
• Surgeons being “dinged” because they did not put the trash can in their office in the right place
• A divide among staff where 80% of people where labeled “concrete heads” and 20% as performers
• Staff members that got in trouble for bringing into their office more then the one allotted picture of their family

My intent of engaging in these conversations as well as writing this post is not to promote the negative side of  Lean work that has happened at other organizations.  Instead, I want to understand the mistakes that have been made elsewhere so that we don’t repeat them. Walking out of the room I had to reflect on some of my own behaviors and actions.  How quickly I have written off leaders that seemed to be resistant to Lean work.  How I have been dismissive in the past when leaders have suggested that I don’t use Japanese words while training our medical staff.  How I have focused on the ideal at the expense of getting improvement today. 

As I think about these cases it is not hard to see how these organizations may have gotten off track.   How easy we can mix up the ends with the means.  How easy Lean became about Lean as opposed to being about improving patient care.  Anything can be taken too far and turned into a religion and as a result you lose the very people you are trying to engage in the process.  In many ways this experience has made me think deeply about the approach we are taking and I will move forward with a greater awareness about ensuring we stay focused on what matter most: improving patient care.

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 Below please find the newest guest blog posting.  The author, Dr. David McCulloch is an incredible Lean leader as well as a nationally respected physician.  David has been on the front lines working with our physician teams to implement our Medical Home model and Lean Management system.  In this posting, David warns us that we need to focus on what the patients need as opposed to just adding new technology.  Enjoy!

There’s an old joke that goes like this:

I was walking home late one night when I came across a man crawling on the ground under a lamp post.  When I asked if I could help him he looked up in bleary-eyed frustration.  “Lost me keys… hic… my house keys.”  For the next half hour I got down on my hands and knees to help him look for his keys.  We turned over every rock, combed through the gravel, and examined every crack.  It was my turn to get frustrated.  “Are you sure this is where you lost your keys?”  The drunk man shook his head sadly.  “I dropped them over there… hic… in the bushes, but it’s too dark to see anything over there.  This is where the light is brightest.”

In the ongoing debate about how to fix our irrational, unsuccessful and bloated healthcare system the blazing light of the media’s streetlamp is focused firmly on electronic medical records.  They are the “key” to unlock the door to a more rational and affordable healthcare system!  Every facet of their brilliance is being examined and debated.  Which ones are the best?  Can they talk to each other? How can we make sure that only friendly and helpful people have access to them?

And yet if we took the time to stroll over to the dark bushes we would find the consumers of the healthcare system hunkered down in frustration trying to hold on to their wallets.  If we asked them to describe what their ideal healthcare system would look like I doubt if you would hear them extolling the virtues of electronic medical records.  Instead, here are some of the things you would hear – I know because these are the things that I hear when I ask my own patients:

“When I have a health care concern I’d like to get answers from my healthcare team right away.  If I call I’d like to get through to a human being, preferably my own doctor.  I don’t always want an appointment either.  If I could get my questions answered by phone or e-mail that’d be great.  But if I do need to be seen in person I’d like to be seen on time, by people who are friendly and respectful, who listen to what my concerns are.  They’d understand how my health issues affect the rest of my life and would help me get the most out of it.  I don’t want dozens of unnecessary, dangerous and expensive tests.  I don’t want unproven or dangerous treatments.  When necessary, I want to know that I’m getting the right tests to diagnose my problem and treatment that is safe and effective.  And when I leave the visit I want all my treatment written down in words that I can understand so that I can remember it, and share it with my family and friends.  I want to know what to look for as I take the treatment, who to call if I have concerns, and I want a plan for my follow up.  And if I’m sent to another doctor I’d like him or her to know all about my medical condition from the health care team who knows me best.  Oh, and one other thing, even if I’m feeling perfectly well I’d like it if my healthcare team knew me well enough to let me know when I should consider getting immunizations, or cancer screening or other things that will keep me healthy.  Is that too much to ask?”

I don’t think that this is too much to ask.  What these “patients,” these customers, these consumers of health care are asking for is a rational, friendly, safe, effective, and affordable system that is designed to meet their needs.  It is well within our capabilities to design and implement this in the USA.

Don’t get me wrong.  I think that having sophisticated electronic medical records could be a tremendous asset in helping to design a rational health care system.  But if we simply apply cool technology to make our current irrational, unsafe, and overpriced healthcare system more “efficient” then we will have achieved nothing. If applied to a rational system then electronic medical records could be the key to unlock the door to a warm, inviting medical home, a place where customers would feel safe and well cared for.  But if applied to make our current chaotic mess more “efficient” then the electronic medical record will simply be the key to a drunk man’s junk closet.

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I have been having a case of writer’s block lately.  At the same time I am sure many of you are probably ready for some more interesting content to get added onto this blog.  As a result, I have asked some of the smartest Lean folks I know to write some posts on behalf of the Daily Kazien.  I will plan on posting them on a regular basis.  First up is a great post by Erika Fox a Lean consultant working deeply in our Primary Care transformation.  Enjoy…

We have had a lot of conversations in our organization lately about change and how we feel about it and how we manage it. We know we need to change quickly to keep up with the ever-changing market and meet our customer demands. We have tremendous opportunity if we could only speed it all up. We also know that change is hard and that many people don’t like it. Many people think we need better change management to accomplish this. Will that help us go faster, do better, become the organization we need to be? Maybe.

Whatever our problems, and there are many, we are changing. Executive Vice Presidents are showing up in the gemba to observe clinical teams taking care of patients. Our executive leadership team is narrowing strategic focus and de-selecting non-priority work. Managers are doing root cause analysis in order to really understand their problems. Doctors are volunteering to attend 5-day kaizen events to design standard work for themselves and their colleagues. Recently, a flow nurse from one of our clinics sat down with a job breakdown in-hand and taught her colleague a new standard process for preparing for a patient’s visit. 

These observations are remarkable because they demonstrate that we are capable of dramatic change in a relatively short period of time with primarily positive outcomes. We are not achieving good results because we have the best change management process or the best Lean training or the best communication strategies (we are working on improving all those things). What can account for these changes? In my observations it comes down to this; we are acting differently. This may sound like an oversimplification but I do not think it is.

Employees, from top to bottom, are starting to act as if they are lean. They may not have received a lot of training or read the right books or even been told exactly ‘how’ but they are trying to do things differently and this is leading them to different thinking which leads to different behavior and so on. If we all waited for the perfect system, perfect environment, perfect change management process before taking action then we would still be waiting around. So, if you want to accelerate the rate of change then I have a recommendation. Act as if.

Simply put, act as lean as you know how to be at all times, even if it’s not much at all and eventually you will become more lean. I do not mean this in the sense that you should fake your way into lean expertise. That would be disrespectful and dishonest. I believe your different action will lead to different thinking which will probably make you really uncomfortable but will hopefully lead you to adjust for the next time around and so on. I have heard our sensei say it this way, “It is easier to act your way into a new way of thinking than to think your way into a new way of acting”.

Why will this work? This approach creates a positive feedback loop. I’m no nuclear physicist but I do know that positive feedback loops have the effect of speeding up a process. Negative feedback loops slow them down.  In our organization we are trying to accelerate the rate of improvement, which means accelerating the rate of change. We need to create positive feedback loops in order to improve at the rate our customers demand. And I think we are doing this by acting differently and living with the tension this creates. I believe it is that simple.

How will you act differently today? Here are a few ideas. Go to the gemba and see for yourself.  Ask for feedback from your staff or peers. Follow the new standard work your team member designed last week in that kaizen event even if you have never heard of a job breakdown. Start with the process, not the tools. Ask why as many times as it takes to understand the root cause of your problem. Listen to your employee’s suggestions for how to improve their work. Make your problems visible. Act as if and see if you become.

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As a kid my father was always quick to yell at my brother and I whenever he would over hear us talking negatively about something we did not understand.  I remember his words “don’t talk unless you know what you are talking about” even today.  This was good advice my father was giving us, but it took me a long time to take notice.  About a year ago a person I work with gave me a good scolding when they overhead me speculating on a problem I did not understand.  At first I was defensive, but spent some time in the area gathering facts.  It did not take long to realize that my assumptions about the problem were wrong and that my behavior was only making things worse.  This scolding really woke me up and I realized just how often I was guilty of this bad behavior.  This last year I have decided to try and not talk about problems unless I have gone and seen them in person.  I cannot tell you how effective, yet, really difficult this practice is to follow.  I still often find myself repeating the bad behavior, but I guess the good news is that at least I am aware of it and trying to get better. 

 In every organization I have ever worked there is a huge amount of waste and frustration caused when people discuss, speculate and make decisions based on information that they do not understand.  As information flows up through the levels of the organization it tends to lose a little bit of its validity with each step up the ladder.  Very similar to the kids game of telephone where the message passed from one kid to another loses it original meaning very quickly as it is passed around the circle.  As a result, many organizations are making their most important decisions at the furthest distance from the facts.  Being aware of my own challenges has made me become keenly aware of when others display the behavior.  It is frustrating to see how often leadership gets caught up in never ending debate or worse make bad decisions based on problems that they do not understand.  I see it every single day.

This is exactly why it is so important for leadership to go to the gemba.  If leaders were required to go see for themselves prior to making any major decision just think how much time they would save let alone how much frustration and waste they would take out of the system.  Many leaders in my organization are spending time in the gemba for the first time and most have realized just how important seeing for themselves is to being effective.  As more leaders adopt this practice it will be hard for others not to follow their lead, because without the first hand experience they will begin to lose their credibility.  I hope this turns out to be the case. 

I will end this post with a quote I read recently from Tanaka-san:

“The most important thing for people is to keep one foot in the production workpace and take a good look at things there before making decisions.  People who excel at anything tend to be people who insist on seeing things for themselves.  That’s because the facts are in the things that we can actually see, and we can only get at the truth through the facts.  Just thinking about things in your own head won’t lead you to the truth.”

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For the first couple of years of our Lean journey our organization focused most of it’s Lean improvement efforts in areas that surrounded patient care, but did not focus directly on the patent’s contact with their care team.  We did a lot of work in Pharmacy, Laboratory, Information Systems, and administration.  Basically, we surrounded the patient care experience, but we did not focus on improving the processes directly related to that experience until now.  There are a lot of reasons why we took this approach that I am not going to get into within this posting.   All I will say is that it was a smart strategy that prepared us very well for the next stages of our Lean journey.  What is really exciting is that we are now deeply involved in the process of improving patient care processes in many parts of the organization and it is very exciting. 

Today I have the pleasure to write this post live from an RPIW (rapid process improvement workshop) that is currently underway in our Primary Care system. The focus of this event is to standardize and improve flow from the time a patient is scheduled for an appointment until the appointment is complete.  Our goal is to ensure that the team is fully prepared for every patient that comes in to our clinics and that all of the patient’s care needs are met.   This includes leveraging every advantage of our vertically integrated organization (insurance and care delivery) including virtual care, managing the health of a panel of patients, and a focus on preventive and chronic care.  

This is the fourth of a series of events that are designed to transform our Primary Care system based on a Medical Home Model.  This is a model based on patient-centric care that is focused on prevention and management as opposed to reactive care.   In just the last six months it is amazing to see how much improvement has been made and how much more is possible.  Some examples of the great work that is being implemented or will be implemented:

•  You can now call your care team located in any of our 26 clinics and 80% of the time get your needs resolved before you hang up. 
• More then 30% of our Primary Care visits are now being performed virtually (secure message or phone).  This is a great service to our patients and leads to a much higher number of patient touches leading to improved quality.
• All chronically ill patients will have a treatment plan and sick day plan that the entire care team is organized around supporting.
• Best access in the marketplace, both in-person and virtual.
• Systems are in place to identify all of a patient’s care needs and then deliver on them in the venue that is most appropriate

It is amazing to see how engaged our Primary Care teams are in improving their own processes, including our physicians.   For the last couple of years there has been an organizational worry that the physician group would not embrace the Lean process.  There seemed to be a non-stated agreement among leadership that we would never ask physicians to follow standard work.  We sure have been worried for no reason.  There is nobody more concerned about improving patient care then physicians and as they have engaged in the Lean process they have seen how deeply it can help us improve patient care.   Our care team members realize that being Lean is not the outcome, but instead the means by which we reach the outcome of excellent patient care.   Today, not a single team member in the room doubts that we will be able to have a huge impact on quality, cost and satisfaction over the next four days.  There is a great sense of higher purpose in the room.  And yes, physicians are willingly signing up to design their own standard work.

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