Daily Kaizen

Last January our senior leadership team (a group of about a 100 folks) gathered for our bi-annual meeting.   Going into this meeting we had all just heard a talk from James Womack (at our annual leadership conference) where he issued us a challenge to become the best Lean healthcare organization in the world.  During this meeting our CEO and leadership team laid out their expectations for the Lean management system at Group Health.   Many of us were really excited, because we have worked a long time to get this far in our journey.  I think the majority of the folks in the room quietly wondered why this was important and what this meant for them and their teams. 

This week our senior leadership team gathered for the first time since this last January to discuss the current state of the organization and to talk about the pressing need to increase the rate of improvement within the organization.   A major focus of the expectation setting and discussion in the room was fastening the pace of putting in place a Lean Management system.  It was amazing to see how different the conversation had changed in just a matter of six months.  There were dozens of more people in the room that were deeply immersed in changing their management processes and very few if any folks in the room that were not at least trying new things.  People were no longer asking why or what, but instead asking how!

Being a Lean consultant I have had dozens of conversations with leaders over the last couple of months asking to either come and provide consultation to them on the management system work they have underway or to help them get started.  I love doing this work.  I thought I would use this posting to share some of my thoughts that I shared with these folks as well as to share where I see many of them struggling.   I am not going to use this post to spend time describing what a Lean management system is.  There are plenty of good sources like David Mann’s book Creating a Lean Culture that you can get a more articulate description then I can provide.  Here are some of my thoughts:

• First, I tell leaders that the best way to implement a Lean management is through the context of an improvement campaign.  They need to first start by defining improvement targets and standards and then deploy those standards down in their organization by engaging staff in the improvement of their processes.  I have seen several leaders get excited and then march out into the gemba and proclaim to staff that “we are moving to a Lean culture.”  This is an excellent way to create skepticism from the start.  After all Lean is an improvement system that is a means to an end and not the other way around. The best way to put the new system in is to support the improvements and sustainability of those improvements you are trying to create.  If you don’t have an improvement campaign, create one. 
•  One of the biggest mistakes I see leaders make it trying to ease into a new management system.  They are trying to manage the amount of change that their management teams are going through.  While their intentions are solid I think their actions have the opposite effect and will create a huge amount of frustration.  Without quickly moving to put the new system in place and asking the managers to adopt new behaviors they find themselves in the situation of having to manage parallel management systems.  The old system that is centered on supporting upward in the hierarchy and the new system that is focused on supporting improvement at the frontline.  This is confusing to frontline teams as well as mid managers who suddenly don’t know what to do and end up having two jobs.  Don’t make this mistake, take the leap and move quickly. 
• When asked by leaders how I think they are doing with their management system there are several things I look for to answer this question.  First and foremost I ask them to show me how they are spending their time compared to how they were spending their time in the past.  If their days are still ruled by the tyranny of the Outlook calendar as opposed to the needs in the gemba it is pretty obvious that they need to re-commit.  Second, I look to see if they are clear about the standards and targets for improvement and if the expectations have been translated down through their function.  If they are still operating in a world of variance reporting and tracking metrics without standards it is pretty obvious that they need to re-commit.  Finally, I look for evidence at the frontline that the teams know what is being asked of them, why they are doing it and that they are engaged in improving their own processes.  The best way to see this is to visit their visual system and see if they are tracking their own data, that it is up to date and that it is clear what processes they are working to improve.  If there is no visual or it is being maintained by management it is obvious that they need to re-commit. 

I could probably write another five blog posting on this subject, but will stop for now.  Please add to my list or argue with the points I have made.

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Erika, an internal Lean consultant I work with has been working with me in the Medical Home workstream.  She has been doing a lot of great thinking over the last couple of months in helping think through how we put in place a system that encourages improvement through learning and recognition.  I am sure you will enjoy her thoughts in the following post.

If we want to become a lean company, from top to bottom, side to side and everywhere on the continuum then we need to learn to incent lean behavior. And yes, I do mean incent with money. But that alone would not do it. People are motivated by different things, both intrinsic and extrinsic. I was rounding in one of our medical centers recently and it was very clear from the beginning that humor was very important to this team. They loved to bring in the most recent humorous anecdote and tie it to their improvement efforts as the team huddled around their tier 1 board everyday. A funny story or picture motivated them and reminded them to do better! The team, by making light of their ‘problems’ got more engagement, created conversation and had a good laugh. And you know what? They also improved!

 If we want to be successful in the long-term then it is important that we create a system of Reward and Recognition that links to our management system, supports our organizational goals and most of all, incents the lean behaviors we want to see in all of our employees. To do this well we have to pay close attention to what really motivates people to do better, at all levels. We cannot simply rely on those few managers who are good at this kind of thing. If so, we will create imbalance and instability in our teams as some are rewarded or recognized and others are not—for doing the same work.

 A place to start might be to ask two simple questions. What do we reward and recognize? How do we reward and recognize? I have seen managers at all levels get tripped up here. Some are naturals at giving recognition (verbal or otherwise) but can be unclear about exactly what they should be drawing attention to in this new lean world. They end up recognizing for the sake of recognizing. Others seem to get the ‘what’ but for some reason are not as capable or aware when it comes to actually giving recognition or rewards. There are risks on both sides. A strong lean manager should be willing and able to do both.

 The “What”

I think there are two key areas to focus on when we think about recognition. One is outcomes, the other behavior.  This list is not complete, but is a good place to start and can be applied at any level of an organization.

•  Recognize the specific improvement that is ‘in the control’ of those at the level where the work happens. Much like our linked checking we focus on different things at different levels. What processes are teams actively working on? Accountable for? What are they actively improving?
• Recognize teamwork. Is the manager driving improvement or has the team really owned their problem and worked together to solve it? 
• Recognize the spirit of continuous improvement. Are teams generating ideas? Are they excited about reducing waste and improving their own processes? Are they using their minds, not just their money?
• Recognize problem solving, A3 thinking and using data to understand problems.
• Recognize when a team or individual has made their problems visible.
• Recognize how the work they are doing supports the goals of the organization.
• Recognize a customer-centered approach. Does a team or individual demonstrate a relentless focus on the customer? Do they understand what matters to the customer and strive to improve on behalf of the customer? 
• Recognize quality gains or cost saving.
• Recognize progress—incremental improvement, day to day, week to week.
• Recognize a great visual system that teams actively use to manage their work, make problems visible, and create improvement.
• Recognize the lean thinking that leads to the lean behavior.

 The “How”

We are never short on ideas, but fall down on execution. What if we set standards for Reward and Recognition? What if r & r was part of our standard work? What if we regularly checked against our targets? What if we adjusted when we were not meeting targets for R & R? Can you imagine? Below are some ideas, collected from various conversations I’ve had recently about this topic. Some have actually been implemented in parts of our organization with great success.

•  Build the recognition into your standard checking.  Make sure to include some form of recognition every time you round. 
• Ask teams and employees how they would like to be recognized. Then do that.
• Be verbal. Say out loud, in front of teams, what you want to recognize.
• Be specific. Make sure that praise and recognition are as specific as possible. Tell them why it matters.
• Empower peer-to-peer acknowledgement by building recognition or shared learnings into daily team huddles or meetings. Make this a standard.
• Give departments or divisions a pool of money to spend rewarding the behaviors or outcomes that are important. Set some standards, and let them go for it! Make it fun!
• Link non-monetary incentives to improvement work. Make the links as clear as possible between process and outcome (i.e. if you improve a process which helps reduce unnecessary demand and creates capacity, you will be given XX amount of time for improvement work).
• Leverage forums or larger departmental meetings to reinforce improvement at all levels, link front-line work with larger goals, draw attention to ‘best practices’ and shine the spotlight on everyday heroes.
• Communicate improvements, outcomes and learnings broadly and often utilizing all available formats—email, web, blogs, newsletters, etc.
• Completely overhaul annual Performance Agreements to monetarily incent desired outcomes and lean behaviors.
• Have more parties! Create space for fun and humor!

 Neither of these lists is exhaustive, but hopefully will get you thinking about some concrete ways to build Reward and Recognition into your improvement system. Remember, no matter where you are on the lean journey there is always room for improvement and Reward and Recognition of that improvement.

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Across the organization on so many fronts we are driving a level of improvement and change that is unprecedented in the organization’s history.  As a Lean team we have worked hard to instill a heightened level of rigor and discipline in our management processes.  And in many ways we have begun to change the culture from one where problems are hidden and not talked about to one where we have made so many problems visible it is hard to often figure out where to start.  All of this is very positive, yet, it often seems like we are not doing nearly enough.  The urgency only seems to grow each day.

This last week I had a chance to talk with a couple of folks from outside of the organization that came to see what we are doing.  After telling me how impressed they were with our discipline and drive one of them asked me if things we always “so focused on business and intense.”  I didn’t think much of this comment until later in the day when one of the senior leaders I worked with asked me if we were making sure to stop every once in a while to recognize the good work we were doing in a certain area.   After BS’ing out an answer I walked away thinking I may have surfaced a problem that I might have been unaware existed.  The problem being that we have gotten so focused on execution that we had forgotten the “fun factor.”   We have a serious lack of processes that ensure that we stop often to celebration, share learning’s and recognizing the great work that is happening every day.

Stepping back it is easy to see how this has happened.  We are so caught up in the nuts and bolts of the technical change that it is easy and often convenient to ignore the soft stuff.   For example, every week we check performance against plan and ”when red” (not on plan) we ask for countermeasures (“please explain”), but we rarely stop to celebrate the greens (when we are on plan).   Don’t get me wrong, this level of accountability is a good thing, but it needs to be balanced.  I personally am one of the worst people at modeling a balanced approach.  I love to focus on the problems and am very direct (some think critical) in speaking about what I observe or think.  I rarely spend time on what is going well with my work or with others. 

I need to think more about what to do about this problem   We are all working so hard and the fun factor needs to be there or we will burn out ourselves and our teams.  I would love to hear other’s views on what we can do.

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“Doing tyranny of the urgent is easier then doing the value added work. Value added work takes a lot of time, is unglamorous and is often not as important to my boss as the crisis of the day.”

 This statement, by an incredibly smart, hard working manager struggling with a lean implementation at Group Health, struck me instantly. It is powerful in its honesty and in its ability to concisely summarize a root cause many of our managers / leaders facing as they work to improve their processes for our customers.

 Given the power this statement had on me, and the tenacity with which this manager goes about implementing and improving the lean work she is a part of, I wanted to interview her to see what else she had to share on the topic. What follows is an excerpt from that interview. If you also struggle in managing the current state and the improvement work to better that current state, I hope you find her insight helpful.

 Q: What are some examples of the “crises of the day”?

 A: A lot of training, resource to the staff. I have become kind of a “go to” for both my staff and other staff within the department. I also spend quite a bit of time in support of customer issues – something goes wrong for the group/broker and I need to help fix it.

 Q: How much of your time would you guess is spent with these daily “crises”?

 A: 10 – 20%

 Q: what percentage of those crises’s are the result of a process that is not fully “in control” (i.e. reliable and capable of meeting our customer requirements)?

 A: I would guess 25 – 50 %

 Q: What is an example of “value-added” work that takes time and is difficult and can therefore be overridden by a crisis of the day?

 A:

-         Collecting data (or putting in the processes to collect the data) to understand our processes ability to meet customer requirements.

-         Developing, implementing, and training standard work.

-         Using A3’s to understand root causes of critical problems

 Q: What human factors do you think draw yourself and others to the “crisis” vs. the “value-added” work?

 A: Urgent work is easy work. I know how to do it. I am more comfortable doing it. This new work is uncomfortable and foreign.

 If it’s going to take me 3 hours to pull the data together, 15 people are going to show up at my door and I am going to get frustrated and quit.

 Q: What factors do you think lead to your boss and other leaders putting more weight on the urgent?

 A: When our boss comes, our culture is to drop everything and help them with their crisis. Even if they’ve asked you to do the value-added work, they’ll expect you to drop it. This is probably the same experience they have with their boss and for the people that report to me as well.

 Q: It sounds like day after day, the crises outweigh improvement work that may not have the same weight that day, but is critical to the long term success. How do you help make the improvement work feel as relevant and meaningful as the crisis work?

 A: First of all, I have learned that I have to schedule time for all improvement work. It won’t happen if I don’t plan the time into my day. Second, I have to break the improvement work up into short term deadlines. If I don’t, this far off task will seem too abstract and I’ll never get started.

 Q: What are some other countermeasures you have used successfully to decrease the crisis work and increase the “value-added” work?

 A: I know that I will only significantly and permanently reduce the “crisis work” if I am managing processes that are in control. Therefore, I have to save the limited time I have in pursuit of that goal. The four things I am trying to do right now are:

 1) Gemba Walks:

Let’s be clear, I have always enjoyed having answers and being that “go to” person. So, it’s been hard for me to admit to myself the effect always having an answer has had. Simply put, I have always provided the fish instead of teaching my staff how to fish.

 Therefore, one of the biggest things I have begun to do is to get out into the gemba and ask questions – and not provide answers! 

 2) Identifying the Critical Few (with everything!):

With measurement, visual systems, or anything else requiring data collection, I have learned the hard way that you have to start simple. Chose the critical few (we are now collecting only 4 measures, down from 19) or else the tyranny will take over and they’ll never be collected consistently.

 3) Continuous Improvement:

I try to fight the feeling that all the right people need to be in the room to make any decision. If a problem comes up or standard work needs to be created, I grab the people I can, and take a stab at it. At worst, we’ve created a straw that people can react to. Showing my staff that we aren’t going to wait for perfection to improve has helped set an important tone with my staff as well. They have already made several improvements to their work.

 4) Making My Work & My Day Visible:

I am also currently working to make my own work visible so that my staff, my boss and I can see my whole day, and what various items are scheduled for the day. Specifically, I am trying to carve out time for e-mail, and other things that can often spur crises. Over time, I am hoping to have control over my day to the point that I can sit down and focus on what I ever I have “loaded” for that time, knowing I have allotted time for all other critical items at some other point in the day.

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