Daily Kaizen

Recently, I found myself listening to a Washington Huskies football post-game coaches show. As the head coach reflected on the teams first win in 16 games, he mentioned a fascinating component of his coaching staff’s week:

             Every Monday night and Tuesday morning they spend 3 – 6 hours making calls to high school recruits, watching game tape, and managing their recruit board.

Whether you’re a football fan or not, you are most likely well aware that college football coaches have one of the highest pressure, time intensive jobs around. However, here was a coach, in the middle of all the management and planning required for the next game (against the #3 team in country) and the current season, spending time to plan for the next season.

 Will that time on recruiting impact the next game? No

Will it impact any games this season? No

Will it ensure they are pursuing and obtaining the recruits that will make them better next year? Yes

 This is Production Planning for a coach football coach, and any coach in the country would be gone within a year or two if they didn’t do it.

 Production Planning

 In general, production planning is the essentials of PDCA applied to demand and capacity: create a plan (P), see what really occurs (D), reflect on that plan in comparison to the actual and understand any variance (C), and finally to improve the plan for the next time frame (A).

 Manufacturing vs. Service Industry

This concept is a basic management skill within the manufacturing world. The throughput of products is their livelihood, and a keen knowledge of demand vs. capacity (staffing, materials, etc.) is critical. However, in the service industry, this concept has until recently been superseded by firefighting, and heroism. Within this culture of everyday heroics, a pride has developed around one’s ability to take on whatever may come that day, and live to face another one. Although an adrenaline rush, what is often lost in this heroics based culture is the ability to consistently learn and improve over time.

 Plans are worthless, but planning is imperative:

Incorporating the PDCA cycle into as many processes as possible is vital to any organization that hopes to continuously and systematically improve for its customers. As many leaders within our organization begin to apply this concept of looking into the future to plan and make adjustments before that future becomes today, they often ask “how can I think about 4 weeks from now, when I have to think about today?”

The answer I offer is this:

Whether we plan for tomorrow or not, it’s going to come. As a result, we have a choice to either Production Plan or Production React. If we go with the later, at the end of the day we are often exhausted, feeling as if we barely survived another day. We will continue to live in this chaos, and leave the next generation of managers, leaders, and most importantly customers in the same chaotic state if we don’t get our span of control “in control,” the target of any process.

By “in control,” I am referring to understanding a few key elements: being a) reliable and b) capable.

A) Reliable – an organization or area within it must have the ability to consistently match capacity to demand and use a standard process to consistently produce a standard outcome in a standard timeframe. (Example: process A consistently produces an item 2 hours after the order is submitted)

B) Capable –  an organization or area within it must be reliable as well as consistently meet the timeliness and quality goals of its customer (example: if process A’s customer wants the item 1 hour after the order is submitted, with 100% quality, then it would be reliable but not yet capable. However, if improvements to both timeliness and quality allowed the process to produce items in 55 minutes with 100% quality then it would be both reliable and capable)

One of the first steps one can take on their journey to being in-control is to begin Production Planning, as this is key to being reliable. Generally it’s the PDCA cycle, but specifically, it might look something like this:

A) Determining Demand and Capacity – You may start by asking yourself the following questions:

Demand:

1) What are all the factors that will influence the incoming work units for the next time frame (anywhere from 1 week to several months)? (Time of the year, time of the month, price vs. competitor’s, actual from previous month, previous year, general trend, etc.)

2) Over time, what additional factors can be added to my equation to help my plan become more accurate? (Often there are predictors from upstream or downstream that can indicate what’s coming your way)

Capacity:

1) On average, how long does it take my staff to complete this work (cycle time)? (If standard work is already in place for each production item, this will be much easier. If not, using a stopwatch to get a baseline is a fine place to start.)

2) Given meetings, vacations, sick days, etc., how much time (min, hours, ?) do I expect to be available to take on this work over the time frame in question?

 B) Once these items have been forecast, simply apply the following equation to see if your capacity can meet your demand:

 (# work units) x (cycle time) < available time?

 - If yes, you would have the capacity to take on the demand.

 - If no, you would not have the capacity to take on the demand and would need to look for a countermeasure to either add capacity or lower cycle time.

 C) Make your cycle time, demand, and capacity visible so that you and your team can learn from them now, and track them over time to ensure continuous improvement.

 D) Establish a set time (weekly?) to go through this Production Planning steps above and to implement countermeasures when necessary. Creating a set time will ensure it becomes a regular part of your role and isn’t slowly displaced by the tyranny of the urgent.

 Over time, looking ahead will create a situation in which you are preventing fires vs. putting them out, moving closer and closer to being in control. Finally, if you struggle to keep this proactive work a priority compared to the here and now, take comfort in the fact that those UW football coaches spent several hours Monday and Tuesday on their recruits for next year, and were still able to upset the #3 team in the nation the following weekend!

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For those of you with years of Lean experience or that work at organizations that are advanced in their journey this post may seem like I am simply stating what is obvious.  For those of you that work at organizations like mine that have had traditional management systems and practices there might be something interesting for you here.  Since I started studying Toyota I have heard countless people make comments about how “Toyota does not think about what it does as Lean, it is simply how they do their work” or ” at Toyota the process of improving employee’s work is integrated into everything you do.”  So what is meant by these statements?  Basically, Toyota has created a powerful management and improvement system that treats improvement like any process and ensures that improvement is integrated into the work people do every day. 

Contrast that with a system like the one I am working to change where for sixty years improvement has always been planed, deployed and executed through a project lens where 80 plus percent of the employees jobs are to “do the work” and not improve the work.  After sixty years of experience it is a hard transition to get folks to think process and not project.  What is exciting is that in several places in the organization we are starting to change the thinking and are at the early stages of learning how to put in place systems of daily, process improvement. 

Just the other day I spent some time with some colleagues planning out an experiment we are going to kick off in one of our large clinical areas.  For the last year we have been working to put in place standard processes, including management processes across the multiple clinics that make up this division.  The results have been exciting and so has the pace of the learning taking place across the 1600+ employees.  Team members were pulled together from a small set of pilot clinics and they designed the standard work for the entire system, but to everyone else receiving this work it has felt top down.  Now that we are nearing the end of the major implementation work it is time to turn much of the work and the responsibility for improvement over to the frontline teams themselves.  In other words, it time to balance the top down with the bottom up improvement. 

The focus on the experiment is to create a standard, daily improvement process where every team has time and responsibility to engage in improving their work.  In order to meet this goal we need to teach people to think about the improvement process just like they would any of their other work processes.   This means we would like to have standard work for the improvement process, standard documentation so we can easily share learnings, standard metrics posted on visual system that are used to track the progress of improvements as they are planned, excuted and checked.  Additionally, we need to change the management process within the clinics to ensure that not only is capacity being loaded into the system so that each employee can participate in improvement related work (yes, taking people out of production!), but also ensuring that as leaders conduct their gemba walks they are not only looking to see how the team is doing against production, but also how the team is doing in achieving their improvement related goals. 

Like I said in the beginning of the post might state the obvious to many readers.  Yet, to my organization this is really big change and there is a lot for us to learn.

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Over the last couple of years I have worked with many different teams as they have put in place effective visual management systems.  Through this experience I have learned first hand just how powerful a tool visual systems can be in helping processes become more capable and teams become more engaged.  Through my experience I have also seen how visual systems can create a lot of energy and sometimes a lot of frustration within teams.  This should not be a surprise, since putting in place visual systems is one of the first steps we make as we transition a team into a new management system.  And like with any change, there is almost always change management issues that arise.  The visual boards make transparent the performance of the process and often the performance of individuals.  This level of transparency is something teams are typically not used to having so visible and thus the boards can become a focal point of the energy created as people manage through the change. 

On occasion, I have seen leaders make some mistake early on in managing this change and the visual boards either end up getting pulled down, given lip service by the team or worst of all end up being ignored.  A couple of hints on how to avoid these challenges:

• Make sure that the team is engaged in the process of creating the boards.  They need to understand why they are important and how they represent their work.  By participating in the design process they will more likely own the visual once it is created.  This also ensures that the board will not only help improve performance, but also the lives of those doing the work. 
• Give teams time daily to “huddle” around the board and discuss the plan for the day or the performance of the process.  I have seen a lot of boards get created, but they get sidelined, because teams don’t have time to use them.  Additionally, one of the purposes of the board is to make problems visible so teams need to be given time to solve problems as well or teams will become skeptical
• Managers must have the discipline to ensure that the board is used and maintained.  This means checking the board every single day and ensuring that problems get solved that are escalated to management.  Without the daily checking teams get the message that the boards really are not that important. 

Finally, as leaders work with their teams to learn how to use the boards it is important that they remember to constantly remind their teams that it is not about the board.  The board is simply a tool to help them as a team get better every day.  The board helps the team get clear about what the plan is for the day, what the expectations are for each step in the process and when things don’t go well what problems got in the way.  The board does not set the expectations for performance nor does the board cause the problems within the process.  It simply makes them visible.  Leaders still need to lead.

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A mentor of mine likes to share the story of a small diner he used to frequent in Montana.  Hanging above the front counter was a sign that said:

• Fast
• Good
• Cheap

Please pick two

 This example illustrates the perceived tradeoff between timeliness, quality and cost.  That in order to get something fast and in good quality you better be ready to pay for it, etc.  Since I have worked in healthcare it is clear to me that this mental model is alive and well.  I can’t tell you how many times I have heard leaders ask for more money and resources in order to be able to meet new quality standards.  One needs to only open the newspaper and read the latest healthcare policy debate to see that as a nation we are stuck trying to address these elements separately as opposed to viewing them as being highly related.

 Over the last couple of years we have had several cases where the traditional mental model has been challenged through the Lean process.  Many of our top leaders are starting to realize that we can improve all three dimensions simultaneously if we focus on reducing waste.  In fact, we have to be able to improve all three, because nobody is willing to slow down on our efforts in improving quality and at the same time the country and our members are demanding improved affordability. 

 Here are a couple of examples to illustrate our early success:

• In Primary Care a year ago a member trying to call there care team with a clinical question had about a 9% chance of getting their issue resolved on the first call.  In the name of protecting the clinicians time we had an elaborate system of message taking and callbacks that frustrated patients and meant at the end of the day a clinician had a backlog of calls to make.  In the mean time patients were getting frustrated and often ending up in the ER or walking into the clinic.  The team decided to redesign the process and ensure that members could have direct access to the care team without adding resources.  Now if you are a patient you have more then an 85% chance of getting your call answered on the first call!  The results of this process surprised almost everyone, because not only did we greatly improve quality for the patient (getting their issues resolved quickly) we also improved the quality for the care team (no backlog at end of the day).  At the same time we improved access and affordability (if people can get a hold of their care team often they don’t need to come in for an appointment as well as reduced volume to the ER)
• A team studied why re-admits to the hospital post discharge and compared current process with evidenced based practice.  What we found is that during transitions of care there are certain standards that if applied consistently lead to far greater quality which keeps people out of the hospital.  After implementing these standards the initial results are stunning with rates of re-admits getting cut in half.  We have seen similar success in treating wounds and developing care plans. 

 These cases illustrate that we can simultaneously improve quality and cost by focusing on waste.  I fully believe that this is the primary answer to many of the healthcare problems are country faces.

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