Daily Kaizen

As our organization enters its third year of strategy deployment, and the usual push and pull over the coming year’s organizational improvements unfolds, an amazing thing is beginning to occur: the term “the critical few” means something.

 Actions speak louder than words

What we do is far more important than what we understand intellectually. In health care, “intellectual” is abundant, as the field is one of the most highly educated there is. However, with all of this education a few simple lessons from our youth can often be lost or complicated in the gray of peer-reviewed articles and oversight groups:

•  Simple is better
• Make problems visible

 Given this, leaders have shown great strides in their learning to un-learn. Specifically, leaders are learning:

• There can only be one daily management system for the front line teams, and it is the processes and measures on the minds and visuals of those front line teams that gain transformational improvement.
• Their pet projects and secret lists can remain in their minds and functional areas, but without incorporation with the daily management system of those front line teams, the implementation, spread, and sustainability will be fleeting at best.
• Disconnected projects blindside front line teams, and only add confusion and slow down improvement.

Until now, our organization has focused almost entirely on projects. The principles of projects are often incredibly valid, and their implementation can appear to have endless potential when considered in isolation. However, as leaders have attempted to roll their project out, they often are blind to the fact that numerous others are activating similar project plans. This causes organizational ADD, resulting in a hodgepodge of projects moving forward minimally, while exhausting and discouraging teams who have no change in their daily work to show for their chaotic efforts.

 This year, many of those leaders, are realizing that their “what” is important, and has lots of potential. But, so do the “whats’” of others, and, that it’s really the “how” that matters. Equally important, they are beginning to see evidence and agree on what that “how” is:

• Identifying a process
• Setting a standard for that process based on the needs of our customer
• Engaging front line teams in creating a process and standard work to reliably meet that standard
• Making the standard (target) and real performance (actual) visible
• Connect management standard work to the front line processes and visuals to ensure:
  • Front line teams meet consistently to PDCA in pursuit of closing the gap between target and actual
  • A set cadence of checking for adherence to standard work and process performance by all levels of operational leadership

Lastly, and most importantly, leaders are realizing that there is limited real estate, in both physical space on front line visuals, and in mental capacity of front line teams.  Therefore, to allow the “how” to flourish, an organization can only focus on a critical few processes.

 “Given this limited space on our daily management system, what are the critical items we want our teams to focus on?”

In many ways the central debate of strategy deployment has become that simple. Just as school children work together on a puzzle, not questioning if the missing piece is how they want to describe the problem; our leaders have gotten beyond their educations and various experiences to agree “we’re putting together a puzzle, and we’re missing a piece”. Just as school children look objectively at the void and scan their environment for a piece that has the same shape and size to fit the problem before them, rather than attempt to convince their classmates that the piece they like best is the right one to fill the gap, this year’s strategy deployment debate is where it should be: “what’s the correct piece to fill the void?”

For several more weeks leaders will continue the debate of what specific processes will be the critical few to inhabit the minds and boards of front line teams in 2010, as reliable processes fall off. But this is the goal of catchball, this is the tension we need. As we continue to mature as a lean organization, it’s become clear that recognizing what we may need to un-learn can be one of the most important things we learn as we continue to close the gap between our actions and our words.

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As an organization we are in the middle of our annual strategy deployment process and spent the last couple of weeks defining the goals and the means for the 2010 plan.  It is a process that creates a lot of healthy tension and I am sure that many would describe it as being painful.  Often the discussions center on the magnitude of the goals (targets) we should be setting for the year.  Personally, I have always been an advocate of setting stretch goals and believe that without setting aggressive targets the organization will never push the envelope of transformational change.  Incremental targets can often be reached through small improvements or by simply working harder, which will never lead to world class processes. 

Since coming to this organization I have been surprised at how hesitant leadership has been in setting stretch goals. There are many examples I could share that have brought up a lot of questions for me: 

• I have listened to countless conversations where senior leaders have debated the single leader that should be accountable for a goal that was clearly a goal that was cross-functional and many leaders should be accountable to.  So why were leaders trying to avoid this accountability? 
• I have often heard leaders say that it is demoralizing to staff to set a goal to high and then not reach the goal.  Why would staff be demoralized? 
• Additionally, I have often seen leaders “adjust goals” part way through the year when it became clear to them that the goal was not going to be accomplish given the current pace of improvement.   Why change the goal if it was the right goal in the first place?  What not quicken the pace of problem solving instead?

This last week I had a long talk with a senior leader in the organization about the conflict that arises during the goals setting process and why setting stretch goals is such a challenge in this organization.   His perspectives were very interesting and I thought I would share since many of you might have similar challenges. Overall, it became clear that many of these challenges are a result of our management by objective history, which linked compensation directly to the achievement of strategic goals.  This of course created a disincentive for a team to get assigned an aggressive goal, because if it was not achieved then it would directly impact their compensation.  In other words, we were being hard on the people and not the process.  Even worse, this type of system creates wasteful behavior in people as they either try to influence the goals to be changed or pass the accountability off to others.  A gaming that focusing people attention on what is in it for them as opposed to defining what we need to do in order to meet customer requirements.

What became clear is that effective goal setting needs to be supported by the right types of performance and incentive systems.  These systems should focus people’s energy on improving their processes and problem solving.  If a team improves cycle time by 75% and the goal was 80% the organization should celebrate!  As an organization we are still challenged in this area, but we have begun to make progress.  Last year we took down our wasteful budget process and replaced it with a system that focused on year over year improvement as opposed to budget vs. actual.  Additionally, this year we will be introducing a behavioral focused performance assessment process.  I am confident as we move our focus to improving process we will soon come to a day where people are ready and more then willing to sign up for stretch goals!

Popularity: 9% [?]

I have been having technical problems with the Daily Kaizen and just found out that a couple of my latest posts seem to have vanished when I hit publish.  I was only able to find this one that I have saved on my desktop.  I am sorry for the delay in new content…

A couple of years ago I spent some time working with a Toyota trained Sensei that was an incredible learning experience.  I was a good student, but a green student.  As a result, I was only able to absorb a fraction of the lessons that he was teaching our group. I am sure that many of you out there that have had similar opportunities to work with Toyota trained folks can relate.  The good news was that the experience was very profound and much of what he said has stayed in my head even if I did not understand it all at the time. 

One lesson in particular has recently begun to make a lot of sense to me.  Over and over the Sensei challenged the team I was working with to get to the root cause.  We would bring forward our latest draft of our A3 and he would send us back working telling us to go deeper and ask why.  After a couple of iterations without success I asked him how I would know if we were getting close to the problem.  He then told me that all problems are the result of one of three factors:

1.  There is a lack of a standard
2. There is a lack of a standard process
3. There is a lack of adherence to the standard process

At the time I was pretty clueless to what he meant by this statement, but I wrote it down in my notebook and have stared at it countless times and pondered the meaning ever since.   

Several months ago the light went off for me about what he meant by this statement as I was gemba walking with a senior leader.  The leader of the area we were walking had done the hard work of translating customer requirements into standards.  The standards were clearly posted and the gap between standard and actual was well defined.  We then spent an hour observing the process (nursing staff providing care management).  The team had gone through several PDCA’s of their standard work and the job breakdowns were clearly posted and understood by the team members.  It was evident that there was a standard process in place that when followed reliably led to the achieving of the standard.  Suddenly, I understood where the problem was.  The team we were visiting had designed the process, which had then been spread to other teams with the standard.  Thus they had great understanding and ownership for the standard process and followed it every time.  As we walked over to another team to observe it became clear as we watched the process being performed that this same ownership was not present.  The other team was not adhering to the standard process and I could now help my leader see where the problem was occurring. 

Having this clarity has helped me greatly ever since as I have worked with teams across the organization to solve problems.  I now always start by understanding if there is a well defined standard.  If not, I spend time coaching the leaders on how to define standards. If so, I then observe the standard process. If the standard process leads to the reliable achievement of the standard I now know that the problem is probably caused by a lack of following of the standard process.  If the standard process is not reliable I coach the leaders in improving their process.  So simple, but it took me a long time to understand.

Popularity: 5% [?]

Most frontline teams in my organization are not used to being asked to improve their own process.  Like most organization in transition most improvement that has taken place in the organization in the past was management driven and usually owned and executed by outside experts like consultants and project managers.  As we transition into a system where teams are asked to be responsible for improving their processes every single day one of the most powerful tools management has is the gemba walk.   There are many reasons why the gemba walk is not only an important tool, but an essential tool in a Lean transformation.  Here are just a few:

• Gemba walks are one of the most important methods for teaching management Lean.  It takes Lean out of the conceptual world and forces management to learn by doing. 
• Gemba walks demonstrate a behavior change from management.  It shows that management is curious about the work and interested in seeing the real problems.   Early on they also demonstrate to the teams that everyone is in the change together.  Management is learning alongside the teams they are coaching.
•  Gemba walks allow management to begin to understand the problems that they create and forces them to begin to take responsibility for solving the gaps in their management system.  They see firsthand the challenges created by unclear or too many priorities, silo thinking, narrow job classifications, etc.    
• Gemba walks teach leaders how to set clear expectations and have the discipline to follow-up to see progress.  In order to do this effectively the manager must understand the content of the work; know how to see problems, and to know how far a team can improve over a set increment of time. 

In several post in the past I have talked about some of the advice I give leaders as the learn how to effectively lead gemba walks.  As my own experience has grown some of my thinking has advanced.  Here are a couple of tips that I hope help:

• Gemba walks can only be effective if leaders are disciplined, consistent and organized.  This is why having management standard work is so important.  In our organization we create visual systems (Kamishibai boards) that track adherence to management system work to help reinforce this discipline.   These boards track the frequency, sequence and content of what should be checked during each gemba walk and clearly make visible that the walks are happening as scheduled.  As managers build these boards they need to determine how often they will visit each team (less frequently the higher you are in the organization), and then the board makes it transparent to the teams how often they can expect a visit thus reinforcing the management responsibility.
• Early on it is important to have some coaching help during gemba walks.  It is nice to have a Sensei to go with you, but it is also effective to walk with a leader that has more experience then you do if a Sensei in not available.
• During each walk a leader should ask the team a series of open ended questions to assess the current situation, challenge the current thinking and prepare the team for taking the next step.  If you are just getting starting it is very helpful to have a set of standard questions you always ask the team as well as a system to track notes from past gemba walks.  The leader should take the time to review their notes and prepare their questions so that they respect the time of the team.
• Gemba walks and visual management go hand and hand.  Without visual systems gemba walks often end up being disorganized, not focused on data and worst of all they turn into PR visits or complaining sessions.  Gemba walks are probably the most important tool in helping set and maintain the expectation that teams make their processes visible.
• Finally, at the end of each gemba walk the leader should summarize what they and the team has learned and then clearly define the follow-up items that the team and the leader need to resolve.  Often the due date will be during the next gemba.  This is the most powerful part of the gemba, because when done effectively it helps move the team to the next level of improvement and at the same time gives leadership credibility as the leaders solve some of the systems problems that get in the teams way.   In order to do this well a leader needs to have a system to track on follow up items.  If they ask a team to try x by y date the leader better show up to check or they will lose credibility quickly.  When they do show up to check on the follow up just like they said they would teams start to see that management is serious and they will invest the appropriate time in the improvement activities moving forward.  Something very important as teams begin to learn how to improve their own processes. 

Popularity: 8% [?]

As I have discussed in many posts over the last nine months we have been working hard to put in place a standard platform across our Primary Care system based on the Medical Home principles. This is no small challenge given that we have around eighteen hundred people working in the system across twenty-six medical centers. A year ago we value stream mapped our primary care processes and developed a future state which identified nine standard work elements that when deployed across our system consistently and capably we would create a system that not only greatly improved quality, but also cost. We then developed a “spread” strategy where we pulled together frontline teams into five day rapid improvement workshops to design each standard work element, which we then piloted in three clinics for ten weeks each and then spread in waves across the other twenty-three clinics on a ten week cadence. The backbone of this system has been our Lean management system with visual controls, management standard work and frontline problem solving.

While all of the standard work was designed by frontline teams, with eighteen hundred employees only a small fraction of the total workforce was able to participate. Thus, to the vast majority of employees in the system it has felt somewhat “top-down.” Additionally, all of the elements that were selected for improvement were chosen by management and in some cases may not solve the problems that are most acute to the frontline teams. The organization has a burning platform from an affordability as well as work sustainability perspective and leadership knew we had to move fast. Now that we are nine month into the deployment and rolling out the final element of standard work it is quite remarkable that we are on plan and improving at a rate exponentially faster then we ever have in the past. What is also remarkable is how high the engagement levels are with staff. They have been amazing in trusting that management is doing the right thing and many have taken on more work trusting that the long-term payoff will lead to improved working conditions and better patient care.

What we also know is that as we now transition into a new phase of work focused on improving sustainability and improving adherence to standard work we need to turn much of the improvement responsibility over to frontline teams. In other words, we need to have the bottom up improvement balance with the top down requirements. Management needs to set the expectation that every team in the system is improving processes on a daily basis and they need to then provide the time and tools to make sure it happens. Otherwise we risk losing the engagement and goodwill that we have created with our teams.

A collegue of mine the other day summed it up perfectly when she said that in a Lean organization there is a unstated contract between management and staff that is based on good faith. This contract is based on the premise that if management provides the resources and capabilities to allow frontline teams to solve problems that are important to them and help out when the problems need to be escalated these same teams will be far more willing to solve problems that are important to management. We have a lot to learn as we transition into this new, more balanced approach. How do we ensure that we don’t lose the important standard foundation we now have across the twenty-six clinics as teams begin to improve their processes? How do we put in mechanisms that will allow teams to share best practices within and across our clinics? How do we ensure that management has the capabilities and support systems to manage, train and coach eighteen hundred problem solvers? All challenging questions we will need to learn the answers to through experimentation.

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