Daily Kaizen

This last Friday was our annual leadership conference where all 900 of the managers in our organization meet once a year to share strategies and best practices.    This was the fifth leadership conference that I have attended and it is interesting how each year the content of the event has changed to match the Lean journey that we are on.  It is so easy to get caught up in the work that we do each day and lose sight of the progress we have made.  Lately, I have been easily frustrated, because the pace seems so slow.  That is why it was exciting to attend the leadership event and be able to look back year to year and see tangible markers of the pace of change. As I walked out of the event this last Friday it felt gratifying, because while it is clear we have all kinds of problems it is also clear that we have been advancing every year and we will continue to advance.   

For example:

• Five years ago the only Lean work in the company was point improvement events and as far as I know Lean was not talked about at all during the event. 
• Four years ago I was part of a team that was showcasing an improvement event that has taken place within the organization.  At the time very few people that stopped by to talk with us knew what Lean was.  Many of those that did were convinced that Lean tools were great for business areas “but would not work in clinical areas.”
• Three years ago the Leadership team had begun to embrace Lean across the organization.  Our Health Plan leadership team shared the learning’s from the Model Line work and maybe 10% of the folks had participated in a Lean event or project
• Two years ago John Toussaint was the keynote speaker and shared the great work they had been doing at ThedaCare.  Our senior leadership team had adopted Lean as our Management System and we used the leadership conference to kickoff our first round of Strategy Deployment.  Maybe 35% of the people in the room had participated in Lean related trainings or improvement events.   
• Last year James Womack was our keynote speaker and challenged all 900 of us to lead the way for Lean in healthcare for this nation.  Our CEO shared with the entire management group the Group Health Management System model and set the behavioral and system requirements for what it means to manage at Group Health.  Far more the half of the managers in the room were deep into the transformation including those in clinical areas.
• This Friday, dozens of teams from across the organizations brought to the convention center their stories and their visual systems and we spent most of the day learning from each other during dynamic poster board like sessions.  There was not a major department in the organization that was not represented and helping others get better.  There was a buzz in the room and it was exciting to see how portable the learning could be.  Customer service agents were learning from nurses who were in turn learning from software developers, etc.    

What started a couple of years ago as a small group of people doing something new has turned into the system by which we all get our work done.  Where three years ago we had to bring people in from the outside to teach us about Lean we now just have to walk across the hall.  It will be exciting to see how far we get this coming year.

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I doubt many of you would argue that the healthcare industry is really challenged in the area of understanding customer’s demands and then delivering on them in innovative ways.  So much of healthcare is structured around perverse incentives and designed to meet the needs of internal stakeholders as opposed to customers.  I spent some time this last weekend leafing through Womack’s book Lean Solutions.  It had been a couple of years since I first read this book and it was interesting to read the notes I had left in the margins about how I was thinking about applying the concepts to the problems we were wrestling with a couple of years ago.  I remember thinking this is exactly what we need in healthcare, and at the same time thinking “boy do we have a long way to go.”   

It is now a couple years later and it is quite exciting to say that we have made real and measurable progress.  A progression that has moved at a much faster rate of improvement then I would have ever predicted possible.  This progress would have surprised me, because designing processes around customer’s specifications often requires re-focusing priorities.  This starts with being crystal clear that the customer is not some internal stakeholder (MD, Pharmacist, Manager, etc.), but instead the end user of the services.  Not an easy task by itself in healthcare.   In practice this means that the processes need to be far more nimble and flexible then in a system that is designed around the stakeholders.  For example, a process we just improved this last week in our Pharmacy will have our pharmacists providing consultation to our new members in real time as they call for their first appointment.  In the old process a message was sent after the appointment was made and we would call back the member at our convenience, which meant we often did not reach them and when we did it was bad timing.  The new process was a significant change for the team, but once they understood the customer demands they were ready to make it. 

A couple other examples to further illustrate the changes underway from some of the notes I made in the margins of Lean Solutions: One set shares my frustration with our call center that at the time was primarily focused on measuring the amount of time each representative spends on each call.  You can imagine the quality issues.  Over the last couple of weeks I got to spend time working on some improvement work within our call center and not only is this measure gone, but the center is focused on not only helping solve the customers problems the first time, no matter how much time it takes, but they are also collecting valuable data that is supporting improvement efforts throughout the organization. 

A similar set of notes vent my frustration with some complaints from members at the time having a difficult time trying to access our Primary Care system.  Since then our Primary Care teams have listened to our customers and learned that most of their demands could be answered without a face-to –face visit.  Now more services are being provided via secure message and phone then in the exam room and customers are happier, quality is improving and the care teams are more satisfied.  There are very few complaints.   I could tell other exciting stories about our Urgent Care, Specialty Services, Pharmacy, etc.   All making good progress, but to be clear we still have a long way to go. 

I thought I would end by stating that a couple of years ago I would have been surprised by the progress we have made, but looking back today I am not surprised at all.  This is because I have come to understand that nobody is more frustrated by the broken healthcare system that we have then the people that work in the system.  There is an incredible pent up demand within the care teams and supporting staff to make improvements on behalf of the patients they serve.  This demand has been slow to be tapped, because of a lack of an improvement system that helps these teams actualize the customer first principles that they all believe in.  What I can tell you from experience is once care teams get over their initial skepticism and spend time understanding the customer needs they become the biggest advocates of driving Lean Solutions.

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Like most organizations it is clear that our greatest opportunities for improvement are cross-functional.  Over the last couple of years we have made significant progress in learning how to more effective align our functional areas, but we still struggle in effectively linking our processes and keeping them linked.  Being an integrated health system we have an incredible advantage in providing more effective care and financing as opposed to the competition, but we will never fully realize this opportunity until we learn how to manage and improve cross-functionally.  

Our last two Hoshin plans have had a dual focus:  putting in place a management system grounded in standard work as well as driving cross-functional improvements.  Being an organization of 10,000 employees there is a lot of variation in how far teams have made progress in both these areas.  What has become increasingly clearer is that the teams that have focused on standardizing their work and putting in a daily management system are able to far more effectively manage cross-functional change.  Having the stable platform of standard work and standard management work ensures not only that the improvement will be sustained, but also creates an environment where almost all changes are viewed as adjustments to a current process as opposed to an entirely new project that needs to be implemented.  The later point means that we can be far more nimble and can improve at a much faster rate then without these systems. 

I have reflected a lot on these learning’s and thought a lot about where as an organization we should focus our time and energy in the near term.  Should we first focus almost exclusively on putting in place standard work and a daily management system in order to give us the foundation we need for innovation?  Do we need to first demonstrate our ability to improve functionally before we try and improve cross-functionally?  For me there is a lot of evidence that suggests that this may be a wise, yet, not very flashy path to take.  It could be viewed as an investment that if stuck with will pay off in a significant way in the future as each function gets their own house in order and begins to problems solve up and down stream.  At the same time there are many leaders in the organization that would argue that this in insufficient.  That from a patient and from a business perspective we cannot wait for the results that can only be delivered from cross-functional change. 

The right answer is probably not doing one or the other, but instead being intentional and deliberate about how we do both.  As we drive cross-functional change we need to ensure that we put in place the functional management system that will allow for sustainability and continued improvement.  It is easy for leadership to focus time and resources on the cross-functional change and then neglect the less exciting and mundane work of putting in the daily management system.  We need to ensure there is a balance to our approach.  Additionally, we need to be sure that all areas are starting to work on the basic Lean capabilities around standard work and standard management, so that in the long-term this blog posting become irrelevant.

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Happy New Years everyone!  Just back off a much needed break and ready to jump into things. 

Over the break I had a chance to chat with several friends and family members about the work that I have been doing over the last year.  This is a subject I have blogged about often in the past.  As I listened to myself try and explain what it means to be a Lean consultant at Group Health it was really interesting how much I talked about leadership and management and how little I talked about the technical sides of Lean.  Having these conversations helped me realize how little of my time each day I spend coaching leaders, staff and consultants on technical related problems and how much time I spend helping managers and leaders manage through change and put in place effective management systems. 

These conversations created some questions for me.  If I am a Lean consultant should I be spending more time teaching technical aspects of Lean?  Why am I spending so little time in this area?  After reflecting for a while I have begun to better understand why the current state exists and much of it has to do with the philosophy we have adopted Lean and how we are approaching our transformation.  It is also an outcome of where we are in our journey, which is still in the infant stages.  Early on in our journey we set the goal that Lean needs to become integrated into how everyone does their work.  That Lean should not be defined as a set of projects or events, and Lean should not be something that is “done to people”.  This is a slower approach to transformation that I believe can only be successful if new capability and new mental models are adopted and utilized by all employees.  In order to achieve this goal it is absolutely essential that you start first with leadership and work your way down with each level of leadership leading and teaching in a new way.  We have avoided higher the army of consultants to come in and function on leadership’s behalf. 

Based on the approach outlined above it makes sense to me that I need to spend most of my time working with leaders to adopt new mental models and to “unlearn” many of the behaviors of the past.  Much of what I am doing might not even be described by some as Lean.  Things like helping clearly establish standards and communicate them, connecting teams to the big picture, holding firm on expectations, etc.  Please don’t get me wrong, I am by no means saying that the leaders don’t need to understand the technical applications of Lean.  Leadership is not content free.   It is just that at this point in our journey we are still at the basic level of putting in place standard work, visual management and basic problems solving.  We have not earned the right in many ways to go beyond the basics.  As we progress over the next couple of years I would expect that more and more of the problems I am helping leaders work through will be technical in nature.  We just are not there yet. 

Do others have a different perspective?  Do you think I am off base?

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