Daily Kaizen

A couple weeks ago I had a chance to participate in the Lean Healthcare summit.  During one of the breakout sessions the presenter made a comment that it is only possible to have a Lean transformation if it is “led from the top.”  I could tell that this statement was frustrating to many folks in the room since they are trying to make things happen from somewhere in the middle of the organization.  While I do agree that a transformation is not possible without senior leadership ownership, I don’t believe that you have to start there.  I wanted to share a little of our story from this perspective in the hopes that it might give some of those same people working to start something from where they stand a little confidence.

As an organization we are entering the 6^th year of our Lean journey.  In some ways it feels like it has been an eternity and in others it feels like we just got started.  Unlike many Lean organizations that had their journey start with a zealot leader at the top our journey can be described as a long enrollment process.   A process that started in small pockets within the organization, slowly spread through the early adopter ranks, gained attention of the senior leadership and is now become a system that is integrated into “how we run the business.”  Literally, our transformation has happened one leader at a time. 

This process described above has not happened organically, but instead has been defined and moved along by a group of Lean Champions that really started as a handful and has grown in number each year.  Meeting late at night and early in the morning this group week by week and year by year has shaped a focused strategy that would gain more and more leadership attention through sharing knowledge and getting results.   Focused, because these Lean Leaders understood that we are a really big organization and a strategy that tried to get too many people involved too quickly might be to diffuse and lack getting the traction and results that we needed to “prove the concept.”  This meant carefully picking areas and leaders to “get involved” and then deeply supporting them in adopting Lean methods and principles until it was clear that they would never “go back” to old leadership behaviors.  This also meant we could more effectively demonstrate the results of the change. 

As more and more areas/leaders became involved more and more leaders began to take interest and pull.  After a couple of years most of the senior leaders were actively involved and there was enough “in-house” experience that Lean could no longer be discounted as not working in Healthcare.  We had real life examples of transformation within our own gemba! At that point, our executives were able to make a commitment to Lean as a transformational strategy and in the words of our CEO we are “all in.” 

This strategy has been slow going and there have been many times where a lot of us doubted the organization would continue to move forward.  There has also been many times, especially early on where I wished we had zealot Lean senior leaders from the start. I am now not so sure this would have been a good thing.  This is because the journey I have described above has required a lot of leaders at all levels of the organization to take risks and responsibilities without being told they had to.   At the end of the day this might lead to greater ownership and capability.  I guess time will tell.  What is clear to me is that Lean transformation may need to be senior leader led, but it does not need to start there.

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Over the last couple of months I have becoming increasingly excited about the potential of using Lean principles and methods at Group Health in the design process for new facilities.  Like most organizations we have approached facility design from a “traditional” perspective where are primary goal has been to maximize the utilization of our most expensive assets (MD’s time, room utilization, etc.).  To be fair, I believe that we have started each of these design processes with the intention of making our facilities “customer focused”, but we have never known how to do this effectively.  As a result, the process would quickly migrate to what we did know and what we could measure which included stakeholder requirements and financial/capacity based measures.  As a Lean facilitator working with an operations team to improve flow it has always been frustrating to try and improve flow in these buildings when so many of the obvious opportunities to increase patient value are off limits due to change over costs. 

Lucky for Group Health there are several healthcare organizations that have paved a path for us to learn from.  Right here in the Puget Sound Children’s Hospital is doing amazing facility work using 3P and rapid prototyping and around the country organizations like Park Nicolett and ThedaCare have demonstrated incredible results by almost every measure.  For example, Park Nicolett opened a new Cancer center this last year that was designed using Lean principles and methods.  The center is designed to ensure that once the patient arrives they never have to leave their room, everything is brought to them!  For patients with Cancer this is an amazing benefit (saving energy as opposed to walking for miles to get care!).  The Center was built for significantly less then what was originally forecasted using traditional methods and the staff and patient satisfaction measures are through the roof! 

Over the next couple of years Group Health has plans to make significant investments in new facilities.  The reason I am excited is that not only will I get the chance to learn new Lean methods, but I will also be able to work with operations leaders and patients on a “Greenfield” design that could truly be transformational.  I believe we have an opportunity to not only greatly reduce capital and operating costs, but also create an environment that leverages our integrated model.  Imagine going to your Primary Care MD and it there is no waiting room, it takes 30 minutes from door to door and before you leave the exam room your prescription has been delivered?  Not to over promise, but I believe all of this is possible!

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A recent opportunity landed us at two Seattle-area lean manufacturers; Kaas Tailored and FastCap. Connor went to Kaas and Erika went to FastCap. Even though these are two very different companies with different products and different journeys, our experiences were remarkably similar. What we both observed was beautifully simple. Humbling, and initially discouraging, as it was clear how far we have to go, but ultimately inspiring to see what’s possible and what lies ahead if we continue to persevere.

Why beautifully simple?

Kaas provided a living example of how removing Muda greatly reduces complexity, confusion, and frustration. They also demonstrated how continuous improvement aligns forces into a common direction to improve the larger system toward the customer instead of adversarial forces pulling people and systems in multiple directions – resulting in stagnation.

One clear example of this was the training itself. In most organizations, outside tours seem at best to be altruistic acts to “share what we’re doing” with the abstract notion that this will repaid and benefit the tour giver at some future date by going to see what their doing. At Kaas, the tour / training is simply an integral part of Kaas’s business and serves multiple functions all in pursuit of real time and ongoing improvement. Examples are:

• By providing training to vendor and direct business partners in exchange for more frequent deliveries, lower rates, etc, training becomes a leverage tool to reduce waste and cost, and those benefits get passed along to the customer. 
• Kaas involves front line staff in the trainings which reinforces the principles of lean and development of the Kaas culture. This allows an avenue for reflection while producing better thinking and more improvement.
• At each area we toured the staff asked the team, “Do you have any ideas for us, any opportunities for further improvement?” This shifted the paradigm of a tour from one of passive sharing of past accomplishments, to one of proactive improvement for their processes.

FastCap gave a stark example of the power of developing your people. They invest large amounts of time (daily), resources and energy to create the culture. It would be clear to any visitor within minutes of arriving at the factory that the principles of continuous improvement and respect for people are alive and well. How do they create this culture?

• Invest in the education & development of your staff. Every day the team comes together for shared learning. Whether they are reading ‘The Toyota Way’ or studying the U.S. Constitution there is designated time every day to learn and reflect together.
• Create a culture where problems truly are ‘gold’. Every morning FastCap employees review the mistakes they made the previous day. They share them openly, own them fully and work to get to root cause and eliminate them because they know that the focus is on the process, not the people!
• Everyone’s job (no matter what your title) is “process engineer”. It is everyone’s responsibility to improve processes every day. Improvements are shared daily and celebrated.
• Keep it simple! Everything—from creation of job aids to training videos to work station layouts to product development processes—everything is as simple and visual as possible.

What does all of this have to do with ensuring improvement in a consulting team?

The overarching theme from our time spent at Kaas and FastCap was the culture of continuous improvement that was owned by all staff. At Group Health, we talk theoretically of the power of having all staff feel ownership and a “know how” to improve what they can control vs. an attitude that improvement only comes from consultant lead events. Pockets of this are developing, and we are being very intentional about helping to develop this culture in some areas, but it’s certainly not consistent.

An outcome, and potentially incentive for this improvement is the fact that at both these companies, removing waste from ones processes translates into additional time for improvement. 5 minutes of waste removed from the process = 5 minutes more time for improvement.

This is the gap for consulting groups. As we recently got together and brainstormed what is preventing our consulting teams from continuously improving, we realized that we, as consultants, had all the same excuses as our clients:

• Tyranny of the urgent
• Reactive vs. proactive
• Too busy
• Improvement feels like extra work – what’s the incentive?

We pondered this last bullet – what is the incentive? Our work is not as tangible as building furniture at Kaas or tape measures at FastCap. If 5 minutes of muda is removed from their process, the item is done 5 minutes earlier, allowing 5 minutes for improvement almost by default. In the consulting world, will removing 5 minutes just result in additional work, or worse, filling it with overproduction or another type of muda? We don’t know, but believe that question, or lack of an answer is a major barrier within our culture.

Therefore, our hypothesis is: if removing waste from consulting processes led to protected time for further improvement (maybe not 1:1, but in same related ratio) the rate of improvement would increase dramatically, and would become sustainable.

At this point, it’s just a hypothesis – and one we’ll need to test in the weeks to come. As we do, and prepare to share our findings, we would love to hear your thoughts on ensuring continuous improvement among consulting groups. What has worked for you? What hasn’t?

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This last week I got the chance to present at LEI back in Florida.  It was a great conference and we learned a lot.  I also had a chance to get to know a couple Group Health folks better.  One of them was Dr. Chapman who presented with me and is a really thoughtful clinical leader.  Dr. Chapman wrote up some of his reflections and I asked if he was willing to share them on the blog.  Here they are…

I had the opportunity this week to travel with an impressive group of colleagues to Orlando, Florida, for the Lean Enterprise Institute (LEI) Healthcare Transformation Summit. Group Health had the opportunity to present our experience in piloting, spreading, and stabilizing the Medical Home, as well as to demonstrate how we use lean to maintain and improve what we’ve built. Our group also got to hear several fantastic presentations from other organizations doing similar work. These are a few observations I brought home with me.

1. My conference name tag had no letters after my name. No one’s did. No MD, MPH, PhD, MBA, CEO. None of that. It was refreshing. Everyone was, at first impression, simply someone with enthusiasm for doing healthcare better. Removing the pretenses that titles haul into the mix made for refreshing, fun, frank discussions. This reminded me of some of the “just culture” discussions I’ve had around Group Health: each of us deserves a voice and should not feel intimidated by the title of coworkers.
2.  ”If a problem is well-defined, it is half solved.” I heard someone say this in a presentation and missed the next ten minutes of the talk while thinking this over. I like a good solution to a tough problem, and am quick to jump to the solving part of problem solving, usually before I’ve nailed down the actual problem. How many solutions have not worked out because I didn’t spend enough time learning what problem I was really trying to solve? Lots.
3. Jumping too soon to solutions tricks us into treating symptoms instead of causes. In return we get more symptoms to treat. It keeps us busy, but not successful. I’m going to spend more time defining problems.
4.  We can’t improve until we learn to see. When I wanted to increase the amount of exercise I was getting, I had to step well back from my daily patterns to really understand them, to see how an intention to run six miles became, instead, “running” an errand, making another throw-away spreadsheet, or writing a blog post. Seeing the patterns took some right brain work–journaling, drawing pictures–before I could develop a useful approach to getting my running shoes on and making them go.Likewise, we’ve got to see our work before we can do it better. Day to day, we follow familiar patterns with results that don’t satisfy completely, but we’re so used to the path, because it is familiar, that we don’t look for or create a new one. I’m afraid to draw a picture of how much wandering I do around my clinic looking for things, but it would certainly help me see how much time I could be spending doing things that matter. I’ll give it a try. (Maybe there’s an app for that.)

   Okay, one more…

5.  If this work isn’t fun, we’re not doing it right. The only way to make meaningful improvements is to think differently. And to do that, we have to agree to play. Play nicely, yes, but PLAY. New insights come when we follow our ideas in amusing, creative ways. The most inspired problem solving examples presented at the LEI Summit were developed with pictures and games. Play will get people listening to our stories, and if we give it a try, someone might have fun.

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On May 16^th I wrote a post about the simple process for improvement we are currently experimenting with in a pilot clinic.  The goal of this work it to develop a process by which frontline teams can begin to improve their own processes on a daily basis.  We are trying to move beyond events and projects being the only outlet for improvement for team.  Eventually we would like this system to evolve to the point where it is part of the daily work of all employees and all employees are expected to improve their process. 

I thought it might be useful to share some of our learning’s thus far from this experiment.  Here is a starter list:

•  First and foremost leadership must be willing to create the time and capacity for teams to engage in this process.  There is no clear upfront ROI and since in our case there are no additional resources available the leadership team needs to be willing to take a short-term “hit” on performance with the belief that in the long-term the small improvements and staff engagement will more then make up for the investment.
• Second, it is very important to establish a set of principles and norms with the team that you constantly return to and discuss.  We have a list around eight and some examples include: “patient-first”, “improve what we can control”, “50% improvement” and “keep it simple.”  At the start of each session we pick one or two of these principles and have each team member discuss what it means to them.  They have been invaluable in keeping us on track. 
• Third, as I discussed in my last posting it is really important to keep the process simple.  Don’t overproduce.  We have focused almost exclusively on reducing waste and fixing problems based on what “bothers them daily.”   We run simple experiments, see if they work and then adjust as needed.  We are also beginning to use photos and video to document before and after processes to make it easy to communicate the changes to the entire clinic. 
• Fourth, we have made the entire process transparent to everyone.  All of the brainstorming and experiments are done out in the open and not in meeting rooms.  We have a simple visual system that tracks the progress of experiments from “idea” to “done.”  Each day participants in the experiment update their colleagues during huddles and ask for feedback throughout the day.  We are trying to make this work be part of what happens daily within the clinic and not something that is separate and disconnected. 
• Finally, we have focused on building the capability into the operations managers.  They are leading the brainstorming sessions, checking on progress of experiments and securing resources.  As consultants we are playing a coaching and support role, but not leading the team.  We have 900 teams in this organization and so creating a consultant dependent model would not be sustainable. 

 I would be very interested in hearing your thoughts and feedback.

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