Daily Kaizen

The following is a post by Dr. Wellesley Chapman.  Dr. Chapman is a brilliant leader and physician and his team is doing amazing things every day.  I am glad he has taken the time to share some of his thinking with us all.  Enjoy…

I was at a conference in June and ran into a doctor from Boston who suggested I read Michael Lewis’s Moneyball, a 2004 nonfiction book about baseball. He thought it would influence the way I think about health care.

Because baseball and health care are exactly the same, right?

I like baseball so I read it. And it did change the way I think about health care and how we do it at Group Health. To explain, I have to give you a “bullet presentation” of the Moneyball story:

• Baseball is full of things to measure. Most of what people currently measure doesn’t help teams win games;
• The Oakland Athletics (A’s) baseball club has a limited budget to spend on players (compared to other teams);
• The A’s think measuring the right things (that others don’t) will help them win more games than richer teams that can buy star players;
• The A’s are right.

Oakland players focus on key behaviors that link, step by step, to the ultimate goal of winning enough games to make the playoffs. Players practice patience when batting, they wear out pitchers, and they don’t take low-yield risks. Mastering these critical behaviors is difficult for players, who have risen to the highest levels of baseball by doing just the opposite (heroic acts and big risks).

What about this baseball story resembles health care? Lots:

•  Health care is full of things to measure. Most of what we currently measure doesn’t help patients to be healthier;
• Health care has a limited budget to spend on making patients healthier (though we haven’t yet learned to live within our means);
• Group Health knows that measuring the right things will help us help patients be healthier, and we’ll do it more affordably than everybody else;
• We’re right. Right?

By developing our Medical Home Model of care and managing it with Lean methods, we link day to day behaviors of primary care teams to the ultimate goal of affordable excellence. We seek out care gaps, develop care plans to manage disease, encourage prevention, and give patients multi-modal access to our whole team. And team members talk—in person—about patients, processes, and outcomes. We’re learning what is effective as we go.

But this is hard work! The skills we are asking one another to master are not what got us here. We have to work against our training, conventional wisdom, and—hardest of all—our habits. I am awed by the size of the challenge and the enthusiasm my colleagues show for taking it on.

Primary Care is unique in its complexity: breadth of scope, information volume, rapid scientific change, and human (patient) variability. There is so much to measure. As in baseball, conventional wisdom encourages health care folks to measure things that don’t matter much. Even our current Medical Home systems follow flawed metrics. We can improve our metrics and our processes by careful observation, respectful questioning, and incessant experimentation. We reinvent the work as we do it, share what we learn, and script—temporarily—the moves we believe critical to achieving affordable excellence.

We are in the infancy of our work with Medical Home and Lean. In 2013 we’ll look back at our 2010 processes and metrics and say: “Why did we measure that? We’re so much better at this now.” And in 2015? We’ll be better still, our work will look different, improvement cycles will be shorter; 2010 will look like the Middle Ages.

Several major league teams have adopted Oakland’s “evidence based baseball” methods. As we get better, others will adopt ours. This is good news. Health care needs change. And Group Health has to lead it, because we can.

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A couple of years ago I got a chance to attend a Lean training session where the topic was “how do you assess the progress of a Lean transformation.”  The instructor, who is very well respected, made a comment that he thought it was fairly easy to tell how successful an organization was at putting in place a culture of continuous improvement.  All you needed to do was to spend some time with managers at any level in the organization and observe how they handle problems when they come up. 

• Do they ignore the problem?
• Do they blame the problem on others? 
• Do they accept the problem as “always having been there” and do nothing about the problem? 
• Or, do they accept that most problems are a result of the process and/or the system and they take responsibility for doing their part in helping solve the problem?

The class had a robust discussion for the remainder of the day and I still have not found a better way to think about assessing Lean capability. Every day I am in situations where problems are made visible.  This gives me ample opportunity to assess my own behaviors and the behaviors of the leaders I am working with.  While this all sounds fairly remedial I would encourage everyone to spend a day assessing your organization through this lens if you don’t already, because you will be surprised with how much you learn. 

I also find it useful to pay particular attention to assessing how teams manage problems over time.  They often follow a fairly predictable pattern:

• First, teams get frustrated as Lean tools begin to make problems visible (especially if their individual performance is transparent) and while the problems have always been there and were talked about, they were never documented.  This often turns into a conversation about integrity of the data. 
• Second, they then often complain that the problems are caused by someone else.  Upstream, downstream or management.
• Third, teams begin to accept that they may have some control over the problems, but they do not have time to solve them (got to do the “real work”).
• Fourth, teams begin to solve some of their own problems and realize that it is okay to talk about problems.  Responsibility begins to take hold.
• Finally, teams are completely engaged and not only do they take responsibility for their own problems they are willing to take responsibility for problems that are not clearly within their sphere of control. 

How would assess your team?

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As I continue to work with teams and observe effective leaders swiftly navigate their teams through rapid improvement, while less effective leaders struggle to create and sustain momentum, a correlation has caught my eye:

• Leaders whose actions indicate that they define themselves as martyrs to broken processes, and therefore champions of continuous heroic efforts, are among the least successful as lean leaders.

It seems as though many people, often with great initial intentions, dive into complex problems and complicated work environments. However, for a sub-set of those people, this original intention is slowly replaced by a personal identity that is centered on being a hero to the chaos of their work, and to protecting their staff from that chaos. Over time, this personal identity can become so engrained that any form of process improvement is seen as adversarial.

This is a monumental ideology to change – which brings me to bowling.

In 2000, Robert D. Putnam wrote Bowling Alone. Essentially, the book describes the decline of civic engagement in America and the ramifications of this decline on everything from democracy to health and happiness. Among the examples of civic engagements are Rotary clubs, bridge clubs, and bowling leagues. Although I don’t believe Mr. Putnam specifically referenced the negative impact this decline would have on lean in the work place, I will attempt to make this connection.

We as humans derive a critical bond from feeling needed, from being important, from feeling at times heroic to those in our social circle (I will reference this collection of needs as “social bond”). No matter how large or small, having a consistent source of this social bond is important to our emotional well being. Robert Putnam clearly demonstrates the decline of meeting these social bond needs through civic engagements. I propose that more and more of us in America have replaced civic engagements with work as the primary source of our needed social bonds, which can negatively affect lean thinking at work. This impact is specifically dramatic for the subset that are both hero/protectors and derive their social bonds at work, as process improvement may put in jeopardy the role their social bonds are built upon; threatening their identity, and putting into question the validity and honor of their (perceived) sacrifice for being a protector.

On the other hand, a leader who has primary social bonds outside of work can develop an attitude toward work focused on getting the job done in the most efficient and effective way possible – as there are other places they’d like to be when the job is done. Further, a leader whose social bond needs are fulfilled outside of work may keep a perspective on work that gives just enough distance to see waste and opportunities, as well as an openness to take a chance on something new. Given this, I propose that a leader who has primary social bonds outside of work, hero/protector or not, has a better chance of unbundling old management habits and becoming an effective lean leader than one that does not.

If lean consultants were as influential as we sometimes hoped, maybe we’d be on the front lines of the civic rebirth in America — challenging this social bond issue directly with our clients and creating a domino effect that eventually lead to a decline in work as the primary source of social bonds. Ultimately, this would allow a perspective of work that kept it within the context of a larger life and purpose, thus making lean a welcomed framework to continuously improve processes – as work could be done more efficiently and effectively and individuals would have more time and energy for other priorities. This is a nice utopian thought, and if a solid relationship is established with a client who fits this description, maybe challenging this issue directly could be successful. However, in working with the majority of clients we will encounter who derive their primary social bond from work, I offer these more humble suggestions:

• Focus the initial consulting on connecting the goal of their processes to the customer. Even if establishing a primary social bond outside of work isn’t possible, being a hero for the customer (vs. their staff) is a much better foundation for lean thinking and has the potential to begin loosening some of their rooted ideologies.
• Challenge their conception of respect for people. Hero / protectors often see what they do as respect for people – insulating staff from broken processes and external forces. Unfortunately, this perspective can often mean their staff continues to work inefficient processes, full of waste, without a voice or process to remove the frustration they feel and observe from the customer. This situation is counter to the lean definition of respect for people. If they can begin to move to a lean based perspective that shows respect by treating all as equals, allowing problems to be made visible and countermeasures tried, and challenges all staff to be equally accountable, a foundation for lean thinking can form.
•  Finally, if all else fails, seek out clients who are great bowlers.

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As an organization we are learning how to think about and use measurement in a completely different way than we did in the past.  A couple of years ago when I first started working with teams it was most often the norm that there would be no process measures in place and most of the outcomes that were being measured were lagging, often times by months.  Much of the management system was focused on looking backwards and asking (or blaming) on what had happened.  I am sure this is not unfamiliar to most. 

As teams have begun to think and manage through a process view the requirements for measurement have greatly changed.  Teams have realized that without real time or close to real time feedback on their actions it is very difficult to improve a process and almost impossible to proactively adjust to problems.  This shift is requiring us to often throw out our current measurement systems and rebuild them from scratch.  We have become much more active with our data collection and many of the automated systems have been transitioned to manual. 

As teams progress through this transition it has been fun to see them mature in their thinking.  Usually the progression of questions they ask over time looks something like the following:

• What are the key requirements our customer has of us?
• What is the process that allows us to meet these requirements (outcomes)?
• What are the indicators we need to measure within this process?
• How often do we need to measure these indicators to stay on track?
• What problems get in our way?  How do we know these are problems?
• How do we start to anticipate customer requirements and become proactive? 
• Etc. etc. 

There is clearly no right answer for all of these questions.  Often times the answer changes over time or changes based on the process.  For example, there is no right answer to how often you need to measure your process.  This depends on the takt time, cycle time and how quickly you are looking to improve.  If you are working in a call center you might need real time measurement to be effective since you are taking thousands of call.  This is different than a surgery center that might have four patients per day per operating room.  The important part is that teams begin to learn their process and move toward becoming more proactive.

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