Daily Kaizen

Earlier this week I had a chance to gemba (we call it rounding) with several teams that span the spectrum of Lean maturity and performance.  Two weeks ago I had a similar gemba with the CEO of the organization.  At the time I realized that both gembas were different, but I struggled to figure out why.  It is always fun when you have representatives from four levels of management participating (Executive all the way down to the frontline managers).  While it is hard to stay focused, especially on work content when it is a large group it was a unique opportunity to check on the effectiveness of our Lean Management system.  We have often in the past had the different levels of management gemba together, but we have never been very clear on the purpose nor were the differently levels able to easily find shared content to discuss.  Thus, it often took the form of the lower two tiers of leaders rounding together and a bunch of “suits” along for the ride. 

Reflecting on these gembas I am now beginning to grasp what is different from the past and the implications are profound.  For several years now we have worked to define and implement a Lean management system, but the journey has been slow and we have often not understood what we were doing.  In other words, on a massive scale we have been “acting our way into a new way of thinking.”  Each level/area has been working to improve performance and change behavior, but the linkages between the level and across areas have been slow to develop.  This is what is different; the linkages are beginning to form. 

For example:

• All four levels were really comfortable with each other.  It was not a PR visit and if the executives were not wearing suits you would not have known who they were.  Each level talked about problems and nobody was blaming. 
• All four levels were speaking the same language of improvement.  Everyone understood the PCDA process, how to read A3’s, etc.
• Follow up from previous gembas was visual at each level and everyone had done their work from the last gembas.  The level of discipline was evident everywhere.
• At each level the performance has been made visual and you can clearly see the “deployment” of measures down through the organization.  While many of the cause and effect relationships between measures are not always understood for the first time the leaders could see where these gaps exist and the dialog was rich in debating how close them.  The executives could ask questions about the strategic plan and the frontline leaders could easily point to what they are doing each and every day to support that plan. They all knew something about each other’s work and they all had shared work. 
• At each stop problems came up and there was a conversation about where was the best place to solve this problem.  Was it localized, or was there a more systemic problem that needed a higher level sponsorship to solve.  All four levels ended up with follow-up.  A couple of years ago in most of those cases we would have just talked about the problems, gone through and explanation and then moved on. 

For 64 years the organization has strived to have this level of alignment.  With the Lean management it is coming to life.

Popularity: 10% [?]

“If we just had more staff, we could keep up with the work.”

“We won’t have time for that improvement until we hire new staff.”

If you spend enough time in the gemba, you’ve likely heard the above quotes or similar spin-offs. I recently had the pleasure to accompany a senior leader of our organization on a gemba walk. The purpose was for the leader to check the status and extent to which daily management exists. During this walk, a local manager oriented us to their visual boards, their key processes, and shared the notion several times that the biggest “problem” was that the teams were short-staffed. I remained silent and hopeful that this coaching opportunity would not go unnoticed, but the claim was neither questioned deeper nor acknowledged in agreement.

The staffing issue is a thorny one. There is a common misperception by managers, front line staff and even leaders that there are simply not enough capacity or workers to complete all the work. Compounding this is the overwhelming feeling, either in perception or in fact, that workloads and daily demands placed on frontline staff is increasing. The logical conclusion for many managers is there is little to be done other than reiterate “we need more staff.” Granted, that is not to say that there aren’t teams short-staffed or without needed resources or that it is somehow justifiable to overload those who perform the work beyond their means (a common byproduct).

Lean management forces us to think more critically about staffing needs, required levels, and even roles. Every manager should understand not only maximum and minimum staffing requirements to meet demand, but also the ideal balance of right staff at the right time to balance and level workflows. However, all too often, there is evidence that individuals are overburdened (muri) without managers ever recognizing and thus taking action. This is a clear sign of a knowledge gap. When we hear common claims like the above on a gemba walk, the leader needs to put on his coaching hat and probe the issue further:

•  Can you show me data that shows average demand in the form of takt time?
• What is the daily production standard or expectation for staff?
• Have you timed how long core activities take in your daily processes in the form of cycle time?
• Have you used lean methods to reduce or eliminate waste in these key processes to the fullest extent possible?

More now than ever, as our organization stabilizes more processes and continues to surface problems in operations, leaders need to “learn to see.” This is a difficult skill that takes time and careful attention. With more practice, I’m confident we will build more capable lean experts as we address more difficult issues ahead.

Popularity: 7% [?]

My team at the Burien clinic has had some breakthrough experiences recently in our lean journey that could significantly accelerate the rate of improvement.

During this calendar year, we have focused our energy on learning the language of lean and feeling comfortable with experimentation. We have done this in small teams of 6-10 people (clusters, CORE, Bus Ops…). We started with building team identities, trust, and accountability with retreats in January 2010. We followed with the launch of the new Burien Forum, a monthly lunchtime event designed to bring all teams together to strengthen a Burien identity and teach short lessons introducing lean thinking and tools.

Our small teams have developed impressive experiments to improve workflows and eliminate waste. Examples include standardizing checkout processes in one cluster and minimizing equipment search time for impromptu procedures in another cluster.

Because of Burien’s architecture, our teams work in isolation. Patients walk from team to team in the course of a visit, but our teams can’t see one another. Handoffs are invisible and lack standard communication. This is true for movement of flesh and blood patients and the data that precedes or trails them (electronic items and “old school” pieces of paper).

Waste rules the empty spaces between teams. It’s scary.

To improve in meaningful ways, we knew we needed to move from high-functioning small teams within Burien to a high-functioning Burien team. So we’ve started down that road.

In September I took 14 clinicians to the woods near Mr. Rainier for a two day retreat. Following Lee Fried’s wise advice, we worked with Group Health’s True North statement, Affordable Excellence, citing examples of excellence and affordability from patient and staff perspectives. With a good picture of what affordable excellence looks like (and what prevents it), we hashed out three goals and brought them back to our entire clinic at the Burien Forum. This large group took on the question again and we improved the work further, finally agreeing on these goals in support of Affordable Excellence:

•  Always provide complete and timely care while finishing today’s work today;
•  Ensure a highly effective team;
•  Excellent customer service: a culture of yes.

We’ve posted these goals around the clinic. They are our target condition. Each day in our huddles we will discuss our target condition, current condition, obstacles, what small experiments we might undertake, and what we have learned from yesterday’s experiments. 

At the clinic level, with the help of Primary Care Leadership and lean consultants, we will begin this month the effort to improve across teams, each month pulling from several teams to learn how patients and their data move across our system and then to pull the waste out of those workflows.

We are focused on the patient (our customer) in this effort.

We are on the lookout for the Eight Wastes of Primary Care.

I get dizzy when I think how far we can go with this.

Popularity: 9% [?]

I recently had the opportunity to coach several leaders in our organization to plan for and facilitate a kaizen event originating from the revenue cycle future state map. These leaders had great expertise in the topic at hand, but were struggling to develop a process that allowed the difficult deliverables of the event to be systematically reached. This was a great match, as I had very little content knowledge, but could share what I’ve learned about preparation and process.

The leaders did a tremendous job, and the event was a success. However, I am not sure it would have been if they hadn’t found a process that allowed their expertise and the knowledge of the event participants to emerge, and work productively toward the deliverables.

The experience reminded me how important process is to successful lean events, and to reflect on the critical components I’ve learned through observation and direct experience. These crucial elements, regardless of the deliverables, are:

-  Involve leadership: Involving an operational leader, who owns (even partially) the process impacted by the kaizen, in the preparation and facilitation will greatly improve the chances of sustainability and future improvement. They will care about the success of this event, and won’t be dependant on you to run the next one.

- Apply the logic of A3 thinking to make the problem visual: One of the most powerful aspects of A3 thinking is the simple logic of it, and therefore the ability for groups (large and small) to connect with the thinking and story that it presents. Most kaizen events exist to close a gap between a target (future state) and the actual (current state). Given this, it’s not always immediately apparent, but understanding the event in the context an A3 problem statement is a great place to start. From there, the root cause thinking, Pareto, and draft countermeasures can all be made visible.

- Once the logic is visual and concise, share broadly through Nemawashi:

Once the event preparation has been put into the context of an A3, it is ready to be shared. Nemawashi is a crucial element to successful preparation – as the sharing achieves several outcomes:

• The thinking is improved, ensuring the starting place of the event is of high quality.
• Alignment of members is reached prior to the event – allowing the event to be focused on what it should be – taking action.
• Gaps in logic, guardrails, and data are identified early and often. This allows the facilitator to fill gaps in advance instead of being stopped dead in their tracks during the event.

As the A3 brings the specifics of the event further into focus, you’re ready to draft the details of the event. This often includes: an agenda, facilitator agenda, training materials, event guardrails, support documents, etc. Some keys for this stage are:

- Create a logic and flow to the physical environment of the event: Use the physical space you’re in to help drive the sequence and plan for the day versus working against it. Creating visuals that display the logic of the day (often this can be the 4 quadrants of an A3) can keep the group focused and progressing through the day. Just as tape on the floor can help a worker know if they’re staying within cycle time on a moving line, a visual event can help the group know if their working through at a pace to reach the deliverables.

- Adjust language to the current state / knowledge of the audience: translating the concept and terms (lean and other) into language that fits the group is critical. A recent example comes from the revenue cycle future state mapping completed in July. The group, process, and data were not ready to incorporate the word takt time, so trying to future state map to this word would have lost the group. However, the concept had to be applied, and the language below was used to do so.

1. What are the major demand sources?
2. What are the indicators that we can or can’t keep up with demand at these sources?
3. 3 choices: creating, shaping or stopping demand – what ideas do we have to improve with these choices?

Making this simple change in language was incredible helpful in making the idea of takt time relevant and building a future state to meet it.

- Attention to details: I tend to believe that you only have a few seconds to gain a groups attention, and that it must be regained every 30 seconds or so. Instilling a confidence in participants that they’re marching toward the deliverables every 30 seconds requires a well thought out plan. The best facilitators I’ve seen have an incredible attention to detail with their agenda, language, and process. This does not mean a rigid plan, as rigidity will often backfire, as things never go exactly as planned. Instead it is detail that allows you to be ready for any situation / issue that arises. Over time, this attention to detail will allow an understanding of the root cause of those issues, and an ability to build countermeasures into the preparation, reducing them over time.

- Always give them something to react to: Sometimes there is a fear to “tell people the answer” or “do the thinking for them”. This fear can often result in not having a draft or straw for the group to react to, causing quite a bit of unfocused conversation, as the group struggles for a shared framework of the issue. This can lead to a frustrated group and unmet deliverables.   

I agree completely that telling people the right answer is the wrong method. But, that is not the goal or attitude that should be brought as the lean facilitator. Instead, like the mental model of A3 thinking, this straw is not “the answer”, but rather the best thinking to date. If the logic is clear and it is presented with the tone “this is the thinking to date, here’s how we got here (the logic and guardrails that shaped the thinking), please join me in improving this thinking” the group is immediately in the same ball park, as they have a process and logic that’s visible to them. Further they have something to react to – which even if dead wrong, always brings people to action more effectively then starting with nothing.

Popularity: 29% [?]

Over the last couple of years if you studied the Group Health Lean journey you would see that we have focused primarily in two areas: implementing a Daily Management System (Standard work and Manager Standard Work) and implementing a Strategy Deployment system that utilized Value Stream and Rapid Improvement Events to transform processes. As a result of this work our processes have become far more stable and capable. Yet, one of the criticisms you could reach from our approach is that we have taken a long time to teach, incent and make responsible the frontline teams and managers to improve their work on a daily basis. It is clear that participation in Rapid Improvements is powerful, but only gets you part of the way. The bigger opportunity by far is having self managed teams that improve all the time.  

As we move into the next chapter of our journey it is clear that our ability to engage everyone in the improvement process will be the most important outcome we measure. Across the organization there are many teams that are already pushing down this path and for those involved there is a growing excitement as the realize just how big the opportunity is to drive improved performance. Every time I gemba with these teams I am amazed by how much waste they are identifying and taking out of the system.

While this excitement grows for those involved there is also a noticeable reluctance/caution that is coming from both the frontline and senior leadership teams. The frontline teams are skeptical of the intentions of leadership. They are worried that they will improve the system only to be rewarded less staff and more work. Senior leadership still remembers the days of TQM where the organization invested millions of dollars in training staff and managers, which led to a lot of activity, but little result. Both groups have legitimate concerns that are based on the past and need to be managed. We need to learn from the past and do things differently if we want to get a different result.

 So if we do this right, what will be different this time? Here are my thoughts:

•  First, unlike during the TQM days we now have a Management system. Managers are far more present in the gemba and our goals/standards are clearly defined and transparent. We now have managers that are far more aware of what is happening in their areas and a system that will help us sustain the outcomes.  

 

• Second, in the past our improvement efforts were usually focused on maximizing the value added time as opposed to reducing the waste. Additionally, they were almost always $$$ focused. This translated into doing more work with less people. By focusing on reducing waste we can free up people’s time to do the things that matter to them most (Seeing patients!). Clinicians often get frustrated with taking on larger case loads of patients, but when you dig deeper it is usually not the time with patients that bothers them, but instead all the other stuff that keeps them from seeing the patients (searching, documenting, etc.). I believe clinicians would be happily willing to see more patients if the system reduced the overburden in other areas.  

 

• Third, it will be important that senior leaders learn how to deploy broad, process based goals that if reached will drive the financial results. Having goals like reduction in Cycle Time and reduction in Defects will provide the teams with guidance, but not tell them what to do. Senior leaders need to have faith that if teams focus on these goals they will drive out waste and the results will follow.  

 

• Fourth, we now have tools and systems that allow us to effectively translate customer requirements into our processes. By making these requirements transparent and designing our processes to reaching these requirements we will be less likely to sub optimize the results.
• Finally, and most importantly, senior leaders to need to create the support systems that allow frontline improvement to come alive. They need to provide training and coaching, provide common methods, allow the teams to have time to get started and most importantly they need to show up and participate.

Popularity: 8% [?]