Daily Kaizen

The following was written by Alan Fine one of our very smart and capable MD’s at our Capital Hill Medical Center.   I love the creativity and fun this team is having.  I hope they are okay with me sharing.  They are an amazing group.  Enjoy…

• T’was the night before Christmas, and down on The Gemba*
• Group Health is Leaner than we ever rememba
• Our leaders are nestled all snug in their beds
• While visions of Standard Work* dance through their heads
• Dyad partner and I Huddle daily to Fish
• Continuous Improvement* our big holiday wish.
• We’d just settled our brains for some real A3 Thinking*
• When
• From an RPIW* there arose such a clatter
• (We wish they’d produce more ideas and less chatter)
• We flew like a flash to the latest Report-0ut*
• To see what new work we’d now have to sort out
• What to our wondering eyes did appear
• But a Pacesetting* Sensei*—without one reindeer!
• Our Sensei was ever so lively and quick
• But he surely was nothing like good old St. Nick
• He made us feel Leaner than ever before
• He whistled and shouted Lean teachings galore:
• “Now Kaizen*, now Kanban*
• Now Value Stream Mapping*
• On Muda* and Mura*
• And Minimal Staffing*!”
• To the top of the Hedis score GHP will be shining
• Our Dashboard* tachometers will all be red-lining!
• And then in a twinkling (even faster than that)
• Down the chimney our Sensei came with a Splat*!
• He was dressed all in saffron from his cowel to his sandels
• He leaned on a cane of  Toyota brake handles
• A bundle of Lean tools was flung on his back
• An Air Traffic Controller* and Lean maniac!
• His 5-Whys*—how they sparkled! His A3*—how downtown!
• His 5S* was 3 Actuals* walking fast from a Burndown*!
• He had a Lean face and a sunken in belly
• When he laughed nothing shook like a bowlful of jelly
• He was, nonetheless, a right jolly old fox
• As Level* as any Heijunka* Box
• He spoke not a word, but went straight to his work
• And pulled on that ol’ Andon Cord* with a jerk!
• Outcome Measured Production* then ground to a halt
• That cord-pulling Sensei was sure worth his salt
• Then, laying his finger aside of his nose
• It was Just in Time*—up the chimney he rose
• And I heard him exclaim as he Process Walked* out of sight
• “Our Fat Years** are over—the Lean start tonight!”

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I have been thinking a lot lately about how as an organization we can do a more effective job at engaging people in their every day work. Over the last six months we have learned a lot through our Frontline Improvement (FLI) work, which I have written about extensively in past blog posting. While this work has been exciting and is showing results it also still relies on a lot of focus and project organization from management. It may be influencing the culture in the right direction, but it seems insufficient to meeting our aspirations. FLI is one important part of a much larger and lagging people management system.

Being the geek I am I spent a couple of hours yesterday reading through a set of old documents that were compiled in 1996 out of the Japan Society of Production Management to try and gain some insights into how Japanese companies approach engagement. This study reviews some of the best practices in Japan including Toyota, Nissan, Canon and Honda.

A couple of key points that I took away:

These organizations have robust strategies to “draw out willingness.” The technical skills can be taught, but motivation can only come from within and it is motivated workers that make a company successful. Thus they use robust psychological approaches to motivate their workers.

These organizations make huge investments up front in hiring the right people that will fit in their cultures. They tend to be far more picky then other organizations in selection and require far more rigorous hiring processes then their competition. For example, Nissan requires all new operations managers to spend two weeks with their sales force learning how to interact with the customer before they finalize their job offer.

These organizations make huge investments in training and developing their people. Frontline workers as Toyota average five days annually in workplace training.

Most interesting to me was the fact that all of these organizations look at the primary purpose of “daily improvement” (our FLI) as a system to develop and motivate people and secondarily as a way to make the work more efficient.

Overall, I was impressed by how intentional and strategic these organizations are in approaching how they motivate their workforce. They understand that organizations are simply collections of people and that the organization with collection of the most motivated people will be the one that in the long run wins. This takes a much deeper understanding and faith in the ability of people. This is Respect for People in action.

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This morning, while waiting (and waiting) for for some gifts to be wrapped, I followed a link from Twitter to today’s London Telegraph, a nice little piece about Andre Geim and Konstantin Novoselov, the recipients of the Nobel Prize in physics. It turns out that their Nobel-worthy product, a promising substance called graphene, didn’t come from their formal, funded work, but from their “Friday Evening Experiment” sessions, driven by their own curiosity. They just thought it would be fun. (And what did you do last Friday evening?)

Several high profile companies have created opportunities for employees to enjoy a version of Geim and Novoselov’s Friday evenings. Google, for example, uses “twenty percent time,” (equivalent to one day a week) to encourage innovative product development. Twenty percent time gave us Gmail. I have no idea how I managed before Gmail.

Some balk at the idea of “giving up” so much productivity for unguided, non-standard work. But every once in a while a Gmail or a graphene pops out of the effort. It doesn’t take many wins like that to justify the “lost” productivity.

Daniel Pink described nicely in his book Drive the motivational benefits of unstructured work time. People love autonomy and the opportunity to grow. Twenty percent time creates motivated employees.

Most of these twenty percent victories are innovations from companies whose survival depends on bringing new products to the market. What if your company doesn’t depend on innovation for success? What if success requires just being really great at delivering your existing products? In that case, why would you need twenty percent time?

With the guidance of primary care leaders and our Lean consultants, our clinic (70 staff, 13,000 patients) recently launched a regular set of experiments called Front Line Improvement (FLI). I think of FLI as a kind of twenty percent time (though technically it’s about 4% of our time, spread over a month). Like Google, we spend productivity to get better.

But we don’t innovate. We don’t create new ways to deliver care. We focus on pulling waste from our daily work. And there is plenty of waste. It may what we produce most.

In these sessions, we’ll never come up with a Gmail. Nor graphene. It’s not sexy. But FLI has the same positive effect Pink describes. Autonomy motivates. And our patients get better care. (More on that in another post.)

There are opportunities on the horizon to bring to the market a fundamentally new way of delivering care. Medical Home 2.0. Gmail with a stethoscope. That’s beyond the scope of FLI, for now.

We’ve only just begun, but I am already not sure how I would manage without my twenty percent time.

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A couple of years back James Womack came to Group Health and spent a day in the gemba with a small group of us working at the time on our Model Line in Health Plan.  We were early in our Lean transformation and just starting to try and figure out what a Lean Management system would look like in the organization.  The purpose of the gemba walks was to see firsthand the different improvement activities that we had underway and to seek Dr. Womack’s consultation. 

To say that at the time we were a little scattered with our approach would be an understatement.  Looking back now it was clear that much of what we were doing could be described “as just trying new things” since we had so little experience and even less focus.  The leadership team and Lean consultants were busy reading about different tools and techniques and then we would quickly turn around and looked for applications within the areas we were working in to apply them.  Appropriately, throughout the day Dr. Womack recognizing our challenges and thus steered the conversation through questioning to describe the purpose:

• Why were we doing something?  What difference would it make to the customer, the business?  What is in it for the staff?
• What experiment were we running?  What are the learning objectives?
• What behaviors and principles are we trying to reinforce?  Why?

I learned a lot from the questions Dr. Womack asked that day and it has greatly influenced my approach since.  It became clear very quickly that much of what we were asking teams to do we were unable to describe “the why”.  We were either lazy in our thinking or undisciplined in our translation of requirements (leadership and business).  Either way we had not earned the right to improve.   We needed to take the time to go back and make the case for the change.

I write this post today, because while it sounds so simple and fundamental I believe that understanding and clearly articulating purpose continues to be a challenge for me and the leaders I work with.  We still get caught up in the excitement of the change, the new method or the changing business conditions and it does not take us long to lose sight of what we are trying to do in the first place.

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