Daily Kaizen

I think there is little doubt that the healthcare industry is under attack.  The pressure is building. Years of exponential cost growth with marginal improvements in quality and declining value is creating a perfect storm.  Incremental improvement is no longer good enough for anyone, including those of us that work in the industry.  I would be willing to bet that ten years from now we will look back and hardly recognize the system we current work within. 

I think all of us that are working in healthcare regardless of our roles are feeling the everyday impact of this growing pressure.  Across the nation delivery systems, policy makers, insurers and consultants are searching for new ways to solve problems or create value.  Systems are banding together to form Accountable Care Organizations, we are reorganizing around Value Streams, Value Based Benefit plans are getting created to shape behaviors, large hospital systems are buying practices and consolidating the market etc.  The list goes on and on. 

The good news is that there seems to be more experimentation taking place than ever before and some ideas are gaining traction (just read Atul Gwande’s article last week in the New Yorker or my own organizations work in the Medical Home and Hospital Transitions).  The challenge is that so many things are happening all at once that our current management systems are neither disciplined nor flexible enough to effectively manage this change.  My own experience of trying to support a strategy deployment system has been one of frustration and only illustrates this challenge.  While we have made great progress every week the internal and external requirements and priorities seem to change. We often complain to each other about the need for to “deselect work,” but at the strategy level everything seems to be a “must do.”   How much of this is a leadership challenge or as I stated above a result of an industry in crisis?  I am not sure.  Without the Lean work we have done I am not sure we would still be in business.  That being said, we have not gone nearly far enough. 

Last week I discussed this topic with a senior leader who works in a large hospital system in the Seattle area that is also deeply committed to the Lean journey.  Like us they are struggling with the very same challenges and she commented that the “complexity caused by the sheer number of changes is often leading to paralysis in her organization.”   One comment she made I have reflected on often over the last couple of days, because in many ways it reflects my own experience.  She stated that five years ago if you really boiled it down as a member of the senior team they had 2-3 “make or break the company” type of decisions they needed to make each year.  Now, she feels like she is making 2-3 a month! 

Is the problem we are trying to do too much?  Or is it that we are not moving fast enough with the resources we already have?   The answer is probably both.  Overall, I am hoping that this blog posting does not sound like I am making excuses or playing the victim card.  The responsibility for managing the complexity and change listed above is mine, but luckily there are millions of others that work in this industry that will share this responsibility with me.  The Lean Management systems have helped several other industries work out of crisis, but now more than ever we need to stay committed.

Popularity: 59% [?]

I’m beginning to understand why the “Check” and “Adjust” of “PDCA” is so easy to understand, but so rarely seen as a consistent component of our management systems. Check and Adjust is nerve racking, humbling, and difficult.

The system that existed before, regardless of its ability to meet desired goals, is blown apart. The comfort of knowing what the pieces are, and how they interact, is gone. Instead, each piece is pulled apart, examined, reshaped and then left to be put back together. The skill comes in how they’re examined, and how they’re reshaped, to ultimately determine the success of them coming back together as an improved system, if one at all.

It’s at this time, when the engine no longer looks like an engine but instead just a mess of parts, that the white space is the greatest, and the management of this white space paramount.

The current experience isn’t an engine, but a management system across a value stream. As part of the check and adjust, clear priorities, measurable targets, and a defined pace of improvement have all been established for the value stream management system.

Finally, to achieve these targets, a hypothesis has been developed around the following four components being essential to focus the check and adjust on:

1) An executive group (at Tier 4) responsible for setting the targets for improvement, and checking on the management standard work (the in-process check), as well as the results, and demonstrating the behaviors expected throughout by setting a clear target, understanding actual performance, and going to the gemba to understand any deviations and engage teams (Tier 2 and 1) in countermeasures

2) An operational group (at Tier 3) responsible for making the value stream visible, defining in-control and out of control, taking the same actions described above for out of control, and managing the implementation of the management system.

3) A Pacesetter responsible for meeting the customer requirements across the valuestream daily and driving the implementation of the future state

4) A consultant group in support of the Pacesetter’s implementation plan by facilitating detailed plans to accomplish goals and shaping the thinking and behaviors of leaders and teams into the systems that are desired.

All four elements are essentially out on the table right now, processes and people pulled apart; hovering between a desire to come back together better then before, and an opposite pull to submit to the inertia of an organization that has many other uses of their time and energy, with little discernable direction on which may outweigh any other.

It is at this time that it seems the consultant’s focus and logical planning is most important. Focus to not be swayed by the multiple directions that may not be prioritized in the organization, but are clearly prioritized when juxtaposed to the lean management system and transformed value stream that is the goal.

Logical planning to coordinate leaders and teams to ensure that the changes made, and the timing that they’re put back together comes together – so that the joke of the engine being put back together except for that one mystery part, isn’t our reality. Or, maybe more realistically, that our reality isn’t an infuriating process of trial and error, searching for the sequence that brings the parts back together in a meaningful way. Neither can become our reality, as check and adjust must become a part of business as usual instead of a singular, extra effort on top of business as usual. To make this leap toward check and adjust being an ongoing norm, standard work for the check and adjust must accompany the much more defined standard work for the plan and do.

As we work toward this goal, I’m interested in your insights on coordinated check and adjust among several management system components simultaneously. How have you managed this white space? How have you ensured this phase embodies forward progress on the path of continuous improvement?

Popularity: 57% [?]

The following is a post by Chris Boone that shares his experience as an IT expert in concurrently designing process and technology.  As an organization we are getting better at integrating our technology design teams into our rapid process improvement workshops.  The results are really amazing.  Thanks to Chris…

Removing waste is all about designing processes that minimize the effort required to achieve goals and eliminate steps that don’t add any value.  Some hidden barriers to reducing waste are:  

• Focusing on making a change before fully articulating the goals being sought
• Not knowing how changes will affect upstream and down stream processes.
• Not knowing how technology can be leveraged to improve processes thereby limiting possible solutions to what is available now versus what could be available.

I have been involved in a couple RPIW’s in the last year where I was able to gain a much greater understanding about the needs of different groups of people in the context of goals that the organization was trying to achieve.  For the Avoidable Day/Avoidable Admit RPIW, IT people representing Caretraker, RMS and Claims were included in the process.  This allowed us, the IT representatives, to better understand the nuances of what people were trying to accomplish so that we could then jointly collaborate on designing solutions that allowed us to more tightly integrate business processes and system design.  The result was that we were able to offer a comprehensive technology solution that neither the IT people nor the business community would have thought possible. 

The Pre-Vist RPIW that happened this December, once again allowed IT staff to work jointly with our clinical and management staff in order to adjust our business processes and system design so that business processes and system could be designed to work together instead of working around each other.  In this RPIW, the technology team had been working with a core team and had been making site visits in order to get a feel for what was needed, but there were a number of design and process decisions that needed to be made in order for the technical team to know how complete their work. 

We came to the RPIW with a partially constructed system: some working components and some conceptual designs.  Through the RPIW process, we refined some of the web pages we were building and were able to make some infrastructure choices that were better aligned with how the organization does business as it pertains to outreach and prepared for visit work.  I left the RPIW with definitive answers about how I should finish the design and the users left with standard work that described how our system fits in with their work. 

It is important to note that we were not able to provide users with everything they wanted right out of the gate.  There are just so many hours in the day.  But there were a number of strategic decisions that were made that will be implemented in time for go-live of the new panel support tool.  Some of those decisions included:

How best to manage adding people to the diabetic population – favoring the identification of patients as candidates unless those patients are currently on the problem list.

How the system should identify and manage our birthday outreach lists.

What information should be available on the new pre-visit summary and what options should we support when making that summary available.

The December RPIW really did a good job of helping us to do concurrent planning for how things will work now and how they will work in March when panel support goes live.  The RPIW gave the IT team enough information so that we could also design for the future as we build for today.  This puts us ahead of the game when we return and expand the capabilities of the panel support tool in the future.

Popularity: 47% [?]

Happy New Year to all!  From a Lean and learning perspective I had an amazing opportunity to start the New Year off on a great path.  This week I travelled back east to St Louis with a small group of executives to the headquarters of the Barry-Wehmiller companies.  Our purpose was to study the “People Engagement Systems” that Barry-Wehmiller has successfully put in place over the last 20 years.  We were originally put in contact with Barry-Wehmiller a couple years back when we both presented at the LEI conference.  The Group Health team in the audience was very impressed with what we had heard.  While most companies on the Lean path had figured out how to connect with peoples “heads” and “hands” Barry-Wehmiller had created a system that connected with people’s “hearts.”  To give you a flavor of what I mean below is the Barry-Wehmiller guiding principle which believe me is more than just words:

• “We measure success by the way we touch the lives of people.”  “
• “We commit to a sustained leadership model that creates a culture where each of us returns home with a sense of fulfillment.”

There are many companies in this world that claim to focus on employee satisfaction and engagement.  Yet, while the intention and goodwill may be there they have never figured out how to put in place a leadership model and management system that makes these claims a reality.  I believe Barry-Whemiller in an exception and they have figured this out.  There system is very simple in concept and incredibly hard to put in place in practice.  This is because it relies on a fundamentally different model for how leadership must lead and a trust in the capability of people to do great things.  Here are a couple of examples:

• Leadership begins every conversation by asking how the people are doing.  Everything starts and ends with a conversation about how on a daily basis the organization is helping employees live more fulfilled lives.  Metrics are important, but secondary.  By focusing on the people the results will follow. 
• Senior leadership is present, active and spends the vast majority of their time in dialog with staff.  The CEO is only at the corporate office four days per month. 
• Over and over again I heard the words “don’t mandate, inspire.”  You could see this slogan in practice throughout the company.  Leadership really spends the time to make the connections for people in terms of purpose.  Everyone could tell you why what they were doing was important.  They don’t talk about “reducing waste,” but instead reduce waste by having people connect to making their jobs simpler, faster and safer.   
• They focus on “catching people doing things right.”   If you look it is not hard to find people doing this right or wrong.  The culture is created by what you emphasize

To be honest I was a little skeptical before getting on the plane to head back east.  I left truly inspired.

For those of you that are interested in learning more about Barry-Whemiller I would recommend spending some time on their website, they are incredibly transparent in describing how their management system works.

Popularity: 80% [?]