Daily Kaizen

I was recently asked to teach part of a class on lean methods to a group of eager learners. My task was to educate the group on manager’s standard work and it’s particular application in the Primary Care Medical Home implementation.  I decided it would help to set some context by first describing the elements of a lean management system. The moment I had completed writing the fourth element on the board several hands shot into the air.

 “What do you mean by “discipline”? Are you talking about punishment? Doesn’t that go against the respect for people principle?”

I was only a little surprised that the first reaction to the word discipline was a negative one. In our American culture I think this may be one of the most difficult elements of lean to embrace. Why is this? I see a few possible reasons. 

• Discipline is not sexy or dramatic. It will probably not get you a lot of attention, accolades or promotions. And this, dear readers, is veryun-American.
• Discipline is hard. And sometimes boring. And really, really hard.
• Discipline takes the long-term view of success. It believes that the day-in and day-out practices and methods of lean will pay off over time.
• Discipline requires us to walk our talk and see things through even when they get challenging (i.e. boring, hard or unpopular).  

What might it look like to apply discipline to our lean management?

• Commit. This is about trust–making a pledge and sticking with it. Whether we have committed to an annual hoshin process or a no-layoff policy we do not abandon them when circumstances change or we experience failure or frustration.  
• Practice: This is about doing things over and over again to gain skill and proficiency.  We are all lean learners and one key way we deepen our knowledge and experience of lean is to practice. We don’t stop because things are not working and we don’t stop because we have achieved a level of success. We must do things over and over again continuously incorporating our learnings into our practice.
• Follow Through. This is about doing what you said you were going to do. Always show up for scheduled gemba times. Always send the email you said you would send. Always check back when you give an assignment or expectation to an employee. Follow through is where we leverage both commitment and practice. It is how we build trust.  

Discipline is the fuel that drives the lean engine*. None of the other elements of the lean management system will amount to anything without it. You can have the hottest improvement plan there is, with the best visual controls and have all the right lingo and tools, but without the discipline you are not going to get where you want to go and need to be.  

* I highly recommend reading “Creating A Lean Culture: Tools to Sustain Lean Conversions” by David Mann

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This last week Dr. Chapman submitted a post discussing the very real gap he faces every day as a Primary Care physician having relevant measurement to manage the cost and quality of the clinic. I have been doing a lot of thinking about his post so I decided to make my comments public. This subject is one that every healthcare organization in the United States is wrestling with so hopefully others have some perspective.

In many ways at Group Health we have a real advantage as well as some added complexity in this area as compared to fee-for-Service medicine. In a fee-for-service environment the metrics for running the business are straight forward: you can measure cost per unit of service and compare to amount of revenue collected. You can also look at productivity measures like the number of units produced divided by the number of FTE. While these metrics may be easier to understand they also drive all kinds of adverse incentives (like driving up unnecessary services).

At Group Health we have both the insurance and delivery sides of the business, thus our metrics are more population based. Currently, we try and measure the total to cost of each member each month (PMPM). This measure matches our belief that if you manage care, focus on preventative medicine, etc. in the long-term it will lead to lower costs. Basically, the belief is that by improving quality it will give you the best leverage on managing long-term cost. The complexity is driven by the challenge of measuring the impact of cost driven by improved quality. For example, what is the reduced cost a healthcare provider will experience over a patient’s life time if we ensure that they have 100% of their immunizations? Organizations going down this path need to truly focus on the long-term.

I believe deeply in the theory of our business, but to be successful the theory needs to be translated into processes that team members can manage each and every day. In his post Dr. Chapman rightly points out there are several gaps we have as an organization in effectively making this translation. Most of our measures are high level or retrospective and few give us sufficient information to help manage daily decision making. It would be a powerful incentive to have measures like:

Cost per patient care gap

$ saved per day in prevented ER visits

$ saved per day in prevented hospitalizations

With the right information frontline teams can begin to ask the right questions. Why did this patient end up in the Emergency room? What could we have done different? What processes need to change? Dr. Chapman asked in his post do we have the right denominator to drive the right behaviors? I believe that we currently do not have the right measures, but we are heading on the right path, because the Care Teams are already having the right conversations. Thanks Dr. Chapman for getting them started!

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I’ve been working my way through Jim Collins’ Good to Great, and spent this afternoon wrestling with his hedgehog model of performance metrics. Collins’ hypothesis is that companies that become great performers identify, among other things, a unique metric that measures their particular economic engine. For Walgreen’s, for example, the right measure is profit per store visit, not profit per store as others might track. Discovering the right denominator drives the right behaviors in daily management.

So what about us? Is cost per member per month our unique metric? It helps drive behaviors toward affordability, which matters a lot. How about outcomes? How does PMPM move us to excellent outcomes? And how much do poor outcomes (heart attacks, strokes, hospitalizations…) drive costs?

 Would a different denominator help us to clarify behaviors and better attune our integrated system? What’s our cost per care gap, for example?

 As a primary care doctor, I have my eye on the health of my patients, which I can measure, and on being a good steward of member resources, and I can measure that too. I wish I knew how to integrate these and track them once a month. That might drive great improvement at the front lines.

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There are several reasons I found myself reading John Wooden’s “Wooden: A Lifetime of Observations and Reflection on and Off the Court” last week:

1. March Madness will conclude tonight (4/4/11), and as an avid college basketball and Pac-10 fan, it’s hard to escape mention of Mr. Wooden, and his legacy this time of year.
2. As several earlier posts have discussed, Group Health is choosing 2011 as a year to deepen our understanding of what respect for people is, and how we create a work environment that focuses on creating great people and supporting our employees to reach their highest potential as a critical means to the business and customer goals we must achieve. Of the little I knew about John Wooden before reading this book, I knew that a core element of his philosophy and practice was developing people first, and winning games / national championships second. This philosophy, and the success it brought, seemed to mesh well with where Group Health was looking to go.
3. I got married on March 26^th, and was able to do some pleasure reading on our honeymoon. Given that Mr. Wooden is also well known for his focus on family and the longevity of his marriage, I thought he might also be a good person to learn from for my personal life.

What I wasn’t expecting as I read through John Wooden’s reflections and beliefs was to have a plethora of lean principles come shining through. Although not earth shattering, this is a good reminder that there are some foundational elements to success among complex human systems – whether they are a basketball team, a health care business, or any other organization. From this perspective, it was humbling and reassuring to be reminded that lean thinking is largely not new ideas – but a system of principles and philosophies that allows organizations to maximize their people and ultimately through these people operating at their highest potential – achieve new standards in what our customers experience.

A few examples from Mr. Wooden’s book (all within 10 pages of each other in the middle of the book) that struck me as poignant to the principles and practices we strive toward as lean thinkers are:

• “Being too Competitive: Competitiveness must be focused exclusively on the process of what you are doing rather than the result of that effort (the so-called winning or losing)…Therefore, I never mentioned winning or victory to my players. I never referred to ‘beating’ an opponent. Instead I constantly urged them to strive for the self-satisfaction that always comes from knowing you did the best you could to become the best of which you are capable. That’s what I wanted: the total effort. That was the measurement I used, never the final score.”

• “Is Winning the Only Thing?: … I believe making the total effort is everything. And that’s all I ever wanted and all I ever asked from myself or my players. It’s all you should ever ask for or expect. Understand that you won’t actually ever become the best of which you are capable. That’s perfection. We can’t obtain perfection as I understand it. But we can work, and work hard, toward obtaining it.”

• “Zero National Championships: If UCLA had never won a national championship while I was coaching there, I would still have considered myself very successful because I was judging myself on other things, things I had some control over. For example, how hard am I trying to produce the very best team we can possible be? Had we not won any championships, I would have been disappointed, yes, but still a success in my own eyes. I would have had peace of mind because of the effort I put forth.”

The highest functioning lean teams and organizations I have seen, and read about all share these characteristics of John Wooden’s UCLA basketball teams: a) goals set on obtaining perfection (for the team, or the customer), not the current capabilities, knowing perfection will never be reached b) a focus on preparation and process (things that can be controlled) as a means to improve toward those goals, and the lens by which success is measured, and c) an enduring spirit that engages all team members to be creative and industrious in improvement toward maximizing individual/team capability in pursuit of perfection.

• Was John Wooden a lean sensei? 

• Are lean organizations simply learning from the success of John Wooden and UCLA basketball?

 Of course, the answer to both is no. Instead, both John Wooden and successful lean organizations have tapped into and stayed committed to fundamental truths about achieving incredible results with teams of people.

I am pleased to know that on this lean journey, guidance and wisdom can come from a wide range of sources.

Whether it’s a basketball team or a health care organization, we know long term success comes from creating a unique, authentic identity. As Group Health deepens its understanding of lean thinking and continues to develop the philosophy, principles, and tools that work for us, I hope that we’ll continue to look far and wide for this wisdom, whether it’s from the Wizard or any others, and quickly improve our mental model and processes as a result. I believe it will ultimately be this ability to learn, and rapidly improve from what we’ve learned, that will determine our success.

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