Daily Kaizen

This post was written by Rupal Badani, an inspiring frontline physician leader at Palo Alto Medical Foundation.  She and the organization are starting some really exciting Lean transformation work and we are just trying to keep up.  Love it…

Of all the errands on our weekend to do list, my least favorite is grocery shopping. In fact, over the last 10 years, I have tried to go into the grocery store as seldom as possible. When I did, I felt lost – often searching for items, backtracking to aisles I had already walked down, and invariably forgetting something I needed.  Luckly,
my husband finds trips to the store enjoyable.
But, there was a recent stretch when circumstances led to me having to be the one to go to the store several times in a row. To my surprise, I found that the more I did it, the less averse I was to going back. And each time, I got a little better. It helped that all the Safeways near us are “standard” in their layout. So anywhere I go, the store seems surprisingly familiar. Armed with a pre-set list, ample time and set goals, I can actually do the trip efficiently, without wasted effort or errors,  and at the end of it all, feel like I accomplished something good for myself and my family. The errand that was fraught with inefficiency, frustration and stress, was now tolerable (at times, dare I say? enjoyable). The difference? Once I learned how to shop in flow, everything changed.

The same applies at work. In May, I had the pleasure of visiting Virginia Mason to
learn about LEAN and flow. After that trip, we began to pilot flow in the pediatrics department in Fremont. We started small. Just me and my medical assistant.
She became my flow manager – in charge of making sure we were staying on track,
smoothing the day and teeing up the work for me to do between patients. We
learned a lot.

We learned that I was doing a lot of work in the exam room that she could do. We
learned that if we huddled each morning, we could avoid many pitfalls (or, as
we like to call them – flowbusters!). We learned that agenda setting with every
patient everytime helps keep the team on track and meet the patient’s needs. We
learned that we needed to formalize the role of the RN in our departments and
officially bring together the entire care team (front desk patient service representative, medical assistant, nurse, physician) to work towards this goal
because staying in flow is a team effort. We learned sitting together facilitated easy communication and reduced frustration. On a personal note, I learned that though I still occasionally need a private space, it is seldom and not nearly as often as I thought I would.

In August we invited 3 additional medical assistant-physician teams to participate
in designing the role of the flow manager. Our 4 week pilot ended last week.
Feedback has been mostly positive and we are starting to get some interest from
other members in the department. Chart closure is improving. Medical
assistant-physician communication is improving. Everyone in the pilot sees the
efficiencies gained by working in this manner. None of the piloting physicians
wants to leave the workstation to return permanently to their office.

We still have a lot of questions with regards to spread across departments and
sites. We presented our initial findings to the model line team this week and
will be working to design and pilot this in the other primary care departments
next month. But I can tell you there have been several instances during the
pilot where I left work, with all my work done, before my MA (whose day ends 30
min after my last patient leaves). In fact, it has become a bit of a friendly
contest to see who can leave first! My workday, once fraught with stress,
frustration and inefficiency, is now enjoyable, efficient and with the waste
removed, i get to do what I like best – spend time with my patients. As with
shopping for groceries, once I learned to work in flow, everything changed.

Now if I can just figure out how to implement a two-bin kanban in my pantry….

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Background:

We take down paper trophies of past work – future state visions, consulting plans, and the other remnants of a job whose primary output ends up on flipcharts and Visio’s lost to the recycling bin, or the Bermuda Triangle that is our G:drive. It’s painful to let go of the few tangible outputs of our work!

We remove bike race numbers, family photos, and other reminders of life outside of work – furthering the hurt.

Our space is becoming anyone’s space, so that it can become the team’s space. It is becoming flexible and dynamic, to allow easy transformation to meet the needs of an ever morphing consulting group.
We are leading by example, applying lean principles to our own space, partnering with our facilities colleagues in hopes that the outcome will be a model for a paradigm shift away from 1 worker = 1 cube/office.

As consultants, we often spend our time in the gemba, as close to the work and the culture of our clients as we can. As a result, we don’t regularly inhabit our personal desks. This is not unusual. Administrative managers across the organization request more space, yet the people who manage our facilities often see vacant work spaces. Unless we change our use of space, we’ll need to rent more: a costly waste; and not addressing root cause.

As we leap into this new world, we are filled with excitement about working in a new way, and modeling a space improvement methodology we hope will spread across the organization. However, experiencing this change first hand, is a strong reminder of the emotional component involved in any change – something that’s so easy to lose sight of as the consultant, who (until now) could leave an engagement, and clients swamped with change, and return to their own, unchanged, desk.

Current State

We gathered requirements and data from our team, and from others who use or walk through our space.

• 26% utilization rate
• 24 spaces with file cabinets, shelves and flipper cabinets to accumulate inventory, but not enough wall space or team meeting space.
• We took over a nearby conference room, and had overlapping visual systems in some situations.

Target

1- Improved use of space

• 50% reduction in individual workstations
• 100% improvement in utilization rate
• 30% reduction in footprint

2- Model the process for future use:

• Partner with Facilities (CBRE) as we complete the improvement, ourselves
• Provide a toolkit to support the behaviors we’ve demonstrated
• Coach them in their first application.

Root cause

Our space was set up with:

• One work station per employee– even if people are off site for months.
• For each work station, two pedestal files and two shelves on the wall.
• Manager has an office removed from the team.

This provided space for individual work but not for visual management, team collaboration or confidential conversations. It was also not flexible to our changing work needs; any revision requires a work order, and is expensive.

Countermeasure

We engaged the team in reviewing the data and had a future space visioning session during one of our regular team meetings:

• Three breakout groups organized by type of user (deployed, core, large workteam project, analytical and creative)
• 40 minutes to create 2 versions of future state: One with minimal cost using current layout and one with “blue sky” using new equipment and moving Action Office walls.
• Targets were set to increase utilization to at least 50% and reduce supplies and equipment. In “blue sky” version, added target of reducing space by 30%.
• Once teams presented their visions, we took the best qualities of each and combined into one version that team agreed on and proceeded with plan to mock up and test.

Implementation Plan

In collaboration with CBRE, we then developed a budget for carpentry, equipment and furniture to build out the new space. Prior to the actual build, we will use one of the existing cubes for mock up and testing of key elements.

 What’s Next

Mock up will continue through middle of November and we will collect feedback and data.

We will complete the space redesign by the end of December and will begin additional feedback and data collection as well as a PDCA plan at that time.

We look forward to sharing what we learn. In the meantime, what consultant team space redesigns have you been a part of? What did you learn?

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