Daily Kaizen

In my second life I am a writer. I think a great story can help us learn, understand, and find hope in even the impossible circumstance. On way to communicate is through metaphor, and as I reflect on work I’ve participated in of at the Palo Alto Medical Foundation, Group Health, and KVCH, I can’t help seeing the parallel in the hero’s journey and lean transformation of an organization.

The hardwork and dedication of the lean heroes at each of these organizations is the inspiration behind this blog posting. A brief aside: Several writing resources outline the hero’s journey, and to give this post context here is a brief description. “The Hero’s Journey is a pattern of narrative identified by the American scholar Joseph Campbell that appears in drama, storytelling, myth, religious ritual, and psychological development. It describes the typical adventure of the archetype known as The Hero, the person who goes out and achieves great deeds on behalf of the group, tribe, or civilization.”
Following are the stages of unfolding for the lean hero on the road to change.

“THE ORDINARY WORLD. The hero, uneasy, uncomfortable or unaware, is introduced sympathetically so the audience can identify with the situation or dilemma. Some kind of polarity in the hero’s life is pulling in different directions and causing stress.” In an organization, just as for the hero, this is where trouble is first felt. The burning platform may still be unknown, but there is a sense of danger and uncertainty of the future.

“THE CALL TO ADVENTURE. Something shakes up the situation, either from external pressures or from something rising up from deep within, so the hero must face the beginnings of change.” This is the activation of the lean journey. It may be that our competition has just leapfrogged ahead with a new product, price, or delivery we cannot match. Whatever the case, the burning platform becomes visible to the organization, and a champion arises to confront the problem and begin the process of change.

“REFUSAL OF THE CALL. The hero feels the fear of the unknown and tries to turn away from the adventure, however briefly. Alternately, another character may express the uncertainty and danger ahead.”
Lean transformation encounters resistance on several planes. It can come from within, and may be denial, or reluctance that change is even possible given what seems to be insurmountable odds. Doubt may surface, and there may be conflicting paths under consideration other than lean.

“MEETING WITH THE MENTOR. The hero comes across a seasoned traveler of the worlds who gives him or her training, equipment, or advice that will help on the journey.” Here the lean champion and followers seek knowledge and learning from other organizations that underwent the transformation. These sponsors may also seek the guidance of a sensei, or master, to offer close mentorship while on the path of lean.

“CROSSING THE THRESHOLD. At the end of Act One, the hero commits to leaving the Ordinary World and entering a new region or condition with unfamiliar rules and values.” The special world in lean is future state and when the current state is left behind and the organization enters the realm of change.

“TESTS, ALLIES AND ENEMIES. The hero is tested and sorts out allegiances in the Special World.”
This is where it gets really exciting…improvement work is initiated at all levels in the organization and confrontation with the current state (ordinary world) identifies challenges for lean sponsors to address.

“APPROACH. The hero and newfound allies prepare for the major challenge in the Special world. THE ORDEAL. Near the middle of the story, the hero enters a central space in the Special World and confronts death or faces his or her greatest fear. Out of the moment of death comes a new life.” The approach and ordeal are significant moments where the leadership and tools of lean are put to the test, and the sponsors must make a decision to continue despite resistance and challenges to lean.

“THE REWARD. The hero takes possession of the treasure won by facing death. There may be celebration, but there is also danger of losing the treasure again.” The fruits of transformation begin to be borne, but also the awareness for the necessity of continuous improvement to hold the gains. Leader standard work and frontline PCDA becomes a foundation of practice.

“THE ROAD BACK. The hero is driven to complete the adventure, leaving the Special World to be sure the treasure is brought home. Often there is clear signal that defines the urgency and danger of the mission. THE RESURRECTION. At the climax, the hero is severely tested once more on the threshold of home. He or she is purified by a last sacrifice, another moment of death and rebirth, but on a higher and more complete level. By the hero’s action, the polarities that were in conflict at the beginning are finally resolved.”
Lean becomes the operational system of the organization, the practice of lean becomes deeper, and is accepted as the routine

“RETURN WITH THE ELIXIR. The hero returns home or continues the journey, bearing some element of the treasure that has the power to transform the world as the hero has been transformed.” The champion always continues the journey in the lean world, and shares that the elixir is not something magical that instantly cures all, but is an operationalized way of thinking that allows challenges to convention and experimentation leading to improvement. Along with some plain ‘ol hard work with the will to execute.

A special thanks to the Writer’s Resource which gives an excellent description of the hero’s journey. Text in quotes above were adapted from this source.

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One of the most powerful aspects of Lean is that it teaches team members to view their processes through a new lens.  It teaches  us to understand and seek out waste and it requires us to question “why” things are done the way they are done.  Whether it is at work or living my life I have learned to see waste and thus opportunities everywhere.  One of my favorite experiences is when cross-functional teams come together and walk the process.  It does not take long for them to start asking each other “why do you do that”, because “your team needs it”, “really we have been doing that for years”; “oohhh.”

Having the ability to see waste can also be a challenge, because it can quickly lead to frustration.  The more opportunity you see the more you can become impatient with how quickly things change.  While impatience can be a good thing it can also lead to bad behavior and bad outcomes. I have seen many leaders become frustrated with their teams, because they were not able to “see the opportunities” that the leader could see.

It is important to always take the mindset that things are how they are, it is not anybody’s fault, and now how can you help coach/teach others to see the waste and improve the process?  Leaders have to realize that often for many years team members have worked very hard in often wasteful processes.  Over time unnecessary work can seem to those doing it like very useful work.  All of us confuse activity for value.  The trick is teaching people, in a constructive way to step away from the process and to question the process.

Just last week I walked a process with a team where an administrative worker had been manually entering data to support a downstream process that ceased to exist over a year prior.  The change had never made it back upstream and the activity was for nothing.  This presented a great opportunity to redeploy this effort, but also presented a very sensitive situation.  Nobody likes their work to be labeled waste nor do they want to do wasteful work. The leader did a wonderful job in handling the situation and ensuring that the outcome was constructive.  Yet, they could have chosen to be frustrated or critical thus ensuring the future waste will remain undiscovered.

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Sometimes what seems like really small and simple changes can make a huge impact.   The type of changes that team members ask “how did we ever work in the old way?”  A great example I have seen again and again in healthcare is the lack of teams being “co-located.”  The traditional ambulatory model has the “flow staff” located centrally surrounded by the exam rooms and the Providers located along the parameter in their offices.  Flow is designed so that while the Provider is seeing one patient the flow staff is “rooming” the next.  Thus, often based on the building design their paths rarely cross.  I think somehow we thought with the implementation of an EMR teams no longer had to
communicate.

As a result of this design all kinds of waste is built into the process.  The opportunities to prioritize together, problem solve, ask for help, and relay important information, etc. are lost.  Flow staff and Provider waste
incredible amounts of time looking for each other and patients are often left
repeating themselves multiple times, waiting, or not having their needs
met.

Back to small changes that make a huge difference.  I am working with a client that is working on synchronizing the process between the flow staff and the Providers and one of the elements of the change is “co-location.”  The MD’s have moved out of their offices and into the “flow area.”  The team has 5S’d and worked (through a lot of challenges) to reconfigure the space and to make room.
It is early in the change, but teams are feeling an immediate difference
and so will soon the patients.  It is easy to see the improved efficiency and to feel a growing sense of “team.”  Small changes = Big Difference!

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Last week I had a chance to catch up in the hallway with a Medical Leader I had not seen in over a year.  This conversation made me proud, because it showed me how powerful Lean Management can be if you stick with it over time.

I always liked working with this leader, because while he was always a little skeptical, but he also always showed up as a good student and would immediately take the learning and apply it in his practice.  We had some good debates.

One of the areas I often gave this leader feedback (usually during gemba walks) was his tendency to take problems away from frontline teams and managers too luickly.  He grew up in a management system that was based the premise that managements job was to solve problems so that frontline teams could do the work.  Thus, once he started to gemba he got a lot of feedback and ended up taking a lot of “to dos” many of which were missed opportunities to turn the request into a coaching opportunity.

During one of my training opportunities a Toyota Sensei once told me that the highest form of “respect for people” was allowing people to solve their own problems.  This statement stuck with me and I have often used this during training/coaching sessions.  Apparently, this statement also stuck with my friend.  In the hallway last week he said after a year of gemba he finally understood his role as a leader and what I meant when I talked about “respect for people.”   He said at first he loved the Lean approach, because he loved being in gemba, but after a while the follow-up became overwhelming to him and frustrating to the teams he worked with.  He said each time he went to gemba he felt guilty about the increasing number of problems he was not having the time to solve.

Finally, he said he had a really rough week and realized he needed to do something differently.  He asked for help from his boss.  He started to ask more
questions.  He started to trust that others can take the ownership for problems.
He told me it is fun again and he is amazed at how many people are
stepping up to the challenge.  He also told me it is really hard work to not step back into the problem solving mode and that he is only just getting a knack for it. I give this leader a lot of credit, because it would have been an easier path to go back to the traditional management approach.   I share this story, because I believe that most leaders follow a similar path.

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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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I love that my job gives me so much variety. Two weeks ago I am in the gemba in California mapping frontline Primary Care processes, and this last week I am working with the senior executives of Group Health to define the critical hoshin’s for the year. This week I am back to define the future state of Primary Care. I am working at different organizations, with different levels of structure, solving different problems; yet, what I love about Lean is that the thinking process is the same. The simplicity is what makes Lean so powerful.

By approaching all work through the Plan, Do, Check and Adjust (PDCA) cycle is incredibly powerful and transferable. It allows everyone to think and talk about their work in a consistent way and it creates a repeatable, data driven approach to improvement.

• The process always starts with the check where you focus on “grasping the current situation” and reflect on what is happening and learning’s from the prior cycle. At the frontline this may look like the huddle in the morning where the team reviews the results from the day before and identifies problems. At the value stream level this might look like the weekly stand up meeting to review demand vs. production levels and common defects across the system. At the strategic level this might look like a review of last year’s activities and a reflection on learnings.

• Next we move to the Adjust cycle. In this cycle we review the data to decide if we need to adjust to correct problems, adjust to improve processes or Act to maintain the current process. At the frontline this may look like the at the huddle in the morning where the team defined what worked well the day before and what experiments they want to run during that day. At the value stream level this might look like a gemba to check on standard work or an assignment to complete an A3 on a particular problem. At the strategic level this looks like the shaping of hypothesis for improvement for the year including defining critical goals the organization must meet.

• Next we move into the Plan cycle. At the frontline this might look like the number of patients we will see today by hour and the cycle time targets we must meet to keep up with demand. At the value stream level this might look like total cycle time the clinic must meet from door to door to keep up with demand. At the strategic level this might look like the small number of strategic improvements the organization will make over the next quarter.

• Next, we move into the Do cycle. At the frontline this is the team seeing patients. At the value stream level this is moving resources between teams to keep up with demand. At the strategic level this is implementing the future state vision through a series of kaizen events.

• Finally, the cycle continues. We are back to the Check. Where the frontline teams reviewing their visual system know that they are off from the plan and pull resources from another department. Where the value stream leaders review the plan for the week and bring temp employees in to work down the backlog. Where the senior leadership team completes their monthly check and develops a countermeasure to respond to a competitor’s new pricing. Each cycle supports the next.

Each level of the organization follows the same approach. Very powerful.

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This last week we had a fantastic time kicking off the Model Line at Palo Alto Medical Foundation (PAMF).  It was a really great team that will do really great things.  As the Model Line they are challenged with piloting not only the care
model for the organization, but also the Lean Management system.  As you might imagine a lot of questions and concerns were raised about how the work would be “spread” from one site to the next.  Spread being defined as “how do you get more than one team to do the same thing across a system?”  Or overcoming the “not invented here” mentality.

I shared with the team my confidence that they will be successful in overcoming this challenge, because they are committed to Lean Management.  My experience on this subject is that organizations often approach spread as a technical problem (standards and standard work) as opposed to a leadership opportunity (Lean management system).  While spreading standard work over time is essential to increasing the rate of improvement of an organization it will never occur or sustain without simultaneously putting in place a Management system.  The problem of spread becomes much easier to solve if leadership takes the approach that management is a process, and like any process to get a consistent outcome the process must be standardized, stable and capable.  If as leaders we would like teams to standardize and improve then we should ask no less of ourselves.

As leaders begin to define and put in place a consistent process of management it removes all kinds of waste and overburden from the system.  Management and teams begin to speak a common language and exhibit common behaviors/practices as they work across teams, sites and services.  At each level the organization is forced to clarify and define who needs to come together to do what how often?  Performance within and across sites become visible and if the system is put in place with the right incentives teams will start to become curious about what is happening beyond their own walls.   You know you are on the right track when “spread” becomes pull as opposed to push.

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Tomorrow I get to help lead the kickoff a Model Line effort in a large medical group on the West Coast.  Over the next five days we will begin mapping the current state of four large service lines and will train the team Lean principle and practices as we go.  By the end of the month we will be deeply involved in kazien.  It is very exciting

Over the last seven years I was lucky enough to participate from the beginning in a Lean transformation.  We started with point improvements, began a proof of concept transformation (Model Line) and then had the chance to coach leadership as they focused on putting in place a Lean Management system.  I was part of the
first group of internal resources that were trained in Lean.  We hired great Sensei and right from the start they put us to work leading kaizen.
It is amazing how fast time seems to have gone by and how quickly the
transformation moved.   Throughout the process it has felt like I have been holding onto the side of my chair (just the way I like it!) since I was constantly working in unfamiliar territory and learning as I went.

Flying south on an airplane I am reading through the PowerPoint slides I will be teaching over the next couple of days.  The focus of the materials is mainly Lean 101 modules including Value Stream Mapping, Steady Flow, Standard Work and Visual Management.  It has been a while since I have trained teams on the basics so I hope I am not too rusty.  Seven years ago I stepped up in front of a room and trained on similar materials. The difference now is that I have a lot of stories of my own to go along with the didactics.  Instead of talking about cars, airplanes and concepts I can talk about patients, docs and nurses and real experiences of how Lean has improved people’s lives.

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For many years I have had the dream of one day owning my own business.  I am excited to announce that day has come!  I am joining my close friends and teachers Kris and Ed as a partner in Triad Consulting. We are a small firm focused on helping organizations transform through Lean principles and practices.

In 2004 I was a graduate student at the University of Washington and somehow managed to talk my way into an internship at Group Health Cooperative.  The project I was assigned was to help Group Health select an improvement methodology and for me
the Lean journey had begun.  It has been fun to read back through the posts on the blog that chronicles my story and the
story of Lean at Group Health told from my perspective.  What started as a small project with only a small group of people evolved into a transformation across 10,000 amazing people.

I feel so very fortunate to have been given the opportunities that I have been given by a truly great organization that is full of truly great people.  Along the way many, many people have taken a chance on me and for that I am very grateful.

I plan on continuing to share my reflection and stories on the Daily Kaizen for many years to come. The story will be broadened to include many other organizations all in different places on their journey.  Connor and Erika will continue to tell their stories and the story of Group Health as the organization continues its leadership role in Lean and Healthcare in this country.

Thanks to all of you who have read along with me over the last couple of years.  The journey continues, and this will be a start of a new chapter.

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Like many organizations when things do not go as planned we often react in ways that are not constructive and lead to additional problems.  I remember a couple of years ago we joked that the firestorm always started in the executive conference room and burned downhill.  A simple question by the CEO would lead to people scrambling all over the place to try and find an answer, which quite frankly we often had no capability of providing.  Our processes were not stable, we had very few standards (no daily management) and our leaders lacked standard work (far from the gemba).  Nobody had bad intent, and everyone wanted to do the right thing for the company, but our systems were not set up to tell us if a problem really existed and if it did they did not encourage appropriate problem solving. 

Fast forward a couple of years and we still are challenged in this area, but we are much better.  The entire organization speaks a common improvement language and has common methods.  Instead of special teams of analysts being deployed to find answers our operations managers work through simple A3 thinking.   We have taken the time to define standards at each level and defined how they connect between levels.  While not perfect, we now know when a problem is occurring or about to occur (no standard, no problem).  Additionally, with leadership rounding (gemba) and standard work the escalation process has greatly improved and problems that used to have to go all the way to the top are being solved at lower levels in the organization. 

The truth is that we have a lot of variation in our management processes.  The divisions/departments that have had the discipline and taken the time to put in place the system described above are far more effective then the ones that have not.  I believe that reducing this variation is our biggest opportunity as an organization over the next few years.   As problems continue to come up you only need to watch how management responds to know where we still have work to do.

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