Daily Kaizen

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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I am reading a great book right now about the Revolutionary War.  In the book it discusses the different approaches taken by the American and British generals in the southern campaign.  The British had almost every advantage in terms of resources, military training, etc.  Yet, the Americans ended up winning the field and as a result the war.  Why?  The book argues that one of the most important reasons was the untraditional approach the generals took to leadership.  Unlike the British leadership who refused to share their strategy and tactics with lower level ranks the Americans focused on teaching every solider the battle plan for the day.  It was mandated by General Greene who allowed even the privates to push back on tactics (something unheard in the military of the day).  As a result, every American solider knew the reason “why” they were being asked to do something.  Thus when the British charged; for the first time in the war the militia held their ground until they got two shots off.  Why, because they knew what the entire plan and they knew standing behind them was the regulars who were ready to support them as they fell back. 

I believe there is a lot to learn from the American generals. Yet, it is a much harder approach to follow.  It requires a faith in the ability of team members, a willingness to share power (through information) and a requirement that leadership is capable of explaining and effectively promoting the reason why.  Taking the time to engage the organization in a continuous conversation about the “why” is the most powerful change management strategy that leadership can deploy.  So many organizations that skip this step end up making the improvement about the tools and methods and eventually fail. 

Each and every time I go to the gemba and stand in front of a visual system the first question I ask to the teams is “so what?”  Why is this important?  It does not take long to understand how well the connections have been made and thus judge the team’s engagement.  Can the team describe the connection of the daily improvements to improving the customer outcomes, the business outcomes and their own experience as a team member?  When the connection is effectively made it is amazing how powerful the impact can be.  One team described to me how the use of a checklist had reduced defects by 50%.  When I asked why it was important they showed me how many patients were still alive as a result.  The manager had taken the time to bring everyone into the plan.  Powerful!

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Hello everyone.  I am back after an amazing five weeks off for paternity leave.  My wife and I welcomed a healthy daughter, Aleah Fried to this world on May 24^th (and just so everyone knows the care we received at Group Health was amazing!).

I am excited to be back to work, but would be lying if I said it has been easy.  Over the last five or six years I have not needed to be very efficient at managing my time.  Each and every day I make choices that result in wasted time and efficiency, many due to the fact that I am undisciplined.  As a result, I have gotten used to working most nights and at least one day during the weekend.  Coming back to work I am committed to trying to get much of this time back so that I can spend it with my family.  More importantly, I want to be present when I am at home.   At the same time I believe that I owe it to the organization to provide as much or more value as before I left. 

I clearly have a problem that I must solve.  I must find a way to do more in less time.  In other words I need to be more efficient with the time I am at work so that less work needs to be completed at home.  So in order to understand the problem and begin to create strategies to reach this goal I need understand how I currently spend my time.  Having been out for five weeks I have a great opportunity to capture this data as well as be more deliberate about the choices I make about how I spend my time.  This is because I have a huge email backlog and much of my calendar is not yet booked by the usual 7-8 hours of meetings.  Managing emails and participating in meetings are by far the two most time consuming activities I engage in each day and are often the reason I am unable to get done my other work, which I bring home. 

•  Email: as I worked down my backlog I decided to capture some data.  What I found might not be surprising to many of you, but it became very clear to me how much time I waste each day.  On average I spend approximately 90 minutes a day reading or responding to an average of 81 daily emails.  I estimated that over 70% of emails I receive lead to no action.  Most of them are cc’s that continue needlessly or are group emails for work/teams I am no longer associated with.  I have known for a long time I am getting these unnecessary emails, but have never done something about it.  I never realized how many minutes it take to manage this work and am taking action now to get off group lists, pick up the phone, etc.
•  Meetings: I am sure everyone has participated in many meetings where at the conclusion you are unaware of why you were there and what value you added.  Often the meetings lack purpose, could have been managed more efficiently, or simply you were not the right person to participate.  Now that I am back I am starting to receive a lot of meeting notices.  More than a third so far I believe either should not happen or I am the wrong person to participate.  I have also learned that many of these meetings are being generated in response to direction I providing clients or consultants that is unclear.  Where is the past I would just go along I am going to now try and be much more disciplined about what meetings I attend and why. 

My final action is to bring back a practice that I started several years ago, but somewhere lost along the line.  When I first started doing consulting work a mentor of my recommended to me (in response to me being overwhelmed) that at the start of each week I write down the three things I need to get done that week and that the start of each day I write down the three things I must get done that day.  I would then manage my week and day in order to ensure that those things got done no matter what.  This simple system helped me stay focused and it felt good to see that I was actually making progress. 

Overall, as I have reflected, collected data and decided on actions it became clear that there is not a simple solution to being more efficient.  Time is mostly wasted in small increments that add up very quickly.  Being disciplined is the best countermeasure I can take.  And the payoff is huge!

PS—A great resource on this subject is the blog timebackmanagement.com

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Group Health had an amazing opportunity a couple of weeks ago to learn from Sensei Imai thanks to the Kaizen Institute.  Joan DeClaire a senior communication manager from Group Health Research Institute attended and wrote this blog to share her reflections.  Thanks to Joan and the folks from Kaizen Institute. 

Because Group Health Research Institute Director of Operations Helga Ding had a conflict, I got to attend a “Knowledge Forum” hosted by Group Health’s Improvement Promotion Office a few weeks ago. The guest speaker was Japanese Lean expert Masaaki Imai, founder of the Kaizen Institute and author of the first book on Lean management.

At age 81, Mr. Imai is known as “the father of continuous improvement.”  At age 55, I often feel like its rebellious stepchild. Maybe that’s why Helga pegged me for this event. I’m not the most Lean-leaning manager at the Institute. Nor am I anti-Lean. It’s just that I manage a small communications team that’s constantly chasing deadlines. Who’s got time to continuously improve? But I do continuously crave sushi, and this was an after-work event with appetizers. So I schlepped down to GHQ, hoping for wasabi and fresh tuna.

Michael Erikson, interim executive vice president of the Group Division Practice, kicked off the event with an overview of Group Health’s “Lean journey,” which began in Laboratory Services in 2004. Next, the Health Plan Division embraced Lean before it spread through Primary Care. In fact, Lean was a big part of Group Health’s success at expanding the patient-centered medical home to all 26 of it medical centers, Michael said.

Then he introduced the guest speaker, using words like “master” and “sensei” (Japanese for teacher). Wearing gray pinstripes and a dignified smile, Mr. Imai set out to describe several high-level precepts of Lean thinking.  He didn’t say a thing about visual trackers or the size of A-3 paper stock. There was not a white board or yellow sticky pad in sight. But there was something quite familiar to me about his presentation.  It reminded me of lessons in “mindfulness”—a philosophy that I’ve been studying outside of work for the past five years or so. The connection between Lean and mindfulness may be old news to many of you. But Helga asked me to share my impressions, so here are my take-aways:

• See change as a good thing. Mr. Imai explained that the word “kaizen” (used interchangeably with “continuous improvement”) comes from “kai,” which means change, and “zen,” which means good.  “The Kaizen spirit encourages thinking about how to change, rather than why it can’t be done.”
• Don’t wait for the perfect solution.  This reminds me to let go of the illusion that I can make everything flawless.  If I seek perfection, I’ll feel overwhelmed. Better to do what’s actually possible to bring about positive change right here, right now.  Said Mr. Imai, “Seek improvements right away, even if you’re only 50 percent on target.”
• Ask “why” five times. This helps get to the root cause of problems, Mr. Imai said. And, of course, I’m thinking, “Five times? That’s a lot of thinking!” But such persistence and commitment could allow me to see things as they really are. Am I really ready for such clarity on the job? Are my co-workers? What about our bosses? “Wisdom comes from facing hardship,” said Mr. Imai.
• When you solve one problem, you will see ten more.  And this is a good thing because….?  Oh, right.  Because it might actually help me find more solutions!
• Use Lean to go green. “Because Lean uses less space, less equipment, fewer people, and less time to produce maximum output, it’s a way to be nice to the good old earth,” said Mr. Imai. It may also lead to kindness for my good old staff. “If you don’t want to work weekends and holidays to meet your goals, do Kaizen,” he said.  Many Americans don’t appreciate this, he added.  They believe we need more money, more time, more resources, and more staff to solve our problems. “If you have no money, use your brain,” said Mr. Imai. “And if you have no brain, sweat it out!”
• Be present with your co-workers and staff. The Leanophiles say, “Go to the Gemba,”—a Japanese word that means “the real place.” “The most sacred place in management is the Gemba,” said Mr. Imai. “This is where value is created.” In fact, Japanese police detectives call the crime scene a “Gemba.” Mr. Imai asked, “Did you ever see Colombo sitting at his desk waiting for a report?”  Of course not. He needed to see the reality of the work before him with his own eyes.
• Practice Lean every day. “Kaizen is everyday improvement, everybody improvement, everywhere improvement,” Mr. Imai said. Everything in the Gemba deteriorates if you don’t pay attention, he added. Even sustaining the current status requires effort.  But if you pay attention daily, your efforts naturally become part of long-term improvement.
• “Seek the wisdom of ten people rather than the knowledge of one.” That was one of my favorite quotes. I suppose everybody who accepts Lean management finds their own reason to value it. And maybe if we share our perspectives with each other, we’ll all become a little wiser.

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A couple of years ago I got a chance to spend a week with a Japanese Sensei at a medium size manufacturing company in the Midwest. The company was running a large scale kaizen blitz with a several events with different purposes taking place simultaneously. This included rapid improvement of current processes, a set of large scale simulations testing the entire supply chain and two different 3P events on new products. It was quite an experience and very impressive how the entire organization was able to organize and support such large scale improvement.

One of the most important learning’s I took from the experience was how effective rapid prototyping and hands on experimenting could be in an event. The Sensei went from team to team throughout the event and kept telling us to stop brainstorming and start “trystorming (actual simulation or creation of the idea).” This meant putting away the flip charts and sticky notes and getting out on the floor and getting our hands dirty. Having the 3D, tangible “mock-ups” allowed the teams to quickly understand each others ideas and iteratively improve the solution in a way that would not be possible on paper. Simulations became real and many of the bugs of standard work could be worked out in advance prior to a “down stream” implementation.

Being a service industry it has been difficult to find opportunities to take advantage of rapid prototyping and “trystorming” techniques since the customer is “onstage” and directly interacting with the processes. Yet, at the same time it is clear that the complex environments that care team work in are very difficult to understand and improve on paper. How else, besides prototyping and simulation can you understand the experience and feelings of the customer as they interact with the product?

As I have mentioned in several postings in the past over the next couple of months we are going to be mocking up an entire “clinic of the future” and testing breakthrough improvements and design. This will represent a large investment by the organization and will allow teams to “tryout” many solutions to each problem. We will have actual patients participating in the process and test based on real life situations. I believe over time we will learn that approaching improvement in this way is well worth the additional investment.

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Late this last Friday night I spent some time with two of my favorite leaders sitting in an empty warehouse reflecting on the work we had completed over the week. The three of us were exhausted having just completed a five day rapid improvement event with over sixty people and six competing teams that had participated. Quite literally, the teams had come together to redesign the future Ambulatory experience for our Group Practice. What they designed and will soon begin to implement will significantly improve the quality and experience of the care process.

There have been many similar Friday nights that the three of had shared over the last couple of years. If you have ever experienced one of these types of events you know the magical feeling that is earned throughout the week. Not because of the new processes and systems that the teams design. You basically know when given common methods and principles what they will produce. The magic comes from the way the team comes together and works together in the spirit of improvement. Having led so many of these events you would think I would get used to this feeling by now, but that is never the case. Each and every time I experience one of these events I leave recharged and with an incredible respect for the experience, capability, goodwill and good intent that each and every person I work with is willing to contribute to the organization. We just need to be willing to ask.

As one leader put it for many years we have asked these people to give us their hands, sometimes we have them use their heads, but nothing compares to when we have them engage with their hearts.

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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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So how should one think about inventory in a service organization? I am often in meetings where I hear leaders say “well I can see why reducing inventory is manufacturing is important, but we see patients and it just not the same.” Is this really true?

A couple of years ago I had a chance to spend a week with Japanese sensei during a kazien blitz at a large office products manufacturing company. All day he hammered the local managers to try and double their inventory turns even when they said it was not possible. One of the managers produced some reports that showed that reducing inventory one one of the lines was only going to save the company a couple of thousand dollars a year. Before he could share this with the Sensei (which would have been a big mistake) the local Lean champion told the leader the financial gains from reducing inventory where not nearly as important as the improvements associated with quality. This comment stuck with me.

Later that evening at dinner the Sensei talked a lot about the evils of inventory and how it led to sloppy practice. Inventory allows teams to smooth over problems and creates a buffer from variation in demand and production. By reducing or eliminating inventory it forces managers to deal with problems when they happen and even more importantly it forces the business to become proactive. Without inventory a team can no longer run their business by looking in the rear view mirror, the must instead anticipate the needs of the customer and plan.

From a healthcare perspective there are many examples of where if we had less or no inventory we would be far more effective. If we reduced our pharmacy and medical supplies down to 1-2 days on hand it would no doubt free up some capital. Yet, far more importantly it would force our managers to come together in order to anticipate our patients demands in ways far more proactive then we do today. We would need to know what patients are coming into our medical centers and what they need. It would call out how our schedules and hour of operation create huge amounts of waste due to variation.

For our medical practices building patient backlogs could be looked at as an inventory to buffer our supply of appointments and services from the changes in demand. If we move away from having backlogs and reduced the inventory of appointments not only would be have a better experience the chances are the quality of clinical outcomes would improve. We know patients with unmet care needs (inventory) have expensive outcomes and a lower quality of life. Additionally creating a system that responds in real time to patient demands would also help us understand how our own internal practices are driving huge amounts of waste.

For all of the reasons listed above I believe inventory reduction has a place in a healthcare organization.

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