The same type of paralysis that often occurs at the team process level also occurs within the strategic planning process. Teams spend a lot of energy and time trying to assess which improvements will have the largest impact, opportunity costs, etc. Huge amount of energy are spent scoring, prioritizing, re-prioritizing strategies. While this type of assessment can be valuable it is often overdone. I believe most of the time it is more advantages to pick a focus area, set goals and then begin. It does not take long to begin to see how the system is connected and improvements can easily be extended from one area to the next.

Leo Tolstoy famously wrote – “All happy families resemble one another, but each unhappy family is unhappy in it’s own way” (Anna Karenina – page 1)

This to is true in business, as well as any process in which consistent, high quality outcomes are required: all successful businesses / processes resemble one another, while each unsuccessful business / process is unsuccessful in its own way.

Group Health is learning this lesson once again as we take on a process to dramatically reduce the variation that enters the production system of our health plan.

A pilot is beginning in the initial three rule areas below, to apply a standard process and scoring criteria evaluating new opportunities against a standard, based on the strategic priorities of the organization.

• New Benefits / New Plan Designs
• Provider Contracts
• Authorization Rules

Designing the process and scoring criteria has been challenging, with leaders working long and hard on a process that’s applicable across all areas of the organization. This complete, the biggest challenge ahead will be changing ingrained behaviors.

In the past, a plethora of governing bodies have made decisions on various components of our health plan production system. These groups attempt to make a decision that takes into consideration all impacts to the organization. However, each group has limited visibility to the entire value stream that their decision impacts. As a result, there are unfortunately plenty of examples of decisions made with the best intentions, but which cause significant downstream defects. As a result, we have the waste of band-aids on band-aids, as we administer to these new defects while still addressing previous ones.

Within and between many downstream functional areas, the unfortunate equation resulting from the current variation entering our system is:

Complexity + rework + extra movement =

waste in process = cost and diminished respect for people.

Rightly so, these are unhappy families.

The challenge in changing behavior comes from the fact that leaders and existing governing bodies will be required to use a process that will feel like “extra” to them, but will actually result in much less for the organization as a whole. Further, they will be required to value the input from a scoring criteria that may give an answer that’s different than what they’re used to, or what they’d like to do.

Tolstoy’s quote comes to mind, as there’s an underlying principle always at play with cross-functional process and management system change: a discipline by each individual, small team, leadership group, to stay committed to something that they know intellectually is better, but emotionally feels worse – until it becomes habit. Successful processes resemble each other through commitment to this principle.

This is true with Hoshin Kanri, where:

• Commitment to say no to many improvement ideas (including many individual’s “pet projects”) to ensure the critical few get completed successfully must occur
• The divisional rivalries must take a back seat to enterprise success
• Commitment to a single process must trump what can feel like a faster, more efficient way to get divisional improvement done

This is true with 3P.

This is true with a management system and manager standard work.

It seems the organization that keeps the key principles of lean front of mind, recognizing the realities of discipline and patience will be needed for all elements of the system, and therefore shouldn’t be run from, is the organization that makes lean thinking their own thinking, and who moves from attempting to emulate the Toyota production system, to living their own production system every minute, every hour, every day.

The leaders of Group Health have struggled in the past, but they keep trying, which is more than half the fight. I look forward to this new process for health plan production rules being the stepping stone for this discipline to be followed by more and more of our leaders, so their actions begin to resemble each other – and our processes are happier.

So why is it so difficult to set a standard? Often leadership in a professional environment does not want to declare an expectation for what success looks like. This often has to do with the lack of evidence to show the cause and effect relationship between the process and the outcome; or the focus on perfection as opposed to improvement. Leadership is uncomfortable making anything binary since it may force an uncomfortable conversation.

I always push an aggressive approach in terms of standard setting. I steer my clients to bring science and intuition into the calculus of setting the standard, and I push to bring the voice of the business and customer into the process. Yet, if there is incomplete information I believe the right approach is to still set the standard even if it is not backed by evidence or in other word is might not turn out to be accurate. Why? By setting the standard, even if it is “wrong” it creates the basis for the “right” conversation. Teams are forced to think about what is the right way to define and then achieve the outcome. If this is done in a constructive way the team/organization can begin to put in place the processes that will allow them to be successful. This will create a venue to address variation and talk about best practices. In other words, setting the standard is the right first step, even if the standard must change once we understand more.

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.

On a much smaller scale, a great innovation is emerging from the adversity of recent financial outcomes at Group Health: a process to provide a line of site from our Hoshin goals to a quantitative gap between target and actual for key organizational drivers that illuminates the need for improvement, and serves as the measuring stick throughout implementation.

This opportunity arises from the work of Mike De Luca and his team in the Delivery System Finance consultancy, who have been guiding the organization through a systematic root cause analysis to identify causes of abnormal expenses. This process has brought a calm, systematic, fact-based method to what had the potential to turn into fire fighting actions. From this approach the organization has learned that there is no one culprit in the current situation, but instead many process-based causes or drivers.

Specific to our lean journey, the organization has also learned something that has the potential to greatly increase lean improvement – a systematic approach to drill down from strategy to measurable targets, creating the opportunity to apply this thinking and process as a standard foundation for improvement, versus the optional outcome of improvement that it is now. Lean, finance, and others have known about this problem for some time, but the finance and lean consulting functions are still figuring out how to partner in supporting operational leaders toward more focused improvement.

The standard process created by Mike and his team, and the Toyota Kata concept of the “Target Condition” (describing both the target measure and a description of the desired process to achieve this target), seems to provide the framework for lean and finance consultation to merge into a shared cross functional process, greatly enhancing the way by which the organization does improvement.

An example of how this could play out:

• Operational leaders, with consultation from lean and finance use a standard process (based on above) to drill down to key drivers from yearly Hoshin focus area goals.
• From these key drivers, targets are set, as well as the process description to consistently meet those drivers forming the target condition.
• A quick assessment is done to identify the gap between the target condition and the current state (does the gap require transformational or incremental improvement?).
• If transformational, improvement work is built toward achievement of target condition (contracting, method chosen, etc).
• If incremental, connect the target condition to the Daily Management Systems of front line teams, putting the team in position to use their lean tools and skill to continuously improve toward it.
  • Note: Although the focus here is on key cost drivers – it’s of equal importance that all teams experience all the focus area goals becoming meaningful at the front line (not just those involved in key cost drivers). For example:  the lab supervisor at any clinic should clearly understand how to identify and drive daily improvement in line with the affordability target even though they won’t see clear evidence of their impact on the key drivers of inpatient days.

• For both transformational and incremental, targets are added to the linked management system to ensure leader standard work continues to pace improvement on the gap.

The opportunity for our consultancies is to take a process that we have successfully applied to specific situations and apply it more broadly. We can help the organization translate Hoshin goals into specific improvement activities at the operational level. We can do this by improving our own consulting standard work to include cross-functional and shared consultation. From this improved process will come the opportunity for two consultancies to find a harmonious partnership that greatly increases our value to the client—the operational and strategic leaders of this organization. And most importantly it will help us to deliver increased value to our patients – through focused, data based improvements.

I continue to be encouraged by our organization’s ability to turn performance gaps into opportunities to learn, living out the phrase “problems are gold”. What other improvement opportunities on the lean journey are emerging from problems at Group Health and / or other organizations? Help us learn from your experiences too.

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.

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!

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.

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….

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?