Lean Healthcare Exchange

After finding out my flight had been delayed, I took advantage of the opportunity to stop at one my favorite eating establishments. It was too late for lunch but too early for dinner. Nevertheless, the establishment was unusually crowded. Patrons queued at the hostess station, servers queued at the portal between the kitchen and dining area, advocating for their orders, while recently seated patrons waited to have their orders taken. The scene was nothing less than chaotic. Patrons began losing their tempers and this only added to the chaos as the harried staff responded to the frustrated requests. Eventually, what occurred could only be described as a total service breakdown and the manager was summoned from a back office.

It was amazing to me how quickly the manager was able to restore order. With a very methodical approach, she began directing the team to alleviate the bottle-necks in the process from the back of the line to the entry point. I began to observe her correct subtle deviations from standard process that had been abandoned in the chaos. Her actions were focused, directed, and confident. It was clear, that she had been here before and knew exactly what was required. This seemed to have a calming effect on both the staff and the patrons. It was a magnificent example of service recovery.

Naturally, as both a lean healthcare coach and as a life-long and avid student of human behavior the opportunity to observe this left me with a lot to ponder. Within nearly all healthcare institutions there are completely analogous breakdowns and recoveries that occur on a regular basis. This is especially true in services that encounter significant variability in demand. The two questions I was left pondering were: 1.) Why did it take a service breakdown to pull the manager from the back-office? 2.) Why was the manager able to restore order so quickly but the team could not? They are a lot of contributing factors that could be considered. I would propose that the primary concept for consideration in this case is the Andon.

So what’s an Andon? In the Toyota Production System (TPS) an andon is an indicator of status. This indicator is usually visual, at times audible, and is used to prevent a breakdown in process. These are often associated with highly automated processes but most definitely have their place in a lean healthcare setting. In fact, the essential concepts associated with andons are not new to healthcare and, collectively, are often referred to as a system of thresholds, triggers, and responses. So let’s apply the andon concept to the service breakdown described above and use the example to translate the concept to healthcare.

The first concept associated with the andon is that of a threshold. This is some visual indicator that helps the team to understand that a potential problem exists. In our case study above, the andon was a complaint reaching the manager’s office. Not the best possible andon, but an andon. In healthcare, one example of a threshold associated with an andon may be the number of patients within a waiting or service area; where an exceeded threshold serves as an indicator of abnormally high volume. The idea is to make this visual to the team to drive a change in behavior.  This leads to the second concept associated with andons, the trigger.

Who has the authority to pull the trigger? For the andon to be fully functional, authority to pull the trigger must reside in the individual(s) best positioned to observe that the threshold has been exceeded. In many healthcare institutions, as in the case study above, the ability to pull the trigger lies exclusively with the manager. In our case above, only the manager had the authority to pull the trigger; to initiate a change in directed action. The down-side to this was that the team floundered until she was roused from her office by the complaint(s). Managing under these circumstances becomes habitual fire-fighting. Implementing a well designed system of andons removes the manager from the fire-fighting role into a coach and resource allocator role. This leads us to the final concept associated with andons, the response.

Once the trigger has been pulled, proactively and in advance of service failure, a systematic and well defined set of actions are executed in response to the trigger to prevent service failure. In our case study, the manager’s approach to service recovery was focused, directed, and confident. It was clear, that she had been here before and knew exactly what was required. However, the team did not have a common understanding of her method and, basically, just followed her lead. Sound familiar?  After-all wasn’t it her experience that landed her in the manager role? The success of her actions in restoring service, however, is not unique. They are, in fact, possible to duplicate, document, and coach. It is, often, the fundamental failure to duplicate (test), document, and coach that inhibits the team from being able to proactively anticipate and course correct.

Returning to the original questions my experience left me to ponder: 1.) Why did it take a service breakdown to pull the manager from the back-office? 2.) Why was the manager able to restore order so quickly but the team could not? Consider the following:

• Andons are informal and undocumented versus andons are well defined, documented, trained, coached and evaluated on an ongoing basis.
• Thresholds are intangible and not easily identified versus thresholds are defined and easily observed.
• Triggers are informal, not clearly visible and only invoked by management versus triggers are defined and visible with authority delegated to resources best positioned in the service process to observe and invoke.
• Thresholds and triggers predict and prevent service failure versus thresholds and triggers are in response to service failure.
• Responses are informal, undocumented, understood by few versus responses are well defined, documented, trained, coached and evaluated (tested) on an ongoing basis.

The above list is not intended to be exhaustive, but rather, thought provoking. If the experience described in the case study above is frequently analogous to experiences within your department, a well designed and implemented system of andons may serve to empower the team to course correct independently while simultaneously transitioning managers out of the fire-fighter role and into a coach / resource allocator role. 

This week’s blog was written by Bradley Schultz, a director and consultant for HPP. Before joining HPP, Bradley was serving as Vice President of Operations & Quality for Infinity Resources Inc. where he pioneered the application of Lean, Six-Sigma, Work-Out™, and CAP (Change Acceleration Process) in the retail market sector. Bradley’s educational background includes: a Bachelor of Science degree in Business Administration from Cardinal Stritch University in Milwaukee, Post Graduate Certification in Quality Engineering from Milwaukee School of Engineering, a Master of Arts degree in Business Administration from Marquette University in Milwaukee, Six-Sigma Master Black Belt Certification from General Electric, and Front-Line Leadership Development Certification from Achieve Global.

This is the third and final installment of a three-part series on strategies to stop upward delegation.  In many healthcare institutions there are managers whose daily work looks more like that of a supervisor.  You will also find senior executives whose daily work is less focused on strategy deployment and more focused on resolving operational issues.  Most healthcare leaders are interested in breaking this trend — however, few know how. 

Part One of this series defined a strong prescription for stopping the process of upward delegation using three key concepts of the Toyota Production System (TPS, or Lean).  The three key concepts included the appropriate deployment of Visual Management, Leadership Standard Work and A3 (Root Cause) problem solving.  Part One further demonstrated how a well designed Visual Management system can focus the front-line team’s efforts on those elements of process and those behaviors upon which successful outcomes depend.  In Part Two, the concept of Leadership Standard Work was introduced, illustrating its ability to drive process definition, disciplined adherence to process and daily accountability.  Remember, outcomes cannot be separated from the processes designed to deliver them.  When there is less than disciplined adherence to well defined process, then the outcome is, simply, a matter of chance.

This final installment of the series is focused on A3 deployment.  This is not a how-to guide on the ten-step problem solving process but rather a guide to getting A3 problem solving to occur spontaneously within the organization and in accordance with Rule 4 of the Rules-In-Use¹.

Rule 4 states that problem solving occurs: 1.) closest to the problem, 2.) by those who actually do the work, 3.) using scientific method, and 4.) supported by a coach.  Reflect for a moment on how problem solving occurs in your organization — does it meet these conditions?  I have often found that it does not.  Worse, I have often found that the ability to work around problems is highly valued and often a consideration in the promotion process, cementing this behavior into the organization’s culture.  We may get through the immediate moment, but the same issues recur over and over as the firefighting continues on.  When processes are characterized by many workarounds, outcomes are no longer predictable, but rather simply, a matter of chance. This creates many small problems that evolve into bigger problems as customers demand higher standards of performance and care. These become the primary source of upward delegation.

Deployment of A3 problem solving fell third in the lineup of this series for a reason.  Specifically, a solid visual management system and process focused Leadership Standard Work are enablers of A3 deployment.  In Lean Healthcare we learn to recognize three categories of problems:  1.) a standard does not exist, 2.) performance fails to meet the standard, and 3.) the standard needs to be tightened.  With these in mind, the Visual Management system becomes a powerful tool in driving A3 problem solving.  Challenge the team to solve the department or unit’s top three issues (performance does not meet standard) using A3 problem solving.  If all metrics meet standards, then, which ones can be tightened?

Leadership Standard Work also identifies opportunities for root-cause problem solving.  In simplest terms, Leadership Standard Work is a checklist of leadership activities to be performed on a daily, weekly and monthly basis.  When Leadership Standard Work is well defined and process focused, it becomes exceptionally effective because it drives process definition, disciplined adherence to process, and daily accountability.  Where does your Leadership Standard Work indicate less–than-disciplined adherence to process?  The answers to this question are opportunities for A3 deployment.  Deviation from established process is often a leading indicator that the process is not capable of yielding its entitlements and a network of workarounds is forming.  Again, challenge the team to solve these issues using the A3 method.

These three strategies combined — Visual Management, Leadership Standard Work, and A3 deployment — are very capable of stopping upward delegation and reversing the direction of strategy deployment.  To maximize the utility of these strategies they must become natural for the organization.  Initially, we have to challenge the team at each of the contact points described above.  This is an essential element of a pathway that leads to empowerment.  By issuing the challenge, we let the team know not only is it OK to surface and resolve problems, it is expected.  For this type of empowerment to thrive we must also create a blame-free environment.  When systems thinking and root-cause problem solving replace blaming and workarounds, the results have significant impact on outcomes.  When viewed from the outside, these can appear time consuming and daunting.  However, organizations that have adopted Lean Healthcare understand that there are ways to implement these strategies in the current stream of work.  When embraced, this approach to work becomes the way we work as opposed to incremental work.  In a Lean Healthcare environment, mid-level managers become coaches and resource allocators instead of firefighters, allowing executive leadership to focus more clearly on strategy deployment and positioning the organization to meet tomorrow’s competitive, economic and technological opportunities and challenges. 

¹Steven Spear, Decoding the DNA of the Toyota Production System. Harvard Business Review, 1999.

This week’s blog was written by Bradley Schultz, a director and consultant for HPP. Before joining HPP, Bradley was serving as Vice President of Operations & Quality for Infinity Resources Inc. where he pioneered the application of Lean, Six-Sigma, Work-Out™, and CAP (Change Acceleration Process) in the retail market sector. Bradley began his career in manufacturing with GE Healthcare and was working as a Manufacturing/Quality Engineer when GE adopted the Six-Sigma methodology from Motorola. In 1995, GE Healthcare began providing consulting services based upon these tools to its customers through its Performance Solutions business unit, pioneering the application of Six-Sigma in healthcare. Bradley joined Performance Solutions in 1996 during its infancy and remained with the business unit for seven years. Bradley’s educational background includes: a Bachelor of Science degree in Business Administration from Cardinal Stritch University in Milwaukee, Post Graduate Certification in Quality Engineering from Milwaukee School of Engineering, a Master of Arts degree in Business Administration from Marquette University in Milwaukee, Six-Sigma Master Black Belt Certification from General Electric, and Front-Line Leadership Development Certification from Achieve Global.

This is part-two of a three-part series on developing strategies to stop upward delegation.   In many healthcare institutions across the country there are Managers whose daily work looks more like that of a Supervisor.  You will also find Senior Executives whose daily work is less focused on strategy deployment and more focused on resolving operational issues.  Most healthcare leaders are interested in breaking this trend, fewer know how.  Part-one of this series defined a strong prescription for stopping the process of upward delegation using three key concepts of the Toyota Production System (TPS or Lean).  The three key concepts included the appropriate deployment of:  Visual Management, Leadership Standard Work and A3 (Root Cause) problem solving. 

Part-one further illustrated the fact that outcomes cannot be separated from the processes designed to deliver them.  When processes are characterized by many “workarounds” outcomes are no longer predictable but, rather simply, a matter of chance.  This creates many small problems that evolve into bigger problems as customers demand higher standards of performance and care.  These become the sources of upward delegation.  By implementing a visual management system, care delivery teams begin to build a greater awareness of the impact of specific behaviors on outcomes.  Once identified, these behaviors can be managed on a daily basis.  Refer to Stopping Upward Delegation – Part 1 Visual Management, September 2009 for further detail on leveraging visual management.  The focus of Part-two is Leadership Standard Work.

Leadership Standard Work has been described as the “engine of lean” and as the “highest leverage tool in the lean management system” 1. Leadership Standard Work is based on the idea that all work should be “specified for content, sequence, timing, location and outcome” 2. This concept extends to include the work of leadership at all levels of the organization.  In simplest terms, Leadership Standard Work is a check-list of leadership activities to be performed on a daily, weekly and monthly basis.  What makes this tool exceptionally effective is that, when well defined, Leadership Standard Work drives process definition, disciplined adherence to process and daily accountability.  Remember, outcomes cannot be separated from the processes designed to deliver them.  When there is less than disciplined adherence to well defined process, then the outcome is, simply, a matter of chance.  This is a key difference between Lean Healthcare and typical Management by Objective (MBO) philosophies.  In an MBO context, if a bad process yields a good outcome…it’s a good thing.  In a Lean Healthcare environment, it means you got really lucky or worked really hard (excess processing waste) to overcome the obstacles of a bad process.  In Lean, the methods are equally important as the results.

Beyond being, simply, a checklist of leadership activities to be performed on a daily, weekly and monthly basis, Leadership Standard Work has three other key characteristics.  First, it is designed and built from the bottom to the top…not top down.  It must begin with managing the process.  Second, it has interlocking and layered accountability built into it.  This means that a portion of mid-level management’s Leadership Standard Work includes verifying functional adherence to front-line Leadership Standard Work.  This is not a process of micro-management.  Just as a well designed visual management system creates a line-of-sight between strategic imperatives and the specific behaviors necessary for their accomplishment; Leadership Standard Work creates a line-of-sight between those behaviors and the results.  Finally, it is dynamic.  As problem solving activities yield process improvements, Leadership Standard Work is modified to support these improvements.  New process in healthcare, typically, means new behaviors.  This should translate into new behavior based process metrics on the visual management system and updating Leadership Standard Work to drive disciplined process adherence.  These can and should be performed, very simply, within the natural stream of work.

If the connection between the behavior and the outcome is well understood and if it is tracked visually in a very simple way, no team member wants to be responsible for driving a miss by not performing to standard.  Performance misses become an opportunity for root cause problem solving, thereby reducing the number of “workarounds” and instilling both accountability and a disciplined adherence to process.  Process definition, disciplined adherence to process and daily accountability are further enhanced through the implementation of Leadership Standard Work.  Implementation of a well designed visual management system represents the beginning of the team’s journey into self-facilitation and begins to slow the rate of upward delegation.  Implementation of well designed Leadership Standard Work represents further commitment to self-facilitation and further slows the rate of upward delegation.  Together, these create a very close association and closed circuit line-of-sight between strategic imperatives, the behaviors necessary for their accomplishment and results.

Endnotes:
1.) See David Mann, Creating A Lean Culture; Tools To Sustain Lean Conversions.  Productivity Press, 2005.
2.) See Steven Spear, Decoding the DNA of the Toyota Production System. Harvard Business Review, 1999.

This week’s blog was written by Bradley Schultz, a director and consultant for HPP. Before joining HPP, Bradley was serving as Vice President of Operations & Quality for Infinity Resources Inc. where he pioneered the application of Lean, Six-Sigma, Work-Out™, and CAP (Change Acceleration Process) in the retail market sector. Bradley began his career in manufacturing with GE Healthcare and was working as a Manufacturing/Quality Engineer when GE adopted the Six-Sigma methodology from Motorola. In 1995, GE Healthcare began providing consulting services based upon these tools to its customers through its Performance Solutions business unit, pioneering the application of Six-Sigma in healthcare. Bradley joined Performance Solutions in 1996 during its infancy and remained with the business unit for seven years. Bradley’s educational background includes: a Bachelor of Science degree in Business Administration from Cardinal Stritch University in Milwaukee, Post Graduate Certification in Quality Engineering from Milwaukee School of Engineering, a Master of Arts degree in Business Administration from Marquette University in Milwaukee, Six-Sigma Master Black Belt Certification from General Electric, and Front-Line Leadership Development Certification from Achieve Global.

When I discuss operational and cultural issues with many of my healthcare clients and colleagues, a common and recurrent theme is upward delegation. In many healthcare institutions across the country there are Managers who’s daily work looks more like that of a Supervisor and Senior Executives who’s daily work is less focused on strategy deployment and more focused on resolving operational issues. Most healthcare leaders are interested in breaking this trend, fewer know how. A very strong prescription for stopping the process of upward delegation may be found in the core tools associated with the Toyota Production System (TPS or Lean). When appropriately deployed, Visual Management, Leadership Standard Work and A3 (Root Cause) problem solving can stop upward delegation and pave the way for the correct flow of delegation and strategy deployment.  This is the first in a series of three articles focus on stopping upward delegation and will illustrate how Visual Management can help.

Many care delivery teams are well aware of what is necessary to get the “daily work done.” Fewer are aware of the fact that outcomes cannot be separated from the processes designed to deliver them. When processes are characterized by many “workarounds” outcomes are no longer predictable but, rather simply, a matter of chance. This creates many small problems that evolve into bigger problem as customer demand higher standards of performance and care. These become a source of upward delegation. By implementing a visual management system, care delivery teams begin to build a greater awareness of the impact of specific behaviors on outcomes. Visual Management Systems can be seen as containing three key elements: 1.) Visual indication of process performance, 2.) Visual control of patient flow, 3.) Visual control of maintenance processes necessary to insure up-time. Let’s examine an illustration based on visual process performance.

On a medical-surgical unit a key outcome metric is the time interval between discharge order written and patient exit. This metric, along with others, is visible on the unit indicating performance to goal.  When the goal is not met, it drives problem solving activity on the part of the team. In this example, the team discovers that the most frequent reason for missing this metric is that the patient did not have a ride home (sound familiar?). Through experimentation the team learns that when the anticipated discharge date is written on the white-board in the patient room upon admission, updated daily, and used as a focal point for discussion with the patient once daily, the probability of the patient not having a ride home upon discharge decreases substantially and the outcome metric improves. This means that the number of white-boards (% compliance) containing this information can serve as a leading indicator of the time interval between discharge order written and patient exit. This leading indicator can be managed to on a daily basis. If the connection between the behavior and the outcome is well understood and if it is tracked, visually in a very simple way, no team member wants to be responsible for driving a miss by not performing to standard.

Success in the above illustration comes from using the visual management system to drive behavior. It was an initial variance to goal in the outcome metric that drove problem solving by the team. When scientific method demonstrated a clear connection between behavior and outcome and appropriate process metric was included in the visual management system as a leading indicator that can be managed to daily and that can drive the behavior necessary to realize the desired outcome. By following this methodology and leveraging Visual Management the process of delegating upward begins to slow. This occurs because the team has an appropriate “yardstick” by which to measure both their collective performance and specific behaviors that influence outcomes. Performance misses become an opportunity for root cause problem solving, thereby reducing the number of “workarounds” and instilling both accountability and a disciplined adherence to process. Implementation of a well designed visual management system represents the beginning of the team’s journey into self-facilitation and begins to slow the rate of upward delegation.

This week’s blog was written by Bradley Schultz, a director and consultant for HPP. Before joining HPP, Bradley was serving as Vice President of Operations & Quality for Infinity Resources Inc. where he pioneered the application of Lean, Six-Sigma, Work-OutTM, and CAP (Change Acceleration Process) in the retail market sector. Bradley began his career in manufacturing with GE Healthcare and was working as a Manufacturing/Quality Engineer when GE adopted the Six-Sigma methodology from Motorola. Bradley’s educational background includes: a Bachelor of Science degree in Business Administration from Cardinal Stritch University in Milwaukee, Post Graduate Certification in Quality Engineering from Milwaukee School of Engineering, a Master of Arts degree in Business Administration from Marquette University in Milwaukee, Six-Sigma Master Black Belt Certification from General Electric, and Front-Line Leadership Development Certification from Achieve Global.

Employees of healthcare institutions who have undertaken the adoption of the Toyota Production System, often referred to as TPS or Lean, will be all too familiar with the following sequence of events.  The kaizen event was a big hit with the team.  The rapid deployment of well developed, tested countermeasures, designed by those who actually do the work has paid off and a dramatic improvement has been realized.  The team comes to the understanding that things can change and that their ideas and involvement can make a difference.  As a result, more ideas begin to surface.  Perhaps this is the first time that the team felt, truly, heard and empowered.  Now, the ideas are really flowing but not all of them are implementable right now.  So where do they go?

Sometimes, these ideas are captured in follow-up action plans or in “parking lots”.  More frequently, however, they run the risk of evaporating.  Uncleared, “parking lots” become bone-yards and idea generation becomes less enthusiastic.  Implementing Lean Healthcare is not easy.  As the kaizen team returns from the event they find that, initially, making this improved process “the way we work” takes some follow-up effort.  Moreover, in a truly Lean operation the team is executing very precisely to a pre-defined takt time.  Together these influences lead to the question; “Where are the resources to act upon these ideas?”  The following are three suggestions to keep the idea generation process alive and vibrant through action.

1.) As waste is eliminated from the process, resources become more available.  Unless this availability is understood and reinvested, wisely, it runs the risk of being applied to more non-value-added work.  With less defects and the seemingly requisite fire-fighting, charge nurses, team leaders and supervisors win back time to focus on further improvements.

2.) A well executed gemba walk process is another Lean Healthcare tool that may be very successfully leveraged to keep ideas flowing and transforming operations through action.  Often, this process can replace less effective operating mechanism and therefore not involve incremental work.  It is not uncommon, in this process, to see the departmental dashboard augmented by A3’s on the top issues.  Add to this an “on deck” area where ideas may be captured and subject to an ongoing process of prioritization for implementation.  This may be as simple as a white board area or designated Post-It™ note space.  What is more important is that the gemba walk process leads to ongoing evaluation and selection from these ideas.  In this format there are no suggestion boxes to maintain.  There are no expensive and bureaucratic committees to manage.  Instead a very simple process of ongoing evaluation, selection, testing and perfecting of ideas takes place naturally and within the stream of daily work.

3.) Notice that the sequence of events illustrated above begins with evaluation.  With that in mind, the Lean tool of Reflection can be as powerful in implementing lean healthcare as it is simple.  By simply taking the time as a team or in smaller, natural, work groups at key points in time to reflect upon what worked and what could be better, a habit of evaluation and idea generation may be established.  Add these to the idea board mentioned above to fuel the selection for implementation process on an ongoing and very natural way.

Collectively, these three simple steps can serve as a powerful catalyst for change and as a control tool. Ultimately, the team begins to understand that focused evaluation, supported by idea generation, testing and ultimately action are not confined to kaizen events, but rather, an integral part of daily work.

This week’s blog was written by Bradley Schultz, a director and consultant for HPP. Before joining HPP, Bradley was serving as Vice President of Operations & Quality for Infinity Resources Inc. where he pioneered the application of Lean, Six-Sigma, Work-Out™, and CAP (Change Acceleration Process) in the retail market sector. Bradley began his career in manufacturing with GE Healthcare and was working as a Manufacturing/Quality Engineer when GE adopted the Six-Sigma methodology from Motorola. In 1995, GE Healthcare began providing consulting services based upon these tools to its customers through its Performance Solutions business unit, pioneering the application of Six-Sigma in healthcare. Bradley joined Performance Solutions in 1996 during its infancy and remained with the business unit for seven years. Bradley’s educational background includes: a Bachelor of Science degree in Business Administration from Cardinal Stritch University in Milwaukee, Post Graduate Certification in Quality Engineering from Milwaukee School of Engineering, a Master of Arts degree in Business Administration from Marquette University in Milwaukee, Six-Sigma Master Black Belt Certification from General Electric, and Front-Line Leadership Development Certification from Achieve Global.

Building accountability is a common topic among leaders within clinical environments.  When implementing lean healthcare, this tends to come up when a desired process change fails to “stick”, old behaviors return and the process slumps back into its former sub-optimal state.  Sometimes you hear it stated explicitly as the diagnosis for the failure; “There was no accountability”.  Webster defines accountability as “…an obligation or willingness to accept responsibility for one’s actions”.   Based on Webster’s definition let’s examine further.

Imagine what would happen if someone attempted to enter an in- use operating room without a mask or gloves?  The reaction would be immediate and would extend beyond just “responsibility for one’s actions”.   It would include a strong demonstration of process ownership and conformance of the actions of others in the environment where the process is performed.  This reaction demonstrates the presence, not the absence, of accountability.  How is it, then, that mutually agreed upon improvements, tested and validated, would fail to stick for lack of accountability in the same environment that would produce so strong a reaction?  The answer to this question lies in the “actions” portion of Webster’s definition and has more to do with leadership than with the extended clinical team.

Let’s take actions first.  The use of surgical mask and gloves is a great example of fully internalized standard work.  Rule-1 of Lean’s (TPS) Rules in Use indicates that all work should be specified with respect to content, sequence, timing, location, and outcome.  The use of standard work takes the guess work out of the individual action portion of Webster’s definition.  This clarifies the specific actions to which an expectation of accountability extends.

With regard to leadership, the key failures of a Lean Healthcare transformation tends to be over-use of delegation and under-use of follow up.   Implementing lean healthcare involves new behaviors for all members of the organization.  It is not uncommon, therefore, that old behaviors present themselves and new problems arise.  The following is a list of questions that leaders, implementing lean healthcare can ask themselves:

1.) How often does your daily work take you into as opposed to out of the gemba?
2.) Does your gemba walk include process audits?
3.) How frequently do gemba walk observations meet stated expectations?
4.) Does the emphasis extend beyond “what” failures occur and into “why” failures occur?
5.) Is there observable and visual evidence of on-going improvement activity?
6.) Do you retreat from the gemba walk process during a crisis?

Standard work, within a Lean Healthcare context , builds accountability by clarifying the specific actions to which expectations extend.  Frequent gemba walks, that surface observed variance from expectation, reinforce this accountability.  By pushing the emphasis beyond “what” failed into “why” failures occur, accountability is further developed as systemic barriers to getting it right are eliminated.  Including observable and visual evidence of on-going improvement activity builds further momentum.  Finally, maintaining the gemba walk process during periods of crisis and conflicting leadership demand, models the correct behavior…we do not retreat to the old ways at the first sign of crisis.  This also creates the opportunity to accelerate the team’s efforts through on-going coaching.  Collectively, these build and enable accountability by making accountability a two-way street.

This week’s blog was written by Bradley Schultz, a director and consultant for HPP. Before joining HPP, Bradley was serving as Vice President of Operations & Quality for Infinity Resources Inc. where he pioneered the application of Lean, Six-Sigma, Work-Out™, and CAP (Change Acceleration Process) in the retail market sector. Bradley began his career in manufacturing with GE Healthcare and was working as a Manufacturing/Quality Engineer when GE adopted the Six-Sigma methodology from Motorola. In 1995, GE Healthcare began providing consulting services based upon these tools to its customers through its Performance Solutions business unit, pioneering the application of Six-Sigma in healthcare. Bradley joined Performance Solutions in 1996 during its infancy and remained with the business unit for seven years. Bradley’s educational background includes: a Bachelor of Science degree in Business Administration from Cardinal Stritch University in Milwaukee, Post Graduate Certification in Quality Engineering from Milwaukee School of Engineering, a Master of Arts degree in Business Administration from Marquette University in Milwaukee, Six-Sigma Master Black Belt Certification from General Electric, and Front-Line Leadership Development Certification from Achieve Global.

Zealous guardianship of the status quo is a very common barrier encountered by healthcare delivery systems attempting to adopt and implement lean healthcare.  It is amazing to witness the extent to which this behavior is present in nearly all organizations interested in pursuing the lean healthcare journey.  During Kaizen Events this guardianship manifests in one of two ways:  1.) either an amazingly strong reluctance to change or, 2.) proposed changes to current state that are so enmeshed in what we have today as to be nearly indistinguishable.  How this guardianship is approached and managed during an event can mean the difference between “bold moves” and “rearrangement of the sock drawer for the tenth time”.

There are four things facilitators, coaches and leaders must keep in mind when dealing with guardianship of the status quo during a lean healthcare transformation. 1.) Honor the past. The segments of the value stream under consideration have been developed by the participants of the event or their forerunners.  At times there can be an unspoken and even unconscious sense that to change is to dishonor what is currently in place and what it took to get there. 2.) Challenge the team. Team members must be adequately challenged to the extent that the need for change is undeniable and a healthy dissatisfaction with the status quo has been created. During a Kaizen Event direct process observation goes a long way toward the accomplishment of this objective but more is required to truly embolden teams. It is also important to keep in mind that the event team is only a cross section of the extended team when implementing.  3.) Create and communicate a new vision.  Teams need to know that what they will build is better than what they already have…not only for themselves but for the extended community as well. By building in constituencies beyond just the participants, systems thinking is promoted.  This is an essential step, combined with honoring the past in empowering teams to let go, to adopt something new, and to take bold moves. 4.) Engage the team. This seems so fundamental that it almost questions its mention in this article. Engaging the team, however, moves well beyond their active participation in the event. It is a process of creating internal champions, one at a time. 

The Scientific Method, applied while testing solutions, will ultimately prove or disprove the quality of the “bold moves” selected for implementation. However, regardless of the quality of the solutions or counter-measures, unless there is acceptance, there is no net improvement. Things must change from current state toward future state in objective reality. This means that ultimately, along the way, every mind in the organization must be engaged. Facilitators, coaches, and leaders that recognize this and that understand that honoring the past, challenging the team, creating and communicating a new vision are prerequisites to engaging the team, will find their fields well prepared when planting the seeds of lean healthcare. Those that fail at this should not be discouraged as the lesson will repeat itself, again, (hopefully not and again and again…) until learned.

This week’s blog was written by Bradley Shultz, a director and consultant for HPP. Before joining HPP, Bradley was serving as Vice President of Operations & Quality for Infinity Resources Inc. where he pioneered the application of Lean, Six-Sigma, Work-Out™, and CAP (Change Acceleration Process) in the retail market sector. Bradley began his career in manufacturing with GE Healthcare and was working as a Manufacturing/Quality Engineer when GE adopted the Six-Sigma methodology from Motorola. In 1995, GE Healthcare began providing consulting services based upon these tools to its customers through its Performance Solutions business unit, pioneering the application of Six-Sigma in healthcare. Bradley joined Performance Solutions in 1996 during its infancy and remained with the business unit for seven years. Bradley’s educational background includes: a Bachelor of Science degree in Business Administration from Cardinal Stritch University in Milwaukee, Post Graduate Certification in Quality Engineering from Milwaukee School of Engineering, a Master of Arts degree in Business Administration from Marquette University in Milwaukee, Six-Sigma Master Black Belt Certification from General Electric, and Front-Line Leadership Development Certification from Achieve Global.

Last week, as the day’s activities closed on a 5S event, I had a conversation with the hospital’s Lean Coordinator that was so familiar to me that I thought I would make it the topic for this week’s newsletter.  First, let me say that the coordinator at this facility is a very talented individual and very courageous in accepting the role of leading this institution through the early stages of a lean healthcare transformation process.  Next, let me preface the conversation as it took place at the end of a 5S event where the team struggled significantly but was able to develop a solid Standardize and Sustain plan.
The conversation, paraphrased below, went like this:

Lean Coordinator: “You’ve done these before.”

HPP: “Yes.”

Lean Coordinator: “I saw the report-out presentation template in your materials.  I’ll bet you archive these.”

HPP: “Yes.”

Lean Coordinator: “So, your team probably has a lot of Standardize and Sustain plans archived on some server, somewhere.”

HPP: “Yes.”

Lean Coordinator: “Why didn’t you just give this team one of your templates?”

HPP: [Big Smile!]

I really enjoy moments like these and thought I would share the answer to that question with you in this newsletter.  Seems simple…let’s not reinvent the wheel and lean healthcare is all about keeping it simple.  First, the essential elements of a Standardize and Sustain plan are included in our materials, with several examples of how others have approached this.  The source of the team’s struggle was not with “what will we do” as much as it was with “how we will do this”.  How the team will approach Standardize and Sustain, without making it “work on top of work” is different within every team and every work area.  There are certainly common themes but not to the extent that a “point and click” ready to edit template will suffice.   Next, the transformation process involves bringing about a transfer of knowledge.  While the team struggled, connections were made, lights went on and knowledge was transferred.  Finally, I am reminded of the many “binders” sitting on shelves in many offices.  They contain detailed assessments, great analytics, powerful insights, and very well written implementation plans.  Yet often, objective evidence of actual implementation is absent…why?  Transformation means not only new ways of thinking but also new ways of doing and the latter must come first.  I am reminded that: “It is easier to behave your way into a new way of thinking than to think your way into a new way of behaving.”1 Through the struggle to define the plan, rather than populate the template, the team invested and committed to new behaviors…their plan, not mine. 

¶ “Kegley’s Principle of Change”
In J. Peers (ed.) 1,001 Logical Laws (1979)

This week’s blog was written by Bradley Shultz, a director and consultant for HPP. Before joining HPP, Bradley was serving as Vice President of Operations & Quality for Infinity Resources Inc. where he pioneered the application of Lean, Six-Sigma, Work-Out™, and CAP (Change Acceleration Process) in the retail market sector. Bradley began his career in manufacturing with GE Healthcare and was working as a Manufacturing/Quality Engineer when GE adopted the Six-Sigma methodology from Motorola. In 1995, GE Healthcare began providing consulting services based upon these tools to its customers through its Performance Solutions business unit, pioneering the application of Six-Sigma in healthcare. Bradley joined Performance Solutions in 1996 during its infancy and remained with the business unit for seven years. Bradley’s educational background includes: a Bachelor of Science degree in Business Administration from Cardinal Stritch University in Milwaukee, Post Graduate Certification in Quality Engineering from Milwaukee School of Engineering, a Master of Arts degree in Business Administration from Marquette University in Milwaukee, Six-Sigma Master Black Belt Certification from General Electric, and Front-Line Leadership Development Certification from Achieve Global.