Lean Healthcare Exchange

As a consultant in lean healthcare, I have the honor of working with individuals and teams who come together to improve their work and the care they provide to patients.  The reason I do this work is the brilliance of the front line staff never fails to amaze me.  I am totally jazzed when I see the light bulbs go on and an idea is transformed into reality that makes a difference.  Recently I observed the evolution of a front line supervisor from skepticism to total engagement as she adopted the principles of lean thinking into her daily work.  With the coaching of a colleague, I was reminded of the change cycle; and the impact on leader’s implementing lean healthcare. 

Uninformed Optimism
Exposed to the possibility of improvement in our everyday work, most of us will be at least a little bit open to change.  Early in a Lean journey, healthcare leaders hear words that philosophically they can embrace; increasing value/decreasing waste, increased satisfaction & quality, decreased cost & time, and increased decision making or empowerment of staff to name a few.  We do not know what will be expected of us, but we know the problems we are dealing with that we would like to go away.  Front line supervisors, generally demonstrate behaviors consistent with such optimism; attending leadership training sessions, volunteering staff to participate in kaizen events,  showing up at stakeholder meetings and asking good questions. 

Informed Pessimism
Following the first request to change our work, informed pessimism frequently takes hold.  Fixing one set of problems will often result in exposing more problems.  Lean healthcare supervisors, who previously made the change decisions, now have first hand exposure to staff making decisions and are confronted with a new reality to support change that was not their personal decision.  Part of supporting that change is holding staff accountable to new standards and coaching staff in solving the newly exposed problems using the scientific method.  It is at this juncture that lean leaders need to reflect on the areas they have control over, instead of looking to blame other departments and the “lean” process.

Informed Adoption
As leaders support the changes made by their staff they adopt valuable skills to promote the lean journey.  Critical to every lean healthcare transformation is leaders moving from asking “who” questions to asking “why” questions. One front line supervisor gave me a terrific example of her own evolution of moving from “who to why”. Following a kaizen event, she learned that clear expectations for what to document and at what time were not in place.  Working with her staff they identified that charting as they went instead of batch charting cut down the time information was available to other disciplines from an average of 32 minutes to 6 minutes.  On further examination, a few of her employees were outliers and appeared to be non-compliant with the new standards. When she went to talk to these employees to find out why, she learned that as night employees utilizing batch charting was difficult due to inadequate lighting on wireless laptops. After implementing new lighting these employees also were able move to one piece flow charting.

 Building Competencies
One lean event or change does not make a lean healthcare organization. Stringing together multiple improvements, such that leaders & staff begin to solve problems using lean principles every day at every level is a sign the organization is on its way. It is in coaching these improvements daily that leaders build their own competency in lean leadership.   Continually reflecting on and building our own competencies is essential to the growth of our organizations. Our organizations can only become lean as fast as we as leaders, including consultants embrace, and change our own behaviors, skills and competency in lean principles. 

This week’s blog was written by Maureen Sullivan, a senior associate at HPP. Maureen has over 28 years of healthcare experience in clinical nursing, management and quality leadership to Healthcare Performance Partners. Previously Maureen was the director of lean and quality improvement for Exempla Lutheran Medical Center. As a registered nurse, Maureen’s clinical experience is in medical surgical nursing with progressive responsibilities in nursing management at the front line, middle management, and administrative levels. Maureen began her quality management career in 1996, coordinating, facilitating and managing improvement and accreditation programs at a departmental, site and system level within Exempla Healthcare. Maureen has an associate degree in Nursing from Joliet Junior College in Joliet, Illinois and a bachelor of science in nursing with an emphasis in healthcare management from Metropolitan State College in Denver, Colorado. Maureen achieved certification from National Association for Healthcare Quality, certified professional in healthcare quality (CPHQ), Colorado State University in process mapping, and University of Michigan in lean healthcare.

I frequently face a challenge when trying to coach Rule 4 of the Four Rules in Use (Improvement Close to the Work).  In lean healthcare, we want problem solving close to the work (in space and time) by those doing the work.  But many of the problem solving activities that we are doing in an initial lean activity (Kaizen Event or A3 Problem Solving in a reVIEW class) is really not what I would call “true” problem solving.  What we are modeling and demonstrating is really doing some basic clean up of fixing broken things and standardizing processes.  I have added several levels of problems, as a way to contrast what I am doing and where I want to get to eventually.

1. Broken things
2. No Standard
3. Standard Not Followed
4. Standard Not Ideal

When we do have a problem, the first question we will ask is “What happened?” and “Did we follow the standard?”  Of course, if there is no standard, we cannot have followed it.  If equipment is broken, that will prevent us from following the standard (had it actually existed to start with).
 
If there IS a standard process and our equipment works such that we CAN follow the standard, we must have some means to monitor if we actually followed the standard.  And, if we have followed the standard, we must ask ourselves if the standard is ideal (meets the customer requirement with minimal waste)
 
To sustain a change, we must monitor the process (such as tracking OR Turnaround Time or ED Patient In Room to Discharge Times).  As we monitor the process, results must be compared against the standard and problems documented when we deviate from that standard.  By collecting the problems, counting and prioritizing this information will direct us to the next, deeper level problem and lead us to a root cause to permanently put to rest.
 
We must change our thinking from a problem being broken items and bad outcomes, to the view that a deviation from a standard is a problem and continually move our processes back to that standard.  Only then will we sustain changes implemented in our lean healthcare activities. 
 
The highest level of process management in lean healthcare is to have a standard that is consistently followed and deviations from the standard are recognized, then the next question will be “How can we improve the standard?”  This 4th level of problem solving is the only true improvement.

This week’s blog was written by Richard Tucker. Richard is a Director with HPP and has served as a coach, facilitator, and project manager for healthcare clients in the training and implementation of Lean Healthcare Tools and Methodologies. Prior to joining HPP, Richard had over sixteen years of business and industry experience in operational and leadership positions. With his work in healthcare, Richard has lead teams in the utilization of lean healthcare tools to eliminate waste, giving back precious time to the front line caregivers to focus on their patients. One project eliminated over 2 miles of walking (and one hour of time) per nurse each shift by relocating frequently used supplies closer to the point of use. A critical care team standardized the care of central line catheters to significantly reduce blood stream infections and improve staff satisfaction with the new process. In addition to his ongoing support of healthcare organizations in their lean journey, Richard is a founding faculty member of Belmont University’s Lean Healthcare Certificate Course. Richard’s educational background includes BS and MS degrees from Tennessee Technological University in Cookeville, Tennessee. Richard has attended formal training courses in Lean Manufacturing, Leadership Development, and Shainin Statistical Problem Solving.

When I buy a Coleman tent, I am the ultimate judge of satisfaction with the product that Coleman offers. I decide, based on a number of factors, whether I will buy another Colman tent (if the one I have ever wears out).

When I purchase a Lexmark printer, I will ultimately judge my satisfaction with the printer. When the time comes to buy another printer, I will decide whether to buy another Lexmark.

When I go to Carrabba’s Italian Grill and enjoy the Pollo Rosa Maria, I will be the final arbiter of the quality of the meal. I will decide whether to order the Pollo Rosa Maria when I return to Carrabba’s. (Noticeably absent from the discussion is any question about whether to return Carrabba’s. That’s a foregone conclusion. My wife made that one.)

And so it is with most consumer goods and services. Coleman, Lexmark, Carrabba’s and all other producers must ensure they are listening to the customers. To be successful, they must ensure that they are constantly in tune with and responding to our collective voice.

Not so, in healthcare. Here are a couple of personal examples. I’m sure you could add several of your own.

When I go to Jewish Hospital Medical Center East for out-patient surgery, I am so pleased with the services provided by the excellent care-givers there. But, no matter how great my experience, I am not necessarily the decision maker for whether I return. Ultimately, others will make, or at least heavily influence my decision about whether to return to Jewish East for future procedures. My physician may choose to practice elsewhere. My insurance company may no longer include the Jewish Hospital system in its covered providers group. And myriad other factors may prevent me from choosing Jewish Hospital Medical Center for future procedures.

When I had labs drawn at LabCorp in advance of a procedure, I was so pleased with the friendliness of the staff, the cleanliness of the facility, and the minimal wait time that I would certainly choose LabCorp for future tests. But, it will not likely be my choice. A contract negotiated with very little consideration given to my satisfaction will likely determine where I go for future testing.

One of the fundamental tenants of Lean healthcare is to focus on the customer. These examples illustrate that in the application of Lean Healthcare, the patient is not always the customer. Every successful Lean Healthcare improvement event must include a proper consideration of the voice of the customer. Unfortunately, in health care, the customer is often not easily identified. A partial list of “Customers” can include  the patient, the patient’s family, the patient’s physician, the payer (private or public), numerous regulatory agencies (private or public), other caregivers and so on.  In some extreme cases, these customers have opposing criteria for evaluating the quality or value of a service. Criteria that are important to these customers may be of little or no concern to the patient. So how do we, as practitioners of Lean healthcare proceed?

It’s obvious that if we fail to properly consider the impact of our process improvements on patients, we will fail. So the voice of the patient must always be valued highly. But, Lean healthcare purists, who insist on focusing only on the voice of the patient, while ignoring the voice of other customers, run the risk of alienating those on whom they depend for success. 

For these reasons, it is important to be disciplined to include the full range of customers when implementing Lean healthcare solutions. Recognizing, early in the improvement process, that your customer may include more than just the patient, will help your organization to reach a solution that is mutually beneficial to all your “customers”. Engaging these other interests and considering their voices will help ensure that your team’s efforts optimize a greater part of the healthcare delivery system.

This week’s blog is written by Jeff Wilson. Throughout Jeff’s career, he has delivered and applied progressive management and process improvement tools to help organizations reach new levels of performance. The industries span from healthcare to manufacturing, financial consulting and accounting. His experience with Six Sigma and Lean goes back to the early days of his career while working with Colgate Palmolive. Jeff had the opportunity to use process improvement tools as a participant on project teams and was so impressed with the effectiveness of these tools he began to further develop his understanding of and expertise in the implementation and use of them. Throughout his career as a front-line Supervisor, Materials Manager, Logistics Manager and Plant Manager, Jeff has used and championed the use of Lean tools to deliver exceptional results.  Most recently, Jeff served in a consultant role with the Manufacturing Extension Partnership where he had the opportunity to support other organizations as they seek to improve processes by implementing Lean.  He has developed Lean transformation plans, facilitated Kaizen events and developed training materials for numerous client companies. Jeff has a Bachelors Degree in Economics from Western Kentucky University.  He also holds a Certified in Production and Inventory Management (CPIM) designation.

This is a recent feature story shown on the CBS Evening News, about how Lean Healthcare is being applied in a Pacific Northwest hospital. There isn’t a cookie cutter approach for Lean/TPS in Healthcare in my opinion, that is a perfect fit each hospital system. Of course lessons can be learned and there are certain aspects of Lean in Healthcare that apply equally in most all cases. Most of all, Lean is a system and involves a systematic approach to solving problems and improving how work is done and how leaders manage. It involves seeing with new eyes, “Lean Eyes”! But this segment highlighted in the video of a recent news cast is one example of what has been done in applying Lean to healthcare. Hope you enjoy.

I frequently have had the privilege of working with some incredibly committed individuals and teams in lean healthcare organizations who share a tendency to being “perfectionists”. A previous mentor often reminded me that the journey is not about being perfect, rather the goal is to constantly pursue perfection to catch excellence. In the pursuit of perfection, lean processes are designed with the goal of being ideal. One aspect of an ideal process is that it is delivered 1 by 1 to meet the customer’s demand. Within most hospitals the concept of 1 by 1 is referred to as “patient flow”, a desired ideal state where patients never wait and there are no bottlenecks in care or treatment. To achieve patient flow, lean healthcare organizations need to eliminate waste and standardize work first in each phase of the value stream and then move on to improving the connections between processes. A recent team, facilitated by my colleague Marshall Leslie, demonstrated the application of these concepts in a group of ED patients who require an assessment and referral prior to admission to the hospital. The team reduced documentation by 50% and sequenced the workflow to minimize interruptions for those conducting assessments. Then they looked at the connections and found solutions to shorten response times from an average of an hour to less than 5 minutes by implementing a 1 call process. So, in your own pursuit of perfection, try looking at the steps before and after the value stream connections for the waste to eliminate then move on to improving the connections.

This week’s blog was written by Maureen Sullivan, a senior associate at HPP. Maureen brings over 28 years of healthcare experience in clinical nursing, management and quality leadership to Healthcare Performance Partners. Previously Maureen was the Director of Lean and Quality Improvement for Exempla Lutheran Medical Center and successfully led the implementation of Lutheran’s Lean production system from 2004 to 2008 demonstrating improvements in clinical quality, employee engagement, and financial stewardship. Maureen has an associate degree in Nursing from Joliet Junior College in Joliet, Illinois and a bachelor of science in nursing with an emphasis in healthcare management from Metropolitan State College in Denver, Colorado. Maureen achieved certification from National Association for Healthcare Quality, certified professional in healthcare quality (CPHQ), Colorado State University in process mapping, and University of Michigan in lean healthcare.

Do you ever ask yourself, “Who Killed Change?”, or maybe more specifically, “Who Killed “Lean Healthcare” (aka Change) in Our Organization”.   Was the murderer Mr. Culture, or Miss Commitment, or was it your CEO, Mr. Urgency? Maybe it was Mrs. Budget or Dr Vision.  There are a host of other suspects for who may have killed Lean Healthcare in your organization or any other significant “Change” you’ve attempted.

In Ken Blanchard and John Britt’s new book, “Who Killed Change?”,  they address in a very fun and murder mystery sort of way, “Who Killed Change.”   As we know, many organizations attempt Lean Healthcare as a new way of doing business without addressing the  potential  killers of this work.   There are a host of things that could kill Lean and declare it dead on arrival.  Or, maybe it was another quality or IT related change that was the victim of a homicide. As stated in the intro of their book, “Every day organizations…launch change initiatives. Yet, 50 to 70 percent of these change efforts fail. A few perish suddenly, but many die painful, protracted deaths that drain the organizations resources, energy and morale.”  We’ve all witnessed these homicides ourselves as have most employees in our organizations, and most want into the witness protection program when asked about what they may have seen.  When you introduce Lean for the first time, many in our organizations have flashbacks to past crimes of change of which they were a victim.  Or, maybe they are witnessing the poisoning of Lean in your organization now and not sure of how to prevent it.

As you will  find in the book regarding any type of change, there are a number of questions that should be asked as a part of your Lean Healthcare transformation, which we all know involves intense change in how work is being done and learning to see with “New Eyes” and “Lean Eyes.”  The authors sum it up best in stating, “Change Can Be Successful Only When The Usual Characters In An Organization Combine Their Unique Talents And Consistently Involve Others In Initiating, Implementing And Sustaining Change”.   For a quick and fun read, grab a copy and ask yourself how this applies to you and your organization, specifically your Lean transformation.

HPP is proud to offer an on-site one-day and two-day workshop titled, “Preventing A Homicide of Change” based upon the book “Who Killed Change?”, specifically targeting your Lean Healthcare initiative. The workshop is offered via a license with the firm Mountjoy & Bressler, LLP and the co-author John Britt.  HPP is the only firm licensed by the author and his firm to bring this workshop to your organization, designed specifically for a Lean initiative.   Email us at info@hpp.bz if you would like to know more about this workshop and how we can bring it to you and your organization. Whether you’re just starting your lean journey or any other another change, or you’re seeing the potential death of it, such a workshop would be healthy for your organization. At least grab a copy of the book and read it!

The blog entry for this week was written by Charles Hagood, with quotes from the book “Who Killed Change?”.   Charles Hagood is the CEO and Founding Principal of HPP, and the former Managing & Founding Partner of The Access Group, LLC in Nashville, Tennessee.

Below is a great article, written by Paul O’Neill, published yesterday in the New York Times, Titled “Health Care’s Infectious Losses”.  I’m not one that desires to engage in political debate, although I do want to promote the debate in how to best remove waste from health care, in all shapes and sizes.  All of these goals are achieved utilizing Lean Healthcare Principles, as difficult as it may be to change our healthcare system’s way of thinking. Recently I was discussing the same question presented below with a group of hospital executives regarding the healthcare debate in Washington, “Which of the proposals will capture even a fraction of the roughly $1 trillion of annual “waste”.” Although I’m a fan of technology when used in a Lean fashion, EMR/EHR alone will not remove the waste.  It is likely when not planned carefully to expedite the speed at which we can make errors and create additional waste if not removed from the process beforehand.  I do believe that such questions below must be asked and acknowledged by all in order to make our system the best it can possibly be. Regardless of how the system may look in the future or which side of the aisle you’re on, such debate is not only healthy but essential.

In conjunction with Karen Feinstein, PhD, Paul O’Neill was a co-founder of the Pittsburgh Regional Health Initiative (A Partnering Firm With HPP), which was a pioneer in the application of Lean Principles into the healthcare industry to promote efficient, safe, and reliable care. Let’s join together in asking these questions of each other.  Enjoy the article! Charles Hagood
 
New York Times
July 6, 2009
Op-Ed Contributor

Health Care’s Infectious Losses
By PAUL O’NEILL
Pittsburgh
 

HEALTH care reform seems to be on the way, whether we want it or not.

So I have been asking questions about the various proposals. Here is a sampling.

• Which of the reform proposals will eliminate the millions of infections acquired at hospitals every year?
• Which of the proposals will eliminate the annual toll of 300 million medication errors?
• Which of the proposals will eliminate pneumonia caused by ventilators?
• Which of the proposals will eliminate falls that injure hospital patients?
• Which of the proposals will capture even a fraction of the roughly

$1 trillion of annual “waste” that is associated with the kinds of process failures that these questions imply?

So far, the answer to each question is “none.”

Let’s consider that $1 trillion of waste. If we could capture all of it, the savings over 10 years would be five times what President Obama has said he will extract from insurance companies over the same period. The president’s vision of bringing down health care inflation by 1.5 percent a year over the next decade would not be a victory, but a capitulation to the enormous waste in the delivery of medical care.

The president says he likes audacious goals. Here is one: ask medical providers to eliminate all hospital-acquired infections within two years. This is hardly pie in the sky: doctors and administrators already know how to do it. It requires scrupulous adherence to simple but profoundly important practices like hand-washing, proper preparation of surgical sites and assiduous care and maintenance of central lines and urinary catheters. With these small steps, we would no longer have the suffering and death associated with infections acquired in hospitals and we would save tens of billions of dollars every year — money we should have in hand before new health-care entitlements are enacted.

What policymakers tend to forget is that only the people who do the work can make this happen. Legislation can’t do it, regulation can’t do it, infection-control committees can’t do it, financial incentives and disincentives can’t do it. But excellence is possible, and it has been demonstrated.

Where it works, the common denominators are strong leadership and a committed work force. Among those doctors showing the way are Brent James at Intermountain Health in Utah, Gary Kaplan at Virginia Mason Clinic in Seattle and Richard Shannon at the University of Pennsylvania, who have helped bring infection rates down drastically at their own hospitals and at others.

Hospitals and medical schools have great impetus to increase the ranks of such doctors: these improvements in patient care don’t cost money, they save money. And they represent only the tip of the iceberg in opportunities for improving outcomes and reducing costs at the same time.

A next step would be for the government to finance a prompt, detailed and hard-headed study of every example of error, infection and other waste in five major medical centers. Such data would give policymakers and caregivers a clearer picture of the possibilities for cost-saving improvements.

It would also help if reporters and pundits became more informed about the opportunities for improvement, so they could help educate the public and improve the level of the reform debates. As for members of Congress, perhaps it would help them to understand the problem if we assembled the data, by House district, on hospital-acquired infections, medication errors and other waste indicators. They are more likely to push for the right sort of change when they realize that people they know and represent are being hurt or killed by practices we know how to stop.

In the end, any health care reform that does not address the pervasive waste and the associated burden of needless suffering for patients and staff alike will give us little to celebrate.

Paul O’Neill was the secretary of the Treasury from 2001 to 2002.

Whether you are facilitating a Kaizen Event or completing a problem solving A3 in your department, a deep understanding of the Current State is a requirement of any well planned Lean Healthcare activity.  In the effort to define the existing process, we find, almost without fail, that there are as many different versions of the Current State as there are people involved in the activity!  I have witnessed many different reactions to this realization over the years including shock, complacency and pride in the independence of staff performing the work in their own unique fashion.  Through these different reactions, a second prediction can be made just as easily: no one will stop to ask “Why?”

While there are many factors that contribute to this condition, my first answer to the question of “Why?” would be a lack of documented standard work.  While the development, creation and maintenance of these documents rarely receives the fanfare of a Kaizen event report out or Lean project that shows significant savings, they are arguably more important.  One of my associates uses the illustration of giving directions to the airport as a quick point lesson on the importance of knowing the current state and having standard work.  He asks the group to give him directions to the airport and then allows the audience to proceed with detailed and sometimes accurate directions to the nearest airport.  He then follows with the question, “How could you give me directions when I haven’t told you where I’m starting from?”  It is the same with the Lean activities described above.  We can’t get where we are going if we don’t know where we are starting from.  We don’t know where we are starting from unless we have standard work in the Current State.

Consider an organization that never reinvented the wheel, could move staff into new roles with minimal ramp up time, and always produced a predictable and quality outcome.  This vision is often the reason that healthcare facilities begin their Lean journeys and creating and maintaining standard work is an essential part of reaching these goals.  Maintaining standard work enables consistent knowledge transfer and lays the foundation that is necessary to accelerate organizational learning and ultimately leads to consistent quality outcomes. 

Does your organization use standard work?  Do you have a method for maintaining and improving this work?  Without it, we will continue to see many different versions of the Current State and struggle to achieve the quality outcomes that the organization works so hard to deliver.
 
This week’s blog was written by HPP’s Marshall Leslie. Marshall, a Six Sigma Blackbelt, oversees various HPP projects and Lean Healthcare transformations for clients throughout the USA.  As a former multiple year “top-ten percent” performer at General Electric, Marshall brings clients the much needed tools and techniques needed in any industry, including healthcare. Marshall is a graduate of General Electric’s Operations Management Leadership Program; he has experience in various supply chain capacities including quality engineering and global sourcing for both GE and Procter & Gamble. Marshall’s expertise in both Six Sigma and Lean enables him to apply a broad spectrum of process improvement tools tailored to the healthcare industry’s needs. He holds a degree in Industrial and Systems Engineering from Georgia Tech.

This year’s 3rd Annual Lean Healthcare Conference in Denver demonstrated the growing interest and activity of Lean in healthcare. With all of the 44 presenters, the sophistication of topics and depth of experience was evidence of Lean’s solid position in current process improvement strategies.

Presenters and participants from 4 countries and 22 states convened to share research, new methods and organizational experience with traditional and modified Lean principles. An excerpt of the keynote presentations of the conference can be reviewed at:

http://leanhealthcarewest.com/video/conference_review_denver.html

The next event sponsored by Lean Healthcare West and Healthcare Performance Partners will be the 4th Annual Lean Leadership Retreat, August 18-20, at Big Sky Montana. This event focuses on leadership roles and opportunities, sustainability techniques and challenges, and cutting edge expansions of Lean applications. More details can be viewed at:

http://leanhealthcarewest.com/leanhealthcare_workshops.html?workshop_key=55

3rd Annual Art of Innovation Award Winner

One exciting element of the Annual Lean Healthcare Conference is the presentation of the Art of Innovation Award. This recognizes the Lean efforts of an organization in the following areas:

1. Leadership engagement
2. In-house education program
3. Percentage of employees trained/engaged
4. Efforts to share learning in-house and out
5. A great activity description!

This year’s winning organization was Northern Arizona Healthcare. Their parent organization, Flagstaff Medical Center, initiated their journey in 2007 after 2 years of diligent self-education and persistence by Steve Spravzoff, VP for Process Improvement. The newly appointed CEO, Bill Bradel, saw the opportunity to incorporate Lean into his leadership strategy and truly led in the Toyota model, by attending the education and improvement activities himself. The rest of his team shared his commitment and physicians report feeling truly involved with the hospital management for the first time.

The dedication and skill of the staff also stood out. They were ready to use the lean framework and tools to improve work processes. The surgery team removed $360,000 in waste and immediately proceeded to expand their efforts. They now spend 2 hours every other week making on-going improvements. The favorite quote heard by Mr. Bradel: “This is the best thing to happen to health care since penicillin!”

Congratulations to all of the staff and management at Northern Arizona Healthcare!

Cindy Jimmerson, who leads HPP’s affiliate company Lean Healthcare West, is a pioneer in Lean healthcare, having initiated her work with a grant from the National Science Foundation, 2001-2004. She is the author of the Lean Healthcare West Review© Course and many journal publications. In addition, as part of the HPP’s Lean Healthcare West team, Cindy travels internationally speaking on the subject and organizes the National Lean Healthcare Conference. Cindy has been featured in Industry Week, Business Week, and numerous business and healthcare periodicals for her work in Lean Healthcare and has been a featured lecturer on the subject at the Harvard School of Medicine.

Lean Transformation changes not only the tools and methodology of an organization, but also the people. That is why we say- Lean is not what you do but how you do it. People can be taught and told what to do but true cultural transformation begins when people start thinking how to do things differently.

In most organizations, people have different aptitudes which determine their desire for the rate of change. The rate of how fast someone changes can be divided up into five general classifications that indicate their aptitude. They are the Innovators, Adaptors, Settlers, Mainstreamers and the Cave People. On average in Healthcare, the number of people having the five general aptitudes for change is distributed in approximately the same proportions as the general population in the United States. Usually the organization will have 10% Innovators, 20% Adaptors, 40% Settlers, 20% Mainstreamers and 10% Cave People. Professional change agents in an organization must be able to identify and work with each general type of person’s aptitude for change. Facilitators during Kaizen events should be particularly aware of the types of persons and the following tips for dealing with them.

So, in a team of ten people gathered from an organization there should be at least one who has the aptitude of an Innovator. They seek change at a rapid rate. They will think that Lean is the best thing since sliced bread and will immediately become a proponent for Lean during the event and throughout the organization. When the team is in the Forming stage during the event, the facilitator can look for the Innovator for assistance in encouraging the rest of the team to open up to the Lean tools and methodology.

The Adaptors will on average be two of the people on a team of ten. Adaptors are the ones who are willing to give it a try but will reserve judgment until after they have experienced some of the change. The facilitator will be able to identify Adaptors by their willingness to participate in observations and simulations during the event’s training sessions. Facilitators should be able to clearly identify the Adaptors by the time the team reaches the Norming phase of the event. The Adaptors can be used to give a more open minded opinion of Lean and their experience during the event’s final report out.

Settlers make up the largest segment of a team. In a team of ten, on average facilitators should look for four Settlers. They are best described as being people whose aptitude for change is contingent on the potential benefits of the change verses the benefits of remaining in the current state. Initially a facilitator will have difficulty identifying them from the Mainstreamers described below. However, by the time the team reaches the Performing phase of the event, the Settlers will begin the move to the new culture. Until the organization as a majority has established the new Lean culture, Settlers can move between continuing the change and returning to the previous state. During the preparation for the report out, the facilitator should try to mingle suspected Settlers with either the Innovators or Adaptors.

In general, Mainstreamers comprise two of the ten people on a team. Mainstreamers are not opposed to change. They just rather wait till the rest of the team or organization has changed before they do. Their aptitude for change is very neutral and usually occurs through a process of unconscious Osmosis rather than conscious decision. During the event, a facilitator will find Mainstreamers to be actively participative during the Performing phase of the team. During the rest of the event, Mainstreamers will participate only if they see others initiating participation. The rate of change for mainstreamers will depend on the rate of change for the organization as a whole. Therefore, facilitators should not push Mainstreamers to change. Their complete change will occur naturally with the rest of the organization.

There is usually one person from the tribe of Cave People on a team of ten. The Cave Person has no aptitude for change. They are comfortable with the current state of the organization. They will also consciously make a decision to try to keep others from changing. By the time the team reaches the Storming phase, the Cave Person should be readily identifiable. “Never” is one of their favorite words. They also rely on past failures as examples of why something won’t work. They are also quick to point out that their organization is the “Best” and change will only make it worse. In some situations during the event a facilitator may need to isolate the Cave Person from Mainstreamers and Settlers. Sometimes, know Cave Persons are not included on event teams. However, organizationally this is a mistake. They do have knowledge and experience that other team members need to acquire. The facilitator’s job is to manage the Cave Person while harvesting their experience and knowledge. As an organization, Cave People will become extinct either by finally evolving professionally or deciding to leave.

Facilitators should be aware of the cultural tribes that comprise the team during events. Some disciplines in Healthcare are comprised more of one type of tribe than the average. Historically in Healthcare, areas of the organization that utilize technology more or that have a higher degree of regulatory requirements are the ones that will actually a have greater population of Cave People. Those that have more of their time devoted to direct patient care have a higher population of Innovators and Adaptors. No level of the organization is immune from any particular type of tribe member. They exist at all levels. Facilitators and executive management both need to understand the team and organizational dynamics that can enable or interfere with the cultural transformation.

David Pickens is the author of this week’s article. David is an HPP Lean Healthcare facilitator, consultant, trainer, and certified lean six-sigma Master Black Belt. Dave has a B.A in Statistics and M.B.A., and is currently working on his DBA.  Dave has worked with HPP healthcare clients throughout the USA by assisting them with their Lean Transformations. Dave has years of industry experience from his time in the automotive and consumer goods industry, including time with Panasonic, Allied Signal and BOSCH. He has trained with Matsushita in Hong Kong, Japan and Singapore in Japanese Manufacturing Management.