Lean Healthcare Exchange

It’s that time of the year! Football time is here in the state of Tennessee but I know that Tennesseans certainly don’t have any kind of monopoly on the excitement and anticipation associated with this sport season. No matter where I go, many of the people that I run into are anxiously awaiting their team’s opening game. It’s hard to miss the level of enjoyment that comes from this annual fall activity!

All team sports generally have one thing in common: a coach who is committed to making their team as successful as possible. Organizational improvement efforts, like applying Lean Healthcare concepts and tools to the improvement of regular healthcare value streams and work processes, need coaches too! Lean Healthcare initiatives can have a successful ‘kick off’ if leadership—especially at the middle management levels—accepts and relishes the opportunity to ‘Coach ’em Up.’

When we think about coaches of athletic teams, we typically can all agree on several of a good coach’s basic attributes:

• Knowledge of the game
• Ability to organize practices
• Capability to develop game strategies
• Interest in developing the skills of the team members
• Recognition of team strengths and weaknesses, and the ability to make appropriate adjustments when required

A successful Lean coach certainly needs the skill set listed above. However, Lean coaches who are focused on improving team performance often need a few additional skills. These include:

• The ability to resolve differences
• An interest in building relationships
• A drive to pursue creative solutions
• The talent and commitment to motivate and empower those on the team to improve how they do their work

How does this list differ from what we typically expect from our supervising level of employees? Our observations often reflect that the typical supervision situation might be almost exclusively focused on accountability (i.e., “Let’s get it done!”). There is certainly nothing wrong with this. Even in a mature Lean operating environment, supervisors are always responsible for adherence to work standards.

However, Lean success requires a more balanced role for supervision, one that includes actively coaching for improvement. For supervisors, the Lean coaching begins with a clear recognition of performance gaps (perhaps through process performance metrics), and moves toward the empowerment and motivation of those who do the regular work to respond with improvement ideas. We coach to make sure that these ideas include the appropriate Lean concepts and tools!

Coaching requires practice, but good coaching almost always begins with an attitude: “We’re good but never good enough!”  As always, the commitment to ‘Coach ’em Up’ is the vital first step!

This week’s blog was written by HPP consultant and engineer David Krebs. David, a Six Sigma certified engineer, oversees various HPP projects and Lean Healthcare transformations for clients throughout the USA. David is also a Licensed Professional Engineer in the state of Tennessee, with over 30 years of experience in a variety of process and systems intensive industries, as part of firms in the U.S, Germany, and France.  David has achieved and maintained QS-9000 and ISO-14001 certification & received Nissans’ “Quality Master Award” on three occasions.  He holds a Bachelor of Science degree in Mechanical Engineering from the University of Detroit & an MBA from the University of Notre Dame.

I have seen a shift over the past year in the discussions  that I have with Healthcare leaders.  We are facing considerable financial pressures in the Healthcare Industry  today – increased demand on an already overburdened system with skyrocketing technology costs.  With well documented results from Lean Healthcare implementation around the world, leaders are taking into consideration the time tested philosophy and methods of Lean.  However, leaders are increasingly concerned with one question – What will my Return on Investment (ROI) be for Lean Healthcare implementation? 

First, let’s start with the basics.  Without spiraling into a discussion of Net Present Value (Google it if you don’t know about NPV), the textbook method for calculation of ROI would look like this: 

(Profit – Investment)/ Investment

It simply answers the question of will we make (or did we make) money on an investment.  It can be used when making business decisions such as whether to purchase a new piece of equipment.  Will it make us more profit than it costs us?  Or in other words, what is the Return on Investment?

However, ROI calculations for Lean Implementation can be incredibly complex because of the many variables on both the Profit and the Investment (expense) side of the equation.  In healthcare organizations, employee expenses (fulltime and supplemental labor) make up a significant percentage of the expense side of the equation.  In fact, full time and contract labor can make up between 50 – 60 percent of a hospital’s expenditures. 

Hospitals under considerable financial strain have traditionally looked at their largest expense category, labor, to identify savings.  With a short-term focus on cash, organizations may be cutting short the true benefits of Lean Healthcare implementation.  For example, under a Lean Healthcare program we look to identify and eliminate wasted time, effort, and resources.  The CFO rightfully questions,”Where are my savings? “  Unfortunately, it is not that easy.  I have reviewed many healthcare income statements and have yet to see where “wasted time” is captured on the current list of expenses.  Waste is hidden.  It is woven into the fabric of the organization.   So if waste is eliminated, where can we carve out savings from the P&L?  No savings = no ROI, right?

Not so fast.  A long-term view of Lean Healthcare implementation would see that additional service growth can only come from additional capacity.  By eliminating wasted time, effort, and resources through Lean Healthcare, we effectively increase an organization’s capacity.  In fact, it is the lowest cost capacity because we are already paying for it!  If we can do more procedures with the same staff without people feeling like they are working any harder, then we can show significant returns on the waste elimination efforts.  Service is better, patients are happier, and profits grow with increased volume flowing through the existing cost structure.

This week’s article was written by Tom Stoffel, a director & consultant for HPP. Before joining HPP, Tom served as President of Transformation Group, Inc,. Tom developed TGI Healing Healthcare – a brand of Lean Healthcare training tools designed to share lean principles through hands-on learning. Tom has led healthcare organizations in both the development of high-level Lean Strategies down to hands-on implementation of Lean in a clinical setting. Tom has achieved the levels of Certified Lean Specialist from the Business Improvement Group and the National Institute of Standards and Technology (NIST), along with being an ASQ Certified Quality Engineer. These certifications build on an Engineering Degree from the University of Michigan. Training experience includes Lean, Quality, and Leadership Training, as well as serving as an Adjunct Faculty Member at Waubonsee Community College.

This is a common problem we run across with Kaizen teams. The improvement team is working diligently on a process; understanding and analyzing current state, performing tests of change, developing counter measures and an implementation plan. They gave management and staff the opportunity to check in with the teams during the Kaizen event. Attendance at these stakeholder sessions is sparse, by both management and floor staff. When it comes time for implementation the Kaizen team is told a certain group needs to approve the new process before they can implement. The Kaizen team feels unsupported and possibly angry after all the hard work they put into this effort. Their understanding is that the future state that they developed would be implemented. This type of dilemma is not uncommon and there are very important issues illustrated in this example that deserve comment.

The 14 Lean Principles as described by Jeffrey Liker, in their entirety, will guide successful implementations. Focusing on a few of them and ignoring others welcomes the risk of failure. It is easy to lose site of this, to pay attention to the more technical aspects of this approach ignoring the adaptive and behavioral principles. The thirteenth of these principles describes the importance of achieving consensus, Make Decisions slowly by consensus, thoroughly considering all options; implement rapidly. This is achieved through dialogue in a process of “catch-ball”. The more people that understand and agree with the future state, the more likely implementation will be successful. This is what the stakeholder sessions on days two and three of the Kaizen event are designed for. 

So, in the scenario above, if the Kaizen team exercises “authority” and imposes the implementation, it is likely to fail over time because consensus was not achieved. On the other hand, if the decisions of a diligent Kaizen team must go through layers of approval by groups or councils that did not observe the current state, they will likely suffer the fate of “Death by Committee”. Failure is likely either way. 

Kaizen events, or rapid improvement events are just that, rapid. It is critical for the management and staff to take advantage of the time given during the stakeholder sessions to have the necessary dialogue and gain consensus such that the improvements are not bogged down in layers of committees and approvals. The Kaizen team must have support by the rest of the organization and it is leadership’s responsibility to see to it that the support is given. It is management’s responsibility to give the support. That means presence at key times during the Kaizen process to understand the activity and recommendations. It means showing up with active listening and inquiry, being open to the changes that have been developed. It means dialogue around the areas of valid concern and disagreement until consensus is achieved such that the Kaizen teams recommendations can be implemented right away. It means supporting the Kaizen team by addressing organizational barriers that are all too common in hospital environments. It means understanding the standard work that has been developed and actively coaching this change to the front line staff. Successful implementations must be owned by operations. Absolving themselves of this responsibility and delegating this to the Kaizen team or the “quality department” without the above support will prove to be fatal to the events success.

Consensus in the above context does not necessarily mean a majority. It means critical mass. Critical mass is that number that is sufficient to drive success. W. Edward Deming stated that the number of people to achieve critical mass with most changes is the square root of N,  N being the number of people who must change. For a group of 9, the critical mass is 3. For a group of 100, the critical mass is 10 and so on. These aren’t just people who approve of the change, they are the ones who lead the change. These are the people who have passion for the change and are willing to have the interactions with the rest of the team to drive the success. 

Taichi Ono’s advised developing leaders in his organization to “Lead is if you have no authority.” That requires dialogue, listening, inquiry and consensus building.  It is far more effective than command and control.  It takes more work in the beginning, but far less work in the end. The 13th principle.

This week’s article was written by Dr. David Munch, Chief consulting and clinical officer at HPP. He comes from Exempla Lutheran Medical Center as their Chief Clinical and Quality Officer. At Exempla, Dr Munch led their Lean Production applications resulting in substantial improvements in both clinical and non-clinical processes. Dr. Munch is an instructor for the Belmont University Lean Healthcare Certificate Course, and was previously an instructor at the University of Michigan’s Lean Certification Program and has been a frequent speaker on the subject of leadership effectiveness and Lean transformation for a number of healthcare organizations including Institute for Healthcare Improvement (IHI), The University of Rochester Medical Center, Yale-New Haven Health System, Tulane University Medical Center, Pittsburgh Regional Health Initiative, Institute for Clinical Systems Improvement (ICSI), and the Voluntary Hospital Association (VHA). Dr. Munch has served on the Agency for Healthcare Research and Quality’s High Reliability Advisory Group, has an extensive background in hospital operations, health plan governance, physician organization governance and clinical practice in Internal Medicine. 

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.

Imagine an existing hospital located in a large metropolitan U.S. city that is highly effective at delivering high quality patient care in an efficient manner. Those of us who are ‘on the voyage’ to achieving a truly LEAN organization maybe already familiar with this place. However, if you’re just beginning your LEAN healthcare ‘voyage’ maybe you’re not quite ready to venture a guess on who this is. However, I’m sure that you will all ultimately recognize the name!
 
Let me give you a few more hints:

• The 2008 Dartmouth Atlas of Health Care reported that of the 5 best ranked medical centers in this country, this location provided the most cost efficient care.
• This medical center works so well that its cardiac services ‘unit’ attracted over 39,000 ‘out of state’ as well as over 2,300 foreign residents from 102 countries. The revenues gained from these ‘out of towners’ easily offsets the poor margins that are associated with an even larger census of both Medicare and Medicaid patients.
• This facility is reported to be at the forefront of measuring and publicizing its results! This medical center is typically one of the few that that makes its own analyzed outcome data easily accessible to any interested party.
• This medical center has a fully staffed Continuous Improvement department led by a systems engineer with no healthcare experience. This department maps and analyzes every value streams that does not have outcomes that match the organization’s targets (i.e., the opportunities for improvement).
• This medical center has a fully implemented electronic patient charting system that not only includes order entry and routine patient charting but also provides “decision support” functions to clinical personnel that reduce med errors and allows real time IV medication effectiveness monitoring.

For those just starting the LEAN healthcare ‘voyage’, take heart! The Cleveland Clinic probably started their journey just as you have, uncertain of where it would lead them! Their LEAN healthcare journey probably isn’t complete but I’m certain that they (and their patients) are glad that they started.
  
Newsweek magazine highlighted these and other accomplishments of the Cleveland Clinic medical system in an article titled, “The Hospital That Could Cure Health Care’ written by Jerry Adler and Jeneen Interlandi in its December 7th edition. 

This week’s blog was written by HPP consultant and engineer David Krebs. David, a Six Sigma certified engineer, oversees various HPP projects and Lean Healthcare transformations for clients throughout the USA. David is also a Licensed Professional Engineer in the state of Tennessee, with over 30 years of experience in a variety of process and systems intensive industries, as part of firms in the U.S, Germany, and France.  David has achieved and maintained QS-9000 and ISO-14001 certification & received Nissans’ “Quality Master Award” on three occasions.  He holds a Bachelor of Science degree in Mechanical Engineering from the University of Detroit & an MBA from the University of Notre Dame.

You have probably heard the phrase – a picture is worth a thousand words.  It is certainly quite true.  Trying to describe a situation or improvement during a Lean Healthcare kaizen event is much easier through pictures.  The Lean tool of visual controls leverages this principle by clarifying through use of pictures.  However, just as Yogi Berra states, “You can observe a lot just by watching”.  While a picture is better than words, nothing beats seeing it for yourself. 

I was reminded of this last week during my first visit to London, England.  I had seen pictures of the famous sites, but was blown away in my short visiting time squeezed in between Lean Healthcare work.  Nothing will replace the memories of seeing Trafalger Square, Big Ben , and London Tower with my own eyes.  I tried to bring back pictures to describe the experience to my family (who did not accompany me on this trip).  However, I could not muster the emotion of the experience through my iPhone photo gallery. 

This principle applies equally to the Leadership teams that we coach during a Lean Transformation engagement.  It was telling this week to hear a team member from a Kaizen Event Team say how refreshing it was to see a hospital “O” on the floor during improvements.  It is easiest to truly understand the care being delivered to patients by watching it happen.  Getting leaders out of offices and into “gemba” (Japanese for actual place) is a key component of Leading in a Lean environment.  You might find you can observe a lot just by watching.

This week’s article was written by Tom Stoffel, a director & consultant for HPP. Before joining HPP, Tom served as President of Transformation Group, Inc,. Tom developed TGI Healing Healthcare – a brand of Lean Healthcare training tools designed to share lean principles through hands-on learning. Tom has led healthcare organizations in both the development of high-level Lean Strategies down to hands-on implementation of Lean in a clinical setting. Tom has achieved the levels of Certified Lean Specialist from the Business Improvement Group and the National Institute of Standards and Technology (NIST), along with being an ASQ Certified Quality Engineer. These certifications build on an Engineering Degree from the University of Michigan. Training experience includes Lean, Quality, and Leadership Training, as well as serving as an Adjunct Faculty Member at Waubonsee Community College.

Over the past few weeks I have had many conversations with healthcare organizations that are in the initial stages of their Lean Healthcare journey and are actively seeking a Lean Facilitator for their facility. After much enthusiasm and many resumes screened, most have been discouraged to find that these resources do not “grow on trees”. Phrases like “searching for a needle in a haystack” and “Mission Impossible” have been used to describe the process. The current labor pool is filled with experienced Lean facilitators from other industries; however, many will struggle to translate this knowledge to the healthcare arena. Meanwhile, internal candidates must be taught Lean methodologies and may be too entrenched in “how things are” to see “how things could be. While the typical interview process focuses on past accomplishments as a predictor of success, our experience has shown that the presence of specific behavioral traits may be more useful in identifying the “right” (and “wrong”) candidates. Some of the most significant traits are listed below:

Energy:

Leading a Lean Healthcare initiative can be taxing work and energy is a must. Those who are selected must have the ability to energize teams, especially when the going gets tough. Likely candidates are known for exhibiting a passion for change and demonstrating a “Just Do It” attitude in the course of their daily work.

Interpersonal Skills:

An effective facilitator must be able to build relationships easily with teams. Candidates are often seen as informal leaders or “resident experts” within the organization. They are known for having the ability to “get things done” through influence rather than administrative mandate.

“Eye for Waste”:

The ability to identify all types of waste in processes is paramount to good Kaizen facilitation. Search for those with a reputation for constantly examining their own activities and eliminating waste. 

Learning Orientation:

Those selected to carry on the Lean work in your facility must have a strong desire to learn and teach Lean concepts. This will allow your organization to continue to innovate and truly become a learning organization.

Innovation/Creativity:

Truly great Lean facilitators have the ability to pull their view away from “doing what we do better” and drive towards “what could/should be”. A large majority of candidates are adept at optimizing your current state but few can create a vision for a radically different future state that can take your organization to the next level.

Facilitating a Lean transformation requires not only significant effort but also considerable skill. Often the answer to this classic “Make” vs. “Buy” question lies more in behavioral traits of the candidate than any past experience that could be considered a “head start”. While the previously mentioned qualities and traits are only a subset the criteria that must be considered in the selection of a Lean resource, it is our hope that applying these filters will assist in narrowing your search.

This week’s blog was written by HPP’s Marshall Leslie. Marshall, a Six Sigma Blackbelt, is the Vice President of Operations at HPP. He 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. 

Transforming your healthcare organization into one that fully utilizes the Lean concepts and tools takes time. Many experts estimate that this Lean Healthcare ‘journey’ will lead to truly tangible results only after as much as 3 years of dedicated, transformation effort! Now the ‘good news’! I believe that the much anticipated changes associated with the proposed U.S. healthcare reform effort offer a perhaps “once in a lifetime opportunity” to create a clear case for major change in any healthcare organization that counts on government reimbursement as a major element of their revenue stream. If you are familiar with change management, you’ll remember that one basic element of change management is the need to identify and articulate, as clearly and forcefully as possible, the need to ‘do something different’ in order to assure survival.  Since it has never been very likely that U.S. healthcare services would ever be ‘outsourced’ to Mexico, finding a rationale for the absolute necessity to get better at improve the levels of healthcare quality and service have been few and far between!

Why now?  As I have consistently read the multitude of commentaries on pending healthcare reform, I have picked up on a few common threads:

1. Our government leaders have clearly focused the coming legislation on increasing the accessibility of health insurance, including that available from both government and non-government sources. Most reviews of the current healthcare reform proposals focus nearly exclusively on how many additional people will be insured through each of the various options. An additional 30 million insured healthcare consumers through these reforms seems like a popular estimate.
2.  The ‘quid pro quo’ of expanding the pool of insured people in the U.S. (and significantly increasing the demand for healthcare services) appears to be a long term series of big time price concessions (something like $150 billion, that’s billion with a ‘B’) via reduced government reimbursements, over the next 10 years. I’ve read that this represents about $2.7 million in annual concessions per hospital!

There you have it! The typical U.S. hospital will see significantly higher demand for services but receive less reimbursement for government paid for care; a true ‘burning platform’ for working smarter not harder! The proposition of providing more of something and getting paid less for it easily registers as a bad strategy for long term success!

Lean healthcare leaders, don’t let this opportunity to clearly state the need for change go by without capitalizing on it in your organization! Three years of effort is a formidable investment but if not now, when?

This week’s blog was written by HPP consultant and engineer David Krebs.  David, a Six Sigma certified engineer, oversees various HPP projects and Lean Healthcare transformations for clients throughout the USA. David is also a Licensed Professional Engineer in the state of Tennessee, with over 30 years of experience in a variety of process and systems intensive industries, as part of firms in the U.S, Germany, and France.  David has achieved and maintained QS-9000 and ISO-14001 certification & received Nissans’ “Quality Master Award” on three occasions.  He holds a Bachelor of Science degree in Mechanical Engineering from the University of Detroit & an MBA from the University of Notre Dame.

Previous Lean Healthcare blogs have discussed the basic principles of the Toyota Production System in detail. Like Toyota’s own improvement efforts, we can apply Spear and Bowen’s 4 Rules in Use to move any healthcare value stream as close as possible to an ideal condition. However, from a training perspective, the 4 Rules are perhaps, not as explicit as one could hope for. This leads to the question, how do the workers in Toyota’s own operations learn to do standard work?

Interestingly, Spear and Bowen also tell us that Toyota’s managers don’t directly tell their associates how to do standard work! They use a teaching approach that allows their workers to discover the rules as a consequence of solving problems. This is, of course, an extension of the ‘old and reliable’ Socratic teaching methodology. Spear and Bowen have observed that at Toyota, the supervisor teaching a person standard work will come to the work site and while the person is doing their job, ask the following:

• How do you do this work?
• How do you know that you are doing it correctly?
• How do you know that the outcome is free from defects?
• What do you do if you have a problem?

This process of continual questioning is the catalyst for providing the worker with opportunities to achieve deeper insights into their specific work. Through this questioning approach to training, Toyota workers continually gain an implicit and deep understanding of the standard activities required in their work.

Most importantly, Spear and Bowen maintain that the Toyota Production System has so far only been successfully transferred when managers are able and willing to engage in this process of questioning that facilitates learning by doing! If this is the case, how many of us who are attempting to ‘cement our culture’ to Lean Healthcare concepts and tools are operating in this fashion? If Toyota’s sixty years of Lean success demands that worker’s are educated in this manner, how can those of us who are just beginning our Lean Healthcare journey train our associates in our standard work otherwise?

As we have said many times before in this blog, successful Lean transformation begins and ends with Leadership.  One of the most critical parts of that role to changing culture is the development and training of your staff in not only how to do the work but also how to think about the work.

This week’s blog was written by HPP consultant and engineer David Krebs.  David, a Six Sigma certified engineer, oversees various HPP projects and Lean Healthcare transformations for clients throughout the USA. David is also a Licensed Professional Engineer in the state of Tennessee, with over 30 years of experience in a variety of process and systems intensive industries, as part of firms in the U.S, Germany, and France.  David has achieved and maintained QS-9000 and ISO-14001 certification & received Nissans’ “Quality Master Award” on three occasions.  He holds a Bachelor of Science degree in Mechanical Engineering from the University of Detroit & an MBA from the University of Notre Dame.

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.