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.
3 Comments until now
Brad-
Great article. You need to write a book! This is such a key to organizations taking Lean to the next level. Those that “get it” free up time and resources by changing the culture; solving problems within the course of work. THis eliminates the need for countless meetings and committees. Leaders spend their time in GEMBA where they can make a difference for the patient. Thanks for so clearly summarizing the difficult concepts of Lean Culture Transformation.
Another greater article from the HPP team and comes on the heels of a recent discusssion I have had with colleagues on standardising work. Standardising leaders work has a vital role to play in service improvement and I wonder whether the fact that it’s missing is one reason why patient and environmental safety problems in some of our hospitals in the UK have been flagged recently.
When working for a Canadian healthcare group in a regional management role I visited those sites I was responsible for at least monthly. Part of what I had was a check list of actions to take and inspections to make. The value of this was a structured approach to the visits and meetings and constant preparation for regulator inspections. Coupling the standardised review of operations with impromptu chats with patients, relatives and staff helped focus on standards of care and developed relationships; it also identifed additional or alternative issues that my review should take into account. And a for me a big bonus was that the check list meant that I had to be out and about in the corridors and on the wards; and that’s where you meet people and hear (or overhear!) problems, challenges or receive compliments.
This approach does improve services. At a very basic level it improves those things that are being reviewed but it also has a knock-on effect to other behaviours; self-management and acceptance of personal responsibility being just two.
Were we perfect because of this approach? Of course not, but I believe we were always getting better. And I will freely admit that having good facility managers helped to maintain and build standards.
So here’s a vote in support of Leadership Standard Work.
Although I can only speak with authority from the healthcare supply chain aspect, I certainly agree that many care and support services delivery teams are well aware of what is necessary to get the daily work done. The simple fact that the work is accomplished does not mean that it was accomplished efficiently and cost effectively while still supporting the requisite high quality clinical outcomes.
Healthcare workers have a right to clearly defined, well documented processes for which they should be held accountable. Well designed and easily accessed policies and procedures provide the necessary process definition and scope of responsibility.
To assure that defined and implemented processes lead to the desired effect, the goal of the process must be defined and metrics must be established and continuously monitored to reveal whether the processes are moving the provider toward or away from the defined goal.
Many provider facilities have high level supply chain metrics that provide little guidance to workers executing basic business processes. When these metrics exceed the acceptable range, there is little understanding of how to determine and mitigate the root cause.
By establishing goals for more granular business processes, establishing metrics and continuously monitoring and posting the results, workers are better informed and more capable of understanding the reason and organizational benefit of their business processes and the management staff is provided with a tool to more effectively manage their responsibilities.
In addition to making these metrics visually available, workers must be educated to the variables that contribute to the measurement so that they have the knowledge to examine and correct poor performing processes. As they are enlisted as team members in resolving poor performance, they assume a vested interest and take ownership in business redesign. The iterative cycle of defining goals, establishing and monitoring metrics and adjusting processes is an ongoing necessity to root out waste and unnecessary cost.
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