Healthcare - Do Passionate Practitioners Sometimes Slow the Spread of Lean?

There is an excellent blog posting on the Lean Blog linking to video clips of an interview with Dr. John Toussaint, the CEO of Thedacare, a healthcare organization gaining notoriety for its successful application Lean. I will not summarize the content here - Mark Graban, who publishes the Lean Blog, has done an excellent job already – you can read his posting and access the video clips here - Thedacare News Coverage & More from Fox News.

However, I thought the first comment after Mark’s post, submitted by Michael Balle, asked an interesting question, “Why isn’t Lean spreading more quickly.” I’m not a Healthcare industry expert, but, for the sake of discussion, let’s assume Lean could be moving more quickly to improve Healthcare as well as other industries.

I recently made a presentation to a small group interested in learning about the application of Lean to Healthcare. The following discussion regarding the perception of Lean making a negative impact on Healthcare may shed some light on the subject.

Craig:

I see two major concerns about Lean from the Healthcare community:

1. it will have a negative impact on the patient experience

2. it will have a negative impact on service providers by making things worse for the physicians, the nurses, the technicians, and so on … (they understand eventually this comes back around to impact the patient in a negative way)

I think people are seriously and legitimately concerned that Lean will have a negative impact on health care; that it will make it more difficult for the providers to do their job in the best way. They are saying, “Lean might reduce cost but at what expense?”

Audience member question:

You said the concerns are legitimate - I’m not so sure. Aren’t those concerns just “resistance to change”?

Craig:

I don’t see it that way. I don’t believe healthcare providers have anything against reducing waste and lowering costs; they understand Lean is a way to accomplish those objectives and they know Lean has worked well in other industries. They just see the Healthcare industry as different. They are concerned applying Lean to Healthcare will make some things worse as it makes other things better. They are particularly worried it might make things worse for the patient.

To gain a better understanding, it is important to note how healthcare providers see their industry as different. They see Healthcare as more concerned about the “human experience” than other businesses. …I use the word human in this instance to make sure we don’t miss the fact that there is an important special perspective involved here.

Let me explain further- if you are making a car there is the perspective of the car. In the auto industry, efforts to improve production and quality often take on the perspective of the car and ask, “What is it that leads to the production of the best car?” But a car is not human. A car is a car.

In healthcare the product is a healthy human being, or better quality of life for humans, or affecting a cure for a human disease. The fact that we are talking about human beings makes it different – human beings and inanimate objects are different. If service providers know of Lean mostly as successful in industries dealing with inanimate products and services, and now it is being applied to an industry dealing with human beings – well I can certainly see a legitimate concern.

Audience Member

I understand what you are saying but I am not sure I agree. Making cars isn’t just about cars. People buy cars for a reason - so in the end it’s about what cars do for people – it’s about the impact on people. So there really is no difference.

Craig:

Excellent point! What that reflects - and you are correct – is your deeper understanding of Lean. You realize producing cars is not just about cars – it’s about transportation; it’s about transportation for people.

Audience Member

…and status and other things.

Craig:

Right again - and I’m glad you bring it up - cars are about all the other things they do for people as well. Again, I think your points reflect your deeper understanding of Lean. What I want to point out here is that when people from the healthcare industry are first introduced to Lean, it looks pretty obvious to them – working on humans is different than working on cars. And that makes the healthcare industry different. To a healthcare worker being introduced to Lean, the difference is justifiably very important. In fact, I think it is so obviously important, it will likely be pointed out again and again. If a Lean practitioner dismisses this important difference, or communicates a superior attitude by explaining the deeper understanding of Lean, before they recognize the valid concern and acknowledge its importance, they will not win many friends of Lean in the healthcare industry.

Audience Member

I can see what you are saying. It makes sense.

Summarizing A3 Management on Last Minute Notice

 

A friend asked me to help him prepare for a last minute interview by summarizing what I know about A3 management.  I thought others might find my response useful.  The summary follows: 

Bruce, (not his real name) 

A3 is being promoted heavily by the Lean Enterprise Institute to emphasize the need to apply more than just the technical tools and methods of Lean but the social/ management side of Lean as well.  Thoroughly understanding A3 is a big undertaking – but you have an excellent advantage – you understand many of the components already.  A3 is structured scientific problem solving to:

· meet company goals

· develop/ coach all employees to be better problem solvers

· develop managers to be effective problem solving coaches and to become creators of more managers with the same capability 

Together these goals ensure the organization will continually improve its capability to deploy strategies, meet goals,  respond to changes in the marketplace, and to solve performance problems.

The name comes from the paper size (roughly 11 x 17) used by Toyota as the standard for creating and displaying  their A3 reports.

The important thing to understand is, “it’s not about the tool”.  It is about the points above.

It can get complicated or it can be kept simple.  One resource book I have lists 9 different types of A3’s used by Toyota.  And, on the other hand, I have worked with companies using only one type. 

In its simpler application, a single A3 form can serve as one stop shopping for learning about a project and how it is going.  It may go through the following logical progression:

· At first the A3 describes the problem, goals, objectives  - agreement is established between the manager and leader (usually another manager; an engineer or supervisor maybe at lower levels of the organization)

· Next an action plan is developed – those closest to the work help put it together and again agreement is established – this time all of the people who are responsible for the action plan are included in the agreement (this is done to ensure the plan is realistic and doable – people closer to the work are better able to determine how realistic the plan is)

· Actions are taken to carry out the plan and at appropriate intervals the A3 is updated – for example, a department level A3 may be updated every month while a division level A3 may be updated every quarter. 

· Lower levels A3’s are collected to support higher level A3’s, to ensure the results are rolling up to successfully meet the goal.  It is typically not a straight mathematical rollup – just a general measured push to get the plan completed and meet the goal. 

You can find examples here made available through the Lean Enterprise Institute’s website.   

You can see it is not very different from methods I know you have used in the past – it just emphasizes some things more:

· clear communication

· reaching common understanding and agreement

· bottom-up action planning   - executives say what needs to be done, employees say how it will be done

· maintaining clear evidence that a working plan, based on a scientific process, is in place and working

· ensuring managers are coaching subordinates to apply the process better and better at every level – executives too 

Lastly – you should know the term Catchball.  You can read a simple explanation here   Catchball – Without it You Probably Have the Wrong Plan

Just about anything else I point you too will just confuse you on such short notice.  Descriptions for A3 Thinking are all over the map.  Thinking of it the way I described above should get you through the interview just fine.

I’ll be around in the morning if you have questions.  Good luck!

Craig

Hoshin Kanri Strategy Deployment, Product Development, and Lean Process Improvement Efforts

I came across the video below while doing some research. Mr. Kelley is “the founder and CEO of IDEO Product Development, America's largest independent product design and development firm. In addition to his work at IDEO Product Development, Kelley is a tenured professor at Stanford University in the school's innovative Product Design program.” (taken from his bio)

The approach he describes is by far the most successful way I have found to carry out the design and implementation of Lean process improvements. The video promotes an iterative development method which begins by putting a basic prototype in the hands of users as soon as possible. The iterative tactic represents what I find to be one of the most powerful aspects of the Hoshin Kanri strategy deployment framework. The approach emphasizes learning your way to the best solution by working in partnership with the end users (consumers). Note how he attaches the characteristic of both “speed” and “best” to the method.

If you found the video interesting you will most likely find the posting below helpful:

Does Hoshin Kanri Rely on a Form of Consumer Opinion?

For a more abstract analogy on an executive perspective of the iterative process as applied to a Lean implementation, please read:

Organic Lean, Natural High Performance – A Racing Analogy Explores Executive Perspective

You may also be interested in reviewing the presentation:

An Intro to Organic Lean – A Natural, Resistance-Free Implementation Approach

Does Hoshin Kanri Rely on a Form of Consumer Opinion?

Utilizing the Hoshin Kanri strategy deployment framework to manage a breakthrough initiative often involves a process design/ redesign effort. The framework guides the project in many ways similar to a product development effort. In product development, it can be advantageous to put an early working prototype in the hands of the consumer to find out what works and what doesn’t. The valuable consumer feedback obtained from this kind of exercise is used to modify or change the design to achieve a better fit. The exercise is repeated until the consumers become satisfied and the design becomes stable.

Hoshin Kanri guides strategic initiatives in the same way. An early basic version of the design is put in the hands of the consumers to get their feedback. But who are the consumers? In this case the consumers are those who will be most impacted by the changes required to meet the objectives of the initiative. For example, for a Lean material management/ kanban initiative the consumers might include representatives from the front lines of the operation, operations management groups such as those responsible for scheduling, production and\or or service delivery, inventory management, and distribution. The sales group may also be impacted and in many cases customers or suppliers may need to be included as well.

The team working through the process design/ redesign must recognize the Lean concept of “seeing value through the eyes of the customer (consumer)” as important and work diligently to uncover and incorporate the feedback into the evolving design. When the team recognizes they are receiving the “thumbs up” from consumers of the planned changes all along the value stream, the team has done its job well. The Hoshin Kanri/ strategy deployment framework includes all of the technical elements necessary to make this happen.

Hoshin Kanri and the Quality Management of Systems on the Move

Hoshin Kanri has been described as the application of quality management principles to change management. And it is true, frequent checks are made to ensure the kinds of breakthrough improvement efforts typically managed by Hoshin Kanri are both proceeding as planned and delivering the expected results. Yet there are certain characteristics which make the quality management of breakthrough improvement different from other applications of quality management. Understanding and handling these differences requires experience, good judgment, objectivity and patience.

To read the full article, click here .

Hoshin Kanri \ Strategy Deployment Keeps Your Implementation from Bogging Down and Becoming Stranded

In a recent exchange with the leader of a service organization we discussed Hoshin Kanri \ Strategy Deployment and the impact the approach has on the speed of major change initiatives. Some questions and answers from the conversation follow (with some editing and additions for clarification):

Question: It seems like Hoshin Kanri is a very thorough approach. Doesn’t such a comprehensive method slow things down when compared to a more traditional deployment (i.e. “command and control”)?

Answer: Actually it does just the opposite – it speeds things up. You see, traditional deployments are carried out with plenty of waste occurring during implementation. As a result, each forward implementation step is accompanied by some backward motion. It’s like struggling to climb a steep sand dune – making progress takes a lot of energy because you keep slipping back downhill. When this happens during a major change initiative it's exhausting, inefficient, and in the worst cases, can spell doom for the success of you project.

Question: Can you give me an example of the kind of waste you are talking about?

Answer: Sure. Major change initiatives require your organization to design and learn new ways of doing things. These efforts typically take place under the pressure of traditional project management deadlines and goals. Having firm goals and deadlines at the outset is fine, but discovering and putting new work practices into use can be difficult and progress doesn't always follow the pre-defined schedule. This can lead to serious problems if the implementation team feels it must move forward even when it’s clear problems are going unresolved. Unfortunately, this is the case with most standard deployments, and, as a result, the further a typical effort proceeds, the more the unresolved issues pile up to bog the effort down. obviously this leads to higher costs and lower proejct ROI.

In contrast, Hoshin Kanri follows a more efficient path through the application of quality management principles. The quality process identifies problems so they can be quickly resolved before they pile on top of one another. Furthermore, the Hoshin Kanri approach replaces the problematic pressure of traditional project management with a healthier pressure to "get the job done right". The increased traction of the more careful approach quickly builds speed to deliver results more quickly - often in half the time required by a more traditional approach.

Question: It makes sense but it sounds sophisticated. Do most organizations have the capability to pull it off correctly?

Answer: Yes. Most organizations carry 95% or more of all of the resources and skills needed to successfully put Hoshin Kanri into use already on board. The remaining 5% may be critical to success but it does not have to be expensive or intrusive. Typically, to fill in the remaining gap, you’ll need hands-on guidance from a small number of experienced professionals working in partnership with your team.

Question: Will I, or my staff members, have to attend lengthy training sessions to put Hoshin Kanri into use?

Answer: Excellent question. No, you and your key staff members just need to understand the main concepts, principles, and some of the more important tools and tactics - all of which can be accomplished in an executive review.

Additionally, you’ll need to appoint a staff member as Champion, or perform the role yourself. And, you’ll need to designate someone responsible for gaining a working knowledge of Hoshin Kanri. The person you select will be educated through a combination of training, “learning by doing”, and guidance from an experienced practitioner. Down the road, after you have experienced the benefits for yourself, you may want to create a permanent staff level position responsible for strategy deployment. We can talk more about that when the time comes.

Response: It sounds like something every organization should take seriously. I’ll start thinking of a project or initiative to use as a test case.