Lean Healthcare Exchange

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I am often asked by healthcare organizations beginning their Lean Healthcare journey, “What is the role of the executive steering committee during the transformation?”

In Lean Healthcare, true transformation involves the development of competencies that may not exist or may lie dormant within the enterprise.  Over time, these will become the way we work.  Therefore, the primary responsibility of the executive steering committee during a Lean Healthcare transformation is to provide oversight and direction until this becomes the way the enterprise works.

The key responsibilities involved in guiding the Lean Healthcare transformation efforts include:

1. Define a vision and transformational roadmap for the organization.  This helps employees at all levels of the organization understand where the organization is going, why it is important, what success will look like, and what they need to do, individually and collectively, for the enterprise to get there.
2. Support the vision/roadmap with a set of established milestones and goals.  This means developing and implementing a measurement system that supports appropriate levels of review.  Monitoring and measuring progress against these milestones and goals and, more importantly, making appropriate course corrections where necessary.
3. Define which value streams will be worked in and prioritize major improvement activity based upon relevance to strategic initiatives, customer impact, and ROI.  Improvement activity not linked to strategic breakthrough finds its way to the back burner fast.  Moreover, improvement requires investment of resource.  Nothing sustains investment like a solid ROI and thrilled customers, both external and internal.
4. Evaluate the effectiveness of Kaizen activity continuously.  Where it is ineffective, we need to understand why and adjust accordingly.  Where it is effective, we need to define mechanisms to redeploy resources or realize the value delivered by improvement events.
5. Drive the alignment of systems and structures to support the transformation.  Often, as we aspire and begin to develop something new, we continue to reward old behaviors and fail to recognize the new behaviors we are seeking.  When we get the behavior change, we transform the enterprise.  The specific elements involved include:

• Organization Design – Lean organizations are typically flatter, more horizontal, and less vertically siloed.
• Recruitment & Staffing – Lean leadership attributes should be included in job descriptions and postings.
• Training & Development – All employees should be trained in A3 and PDSA.  These should be included in new employee orientation.  No promotion into operational leadership roles without demonstrated experience in implementing and using lean management systems.  No promotion into executive roles without demonstrated fluency with Hoshin and change management.
• Performance Management – Lean transformational goals should be in everyone’s goals and objectives.  The performance management system includes not only results, but also the means by which results are achieved.  This plays out at both an individual and organizational level.  Service lines and departments have scorecards or dashboards that link into next-level efforts and are therefore predictive of next-level results.
• Reward & Recognition – This is most critical in the early stages of transformation and includes recognition of transformational efforts with incentive compensation tied to implementation and breakthrough results.
• Resource Allocation – If you want improvement, you must staff for it.  This can get expensive unless you have a systematized method for recognizing where waste was eliminated and freeing up resources to engage in further improvement.
• IT Integration & Leverage – Unless they support what we are doing, our IT systems are useless.  Often the data necessary to populate a simple dashboard, must be extracted from multiple and disparate systems.
• Communication – At a macro-level, we need to make sure we are transparent and communicate how the enterprise is doing with the transformation.  This needs to flow down in like kind, or rather, be emulated from the largest service-line to the smallest department.  At a micro-level, we need to make sure the hand-off between teams or departments are direct and in compliance with rules-in-use within all of our key processes.

This covers the primary roles and responsibilities of the executive steering committee in a Lean Healthcare transformation.  Over time, as we do transform, the items listed above are just the way we work and there is no longer a need for a steering committee.

This week’s blog was written by Brad Schultz, a Vice President with HPP.

Brad serves as a Lean Healthcare facilitator, business consultant, and executive coach internationally with HPP.  Brad began his career in manufacturing with GE Healthcare and joined GE’s Performance Solutions during its infancy and remained with the business unit for seven years. He provided significant leadership to adapt the firm’s products to the unique needs of healthcare clients and to translate the firm’s published materials into the language of healthcare.

Brad’s educational background includes a B.S. in Business Administration from Cardinal Stritch University in Milwaukee, Post Graduate Certification in Quality Engineering from Milwaukee School of Engineering, a M.A. 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.

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What is the most important resource you have and how do you manage it? 

Before you read any further, take your eyes off of this page and stop for a moment to reflect on this question and then read on.

What was your answer?  It may be interesting to pose this question to some of your colleagues and see what they come up with.  It could be a very interesting discussion and could lead to some interesting actions.  Also, did you answer this from a personal perspective or a professional one?

Let me pose to you that the answer to this question both professionally and personally is time.

From the lyrics of “No Time to Kill” by Clint Black, my favorite country artist:

If we had an hourglass to watch each one go by
Or a bell to mark each one to pass, we’d see just how they fly
Would we escalate the value to be worth its weight in gold?
Or would we never know the fortunes that we had ’til we grow old?
And do we just keep killin’ time until there’s no time

How many of you thought that the most valuable resource is people?  People are extraordinarily important in what we do in healthcare but it is what they do with their time that really matters to our patients.  Interestingly, our patients are also investing their time as well, not only for the time they spend in the experience of care but possibly with the time they have left on the planet.

So, are you measuring time with respect to your people? With respect to yourself?  Can you tell me how much of your day is spent in the various categories of tasks and responsibilities that you have by percentage without guessing?  Can you tell me how much of your time is spent in value-added work and non-value added work?  How much of your time is spent in meetings and how much of that time is value added to you? To your patients?  Is there any measure of the effectiveness of all those meetings you go to?

One of the most common barriers to successful Lean Healthcare transformations is the lack of executive and middle management engagement in the improvement efforts including their ability to support and sustain those improvements.  These activities are competing with other things on their very full plates that take their time. Unless they deal with all of those tasks, the time it takes to do them, the inefficiencies in them, the prioritization of them, and so on, they will simply not have the time to engage adequately in organizational improvement efforts.

Therefore, we need to apply Lean principles to their individual schedules, their management systems and their leadership methods if we are to be successful in creating the time to engage.  We must take things off of their full plates if we are to put something else on.  The responsibilities of Lean management and leadership cannot be a bolt-on to, but rather must be a replacement of, other activities. This must occur through prioritizing or creating efficiencies in their current work that gives them the capacity to assume these new roles.

• Don’t:  Just tell the managers they need to support the Lean activity then complain when it doesn’t happen.

• Do:  Map the value stream of a manager’s work using the eight wastes and the four rules in use.  Identify the value added and non-value added activity.  Determine the target condition to help prioritize their tasks including the added work they will need to engage in continuous improvement.  Use Lean Healthcare principles to redesign and define their daily, weekly, monthly and annual standard work with measures and visual management.  Coach them for as long as it takes to achieve stability. Use A3 to course correct if you run into barriers.

In A Factory of One: Applying Lean Principles to Banish Waste and Improve Your Personal Performance, Daniel Markovitz takes a fascinating approach to using Lean principles that we normally apply externally and instead applying them internally to an individual’s work.  It guides the development of a person’s standard work using visual management at a personal level.  One of my favorite examples is the use of time as a metric for the effectiveness of meetings.  Most of the time an hour or two is blocked off for a meeting and the whole allotment of time is used whether it is needed or not.  Talk about putting the cart before the horse! Meeting attendees should be present to deal with the issues listed in the agenda, not to spend a specified amount of time together.  If one uses time as a measurement of the meeting’s effectiveness, then it becomes a priority to remain focused on the management of the agenda, staying on topic and dealing with the issues as quickly as possible so the meeting can end early and give back time.

Consider time as a valuable resource and worth measuring at many levels.  It will tell you where the waste is and where the opportunities are.

“Time is what we want most, but what we use worst.”
William Penn

This week’s blog was written by Dave Munch, M.D. and HPP Senior Vice President and Chief Clinical Officer.

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The book, Lean-Led Hospital Design: Creating the Efficient Hospital of the Future cited research that found more than 50 percent of hospital organizations in America now have some form of a Lean Healthcare initiative in progress.  The research went on to say that less than 10 percent were having measurable success with their Lean initiative.  While the percentage of hospitals attempting Lean Healthcare is impressive, what’s the cause of the low measurable success percentage?   What is happening in hospitals and clinics across America that could be stalling their Lean Healthcare initiative, while some hospitals are experiencing impressive success?

I would like to share with you a sampling of the challenges I have seen in healthcare through my years supporting Lean Healthcare and other process improvement initiatives.  Additionally, I will share some suggested countermeasures that have helped other organizations overcome similar challenges while continuing to transform their patient care culture.

Challenge One: Poor Kickoff

When Lean Healthcare comes to Dodge (your hospital), only a few know about it.  You can see a deputy or two running around trying to get things going, but where’s our marshal? For all the “Gunsmoke” fans out there, where’s our Matt Dillon? Why isn’t the marshal visible, letting everyone know how things are going to be from now on, what they can expect, and what is required from each of them?  In most hospital scenarios, the Lean initiative is rolled out in small pockets of the organization.  There is the absence of a deliberate, celebrated, whole-house announcement to all management and to all frontline employees that there is a better way to care for patients and operate in town.  In a sub-standard roll-out, resistance and obstacles immediately surface around the pockets of Lean activity that are started, creating negative vibes among front-line and middle management employees.  Not a good way to start.  Why are we afraid to fully and publicly commit to such an endeavor? Because it might fail?

Countermeasure:  The right way to begin a Lean transformation in a healthcare setting is to communicate. Let everyone know up front.  Lean initiatives are serious endeavors.  They last a very long time; in fact they should never stop once they start.  They require hefty commitment – in addition to resources – in the beginning.  Entering into a Lean Healthcare transformation requires a desire of the board and senior leadership to change the way their hospital does business. It’s a better way, and it’s a matter of survival.  A kickoff is such an important step.  When done in a thorough and timely manner, it communicates to all the commitment of the board, CEO, and senior leadership, and it lays out what everyone should expect and what is expected of them.  Aaron Fausz provided great direction on effective communication in his blog Communicating for Change.  No turning back this time folks!

Challenge Two:  Divided Focus

Hospitals that are not achieving significant success with their Lean Healthcare initiatives have made the common mistake of trying to “add” Lean on top of everything else they are doing.  All the committees, all the meetings, all the special projects aimed at better healthcare or increased quality outcomes in patient care (not to mention all we do to increase our patients’ perspective of the care they receive).  Let’s not forget special efforts we go through when we know the CDC, the Joint Commission, the Department of Health, or the OIG are coming (the equivalent of brushing and flossing really well only the morning of your dental exam).  A great amount of time is spent by middle management and front-line health professionals fretting and working to accommodate these periodic inspections which are always on top of, or detracting from, daily patient care duties.  No wonder employees complain when they are told they need to “do Lean” now too.  No wonder there is resistance to freeing up departmental employees for Kaizen or other Lean activities, let alone teaching them to do their own problem solving.  Not a good formula for success, is it?

Countermeasure:  Shut down the long standing and non-value-added efforts before we deploy Lean, or tackle the root causes that created the need for all those other distractions through Lean.  Let’s combine the most critical committees into one and greatly reduce their agenda items to the most necessary topics.  Take special projects off the backs of middle management and let them begin to fulfill their new duties of coaching and mentoring their employees to become Lean problem solvers.  Bring in a few PRNs to fill in while our key people who do the work are solving important process problems that they themselves will then sustain.  Create agreed upon senior leader standard work that pulls leaders out onto the floors observing the work occur in order to validate and give importance to the efforts being made.  Is this easy to do?  Of course not.  We all know that anything worth doing is worth doing right, from the beginning.  Other hospitals have gone before, made the changes, given the resources, and are reaping the benefits today.

Challenge Three:  Flawed Game Plan

Too often the decision is made to begin a Lean Healthcare journey and the board, CEO, and other leaders assume their job is done. The troops begin to receive some training and rapid improvement exercises are held.  Sounds good, but how about senior and middle management?  When are they trained?  When do they get to participate in Lean concepts and tools training?   What Lean cultural and process improvement exposure will they have before the battle against poorly designed processes and waste begins?  The leaders are frequently out-of-touch with what those who follow them are about to experience when the Lean initiative actually begins in the trenches of patient care.  No leadership team would make this kind of move intentionally.  Most often it is an oversight that is based on an underestimation of what Lean Healthcare really is, and just how immensely important the role of the entire leadership team is to its success.

Countermeasure:  If any hospital wants to be successful with their crucial decision to begin a Lean Healthcare journey, the entire leadership team must be the first to know about, understand their role in, and commit to it.  That means leadership should receive the training necessary to understand Lean culture and concepts, gain a grasp of the tools, play a part in setting the vision, and, most importantly, embrace their role in the transformation to Lean thinking and problem solving.  That means the time must be made to attend training and participate in meetings and events.  This is so crucial, I can’t say enough about it.

I know some of this can be a bit tough to accept, since it is a major commitment (think about the last time you started a major diet or exercise program).  Change is always challenging. It requires understanding, courage, strong leadership, and the respectful drive to get it done.

This week’s blog was written by Matt Hanrion, Senior Manager with HPP.

Matt has more than 30 years experience with Lean and provides consulting services in a variety of areas within healthcare.  He is a lead trainer with HPP and has coordinated TQM teams within every area of a hospital system, developing and rolling out TQM education to staff.  Matt has a B.A. from Westminster University with a double major in Computer Science and Biblical Studies, and a M. Ed. in Education from Columbia International University.  In addition, Matt served in the US Pacific Naval Submarine Fleet as a Missile Launch Systems Petty Officer and is a Vietnam Veteran. 

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President and CEO Maureen Bisognano of the Institute for Healthcare Improvement (IHI) challenged healthcare professionals last December at an IHI conference to learn improvement methodologies, lead change, and spread success.

How do we first find the improvements, lead changes and then spread? Lean Healthcare has proven methods to do both. I often hear the term “Change Management” but managing change is not enough because, to manage change one must know what change is needed.

Lean Healthcare includes the tools to define the change needed, capture the current state to know when change really occurs, analyze for the contributing factors to poor outcomes, develop countermeasures that prove their worth, and then standardize and spread the changes. We believe Lean Healthcare principles have been and will continue to be the keys to changing the challenged healthcare system we know today. We need more change leaders to apply Lean tools on the most critical issues. The late Peter Drucker, in his last book, Management Challenges for the 21st Century, provided an insightful look at the future of management thinking in practice.  Four factors of change leadership from the book stand out to me:

1. Making policy to make the future. Simply stated, the organization must make change a policy. Measuring an annual rate of change is living it. Unless it is seen as the task of the organization to lead change, the organization—whether business, university, hospital and so on—will not survive. As Drucker states, “In a period of rapid structural change, the only ones who survive are the change leaders.”
2. Drive for continuous improvement starts the chain of events that leads to fundamental change. This chain goes like this: Continuous improvement leads to product innovation, which leads to service innovation, which leads to new processes, then new businesses, and finally fundamental change.
3. Pilot on a small scale. Drucker believes, “Neither studies nor computer modeling are substitutes for the test of reality.” Drucker argues that today’s workers are not the workers of the past. Today’s workers provide value in their knowledge, not merely their sweat.  Knowledge workers need to see frequent progress or will leave for opportunities where they can see progress in things that matter today and in the future. “Working on the past versus building for the future can kill a company.”
4. Balance change and continuity. The organization needs to engage its partners. Partners include the organization’s own knowledge workers as well as suppliers, customers, and the community. Sounds like Accountable Care Organizations at work, doesn’t it? Dr. Deming’s phrase for describing the balance of change and continuity is “constancy of purpose.” Change is difficult for many, especially in an organization in which change is not yet the norm. Stability in the mission, strategy, and rewards provides a balance to change.

Healthcare has been a leader in management theory and practice. Peter Drucker tells the story of Frederick Taylor, regarded as the father of scientific management. Taylor testified before Congress in 1912 that healthcare’s own Mayo Clinic is “the perfect example of scientific management.” Taylor based his opinion on Mayo being the first integrated group practice stressing a teamwork approach. By being cured, patients discovered the advantages of doctors pooling knowledge.

Drucker adds, “One does not ‘manage’ people. The task is to lead people. And the goal is to make productive the specific strengths and knowledge of each individual.”

For those who want to apply Drucker’s ideas and believe in spreading progress, we find focusing knowledge workers with Lean on value-based purchasing (VBP) and readmissions metrics is a good place to start. Constancy of purpose is clear as CMS mandates hospitals to adhere to these evidence-based measures that must result in better outcomes for patients over the next few years. As we target our most important measures within VBP, we are more efficient and effective in capitalizing on the strengths and knowledge of each individual. By applying Lean Healthcare principles, we can improve the most important measures, such as preventing healthcare acquired infections and readmissions. It is intrinsic to Lean Healthcare to then spread success. Together, with Lean Healthcare, we are doing it.

Today’s blog was written by Rick Morrow, Executive Director at HPP.

Rick has 25 years of leadership experience in healthcare and other industries as a leader in performance improvement and safety. He leads HPP client engagements in the U.S. and Europe. Prior to HPP, Rick held the position of Director, Business Excellence with The Joint Commission and led the Center for Transforming Healthcare. In this position he was the Deployment leader for the Joint Commission’s Lean Six Sigma initiative leading teams in developing solutions across America and launching globally.  Rick developed The Joint Commission’s Lean Six Sigma belt and leadership training, and leading collaboration in improving hand hygiene and reducing wrong site surgery.  He is an international speaker on Lean and Six Sigma. Prior to the Joint Commission, Rick held senior level Continuous Improvement positions with United Airlines, Motorola, SKF and Eaton.

Rick holds an M.B.A. from the University of Illinois’ Executive Program.

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This is the second of a two-part blog about communicating for change.  If you missed last Thursday’s blog on the guiding principles of communication, catch up by reading Communicating for Change: Part One.

Communication Content

In Lean Healthcare, and with any proposed change, there are a number of important messages to be communicated.  The most important of these messages pertain to the change itself and its impact on managers and employees.  If managers and employees understand the reason for the change, why the organization is committed to this change, and what part they will play in ensuring its success, they will be more likely to support the initiative.

Because people will not typically support something simply because someone tells them they should, key things to communicate include information about the change itself are:

• The current situation and the rationale for the change (why is this change needed)
• A vision of future outcomes after the initiative is completed (streamlined and simplified processes, fewer errors/mistakes, shortened patient wait times, etc.)
• The basics of what will be changing (scope of the change), how it will change, and when the implementation will take place
• The organization’s goals/objectives for the change initiative
• The expectation that the change will happen and is not a choice (risk of not changing)

Obviously, the overall goal of your change initiative (i.e., accuracy, efficiency, effectiveness, waste reduction, cost savings, etc.) and its major components  should be communicated.  The overall benefits of the change effort should also be communicated.

It is also critical to communicate messages about how the change initiative will impact employees, such as

• The impact of the change on the day-to-day activities of managers and employees (What will I need to do?  What’s in this for me?)
• Implications of the change on job functions, if applicable
• Specific behaviors and activities expected from managers and employees during and after the change
• Status updates on the progress of the change, including success stories
• Procedures for getting help and assistance during the change planning, during the go-live period, and once the changes have been made

All communications, both direct and indirect, should be targeted to your good, hard-working employees.  Many organizations make the mistake of focusing on people in problem areas or on those who are believed to be resistant to change.  Keep in mind that you should be trying to reach the majority of people and emphasizing the many benefits to them as a result of the change.

Communication Sources

Like most aspects of effective communication, there is no one best source.  Our experience with numerous healthcare organizations across the country has shown that redundancy and repetition of a consistent message from a variety of sources is most beneficial in creating effective communications and minimizing resistance to change.

A study by Prosci (a company that conducts research on change) examined the success factors associated with change initiatives in 288 organizations located in 51 countries.  Their study, shown in the following graphic, summarizes employee perceptions regarding the most effective sources of communication about change.  From most effective to least effective, employees rated communications from the following sources:

1. Their immediate supervisor
2. The organization’s President/CEO
3. Other organizational executives (i.e., COO, CNO, CFO)
4. Senior managers (i.e., Vice-Presidents, Directors)
5. Department heads and charge nurses
6. Change implementation team member (i.e., change team member)
7. Change implementation team leader (i.e., change team leader)

Because immediate supervisors were rated by employees as the most effective source for communications about change, your change team should begin communication and training with leaders and managers before deploying to employees.  This will provide the opportunity to:

• Help leaders and managers understand why the change is taking place and understand their role in the change implementation
• Help leaders and managers understand the benefits of the change
• Enlist leader and manager support for the change during the employee rollout, including delivering communications to their employees

Communication Roll Out

Your change team should establish communication links with organization leaders, managers, and employees.  Establishing these multiple lines of communication will help to address issues/concerns early in the change effort, as well as help avoid any potential complications in the future.  Frequent and ongoing communication about the change should begin early in the initiative and should continue throughout the change process.  Your communications should strive to:

• Provide stakeholders with the information they need to effectively adopt the change
• Build trust by communicating relevant information that stakeholders need to promote buy-in and ownership
• Provide two-way communication vehicles so that stakeholders affected by the change can be responsible contributors to the success of the effort

As communications are rolled out, be sure to keep in mind that quantity of information is less important than quality and consistency.  It is impossible to communicate too much information if it is significant and substantial, but it is very easy to communicate too much insignificant or irrelevant information.

Aaron will be co-facilitating a workshop at the upcoming Lean Healthcare PowerDay - Leading Change in Lean Times.  This interactive workshop will present a framework to help participants prepare and plan for change initiatives.  Attendees will also learn successful concepts and methodologies to overcome the natural resistance to change and strategies for communicating more effectively.   For more information on all PowerDay workshops and sessions visit www.LeanHealthcarePowerDay.com .

Today’s blog was written by Aaron Fausz, Ph.D., Senior Manager at HPP

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During times of change uncertainty is a given, and fear of the unknown a common factor.  People do not always understand why a change is occurring and tend to be wary of moving away from the familiar—especially in Lean Healthcare.  This is where internal communications can prove invaluable—the more managers and employees know about what is happening within their service lines, departments and units, as well as across the organization, the more they can align themselves with the organization’s values and objectives.

Resolving to communicate effectively is one thing. Achieving it is another.  Change is not just about how people act but how they think, and a change will never be successful if people’s actions are not the result of an instilled belief in the change itself.

There are numerous pitfalls to effective communication, such as one-sided (usually downward) communications, suppression of information, mistakes being communicated, and intentional distortion.  These must all be considered when formulating a communication strategy and structure.  But regardless of the approach adopted, there is no excuse for transmitting baffling or convoluted information.  Careful thought must go into what is communicated as well as how it is communicated.  Transition is inevitable in modern healthcare organizations, and effective communication can have a significant positive impact on how the changes of Lean Healthcare are handled by everyone across an organization.

Communication Objectives

Before communicating about any change initiative, you should formulate objectives for your communications, which may include:

• Developing brand awareness (i.e., create an identity for the change)
• Establishing communication standards
• Ensuring consistency (in tone, content, and delivery of all messages) across the organization
• Promoting the credibility of the change initiative through visible leadership support
• Placing willing participants in the spotlight whenever possible and having them share their story with other audience/stakeholder groups
• Consistently monitoring the organization for and communicating success stories
• Communicating through a variety of channels (i.e., direct and indirect)
• Encouraging involvement and engagement of all stakeholders by providing opportunities for them to participate in the change process
• Communicating personal impacts and addressing personal concerns
• Reinforcing the personal message (i.e., show people what the change will mean to them)
• Maintaining momentum (i.e., share wins, promote milestones, recognize success)

Guiding Principles for Communication

There are a number of guiding principles that should be followed when creating and delivering your communications. These include:

Timing – Most organizations underestimate the length of time required by a change cycle; hence the numerous examples of poor performance following a variety of change initiatives.  Just as Rome wasn’t built in a day, neither do people or organizations change overnight.  Every change initiative should be thought of as an ongoing process of changing some very ingrained behaviors and habits.  Therefore, communications should begin early in the initiative and occur frequently and consistently throughout the entire implementation process.  

Frequency – The frequency of communication should be driven by the type of change being undertaken, the progress of the change itself, and any questions/concerns raised by managers and employees who will be impacted by the change.  There is no best frequency for communications (e.g., monthly, weekly, etc.).  The key thing is to maintain regular two-way dialogue with all stakeholders regarding the change initiative and its status as well as to ensure all stakeholder questions are addressed.

Communication Channels – There is no one best way to communicate about change.  Change is uncomfortable, and adapting to change is messy because behaviors and long-held habits are not easy to overcome.  The most effective communications vary in terms of both the type of communication (i.e., how it is delivered) as well as the specific message and characteristic of the communication (i.e., what is delivered).

In relation to the delivery of the message, direct, face-to-face communications are generally most effective.  Direct communications are regarded as successful for conveying messages about the need for change, providing details about roles and expectations during the change process, describing the future state, and responding to questions.  Examples of effective methods of direct communication include:

• In-service sessions
• Group and team meetings
• Service line, department, and unit meetings
• Town hall meetings
• Presentations and demonstrations
• One-on-one discussions
• Focus group discussions
• Training sessions and workshops

When conducted in a manner that is open, transparent, and safe (i.e., no backlash against staff members who ask questions or raise concerns), direct communications also provide clear evidence of the support and commitment to change by organization leaders and project sponsors.  In contrast, indirect forms of communication should only be viewed as methods to reinforce direct communications.  Indirect forms of communication include:

• E-mails
• Memos
• Newsletters
• Bulletin boards and break-room postings
• Posters
• Intranet site
• FAQ’s
• Videos
• Paycheck stuffers
• Laminated pocket guides 

Both direct and indirect methods of communication should include mechanisms to encourage two-way sharing of information.  All staff members should be given multiple opportunities to share concerns and ask questions.  The more people know about the change itself and the more they are involved in the change process, the less likely they will be to resist the change and/or act as internal saboteurs.  In addition to allowing people to ask questions, responding in a timely manner with answers to the questions and concerns raised should be a top priority for leaders, managers, and project team members.

Tuesday’s blog will continue this discussion by examining communication content (i.e., messaging), communication sources, and the roll-out of your communications to managers and employees.  Update: Part II now posted

Aaron will be co-facilitating a workshop at the upcoming Lean Healthcare PowerDay - Leading Change in Lean Times.  This interactive workshop will present a framework to help participants prepare and plan for change initiatives.  Attendees will also learn successful concepts and methodologies to overcome the natural resistance to change and strategies for communicating more effectively.   For more information on all PowerDay workshops and sessions visit www.LeanHealthcarePowerDay.com .

Today’s blog was written by Aaron Fausz, Ph.D., Senior Manager at HPP

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Many hospitals have experienced very successful, sustainable Lean Healthcare activity. As well, many hospitals have also participated in Lean activities that have not gone as planned or have been followed by deteriorating results over time.

No attempt at improvement is a complete failure, as long as we learn and strengthen our approach for the next process improvement effort. It is healthy to stumble, then to reflect on what caused the failure. Here is a hard question that I first heard from a Lean colleague, Dave LaHote, president of Lean education at LEI.:

What is the most common or root cause of failure?

As with any good coaching question, it isn’t easy to answer. It requires a lot of reflection. Mr. LaHote would advise you that lack of agreement is the answer. While a spirited debate on the answer to this question could certainly be held, for now let’s accept it as true.

That being the case, how do we get to agreement? In many cases, agreement can be achieved with dialogue and reasoning. If disagreement persists, the application of the scientific method can help. The most important piece of agreement is the understanding that it takes time to reach. People have a tendency to resist change, and typically they cannot be convinced of the value of change overnight. Launching into the work with a plan to achieve buy-in from involved parties later will result in long-term failure of the effort.

By allocating the time for agreement before engaging staff in improvement, we set a foundation for long-term success. We need to go slow to go fast.

I’ve seen many Lean Healthcare events fail due to a lack of agreement in the chartering or planning process. Successful improvement requires allocating time to achieve these things in order to avoid failure:

• Participation at every level of the organization.
• Determining the activities that each level must perform and when.
• Communicating role and responsibility to each level.
• Gaining agreement and a commitment to performing these responsibilities reliably.
• Addressing the above issues before the improvement work is launched.

Here is an example:

An improvement team working on timely transfer of patients from the emergency department to the floor is preparing for a rapid improvement event.

A critical aspect of this work will be the willingness of the med-surg floor to accept the patient within a certain amount of time, say 30 minutes.

The process will need to be developed. The staff in med-surg will need to have the support of their managers in the change, which means they will need to find the capacity to do this work, and there will need to be measures and coaching from these managers.

Have the managers agreed to do their part of this work ahead of time? If not, we know what will happen. The managers won’t have this implementation as a priority with all the other tasks they need to do throughout the day. That means that the measures and coaching won’t occur. This in turn will lead to sub-optimal implementation and it will be unlikely that the goal will be met or sustained over time. It is better to have that conversation with the managers before starting the work, surface the problems or barriers that the managers have in accepting these responsibilities and resolve them beforehand.

Similar conversations and agreements will need to occur with the executive team members, the improvement team lead, the facilitator, the team members and the frontline. They all have specific roles to play in the success of the improvement.

Getting to agreement on roles and responsibilities before a project is launched will significantly increase your chances of success. Investing the time before the event is well worth it. Otherwise, you will spend extraordinary amounts of time following implementation dealing with the problems based on confusion or lack of agreement of roles and responsibilities. In the worst-case scenario, you will have spent the time and energy of many people to attempt an improvement that has not sustained itself. Morale is low and you’ve created a self-fulfilling prophesy that Lean doesn’t work.

With just a bit more time invested up front in getting to agreement, this doesn’t have to be the case.

Go slow to go fast.

Dr. Munch will be facilitating a workshop at the upcoming Lean Healthcare PowerDay – Improving Quality Management to Prepare for the New Healthcare Environment.  This workshop will cover requirements and tools for leaders and staff to improve processes that deliver safer, more reliable care.  Participants will learn how to dismantle a culture of “blame,” and how to reward the right behaviors to prepare for CMS’ Value-Based Purchasing and Hospital Readmission Reduction Programs.  For more information on all PowerDay workshops and sessions visit www.LeanHealthcarePowerDay.com .

Today’s blog was written by Dave Munch, M.D. and HPP Senior Vice President and Chief Clinical Officer.

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At the beginning of a Lean Healthcare transformation, I am often asked by clients, “What is the most critical factor for our success?”  My answer is one that I believe in completely:

Leadership, and specifically leadership involvement and support, are critical to a successful Lean Healthcare transformation.

But what that answer means and how it translates to the organization at the beginning phase of their Lean Healthcare transformation is difficult for the leadership to understand or comprehend.  It is easy for the leadership to mouth the words of support, to show up at kaizen and 5S event report-outs and say, “Good job!  We are doing the right things! But, now I have to get back to my real job of running the unit (department, hospital, and so on)…”

Will this organization make improvements?  Improve quality?  Save money?  Yes, it likely it will.

Will this organization sustain change and transform its culture to a Lean Healthcare culture?  It is very unlikely.  The flame will burn brightly but eventually will flicker and die out.

So what is missing?

The answer is Leadership Standard Work.   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 and daily accountability.

Sounds simple enough, but this concept of Leadership Standard Work can be difficult to implement.  It is truly a culture change inside a culture change.  Leadership Standard Work can be divided into three components:

1.  Auditing and Verification of Direct Reports

It starts with the standard work tasks of the front line staff.  The supervisor begins the Leadership Standard Work cycle by verifying the standard work tasks of their direct reports.

That supervisor reports to a director.  That director’s standard work is verifying the standard work tasks of their supervisors.  The director reports to the administrator who verifies the standard work of the director.  The administrator reports to the executive as the standard work builds upward and the executive verifies the standard work of the administrator.

These are the interlocking layers of accountability that are the basis for sustainment.  This layering supports the disciplined adherence, the accountability and root cause problem-solving that is necessary for sustainment and is the first component when building Leadership Standard Work.

2.  Define the Outcome Metrics

What metrics indicate the department is performing well?
What are the process characteristics and attributes necessary to achieve those outcomes?
What are specific behaviors and tasks necessary to achieve those outcomes?
What are the controls in place to ensure those behaviors are present every day, in every case?

Defining the outcome metrics and determining how you as a leader can ensure these attributes, behaviors and controls are occurring is the second component when defining Leadership Standard Work.

3.  Leadership Tasks: 

These tasks are not meetings and answering emails.  These are process related tasks that must occur on regular intervals and fall into three categories:

1. Scheduled tasks -put the appropriate audits in place to ensure disciplined adherence to process
2. Unscheduled but predictable tasks – ensure adherence to service level targets
3. Unscheduled and unpredictable tasks – ensure adherence to service level targets and no disruption to scheduled tasks to accomplish.

Let’s look at a Unit Supervisor as an example:

1. Scheduled task –Passing out medications
2. Unscheduled but predictable tasks – Direct admissions
3. Unscheduled and unpredictable tasks – Call bells or changes in a patient’s condition.

After defining these three components, you now have the basis for the Leadership Standard Work checklist.   Examine the list and prioritize the items.  Prioritizing the list is categorized by the level of the leader or manager.

• At a frontline level the focus is on process, problem solving, and the elimination of waste (muda)
• At the  mid-management level the focus shifts slightly to resources, team development, and the mitigation of unevenness in operations (mura), and overburdening of people and equipment (muri)
• At the executive level the focus shifts to systems and strategic alignment along with the mitigation of muri and mura.

The standard work is documented in a simple format that specifies what the leader will do on a daily, weekly, or monthly basis.  Depending on the level of the manager, more tasks might be in the daily section (front line) versus more in the monthly section (executives).  This list is now the standard work that starts the process.

How do you implement Leadership Standard Work?   

First of all, it occurs at the gemba but, now with a specific focus.  Second, weekly “one-on-one” Leadership Standard Work reviews with direct reports are critical, with checklists reviewed for several key items:   Are the checks being done?  If not, then coaching must occur to understand why this is not occurring.  Secondly, what are the results telling us?  If the checks are being done and the results are good one day and bad the next day then how can we ensure there is a clear standard and standard work is being followed?  If the checks show overall non-compliance, then what are we doing to insure the accountability?  This “one-on-one” is a problem solving session at the gemba.  It occurs at each level of the organization on regular basis with direct reports sharing the results of their leadership standard work with their supervisors.

So why is this difficult?  Because it must be built from the bottom up, not the top down.  It requires a leader to understand what their direct reports are doing every day to affect the goals and strategies of the organization.  Additionally, it is difficult to change the attitude of, “Now I need to get back to my real job…”  In a Lean Healthcare organization this is your real job!

Leadership Standard Work is built into the natural stream of your day and your work.  It allows you to be proactive when addressing problems and gives you the opportunity to truly understand the manner in which your unit, your department, or your hospital is functioning.

Leadership Standard Work is the engine, the driver and the impetus for sustainment of a lean management system and the transformation to a lean culture.

If you need more information on how to implement Leadership Standard Work, come hear success stories straight from the gemba at the 2013 Lean Healthcare PowerDay, April 1 and 2! Register today at www.leanhealthcarepowerday.com. 

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The primary customer in healthcare is ultimately the patient, but who is the customer of leadership?  Who provides the direct value to the patient?  Lean Healthcare leaders understand in a purist sense that their work is non-value added to the patient.  Value to the patient comes from improving processes to enhance the direct caregiver’s ability to provide value.  Thus, the customer for leadership is the staff who provide direct value to the patient.  Just as front line has waste in their work, leadership needs to examine and eliminate waste in how they spend their time.

Recently, I had the opportunity to work with a hospital that was committed to getting leaders to spend more time in problem solving with staff at the Gemba (where the real work of the organization is done).  In assessing their current state, they found that 67% of a leader’s time on average was spent in formal and informal meetings.  As they examined the time spent in meetings they realized two types of waste responsible for the lack of value in meetings; meetings were either “batched” or “botched”.

Batched (Waiting):

Leadership identified that they provide value by helping staff do their job better or by helping staff with employment logistics (e.g. salary, benefits, scheduling, etc.).  The majority of information was communicated in once a month staff meetings.  Even though staff meetings were mandatory, attendance was consistently around only 70% during any portion of the meeting.  Throughout the meetings those who were actually working a shift left to care for patients.  Information was saved from one month to the next to share with staff.  In place of the monthly meetings, managers tested having short daily huddles (5-10 minutes) to share information for the current week.  Information was also tailored to clearly identify what the staff were expected to do differently.  By transitioning the monthly staff meeting time into daily huddles, managers were able to shorten the wait for information distribution from as long as 3 weeks to only a few days, and standards were set to convey only the information that was meaningful to the particular floor or unit.  Eliminating the monthly meeting saved hours of non-productive time each month for staff—especially for one patient care unit who came into work only for the staff meeting.

Botched (Defects):

The other waste identified was that meetings were unproductive.  Numerous examples were given of meetings with no agenda or clear purpose, critical team members being absent from the meeting, and lack of preparation or follow up for the meeting.  These lean leaders recognized that standard work for meetings did not exist.   As the team developed standards, they found that only 40% of their current meetings contained the critical elements identified in their new meeting standard work.  The team identified at least 4 hours of time on average for leaders to redeploy to time spent with the front line staff in Gemba Walks.

Applying the same principles of identifying and eliminating waste in all processes is essential to fully implementing Lean Healthcare in your organization.  Take a look at your own leadership standard work.  What other wastes can you identify and eliminate in the meetings you attend or perhaps do not even need?

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.  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 has an associate degree in Nursing from Joliet Junior College and a bachelor of science in nursing with an emphasis in healthcare management from Metropolitan State College in Denver, Colorado. Maureen achieved certification from the National Association for Healthcare Quality, certified professional in healthcare quality (CPHQ), Colorado State University in process mapping, and University of Michigan in Lean Healthcare.

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Visuals are such an important part of Lean Healthcare, and everyday life for that matter, that it is not surprising that most people focus on the Daily Management Board component of their Daily Management System. After all, it’s a visible part of the system, right?.  This notion can be a bit misleading and can cause employees to miss the true power of the system, akin to ignoring the submerged portion of an iceberg.  A true, disciplined Daily Management System should be the nucleus of a sustaining, engaging Lean transformation process. It’s not about the boards!

Here’s a high-level framework. In addition to the “tip of the iceberg,” is your Daily Management System composed of these pieces?

Daily – It is absolutely crucial that everyone in the organization meet daily for 15 to 30 minutes to discuss how they did against yesterday’s goals, what they need to accomplish today to satisfy customer demand, and what problems they need to solve to meet their goals.  While work and outcomes occur in minutes and hours (and sometimes seconds), we in healthcare are conditioned to look at monthly and quarterly metrics.  By then, it is too late to adjust processes to positively impact those metrics.  Both outcome and process metrics must be reviewed and acted upon by management daily.

Management – Managers organize and lead teams to achieve the organization’s goals in support of its mission.  A brief huddle at the beginning of each day with the manager’s team sets the tone for the day by keeping everyone focused on the team’s objectives and giving them frequent feedback on their performance.  The longer it takes to provide feedback, the less valuable it is.

System – A system is an organized set of processes which delivers value to customers.  It is interesting that the customers of the Daily Management System are the managers and team members.  The ultimate beneficiaries, however, are the patients.  The processes in a Daily Management System include updating the boards each day before the meeting, the meeting itself, and completing the action items that come out of each meeting.

The Daily Management Boards are a powerful visual tool to make the Daily Management System efficient.  The boards are not the system.  They allow each team and individual to see how they are doing at a glance, which allows them more time to use their teamwork and problem-solving skills.  I believe that healthy Daily Management Systems are the single most important ingredient to sustaining a Lean culture in your healthcare organization. 

Has your hospital implemented a Daily Management System?  Share with other readers in the comment section below:  What has made it effective (or ineffective)?

Today’s Blog was written by Dwayne Keller, Executive Vice President of Operations at Medical Reimbursements of America (MRA). 

Dwayne is leading the implementation of Lean in MRA’s revenue cycle operations. Prior to MRA, as COO of Healthcare Performance Partners (HPP), he coached hospital executives and all levels of leadership in the implementation of Lean Healthcare, resulting in significantly improved outcomes.  Dwayne served as a general manager over two manufacturing plants at Alcoa and was also responsible for driving business results through Lean implementation in five Alcoa business units as an executive Lean coach. 

Dwayne holds Master’s and Bachelor’s degrees in Mechanical Engineering from Bucknell University and a MBA from Clemson University.

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