When asked about the greatest challenge in teaching American managers the Toyota Way, former North American President of Toyota Atushi (Art) Niimi simply replied, “They want to be managers not teachers”.  He then explained that every manager at Toyota must be a teacher.  This simple yet powerful statement may well be one of the most important and all too often overlooked aspects of becoming a Lean organization. 

If you were to observe typical leaders in any industry in America, they go about their day almost oblivious to the details of how work is performed.  Dismissively they comment that their people have been through the appropriate training or should have learned what they need to know in school before coming to work here.  Besides they have an arsenal of disciplinary mechanisms at their disposal if associates really screw up.  Yet in so doing, they have hit the start button on a ticking time bomb of process variability (V-Bomb) and sealed their fate as masters of chaos.  

They swoosh through their work areas offering the usual cordialities “how’s every one doing?”  Yet before an answer can be heard they are at their desks reviewing emails and progress reports…tick tick tick.  They attend committee meetings to figure out why quality is mediocre, productivity is low and employee moral seems apathetic….tick…tick…tick…  They construct elaborate incentive programs to motivate employees to improve performance.  Unwittingly they have only added fuel to the V-bomb by encouraging employees to abandon their standard work processes and take short cuts …tick tick tick…. Front line clinical leads spend their day trying to put out fires due to non-standardized processes of the front line staff.  Employees become disgruntled as solutions are developed by management in committee meetings with no front line involvement.  Committee solutions are passed down as formal policy with the threat of disciplinary action for those who violate these new rules, “sign here that you understand this new policy and will follow it or risk termination” …tick tick tick…Time Bomb

KABOOM!…All of a sudden the V-bomb goes off: a patient falls over here, a near miss happens over there, equipment failure over here, missing supplies over there.  Everyone scrambles and starts reacting frantically to “fix the problems” while violating every standard protocol along the way…”just use the Pyxis override and we’ll sort it out later”.  After the usual grilling from the boss about how sloppy everyone was and how “we need to try harder” everyone goes back to business as usual and the start button on the bomb of variability has been reset…tick tick tick…

Contrast this to a Lean Healthcare organization whereby employees are brought together to develop their own standardized work methods based on their own best practices and an educated eye for simplicity through waste elimination.  Nothing is taken for granted as the team documents the work using job breakdown sheets to offer details of technique, quality and safety precautions for each major step of the process.  They explain the rationale for performing each step in order to create understanding for those being trained to perform this standard process. 

Clinical leads have primary responsibility for assuring all front line staff is trained to this standard work using the proven Lean Healthcare Job Instruction method that assures clear understanding and retention of the work detail.  They spend their day providing support to the front line staff and monitoring their ability to perform the standard work in a timely manner.  They observe with great compassion, keenly looking for obstacles to safe and efficient operation.  They ask supportive questions.  Do you understand the steps to your standard work and why they are important to patient safety?  Do you have the supplies you need to do your job?  Is the equipment available and functioning correctly?  They understand that the forces of variability are constantly working against standardization and that it is their primary job to maintain process control.  They correct what they can on the spot yet also begin to document each obstacle as a team problem solving opportunity to be addressed at the end of the shift. 

Meanwhile floor managers/directors are touching base with these clinical leads asking what opportunities for improvement they found today and what they can do to help resolve the problems.  Experts in problem solving and the Lean Healthcare system teach the team how to determine root cause and implement countermeasures through structured experimentation.  They engage support groups such as supply organizations, equipment maintenance, and other departments to collaborate in team problem solving.  They help support the revision of standard work by front line staff and remind them that their continued commitment to following standard work and finding ways to improve it is the most important thing we do in this hospital to assure safe, high quality care for our patients. 

Committee meetings begin with managers/directors sharing success stories from their staffs’ innovations and planning which departments should collaborate to share these best practices across the system.  The other half of the meeting is reviewing where the hospital stands in regards to strategic goals and objectives to help focus staff improvement activities to close performance gaps.  Managers/Directors return to their staff to ask for volunteers to work with other departments to share knowledge and standardize best practices throughout the system.  They communicate performance gaps in the strategic objectives and challenge them to use their problem solving skills to come up with innovative ways to assure hospital safety and prosperity.  

It seems mysterious to the casual observer how Lean Healthcare organizations can simultaneously improve cost, quality, customer service and employee satisfaction.  Yet when leaders take the time to teach employees how to “make the right work easier to do” the mystery is solved.

This week’s blog was written by Gary Bergmiller, Ph.D. Gary brings 25 years of experience directing Lean system design, implementation and cultural transformation  Gary has served as the senior official leading lean transformations for world class companies such as GE, Philips, and Cox corporations. Prior to joining HPP Gary worked with Toyota Way series author Dr. Jeffrey Liker to develop a Toyota Way academy healthcare workshop. Additionally, Gary was hand selected by Dr. Liker to lead the implementation of the Toyota way for the entire western US and Canada Hertz operations. He has authored a series of articles based on his research that have been cited in the EPA’s current research effort Lean and Environment: Next generation and Jeffrey Liker’s book Toyota Culture. Gary holds a Bachelors degree in Electrical Engineering from Northeastern University, a Masters in Engineering Management from University of South Florida and a Ph.D. in Industrial Engineering from the University of South Florida.

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