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The Escalator of Issues

by James P. Womack
September 7, 2018

The Escalator of Issues

by James P. Womack
September 7, 2018 | Comments (5)

I’ve spent a lot of time in recent years trying to understand how organizations can create basic stability in their daily operations through rigorous daily management, with the objective of creating a stable platform for sustainable improvement. One of my most intense efforts was repeated observation of daily management practice at Lantech while serving as the editorial advisor for Jim Lancaster’s book, The Work of Management. This volume presents what I believe is a compelling method of daily management for a relatively small manufacturing business -- fewer than 500 employees with only two production facilities.

Toyota provides an alternative example, using the same basic methods in a very large manufacturing business with 364,000 employees all over the world. This organization is surely the global leader in daily management and continuous improvement targeted to support top-level hoshin objectives, as I described from direct observation in my previous Lean Post The Cascade of Hoshin.

But what about large businesses in service industries that I believe might gain even more benefit from daily management? I have seen many examples of daily huddles at the front lines in financial services, fast food and restaurants, healthcare, etc., with cumbersome attempts to aggregate the findings for higher levels of management. Until recently I had not seen anything that felt like a robust and sustainable process that created the foundation for improvement. (I’m not saying these haven’t existed, of course. It’s a big world and I can’t see everything.)

In March, at the LEI Transformation Summit in Nashville, Dr. Lisa Yerian and Nate Hurle from the Cleveland Clinic asked if I would visit to observe the daily management system they have recently helped install at the Clinic’s operations in Ohio. (12 hospitals, including the 1400 bed main campus, with the intent to involve all 53,000 employees.) (Full disclosure. I have never had any relationship with the Cleveland Clinic and I received no fee for my visit. I did ask the Clinic to pay my expenses.) I was skeptical about what I would find – I’m always skeptical about self-reports in the absence of gemba knowledge – but I agreed to visit in July.

Over the past decade the Cleveland Clinic replicated the familiar story of a large service organization taking swings at the lean piñata but with limited success. Significant focus on projects using lean methods, varying degrees of senior management enthusiasm and engagement, and modest sustainable results.

Four years ago, Lisa and Nate decided to take a more robust approach and focus on implementing systems and building capability where every caregiver was capable, empowered, and expected to make improvements every day. You can read more about their shift here

Last year, Lisa and Nate, along with executive leaders (Dr. Tom Mihaljevic, President and CEO; Dr. K. Kelly Hancock, Executive Chief Nursing Officer; and Dr. Ed Sabanegh, President, Main Campus and Regional Hospitals), decided to take a much more systematic approach by building a daily management system that spans the organization and would expose and elevate information every morning through six levels of management, from the nurse at the bedside to the CEO. It was to be a mighty escalator (my phrase, not theirs) of operational information, including successes, challenges, opportunities to improve, and countermeasures that in typical healthcare organizations are not visible above their level of occurrence and whose resolution, even when flagged promptly, is usually delegated horizontally to staff for attention over extended periods. Hence, challenges persist, and too many remain unresolved.

"Today every organization faces great challenges, major disruption and, in consequence, the need for much more effective hoshin. So there is a healthy urgency to link daily management, targeted kaizen, and focused hoshin for organizational survival."I visited Cleveland in July to see this system in action by taking a ride on the escalator from start to finish. A typical day looks like this: The first huddles begin at 7 am with every manager meeting with his or her team (ie, nurse manager with bedside nurses on an inpatient unit). This leads to a later meeting (typically around 8am) of the managers with their director, the 9:15 meeting of all directors with the hospital chief nursing officer (for the nursing teams) or operating officer (for operational functions), the 9:45 meeting with the leaders of the hospital, the 10:15 meeting of leaders from each of the 12 hospitals and the executive clinical leaders, and the 11 am meeting with the CEO, clinical leaders, and other members of the operations council including  the executive leaders of the major functions from Quality and Patient Experience to IT, HR and Operations. At each level’s meeting the issues from below are elevated and aggregated as the meeting participants see and assess the performance of a larger and larger slice of the total system.

But that’s just the formal structure. The key to making the escalator useful is to determine actual performance the preceding day at every level and flag abnormal or unacceptable performance at that level. These issues are written by the line manager on the right side of the dry-erase management boards for special attention and rapid countermeasures. (If line managers at each level cannot respond to problems quickly, their reports will soon conclude that the whole exercise is only about drawing up problem lists – a bad tendency of bureaucracies in general and many visual management systems in particular. And they will lose interest.)

Once issues are flagged, the question becomes whether they can be resolved by managers in that unit or whether they need to be shared with adjacent units. For example, I observed at the second level meeting that the managers described challenges within their individual units – which may be related to patient needs, staffing, and equipment, among others -- and asked the other units if they could help, with a bit of coaching from the director the unit managers reported to. Decisions to make the day better for patients and caregivers were made in just a few minutes with no back and forth e-mail or additional meetings required.

There is a second type of issue that can only be addressed by elevating (escalating) it to a higher level huddle for discussion and resolution. And a few ride the escalator all the way to the top for a rapid decision. For example:

What to do about the patient from another country, who has no family to care for him in the U.S. and who has been diagnosed with a fatal condition requiring hospice? Answer: Work with the embassy, transportation, and others to safely reunite the patient with the family. (But highlight this issue if it recurs and needs more detailed analysis and a formal policy.)

And what to do about the patient who was discharged and then asked to come back for a procedure, but given the wrong time to return by the automated scheduling system – 6 am rather than 1 pm, meaning an all-day wait in the hospital? Answer: Ask if any of the other hospitals have had this problem and, if the answer turns out to be “yes” (meaning it’s an IT system problem), give the responsibility for the problem to the head of IT (who attends the top-level meeting) with an agreed date for a report back on a permanent countermeasure. Two problems addressed in a few minutes with no e-mail by escalating them quickly to the right level! What the world needs now. Especially in healthcare.

It’s still early days for daily management at the Cleveland Clinic. The first CEO level huddle occurred April 30, and most hospitals started in May. But with the system in place in the Ohio hospitals (and slated for introduction in outpatient practices in Ohio and at other Cleveland Clinic campuses in Florida) it’s a good time to ask what the benefits of daily management have proved to be. Perhaps only 10% of the benefit occurs at the top level where unique challenges can be addressed quickly and where big trends within the organization – staff engagement, falls, infections, etc. – can be spotted and addressed early.

The bulk of the benefit is that performance on every metric is reported daily for the day before at every level and most problems are dealt with at that level by line managers in real time. This gives caregivers the sense that managers are really paying attention, that their challenges really are being understood and addressed, and that over time this will mean stability, a lower level of stress for all staff and an improved patient experience. It also should mean that line-managers in the future will face less daily chaos and have more time for permanently countermeasuring problems and improving performance.

But these achievements also surface problems, the most notable being that many line managers still struggle to distinguish between the need for containing problems (with quick countermeasures) and the need for root cause analysis. And they struggle to conduct rigorous root cause investigations under their leadership rather than delegating problems to the improvement and quality staffs. More problem-solving practice for managers, with coaching from the improvement team, is in the plan but creating the necessary skills will be a long-term process. (Remember that most nurses and practically all doctors have completed their formal medical education without attention to the processof medicine and training in solving process problems. Their training focuses instead on the discrete care-giving practices of medicine.)

The next challenge will then be to create a robust kaizen process for improving end-to-end processes rather than local ones (e.g., better utilization of operating rooms, better coordination of patient journeys across organizational boundaries) and to target these improvements to top-level hoshin (strategic planning) objectives.

This last leap is a great challenge for every organization but the healthcare industry, like many others at this point in history, faces major disruption and in consequence the need for much more effective hoshin. So there is a healthy urgency to link daily management, targeted kaizen, and focused hoshin for organizational survival.

At the end of my visit I could say with relief that the Cleveland Clinic has made a great start facing these challenges. I look forward to returning someday soon when all of the elements of lean management are in place to take another fun ride on the escalator of issues. 

The views expressed in this post do not necessarily represent the views or policies of The Lean Enterprise Institute.
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Michael Ballé September 07, 2018
7 People AGREE with this comment

Great piece as always Jim, but I'm afraid I have to react on this one and can't agree.

In my own exploration of the gembas, this "escalator" vision of daily management has to be the greatest mistake I see the lean movement propagating, particularly in companies with large corporate structures.

Daily management is fundamental - at supervisor level. It's about seeing problems, responding quickly, keeping work repeatable, and yes, as you mention, occasionally looking for root causes. Eseentially managing cause by cause.

The time frame has to be short - and indeed as Mr. Harada reminds us, the standard work for andon is the time it takes to respond - whihc means get the process back in standard.

But without the guiding hand of senior leadership on critical challenges, spirit of improvement and teamwork, development of mutual trust with customers and employees, this mechanisms for daily managment - the indicators, the reporting, the team briefs, all drag managerial level down to supervisory thinking.

As you and I discussed when we first met all these years ago in Turkey the quesiton was when would Toyota revert to the mean and become just another automotive company? As far as I can see this has not happened yet. But I feel the lean movement is doing exactly that, retrenching into operations, reverting to old fashioned monitoring and consequenting and using the Toyota tools to exert pressure on value-adding employees.

As we know, many of the Toyota tools and principles work because they're paradoxical. And as we know, we're always surprised by the reality -and diversity - of how Toyota executives interpret their own system.

This very American-led and corporate-friendly interpretation of lean as "super" daily management system drags everyone into micromanagement and back to command-and-control, rather than challenge-and-support.

A daily management system must absolutely be seen in the light of what Tracey calls "a system to continuously develop people," which means distinguishing from responding to incidents with initiative and common sense at frontline staff level, seeking to resolve causes by cause at frontline management level, managing conditions at middle management level, and facing and shaping challenges at executive level. These layers require very different thinking both in terms of time horizon and nature of problem solving.

The escalator metaphor suggests we're escalating problems. What we've learned was "helicopter thinking" - executives need to be constantly on the lookout for learning and initiative on the gemba, whilst framing challenges at the highest level. Bottom-up "Ringi" only works if executives know how to top-down communicate challenges and look for unfavorable information, employee insight and initiative and support kaizen first.

I'm not arguing against a daily management system - I've been helping set them up repeatedly. I'm arguing that a daily management system with the elevator concept of "cascading" up issues drags managers into the very biases we want them out of micromanagement, overmonitoring and control. We see it when "obeyas" become walls of indicators and action plans. The beauty of lean lies in creating space to think at every level, to refocus on purpose, insight, and values, to develop better judgment and avoid repeating endlessly old known mistakes. 

To do so, we need daily management at the shop floor level - but we also need to break away from it at departmental management level, and certainly at executive level and create different rituals for discussion and thinking and facing challenges together rather than defending functional objectives. 

How about it? What do you think?

Best, always.

Reply »

Dave Kinne September 10, 2018


Great response.  Something I struggle with in our geographically diverse organization (over 30 training centers scattered across the globe).  I am very interested in Jim's response.  Patiently waiting to hear!!



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Marty Anderson September 13, 2018


Very interesting post.  One item in Michael's comment stands out too  - "retrenching into operations".

I don't know enough to know whether the lean movements are retreating, but that "retrenching" comment sparked a train of thought.

HEADLINE: There are almost no organizations left on Earth whose whose operations are only "internal".  So internal real-time processes are only part of the lean story.  

The new challenges to "lean" worldwide are the massive external systems that now seamlessly connect 7 billion humans to each other....and the massive central command rule-sets that governments and others use to try to centrally control individual human behavior in ways once unthinkable.

The Whole World Is Wired

I spent about 10 years traveling the world watching - first hand at the Gemba - what happened as several billion people went online.

The unique thing about the global "cloud" is that people can see behavior at the physical Gemba, but then also in the global electronic Gemba behavior that emanates upward and outward from that physical activity.  

This "cloud" is an electronic manifestation of the "upward reporting" in your post, but it is not constrained within a company or even finite supply chain.

This wired electronic behavior spreads upward, and then OUTWARD in 360 degrees, creating "meta oranizations" that range far beyond any physical company or location.

One way to see this is in the clouds of education that now swamp the universities of their origin.  When a school thinks it is relating to a finite student body, it often finds itself connecting to thousands of "unregistered" folks, via the social networks of enrolled students.

This spreading from "command" networks (paid students) to the "emergent" cloud (people linked to students) models the modern dilemma of all companies on Earth.

Uilitmately, there is Youtube where everyone can learn almost anything, far beyond the walls of the university.

There Are No More Finite, Internal "Operations".  

The linear hierarchy to the CEO is now swamped by a massive external  "emergent" cloud of behavior as individual employees seek guidance and connections with entiies far beyond those conceived of by central management.


The fundamental problem with US healthcare is that it is still thought of as a collection of finite organiztions that can function as discrete units.

But that is not true, especially not in the US

All healthcare organizations are subordinated to massive external  "command and control" networks far beyond their internal operations.  

The ACA is the most visible example.  If one reads the entire ACA (took me 7 hours the first time), one will find that it has very little in it about heathcare.  

Instead, it is a document that mandates almost exactly the 1960's-style management hierarchy that bankrupt General Motors.  

Except that it seeks to control the highly-charged health behavior of more than 300 million citizens, under a small central command of fewer than 100 humans. (Read the law)

As those of us who have walked Toyota's global Gemba know, there is absolutely no way to impose a central command on 300 million persons doing anything.

So what does this have to do with the Cleveland Clinic?

There are no discrete "internal operations" at the CC, or any US healthcare institution.

All of them must respond, primarily, to outside detailed rules, like those contained in the ACA

Those external ACA-style rules have become the primary drivers of internal cost, and the "daily defects" you mention in your post, in all chartered US healthcare facilities.

Example. All US healthcare organizations are required to measure their human behavior according to more than 100,000 "diagnostic" codes, that must be fitted into central command systems such as EPIC.  They are required to do the same with more than 100,000 different  "treatment" codes.

They must do this to a level of "meaningful use" external compliance.  That means they not only must record and transmit to "central command" all the millions of data items from the 100,000 times 100,000 codes, times about 200 million patients....

....they must do a separate audit of this process to ensure that they are complying in a MEANINGFUL way, with the centrallly defined definitions of "disease" and "outcomes".

The best commercial retail inventory system - Walmart - has at least a 50% error rate on inventory metrics for 100,000 SKU's

What do you think the error rate is in the ACA mandated system with all those billions of code combinations?

Again - My central point is that the internal processes of US healthcare systems are overwhelmed by randomizing external control systems, so "internal Lean only" is no longer possible, or relevant 

Back To the Gemba to Document This

Several years ago I was working with colleagues to document the gemba effects of the highly centralized EPIC medical record system.  (Versus more bottom-up systems like those of Athenahealth).

We got legal permission to shadow individual patients as they traveled through a large hospital getting diagnosis and treatment.  This was to see the gemba realities in the patient realm.

(One finding was that doctors who thought they were referring patients to the best specialists, did not understand that poor patients would have to spend 2 hours on public transit to get to this specialist.  This meant the gemba adjusted cost of healthcare to this patient - one of 300 million - had to include the massive cost of transportation.  This explained so many no-shows and knock-on waste.)

We also got permission for another researcher to SIMULTANEOUSLY shadow the physicians and other care provders as they engaged with the shadowed patients in real time.

Both the patient-side, and provider-side "shadow teams TIME CODED THE INTERACTIONS BETWEEN PATIENTS AND PROVIDERS.

We also "shadowed" the doctors online, on the EPIC system, so we could record them staying up late at night which was the only time they could enter the cumbersome "meaningful use" medical records and complance data.

Those of you who have seen real-time Toyota zero defect processes, think very carefully about the quality of this "meaningful use" medical records data, which is a pillar of the ACA.


The" T-nome"

As the team compiled these parallel "shadows" we were able to do a number of operational analyses.

We found that even if a doctor was given an hour with every patient (a luxury today) - all of the doctors began running late about 10AM, which had knock-on effects across the hospital.

We found that individual patients then began to run late to sequential appointments and often got lost trying to rush to the next appointment.

When we mapped these two streams on the time-code, we began to see how the complex CPT codes, and even simple EPIC data entry messed up both the patient "stream" and the doctor "stream"

When we drew these two-stream maps on the wall, we remarked that the maps looked like DNA strands.

Thus, we began calling them the "Transaction Genome" and we could trace most of the wasted time in the hospital, for all stakeholders, to these "T-nomes"

We could trace the knock-on effects of one late patient all the way into the lab, the pharmacy, etc.

We could accurately calculate the knock-on costs of a no-show on all the hospital stakeholders who were scheduled for that visit.


So - Back Up to the Main Point


It was very clear that the vast amount of waste in this large organization was driven by EXTERNAL command and control rules like those in the ACA, insurance company protocols, and the structure of the command-and-control "meaningful use" data system.

Therefore it was almost impossible for the organization to solve its dilemmas with any of the classic internal lean practices.

We need new "meta-Lean" practices at the scale of entire societies - before "internal lean" can work at even the best places like the Cleveland Clinic


Sorry for gemba-wandering post

How do next generations take Lean to the global-social level?




Reply »

Harry Lane September 16, 2018

Escalator sounds like a good jump start.  Am sure they will shift gears as needed which is always a necessity.  Of course, what works well for one organization may not do well in another. 


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Marcus September 27, 2018

I have to take the middle on this one between Balle and Womack. I think both points are valid and most likely are attempting to say the same thing. VP's and executives in my opinion SHOULD be involved in daily management to a certain extent BUT not to micro-manage they are there to support and encourage the process for those involved while asking "coaching questions" for people development AND providing transparency of information throughout. If the largest issue in a particular area needs attention and it isn't getting the attention it needs, there should be some sort of intervention from above to guide and provide assistance. If it is a simple 5S issue, then that would be delegated and dealt with by the area manager and the people working in the value stream. In my opinion setting targets and understanding the problems isn't micro-managing. After all, most companies hardly see the executives so having them involved on a regular basis would provide insight for not only the executive, but also a trust factor for operators and area managers. Its the behaviour while on the floor that matters most when execs are there. LISTEN, ask thoughtful questions and be supportive of the process.

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