The lean healthcare webinar with Kim Barnas, author of Beyond Heroes: A Lean Management System for Healthcare, drew an engaged audience that submitted hundreds of questions, many more than we could address during the hour-long webinar.
We selected questions that represented the main issues you wanted to know more about for a follow-up Q&A with Barnas, a former senior vice president at ThedaCare and faculty member at the ThedaCare Center for Healthcare Value. Here are your questions and her answers.
Q: How has the use of kaizen events changed over time? Have they changed in character? Focus? Scope? This is in reference to the comment about three ways that a problem is addressed.
A: The use of kaizen has been expanded beyond those events generated by a value stream analysis. The structure of the kaizen has not changed. In daily continuous improvement we use three models for problem solving that all utilize plan-do-study-act (PDSA) thinking with A3 formats. One of them includes kaizen.
- A “just do it” uses an improvement card at the huddle board and must be solvable in your work area with 3 steps or less. It uses PDSA thinking and is revised after 30 days to discuss the study/adjust actions that may be necessary… and assure the change is sustainable.
- A project uses an A3 and is specific to the work area. It is not a breakthrough or “driver” level of work, but does require adherence and action plan. A unit team is formed and the action plan progress and is reviewed weekly. This is usually a 1-2 month process.
- A kaizen is used for a defect or problem that is breakthrough in its objectives, connects to a driver for the system or division or crosses work areas (unit boundaries). It requires an A3 and the kaizen standard work is the same as if the work was attached to a value- stream analysis. This work is reviewed weekly and may involve a countermeasure which would be reviewed at the unit or divisional leadership monthly performance review meeting.
Q: Does senior leadership select top projects to work on to help financially with the bottom line or are all projects taken from individual areas?
A: This question has a complicated answer. As it relates to daily continuous improvement (the topic of this webinar) the work is developed at the individual area. However all work ties to the system’s true north metrics which are driven from the executive level.
The system and divisional leadership identify the top projects and develop A3s. These high level, critical to success A3s we call drivers — this is the work that moves the system metrics- including financial performance. So there is a combination. If additional resources are necessary to address the defect or process improvement, the system drivers take priority.
Q: One thing I have heard arising more recently about lean management is the need for more empathy. What is your perspective on this?
Empathy is not the word we use. But it does make me think about how we behave, and demonstrate to our people how we care about them and their work experience.
- We (leaders) listen more than we talk
- We try to understand the process that leads to defects
- We use a lot of peer and leadership mentoring and coaching
- Going to see the work and using the experience of the team to solve problems and develop appropriate standards
Those who are closest to the work are the best candidates to see, understand, and solve problems. We certainly do need to understand and respect the perspective of our staff and how improvements/changes impact our people and our patients, so I guess empathy is part of that strategy.
If using lean as a “tool box” is the objective, without the critical pairing of developing your people, managers may find resistance to implementing the process changes and it may also be more difficult to spread and sustain improvement.
Q: How were you able to establish the “no meeting zone” making it to do PI work?
The divisional leadership team determined the need for dedicated time to do improvement work and was committed to being present in the work (gemba) during this time. It did not require the addition of new resources, but a reconfiguration of leadership time. We made explicit the philosophy that leadership’s job is to support the teams and remove barriers to solving problems.
When learning daily continuous improvement, we used this time to teach and observe. Once the unit leadership is trained and developed in the lean management system, the purpose of the no meeting zone from 8-10 each morning is to provide the space to do this work – to develop the staff, to improve critical thinking skills, to see and solve problems using PDSA methodology, and to improve performance.
Specific standard work is in place so the time is valued and utilized in a predictable fashion. All management and leadership are expected to be in the gemba observing the work, collecting and sharing information from each other, and supporting the team. Project teams may meet, but more specifically, standard work for this time is in place to support improvement. A few examples of this standard work include:
- Specific questions are asked with Stat Sheet
- Observations of standard work is initiated
- Defects are raised and progress on improvement is discussed in the huddles
- All is made visual on the area improvement centerboards
There are still system meetings or urgent physician conversations that interrupt this time, so the goal is to be present in gemba 80% of the time and patient care is not interrupted or delayed.
Q: About how long does a driver improvement process take?
This is an excellent question. The answer is not so clear. It depends on the driver. Examples may help. If you are working on a driver for quality and you achieve the A3 target condition and are able to sustain it, 3-6 months might be the right time frame.
The business rules may require that the process is stable for a specific period of time; ours was two months. On the other hand if your area has an aggressive financial target you may need a year to achieve the target condition. The associated A3 should give you an anticipated timeline.
Q: How did you set standards for how many improvement initiatives a leader/department can work on at one time?
Our steering committee actually ran some experiments on this in different units (cells) we learned a couple of things.
- The stability of the unit is a significant input.
- New leadership or staffing issues effect the number a unit can manage. So our standard for drivers is four to eight. Most units have six.
- When leading daily continuous improvement the manager could only manage one driver during the training period where she or he could see the whole cycle.
- Each unit has business rules around the number of additional projects they can handle. These are unit-specific and smaller in scope than a driver. Most units can handle about four.
- Each unit also has a rule around the number of “just do it” process changes that take 3 or less steps. Many of these may be going on at the same time. It depends on the unit size and maturity of the team in problem solving. It is common to have three to six in some stage of action.
Q: How do you use value-stream maps (or unit flow maps) on a regular basis? Do you make them visible on the units?
Each unit has a value-stream map that is visible on the unit at the area improvement center. It is visible to all including patients and guests. This tool, the value-stream map, helps our employees see process waste and creates the opportunity to improve the work. We talk to the map in the daily stat sheets, huddles, and monthly performance review meetings. These are living maps that help guide our daily work. We use kaizen and projects to remove the waste, improve the process, and improve performance. It is expected that each unit re-map annually.
We have also discovered that some units have similar wastes and process concerns, and they often join together to improve those processes they have in common.
Q: How do you obtain input from the night staff? How do you make them feel included in this process; it seems like most of this occurs during the day time hours?
This is an excellent question. ThedaCare has not mastered it and continues to experiment. First, management from the charge nurse to the president has standard work. Some for specific processes, and other leadership standards that are time or calendar based. (Night shift charge nurses have specific standard work). The standard work is changed on a regular basis through a team process on each unit, where they experiment with process and times and come to agreement on the one best known way for now, knowing they can adjust as the environment changes. On the night shift we expect the manager and supervisors to be present on these shifts on a regular basis to do a stat sheet and a huddle.
Members of the night shift also complete the “performance improvement cards” located on the huddle boards to identify defects and process problems. The manager follows up with them and brings it to the next huddle for processing and prioritization.
Many units have a stat sheet at shift change. This also is critical to understanding trends and defects. If the leader cannot be present on site, it may be done by phone but the conversation must occur.
Q: Did your organization initiate a “lean culture” from the very top of the organization? If yes, can organizations be successful in starting on a lean journey and pulling their executive management along the way?
A: ThedaCare initiated lean as an executive directive. So, yes, it started at the very top with the CEO. Innovation occurs at other levels, but it is very hard to pull the executive management along the way. The cultural transformation requires significant commitment from the executive level.
Q: In your 10-year journey, how long did it take to land on today’s version of leader standard work? It doesn’t seem like something you just “flip the switch” on.
A: I think it’s important to note that this work developed because of a need; to solve a problem. First to support our managers who were integrating lean into their work and did not know how to manage using a consistent repeatable methodology, and feared failure. Second, this work was developed to support and sustain the value stream and kaizen breakthrough work. So we had some tools to start with.
We created standard work, we observed it, and improved it, and validated it before we spread it. This was very time consuming. We really learned about study and adjust in the plan-do-study–adjust cycle. It requires both discipline and courage with a healthy dose of vulnerability. We did not have a road map and the hope is that by observing the ThedaCare journey, the time line can be significantly shortened for other organizations.
ThedaCare’s model fits the culture and continues to change and evolve. Each organization on this journey must learn what is relevant and compatible with its culture. This cannot be a cookie cutter approach. That being said, look at the work and steal shamelessly from what fits, adjust it to your culture, and disregard or improve that which doesn’t work. And wonder what comes next. Anticipate change, innovate processes, and improve the system.
Q: Standard work can sometimes carry with it a negative reaction from people who see their opportunities to be unique and innovative replaced by standard work that everyone does. How do you change this mindset and encourage innovation?
A: Standardizing a process is the critical first step toward improving it. Only a consistent, standard process permits us to see inherent errors. Our focus is on process problems – not people problems. We ask teams to write standard way as the best known way to do a process today. Once that is done, we explain to our teams that only then can we begin to first improve it, and later innovate from it. This is done through experiments in cells where effectiveness is established before spreading it can occur.
The example I use in the book is thinking about a series of people arriving in the emergency department with chest pain. If we treat each one differently with EKGs and other diagnostic tests given randomly each time, it’s nearly impossible to pinpoint why some patients are diagnosed and treated more quickly than others. One patient may wait an hour for treatment while others are treated in 20 minutes. Without consistency (a protocol or standard work process), every time a patient has a less than optimal outcome seems unique, and we respond with a new work around or quick fix, further obscuring the nature of the problem and multiplying the number of work arounds without documenting any scientific evidence.
We can innovate. Create the standard, develop the hypothesis for improvement, experiment with it, validate the improved outcome, train to the new standard, and safely spread real improvement.