This quote has been sitting with me a while and I hope it is relevant for you too. So often, even a gemba experience may be different for people. Even though facts are found at gemba, people may only see certain things and not the whole picture (like the four men & elephant story). I think the Respect For People principle is at play here too because it suggests to mutually respect multiple perspectives and put together into one common view.
“Most disagreements about the right solution, decision, or course of action are really disagreements about the interpretation of current reality…Most statements about current reality are not wrong; they are incomplete. The person who adopts this principle seeks to put multiple views of current reality together to build one common and more complete view of it.” – The Hitchhiker’s Guide to Lean: Lessons from the Road by Jamie Flinchbaugh and Andy Carlino
Time spent trying to please your boss is processing waste and provides no value to your customers. Leaders and staff need to recognize this as a major cultural problem because it will negatively affect the long-term success for your organization.
Leadership: how much time do your people spend trying to please you versus getting the desired results? Are they experts at managing their leaders and mediocre at doing the actual thing? Are they getting good at the job or managing up? I’ve found a tremendous amount of time can be wasted by approval seeking within a company. Powerpoint, meetings, and calls devoted to finding a sense of confidence in the organization, not doing the actual thing.
In my experience, most leaders are not people who consciously demand this sort of activity, but it often persists because those that manage up often receive public praise and promotions. You would be surprised how much time is spent when staff feel the need to game the system to look good for the boss. Think about how that time could be better spent doing Kaizen!
Spend time assessing for “managing up” behavior. It will be a challenging improvement because the causes will be deeply embedded in the system. The benefit will be a clearer focus on the customer, freed up time to use in creating value, and capacity for future improvements.
2012 is the year to be a difference maker for all of us. We have a lot of opportunity to make things better for our customers and better engage our teams. Here are some tips to make a deep impact this year:
Embrace The Kaizen Spirit: Masaaki Imai says “The Kaizen spirit encourages thinking about how to change, rather than why it can’t be done.” Don’t let the excuses (even really good ones) hold you back from looking to find a way to make a difference. As Mark Graban suggested recently, let the identified barriers become your first problem statement.
See How Your Role Makes A Difference: Seek to discover how your role directly makes things better for customers or how it supports those that interact with them. Also consider what you can do to make a difference with the people on your team by being a better listener, encourager, or other things that help people make improvements.
Be Approachable: If people avoid talking with you, you can’t make a difference because you will not understand the current situation. Being inclusive allows you to build trust and begin to help influence positive changes.
I am sure many of my readers are already making huge impacts on people’s lives and in the organizations they work with. What other suggestions do you have for people to be a difference maker this year?
Does your workday frequently feel like mayhem? I have talked with many people who feel like their job is filled with unnecessary chaos. I believe a lot of organizations self-inflict themselves with craziness. There is a way to stop the mayhem!
Overburdening people (and equipment) is a form of waste. Your organization must first identify where people experience this waste. Usually it is very easy to find just by asking who feels they are overwhelmed.
Here are some examples of what you may find (also note that most below do not have a paying customer waiting for the outcome):
Leaders asking for non-standard reports with quick deadlines (usually to sit on their desks for weeks before they look at them)
Constant edits or change of direction to documents because planning is often done afterthe content was created
Support departments get projects dumped on them without ever problem solving around their ability to have capacity to do the work
Somebody’s procrastination or lack of planning becomes another person’s urgent priority
The next step is to acknowledge this kind of mayhem is a problem. This step is difficult because firefighting heroics and the rush of adrenaline from last-minute deadlines becomes “how things are done around here”.
As an outside observer, I usually see little need for subjecting employees to this kind of work condition and believe it lowers engagement. Until teams align that overburdening staff is a problem, it will continue unabated.
The final step is to identify the root causes of the mayhem and eliminate them.
What sort of unnecessary mayhem do you experience in the workplace?
(NOTE: The attached video is only related to this post because of the title and I thought it was a cool rockabilly song!)
Technology can sometimes seem like the right way to address issues but most people do not know about the extra problems it can create. You may get a short-term win with technology but end up suffering in the long-term.
If your hospital or organization in on a Lean journey, technology can sometimes go against your philosophy and management system.
Here are some things to consider if you are looking at technology:
Never automate a bad process. Eliminate waste and understand what the process really needs before you find a way to make it faster. Quicker waste is still waste.
IT systems should fit the process, not the other way around. In The Birth Of Lean, there was an early Toyota document with the following: “It is not a conveyor that operates men…it is men that operate a conveyor…” So often people change processes to meet the rigidity of the technology. Ensure the technology does not force standardization that has waste, lowers quality, or makes no sense.
Be able to make changes after it is implemented. So often organizations are stuck with wasteful systems because nobody has knowledge to make iterative improvements or the cost to bring someone in is so high that nobody fixes it until it is totally broke.
Trial first instead of piloting. Pilots usually happen after you buy the system. I have rarely seen organizations stop implementation if a pilot does not work out like they expected. Organizations usually just change their messaging and training to fit what the technology can do instead of ensuring it does what they wanted it to do. Trialing is part of PDCA thinking and will help ensure the IT system meets the needs of the process without being financially committed to rolling it out.
Know the problem you are addressing. With today’s technology, there are all sorts of bells and whistles that seem great. Although impressive, the added features may be more than needed (overprocessing waste) and can sometimes distract from why you were looking for technology. These ‘extras’ can also add complexity to your processes.
I think technology can be embraced in Lean organizations but it is important to ensure it is thoroughly tested, reliable, and improvable before you commit to implementing.
“On The Mend” by John Toussaint, Roger Gerard, and Emily Adams is highly recommended for any level of leader in a hospital.
The authors stress the importance of how leaders need to change themselves in a Lean transformation. Insights to the thinking of leaders at ThedaCare will challenge a hospital’s current management approach and hopefully inspire experimentation of a new style.
Woven throughout the book is the continual discussion of the impacts of a shame and blame culture. The authors discuss some of the root causes of shame and blame. They explain some of the counter-measures they used to improve the culture. There is a whole chapter on engaging doctors that is of value for any healthcare leader.
The book greatly shows how time reduction is not only a productivity metric, but how timeliness impacts the health and safety of the patient. Other examples throughout the book demonstrate that Lean can make great improvements in a hospital.
I appreciate the credibility of the authors. Many times, they state when things did not work well, how they were the problem in some cases, and how they would approach differently in the future. I think it is important for these sort of books to be honest since a Lean journey is not easy. “On The Mend” provides a realistic look at how this kind of thinking can make lasting transformation in hospitals.
More information about the book including videos, author interviews, and a free chapter available at L.E.I.
Disclosure: A review copy of this book was provided to me by the publisher.
Does your hospital have a system to ensure nurses have working equipment or they know how to get them fixed?
I recently visited a hospital where the answer would be “NO”.
Last week, a family member needed a day surgery procedure done at a local hospital. There were signs in the prep/recovery room touting their move to electronic medical records and no longer needing paper charts. The problem for the nurse was, the Computer On Wheels (C.O.W.) did not work. The nurse was unable to access or update the electronic chart!
A second nurse came in during the morning before the procedure to try to troubleshoot the malfunctioning C.O.W. It was decided to grab a C.O.W. from another room and use it instead. I am not sure if other nurses had to search for the missing C.O.W. now that it has been moved into our room where it sat there for four hours. A third nurse eventually pulled it away to put back where it belonged.
The first nurse came back in and tried to access the original C.O.W. in our room and commented “This still doesn’t work yet?”
I looked at the C.O.W. and there was no signage about how to troubleshoot or who to call. I do not know if a nurse tried calling their helpdesk out of my view but it looked like nobody knew what to do with the broken computer. It seemed like nobody knew who was to take charge in fixing it. One can almost infer they expected it to magically fix itself!
Three nurses spent time reacting to faulty equipment that could have been better used providing care to patients. Instead of spending their creativity solving patient issues, they use it creating workarounds.
Lean thinking can help hospitals put systems into place to ensure equipment always works. Procedures can be created for what to do when something is broken and how to handle. Make things visual so staff doesn’t have to rely on memory or look up procedures because instructions are attached to the item being used.
Helping remove waste and frustration from those giving care with make a better experience for those receiving care.
Mark Hamel’s “Kaizen Event Fieldbook” is an excellent addition to the library of Lean literature. Don’t let the title fool you though, there is more to this book than just the technical details behind a kaizen event.
The book definitely delivers on the myriad of details for progressing through the different phases of a kaizen event. Instead of just explaining what to do, the author provides the reason why it is done. The book’s emphasis on the thinking behind the actions is valuable for Lean leaders, facilitators, and consultants . While there are a lot of similarities to how my organization conducts events, it is nice to see the differences recommended by the book.
There are many great tables and visuals throughout the book. A few of my favorites are the decision tree for what should be a kaizen event, a table with nine symptoms of event malpractice, and a team behavioral audit for the facilitator. There is also an exhaustive appendix with blank forms to use for kaizen events.
In addition to the technical details, the book has a lot of insight for transformational leadership. I enjoyed the different short stories in the “gemba tales”. I like to learn how others teach Lean concepts and the book has an excellent chapter where the author does just that. I am glad the book also discusses the need for daily kaizen and what that looks like in relation to kaizen events. Lastly, there is an outstanding section about the role of a kaizen promotion office and the core competencies of those who work in it.
The “Kaizen Event Fieldbook” is a book I open often and refer to. I highly recommend it.
WHY is one of the most important questions for your Lean journey. Here are the reasons:
IMPROVE ROOT CAUSES – Instead of fixing symptoms, determine what is causing the problem by asking WHY five times (Wikipedia example)
GOOD CHANGE MANAGEMENT – Ensure your staff knows WHY an improvement is made or the reasons for standardization. This is only helpful if the answer to WHY isn’t “because I told you so”.
SUSTAIN GAINS – Just because a brilliant process has been designed for standardization does not mean all staff will follow it. Leaders need to ask WHY an individual does not perform to standard. It could be because of lack of training, a misunderstanding of WHY change was made, a physical or space limitation preventing the ability to follow it, a flat out refusal to adhere to it, or many other reasons. You can not sustain unless you find out WHY people are not following it.
BETTER TEACHING – In my experience, teaching the reasons WHY behind the Lean tools helps people think critically. Just explaining how the tools are used can lead to a misuse of them.
IMPACT PERFORMANCE – Your organization probably has a lot of demand for projects. Find out WHY the projects are needed and use that information to select those that impact your performance. Projects can keep a lot of people flurrying in activity but are not always conceptualized to achieve improvement for the organization’s performance, creating value for customers, or achieving strategic aims.
What other use of WHY have helped you on your Lean journey?
While this picture is a piece of artwork it made me think what your organization can look like if you view Lean only as a set of tools. Losing the perspective of your system can easily lead to creation of complex and unusable solutions like this traffic light.
When I look at this traffic light tree, I picture one team adding one of the lights, then another team comes along and adds a light for their use, then a management team adds a third light to summarize what the other two teams lights represent, then more teams continue to add their light for their own use, and so forth. While a new light may be a solution for each group individually, the net result is a confusing and unusable tool for the system.
When you set out to improve things, think about the needs and impacts to the system. Take the time consider all options before acting. It is not true improvement if you optimize one area but the result is sub-optimizing another.
I am now back from my wonderful 4.5 weeks of paternity leave and am more committed than ever to help hospitals become lean. Through the birth and follow-up pediatrician visits, I have been a customer of health care and see many opportunities for staff and patient satisfaction. Here are some of the things I experienced:
New IV Ports – One nurse had trouble connecting an IV port on my wife during labor. She exclaimed “they changed our ports a few months ago but we kept on using the old ones. Now the old ports have been thrown away and we are forced to use the new ones. I don’t see why they switched them.” Another RN mentioned the ports later and said “I was on vacation when the ports changed so I never got the training for how to use them”.
Lack Of Patient Centered Care – Our OB seemed to have an agenda on the day of labor and increased medications without telling us first despite our birth plan and previous conversations requesting informed consent for things like this. The OB was using scare tactics to push for a c-section without explaining pros and cons for alternatives.
Pediatrician Office Visit Late – For our one month check-up the pediatrician was 20 minutes late. The doctor looked visibly flustered and distracted. He apologized for running late and expressed how bad he feels to be running behind and hates to make people wait.
What Is Up With Our Hospital Bill? – The day before we discharged, a person provided an estimated amount and asked for a credit card. A month later we get a bill in the mail for half the amount we already paid without any indication our initial payment was credited towards anything. I called their billing customer support only to be told the initial credit card amount was applied later in the day that my bill was mailed. The rep told me the lower bill we got in the mail was incorrect and we really owed the larger amount we originally paid for with a credit card (plus an additional $68).
Lean transformations can help each of these situations. Using better training, job instruction sheets, and explaining why would help the nurses with their ports (although I question what prompted the change if they were allowed to use the old ports for a few months if someone claimed safety was the reason). Helping providers understand what their patient’s wants and needs are will allow them to better serve their community and will most likely help with growth. Doctors can have reduced stress and better engagement if the root causes for being late for appointments are improved. Lastly, recognition that the patient experience usually ends once everything is paid can help improve billing accuracy/clarity and save money from rework due to patients calling in to ask about their bill.
With renewed energy and passion I return to work to help those in hospitals see the opportunities all around them while providing guidance for how to capitalize on them.
Lost In The Land Of Firefighting – This short video shows how we can easily lose sight when putting out fires. I think it also shows why gemba walks need to be done instead of those doing the work saying “I already know it because I do it everyday”.
An Idea Is Not Always Enough – Jamie Flinchbaugh uses an Aesop fable to demonstrate the importance of taking action on an idea instead of just talking about it.
Of 777s and Heart Rate Monitors – Mark Graban tells a story about a hospital death due to a heart monitor being turned off and illustrating the need for error-proofing.
Youngme Moon is coming out with a book called DIFFERENT. The attached 3 minute video (RSS readers may need to open post to view) gives a great visual overview of how businesses can be different. The video was created by XPLANE, a company that I enjoy their visual communication. The book looks like something the Lean community would enjoy.
Mark Graban’s “Lean Hospitals” is a must-read for any hospital going through a Lean transformation. I recommend it for all staff and not just leadership.
I am an internal consultant in a Lean hospital. One of the biggest challenges is helping clinical staff understand how stuff from the automotive industry and manufacturing is relevant to their work. Mark’s book provides descriptions and case examples that tie the Lean philosophy and tools directly to hospital work.
A strength of the book is the realistic way to approach Lean in a hospital. There are many nuances for standardized work that are valuable. Wastes are identified as things people in hospitals experience. Mark points out common issues faced by hospitals if you are looking for a place to start. I can not emphasize enough how many valuable tidbits are throughout this book.
Leaders will get a lot from this book. Lean requires management to change in order to support front-line improvements. Mark provides many concrete things leaders can do to make their journey successful.
The continued focus of patient needs and employee engagement drives all aspects of the book. This brings purpose behind everything else that is explained. This book will help drive valuable change for hospitals.