Lean leadership

How do managers lead at Toyota? When we (two groups of doctors and managers from the St. Elisabeth Hospital) were trained in the Toyota Training Centre in the Netherlands it became clear that Toyota has a very different leadership style then what we are used to. For example, progress is reported with three symbols:
  • A circle: progress is good
  • A triangle: progress is problematic, but I'm working on it
  • A cross: I don't know what to do, help!
At first, it felt similar to the traffic light symbols we see often in dashboards in Dutch hospitals, usually based on system measurements: green is above the norm, orange is below the norm, but within a close margin, red is too far below the norm. The three symbols of Toyota however are a personal reflection: that is how I think progress is. Furthermore, they are about 'progress', not status.

In the Dutch culture (Western culture?) I'm used to it that management wants to see as much green as possible. The more green, the better. Reporting on orange or red is something to be avoided. You try to solve your problems before you need to report them. When this does not work, the temptation is strong to influence the numbers to reach the green levels. People get a compliment for green. Conversations become difficult when there's orange and red to talk about.

Learning from problems
At Toyota the circles are pushed aside. They are not interesting. The triangles, they are interesting. How are problems dealt with? How are they analyzed? How are countermeasures searched for and how are they being tested? How does the team learn? The manager coaches on the application of the methods and principles when dealing with problems. Do they go to the source? Are tests fully evaluated?

Their approach is that someone who reports a lot of green does not stretch the boundaries, he does not learn much. The do not give compliments for green, but for the learning process at orange. But what if you are very effective and your results are simply good? If a process is stable (green), a manager at Toyota might take away either ten percent of the time that is spent on the process or ten percent of the throughput time. This will make the process unstable (orange). Then the operational manager coaches the team to stabilize the process again (green). The manager of the operational manager coaches him or her on that learning process. There lies the essence of quality thinking at Toyota. It can always be just a little bit better tomorrow.

Their philosophy is: be hard on the process en soft on the people. This works with very short cycles. Coaching happens on a weekly or even daily basis. Crosses are almost never reported before a triangle has been reported before. Upper management is already involved in solving problems when they are small. Surprises are rare.

Another difference: they coach on the shop floor. By visualizing their processes, the problems and the countermeasures as they occur (for example with colors and improvement boards) they directly see the triangles in the processes. That enables them to coach from a deep understanding of the situation en conclusions can be applied directly.

To enforce the methods and principles of lean thinking, we will also need to address the way we lead and the way we develop leadership in healthcare.

Can you relate to this?


The art of making things small

There are different ways to improve processes. 'The art of making things small' refers to the choice to reach your goals in small steps. This relates to principle 14 of the Toyota Way: "Become a learning organization through relentless reflection (hansei) and continuous improvement (kaizen)". Why would you want to make things small? Because a pitfall of projects is that we discuss for weeks or even months before anything changes. The  risks with this approach are:

  • The longer it takes for the first change to take shape, the more people who experience the problem loose faith that it will be resolved. The support for any change crumbles.
  • Many of those who perform the work in the process where the problem occurs are not involved in the thinking process. This means that you need good communication (which is often problematic) and often the much feared 'resistance to change' starts to take shape.
  • The solutions are developed separate from the work floor, separate from the (physical) place where the problem occurs. That means there's a real risk that the solution will not exactly fit the complexity of the situation where it's supposed to work.
  • Perhaps the solution will be piloted, but by now those who are in favor of the solution have argued for weeks or months to promote it and they now have to prove that it works.They have connected their personal reputation to the solution and will not like to see that it fails. Those who are not in favor of the solution hope that it will not work, they might even influence the results of the test to make it not work. Will this be a good test?
Recognizable? I have seen this happen over and over again. The art of making things small is a method that approaches it very differently. It is based on the teachings of Roger Resar on Reliability. The essence is simple: reduce changes to a size that you can literally test tomorrow. A team can use the next steps do achieve this:
  1. Define the process where change is needed.
    For example: it takes too long before general practitioners receive the letters form the specialist about the results of patients.
  2. Describe the process in four or five steps.
    For example: appointment - dictate letter - write letter - send letter.
  3. Define where a problem occurs. If necessary: describe this step in four or fives steps.
    For example: time between appointment and dictating takes too long.
  4. Define a change that you can test tomorrow. Choose the most easy circumstances for the test.
    For example: one specialist will dictate one letter for one patient right after the last appointment on the less busiest day of the week.
  5. Evaluate whether the test worked. Just yes or no. Evaluate why it did or did not work. Define the next test.
  6. Keep on testing the idea or new ideas until a good countermeasure has proven itself in practice. Make this the standard new way of working.
To solve the complete problem of the total throughput time, the time between the appointment and dictating is probably only part of the problem. There are likely to be multiple causes. The idea is that more then one test run simultaneously. If a team is experienced, four tests can run at the same time, each test lasting one day or week.

Except addressing the risks as described above, there are other reasons to apply this method:
  • By making changes smaller, they are pulled into the sphere of influence of the team. They can achieve more changes themselves.
  • There will be more learning. Learning by doing is more effective.
  • Decisions are more based on facts, more based on experience. Opinions and emotion become less influential. 
  • Changing becomes more fun, because the people that undergo the change decide and evaluate the change themselves. There is more ownership, more pride.
  • Less time is spent on meetings.
This method is based on the 'plan-do-check-act' cycle of Deming or perhaps more accurately from Shewart. Reread the six steps above to recognize them.

There are also pitfalls with applying the art of making things small:
  • Not enough analysis why there is a problem
    Suggestion: you do need an understanding of the cause of the problem. Often this is clear enough and you can start testing directly. But sometimes you do need further analysis to assure that you are not addressing aspects that are not relevant to the problem. 
  • Not enough coordination of the tests. The team goes testing changes without keeping track of the effect on the problem that needs to be solved.
    Suggestion: keep going through the complete cycle (see above). Not only for each test, but for the complete problem. Someone is responsible for the coordination (the owner of the problem).
  • Reluctance to start testing because the person that does the test is not convinced it will work as the new method of working.
    In the example the specialist might not want to test dictating directly after the session for one patient, because she expects it might work for one patient per session for one test, but not for all patients every day.
    Suggestion: test anyway! Doing a test is no obligation to keep doing it, also not if it works. You can only judge whether the idea is feasible after the test. Then you can decide based on facts instead of imagination. More importantly, doing the test can lead to a better idea that is feasible.
Achieve great things by making them small!


The tendency to erect a wall around lean

Recently I reflected with two teams on their progress with applying the lean principles. Both teams stated that the past months nothing had happened.


We discussed that they did not have time due to illnesses in the team and different other reasons why they were so buried under work that they did not have the opportunity. Then someone asked whether a period like that doesn't create a pressure to make changes to keep everything running. Sure, was the answer. And to the question how they had managed that they gave a range of examples how they had made improvements that reduced the time needed for activities, so that they could perform the work with less people. Different scheduling of nurses, different scheduling of patients, other task division, stop unneeded activities.


If that's not working on lean, what is?

They soon concluded that they did apply the principles. Why did they at first answer that they had done nothing? It became clear that they work 'on lean' when it explicitly carries that label. They apply lean when:
  • a change is introduced by the 'lean team' that regularly meets and thinks of new things
  • a change is decided on a workshop or so that carries the name lean in the title
  • or when it is directly connected to one of the instruments of lean
Changes that are made that reduce waste, increase value, improve flow etc., but without explicitly being labeled lean were, until now, not considered lean.

Ah, now I understand 'nothing'!

Why do we erect a wall around lean? Why do we create boundaries to say when activities are part of lean and when not? In this way lean can only have a very limited effect. We do not systematic lean from experiences that are relevant, but not labeled as lean. We do not acknowledge good progress that's made. We do not integrate the principles with other activities. We get less close to the hearts of people, because lean stays something foreign, that needs a label to work on. Every team has reduced waste or improved their working conditions etc. If we recognize those improvements as good examples of lean thinking, we can integrate the principles with daily practice. We can integrate it in the DNA of the team. So, we lack so far in this ability?

I consider lean thinking as a set of principles, a coherent way of thinking and seeing that can be inspiring. Lean asks questions why you do things as you do. Lean gives examples from other organizations that give food for thought, not least examples from Toyota. Lean challenges you to reach higher. lean thinking also describes instruments that have proved themselves, but that is secondary. But apparantly that's not how we communicate it?

In my view, embracing lean thinking means that you systematically elevate your efforts to reach higher levels of performance. Lean thinking means per definition that you apply the way of thinking onto everything where it can be relevant, even in your private life. If you think according to the principles, you cannot not-apply them.

Do you recognize the tendency to erect a wall around lean? What causes this tendency? What is the root cause of 'nothing'?


What is your first association with lean?

Often I ask people what their first association is with lean. I invite you to answer that question for yourself. What is your first association with lean?

................. .............

The answers I get usually are synonyms  for 'reducing waste' or 'improving efficiency'. That was also my first association when I started to dive into lean. By now I regret it. My first association is now 'value'. I'd state that if you don't take 'value' as the starting point of lean, your efforts sooner or later will work against you. A personal anecdote:
As a physiotherapist, my mother often treated people at their homes. When I came out of school, I often went with her. One day, we visited a woman that was not able anymore to move her fingers well. My mother asked her what she would like to do again with her hands. She said shet would love to play bridge again with her friends. My mother asked whether she had a deck of cards in the house en I got them. Then my mother invented exercises with the cards.
Care providers connect to a person asking a personal question. They try to understand what is of value for this person. It does not make much sense to reduce waste if this process is not well understood. It can be useful to consider two types of value:
  1. The reason why someone asks a question to a care provider. What's happening to me? What should I do? Why? Activities that help answer those type of questions add value, for example a consultation, diagnostic research and an operation.
  2. That what is important for a patient during the process. Comforting a restless patient, touching a confused patient, giving attention during vulnerable moments. These are not activities that help answer the questions that the patient came for to the hospital, but at that moment they are of value.
If we reduce waste without first understanding value we start of the wrong side. The risk is real that reducing waste will become a goal in itself. Perhaps the biggest risk of introducing lean is becoming anorexic. Few people working in healthcare have a passion for reducing waste. They want to be of meaning to other people. From that motivation, they are willing to improve processes and to reduce waste so that they can spend more time on valuable activities. But in that order.

I'd state that the effects of lean should not be measured by how much waste is reduced, but how much more or better value is created.

What was your first association with lean? How does that relate to value? I invite you to share your association!


Lean thinking and compassionate care

Recently O&I published an interview (in Dutch) with Jacob Caron, Orthopedic Surgeon and chairman of the medical staff of the St. Elisabeth Hospital in Tilburg in the Netherlands. Jacob talks about the relation between 'lean thinking' and 'compassionate care'. A reflection on several quotes using the 14 principles of The Toyota Way.
"...it's typical of 'lean thinking''  not to think from big, future plans, but to initiate change process from problems and issues in the current processes. By staying close to the existing processes, changes are kept small."
Principle 5: Build a culture of stopping to fix problems, to get quality right the first time
Fixing problems directly can only be done by the people that encounter the problems. That implies that every team member considers improving a normal part of every days' work. By keeping lean thinking small you bring it into the zone of influence of teams.
"... this approach creates a deep learning process that leads to sustainable change, because the change process does not limit itself to fighting fires, but is aimed at adressing the root causes"
Principle 14: Become a learning organization through relentless reflection and continuous improvement
Relentless reflection is confronting. Our (health care) culture tends not to show that you have a problem. To learn deeply, people need to be able to make themselves vulnerable so that root causes can be addressed and more fundamental change processes can take place. Trust is a basic condition. To create a culture of trust is very demanding of leadership.
"...it's important to anchor the 'lean thinking' philosophy in a long term vision on excellent care. This vision must include the core values of the hospital and gives direction to the process of continuous improvement that 'lean thinking' initiates. The St. Elisabeth Hospital chooses as a core value: 'compassionate care'.
Principle 1: Base your management decisions on a long-term philosophy, even at the expense of short-term financial goals
The long term philosophy will need to be so well connected to what the hospital stands for and what the environment needs that it will also provide direction in difficult times. In good times buffers need to be created that enable to hold on to the principles in the more difficult times.

It might seem contradictory that the earlier quote he stated that lean thinking does not start from a big future plan, and here he states that a long term philosophy is important. The difference is that, for me, a future plan is not value drive, but control driven. It's oriented at what is not. A long term philosophy is based on values and that provides direction to take decision in the here and now. It's oriented on what is. A future plan takes away initiative from most and gives it to a few. A long term philosophy can and increase initiative.
"Administration and leaders must stay connected to the primary processes and let that feed the vision."
Principle 12: Go and see for yourself to thoroughly understand the situation
Going to the source to base decisions on observations and experience from the work floor. This is extra difficult in health care, because many actions literally take place behind closed doors and because many steps are not taking place right after another (and many should not be). That makes it the more important to do effort to go to the source in health care. For example by attending daily or weekly (short) gatherings of teams that reflect on the day or week.
"In summary, 'lean thinking' creates space for compassionate care if the change process is anchored in a long term philosophy on excellent care. Compassionate care is part of the core value that is being optimized with 'lean health care'."
Principle 1: Base your management decisions on a long-term philosophy, even at the expense of short-term financial goals
"You need to understand your patient, what he wants and expects. Try then, each time again, to meet that expectation perfectly."
Principle 14: Become a learning organization through relentless reflection and continuous improvement
By connecting the first and the last principle it becomes full circle: relentless reflection on the way value is created, related to the changing expectations and values of patients, feeds the continuous, steadily improvements to deliver better value.


How does 'pull' work in a hospital?

The 'pull' principle is probably the most important logistical innovation of Toyota. Because it uses a different way of thinking it already requires some effort to understand the principle in a factory. But how can you apply it in a hospital?

How does 'pull' work in a factory of Toyota?
The traditional way to manufacture is in stock. Production is based on demand forecasts, or sometimes just as much as possible, then we'll try to sell it. Because there are many different versions of a product (e.g. different colors and options for a car) a lot of supply is needed to prevent that you can't produce enough of each version of your poduct. This is part of the reason why so much money is tied up in the stock in factories. This is also one of the reasons that led Henry Ford to his classical quote: 'You can order any color T-Ford, as long as it is black'. The less versions of your product, the less stock you need to produce it.

In the nineteen fifties Toyota understood that the future lies in more variations of cars. At the same time Toyota was in deep financial problems and spend a lot of money on their stock. For both reasons they wanted their production processes to become flexible, so that customers can get their preference fast, with minimal stock. Inspired by American supermarkets where the shelves were filled with the same quantaties that were just 'pulled' out by the customers, Taiichi Ohno translated that 'pull' principle to the Toyota factory. An example how that works:
Imagine you make door handles. Pete next to you puts the handles in the doors. Between you and Pete is a table with three drawings of door handles. When you finish one, you put it on the drawing. Pete takes them from the table. Now imagine that Pete is falling behind because the doors don't reach him anymore. He can't install your handles. Soon the three drawings are filled with three handles. You can't produce any handles anymore, because you can't put them anywhere. You stand still untill Pete starts again to take one away (or better yet, you help the team that builds the doors). Thát is the essence of 'pull': the step after you gives you a signal that you can do your part. Because the whole factory works like this, there are no stocks. The system simply makes this impossible. Also, not one car leaves the factory that is not ordered by a customer. Because 'pull' starts with the order of a customer.
It took Toyota fifteen years before the deceptively simple 'pull' principle was applied in one complete factory. Now, 35 years later, all car manufacturers and many other companies try to work according the 'pull' principle. Between delivery of the 20.000 different parts from many suppliers and the assembly of each part in one Toyota now is on average four (!) hours. They manage this with their 'pull' system. 

How does 'pull' work in a hospital?
A hospital can't produce in stock (let's put twenty CT scans in stock?), so the problem of large supplies is unknown to hospitals. Is the 'pull' principle relevant in a hospital?

We don't have any stock, but we do have a lot of waiting in between steps in care processes. The throughput time from first contact until diagnosis often takes weeks if not months. Despite that the addition of the time spend on each step often is less then a day or only several days. From the perspective of a patient our care processes are a stop-and-go experience. The cause lies in the 'push' way of organizing the characterizes hospital flow.

Essentially 'pull' is:
respond to demand
When care is 'pull' organized the demand determines where care providers spend their time on. In hospitals we currently determine where time is spent on long before care is demanded (= 'push' logistics). Some examples of 'push' logistics:
The number of sessions in an outpatient clinic depends on the availability of specialists and perhaps of supporting staff. It is not based on current demand.
Sessions are programmed with fixed appointments, for example six new patients and twelve follow-up appointments. These programms are not based on actual demand, but on the preferences of the care deliverers. The numbers of each type of appointment will not respond to actual demand in a given week, resulting in unnecessary waiting times.
Supporting staff of outpatient clinics are scheduled two months in advance, when the number of sessions is not yet definite. Often sessions will be canceled or added afterwards. It will be difficult to reschedule the staff (and they will not like it). This results in overstaffing and shortage of staff. Also, the canceling of sessions is not based on less demand, but absence of care providers.
The number of OR (operating theaters) for a specialism per week is determined every year with a fixed planning for each week (on Mondays General Surgery has three OR's, Orthopedics two etc.). This is done before any patient is known. Why? In the words of professor Frits van Merode: the division of OR capacity is not a planning instrument, but a 'peace treaty'.
These are all symptoms of 'push' logistics: demand has to comply to our scheduling of capacity, instead that we respond to demand (by the way, that's why my phd research is about the 'reactive capacity of hospitals').

What would 'pull' logistics look like in a hospital? An example:
If in January more patient request an appointment for a Gynecologist, he or she takes more time to see patients and gets more staff support for the extra sessions. Later he or she performs more operations for these patients and gets more OR capacity to do so.
OR capacity is not divided anymore per specialism, but on actual demand. OR capacity is given to individual patients.
This requires a large flexibility from the system. It also requires trust from the care providers in the system 'I'll receive OR capacity for my patients when they need it'.

How can you recognize the consequences of a 'push' system?
General practitioners call to arrange priority for their patients ('push')
This lab result needs priority ('push')
The surgeon needs to call the radiologist to make sure his patient gets a MRI slot sooner ('push')
Or more in general:
'I push todays demand to tomorrow, because today I'm full" ('push')
Instead of:
'I do todays work today' ('pull', as proposed by general practitioner Mark Murray in his 'Adanced Access' concept)
Push and pull in a hospital
 I don't believe that a hospital can be organized completely 'pull'. There are two major reasons why 'push' is for some part inevitable:
  1. Uncertainty what the value stream will be. When I order a car the factory knows exactly the specifications before the car is assembled and all steps required to build it. In care processes next steps are often determined during the process (for example: only after diagnosis treatment can be determined). Better yet, often steps change during the process because of complications or because a patient changes his or her mind.
  2. Natural variability in care processes. Installing a door handle can be repeated each time in the same time. The same operation will take more time with this patient then the other because one body is not the same as the other.
Because of both factors a hospital cannot create complete work load leveling ('heijunka'). To organize care processes completely 'pull' unacceptable levels of overcapacity are needed. That's why a mix of 'push' and 'pull' will be required. However, it is evident that a lot more 'pull' is needed. For the benefit of patient flow, but also for the benefit of care providers. 'Push' systems lead to strong tensions (who gets how much capacity? Why do my patients need to wait for your department?). 'Push' systems tend to stimulate people to look after their own interest, even at the cost of the common interest.

'Pull' is not better then 'push'. They are two logistical principles that both can be useful, depending on the situation. The interest is to create 'flow': no unnecessary waiting. And that every care provider can spend as much time as possible on providing care (instead of pushing patients through the system or to claim as much capacity as possible). The interest is to have patients experience care as one, fluent process.

How to start?
A good starting point is the planning processes and policies (e.g. scheduling staff, scheduling sessions, programming sessions, OR capacity planning etc.). Use these questions:
  • do we base our decisions on actual demand, or on internal (non-demand related) criteria?
  • which information do we use concerning actual demand? If there is none: how can we get it?
  • does this policy change increase or decrease the flexibility to respond to actual demand?
Finally, we should improve the flow of care processes in respons to the problems that are experienced on the work floor ('pull').


Pitfall of lean

Lean is one of the most widely used and proven management approaches. Yet, also with lean applications there are many organizations that do not achieve a real lean journey. Projects might deliver results, but they rarely lead to a sustainable development. After a while the attention drops away. What are the pitfalls of lean? A first exploration.

What characterizes the (popular) literature on lean? The approaches are largely based on a rational, predictable approach to organizations. Read the most common lean method another time:

1. Determine value
2. Identify the value stream
3. Create 'flow'
4. Let the customer 'pull'
5. Continuously improve
(Womack en Jones, Lean Thinking)

Step 1. Determine value
Could it be that different caregivers often think differently about what is of value to a patient? And that patients themselves have a completely different view? Hoe do you handle a great diversity of views? An example:
A department realized that they offer a poor service by giving their patient their date to be operated just shortly before the operation. Therefore they started a project to offer every patient their operation date directly in the outpatient clinic when the operation is decided. A nice improvement. Yet something felt not right. A later study showed that 95% of the patients indeed highly appreciated the new service. 5% however is very nervous before the operation and can't sleep anymore as soon as they have the date. They prefer to be called as shortly to the operation as possible. Determining value is often more nuanced than at first glance.

Step 3. Create 'flow'
Could it be that many forms of waste are related to historical patterns and relationships? That it can be threatening when this is analysed? Or that in itself rational process improvements create uncertainties for stakeholders? An example:
An outpatient clinic had problems with no shows, pressure of phone calls from patients and GPs requiring priority, much work with rescheduling sessions, and surprisingly enough, also many unused appointment slots. A major cause appeared to be that they used various types of appointments on fixed times in the sessions. E.g. always a new patient at 9am, 9.40am, 10.20am. This offers insufficient flexibility because every week there is a different numer of patients requiring a specific type of appointment. Just stop using fixed slots and plan flexible. The group of doctors however did not allow this. Why did they use fixed slots? Because they wanted to be sure that every specialist sees an equal number of new patients, thereby ensuring that each specialist contributes the same to the group. This had gone wrong in the past. From a flow perspective, the current planning method is a (minor) disaster and there are other solutions, but they would not let go because they feared that the old quarrel would come back.
Step 5. Continuously improve
What are your experiences when you suggests an apparantly good idea? Is it often not put to practice as quickly as you can imagine? An example:
On an outpatient clinic the relations had gone from bad to worse. There was much dissatisfaction. They saw many things they did not like, but they were not able to improve them. Interviews revealed that the assistents perceived that the specialists hold all the power and blocked any improvement. The specialists however said they had many good ideas, but they needed the assistants to realize them. Since the specialists did not have any formal power over the assistents they were not able to influence them. The specialists felt powerless.
With a sense of reality
The examples are not intended to indicate that the lean principles do not apply there. To the contrary. Lean however pays little attention to the non-rational side of change processes. Even thoug they often determine the progress. In the words of Marcel Boonen, manager of a care department: "after the logic starts the confusion".

With a lot of external pressures (higher management, program management, etc.) the rational approach can deliver results. Continuous improvement, a cultural change is something different. Lean thinking can not be implemented. For the non-rational side, to reach inside, other interventions are needed. This starts with the recognition of different views on value and problems and investigating them with a sense of reality. As a secretary once spontaneously shouted during an improvement session:
Do you mean that from now on you are going to take our ideas seriously!?


Never try to change something

One of my favorite statements is:
"Never try to change something if you don't love it as it is now"

What drives you to change something? What is your motivation?

When your make a statement about something that you want to change (eg waiting in a department or the willingness to help each other), do you disqualify the current situation? Do you speak about how it should be, without a deep understanding of why it is as it is now?

Lean thinking is based on systems thinking, which comes down to:
"Every system is perfectly designed for the results it gets"
(Paul Batalden)
If the results are not good, what is the cause? Improving results requires insight into why the current system performs the way it does.

Principle 12 of  The Toyota Way (as described by Liker) is:
"Go see for yourself to thoroughly understand the situation (Genchi Genbutsu)"
A common strategy used in change management is to make people very dissatisfied with the current situation. To make it clear that everything is bad and that everything must change. The jargon for this is 'to create a burning platform'. Then people will have to jump.

When is that a wise strategy? Cetrainly not if you want to improve the way Toyota does. Perhaps it is wise if the current system is so sick that you need a radical change? I doubt it.

Each organization that exists over a longer period has values that under the surface that establish cohesiveness and provide continuity. In terms of Teun Hardjono: that feed the intellectual and social capabilities of organisations.

A burning platform gives momentum for change, but usually the baby is thrown out with the bathwater by also disqualafying what is good.

A deep understanding of the current situation clarifies why the current approach does not lead to the value that you want to create together. In there lies, often dorment, the motivation for every careprovider to do things differently.

To understand the situation thoroughly, and to connect to the experiences of the people involved you must throw yourself into the work processes. To investigate. To understand.

Which motivation fits with this? In any case, not by disqualification of the current situation. Then you do injustice to the people and you distort a clear view on the system.
"If you do not love what you are trying to change, do something else"


Lean Healthcare Transformation Summit 2009 - Highlights

On July 10 the Lean Healthcare Transformation Summit was held in London  with 170 participants from 12 countries, organized by the Lean Entreprise Acadamy(LEA). On www.leanuk.org under 'events' all sheets ánd video recordings of all presentations can be viewed. What stood out? What made me think?

Almost all presentations contained strong examples of visualization of care processes. The presentations themselves also used many pictures and self made movies that made much more impact than just sheets. Some examples of visualization:
  • Thedacare: each department has its "Visual Tracking Center": a wall that visualizes daily how the department performs on (e.g.) Safety, Quality and Cost, including effects of improvement activities.
  • The Emergency Department uses 'real-time flow visualization' for each patient (!). Horizontally you see for each patient the steps and the expected flow. Below that the actual flow is indicated..If it's later then expected, it is circled red. A blue post-is hows where the patient currently is.
  • A3 analysis of problems are filled in with colored visualizations: value streams, fish bone charts, spaghetti diagrams etc.
A surgeon summed up the importance of visualization: "We used to say: 'if you can't measure it you can't improve it'. Now I think: "if you can't see it you can't improve it'".
Thedacare (USA) - John Toussaint, MD, CEO
Very strong and inspiring story. He told his story with the same approach how Thedacare applies lean thinking in her 'Thedacare Improvement System':

1. Purpose
2. Process
3. People

After five years applying lean thinking they translated their mission into three objectives (he states it should be three to achieve a strong focus). For Thedacare it is:

1. Each year 50% less "defect rates", e.g. infections
2. Each year 10% more productivity (they achieve 6% so far)
3. Each year more more improvement ideas from the work floor

2. Process
John talked about outpatient multidisciplinary teams setting up a treatment plan together with the patient. He also gave examples of "check points": points in the care process where the care provider determines whether all conditions are fulfilled before the next stage of the process is entered. He stressed the importance of transparency of their results, both internally and externally. They created a website: http://www.wchq.org where you can see how they perform relative to other providers in their state. They also keep accurate track of how many improvements are made. So far, 5300 A3's realized.

3. People 
Every manager joins every week the discussion of the 'visual tracking centers' and coaches teams with questions.

Applying lean thinking
Dan Jones spoke of the convergence of :
  1. Top-down vision, with 
  2. Bottom-up improvement of processes, with 
  3. The development of value streams.
Value Streams
Many examples and stories were given about improving entire value streams across departments. Also on managing value streams, including the position of a 'value stream manager'. Main task is to gain front to back 'agreement' on the right actions for the value stream, (no line responsibility over the value stream). A value stream manager also gave a presentation. Interesting but not convincing. Hospitals with long lean thinking experience are also still searching for the right approach.

How do people learn?
A demonstration made (hilariously) clear that learning works best when you see it (visualization) and a detailed explanation is given in small increments and you can practice it. Training Within Industry is an old and proven method for this purpose that's is underestimated.

Focus is more on processes and continuous improvement, less on people
There were frequently referrals to the people aspect of the application of lean thinking and there were good examples. Considering the whole however, the people aspect remains subordinate to the improvement of processes. E.g. how people can have different views on reality and how to deal with this is not covered. Even though Toyota teaches us that 'respect' combined with 'challenging people' is one of the two core values of Toyota (the other is 'kaizen' or continuous, steady, improvement). In the lean thinking movement the people aspect remains secondary.

Royal Boston Hospital NHS Trust (UK) - Fill David Ingham, CEO
Besides many examples of the application of lean thinking he gave four stereotypes of the people they encounter in their lean endeavors:
  • Positive outlook on life, but no grip on reality: naive idealist
  • Negative outlook on life and no grip on reality: embittered cynic
  • Negative outlook on life, but grip on reality: disillusioned skeptic
  • Positive outlook on life and grip on reality: enthusiastic pragmatist
The lean drivers obviously are in the last category. They to get the others in that category by:
  •  Rigorous application of lean methods
  •  Convincing data
  •  Experience by applying, e.g. three-day "rapid improvement events"
  • Ratify through change management and leadership
He concluded that slow progress is not because people are obstructive, but because they insufficiently understand what they are trying to do with lean. The only way is by steadily progressing, head strong. 

Both CEO's  considered the most important aspect of leadership: Genchi Genbutsu. Or: go to the source to thoroughly understand the situation. Every Thursday and Friday the day starts at the visual tracking center "(see above) of a department. Also, the CEO's regularly participate in overnight improvement events ('with the phone off'). The aim is to understand what is going on and why. By asking 'why?' again and again departments are coached while the director or manager understands what is happening in the organization. Main purpose of leadership: developing people and creating conditions for experimentation and learning.

Push - pull
Finally, a surgeon defined the complicated 'pull' principle very elegantly::
"pull means responding to demand''
('push means that demand must comply with our supply").

All in all a very informative day with many powerful examples. Several hospitals demonstrated how much difference lean can make after 7 to 10 years' application of the principles. Yet is also clear (and they say so themselves) that they really only just begun. It takes a truly long-term focus and a lot of perseverance. After this day I feel energized again!


Lean and compassionate care

Two hot topics in Dutch healthcare are 'lean thinking' and 'compassionate care' (menslievende zorg). We agree that they are related, but we have little understanding how. Therefore some thoughts about this from the perspective of lean thinking, based on: value, respect, time pressure and system thinking.

Conceptually lean and compassion come together in the concept of value. Lean thinking means that every activity and process is viewed from the question: what value does it add? Compassionate care is a core value of our existence as a hospital and therefore a natural question to ask when improving processes: is this process compassionate? If not, why not?

If an acceleration of a process or standardization or another change is at the expense of compassionate care it is basically not an improvement.
One of the two core values of Toyota is: respect (besides Kaizen). Respect for customers, employees, supply chain partners and society. This translates, among others, that everyone is well equipped for their tasks and that everyone is challenged to perform a little better tomorrow. Respect is a  core value from lean thinking that relates well to compassionate care.

Time pressure and system thinking
Why is care (sometimes / often?) given less compassionate than we would like?  The academic hospital UMC Utrecht performed a study that is published in Journal for Nurses (Tijdschrift voor Verpleegkundigen), April 2009, 4. A quote from p.45:
"Nurses experienced obstructing factors to practice compassionate care. Time pressure was the main factor. Interviewees indicate that it's no excuse, but the amount of duties and hectic of the situation and basic care gets priority over the relationship with the patient."
Lean thinking focuses on reducing non-value adding activities, which can reduce the workload. One of the core principles is: hijunka. It aims to evenly distribute the workload throughout the day and the week. Health professionals often speak of running and standing still as their day rythm. It is conceivable that it is particularly difficult to provide compassionate care during peek levels of workload. Evenly distributing the workload with fewer disruptions can lead to more attention to patients

Compassionate care addresses directly the intrinsic motivation of individual care providers. Lean thinking can add: why does the system lead to inadequate compassionate care for our patients?

Example why there is no 'flow'

Recently I visited a PA lab and one of the analysts gave an example of a lack of flow:
Why does it take several weeks for the results of a smear for "cervical cancer' to get back to you? (Partly) because the smear is delivered only once a week by a courier from the pharmacies to the hospital. Then a big batch comes in. If you have bad luck it takes up to a week between the visit to your general practicioner and the the test getting into the hospital.

The hospital then has a week to process the whole batch (because it must be completed before the next batch comes in). If you have bad luck it takes another one week before your test gets into the process and you have waited for two weeks with, untill now, not one action that added value.
Why are the tests deliverd by courier in batches? Previously this did not happen, the general practicioners used to sent it by mail, which was literally a smear. A while ago, however, a new and better technique was introduced with tubes that do not fit through the letterbox. The GP therefore can not mail it anymore. Therefore, he (or an assistant) has to bring it to the pharmacy (which often also takes several days by the way), and a courier has to pick it up there again.

Suggestion of the analyst: ask the manufacturer of the tubes to create a smaller tube type that will allow to be mailed daily again, taking out more then two weeks of processing time.
His story shows nicely how you can look at processes from a (one-piece-) flow perspective. It shows the problem of batching, it uses root-cause analysis with '5 x why?" and reduction of unnecessary steps. A good example also how poor flow (weekly courier) leads to more bad flow (one week to process the tests).

Symposium lean thinking in healthcare - highlights

June 11 the symposium "lean thinking in health care" took place in the St. Elisabeth Hospital in Tilburg in the Netherlands. 230 participants from 20 hospitals and several research institutions, a packed auditorium.

Besides managers and staf many caregivers (almost half) and a remarkable level of energy. Was there at the first symposium last year an atmosphere of "could lean thinking be something for us?" this year it was' how can we work on it? ". Also, there was a lot of exchange of experiences with lean principles and tools. The application is increasing rapidly in the various hospitals.

In his book "The Toyota Way" Jeffrey Liker describes 14 principles that Toyota has developed over the years. He divided them into four pillars (roughly translated):
  • Long-term philosophy that leads to greater value
  • Improve processes: more flow and less waste 
  • People excel through respect and challenge
  • Countinuous, steady, improvement
I looked back at the program of last year, and noticed how the focus on the application of the principles in the care last year was mainly in the 2nd pillar: the improvement of processes. This year shows a different picture: a lot of attention to continuous improvement and the human side is well represented. Value also is represented in the form of the relationship between lean thinking and "loving care". It would therefore appear that the principles of Toyota are not only applied more in healthcare, but also the application evolves and gets richer.  A development that gives confidence that lean thinking can contribute to a sustainable development of healthcare.