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!