Learning to see

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!

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?

Visualization
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

1.Purpose
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. 

Leadership 
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!