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| Inspired by Stephen Parry |
Posts tonen met het label leadership. Alle posts tonen
Posts tonen met het label leadership. Alle posts tonen
2011-05-01
2009-12-29
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:
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?
- 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!
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?
2009-11-08
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 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.
"...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 timeFixing 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 improvementRelentless 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 goalsThe 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 situationGoing 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 improvementBy 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.
2009-09-19
Never try to change something
One of my favorite statements is:
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:
Principle 12 of The Toyota Way (as described by Liker) is:
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.
"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"If the results are not good, what is the cause? Improving results requires insight into why the current system performs the way it does.
(Paul Batalden)
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"
2009-09-16
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:
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.
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.
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:
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::
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!
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.
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 :
Value Streams - Top-down vision, with
- Bottom-up improvement of processes, with
- The development of 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
- Rigorous application of lean methods
- Convincing data
- Experience by applying, e.g. three-day "rapid improvement events"
- Ratify through change management and leadership
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!
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