Tuesday, October 28, 2014

Healthcare Kata on YouTube

Last month I was honored to be invited to speak at the 10th Annual Northeast L.E.A.N. Conference hosted by GBMP, Inc.  It was my first time attending this conference, and I have to say that it's a truly wonderful event.  Well-organized, great people...awesome vibe.  Go to this event if you can!

Anyway, my 40-minute presentation was not recorded, so I broke it up into a series of six short presentation, added my voice-over to the slides, and uploaded the resulting videos to YouTube:


The presentation is basically me sharing the results of some of my experiments with the Toyota Kata approach in hospitals.  The good, the bad, and the ugly.  Hopefully it's useful to you.

Here's the first video, which is introductory...


The second video is where I provide an overview of the Improvement Kata and Coaching Kata techniques...


Videos 3, 4, and 5 dive into specific examples of the Kata in action in hospitals...


And last but not least, part 6 is where I provide a metaphor that hopefully explains how the Kata approach fits into a lean transformation...


Wednesday, April 2, 2014

The Big Kata

When it comes to improvement methodologies, scalability is important.  It's great when we can use a consistent approach to improvement regardless of whether we're working on a small, incremental improvement on the front-lines or a big, strategic improvement at the enterprise level.

But why do we want a single approach?

There are lots of benefits to having a single approach to improvement:

  • Fewer approaches = less jargon = less confusion
  • Fewer approaches = more repetition on the chosen approach = more "muscle memory"
  • Fewer approaches = less education/training required = more time spent learning-by-doing
  • Fewer approaches = easier to spot errors in technique = easier to coach/mentor others
And so on and so forth.  Plenty of upside, but what is the downside?  It's that whatever improvement methodology you choose must be scalable.  It must be effective for big efforts, small efforts, and everything in-between.  It must also plug & play with improvement tools/techniques such as kaizen events, value stream mapping, job instruction training, KaiNexus, etc.

So what kind of approach would be fully scalable?

The Toyota Kata approach is one methodology that I believe fits the bill.  In my experience as both a Learner and Coach of the Kata approach in a hospital setting, I have observed it to be an effective approach for large value stream transformation-type projects, as well as staff-led incremental improvements on the front-lines.  I've also seen it used in conjunction with kaizen events and several other lean tools/techniques.

However, there is one type of project on which I've not personally utilized the Kata approach:  an enterprise-wide Lean deployment.

The Hypothetical "BIG KATA"


A great proof of concept for the Toyota Kata approach as a fully scalable improvement methodology would be to use it to drive the full-blow Lean transformation of an organization.  I call this the BIG KATA.

How might the BIG KATA look in practice?  Let's do a hypothetical analysis...

First, let's look at the mental model that defines how a Kata practitioner views a continuous improvement journey...


In written form, it's the progression from the Current Condition to the Next Target Condition (there's always a next one) in iterative fashion (via PDSA/PDCA cycles that remove obstacles) in pursuit of a Big Challenge, all in alignment with the long-term Ideal Condition.  

Now, let's dive into each element of this mental model with regards to the BIG KATA i.e. a full-scale Lean deployment (and let's do this in the context of a hospital/healthcare setting).

Ideal Condition


First up is the Ideal Condition, that off-in-the-distance, sort of vague, North Star-like, overall direction that guides our Lean transformation.  Maybe for a hospital, it's something like "Maximize the health of the community in a waste-free manner" as shown below...


In other words, pure value being delivered to the customer.  That's the purpose of Lean, to deliver better and better value to our customers.  We don't "do" Lean for the sake of doing Lean.


Big Challenge


So, now we have the long-term direction for our Lean initiative.  Let's work back from there to establish a Big Challenge that we can rally around in the medium-term (let's say for a project this size, the next 6 months to 2 years).  Maybe the hospital struggles with misaligned and unsustainable improvement efforts, so the situational approach to take in this scenario might be to establish a mature Hoshin Planning system (to drive alignment) while also building competency with the Toyota Kata approach (to drive sustainability).  This is a huge challenge!  Let's see how it looks below...


Now that we have our Big Challenge, that is somewhat tangible, to guide our decision-making over the next few years, we can get down to the real meat of the Kata approach, which is the progression toward successive Target Conditions.


Current Condition


In our hypothetical hospital scenario, let's say we did a study of the current condition of the organization and found that the there was a rudimentary Hoshin Planning system in-place already, but that it lacked some key elements such as the "catchball" process.  And let's say that plenty of improvement activity was taking place via specialist-led kaizen events, operational leader-led "just-do-its", etc., but that these improvements were short-lived and unsustainable once the inevitable force of entropy took hold.  Let's show this below...



Target Condition


Finally, let's assume that our analysis showed that it would be difficult to build consensus with senior leadership for a change to our Hoshin Planning system until we had shown the ability to sustain process improvement results.  In this scenario, me might establish a first Target Condition that calls for the development of an Advance Team of Toyota Kata practitioners who can quickly learn the Kata, start showing sustainable PI results, and start to coach others within the next 3 months or so.  Let's see how this looks below...



PDSA Cycles


So now we're ready to rock & roll.  At this point, we can start pursuing our target condition by identifying obstacles and eliminating them through rapid cycles of PDSA.  The first obstacle might be that we haven't actually selected our Advance Team.  And maybe the next obstacle after that is that the Advance Team doesn't appear to have the time to devote to their Kata practice.  These are all likely obstacles, but all solvable through persistent cycles of PDSA.  Let's look at this below...


Needless to say, whoever is performing these PDSA cycles (and for that matter, whoever is leading this whole BIG KATA in the first place) must be a pretty savvy Kata practitioner.  Oftentimes, but not always, this might imply the need for external expertise/support/coaching.

Once enough obstacles had been removed and our first Target Condition achieved, we would work to establish the next Target Condition (perhaps utilizing the "catchball" process to establish a few strategic objectives that could guide the improvement efforts of the Advance Team and other Kata practitioners?) in pursuit of our Big Challenge of establishing Hoshin Planning and Toyota Kata across the organization.  And of course, all of this is in alignment with the Ideal Condition of the hospital, which is to maximize the health of the community in a waste-free manner.  That's the BIG KATA...in a purely hypothetical sense.


Conclusion


Obviously this is all just conjecture.  Would it work?  I don't know.  I would need more evidence.

I'm sure some advanced thinkers (other than Toyota!) have successfully applied the Kata approach to an all-out Lean transformation, and I'd love to see if the empirical evidence supports my hypothesis that the Toyota Kata approach is a fully scalable improvement methodology, even up to the level of a full-blown Lean deployment.  If that is indeed the reality, then it supports the case to adopt The Toyota Kata approach.

Saturday, March 29, 2014

My Video Webinar with Gemba Academy

A few weeks back I had the honor of collaborating with Mike Rother on a SlideShare titled "Top 10 Toyota Kata Lessons" based on my real-world lessons learned from practicing the Toyota Kata approach for about a year.  Just this past week, I was fortunate enough to share those same lessons learned via a video webinar with Gemba Academy.  Here's the recording (available to the public for 30 days until ~late April 2014):


Delivering this webinar was a challenge for me personally.  Figuring out how to make the slides as eye-catching and minimalist as possible was difficult, as was trying to maintain "eye" contact with the camera while speaking to the slides.  Another great learning experience for me.

My Guest Appearance on the Lean Six Sigma Academy Podcast

Recently, I had the opportunity to discuss my thoughts on the Toyota Kata approach to continuous improvement with Ron Pereira on his Lean Six Sigma Academy podcast.  Here's the link...

LSSA Podcast:  "Michael Lombard, Leveraging the Toyota Kata"

It was a lot of fun.  I had never recorded a podcast before, so it was a learning experience for me.

Tuesday, March 18, 2014

Video Version of "My 3 Best Coaching Kata Mistakes"

With encouragement and guidance from Mike Rother, the great lean thinker and author of Toyota Kata, I turned the "My 3 Best Coaching Kata Mistakes" blog post into a voice-over presentation/YouTube video.  It was harder than I expected to produce this little 10-minute video, but I got plenty of lessons learned from it.  Here it is...



Sunday, March 2, 2014

My 3 Best Coaching Kata Mistakes

Over the past few weeks I've started capturing my lessons learned from practicing the Toyota Kata approach.  First, I posted my top 10 lessons learned to my blog.  This led to some incredibly helpful feedback from the great Jeff Liker over at the Toyota Way group on LinkedIn.  It also led to the equally great lean thinker, Mike Rother, guiding me to the creation of a SlideShare version of my top 10 lessons.  The latest news is that I will have the opportunity to share what I've learned via a webinar later this month on Gemba Academy.

What's valuable to me about all this activity is that it supercharges my learning. Probably 95% of my Kata skill-building comes from real-world application (learning by doing).  But to capture that last 5% requires some reflection and external feedback, which is why it's great to have a coach or sensei as you move forward on your learning journey.  I ask you, how would Daniel-san have fared in that tournament without Mr. Miyagi?


The Challenge


Unfortunately, many of us will not have access to an experienced sensei that truly understands how to coach the Kata approach.  Most of our in-house PI folks like me (Black Belts, etc.) are great at solving problems, but aren't the ideal Kata coaches for myriad reasons, including but not limited to the following:

  • They aren't trained on how to coach in general
  • They aren't familiar with the Kata approach at all
  • They're judged based on the ROI of their projects, not how well they spread kaizen habits

This is problematic because high-quality external senseis can be hard to find and fund.  Internal leaders outside of the PI department can be great coaches eventually, but during the early "incubation" period of the Kata approach they will need room to grow as Improvement Kata practitioners before they can be effective coaches.

In this common scenario, all you can do is move forward and treat your initial foray into coaching as a PDSA experiment.  You will have a hypothesis about what constitutes good Coaching Kata; you will be wrong.  And wrong again.  And again.

For me personally, it took performing about 100 coaching cycles with about 10 clinical leaders from across the hospital just to know what I didn't know about the Coaching Kata.  Now, after about 300 coaching cycles with about 20 people I'm finally just now starting to "get" it a little bit.  Yeah, it has been a humbling experience.

But let me share with you some of my most humbling coaching mistakes so that maybe you can move along that learning curve a bit quicker than me.  Here are my 3 best Coaching Kata mistakes ('best' because they have yielded the most insights for me):

Mistake #1:  Being Too Rigid


The Coaching Kata provides a wonderful framework for coaching.  Specifically, there are two routines we perform:
  1. Instruction/Coaching:  this is the general guidance, teaching, moral support, etc. that is provided while the Learner is performing the first three routines of the Improvement Kata that make up the planning phase.
  2. Daily Coaching Cycles:  this is the structured routine guided by the 5 Questions that is performed frequently while the Learner is performing the fourth routine of the IK that makes up the execution phase (we call it "being on the staircase").
My main mistake was in conflating and confusing these routines.  Because the 5 Questions Pocket Card was like a warm blanket during times of uncertainty, I would revert to it too early on in the IK process.  I was trying to do routine #2 (daily coaching cycle) while the Learner was still in the planning phase.

This made for awkward, rigid coaching.  This is because when the Learner is still trying to see the overall direction, grasp the current condition, and establish a target condition, the path forward is too cloudy to be able to concisely answer the pointed 5 Questions.  During the early planning phase, we should give the Learner a slightly wider birth.

Also, regardless of which of the two coaching routines we're performing, we should remember that these are person-to-person encounters.  Take the time to "break the ice" before jumping into the Kata.  Help the Learner get over the discomfort of a new, foreign management routine.  Acknowledge the inherent awkwardness of two novices trying to pretend like they know what to do next. It's okay!

Mistake #2:  Short-Changing True North 


The first step of the Improvement Kata is to understand the overall direction of the improvement effort.  The overall direction can be comprised of several elements, including but not limited to the following:
  • Ideal Condition (perfection)
  • Long-term strategy
  • 1-2 year challenges
  • Future-state value stream maps
  • Key performance indicators
Taken together, these elements provide a True North by which we can guide our improvement efforts.  Taking the time to properly understand how our individual PI initiatives fit into the the big picture is incredibly important.  Not performing this routine properly increases the risk of poor organizational alignment, ineffective strategy deployment, "scattershot management", etc.  Bad stuff.

Yet, I still find myself to this day doing an inadequate job of coaching Learners on this first step of the IK.  We typically end up spending about five minutes just verifying that "yes, this particular PI project will help improve patient safety, and therefore, it's well-aligned with the overall direction."  That's pretty much a waste of time; we need to do a better job of connecting individual PI projects to the big picture in a less platitudinous and more concrete way. 

On the surface, this appears to be an easy coaching mistake to fix.  It would seem straightforward enough to help the Learner put together an A3 that shows the Ideal Condition, long-term strategy, KPIs, etc. of their PI project.  But in many organizations, it's not so easy because strategy is not transparent or hasn't been cascaded down to the level of the Learner.  We can't expect the Learner to plug & play without a port, no matter how good their dongle is.

What I'm learning as of late is that even if we don't have a mature strategy deployment system yet, we can still harness the fractal nature of the Kata approach (see page 21 of this presentation).  The target condition of a big, strategic improvement initiative can provide the big, longer-term challenge for a smaller PI project.  A practical approach to making this happen could be to have the Learners for the big, strategic initiatives be the coaches for the small PI projects related to them.

In experimenting with this approach, I've seen my ability to recognize potential synergies and detect potential misalignments improve.  It's not a perfect solution (we ultimately need something like hoshin kanri to systematically drive alignment), but it's a start.

Mistake #3:  Not Utilizing Judo


In that Karate Kid clip above, Mr. Miyagi did a great job of using the testosterone-fueled aggressiveness of the Cobra Kai against them, judo style.  He had mastered the art of leveraging momentum in a productive manner.  The same approach should be taken when practicing the Coaching Kata.

One of the toughest things for me as a Coach has been to know when to hold the Learner back a little bit and when to encourage them to move forward with change.  Any good PI professional knows that blindly implementing countermeasures before properly understanding root causes is foolishness.  This is so much a part of the Lean canon that it's self-evident.

However, in practice, it's not always clear if we have properly understood the root causes of our problems.  At some point in our analysis, we hit the limits of our knowledge frontier.  At that point, we have a big batch of root cause analysis work that needs to be validated, and as with any form of batch production, there's always a risk of delayed detection of defects (in this case, the errors would be in the form of incorrect root causes being identified).  Therefore, as Coaches, we need to be adept at sensing when the RCA batch size is getting too big and needs to be validated through some PDSA hypothesis testing.

One way to look at this is as 'mini-cycles of PDSA embedded within the Plan phase of a bigger PDSA cycle.'  It's testing, as opposed to implementing, countermeasures.  Another way to look at this is that it's the recursive nature of the Improvement Kata, with the learnings of the execution phase informing and refining the work of the preceding phases.

However you choose to see it, just know that it's one of the hardest things to get a feel for as a Coach.  You'll need plenty of Coaching Kata repetition and hopefully some secondary coaching from a sensei.  You'll also need to know your audience.  In hospitals, we have some ER nurses that would put this guy to shame in terms of being "action-oriented"...

Courtesy of www.giphy.com

Sunday, February 23, 2014

The Big Batch Theory

Don't you love those moments when you make a connection between ideas that on the surface have nothing to do with one another?    I hate the term "aha moment" but it is appropriate in this case, and it does make me think of this hilarious Eddie Murphy moment (language slightly NSFW):


Okay, so anyway, there's an aha moment insight to be gained from analyzing the batch sizes of different types of work we do and discussing how lean principles such as pull, just-in-time, one-by-one flow, etc. can help us improve our work.  The following paragraphs will dive into three different work scenarios:  1) Big-Batch Production, 2) Learning in Big Batches), and 3) Big-Batch Root Cause Analysis.  Here goes...

1) Big-Batch Production

aka the "Yeah-I-Learned-That-In-Lean 101" example


This is the good old-fashioned example of the Welding Dept. in Ohio producing 10,000 widgets in one huge batch and shipping them to the Assembly Dept. in Michigan, who finds that the whole batch is defective because of one inaccurate measurement or whatever.

The well-understood principle at play here is that we shouldn't push big batches because it obfuscates the connection between customer demand and production.  It's the waste of overproduction, which in turn leads to myriad other wastes:  whole batches of undetected defects, out-of-control inventory, etc.  Instead of this big-batch push approach, we should strive for a target condition whereby downstream processes can pull from upstream processes in pursuit of a True North of perfect one-by-one just-in-time flow that perfectly matches customer demand with production supply.

Those ideas are part of the lean canon; no need to rehash them further.  However, there are so many other scenarios to which we could apply the same logic and benefit from the same lessons learned.  Unfortunately, based on my observations in healthcare anyway, we frequently fail to apply these lean principles to other types of work.  That's what I'll explore in the next two examples...

2) Learning in Big Batches

aka the "Intuitive-When-You-Think-About-It" example


So, applying the aforementioned lean principles of "pull, don't push" or "match supply with customer demand" and so forth, we can analyze our approach to learning.  Specifically, we can look at how we PI specialists teach Lean to the people in our organizations.

The Challenge...

I've been guilty pretty much my whole career of producing large batches of lean training.  I think just about every PI specialist has designed and or delivered all-day or all-week workshops where we cover a broad range of lean tools and principles.  It's pretty much de rigueur in the healthcare world to send Green Belt candidates off for weeks of training at a time.

This "big-batch learning" approach can be quite effective at building awareness of and excitement for the lean approach in general, but I've seen little evidence in my personal practice of this leading to a change in daily habits.  And just to be clear, my belief is that if daily habits don't change then it's extremely difficult to create a culture of continuous improvement.

But why does the big-batch learning approach not lead to habit-building?  It's the same fundamental principle at-play from the previous manufacturing example:  we're obfuscating the connection between supply & demand by pushing tools and principles via classroom training.  This pushing/overproduction leads to all sorts of learning waste:  defects (not remembering how to perform a certain technique because there was too much lag time from exposure to first real-world use), excessive inventory (tools sitting on our mental shelf that may never be used), over-processing (e.g. using five types of graphs when one would do just fine), and on and on, ad nauseum.

The Idea...

Just as in the previous example, the countermeasure here is to establish a target condition of letting the learner pull* lean tools and principles in the course of their improvement work, in pursuit of a True North of just-in-time learning that perfectly matches the supply of learning with the demands of the situation.

* Actually, it's the gap between the target condition and current condition that is doing the pulling.  The learner may not have the wherewithal to know when or what to pull.  This is where having coaches with plenty of coaching cycles under their belt is critical, as they have the pattern recognition ability needed to be the "voice of the gap" so to speak.

It's interesting to think about why we so frequently resort to big-batch learning instead of the just-in-time approach.  I think a root cause might be that most of the time our PI folks don't have a systematic mechanism for delivering just-in-time learning the way we do for big-batch learning (i.e. classrooms, trainee rosters, syllabi, PowerPoint slides, group exercises, simulations, etc.).  Of course, the Toyota Kata system provides a highly-effective mechanism for just-in-time learning, but there are significant barriers that prevent us from adopting this approach universally.*

*Hint:  it seems to come down to whether senior leadership can accept that the future is unknown and unknowable, and that certainty can only come from building strong, repetitive habits that allow us to cope with whatever change comes our way (Carol Dweck's book can provide more explanation).

3) Big-Batch Root Cause Analysis

aka the "Somewhat-Controversial-But-Profound" example


The same big-batch/small-batch, push/pull, supply/demand concepts from the previous two examples apply to the work of root cause analysis (RCA).  Just to state the obvious, as any PI specialist worth their salt knows, we should always strive to properly define problems and identify root causes prior to implementing countermeasures.  This is another sacred element of the lean canon that requires little explanation to PI specialists.

However, the way we go about performing RCA can vary widely.  We have an array of RCA tools at our disposal in several categories:  statistical (linear regression, ANOVA, etc.), practical (5-Why, Ishikawa diagrams, etc.), or empirical (hypothesis testing via PDSA).  We can use any combination of these tools to identify the root causes of our problem, which gives rise to a significant amount of variation in the way RCA is done in the world.

Some interesting discussion regarding various approaches to RCA has been occurring recently on LinkedIn, including comments from the great Jeff Liker.  Here's the link to the discussion thread (you may need to be a member of the group).

The Challenge...

What this discussion thread and Professor Liker's coaching has forced me to do is think about how the RCA approach we select (the combination of statistical, practical, and empirical techniques we utilize) impacts the batch size of the RCA work.  The challenge for us is to figure out what batch size of RCA work will yield the best results for us.  To examine this question, let's look at two extreme batch sizes:

An excessively big-batch approach to RCA work might look like this:  we get a bunch of folks together for an all-day workshop during which we use the wisdom of the crowd to map the current-state process, identify opportunities for improvement, define the problems in a discrete way, and use a combination of statistical and practical RCA techniques to break those problems down to root causes.  At that point, we're ready to hand off that big batch of work from the Plan phase to the Do phase of PDSA.

This approach has the advantage of being efficient from a facilitation standpoint, but all the disadvantages of big-batch over-production as discussed above (but especially defects in the form of incorrect identification of root causes due to faulty assumptions, group-think, etc.).

An excessively small-batch approach to RCA work might look like this:  after engaging the team to do a small bit of current-state analysis, we identify a few potential root causes.  We then select the one we think is the most likely culprit and start testing countermeasures using mini-cycles of PDSA.  If the countermeasure isn't effective at removing our hypothesized root cause, then we try other countermeasures one-by-one.  If we find that a countermeasure is effective at removing our hypothesized root cause, but has no positive impact on the problem at-hand, then we select other potential root causes one-by-one.  Lather, rinse, repeat.

This approach has all the advantages of one-by-one just-in-time production as discussed above, but the significant disadvantage of being a nearly unmanageable process in the real-world due to the myriad factors that can distort, taint, delay, or otherwise invalidate our supposedly scientific experiments.

This is clearly a complicated challenge with no single answer.

The Idea...

It feels as if we will need to find the sweet-spot between these two approaches to be able to mitigate the risks of big-batch work while coping with imperfections of real-world testing.  I think in the current condition, the majority of PI specialists tend to error on the side of big-batch RCA work as described a few paragraphs ago.  Those of us practicing the Toyota Kata method in a strict way probably error on the other side.  Let's find the sweet spot in the middle and move forward, shall we?

Wrap-up


Whether it's our process for producing widgets, teaching Lean, or performing a root cause analysis, we can benefit from understanding how the concepts of pull, just-in-time, one-by-one flow, etc. impact the waste level of our system.  In healthcare, we PI specialists tend to be good at understanding these concepts in the context of the typical clinical process (e.g. a nurse pulling meds from a Pyxis machine, triggering a replenishment from the Pharmacy, etc.), but not so good at applying them to our own work processes.  A true lean thinker is consistent in applying lean concepts to any process.

I shudder to think of how many of my own work processes are poorly aligned with lean principles. Yes, the learning continues.