On the day after Jimmy Fallon debuted as host of the Tonight Show, I'll go against the grain and do a Letterman-style Top 10.* My topic will be the lessons I've learned from my grassroots effort to infuse the Toyota Kata methodology into the culture of an acute care hospital in the Dallas-Ft. Worth metroplex.
*I'm not a huge fan of any of the late-night shows. I like Kimmel and Conan as comedians, but the format just doesn't do it for me. I much prefer the format of Jerry Seinfeld's new show, "Comedians In Cars Getting Coffee" (it's as ridiculous as it sounds, and pretty hilarious). I just wish he had Chris Rock or Don Rickles hanging out in the back-seat for every episode.
When we began testing the Toyota Kata approach we had no experience with or knowledge of it at all, outside of having read the book a few times. We had no budget to bring in experts or send ourselves off for formal training. But, thankfully, we did have senior leader support to try something different; they were ready to invest significant effort in building a sustainable culture of continuous improvement at our hospital.
That's how we started. We didn't know where the path would take us, but we took a step forward anyway. First, we selected an Advanced Team from different departments and levels of the organization. Then, we did a tiny bit of home-grown training and quickly got to work practicing the Kata in the real-world. Now, after about six months of real-world application including several hundred coaching cycles, I have some lessons learned that I'd like to share...
#10: A PDSA cycle is not what I thought it was. I always thought a PDSA cycle was when you had identified a countermeasure to a problem and wanted to test it. Well, yes, that is one type of PDSA cycle, but there's more than one kind. Sometimes, our PDSA cycle consists of nothing more than a quick "go & see" to confirm or deny a hypothesis, without changing/implementing anything at all. I've come to see a PDSA cycle as simply the act of taking a step forward with the intent of learning something in the pursuit of improvement.
#9: Cues, routines, & rewards matter. In The Power of Habit, Charles Duhigg explains that for habits to form, we must have a habit-building loop in place consisting of a cue, routine, and reward. Since modern organizations have so many built-in impediments to organic continuous improvement (annual performance reviews, TPS reports, etc.), we must actively pursue continuous improvement through organizational habit-building. The Toyota Kata approach provides all three elements of a habit-building loop in abundance: 1) cues via formal coaching sessions and visual signals such as the 5 Questions pocket card; 2) routines (i.e. the Improvement Kata and Coaching Kata); and 3) rewards via the intrinsic satisfaction of learning, solving problems, attaining Kata mastery, etc.
#8: Track the metrics of habit-building. In the early stages of Kata adoption the focus is more on building habits than producing huge process improvements with eye-catching ROI calculations. Therefore, it's advisable to have a way to measure progress in terms of habit-building. For example, we can track the # of Kata "practitioners", # of Kata coaches, # of PDSA cycles performed, etc. I'll admit that this is a highly imperfect set of habit-building metrics, so I'm hoping as a community we can come up with something better. One option might be to measure what level of mastery our people have attained using a standardized rubric, as suggested in some of Mike Rother's online material.
#7: Clinicians and other front-line staff tend to like the Kata approach. I think this is because it allows them the freedom to take one bite of the apple at a time. They are free to try a small change or just go get more information, all in the pursuit of learning and iteration. This reduces the fear of failure and the stress of trying to do too much all at once. It's quite liberating actually.
#6: It works on big projects too. We've seen great success in using the four routines of the Improvement Kata as a roadmap for fairly large improvement projects. This is where the fractal nature of the Kata approach comes into play. In our model, the first three routines (1. Understand the Direction, 2. Grasp the Current Condition, 3. Establish the Next Target Condition) are performed in a team environment utilizing techniques such as kaizen events and work-out sessions. While this has the downside of producing large batches of improvement work with fewer opportunities for iteration, it has the upside of allowing us to build cross-departmental consensus quickly. The fourth routine (PDSA Toward the Target Condition) occurs via multiple "learners" pursuing their portion of the target condition in parallel, with a single coach guiding their work and connecting the dots. It's not perfect because doing multiple tests simultaneously makes it harder to understand cause & effect, but this approach does have the advantage of allowing us to expedite the change process.
#5: Target Conditions ≠ Numerical Targets ≠ List of Countermeasures. This was one of the hardest things for me to grasp as a coach. I almost immediately understood that a target condition is not the same as setting a numerical target or goal; yes, we actually have to describe the future mode of operation that will produce the results we seek. This I understood. What I didn't understand was that describing the future mode of operation does not require us to know exactly how we will achieve it. In other words, we don't need a specific list of countermeasures to be able to describe the target condition. In fact, it's better not to lock ourselves into pre-conceived notions of what solutions are needed before we've began testing via PDSA.
#4: Root cause analysis is an iterative process. I always thought of root cause analysis as a routine we performed prior to identifying potential countermeasures. We'd use 5-Why? or whatever to identify a root cause, then come up with countermeasures to address it. What I learned through the Kata approach is that we don't have to fully understand the root causes of a problem before we can start testing countermeasures. In fact, the act of testing countermeasures (via PDSA) is in and of itself a fantastic way to identify root causes in an iterative and scientific manner.
#3: Coaching is tricky. Even though the Coaching Kata provides clear instructions on what questions to ask (the 5 Questions), novice coaches typically struggle with how to stick to the script without being too robotic and awkward about it. It's a balancing act. A coach must be able to sense when the learner is in need of strict structure (new learners often go off in ten directions at once and need to focus on the single next step) and when a more creative, free-flowing discussion is appropriate.
#2: Coaching is largely about providing a safe environment to fail. This is because mastering the Kata is mostly a learning by doing approach that relies heavily upon repetition and deliberate practice. A coach must foster an environment that allows the learner to practice and fail (and trust me, in the early going most of the practice results in failure). Because 'practice' in this context occurs in the real-world (not in some classroom simulation), these failures must also be done in a safe manner that causes no irreparable harm or embarrassment.
#1: When in doubt, take a step forward! Fortune favors the bold.