tag:blogger.com,1999:blog-7774713036722286352024-03-04T22:05:09.231-06:00Hospital KaizenThoughts on Continuous Improvement in Healthcare by Michael LombardMichael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comBlogger37125tag:blogger.com,1999:blog-777471303672228635.post-30498446748163605362015-02-27T08:25:00.002-06:002015-02-27T08:26:50.595-06:00Latest Webinar: "The Kaizen/Kata Nexus"<div dir="ltr" style="text-align: left;" trbidi="on">
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I had a great time with my good buddy, <a href="http://www.markgraban.com/" target="_blank">Mark Graban</a>, yesterday doing this webinar. It was an experiment, actually. We were attempting to articulate the ways in which Kaizen & Kata reinforce and enable one another. They're not just complementary, and they're certainly not in competition with one another; rather, we believe them to be symbiotic. This is just one attempt at reconciling this in our heads, and we'll continue these types of discussions so that we have a stronger grasp of how Lean systems interact.</div>
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Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-7935818623577685842014-10-28T09:18:00.001-05:002014-10-28T09:20:19.696-05:00Healthcare Kata on YouTube<div dir="ltr" style="text-align: left;" trbidi="on">
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Last month I was honored to be invited to speak at the 10th Annual <a href="http://www.northeastleanconference.org/" target="_blank">Northeast L.E.A.N. Conference</a> 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!</div>
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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:</div>
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<a href="https://www.youtube.com/playlist?list=PLKojOFEIsVWpijLOIFqVJX35bxBGpF8jV" target="_blank"><b><span style="font-size: large;">"Healthcare Kata" Series on YouTube</span></b></a></div>
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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.</div>
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Here's the first video, which is introductory...<br />
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The second video is where I provide an overview of the Improvement Kata and Coaching Kata techniques...</div>
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Videos 3, 4, and 5 dive into specific examples of the Kata in action in hospitals...</div>
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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...</div>
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Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-21905263047721802572014-04-02T16:40:00.000-05:002014-04-02T16:55:23.514-05:00The Big Kata<div dir="ltr" style="text-align: left;" trbidi="on">
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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.</div>
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<b><i>But why do we want a single approach?</i></b></div>
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There are lots of benefits to having a single approach to improvement:</div>
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<li style="text-align: justify;">Fewer approaches = less jargon = less confusion</li>
<li style="text-align: justify;">Fewer approaches = more repetition on the chosen approach = more "muscle memory"</li>
<li style="text-align: justify;">Fewer approaches = less education/training required = more time spent learning-by-doing</li>
<li style="text-align: justify;">Fewer approaches = easier to spot errors in technique = easier to coach/mentor others</li>
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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.</div>
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<b><i>So what kind of approach would be fully scalable?</i></b></div>
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The <a href="http://www-personal.umich.edu/~mrother/Homepage.html" target="_blank">Toyota Kata</a> 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.</div>
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However, there is one type of project on which I've not personally utilized the Kata approach: an enterprise-wide Lean deployment.</div>
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<span style="font-size: x-large;">The Hypothetical "BIG KATA"</span></h2>
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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.</div>
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How might the BIG KATA look in practice? Let's do a hypothetical analysis...</div>
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First, let's look at the mental model that defines how a Kata practitioner views a continuous improvement journey...</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_rBt714sfx_O4jO08rUSQkQlymgE_ibOBU_9c4F7ktn3ZPHdm_pEBSpzvfQwF5DaMyIkLnyiFiyzClGY55tpI-gSq0Q_YqjsaFQ9ljoS3Als28wNxYvR7nN_hTwQV_mxvcN1ULnnisQ/s1600/The+Big+Kata_overview.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_rBt714sfx_O4jO08rUSQkQlymgE_ibOBU_9c4F7ktn3ZPHdm_pEBSpzvfQwF5DaMyIkLnyiFiyzClGY55tpI-gSq0Q_YqjsaFQ9ljoS3Als28wNxYvR7nN_hTwQV_mxvcN1ULnnisQ/s1600/The+Big+Kata_overview.jpg" height="225" width="400" /></a></div>
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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 <a href="https://www.deming.org/theman/theories/pdsacycle" target="_blank">PDSA</a>/PDCA cycles that remove obstacles) in pursuit of a Big Challenge, all in alignment with the long-term Ideal Condition. </div>
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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). <br />
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Ideal Condition</h4>
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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...</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgrRGc23YBYuQYWO9JS_oJ7exGEh7gQ0Uv-DZDKZXd4IhO_KYYQ0hCeZMC1NQrsa_yrYwuqEkdjOq_dNTTlGYIvEbXpVtXlESFrn2vOqcQNcl0H93wZdiu_m4EFDDOlAB6rNKIg59k76Q/s1600/The+Big+Kata_Ideal+Condition.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgrRGc23YBYuQYWO9JS_oJ7exGEh7gQ0Uv-DZDKZXd4IhO_KYYQ0hCeZMC1NQrsa_yrYwuqEkdjOq_dNTTlGYIvEbXpVtXlESFrn2vOqcQNcl0H93wZdiu_m4EFDDOlAB6rNKIg59k76Q/s1600/The+Big+Kata_Ideal+Condition.jpg" height="225" width="400" /></a></div>
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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.</div>
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Big Challenge</h4>
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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 <a href="http://www.slideshare.net/Lightconsulting/hoshin-planning-presentation-7336617" target="_blank">Hoshin Planning</a> 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...</div>
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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.</div>
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Current Condition</h4>
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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...</div>
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Target Condition</h4>
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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...</div>
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PDSA Cycles</h4>
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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...</div>
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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.</div>
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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.</div>
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Obviously this is all just conjecture. Would it work? I don't know. I would need more evidence.</div>
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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.</div>
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Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-70257461579550263072014-03-29T20:18:00.001-05:002014-03-29T20:18:05.273-05:00My Video Webinar with Gemba Academy<div dir="ltr" style="text-align: left;" trbidi="on">
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A few weeks back I had the honor of collaborating with <a href="http://www-personal.umich.edu/~mrother/Homepage.html" target="_blank">Mike Rother</a> on a SlideShare titled <a href="http://www.slideshare.net/MichaelLombardMBAPMP/top-10-toyota-kata-lessons" target="_blank">"Top 10 Toyota Kata Lessons"</a> 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):</div>
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Gemba Academy webinar: <a href="http://www.gembaacademy.com/video.php?video_id=GuANmt%2BlTktSC5nALFSiUw%3D%3D&part=1" target="_blank">"Michael Lombard - 10 Lessons from Practicing Toyota Kata"</a></div>
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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.</div>
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Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-45343329118095089992014-03-29T19:59:00.004-05:002014-03-29T19:59:50.597-05:00My Guest Appearance on the Lean Six Sigma Academy Podcast<div dir="ltr" style="text-align: left;" trbidi="on">
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...<br />
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<b>LSSA Podcast: "<a href="http://lssacademy.com/2014/03/19/lss-016-michael-lombard-leveraging-the-toyota-kata/" target="_blank">Michael Lombard, Leveraging the Toyota Kata</a>"</b><br />
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It was a lot of fun. I had never recorded a podcast before, so it was a learning experience for me.</div>
Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-23635558308699967062014-03-18T11:02:00.000-05:002014-03-18T11:02:05.916-05:00Video Version of "My 3 Best Coaching Kata Mistakes"<div dir="ltr" style="text-align: left;" trbidi="on">
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With encouragement and guidance from <a href="http://www-personal.umich.edu/~mrother/Homepage.html" target="_blank">Mike Rother</a>, the great lean thinker and author of <a href="http://www.amazon.com/Toyota-Kata-Managing-Improvement-Adaptiveness/dp/0071635238" target="_blank"><i>Toyota Kata</i></a>, I turned the "<a href="http://hospitalkaizen.blogspot.com/2014/03/my-3-best-coaching-kata-mistakes.html" target="_blank">My 3 Best Coaching Kata Mistakes</a>" 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...</div>
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Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-28911503658189513242014-03-02T14:38:00.001-06:002014-03-02T17:37:50.941-06:00My 3 Best Coaching Kata Mistakes<div dir="ltr" style="text-align: left;" trbidi="on">
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Over the past few weeks I've started capturing my lessons learned from practicing the <a href="http://www-personal.umich.edu/~mrother/Homepage.html" target="_blank"><b>Toyota Kata</b></a> approach. First, I posted my <a href="http://hospitalkaizen.blogspot.com/2014/02/my-top-10-lessons-learned-from.html" target="_blank"><b>top 10 lessons learned</b></a> to my blog. This led to some incredibly helpful feedback from the great Jeff Liker over at the <a href="http://www.linkedin.com/groups/Lessons-Learned-via-Toyota-Kata-4797470.S.5841893905922039808?view=&gid=4797470&item=5841893905922039808&type=member&commentID=discussion%3A5841893905922039808%3Agroup%3A4797470&trk=hb_ntf_COMMENTED_ON_GROUP_DISCUSSION_YOU_CREATED#commentID_discussion%3A5841893905922039808%3Agroup%3A4797470" target="_blank"><b>Toyota Way group</b></a> on LinkedIn. It also led to the equally great lean thinker, Mike Rother, guiding me to the creation of a <a href="http://www.slideshare.net/MichaelLombardMBAPMP/top-10-toyota-kata-lessons" target="_blank"><b>SlideShare version</b></a> of my top 10 lessons. The latest news is that I will have the opportunity to share what I've learned via a <a href="http://www.gembaacademy.com/webinars/lombard-kata.html" target="_blank"><b>webinar later this month</b></a> on Gemba Academy.</div>
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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 <i>sensei</i> as you move forward on your learning journey. I ask you, how would Daniel-san have fared in that tournament without Mr. Miyagi?</div>
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<u>The Challenge</u></h2>
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Unfortunately, many of us will not have access to an experienced <i>sensei</i> 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:</div>
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<li style="text-align: justify;">They aren't trained on how to coach in general</li>
<li style="text-align: justify;">They aren't familiar with the Kata approach at all</li>
<li style="text-align: justify;">They're judged based on the ROI of their projects, not how well they spread kaizen habits</li>
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This is problematic because high-quality external <i>senseis</i> 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.</div>
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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.</div>
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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.</div>
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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):</div>
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<u>Mistake #1: Being Too Rigid</u></h2>
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The <a href="http://www-personal.umich.edu/~mrother/The_Coaching_Kata.html" target="_blank"><b>Coaching Kata</b></a> provides a wonderful framework for coaching. Specifically, there are two routines we perform:</div>
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<li><b>Instruction/Coaching:</b> 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.</li>
<li><b>Daily Coaching Cycles:</b> 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").</li>
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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.</div>
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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.</div>
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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!</div>
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<u>Mistake #2: Short-Changing True North </u></h2>
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The first step of the <a href="http://www-personal.umich.edu/~mrother/The_Improvement_Kata.html" target="_blank"><b>Improvement Kata</b></a> 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:</div>
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<li>Ideal Condition (perfection)</li>
<li>Long-term strategy</li>
<li>1-2 year challenges</li>
<li>Future-state value stream maps</li>
<li>Key performance indicators</li>
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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, <a href="http://www.idatix.com/manufacturing-leadership/avoiding-scattershot-management/" target="_blank"><b>"scattershot management"</b></a>, etc. Bad stuff.</div>
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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. </div>
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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.</div>
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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 <a href="http://www-personal.umich.edu/~mrother/Handbook/Direction.pdf" target="_blank"><b>this</b></a> 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.</div>
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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 <a href="http://www.gembapantarei.com/2009/05/9_ways_to_struggle_at_hoshin_kanri.html" target="_blank"><b>hoshin kanri</b></a> to systematically drive alignment), but it's a start.</div>
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<u>Mistake #3: Not Utilizing Judo</u></h2>
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In that <i>Karate Kid</i> 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.</div>
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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.</div>
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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.</div>
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One way to look at this is as 'mini-cycles of PDSA embedded within the Plan phase of a bigger PDSA cycle.' It's <i>testing</i>, as opposed to <i>implementing</i>, 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.</div>
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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 <i>sensei</i>. 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"...</div>
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<tr><td class="tr-caption" style="text-align: center;">Courtesy of <a href="http://www.giphy.com/">www.giphy.com</a></td></tr>
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Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-31047064329055710152014-02-23T18:16:00.000-06:002014-02-24T13:17:05.821-06:00The Big Batch Theory<div dir="ltr" style="text-align: left;" trbidi="on">
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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):</div>
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Okay, so anyway, there's an <strike>aha moment</strike> 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...</div>
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1) Big-Batch Production</h3>
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<span style="font-weight: normal;"><i>aka the "Yeah-I-Learned-That-In-Lean 101" example</i></span></h3>
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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.</div>
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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.</div>
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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...</div>
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2) Learning in Big Batches</h3>
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<span style="font-weight: normal;"><i>aka the "Intuitive-When-You-Think-About-It" example</i></span></h3>
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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.</div>
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The Challenge...</h4>
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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 <i>de rigueur</i> in the healthcare world to send Green Belt candidates off for weeks of training at a time.</div>
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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.</div>
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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.</div>
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The Idea...</h4>
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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.</div>
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<i>* 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.</i></div>
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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 <a href="http://www-personal.umich.edu/~mrother/Homepage.html" target="_blank">Toyota Kata system</a> provides a highly-effective mechanism for just-in-time learning, but there are significant barriers that prevent us from adopting this approach universally.*</div>
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<i>*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 <a href="http://www.amazon.com/Mindset-The-New-Psychology-Success/dp/0345472322" target="_blank">book</a> can provide more explanation).</i></div>
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3) Big-Batch Root Cause Analysis</h3>
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<span style="font-weight: normal;"><i>aka the "Somewhat-Controversial-But-Profound" example</i></span></h3>
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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.</div>
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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.</div>
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Some interesting discussion regarding various approaches to RCA has been occurring recently on LinkedIn, including comments from the great <a href="http://www.amazon.com/Jeffrey-K.-Liker/e/B001H6NRUQ/ref=sr_tc_2_0?qid=1393185182&sr=1-2-ent" target="_blank">Jeff Liker</a>. Here's the <a href="http://lnkd.in/bv5m4Je" target="_blank">link</a> to the discussion thread (you may need to be a member of the group).</div>
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The Challenge...</h4>
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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:</div>
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<u>An excessively big-batch approach</u> 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.</div>
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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.).</div>
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<u>An excessively small-batch approach</u> 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.</div>
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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.</div>
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This is clearly a complicated challenge with no single answer.</div>
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The Idea...</h4>
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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?</div>
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Wrap-up</h3>
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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.</div>
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I shudder to think of how many of my own work processes are poorly aligned with lean principles. Yes, the learning continues.</div>
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Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-72080377979602271062014-02-18T22:43:00.000-06:002014-02-18T22:43:17.640-06:00My Top 10 Lessons Learned from Practicing the Toyota Kata Approach<div dir="ltr" style="text-align: left;" trbidi="on">
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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 <a href="http://www-personal.umich.edu/~mrother/Homepage.html" target="_blank">Toyota Kata</a> methodology into the culture of an acute care hospital in the Dallas-Ft. Worth metroplex.</div>
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<i>*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 <a href="http://comediansincarsgettingcoffee.com/chris-rock-kids-need-bullying" target="_blank">Chris Rock</a> or <a href="http://comediansincarsgettingcoffee.com/don-rickles-you-ll-never-play-the-copa" target="_blank">Don Rickles</a> hanging out in the back-seat for every episode.</i></div>
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<b><u>Background/Context</u></b></div>
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When we began testing the Toyota Kata approach we had no experience with or knowledge of it at all, outside of having read <a href="http://www.amazon.com/Toyota-Kata-Managing-Improvement-Adaptiveness/dp/0071635238" target="_blank">the book</a> 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.</div>
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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...</div>
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<b>#10: A PDSA cycle is not what I thought it was.</b> 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.</div>
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<b>#9: Cues, routines, & rewards matter.</b> In <a href="http://charlesduhigg.com/the-power-of-habit/" target="_blank"><i>The Power of Habit</i></a>, 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.</div>
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<b>#8: Track the metrics of habit-building.</b> 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.</div>
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<b>#7: Clinicians and other front-line staff tend to like the Kata approach.</b> 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.</div>
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<b>#6: It works on big projects too.</b> 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.</div>
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<b>#5: Target Conditions <span style="background-color: white; font-family: 'Helvetica Neue', Helvetica, Arial, san-serif; font-size: 13px; line-height: 16px;">≠</span> Numerical Targets <span style="background-color: white; font-family: 'Helvetica Neue', Helvetica, Arial, san-serif; font-size: 13px; line-height: 16px;">≠</span> List of Countermeasures.</b> 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.</div>
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<b>#4: Root cause analysis is an iterative process.</b> 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.</div>
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<b>#3: Coaching is tricky.</b> 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.</div>
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<b>#2: Coaching is largely about providing a safe environment to fail.</b> 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.</div>
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<i><b>and finally...</b></i></div>
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<b>#1: When in doubt, take a step forward! </b>Fortune favors the bold.</div>
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Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-17883978121669403732014-02-09T15:26:00.000-06:002014-02-18T23:05:46.956-06:00The Waffle House of Cards<div dir="ltr" style="text-align: left;" trbidi="on">
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Have you been to a Waffle House? For any of my Southern brethren, I already know the answer is an emphatic "heck yeah!" For those of you that haven't, go ahead and grab $10 and get there right away. It doesn't matter if it's 2am Saturday night and you're leaving the bar, or noon on Sunday and leaving church; the Waffle House will treat you right. And ignore those hateful monikers i.e. the "Awful House" or the "Poor Man's IHOP." What does Vince Vaughn have to say about that?</div>
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<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.youtube.com/embed/Z1bbxzoG5Ek?feature=player_embedded' frameborder='0'></iframe></div>
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Okay, I promise this isn't some ridiculous paean to the Waffle House. No, it's not about how they produce tasty food, incredibly fast, at dirt cheap prices (they do). No, I won't be celebrating how these dingy, cramped, greasy joints with skeleton staffs have somehow managed to satisfy the masses for decades (they have). Don't believe me? Well, any company that can claim to have served 1.8 BILLION hashbrown orders is doing something right. <a href="http://www.wafflehouse.com/our-story/did-you-know" target="_blank">For real</a>.</div>
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But alas, that's not what this post is about. In fact, I'm going to recount an imperfect experience I recently had at the Waffle House. This overdone and excessive analysis is being done in an attempt to draw parallels with my own work experience and to learn from the analogy. Let this trivial pursuit commence.</div>
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<b>My Waffle House Experience...</b></div>
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So, I recently went there for a late Saturday morning breakfast with my wife. It happened to be really busy when we arrived and there was a wait for a table, but we were in no big hurry so we decided to wait. We actually got a table after only a few minutes, but we could tell the restaurant was super busy and our waitress, Tish, seemed to be the busiest waitress of all. Several fairly large groups had been sat in her section at the same time, along with my wife and me, so she was slammed. Again, we were in no big hurry so even though we waited several minutes without even being acknowledged by Tish, we never felt the need to do the whole "excuse me, miss, can I get a coffee" thing.</div>
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But then an interesting thing happened. A different waitress, Sandy, saw that Tish was slammed and came over and asked if she could get us something while we waited. My wife ordered a coffee. While she was ordering it, my wife had been inadvertently pointing to the meal she wanted to order on the menu. The waitress saw this and asked my wife if that's what she wanted to eat. My wife said yes, even though she had not intended to place her food order yet. I was observing, thinking that we should order only coffee from Sandy and wait for our waitress to take our full order. But I went along with it and ordered my meal as well. Then I sat back and waited to see if my hypothesis would prove to be valid.</div>
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<b>Hypothesis?</b></div>
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Yes, I made a prediction. You see, these types of scenarios pop up everyday at work. In a hospital, just like any other workplace, we are always dealing with issues: errors, delays, miscommunication, dissatisfied customers, etc. If somebody spots the issue, they'll usually respond. On a process improvement project, for example, a team member may get the impression that the project is is not making progress, and in response she might lobby the project's executive champion to intervene. This act may be totally well-intentioned, yet still cause unintended consequences.</div>
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For example, the project facilitator might be intentionally reigning in/throttling progress during the early stages when we're analyzing the current-state, so as to prevent jumping to the wrong solutions (a tendency with clinicians). If somebody like an executive champion intervenes without understanding this rationale it can cause us to proceed too quickly, select the wrong solutions, and end up having to go back to the drawing board. This sort of thing happens all the time, but an experienced facilitator can see it coming from a mile away and preempt the situation through good communication, consensus-building, etc.</div>
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<b>Back to the Waffle House Story...</b></div>
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Similarly, at the Waffle House, I could see an an unintended consequence coming from a mile away. When we proceeded with ordering our whole meal with Sandy instead of waiting for our waitress, I predicted that we'd wait forever to get our coffees. That was my hypothesis anyway.</div>
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My hypothesis was valid. Sandy, who initially was just going to grab our coffees real quick, ended up handing our full order off to our waitress and completely forgot about our beverages. Then, after the order hand-off, our waitress had to go back to Sandy twice to get missing information about our order. Next, our waitress immediately placed our order with the cook, but she never thought to bring us our coffee. So, yep, we did wait forever to get our coffees.</div>
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<b>Analysis...</b></div>
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So, let's analyze some of the behaviors we saw. First, the positive behaviors:</div>
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<li style="text-align: justify;">Sandy wanted to help us (good customer focus)</li>
<li style="text-align: justify;">Sandy wanted to help our waitress (good team-oriented culture)</li>
<li style="text-align: justify;">There was a quick hand-off of the order from Sandy to our waitress (good sense of urgency)</li>
<li style="text-align: justify;">Our waitress quickly placed our order (good sense of urgency)</li>
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All those are great behaviors that we'd want in any organization. But there were several other behaviors that had unintended consequences:</div>
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<li style="text-align: justify;">Sandy, thinking she was just taking our beverage order, was just scribbling it on a napkin instead of using the standardized order template they normally use. This resulted in errors/missing information that Tish had to go get from Sandy later.</li>
<li style="text-align: justify;">Sandy, after handing-off our order to Tish, forgot to get our coffees which was the whole reason she approached us in the first place. This put our coffee order in limbo, with no clear owner.</li>
<li style="text-align: justify;">Tish didn't get our coffees either as she was focused on placing our food order, probably thinking we were starving because of the fact that we had hurriedly placed our order with the nearest waitress, Sandy.</li>
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As you can see, the intentions were all good but the outcomes were not. This was predictable to me, just because of how many times I've made these mistakes on projects at work. It all boils down to the fact that the Waffle House system of food delivery, while incredibly effective and efficient normally, is actually a house of cards (pun intended). The whole model is predicated upon these waitresses performing the same routines over and over again. When we "intervened" and allowed Sandy to take our full food order, these routines were circumvented and predictable unintended consequences resulted.</div>
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<b>Back to the Waffle House Story once again...</b></div>
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So, our coffee order was in limbo and we waited and waited. Eventually, we asked a third employee if he could bring us coffee, which he did promptly. But right around the time he was delivering our coffee, Tish also brought us coffee. So, we went from no coffee for 15 minutes to a total of 4 full cups of coffee at our table in a matter of a minute or so.</div>
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You see, Tish had been taken out of her normal routine. She normally would have been aware of our coffee situation and responded accordingly, but because she had not even spoken to us yet she was acting on second-hand, outdated information. This resulted in duplication of effort...and cold coffee.</div>
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This sort of thing also happens quite often at work. We see a problem pop up on our project and want to resolve it as soon as possible, often unaware that somebody else is also working on a resolution. Predictably, this results in duplication of effort...and probably cold coffee somehow.</div>
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<b>Countermeasures...</b></div>
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So what can we do to prevent all this waste? At the Waffle House and at work, we want people's positive behaviors (customer focus, teamwork, urgency, etc.) to result in positive outcomes. When they don't, we need to address the system. Here are some potential approaches to addressing the system:</div>
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<li style="text-align: justify;"><b>We can blame each other and tell the employees to do better.</b> This is obviuosly a really bad option, but unfortunately this continues to be the one most commonly selected. STOP DOING THIS!</li>
<li style="text-align: justify;"><b>We can work on the root causes of the issues.</b> In the case of the Waffle House, we would probably want to tackle the workload imbalance and inefficient processes causing our waitress to be so busy that Sandy needed to intervene. Addressing root causes is always a great option, but this approach can take time and process improvement skill, which are not always abundant in organizations (more on this later).</li>
<li style="text-align: justify;"><b>We can facilitate the process.</b> By this, I mean having somebody in-place whose role is to coordinate between the involved parties to prevent the unintended consequences. In healthcare, for example, we have patient navigators, patient advocates, care coordinators, project managers, etc. whose primary function is to prevent issues from arising due to poor coordination. In the case of the Waffle House, I could have prevented the predictable sequence of events from occurring by not allowing Sandy to take our full order, but that would have put me in the position of facilitator when I should be in the position of paying customer. Paying customers shouldn't have to facilitate. But with the way the Waffle House is staffed, having somebody assigned to this role is not feasible. That makes option #3 impractical for their business model.</li>
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So, what to do? For a system like the Waffle House that is essentially a house of cards relying heavily on repeatable, consistent routines to maintain order, it's absolutely critical that anything that takes waitresses out of their normal routines be eliminated. This requires getting to the root causes of the issues, so option #2 is the right approach. This is also the right approach for healthcare, even though we may sometimes have the resources to pursue option #3 as well. But option #3 is a band-aid, not a cure. Option #2 is the sustainable strategy.</div>
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<b>Executing the Right Countermeasure...</b></div>
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So, how do we go about pursuing option #2? Well, there's no one-size-fits-all approach to driving continuous improvement, and it can take a lot of patience and skill to execute. Most organizations have severe shortages of patience and skill, so it's critical that we tackle both deficiencies in the most effective and efficient way possible. We have to be better at making things better. Here are some strategies to do that (again, there is no one-size-fits-all approach):</div>
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<li style="text-align: justify;"><b>Don't delegate process improvement work</b> to PI specialists. Operational managers should lead improvement efforts. This is the only way they will get better at it.</li>
<li style="text-align: justify;"><b>But, make sure operational managers are properly supported and coached</b> as they lead improvement efforts. Owning a process improvement project can be challenging and even intimidating for newcomers. They need to be guided so they can mess up without sinking the project.</li>
<li style="text-align: justify;"><b>Utilize PI specialists prudently</b> to occasionally lead complex improvement efforts. These projects can be great opportunities to demonstrate these advanced techniques to operational managers, but we don't want the specialists to become a crutch.</li>
<li style="text-align: justify;">Bend the learning curve. <b>Give your people a straightforward technique, such as the Plan-Do-Study-Act (PDSA) cycle</b> and let them get started on improvement work quickly. Batching up a bunch of improvement tools into a complex technique such as DMAIC and delivering via months of formal training delays the "learning by doing" that results in the most profound insights and behavioral changes.</li>
<li style="text-align: justify;"><b>Treat the building of improvement capacity in your organization as a PI project in and of itself.</b> Measure the # of improvement practitioners, # of coaches, # of PDSA cycles, etc. Not just to feel warm & fuzzy and report some nebulous employee engagement success to the Board, but to actually test your hypothesis of what will increase the improvement bandwidth of your organization. It's also a great way for senior leaders to practice what they preach.</li>
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That last recommendation is critical, because the previous four may or may not work in your organization. We have to test our hypotheses. If you do so and stick to it, you will increase the improvement capacity of your organization, will allow you to begin addressing the root causes of problems so that you don't have to rely on band-aids (navigators, coordinators, customer service advocates, etc.).</div>
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<b>One Last Word on the Waffle House Story...</b></div>
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I opened with praise for the Waffle House, and I stick by my story. They do a great job with what they have to work with the majority of the time. They can get better too....if they address root causes of waitress workload imbalance, inefficient processes, etc. Ideally, the waitresses would themselves have the ability to use PDSA to test new routines, always looking to get better.</div>
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Sound unlikely that a Waffle House waitress would ever get involved like that? Well, they used to say the same about nurses, physicians, Kentucky auto workers, Latin-American laborers, and just about anybody else that wasn't Japanese. But we've shown over and over again that just about everybody is capable of being engaged in meaningful improvement work. It just takes resolve and endurance. Oh, and coffee. Lots of coffee!</div>
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Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-79299248468902778502013-04-29T15:39:00.004-05:002013-04-29T15:39:53.663-05:00PDSA over PDCA<div dir="ltr" style="text-align: left;" trbidi="on">
Karen Martin wrote an <a href="http://www.leanblog.org/2013/01/guest-post-words-matter-why-i-prefer-pdsa-over-pdca/" target="_blank">excellent post</a> a while back on Mark Graban's Lean Blog, so there's really no need to write this post, but I'm going to do it anyway because it's fun in a really nerdy kind of way.<br />
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<b><u>Study, not Check</u></b><br />
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Anyway, like Karen and Dr. Deming, I also agree that the third step of the Shewhart Cycle for Learning and Improvement should be 'Study' as opposed to 'Check.' Let's play word association with these two words:<br />
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<li>When I think of '<b>Study</b>' I think: learning, impartial, scientist, curious, absorbing, methodical</li>
<li>When I think of '<b>Check</b>' I think: just verifying, yep I got what I expected, let's move on quickly</li>
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Doing a check is better than the approach most people use, which consists of implementing blindly toward an end point that never seems to arrive or which disappoints when it finally does. But, 'Check' does not encourage a scientific mentality our curious learner attitude the way 'Study' does. Improvement activities in their finest form are examples of the scientific method being applied to everyday opportunities for improvement, and we so often fail to understand that. Hence, the quick check on the way to finishing a PDCA cycle and no value given to the learning part of the Shewhart Cycle.</div>
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<b><u>Act, not Adjust (maybe)</u></b></div>
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Where I might (not definitely but maybe) diverge from Karen's view is with my preference of 'Act' over 'Adjust' as the fourth step of the Shewhart Cycle. After studying the results of an experiment, there are actions to be performed regardless of whether adjustments are needed or not. In practice, this is a moot point because adjustments are always needed, but I like to send the message through the use of the word 'Act' that action is required regardless of the outcome we achieved. Other than adjustment, what actions might be required? Here's a short list:</div>
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<li><b>Sharing:</b> regardless of what we learned or what outcome we achieved, we should share our learning broadly across the organization i.e. <a href="http://www.gembapantarei.com/2011/03/how_to_do_yokoten.html" target="_blank">yokoten</a>.</li>
<li><b>Standardizing:</b> even if a change is not perfect (and will require adjustment), we might benefit from implementing the change into our work through the use of standard work, job instruction training, etc.</li>
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<b><u>Semantics Matter</u></b></div>
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Again, I can see why 'Adjust' might be better and I'm not averse to it the way I am with 'Check.' And yes, in the end it's just semantics, but when we're trying to establish a True North for how we go about learning and improving (which I hope all the lean coaches out there are doing on a daily basis), semantics matter. A lot!</div>
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Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-38177707593496180432013-02-01T17:06:00.001-06:002013-02-02T10:37:12.878-06:00Top 3 PDSA Mistakes<div dir="ltr" style="text-align: left;" trbidi="on">
<strike>Everybody</strike> Most people involved with process improvement have heard of the Plan-Do-Study-Act cycle. Many think of it as a tool or technique, but I see it as a habit. In fact, I see it as a keystone habit that, if hardwired in an organization, can set the stage for many other lean habits to emerge. <br />
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Unfortunately, however, PDSA can be deceptively tricky to execute properly. On the surface, it looks simple; "it's just a 4-step routine." But one needs a scientific mentality to perform PDSA properly, and most folks are not trained to think about process problems scientifically.<br />
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Based on my experience from the front-lines of process improvement in healthcare, here are the top 3 most common PDSA mistakes I see:<br />
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3) Not stating a hypothesis in the Plan phase. Maybe the word 'hypothesis' throws people off, or maybe people don't want to admit that they are just making a prediction i.e. aren't sure that their idea will work, but it's extremely common to see people completely omit any sort of prediction or theory from the Plan phase of their PDSA. When I coach people on PDSA, I usually avoid the word 'hypothesis' and ask them to write a "If we do X, then we predict Y" statement instead.<br />
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2) Not being impartial about results in the Study phase. If results are better than expected, we are jubilant instead of curious. If results are worse than expected, we get discouraged and sweep it all under the rug, or we cherry-pick any and every positive indicator we can plausibly use. These behaviors are symptomatic of a non-scientific approach at best, and a punitive organizational culture at worst. When I'm coaching, I emphasize that any good PDSA cycle has value in the form of the learning it generates, independent of whatever the results were for that cycle.<br />
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1) Not properly understanding the problem prior to PDSA. PDSA is a great approach for testing ideas for improvement, but not every idea should be tested. We need a set-up phase prior to PDSA that helps us define the problem on the surface, dig down to root causes, and use the insights we gain to develop good ideas for improvement that can be tested. So often, we get so excited to implement change that we hurry past this set-up phase, which increases the risk of selecting the wrong idea to test. This is okay, in that PDSA will reveal that it's the wrong idea, but we only have so much capacity for testing, so we need to be smart about what ideas we select. When coaching, I try to challenge our understanding of the problem, but in the end, I usually show a bias for action.</div>
Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-15822606805998007142013-01-25T18:38:00.001-06:002013-01-25T18:38:40.085-06:00Value = Quality/CostOver Christmas break down in the Yucatan Peninsula, I read Dr. Toussaint's book "Potent Medicine." He reminded me of the old equation for value: Value = Quality/Cost. Increase quality and reduce cost and you increase value to the customer. Great concept.<br />
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My company, a large healthcare system, defines the 'Quality' part of the equation as Outcomes x Safety x Service. I think that's a great way to look at quality in healthcare.<br />
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Taken together, the two equations are: Value = (Outcomes x Safety x Service)/Cost. If you, like me, are in a position of leadership responsible for engraining a lean mindset in a healthcare organization, keep in mind that you will want to connect the dots between each of these components of value. If you don't, there's a distinct possibility that nobody will.<br />
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Also, you will want to focus on building the habits needed for increasing value via quality improvement and cost reduction. One keystone habit is the use of PDSA to test ideas when an opportunity for improvement is identified. If you can hardwire that habit, it will set the stage for other positive habits to flourish. Habits such as: going to the gemba to find OFIs, using 5-Why? to get at root causes of problems, and engaging teams of people in problem-solving. To help hardwire PDSA as a habit, another habit, the coaching of PDSA, is critical. Or, to simplify the whole thing a bit, just start talking about, teaching, modeling, and using PDSA all the time for everything.<br />
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Improve value. Connect the dots. Hardwire PDSA as a habit. Be a great lean leader.Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-73758563320890335012013-01-13T12:56:00.000-06:002013-01-13T12:59:29.943-06:00Habit-Building<div dir="ltr" style="text-align: left;" trbidi="on">
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I'm really liking <a href="http://www.amazon.com/Power-Habit-What-Life-Business/dp/1400069289" target="_blank">The Power of Habit: Why We Do What We Do in Life and Business</a> by Charles Duhigg. Taken along with the Mike Rother's <a href="http://www.amazon.com/Toyota-Kata-Managing-Improvement-Adaptiveness/dp/0071635238/ref=sr_1_1?s=books&ie=UTF8&qid=1358100523&sr=1-1&keywords=toyota+kata" target="_blank">Toyota Kata</a>, you have the basics of what it takes to create a continuous improvement culture.</div>
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For clarity's sake, I define a continuous improvement culture as an environment in which we strive to improve every process, every day, with everybody involved. No improvement is too small, we don't batch all our improvements into big projects, and anybody in the organization can be an improvement leader. For more information on this concept applied to healthcare, see Graban & Swartz' book <a href="http://www.amazon.com/Healthcare-Kaizen-Front-Line-Sustainable-Improvements/dp/1439872961/ref=sr_1_1?s=books&ie=UTF8&qid=1358101062&sr=1-1&keywords=healthcare+kaizen" target="_blank">Healthcare Kaizen</a>.</div>
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Anyway, in Duhigg's book, the habit-building loop is presented. It has three components:</div>
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<li style="text-align: justify;"><b>Trigger</b>: this is the cue to perform a routine</li>
<li style="text-align: justify;"><b>Routine</b>: this is the standard steps performed to arrive at the desired result</li>
<li style="text-align: justify;"><b>Reward</b>: this is the payoff for performing the routine on-cue</li>
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When these three elements are in-place and clearly related, a craving eventually forms. This craving causes the habituated person to anticipate the reward at the trigger point, even before performing the routine. This phenomenon is the indicator of a well-formed habit (for better or for worse!).</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgwOMaceiF3ZC69eNeKOobSjSwbhLqn8poVNayNjO0YD_JiS6vKlZRTZMPciIO1Eo8CBfVLsv2oqXrkhHPsjs18ZZ5p_9ljEP-lK4g-peB_sHc24KaYhiBNkO8vq1jsjYb2fLq86h4l2w/s1600/good-habits-bad-habits.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgwOMaceiF3ZC69eNeKOobSjSwbhLqn8poVNayNjO0YD_JiS6vKlZRTZMPciIO1Eo8CBfVLsv2oqXrkhHPsjs18ZZ5p_9ljEP-lK4g-peB_sHc24KaYhiBNkO8vq1jsjYb2fLq86h4l2w/s320/good-habits-bad-habits.jpg" width="316" /></a></div>
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While Duhigg's book is about the science behind habit-forming, Rother's book is about the habits needed to drive continuous improvement. Specifically, he emphasizes two habits (he uses the term 'kata'):</div>
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<li style="text-align: justify;"><b>Improvement Kata</b>: this is a 4-step routine that helps us 1) see the ideal condition to which we strive, 2) study the current condition to see our gaps, 3) set a short-term target condition to pursue that is on the path to the ideal condition, and 4) pursue the target condition using PDSA (another 4-step routine).</li>
<li style="text-align: justify;"><b>Coaching Kata</b>: this is a routine, drawing upon the Socratic Method of teaching (asking questions instead of giving answers), that is designed to reinforce the proper execution of the aforementioned Improvement Kata.</li>
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So, how do we put in place the three elements of the habit-building loop for the two kata? How do we create a craving for the kata? The routines (element #2 of the habit-building loop) are established by Rother's book. The other two elements, triggers and rewards, are TBD for me personally. Some thoughts:</div>
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<li style="text-align: justify;"><b>Triggers</b>: eventually, the ideal would be that the trigger is the detection of a problem/gap/opportunity for improvement, but in the short-term, more artificial triggers may be needed (i.e. require each manager to perform one PDSA cycle per month...not a long-term solution, but can get the ball rolling in the short-term).</li>
<li style="text-align: justify;"><b>Rewards</b>: eventually, the ideal would be that the reward would be the intrinsic motivators of mastery, autonomy, and purpose (see Daniel Pink's <a href="http://www.amazon.com/Drive-Surprising-Truth-About-Motivates/dp/1594484805/ref=sr_1_1?s=books&ie=UTF8&qid=1358102286&sr=1-1&keywords=drive" target="_blank">Drive</a>), but in the short-term, more artificial rewards may be needed (i.e. gamification: badges, achievements, recognition, compliance tracking, small gifts, etc.)</li>
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This type of habit-building is tricky business. Culture change is hard. It takes a wide range of knowledge, organizational finesse, and a lot of trust and patience on the part of senior leadership. But the payoff is huge. A culture of continuous improvement is the best, most sustainable competitive advantage available.</div>
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Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-68544446738665098882012-11-05T21:37:00.000-06:002012-11-05T21:37:54.647-06:00Freudian Gaps (The Softer Side of Lean)<div dir="ltr" style="text-align: left;" trbidi="on">
The fundamental talent of a lean coach is to get a team to see the difference between the ideal state and the current state, but in a way that does not alienate team members or cause inadequate solution selection. In other words, in pointing out the gap, we can't just come out and say what the gap is. People in our culture equate identifying a gap with assigning blame for a gap; we're not great at separating problems from personalities. So, don't be blaming, i.e. don't be pointing out gaps. <br />
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Instead, help the team gradually come to gap realization in a methodical way that decouples gap existence from gap culpability by means of an almost subconscious circumvention of the blame-game gag reflex. Before the team members even realize who is "guilty," they will have been introduced to the gap in an impartial manner. This impartiality helps drive more nuanced understanding of the problem, and thus, better interventions that more directly address root causes. So in other words, ask questions; be a coach.</div>
Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-74560655536211683602012-04-07T17:21:00.000-05:002012-04-07T17:24:48.107-05:00Monuments, Sacred Cows, and Measurability<div dir="ltr" style="text-align: left;" trbidi="on">
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The Statue of Liberty, the Eiffel Tower, the Parthenon, the Great Pyramid of Giza...what do they all have in common? They are all monuments. What do monuments have in common? They stay put. </div>
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Because they are monuments, we expect to find them where they are, as they are, for centuries to come. Monuments don't move (I'm not counting the London Bridge). Monuments don't change much either. And for the most part, we don't want them to move or change.</div>
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgU67jCImVv76h5jKoS5cOwVY-c2OVM6jDOHaifGNoMr8qDWz46Bqm2aK6Zx5qfuoWnRSliFJFZDme_Qe6SABu8TCn3RvSQ4x1LA57jbQxWQBTiKiU6Y6nTU7OfHFFvKzgaOBxmjZFHPg/s1600/bridge.jpeg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgU67jCImVv76h5jKoS5cOwVY-c2OVM6jDOHaifGNoMr8qDWz46Bqm2aK6Zx5qfuoWnRSliFJFZDme_Qe6SABu8TCn3RvSQ4x1LA57jbQxWQBTiKiU6Y6nTU7OfHFFvKzgaOBxmjZFHPg/s1600/bridge.jpeg" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">The London Bridge enjoying retirement in Lake Havasu City, Arizona</td></tr>
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<b><i>But what do we do with a monument when it blocks much-needed progress?</i></b></div>
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I ask this question not because I think the Taj Majal needs to be moved down the street to make way for a freeway or anything, but because we encounter monuments everyday in the business world. In this context, the term 'monument' refers to something that is looked at as immobile, unchangeable, or sacrosanct.<br />
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In manufacturing, an example of a monument is a big piece of equipment that can't be moved because it physically can't fit anywhere else. In healthcare, an example might be a department or program that will not change its processes because it has been deemed a "Sacred Cow" that is not to be bothered.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYSb_gSZG7X6QWr9w0oq-SM5Tm51eUGrP4wh3R5B5nc48UsYp62xxvZl1if02EX9BLcxeXE90HSMUx6U6N56iyDYKt-2ps4XO5G0A97VP4AU3hDqdtc84EpOKlh_JOg67_G-ycdSAtWA/s1600/cow.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYSb_gSZG7X6QWr9w0oq-SM5Tm51eUGrP4wh3R5B5nc48UsYp62xxvZl1if02EX9BLcxeXE90HSMUx6U6N56iyDYKt-2ps4XO5G0A97VP4AU3hDqdtc84EpOKlh_JOg67_G-ycdSAtWA/s1600/cow.jpeg" /></a></div>
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<b><i>So how do we deal with these monuments when they block much-needed progress?</i></b></div>
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Dealing with monuments after the fact can be problematic. Once something comes to be viewed as inviolable, we start to use terms like "act of Congress" to describe what it would take to change it. Not good. We need to prevent monuments from being erected in the first place. </div>
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For a physical monument, like a big piece of equipment, prevention can be achieved by simply not purchasing it, or maybe by purchasing smaller, more flexible alternatives. However, for an intangible monument, like a Sacred Cow department or program, the situation is more nuanced. In this scenario, prevention can be achieved by incorporating the concept of measurability into our management decisions. </div>
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Just to be clear, I'm not a person who believes the adage that "if you can't measure it, you can't manage it." Not everything that is important is measurable. And I prefer facts over data, so I'm not saying we should go hardcore Six Sigma and attach a metric to every activity in the organization just for the sake of having more data. </div>
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I'm just saying that, all things being equal, it's better to be able to measure something than to not, because in the absence of measurability, personal influence and persuasiveness rule the day. That's how you end up with Sacred Cow monuments that long outlive their usefulness and block progress.</div>
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For that reason, I'd go with an option that may not be quite as good but that is measurable over an option that maybe be a little better but immeasurable. But I'm not sure many management teams would go along with that. We're just too hardwired to look at the available options and make the best choice based on the evidence on-hand at the moment. That's why we have a lot of problematic monuments in our organizations.</div>
</div>Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-76364326529142136562012-03-07T13:50:00.001-06:002012-03-07T13:51:16.256-06:00Move to Healthcare<div dir="ltr" style="text-align: left;" trbidi="on">
Been so wonderfully busy at the hospital that I haven't had a chance to post at all in a few months. I did, however, have one of my old articles written on the "Move to Healthcare" site cross-posted over to Mark Graban's Lean Blog. The article is nearly two years old now, but I think it is still relevant to those lean thinkers out there looking to get into healthcare. Here's the link:<br />
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<a href="http://www.leanblog.org/2012/03/farewell-to-the-move-to-healthcare-ning-group/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+LeanBlog+%28LeanBlog.org%29" target="_blank">Farewell to the “Move to Healthcare” Ning Group; Sharing a Success Story</a></div>Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-46332500767667131412011-12-21T17:15:00.001-06:002011-12-24T17:27:20.204-06:00IT Systems vs. Busines Systems<div dir="ltr" style="text-align: left;" trbidi="on">
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I was watching a lecture on the subject of information management/information technology/etc., and the lecturer began discussing systems thinking, a favorite subject of mine. I was expecting a Senge-like discussion, and maybe an explanation of how information technology plays a role in a modern business system. But the lecturer had a different viewpoint. I think he saw IT systems and business systems as being synonymous. In other words, the professor's view seemed to be:</div>
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<strong><em>Business System = IT System</em></strong></div>
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This equation implies an IT-centric approach to business with which I disagree. I see IT systems as only one part of a larger business system. My equation is more like:</div>
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<strong><em>Business System = People + Processes + Management + Technology + Lots of Other Inputs</em></strong></div>
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For me, IT systems are just one type of technology, which is just one type of input into a business system. Sure, for e-commerce and other Internet-based endeavors, IT systems are extremely prominent features of the business system. But even then, they're not the only features. So often in the business world it feels like this is forgotten.</div>
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I would recommend to IT professionals and others in charge of developing, managing, or improving business systems that they take a step back and see things holistically. Don't be overly focused on technology as a silver bullet, even if IT is your area of expertise. Use IT systems to <em>support</em> the business instead of seeing IT systems <em>as</em> the business.</div>
</div>Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-72503219889267358912011-10-28T10:49:00.000-05:002011-10-28T10:51:13.555-05:00Top 3 Things I've Learned After 18 Months in Healthcare<div dir="ltr" style="text-align: left;" trbidi="on">
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It's been almost 18 months since I made the move to healthcare, thanks in part to the encouragement I received from my friend, <a href="http://www.leanblog.org/about/about-mark-graban/">Mark Graban</a>. In that time, I've learned a lot and I continue to learn everyday. What have I learned? Here's my Top 3 list:</div>
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<li style="text-align: justify;"><b><i><u>The healthcare business is all about people.</u></i></b> In my article "<a href="http://hospitalkaizen.blogspot.com/2011/05/human-factor-in-healthcare.html">The Human Factor in Healthcare</a>," I discuss how important it is to be agile when it comes to how we approach improvement in healthcare because of the human factor. This is by far the most important lesson I've learned in healthcare. Our "product" is the patient, a human being. Most of our processes are highly dependent upon manual labor, which is performed by human beings. We have front-line workers (doctors and nurses) with much more education, training, and influence that the average front-line worker in a factory. In pediatrics, we have to account for the needs of not only the patient, but of the patient's family as well. In an academic healthcare setting, we have to account for the learning needs of medical students, residents, and fellows. The human element exists in every industry; it's hugely magnified in healthcare.</li>
<li style="text-align: justify;"><b><i><u>The healthcare business is complex.</u></i></b> In my article "<a href="http://hospitalkaizen.blogspot.com/2011/04/10-complexities-in-hospitals.html">10 Complexities in Hospitals</a>," I discuss how many different levels of complexity we encounter in healthcare. The end-user and the payer are often different entities with completely different goals. We are highly regulated by national agencies, state agencies, the Joint Commission, and other entities with differing goals. We implement technology solutions of Rube Goldberg proportions that I've come to believe nobody fully understands. We have a nearly infinite amount of data at our disposal, of which only a fraction is actually timely, relevant, and easy to use. Healthcare reform is creating huge paradigm shifts (pardon the business cliche) in every healthcare organization in the land. Changing priorities are the norm, and it makes things really complex.</li>
<li style="text-align: justify;"><b><i><u>The healthcare business can be wonderful.</u></i></b> Many of the people I've met in healthcare have been passionate, committed, highly-intelligent, experienced, interested in learning, focused on serving the needs of the patient, and highly competent. Not everybody, but a high percentage. That makes for a wonderful workplace. Plus, it's just easier to get up in the morning when you know your work might help make a sick child's life a little better, even if indirectly through process improvement or whatever.</li>
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Like I said earlier, I've learned a lot (a lot more than is shown here) and I continue to learn everyday. If you're an engineer, project manager, quality professional, operations manager, or any other type of business professional, you can make the move to healthcare. Just be ready to focus on people, deal with complexity, and be proud of your work. Most of all, be ready to continuously learn and improve.</div>
</div>Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-16200634817293078272011-09-19T22:15:00.000-05:002011-09-19T22:40:22.852-05:00True Value in Healthcare<div dir="ltr" style="text-align: left;" trbidi="on">
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In the year and a half that I've been working in healthcare, I've heard some really good arguments from some really smart folks regarding what makes an activity value-added. Based on what I've heard, read, studied, and observed, the prevailing approach to defining value in healthcare is the following:</div>
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<b><u>The Standard Definition of Value in Healthcare</u></b></div>
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Under this definition, for an activity to be considered value-added, it must satisfy three requirements:</div>
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<li style="text-align: justify;">The activity must be something the patient wants/needs</li>
<li style="text-align: justify;">The activity must be done correctly</li>
<li style="text-align: justify;">The activity must change the form/fit/function of the patient</li>
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If it does not satisfy all three of these requirements, an activity is considered non-value-added under this approach. </div>
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This is a pretty strict approach, especially considering that it does not recognize the value of activities that contribute to the correct diagnosis of illness, something which I believe is of tremendous value to the patient. Until recently, I've tended to favor a slightly more lax definition of value. </div>
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But the more and more I read about <a href="http://en.wikipedia.org/wiki/Population_health" target="blank">Population Health</a> and <a href="http://en.wikipedia.org/wiki/Accountable_care_organization" target="blank">ACO</a>, the more and more I've begun to question the the standard definition of value in healthcare. I've started to subscribe to a more systemic and holistic definition of value, which I refer to as True Value.</div>
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<b><u>My Definition of True Value in Healthcare</u></b></div>
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The following two guidelines define my current, half-baked view of "true" value in healthcare:</div>
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<li style="text-align: justify;">If an activity is related to providing care for a preventable illness, it is waste.</li>
<li style="text-align: justify;">If an activity is related to providing care for an unpreventable illness, and satisfies the three requirements of The Standard Definition of Value in Healthcare as shown above, it is value-added</li>
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Thoughts? </div>
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FYI, I prefer comments on <a href="http://www.linkedin.com/in/michaelglombard">LinkedIn</a> or <a href="http://twitter.com/#!/MikeLombard">Twitter</a>, so I've shut off comments on this blog.</div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrIheYKL6xQgjd13mrACIE7xOfMhxQihs0AvQKg4MTW1lMswGMzaJUpRSU5Pa_UO5UwkIQ6Pbhyphenhyphense8HTZPi4gmIEaQuEMIoKO9ZaJrxfwUyXS7RYiBgewyD9uVrSWz8rr_ai-h84GLUw/s1600/True+Value.jpeg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrIheYKL6xQgjd13mrACIE7xOfMhxQihs0AvQKg4MTW1lMswGMzaJUpRSU5Pa_UO5UwkIQ6Pbhyphenhyphense8HTZPi4gmIEaQuEMIoKO9ZaJrxfwUyXS7RYiBgewyD9uVrSWz8rr_ai-h84GLUw/s1600/True+Value.jpeg" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><i>Thank you for sponsoring my Little League team. Those mesh hats were sweet.</i></td></tr>
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Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-5117064724079896362011-05-17T17:27:00.000-05:002014-03-05T13:26:48.128-06:00The Human Factor in Healthcare<div dir="ltr" style="text-align: left;" trbidi="on">
Several times recently, I've been asked by manufacturing folks about the challenges of making the move to healthcare as a lean coach. The one challenge that I always emphasize is the human factor. The human factor exists in every industry, but it's magnified in healthcare. This is partly due to the manual nature of the work, partly due to to the fact that the product is the patient, and partly due to the unique cultural aspects of working in an organization that directly saves lives on a daily basis. <br />
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As a lean coach in healthcare, one must adjust both his or her expectations and tactics. <br />
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<b>Adjust Your Expectations</b><br />
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<b></b>Expect a lot of variation. I mean a lot of variation. Even with a calibrated, properly maintained, properly operated piece of machinery, we expect a level of variation. Now take away the calibration, maintenance, and proper operation and see how much variation you get. Now take away the machine altogether, replace it with a person, and see how much variation you get. I could go on, but I think I've made my point. Expect a lot of variation!<br />
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<b>Adjust Your Tactics</b><br />
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As for our tactics, we must adjust them to take into account the human factors. We have to design around the needs of not only the patient, but also the family of the patient. We might have to make choices we don't want to make to accomodate the teaching needs of an academic hospital. We have to define value in terms of not only the patient, but also of the payer. There are so many layers of complexity that prevent us from getting to an optimal future state, but we can't let that stop us from moving towards at least a better future state. We have to adjust our tactics and be much more agile.</div>
Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-53931523243285097232011-05-11T18:33:00.002-05:002011-05-13T15:25:50.524-05:00Experiments as Nemawashi<div dir="ltr" style="text-align: left;" trbidi="on"><div style="text-align: justify;">Lean folks have heard the term <a href="http://www.gembapantarei.com/2007/03/the_art_of_nemawashi.html" target="blank"><i>nemawashi</i></a>. I've heard it described as <i>preparing the roots of a plant for transport</i>. It's related to consensus-building, and is especially critical when we are proposing big changes to a process.</div><div style="text-align: justify;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjFjt93h7P7bfSLmI39KloySQ3iwdFyuZcbZ0DlJfqlHzseYmLp_VPXkhKp0mK5j8IW4bG0vxJrCWe6t6spA7zwDNilC-DCQ3GF7IjYH_jLypBBdFcRSz7XFmGwL3l-vuAFWgwQrWFA-Q/s1600/Nemawashi.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjFjt93h7P7bfSLmI39KloySQ3iwdFyuZcbZ0DlJfqlHzseYmLp_VPXkhKp0mK5j8IW4bG0vxJrCWe6t6spA7zwDNilC-DCQ3GF7IjYH_jLypBBdFcRSz7XFmGwL3l-vuAFWgwQrWFA-Q/s320/Nemawashi.jpg" width="213" /></a></div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">I started thinking about <i>nemawashi</i> last week when I was in Six Sigma training. We were learning about <a href="http://thequalityportal.com/q_know02.htm" target="blank">Design of Experiments (DOE)</a>, which is a methodical and data-driven approach to testing future-state processes, potential countermeasures, etc. Immediately, I started to compare and contrast the DOE approach to the less scientific <a href="http://hospitalkaizen.blogspot.com/2011/04/barn-raising-kaizen.html" target="blank">Barn-Raising Kaizen</a> and <a href="http://hospitalkaizen.blogspot.com/2011/04/quick-pdca.html" target="blank">Quick PDCA</a> approaches that have served me well in the past. I wondered how we were able to achieve what we did without the rigor that DOE provides. Then it dawned on me that one of the reasons for our success with these less rigorous and more action-biased approaches was that we were performing a type of <i>nemawashi</i>.</div><div style="text-align: justify;"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; text-align: justify;"><br />
We have all probably seen this formula...</div></div><div style="text-align: center;"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; text-align: center;"><b><br />
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<b>R = Q x A</b> </div></div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; text-align: justify;"><br />
...which of course stands for...</div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; text-align: justify;"><br />
</div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; text-align: center;"> <b>Results = Quality of the Countermeasure x Acceptance Level</b>.</div><div style="text-align: center;"><br />
</div><div style="text-align: justify;">Whenever we test a new countermeasure, we are doing more than collecting data to check the quality of the countermeasure. We are also impacting the acceptance level for change. If done right, an experiment can help remove the fear of the unknown, send a message that change is coming, and bring out ideas that don't arise until we see a new process live in action. These are all symptoms of <i>nemawashi</i> being performed.</div><div style="text-align: justify;"><br />
</div></div>Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-1599106628465989812011-05-04T16:05:00.000-05:002011-05-04T16:05:54.459-05:00Small-Batch PDCA<div dir="ltr" style="text-align: left;" trbidi="on"><div style="text-align: justify;">I'm a fan of small batches. Partially, this is explained by my appreciation of the many fine single-barrel and small-batch bourbons produced in good ol' Kentucky. But principally, my bias towards small batches is due to the positive impact that batch-size reduction has on process flow, quality, etc.</div><div style="text-align: justify;"><br />
</div><div class="separator" style="clear: both; text-align: justify;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUUOjdCapsVfvd8fROGK9uIU5uNXHwVLkQvQKEqQz3LAeZ3C8QnD6nLhYtaZ6iEzy0YOf7WIrIz1Gg7d13y4ZWqWf5SNcXvMHaJHr2W-0K99y6PWpyitEeOg-gJ9vnCulJVjkOwv6Mdg/s1600/Bourbon.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUUOjdCapsVfvd8fROGK9uIU5uNXHwVLkQvQKEqQz3LAeZ3C8QnD6nLhYtaZ6iEzy0YOf7WIrIz1Gg7d13y4ZWqWf5SNcXvMHaJHr2W-0K99y6PWpyitEeOg-gJ9vnCulJVjkOwv6Mdg/s320/Bourbon.jpg" width="320" /></a></div><div style="text-align: justify;"><br />
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</div><div style="text-align: justify;">Normally, we associate batch-size reduction with process improvement. But if we take a step back and look at our process for conducting process improvement, batch-size reduction is equally as applicable. Specifically, the way we go about testing countermeasures via <a href="http://en.wikipedia.org/wiki/PDCA" target="blank">PDCA</a> can be enhanced by batch-size reduction. I call this principle Small-Batch PDCA.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;"><b>What is Small Batch PDCA?</b></div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">When we're in the planning phase of of PDCA, we have to decide how many countermeasures we want to test during the current PDCA cycle. There's a trade-off between the number of countermeasures we test and the amount of time, effort, and resources that will be required to conduct the test. More countermeasures equals more testing complexity. In order to properly execute a complex test, we might feel the need to utilize a complex tool such as <a href="http://asq.org/learn-about-quality/data-collection-analysis-tools/overview/design-of-experiments.html" target="blank">Design of Experiments (DOE)</a>. My bias is to avoid this testing complexity by testing in smaller batches when possible.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">By reducing the complexity involved with carrying out a test, Small-Batch PDCA allows us to compress the lead time from idea generation to idea testing. This gives us the chance to perform more iterations of PDCA, which in turn gives us a chance to adjust our model more frequently.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;"><b>Is there a downside to Small-Batch PDCA?</b></div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">One of the drawbacks of Small-Batch PDCA is that we don't get to test the future-state in a holistic manner, at least not during the first few rounds of testing. This means that any data we collect early on might not show the dramatic improvement we want, and in fact, it may be impossible to detect any statistically significant changes in performance. This is a valid concern, but this drawback is partially mitigated by the fact that if we are willing to go to the <a href="http://en.wikipedia.org/wiki/Gemba" target="blank"><i>gemba</i></a> and observe the test with our own eyes, we don't have to rely on data as much. </div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">Plus, there are some important things that just can't be measured, so we usually need to go to the <i>gemba</i> regardless. In other words, data isn't everything. Subjective feedback from those involved with the process can be extremely valuable. Insights gained from direct observation can also be extremely valuable. Small-Batch PDCA provides us with most of the feedback we need to effectively carry out process improvements, even if the data is not as perfect as we would like.</div></div>Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-51646350350392200542011-05-03T08:06:00.002-05:002011-05-03T08:14:37.057-05:00To Sample or Not to Sample<div dir="ltr" style="text-align: left;" trbidi="on"><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEils3FZdiJPdWi6557bb0_oJ9SX9Ry-hQevt4EaeIQz8mg-hHoOfrXtFnikELCrXdMHWKJqmTQtrctSiD6w_ZMes6g6GIddycgUGhpdXJUDDLjydjug9LTN4R-xYIMX7Gki0m3csrhs-A/s1600/Population+vs+Sample.gif" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="299" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEils3FZdiJPdWi6557bb0_oJ9SX9Ry-hQevt4EaeIQz8mg-hHoOfrXtFnikELCrXdMHWKJqmTQtrctSiD6w_ZMes6g6GIddycgUGhpdXJUDDLjydjug9LTN4R-xYIMX7Gki0m3csrhs-A/s320/Population+vs+Sample.gif" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Image courtesy of Stanford School of Medicine</td></tr>
</tbody></table><div style="text-align: justify;">I'm sitting in Six Sigma Black Belt training this week, learning all about two-sample t-tests, ANOVA, and other statistical analysis techniques. One thing I noticed is that these techniques are based on sampling. Basically, you collect data based on a sample, not the whole population. An example from a hospital would be randomly picking 10 patients from a census of 100 and looking at their infection rates. </div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">Obviously, data from a sample is not as thorough as that of a population, but often it's thorough enough to be statistically reliable. The benefit of sampling, of course, is that we don't have to go through the time and expense of collecting data for the entire population. However, thanks to powerful database software available to us in healthcare and pretty much any industry nowadays, we can easily pull <i>all</i> the data for <i>all</i> the patients in our system, at virtually no marginal cost. This begs the question--why bother with sampling if we already have the population data?</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">I guess we wouldn't, unless there was some added value in sampling beyond the data that we gather. If we're sampling by just pulling data out of a database, then there's probably not much value beyond the data. But, if we're sampling by directly observing a process, then there's a lot of additional value: we see the process with our own eyes, we get direct feedback from those involved with the process, we often get to directly hear the voice of the customer (the patient), and we get the opportunity to collect data that we didn't even know was relevant by looking at a database.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">So, basically, it's not a question of "to sample or not to sample" but "to go & see or to not go & see."</div></div>Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.comtag:blogger.com,1999:blog-777471303672228635.post-12038437215760688232011-05-01T16:45:00.000-05:002011-05-01T16:45:35.631-05:003 Quick Thoughts on Copycatting Hospitals<div dir="ltr" style="text-align: left;" trbidi="on">Mark Graban over at the <a href="http://www.leanblog.org/" target="blank">Lean Blog</a> got me thinking about the pros and cons of copycatting (using what works somewhere else to fill a need of your own). I'm not talking about plagiarism, intellectual property theft, or anything like that; I'm just talking about one hospital copying the tools and techniques of another, as opposed to coming to solutions independently. Here are three quick thoughts on copycatting:<br />
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<ol style="text-align: left;"><li>Copycatting is supported by the "no need to reinvent the wheel" principle, which is logical and intuitive, especially for hospital folks who are busy saving lives and whatnot.</li>
<li>However, copycatting is a barrier to creative thinking and the building of the problem-solving muscles hospital teams need to foster continuous improvement.</li>
<li>Copycatting precludes the emergence of innovative ideas that other hospitals have not thought of yet</li>
</ol><div>One last thought...there's something about copycatting that makes me think we are sometimes too scared of failure. Maybe our risk aversion prompts us to go with what other hospitals have used, as opposed to trying something new and failing. Does this mindset stem from traditional management philosophy that encourages us to hide problems?</div></div>Michael Lombardhttp://www.blogger.com/profile/16424200866303128001noreply@blogger.com