The Big Kata

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

But why do we want a single approach?

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

• Fewer approaches = less jargon = less confusion
• Fewer approaches = more repetition on the chosen approach = more "muscle memory"
• Fewer approaches = less education/training required = more time spent learning-by-doing
• Fewer approaches = easier to spot errors in technique = easier to coach/mentor others

And so on and so forth.  Plenty of upside, but what is the downside?  It's that whatever improvement methodology you choose must be scalable.  It must be effective for big efforts, small efforts, and everything in-between.  It must also plug & play with improvement tools/techniques such as kaizen events, value stream mapping, job instruction training, KaiNexus, etc.

So what kind of approach would be fully scalable?

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

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

The Hypothetical "BIG KATA"

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

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

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

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

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

Ideal Condition

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

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

Big Challenge

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

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

Current Condition

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

Target Condition

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

PDSA Cycles

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

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

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

Conclusion

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

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

True Value in Healthcare

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:

The Standard Definition of Value in Healthcare

Under this definition, for an activity to be considered value-added, it must satisfy three requirements:

1. The activity must be something the patient wants/needs
2. The activity must be done correctly
3. The activity must change the form/fit/function of the patient

If it does not satisfy all three of these requirements, an activity is considered non-value-added under this approach.  

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.  

But the more and more I read about Population Health and ACO, 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.

My Definition of True Value in Healthcare

The following two guidelines define my current, half-baked view of "true" value in healthcare:

1. If an activity is related to providing care for a preventable illness, it is waste.
2. 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

Thoughts?  

FYI, I prefer comments on LinkedIn or Twitter, so I've shut off comments on this blog.

Thank you for sponsoring my Little League team.  Those mesh hats were sweet.

The Human Factor in Healthcare

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.

As a lean coach in healthcare, one must adjust both his or her expectations and tactics.

Adjust Your Expectations

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!

Adjust Your Tactics

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.

10 Complexities in Hospitals

Having worked in a hospital as a Lean Coach for about a year now, I've grown accustomed to dealing with a wide range of complexity related to healthcare, and hospitals in particular.  Here's a list of some of the types of complexity I've seen in the hospital (it's not an exhaustive list by any means, and is in no particular order)...

1. We often have no ability to control/level the volume going into the system, especially in an ER setting
2. We have seasonal, weekly, and daily volume fluctuations
3. We often have a wide range of acuity levels, which are high-mix, low-volume in nature
4. Clinical workflows are often controlled by complex computer systems, which makes some processes more inflexible that we'd prefer
5. The most highly-trained and often most powerful people in a hospital are the physicians, who are also the "touch labor" for our front-line processes
6. We have 24/7/365 business hours, making cross-shift collaboration a challenge sometimes
7. In pediatric hospitals, we have to design processes that accommodate the needs of both the patient and their family
8. In academic hospitals, we often have to design processes with educational needs in mind
9. The customer and the payer (insurance companies, Medicare, etc.) are often not the same entity
10. In places like Texas, we have huge language barriers that our processes have to accomodate

Every industry has its own sources of complexity.  Healthcare, and hospitals in particular, bring special types of complexity that are pretty challenging.  I personally love the challenge, but I also realize that I have a long way to go if I want to be a Lean Coach who is capable of overcoming the complexity found in hospital systems.

Standard Work for ER Residents

As a non-clinical member of a large hospital, when I can get even 30 seconds with an ER physician, I consider myself lucky.  Today, I got about 5 minutes with one, which gave me the opportunity to throw some ideas out there about ways to standardize and kaizen repetitive aspects of his job.

The Concept

I mention 'standardize' and 'kaizen' together, because as Taiichi Ohno said, "Where there is no standard, there can be no kaizen."  Standard work gives us a baseline from which we can analyze deviations, which leads to the discovery of problems, which through good problem-solving leads to continuous improvement.  Without the baseline, we can't even tell if we have a deviation.  That's why I was discussing standardization with the ER physician today.

The Specifics

We specifically discussed standard work in the context of the Resident-to-Attending report-out.  This is the process by which a Resident (a med school graduate who is in-training) reports to the Attending (a senior physician) on the condition of a patient and what the treatment plan should be.  This is typically done verbally, which makes it critical that there be some sort of structure around the verbal report-out.

In med school, students are taught reporting structures such as SOAP that help provide some standardization to the report-out process.  If we say that the SOAP approach is our standard, we can at least check to see if it is being used and look for deviations.  If there are deviations, we can ask why and keep asking why until we get at the root cause.  If needed, we can find a better standard.  The point is, we need something to get us a baseline from which we can assess the process.

The Reason

But why do we even need to worry about the Resident-to-Attending report-out process?  Because it causes patient delays, which can cause patient safety and quality of care issues.  Until the Resident reports to the Attending and a plan of care is agreed-upon, you don't usually see any orders being placed.  No orders, no treatment.  Nurses can do their best to monitor and support sick patients, but until orders are placed it's hard to provide much care.  That's why we need the best Resident-to-Attending report-out process possible, which is why we need standard work and good problem-solving.

Of course, this whole problem makes me think, is there a better way?  Is there a different model that would allow Residents to get the training and monitoring they need from the Attending without creating delays for patients?  That's true north for the Resident/Attending relationship.