heroics and habits: exploring the implementation of lean

Heroics and Habits: Exploring the Implementation

of Lean Management in Healthcare

National Health Leadership ConferenceHalifax, Nova Scotia

June 4-5, 2012Margaret Seppelt BSN, MBA Provincial Health Services AuthorityCindy Priddy BS, MA, MCS Vancouver Coastal Health Authority

Objectives

•Understand a Lean Management System•Describe the role of a leader in a Lean culture•Explore the journeys of two healthcare authorities in BC•Discuss the implications for Canadian healthcare

•What is a typical day of a manager?

•How much of the day is spent fire fighting versus improving the business?

•How easy is it to train someone to be a successful manager in this environment?

A Day In The Life Of A Manager…So my typical day starts about 0645 and I check in to see if there are any patient safety alerts on line, then move to Patient Unit A and get report on night shift, then upstairs to Patient Unit B to check in with the charge nurse and see if she has everything she needs.

The check in time varies and depending on when my first meeting depends on how much time I can spend in each space. For example my first meeting was a 0645 this morning so I was here at 0615 which did not allow for me to get handover, but did check in with a number of staff before the meeting.

My days are jammed with meetings, they would go until 1700 if I did not refuse to meet after 1600. I usually answer emails while eating my lunch at my desk and then answer a few at home in the evening.

Project work gets jammed in between meetings and I usually end up staying some nights until 1800…..but generally try to leave by 1700….

I think what I struggle with the most is having so many things needing attention and prioritizing and putting off people because I just don’t have time to address their issues at that moment. I think the leadership structure is insufficient for the amount of work that needs to be done. Leadership development for the supervisor group is quite important, but has not been able to really sink my teeth into it because of so many other pressing human resource issues...

Today’s Reality of Healthcare Management

Heroes or Firefighters?

FrontLine Leader

Definition of Lean

Lean is a mindset of continuous improvement

It’s a system that empowers people at all levels to:

• Remove waste• Maximize what is of value to the patient

FOCUS = TOOLS AND “PROJECTS”

LACK OF FOCUS ON LEAN MANAGEMENT TO SUSTAIN

3 YEARS

Results/G

ains

Typical Progress of Lean Adoption

Lean Management•An organization’s culture is a result of its management system. To change culture, you have to change your management system.

•Many lean implementations fail because it is easy to implement the physical trapping of lean methods and tools while failing to address the need for the parallel implementation of lean management.

•Lean transformation requires the adoption of the Lean Management System as the system for managing operations and the foundation for all the improvement work and the strategic plan. (Gary Kaplan, Virginia Mason)

PURPOSE

PEOPLE PROCESS

MANAGEMENT

PURPOSE

PEOPLE

PROCESS

Focus too much on the process and tools -

Andons, Kanban, Cells –lean tools and processes

in place without sustained results

PURPOSE

PEOPLE

PROCESS

Focus too much on people and teamwork –

lots of busy improvement activity

with no significant results

Lack of direction

MANAGEMENT

PEOPLE PROCESS?

Lean Management System

MANAGEMENT

PURPOSE

PEOPLE PROCESS

Management aligned to a defined business purpose to deliver results by maintaining the balance

between people and process.

What is the Role of a Leader in a Lean Culture?

1. Set direction 2. Build the problem solving muscle of the organization

Elements of Daily Management

Source: Creating a Lean Culture (Mann, 2005).

Leader Standard Work


“Standard Work is the Key to our success…”

“We will be auditing standard work and hold all of you accountable… “

Sure glad Standard Work does not apply

to ME!


*adapted from Creating a Lean Culture, p. 43.

Senior Leader standard work

Director standard work

Manager standard work

Coordinator standard work

Lean Management System

Standardized Lean Processes

Leaders’ Responses to Standard Work for Leaders

“I already do this.”

“I have standard things I’m checking on everyday, I just don’t write it down.”

“This is so formal. I would rather just have casual conversations with staff to get this information.”

“I don’t have time to do this.”

Leader Standard Work•Leader Standard Work is the specific timing, sequence, content and outcomes of a leader’s daily routine.

•The Leader Standard Work identifies audit points and specifies where and when in the leader must physically go, what they must check and the normal condition with the aid of effective visual controls.

•Each check point involves Assessment, Assignment and Accountability.

Leader Standard Work - ExampleReference: Joan Wellman and Associates

Charge Supervisor Manager Director Team Standard Work Huddle Charge Huddle and Application

Consistency Coordinator Huddle and Huddle Design / Expectations

Monthly DMS Reviews and Appropriate Huddle Application

Team Integration and Coordination

Shift to Shift Integration and Coordination

Group Integration and Coordination

Value Stream Process Integration

Respond to Andon / Line Stop Learn from Andon and Codify Share Andon Learning Develop Learning Capabilities Monitor Standard Work Performance

Monitor Standard Work Performance



Perform Local Daily Management

Review Performance and Process Metrics

Review Performance and Results Metrics

Review Performance and Outcome Metrics

Analyze Variation Standard Work Variation Management

Variation Trend Analysis Management

Variation Trend Analysis Review

Daily Continuous Improvement Area Continuous Improvement Support

Department Continuous Improvement Support

Organizational Continuous Improvement Support

Individual Accountability Check

Charge Accountability Check Coordinator Accountability Check

Manager Accountability Check

Utilize Visual Management Utilize and Evaluate Visual Management

Support Design and Implementation of Visual Management

Evaluate Effectiveness of Departmental Visual Management

Revise / Reinforce Standard Work

Evaluate Cross Shift Standard Work Change Impact

Evaluate Cross Functional Standard Work Change Impact

Establish Standard Work Expectations

Utilize Five S Process Assure Workplace Organization review for system inadequacies

Evaluate for trends and assure prevention measures are key

Evaluate for principle consistency between areas

Next Day Planning Weekly / Monthly Planning Monthly / Yearly Planning Yearly / Long Term Planning Immediate Issue Problem Solving

Ensure Permanent Problem Solving

Formalized Problem Solving and Assure Effectiveness

Share Effective Formalized PS Approach and Institutionalize

Standard Work Compliance and Correction

Assure Compliance and Resolve Variances

Evaluation Compliance Variances and Resolution Methods

Establish Compliance Expectations and Consequences

Train Team as Needed and Orient to Standard Work

Instruct Charge as Needed and Orient to Charge Standard Work

Instruct Coordinator as Needed and Orient to Coordinator Standard Work

Educate Manager as Needed and Orient to Manager Standard Work

A

Tiered Accountability - ExampleTiered Accountability – Standard Work Huddles

Activity / Response Routine Mgt Tier Frequency

Review for appropriate huddle application and determine departmental huddle effectiveness. Correct for variations of purpose.

Schedule and attend a huddle within each area of responsibility

Director Weekly

Review for process compliance and local huddle effectiveness. Provide coach based on appraisal. Reconcile huddle to huddle variation and adjust organizational structure.

Schedule and attend a huddle within each area of responsibility

Manager Weekly

Assess for process compliance (assess / assign / account), content, duration and effectiveness. Suggest adjustments for inadequacies or inconsistencies.

Attend a huddle within each area of responsibility

Supervisor Daily

Review DMM and respond to abnormalities or failures (assess/assign/account). Utilize appropriate response system. Pursue Continuous Improvement of Standard Work. Correct inadequacies as found.

Lead daily huddle in area of responsibility

Charge RN Daily

Contribute to DMM review. Complete assignments. Generate ideas for improvement.

Attend assigned huddle.

All Associates Daily

A

Source: Joan Wellman and Associates

Routines - Example

Charge Nurse Routine Activity Time Frequency

1. Attend Standard Work Huddle 8am Daily 2. Review and Affinitize Cause Cards Mid Morning Daily 3. Review Offline Activity Mid Day Monday 4. Lead Data Analysis 10am Wednesday 5. Review open action items for

accountability 2pm Daily

6. Audit DMM for Validity Mid Day Wednesday 7. Lead Standard Work Huddle 4pm Daily

Visual Controls


Is Your Workplace Visual?If you walked your workplace, can you quickly and easily see:

•Whether you are on plan, behind or ahead?

•What your key problems/issues are?

•What actions being taken to address issues and by when?

•Who is accountable?

Visual Controls

Continuous Process Monitoring

A Plan for Every Patient in Emergency featuring target times for each process step and highlighting any variance against plan as soon as it occurs

Source: LeanUK.org

Daily Management Gemba Walks1

2

3

Leader Standard Work Cascading Reviews

• The same review is done by all

• All that changes is scope and frequency

VP

Manager

Unit Supervisor

Weekly walk by and one deep dive

Daily walk by and one deep dive

Several deep dives throughout the day

Daily Management Board

Daily Management Board – Example PEOPLE QUALITY

SAFETY

DELIVERY CONTINUOUS IMPROVEMENT

COST

Daily Management Board Industry Examples

Daily Management BoardSeattle Children’s

Performance Walls

BC Mental Health Performance WallStrategic level performance weekly review of the Value Stream

(C&GCR – Charts and Graphs in the Conference Room)

Moving Beyond Social Visits…

Leadership Huddles or Walk-aroundswithout Visual Controls are “social visits” …

Visual Controls without Leadership Huddles become “wall paper”

Daily Accountability


Daily Accountability Process

Brief, structured, tiered meetings focused on performance with visual action assignments and follow-up to close gaps between actual results vs. expected performance.– Leader scrutinizes data daily – Determines what steps to take by whom– Assigns resources, sets due dates– Tiered Meetings

– 1st tier – Daily Huddle (supervisors and staff)– 2nd tier – Daily Status Review (Managers and supervisors)– 3rd tier – Weekly Gemba (Executives and Managers)

Daily Huddle - Example

Issues Log - Example

Staff submit issues and Front Line Leader reviews issues daily.

Daily Accountability Board - Example

Discipline Adherence to Standards


Daily Management Discipline

Change in Leadership Approach from Heroics to Habits

Source: Adapted from Creating a Lean Culture (Mann, 2005).

Her

oics • Focus on results

• Retrospective computer-generated reports

• Focus on the end outcome

• Meetings to discuss reports

• The fire truck

Hab

its

• Focus on process• Looking at what is

happening today in real time

• Focus on the process from beginning to end

• In the moment diagnoses and remedial action

• Fire prevention!

Paradigm ShiftTypical Thinking:Normal daily management plus improvement

Continuous Improvement Thinking:Normal daily management is process improvement

Source: Toyota Kata (Rother, 2010) p. 39

Provincial Health Services Authority• One of six health authorities in BC established in 2001• Responsible for highly specialized services in the

province:– BC Children’s Hospital - BC Centre for Disease Control– BC Women’s Hospital - BC Transplant Society– BC Cancer Agency - BC Provincial Renal Agency– Mental Health & Addictions - Cardiac Services BC– Perinatal Services BC

• PHSA Divisions– Emergency Health Services Commission– Health Shared Services BC

• 16,000 employees• Serve a population of 4M • Budget of $2.3 billion

PHSA’s Lean Transformation Strategy imPROVE, focusing on patients; empowering staff

Based on our organizational values:P: Patients firstR: Results matterO: Open to possibilities V: Best ValueE: Excellence through knowledge

- it’s about improving processes to ultimately improve patient care/outcomes

imPROVE Roadmap

Year 1 - 22007 - 2011

2011 - 20132013 - 2014

Experiment with Lean Methods and Tools as Improvement Projects

Move from point improvements to Value Streams and Rapid Process Improvement Workshops. Leaders Certified in Lean Methods and Tools.

Daily Management supports sustainment and front line staff engagement in identification and improvement of key issues.

Strategy Deployment to define Key Breakthrough Objectives with clear accountability and reporting from the top to the front line.

Developing Lean Leaders

Learning How to Improve•Learning lean principles•Applying methods, and tools•Mapping Value Streams•Leading Rapid Process Improvement Workshops (RPIWs)

Learning How to Manage•RPIW Sponsor Status Report Outs•Quarterly Reviews•Performance Walls•Daily Management•Strategy Deployment

PHSA’s imPROVE Education Program

Lean Leader Certification

Lean Leader Certification Process

Co-requisite: Coaching Out of the Box

Build Capacity to Lead Lean

•200 plus PHSA Leaders on Lean Leader Certification Track•19 Senior Executive Leaders•20 Physician Leaders

imPROVE Productivity

•IMPROVEMENT WORK-13 Active Value Streams

-180 RPIWs completed as of March 2012

-4 3Ps and 8 IFDs completed for BC Children’s and Women’s Hospital Site Redevelopment

-105 5s completed

-12 Rapid Kaizen Events – using A3 thinking

PHSA Lean Management System Overview

MiddleManagement

SeniorManagement

Front LineLeaders

Front LineStaff

SW

Monthly Review

Takt / Hourly Shift / Daily Weekly Monthly

Work station Department Value Stream Organization

HourlyPerformance

Metrics

DepartmentDaily MgtBoard

Value StreamPerformance

Wall

OrganizationPerformance

Room

Daily Huddles Weekly Gemba

QualitySafety

DeliveryCost

Satisfaction

ProblemSolving

Root Cause&

CounterMeasure

Action Plan

Current &Future VSM

RPIWPlanning

StrategyDeployment

BreakthroughObjective

Vision

Daily Management Strategy Deployment

PHSA Strategic Objectives

1. Improving Quality Outcomes and Better Value for Patients.

2. Promoting Healthier Populations.

3. Contributing to a Sustainable Health Care System.

QUALITYCLINICAL

EFFECTIVENESS

SAFETYPATIENT AND

STAFF

DELIVERYACCESSIBILITY,

CONTINUITY, POPULATION FOCUS

COSTEFFICIENCY

SATISFACTIONCLIENT CENTERED

WORKLIFE

PHSA STRATEGIC DIRECTIONS: Creating Better Value and Outcomes for Patients, Contributing to a Sustainable Health Care System, Promoting

Healthier Populations.

Achieve standard practice by use of clinical practice standards adhered to 95% of time.

Eliminate all level 4/5 safety events arising as a result of our care.

Eliminate unnecessary waiting for all patients and care providers.

Reduce waste for both patients and those who provide care.

BCW achieves over 95% top rating for recommended placed for patient care and staff employment as compared to other hospitals.

Target: Year 1 (2011 – 2012) each

area will implement 2 clinical practice standards adopted at 95% reliability rate.

Target: Year 1(2011 – 2012)

from 97 per year to 50

Year 2 (2012 – 2013) from 50 to 20

Year Three (2013 to 2014) from 20 to zero.

Target: Year 1 (2011 – 2012)

50% Lead time reduction

Target: Year 1(2011 –2012) implement systems to retrieve quarterly data for all service lines.

BCWs Performance Walls

BCW Acute Maternity and NICU Performance Wall Review Weekly

BCW Executive Quality Council Performance Wall Review Monthly

BC Mental Health and Addiction Services Performance Wall Weekly Review

BCMHAS ED – Delivery Access Improvement

BCMHAS ED – Employee Engagement

2009 2011 Change3.68 3.63 -0.05

PHSA overall average score

Eating Disorders program score2009 2011 Change3.68 4.15 +0.47

Why Daily Management…• Lean improvement processes and daily management are

intertwined. To maximize improvement, you cannot do one without the other

TIME

IMPR

OVE

MEN

T

KK

K

K

K

K

K

K

K

S

S

SS

K: KaizenS: Sustain

Improvements slide when not sustained by daily management

BCCA Vancouver Center Ambulatory Clinic Daily Management Board

Who WhenAction

Incomplete order

OR

KPI name and a status “At a

Glance”- What we are

tracking.

Performance- How we are

doing and have been doing

Root cause and problem solving

- What issues are making us miss

target

Action plans- What we are doing

to improve or get back on track

Make Data Visual – Status at a GlanceQuality

Who WhenAction

Incomplete order

OR

Performance Tracking VisualQuality

Who WhenAction

Incomplete order

OR

Data is obtained from daily scorecard

% of incomplete or incorrect Patient Orders

0%

5%

10%

15%

20%

25%

30%

35%

40%

Tue-02/01

Wed-02/02

Thu-02/03

Fri-02/04

Mon-02/07

Tue-02/08

Wed-02/09

Thu-02/10

Fri-02/11

Mon-02/14

Tue-02/15

Wed-02/16

Thu-02/17

Fri-02/18

Mon-02/21

Tue-02/22

Wed-02/23

Thu-02/24

Fri-02/25

Mon-02/28

Tue-03/01

Wed-03/02

Thu-03/03

Day

%o

f o

rde

rs

Actual% on time Target

% Patient Calls to Voicemail

Unit Staff enter the data daily

Problem Identification and AnalysisQuality

Who WhenAction

Incomplete order

OR

Action Plan – Kaizen NewspaperQuality

Who WhenAction

Incomplete order

OR

BCCA Daily Accountability Huddle

PHSA Successes

•Leadership driven.

•Managerial fortitude to make tough discussions and stay the course in the political environment.

•Begin with outside experts who have deep knowledge of Lean to establish the discipline.

•BUT build internal capability and infrastructure to support leaders for application in everyday work.

PHSA Lessons Learned

•We have just begun to understand the depth of lean.

•Will not sustain the gains without the foundation of a Lean Management System – Daily Management and Strategy Deployment.

•Shift in the way leaders think, what they see, what they do will shift the culture.

• $2.8 billion annual funding • 22,000 staff • 3 Communities of Care• 556 locations including

• 13 hospitals• 3 diagnostic and treatment centres• 15 community health centres

Vancouver Coastal Health (VCH)

Promote Better Health

for our Communities

Develop the Best

Workforce

Provide the Best Care

Innovate for Sustainability

People First

VCH True North Goals

VCH Lean: 3 Areas of Focus

Strategy Deployment

What do we improve everyday?

Lean Management

How do we manage to improve everyday ?

Continuous Improvement

How do we improve everyday?

Source: Staying Lean (Hines, 2011)

Process management

Technology, tools and techniques

Above the line: visibleBelow the line: enabling

Strategy and alignment

e.g. Birth Center Pilote.g. Regional Patient

Transfere.g. Returning employees

to work

e.g. Strategic Deployment with the various Communities of Care

Above the line: visibleBelow the line: enabling

The Iceberg Model

Leadership

Behavior & Engagement e.g. Lean Management across the various leadership teams

Lean is About CULTURE Change

http://www.brooks.edu/careers.htm�

Evolution of Lean Education at VCH

2006/7 –20010/11 2011/12 2012/13

Upfront Lean education for project teams

JIT Education for project teams

-Lean basics-5 steps to Lean Thinking-Current & Future State Mapping, etc.

Development of formal Lean education program

Development and implementation of Lean Management education program for senior leaders

Integration with other Management Development programs

Lean Management Education for front line leaders and staff

Development of model cells

Implementation of Lean Management system

Coach Lean Management in real time

VCH Lean Education Programs

Intro to Lean

Recommended for: All Staff, Leaders &

Physicians

Value Stream Mapping & A3

Problem Solving

Recommended for:All Staff, Leaders,

Physicians

Leading Lean Projects

Recommended for: Emerging Leaders,

Supervisors, Coordinators Project

Champions

Lean Management

Recommended for: Directors, Managers,

Supervisors, Coordinators,

Physicians

Peop

le

Daily Status Sheet

Exchanges

Continuous Improvement

Huddles

Breakthrough Improvement

Lanes

Proc

esse

s

Standard Work Audit Board

Value Stream Mapping

A3 Problem Solving

Understand & Improve the Business

Performance Dashboard


Managing Daily to Continuously Improve and to Add Value to Every Patient, Client, Resident & Customer Experience

Covered in Lean Management Introduction Course

VCH Lean Management System

Inch Deep, Mile Wide

Mile D

eep, Inch Wide

Educate many and support partial implementation until critical mass is reached?

Or

Intensively educate and support a few to full implementation?

Approach to Implementation: Wide or Deep

Educate and implement with senior leaders

first?

Educate and implement in

local areas with small vertical teams first?

Or

Approach to Implementation: Top Down or Bottom Up?

COOs, Directors and Managers Participate in Lean Management

Course

Strategy Deployment at each Community

of Care

Front Line Leaders participate in Lean Management Course

Establish Model Cells in Each Community of Care and in Corp &

Regional Areas

Implementation of Lean Management in Operational Areas

Implementation of Lean Management in Corporate and

Regional Areas

Lean Education Coaches and internal experts continue to teach, mentor and refine Lean Management System at local levels

Feedback to and Education of Senior Executive Team &

Board

VCH Approach to Lean Management

Before After

Leader Standard Work for Manager

Role/LevelStandard Work Accountability Processes

Manager 60-80% of job is standard work processes as outlined belowDaily huddle with all team leads (15 min) using daily status sheets to review targets/ issues/ day to day operationsDaily huddle with staff using visual board; just in time problem solution and standard work development; barrier resolution; focus on targets and delays; reds from daily meetings for resolution.Coaches staff in solving problems using PDSAResolution of cross team issues; Ensures their area based visual boards are current Resolves issues raised by Team Leader within 24 hrsGemba walk

Responsible for coaching Team Lead in problem solvingTo remove barriers from team functioningAddress complaintsCustomer relationships / Education w/ unions and patients/ clients/ residentsContinuous development for team

Ensures timely response to everyday Lean ideasEnsures Team Leader addresses everyday Lean ideas within time framesEnsures program visual boards current and usedEnsures regular engagement with staff related to improvement ideas


Breakthrough Improvement LanesRichmond Birth Center

Daily Tracking SheetBanfield Pavilion

Leadership Team Learning Together: Banfield Breakthrough Lanes

Standard Work Audit BoardRichmond Birth Center

RH Birth Centre

Staff’s suggestion for continuous improvements

Improvement HuddleRichmond Birth Center

• Multi-faceted approach fits VCH organizational cultures

• Solid education program provides strong foundation for sustainable Lean Management System

• Leadership experiencing renewal and hope

• Deep learning about root causes

VCH Successes

• Establish infrastructure to provide education early

• Develop model cells early

• There is a significant learning curve in applying a Lean Management System in community, corporate and regional areas

• Lean project coordinators may also need additional education in order to coach leaders in Lean management

VCH Lessons Learned

The complexity of modern healthcare

requires a simple and direct management

approach.

Caution!

If we as leaders focus only on the tools of Lean Management, we will not shift the culture to continuous improvement.

A Shift in the Management Process

Source: www.lean.org

Three Keys to Leadership

Coaching Questions

1. What is the target condition?

2. What is the actual condition now?

3. What obstacles are now preventing you from reaching the target condition? Which ones are you

addressing now?

4. What is your next step? (start of the next PDSA)

5. When can we go and see what we have learned from taking that step?

Source: Toyota Kata (Rother, 2010)

Leaders Develop Problem Solvers

Source: Toyota Kata, (Rother, 2010)

What is Lean?

•Lean is a practice, not a theory: there is no roadmap, project plan or strategy. There are no miracles other than going to the front line often, visualizing one’s challenges and patiently teaching people to solve their own problems.

•To succeed in Lean, respect for people is as important as continuous improvement.

Source: The Lean Manager (Balle, 2009)

1. What would you need to change in your current management system to support Lean Management in your organization?

2. What are the implications for leadership development in healthcare?

3. What are the risks in not doing this?

4. What are the top 3 ideas that you are going to act on when you go back to work?

Discussion Questions

References

Balle, Michael and Balle, Freddy. The Lean Manager: A Novel of Lean Transformation. Cambridge, M assachusetts: Lean Enterprise Institute Inc., 2009.

Mann, David. Creating a Lean Culture: Tools to Sustain Lean Conversions. New York: Productivity Press, 2010.

Rother, Mike. Toyota Kata: Managing People for Improvement, Adaptiveness, and Superior Results. New York: McGraw Hill, 2010.

Womack, Jim. Gemba Walks. Cambridge, Massachusetts: Lean Enterprise Institute Inc., 2011.

Additional ReadingKenney, Charles. Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience. New York: Productivity Press, 2011.

Toussaint, John and Gerard, Roger. On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry. Cambridge, Massachusetts: Lean Enterprise Institute Inc., 2010.

Wellman, Joan; Hagan, Patrick and Jeffries, Howard. Leading the Lean Healthcare Journey: Driving Culture Change to Increase Value. New York: Productivity Press, 2011.

Useful Websites

•Lean Enterprise Institute –www.lean.org

•Healthcare Value Network -www.healthcarevalueleaders.org

•Lean Enterprise Academy –www.leanuk.org

•Mark Graban’s Lean Blog –www.leanblog.org

Contact Information

Margaret Seppelt BSN, MBA Provincial Health Services [email protected]

Cindy Priddy BS, MA, MCS Vancouver Coastal Health [email protected]

mailto:[email protected]�

mailto:[email protected]�

heroics and habits: exploring the implementation of lean

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