John E. Billi, M.D. Assoc. Dean, Assoc VP Med Affairs University of Michigan Michigan Quality System: med.umich.edu/mqs Michigan Quality System: Quality Safety Efficiency Appropriateness Service Leadership Issues in a Lean Organization

Issues on Lean Thinking in Health Care Why? “We’ve done well, why change?” “The autos had to do it” –Lack of perceived burning platform “Just the Management Flavor of the Month” –“Program of the Month” - this too shall pass. “Is this cost cutting disguised as QI?” –The term Lean is misunderstood as downsizing, outsourcing… People are not automobiles…

Issues on Lean Thinking in Health Care The Money “How much are we spending on this lean program?” –Silo accounting won’t capture gains. Need product line accounting –Hard to measure “return on time invested”. A generational change. I can’t risk my area’s performance to optimize the whole product line throughput –Accountability, teams, and incentives must cross silos and levels –Evaluation of middle management must match corporate goals

Issues on Lean Thinking in Health Care Where will we find the time? “How can we drop what we are doing to use lean thinking to solve the problem?” –Be sure we’re working on the most important problems –If this is the most important problem and we don’t have time for it, what are we doing now?? “A 3 (or 5) day workshop??!!” –Yet we spend 3 days over 3 years and don’t change anything “I can’t do this on top of my day job.” –Hard to do your job and improve your job at the same time –Management’s role must be to support exactly this –Isolated projects will not change the corporate culture –If a manager’s job is to lead improvement in the most important areas of their work, what are they doing now?

Issues on Lean Thinking in Health Care Standardization is for factories “Let each unit choose QI process it finds most useful.” –Synergy when ED project connects with OR or Admitting “Creativity is our most important asset – standard work will stifle creativity.” –Standard work and improvement are 2 sides of same coin –Can you innovate if you have not first standardized??? –Do you want your cardiologist innovating or giving you statin, ASA? –Standard work can free us to be creative where it counts –Defective processes squander brilliant workers’ talent Culture of rugged individualists, best and brightest, go it alone – v. standardization, team, mentoring We are experts in work-arounds –Every one loves the firefighter, no one loves the fire marshal –I got here by being a great firefighter. I realize I’m also the arsonist

Issues on Lean Thinking in Health Care Who will lead this? “I am a leader, but I don’t know how to do this.” –Need to grow experienced leaders by active participation “How can I get my people to do this?” –You must do this – become the change you wish to see “I’ll join when I see other leaders are on board.” –If not led from the top, many will not engage Do you start at the top, the bottom, or the middle? –No matter where you start, you will have to touch every stone in the wall several times Do the leaders really want empowered workers? If leaders “go and see”, will workers ask, “What are they doing here???” The coach must be teacher, mentor - the leader must be teacher, mentor

Issues on Lean Thinking in Health Care Japanese terms sound like insider jargon –Use English, then official term parenthetically: leveling (heijunka) –See glossary MQS: When someone stops the line? –Does leader come in time to help? –Is the stopper punished? –Does anything happen??? Does Value Stream Mapping help in healthcare? –Healthcare has even more hidden processes than manufacturing Fear of Loss of Job: –Guarantee redeployment –Use the best as embedded coaches

Why do workers like in lean thinking? –Workers can identify something is broken and they can fix it –Workers know what to do when they find a problem –Supervisors respond quickly to help (in job cycle) –Job has less stress (muri), less unevenness (mura) –Workers have what they need to do their work –Lean frees up capacity to do more value added work –Respect for people: letting them fix their work; not wasting their time on non-value-adding work –Respect for their ideas is part of the system: Andon, kanban, 5S, standard work, visual controls, error proofing, value stream maps, A3

What is the leader’s role in a lean organization? –Help workers: Do work in a standard way Detect abnormalities Find and fix root causes Disseminate learningsS. Spear –Ensure workers have what they need to do their job –Respond quickly to help (in job cycle) –Relieve overburden (muri) and uneven workload (mura) that interferes with finding and fixing root causes –Respect people: Not wasting their time on non-value-adding work Letting them fix their work Not solving their problems for them, helping them solve them

What is the leader’s role in a lean organization? –Using lean system elements to cascade responsibility at all levels in the organization: Andon – stop the line Kanban – order your own supplies/parts 5S – design your own workplace, tools, supplies… Standard work – design your work, write it up Visual controls – detect abnormalities right now Error proofing – design and run small experiments Value stream mapping – making your complex job visible A3 – present your analysis of a problem, proposal to solve it, and status report on how its going

The Incredibly Diverse Roles of the Lean Coach Problem solver Lean Coach Teacher/ Mentor Lean practitioner Change manager Group dynamic facilitator Project manager Trouble shooter Process observer

The Incredibly Diverse Roles of the Lean Manager Problem solver Lean Manager Teacher/ Mentor Lean practitioner Change manager Group dynamic facilitator Project manager Trouble shooter Process observer

Getting Started J Womack, Lean Thinking (Ch 11) Find a change agent (why not you?) Get the knowledge (find a sensei) Seize a crisis Forget grand strategy – get started! [Map your value streams: products, services] Important, visible activity Demand immediate results Expand

Why UMHS Chose Lean as the Best Approach …or, is this just CQI/TQM dressed anew? Builds on Traditional CQI: Uses first-hand knowledge of the work Analyzes root causes of problems (5 whys) Expands on CQI: Starts with value as defined by the customer Uses “one piece flow” to surface problems Creates a new future state value stream map, not just a better current state map Focuses on overburden and uneven workload, not just waste and errors Value stream maps are very useful for invisible work of health care

UMHS Michigan Quality System Prioritization Committee Coaches: 8 central, ~25 area (embedded) Education: –5 d course –1 d overview (signature exercise –JIT: 3 d VSM workshop –Website, library

UMHS Michigan Quality System A3 to foster dialog and consensus: –Tracking strategic goals –Capital requests –10 year strategic financial plan –Hospital annual budget –Commission lean projects –Institutional initiatives (advanced medical home, ideal patient care experience)

Learning Projects: So what have we learned so far? Scope: –First projects scoped too large: should create high level Value Stream Map first, then commission projects Transition project to line managers –Managers have difficulty taking ownership of the future state and implementation plan Time – what are they doing now that we can remove as non- value added? Skills: project mgmt, data collection, analysis, follow-up Embedded coach challenges –Not enough time to do lean projects, so need to use lean tools and techniques in all my projects –Can’t criticize the group I live in What if my boss is the barrier?

Problems Found on Project Reviews Issues with competing priorities: - Both workers and managers complained about fitting lean improvements into their busy schedule. - Daily work v. lean project – need more alignment. - Reflects stress of change in management model: from “supervisor” to “leader of work redesign”. Spread of improvements: - Understanding and making changes difficult for those not on team (managers or workers). Fear of job change

Problems Found on Project Reviews Scoping problems: - Some scopes too broad, some scoping inadequate Need for escalation protocol: - When/where to go for help – Andon Cord Transition from “a project” to line management: - Some had extended implementation plans - Project teams request long-term coach help Further development of UMHS coach cadre: - Experts in lean tools, expert teachers and superb people facilitation skills -Development of a standard model for projects

Learnings for UMHS Model MQS Model Changes: Value Stream Analysis by product line Selection of top priority projects for first phase Use of Value Stream Maps in the work place current state validation future state suggestions Consecutive vs. several days between workshop days allow opportunity for feedback

Learnings for UMHS Model Model will include: More teaching of lean methods and tools Promotion of methodology as “the way we improve” This is “our work”, not “added work” Our work is to do our job and improve our job Two coach team for complex projects

Problem and PDCA Tools for different levels Key to success: The Mid-management and First Line Supervisory Level FRONT LINES SENIOR MANAGEMENT MIDDLE MANAGEMENT MUST PROVIDE VISION AND INCENTIVE MUST “DO” MUST LEAD THE ACTUAL OPERATIONAL CHANGE Likes the involvement Likes the results Requires tools and support to lead RoleImpact Problem: MUDA PDCA tool: Policy Management PDCA tool: A3 or VSM PDCA tool: Standardized Work Problem: MURA, MURI Problem: MURI, MURA Shook Muri – overburden Mura – uneven workload Muda – waste

Kaizen Support Coordinated Workshops Lean Education LEI Support LEI Support JW, JS, DJL Guidance, Deployment, Gemba, Roundtables Value-Add Implementation Kaizen  “Do-Ers” DJL Results Deployment  “Managers” Diagnosis of Business Need Q.V.C. O.S. Installation Resource Deployment Reduce Lead Time Mura, Muri VP, Chief Engineer, Plant Manager Policy Deployment PDCA Human Development Results Supplier, Customer Connection Responsible Policy, Strategy  “Leaders” Evaluation Process People Support Elements SR Change Agent, Guide CEO/COO/President CEO/COO/President Exec. VP Exec. VP R.O.I. Market Connection Link Business Processes PDCA “Personal Trainer” Influence Setting Policy Principles Sponsorship Stability Muri, Mura Teller, Nurse, Engineer, Worker Standard Work Jidoka JIT/BTO Tools, e.g. 55, SMED, Eliminate Muda Prerequisites for O.S. (direct connection in value stream)

Kaizen Support Coordinated Workshops Lean Education LEI Support LEI Support JW, JS, DJL Guidance, Deployment, Gemba, Roundtables Value-Add Implementation Kaizen  “Do-Ers” DJL JS Results Deployment  “Managers” Diagnosis of Business Need Q.V.C. O.S. Installation Resource Deployment Reduce Lead Time Mura, Muri VP, Chief Engineer, Plant Manager Policy Deployment PDCA Human Development Results Supplier, Customer Connection Responsible Policy, Strategy  “Leaders” Evaluation Process People Support Elements SR Change Agent, Guide CEO/COO/President CEO/COO/President Exec. VP Exec. VP R.O.I. Market Connection Link Business Processes PDCA “Personal Trainer” Influence Setting Policy Principles Sponsorship Stability Muri, Mura Teller, Nurse, Engineer, Worker Standard Work Jidoka JIT/BTO Tools, e.g. 55, SMED, Eliminate Muda Prerequisites for O.S. (direct connection in value stream) Standard Work Standard Problem Solving (VSM, A3) Standard Planning (Hoshin)

What is Lean Thinking? A quick summary 1.Do our work every day in a standard way that we created - Not just the way the work evolved! 2.Be alert to things going wrong - They always do! 3.Fix the problem now - For this patient or co-worker 4.Find and fix the root causes of the problem -So it never happens again Spear: A – 1 & 2 – design the system to surface errors B – 3 & 4 – problem response: fix it, contain it, redesign to prevent recurrence C – disseminate local learnings D – leaders support A-C

Lean Thinking is just… Mr. Cho, Chairman of Toyota: …shortening lead time …detecting normal from abnormal right now …three steps: –Go and see –Ask why 5 times –Respect people …brilliant results from average people managing brilliant processes, not average results (or worse) from brilliant people managing broken processes

Lean Thinking is just… Steven Spear: …3 simple steps: 1.Detect abnormalities 2.Fix it now 3.Fix the root causes close in time, person, place and process –Role of management is to support 1-3 …a series of experiments: –Solve problems through small experiments –Spread by collaborative experiments –Turn all workers into experimentalists …teach each person to solve each problem at the source in real time …can’t plan complex production from afar – just get it close and trust locals to optimize it daily

Lean Thinking is just… Kan Higashi to Gary Convis (GM/Toyota - NUMMI) …leading as if you have no power Jim Womack: …not having: too many heroes, but not enough farmers …completely solving your customers’ problems permanently H Thomas Johnson (Portland State): …MBM - Management by Means - not MBO – Management by Objectives or Results Barb Bouche (Seattle Childrens): …using your mind first, not your money

Lean Thinking is just… John Shook: …not jumping to solutions …fixing the problem now …hard on the problem, easy on the people …simple and practical, consistently solving real problems in real time, at the source

Lean Thinking is just… …leader saying, “Follow me. Let’s look at it together”. …leading by being knowledgeable, often right, fact-driven, expert negotiator, strong willed yet flexible, by influence and persuasion. …not telling anyone exactly what to do. …having individual responsibility clear. John Shook

Lean Thinking is just… …systematically finding and solving problems. We find problems by asking: How do we expect things to be? How are they now? …progressing from “tools”, to “a system”, to “a way of thinking” John Shook

Lean Thinking is… …not checking your brain at the door …a contact sport, not a spectator sport …not squandering clinicians’ precious time fixing logistics …organized “think outside the box” …eyes for waste, eyes for flow …seeing the schedule as your enemy (Long) …not requiring someone else to lick the stamps (Swarcbord) …not “drive-by kaizen” (Womack) …the 5 why’s, not the 5 who’s

Lean Thinking… It’s not the tools, it’s the system. It’s not the parts, it’s the whole. It’s not the projects, it’s the learnings. It’s about improving the people, as you improve the process. It’s not “best”, it’s becoming better. It’s not a revolution, it’s an evolution. It’s often stability first, then improvement. It’s not a home run, it’s a single, or a bunt, or, sometimes, getting hit by the pitch.

Lean Thinking… It’s focused on quality first, and cost/productivity later. It’s focusing not just on waste (muda), but also on variable workload (mura) and overburden (muri). –Both mura and muri cause waste and are worsened by waste. It’s not “starting at the right place” – there is no right place; it’s modifying the plan as it unfolds, responding to the results of the experiments in learning. It’s not “empowerment” as an abstract strategy, it’s empowerment as a result of daily actions by workers and leaders, using the system together to find and fix root causes of problems –Because most lean tools cascade responsibility: standard work, andon, kanban, jidoka, JIT, VSM, A3.

Lean Thinking… It’s not just PDCA for the front line workers and front line work, it’s also PDCA for how middle management and top leaders plan and lead. It’s not an activity done in conference rooms by experts from outside the unit with special analytic skills using historical data, it’s done by real workers in the real workplace on the real work in realtime. It’s not part of a tool set (from among a large set including SPC/6Sigma) to use for selected problems, it is a business system supporting learning and problem solving at all levels.

Lean Thinking: Troubleshooting Guide 1.What is the problem? 2.Who owns the problem? 3.What is the plan? 4.What is the current status of the plan? How will it be monitored? 5.What worker training is needed? 6.How does this problem relate to the organization’s most important goals?* 7.What leader development is needed? Adapted from John Shook, PhD. Ask questions in order. *As a variation, 6 may be better asked second. J Billi

Billi’s Most Common Lean Lessons Lack of agreement on the problem Lack of agreement on owner of problem –Who is responsible for this product line? –Matrix of responsibility – chief engineer (Shusa) at multiple levels Lack of agreement on the plan (or no plan) –“Buy-in” v. consensus –Plan as prediction v. experiment Status of plan is hidden No follow-up on plan – never heard from again No time to find and fix the root causes –If we/managers don’t have time to: work on the most important problems with the workers redesigning work to benefit customers with leadership report …Then what are we doing instead?

We know half the plan is wrong, we don’t know which half. We have to watch it unfold, detect normal from abnormal right now, and fix it. Traditional companies think of a plan - as a prediction of what will happen. Lean companies think of a plan - as an experiment to be conducted - to tell us what we didn’t know about the work –Paraphrase of Steven Spear, Fixing Healthcare… HBR’05 Plans are useless, planning is essential. (Eisenhower)

Toyota Chief Engineer or Shusa System Body Interior Chassis Elect. Proto. Body Interior Chassis Elect. Proto. Eng. Eng. John Shook

UMHS Chief Engineer System Med Surg Anes Nursing Pharm Med Surg Anes Nursing Pharm Modified from John Shook

Why is Toyota So Much More Successful than Competitors Learned to learn –Learn from mistakes, lots of experiments Consistent, holistic use of TPS throughout –Hiring, selecting leaders, front line work –Stop the line – feel empowered because they are empowered – processes reinforce this.

Why UMHS Chose Lean as the Best Approach …or, is this just CQI/TQM dressed anew? Builds on Traditional CQI: Uses first-hand knowledge of the work Analyzes root causes of problems (5 whys) Expands on CQI: Starts with value as defined by the customer Uses “one piece flow” to surface problems Creates a new future state value stream map, not just a better current state map Focuses on overburden and uneven workload, not just waste and errors Value stream maps are very useful for invisible work of health care

Mission Synergy Patient Care Work as Value Research - Work as Discovery Education Work as Learning

Issues for You to Answer Is it my responsibility to do my job and improve my job? Why can’t front line workers and managers –Create and do standard work –Detect normal from abnormal –Fix it now –Find and fix the root causes How do we help front line workers find and fix root causes of problems?

Issues How many QI/Lean coaches? –Can we get? –Can we use? –Do we need? Balance of “projects” and kaizen in daily work. Marge’s nurse’s 100 med bin. Why do clinicians participate? –?Better patient care? –?Lower cost? To Institution? To Payers? To Patients? –?Make work easier for doctors, nurses, clerks…? How does lean thinking help with P4P?

Issues How do we select projects/priorities: –Low hanging fruit? –Aligned with organization’s few critical goals? –Most serious problem – wolf at the door? –Foster daily improvement in daily work? How do we disseminate learnings? –About the problems and solutions? –About lean thinking applied in that setting? –To other workers, managers? –To leaders?

Issues Facilitator models: –Central coach –Embedded coach –Lean manager –Lean worker Is a facilitator: –Quality improver –Problem owner –Data analyst –Interpersonal conflict resolver/negotiator –Teacher/mentor

Questions What were the surprises? If it’s just common sense, why don’t most people do it? If we had many of the tools for years (RCA, front line empowerment…), what makes us think we will succeed this time? –Better tools? –More tools?