Heroics and Habits: Exploring the Implementation of Lean Management in Healthcare National Health Leadership Conference Halifax, Nova Scotia June 4-5, 2012 Margaret Seppelt BSN, MBA Provincial Health Services Authority Cindy 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? Front Line 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
Typical Progress of Lean Adoption Results/Gains FOCUS = TOOLS AND PROJECTS LACK OF FOCUS ON LEAN MANAGEMENT TO SUSTAIN 3 YEARS
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)
MANAGEMENT PEOPLE PROCESS PURPOSE
PEOPLE PROCESS Focus too much on the process and tools - Andons, Kanban, Cells lean tools and processes in place without sustained results PURPOSE
Focus too much on people and teamwork lots of busy improvement activity with no significant results PEOPLE PROCESS PURPOSE
MANAGEMENT PEOPLE? PROCESS Lack of direction
Lean Management System Management aligned to a defined business purpose to deliver results by maintaining the balance between people and process. MANAGEMENT PEOPLE PROCESS PURPOSE
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 Source: Creating a Lean Culture (Mann, 2005).
Sure glad Standard Work does not apply to ME! Standard Work is the Key to our success We will be auditing standard work and hold all of you accountable
Leader Standard Work Lean Management System Senior Leader standard work Director standard work Manager standard work Standardized Lean Processes Coordinator standard work *adapted from Creating a Lean Culture, p. 43.
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 - Example Reference: Joan Wellman and Associates A 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 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 Charge Accountability Check Coordinator Accountability Manager Accountability Check Check 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 Establish Compliance Expectations and Consequences Train Team as Needed and Orient to Standard Work Instruct Charge as Needed and Orient to Charge Standard Work Methods Instruct Coordinator as Needed and Orient to Coordinator Standard Work Educate Manager as Needed and Orient to Manager Standard Work
Tiered Accountability - Example A Tiered Accountability Standard Work Huddles Activity / Response Routine Mgt Tier Frequency Schedule and Director Weekly attend a huddle within each area of responsibility Review for appropriate huddle application and determine departmental huddle effectiveness. Correct for variations of purpose. Review for process compliance and local huddle effectiveness. Provide coach based on appraisal. Reconcile huddle to huddle variation and adjust organizational structure. Assess for process compliance (assess / assign / account), content, duration and effectiveness. Suggest adjustments for inadequacies or inconsistencies. 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. Contribute to DMM review. Complete assignments. Generate ideas for improvement. Schedule and attend a huddle within each area of responsibility Attend a huddle within each area of responsibility Lead daily huddle in area of responsibility Attend assigned huddle. Manager Supervisor Charge RN All Associates Weekly Daily Daily Daily 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 2pm Daily accountability 6. Audit DMM for Validity Mid Day Wednesday 7. Lead Standard Work Huddle 4pm Daily
Visual Controls Source: Creating a Lean Culture (Mann, 2005).
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 Walks 1 2 3
Leader Standard Work Cascading Reviews The same review is done by all VP Weekly walk by and one deep dive All that changes is scope and frequency Manager Unit Supervisor 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 Board Seattle Children s
Performance Walls
BC Mental Health Performance Wall Strategic 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-arounds without Visual Controls are social visits Visual Controls without Leadership Huddles become wall paper
Daily Accountability Source: Creating a Lean Culture (Mann, 2005).
Daily Accountability Process Brief, structured, tiered meetings focused on performance with visual action assignments and followup 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 1 st tier Daily Huddle (supervisors and staff) 2 nd tier Daily Status Review (Managers and supervisors) 3 rd 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 Source: Creating a Lean Culture (Mann, 2005).
Daily Management Discipline
Change in Leadership Approach from Heroics to Habits Heroics Focus on results Retrospective computergenerated reports Focus on the end outcome Meetings to discuss reports The fire truck Habits 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! Source: Adapted from Creating a Lean Culture (Mann, 2005).
Typical Thinking: Paradigm Shift 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 first R: Results matter O: Open to possibilities V: Best Value E: Excellence through knowledge - it s about improving processes to ultimately improve patient care/outcomes
improve Roadmap Year 1-2 Experiment with Lean Methods and Tools as Improvement Projects 2007-2011 Move from point improvements to Value Streams and Rapid Process Improvement Workshops. Leaders Certified in Lean Methods and Tools. 2011-2013 Daily Management supports sustainment and front line staff engagement in identification and improvement of key issues. 2013-2014 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 Hourly Performance Metrics Department Daily Mgt Board Value Stream Performance Wall Organization Performance Room SW Quality Safety Delivery Cost Satisfaction Problem Solving Root Cause & Counter Measure Current & Future VSM Action Plan RPIW Planning Vision Strategy Deployment Breakthrough Objective Daily Huddles Weekly Gemba Monthly Review Takt / Hourly Shift / Daily Weekly Monthly Work station Department Value Stream Organization Front Line Staff Front Line Leaders Middle Management Senior Management 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.
PHSA STRATEGIC DIRECTIONS: Creating Better Value and Outcomes for Patients, Contributing to a Sustainable Health Care System, Promoting Healthier Populations. QUALITY CLINICAL EFFECTIVENESS SAFETY PATIENT AND STAFF DELIVERY ACCESSIBILITY, CONTINUITY, POPULATION FOCUS COST EFFICIENCY SATISFACTION CLIENT CENTERED WORKLIFE Achieve standard practice by use of clinical practice standards adhered to 95% of time. Target: Year 1 (2011 2012) each area will implement 2 clinical practice standards adopted at 95% reliability rate. Eliminate all level 4/5 safety events arising as a result of our care. 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. Eliminate unnecessary waiting for all patients and care providers. Target: Year 1 (2011 2012) 50% Lead time reduction 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) 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 PHSA overall average score 2009 2011 Change 3.68 3.63-0.05 Eating Disorders program score 2009 2011 Change 3.68 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 IMPROVEMENT K K S K S K K S K K S K K K: Kaizen S: Sustain TIME Improvements slide when not sustained by daily management
BCCA Vancouver Center Ambulatory Clinic Daily Management Board
KPI name and a status At a Glance - What we are tracking. Incomplete order OR 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 Action Who When
Make Data Visual Status at a Glance Quality Incomplete order OR Action Who When
Performance Tracking Visual Quality Incomplete order 40% % of incomplete or incorrect Patient Orders Actual % on time Target OR 35% 30% %of orders 25% 20% 15% 10% 5% Action Who When 0% 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 Day 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 Data is obtained from daily scorecard
% Patient Calls to Voicemail Unit Staff enter the data daily
Problem Identification and Analysis Quality Incomplete order OR Action Who When
Action Plan Kaizen Newspaper Quality Incomplete order OR Action Who When
BCCA Daily Accountability Huddle
Leadership driven. PHSA Successes 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.
Vancouver Coastal Health (VCH) $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
VCH True North Goals Promote Better Health for our Communities Provide the Best Care Develop the Best Workforce Innovate for Sustainability People First
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?
Lean is About CULTURE Change Process management Technology, tools and techniques Above the line: visible Below the line: enabling The Iceberg Model e.g. Birth Center Pilot e.g. Regional Patient Transfer e.g. Returning employees to work Above the line: visible Below the line: enabling Strategy and alignment Leadership Behavior & Engagement e.g. Strategic Deployment with the various Communities of Care e.g. Lean Management across the various leadership teams Source: Staying Lean (Hines, 2011)
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 Value Stream Mapping & A3 Problem Solving Leading Lean Projects Lean Management Recommended for: All Staff, Leaders & Physicians Recommended for: All Staff, Leaders, Physicians Recommended for: Emerging Leaders, Supervisors, Coordinators Project Champions Recommended for: Directors, Managers, Supervisors, Coordinators, Physicians
VCH Lean Management System Managing Daily to Continuously Improve and to Add Value to Every Patient, Client, Resident & Customer Experience Understand & Improve the Business People Value Stream Mapping A3 Problem Solving Leader Standard Work Daily Status Sheet Exchanges Continuous Improvement Huddles Breakthrough Improvement Lanes Standard Work Audit Board Performance Dashboard Processes Covered in Lean Management Introduction Course
Approach to Implementation: Wide or Deep Inch Deep, Mile Wide Mile Deep, 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: Top Down or Bottom Up? Educate and implement with senior leaders first? Or Educate and implement in local areas with small vertical teams first?
VCH Approach to Lean Management COOs, Directors and Managers Participate in Lean Management Course Strategy Deployment at each Community of Care Feedback to and Education of Senior Executive Team & Board 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
Leader Standard Work for Manager Before After
Leader Standard Work Role/Level Manager Standard Work 60-80% of job is standard work processes as outlined below Daily huddle with all team leads (15 min) using daily status sheets to review targets/ issues/ day to day operations Daily 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 PDSA Resolution of cross team issues; Ensures their area based visual boards are current Resolves issues raised by Team Leader within 24 hrs Gemba walk Responsible for coaching Team Lead in problem solving To remove barriers from team functioning Address complaints Customer relationships / Education w/ unions and patients/ clients/ residents Continuous development for team Accountability Processes Ensures timely response to everyday Lean ideas Ensures Team Leader addresses everyday Lean ideas within time frames Ensures program visual boards current and used Ensures regular engagement with staff related to improvement ideas
Breakthrough Improvement Lanes Richmond Birth Center
Daily Tracking Sheet Banfield Pavilion
Daily Tracking Sheet Banfield Pavilion
Leadership Team Learning Together: Banfield Breakthrough Lanes
Standard Work Audit Board Richmond Birth Center
Improvement Huddle Richmond Birth Center Staff s suggestion for continuous improvements RH Birth Centre
VCH Successes 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 Lessons Learned 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
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)
Discussion Questions 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?
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 Reading Kenney, 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 Authority mseppelt@phsa.ca Cindy Priddy BS, MA, MCS Vancouver Coastal Health Authority cindy.priddy@vch.ca