J. Michael Rona
Principal, Rona Consulting Group
Mercer Island, Washington
This is the third in a series of posts about 9 Points that define the lean heatlh care enterprise:
1. A Compelling Vision
2. Enlightened and Fearless Leadership
3. Values Driven
4. Respect for the Customer and Customer Driven
5. Quality Driven
6. Obsessed with Safety
7. Respect for Staff
8. Continuous Improvement
9. Generate Higher Margins or Create Greater Capability
These nine points help characterize a lean health care organization. When implemented and fully engrained, the organization is transformed. Then it lives the principles of the Toyota Management System and produces perfect products, one at a time, in flow synchronized to the demand of the customer. This is what a lean health care organization looks like and how it behaves.
In the first two post in this series, I covered Points 1, 2, and 3. In this post, I cover Points 4, 5, and 6.
4. Respect for the Customer and Customer Driven
In all of its manifestations, such an organization would demonstrate the concept of “Customer First”. In every way, in the layout of facilities, the flow of healthcare processes, in communications, and in the behavior of providers and staff, one would see that there is a deep understanding of customer needs and wants. In every respect, the organization’s production processes would demonstrate a complete understanding of customer rate of demand by product family. In all of its written and verbal communications, the organization would demonstrate a deep respect for the customer. In every way, the presence of the customer would be felt within the organization and Toyota’s concept of “Customer In”, the idea that for the staff, the customer is always present, would be evident. We would call this for health care “Patient on shoulder”; the concept of the ever observant and present patient as customer.
5. Quality Driven
The lean health care enterprise is obsessed with quality. It has a deep understanding of the key quality characteristics, which its customers desire and of the products it delivers. It knows immediately when defects occur in the process and the process stops until the defect is fixed. It is uncompromising in its attack on defects as they occur. It has defect alert systems in place to allow the staff to know when defects occur and to stop the production process if defects cannot be resolved in the process. Quality is assured along the way, or what would be termed through “in-line inspection”, along the production process, so that essentially zero retrospective quality assurance is required. Each staff member is a front-line quality inspector and the role of management is to ensure that the staff can do perfect work.
6. Obsessed with Safety
Safety for the customer and the staff is paramount in a lean health care enterprise. As the organization understands the needs of the customer, it is constantly looking for ways to make the product safer. It not only looks at obvious areas for improving safety and what the customer tells it, but it looks ahead and simulates what could happen in the future and builds in safety for that possible eventuality before the potential safety issue even presents itself. This type of organization is obsessed with safety and cannot imagine that the customer would ever be the one to alert the organization about a defect that has occurred to them.
This kind of organization is similarly obsessed with safety for the staff. It addresses issues of physical safety and stress caused by the working environment to ensure the safety of its staff.
Monday, October 5, 2009
Wednesday, September 30, 2009
9 Points (continued)
J. Michael Rona
Principal, Rona Consulting Group
Mercer Island, Washington
This is the second in a series of posts about 9 Points that define the lean heatlh care enterprise:
1. A Compelling Vision
2. Enlightened and Fearless Leadership
3. Values Driven
4. Respect for the Customer and Customer Driven
5. Quality Driven
6. Obsessed with Safety
7. Respect for Staff
8. Continuous Improvement
9. Generate Higher Margins or Create Greater Capability
These nine points help characterize a lean health care organization. When implemented and fully engrained, the organization is transformed. Then it lives the principles of the Toyota Management System and produces perfect products, one at a time, in flow synchronized to the demand of the customer. This is what a lean health care organization looks like and how it behaves.
In the first post in this series, I covered Points 1 and 2. In this post, I cover Point 3 and discuss the value that drive the lean healthcare enterprise.
3. Values Driven
The lean health care enterprise is guided by its values. They are living foundational beliefs, which drive all behavior and become the yardsticks by which the day-to-day conduct of the organization is measured. The primary value is service to the customer. If service to the customer is flagging, then nothing else matters. It is this priority which is essential in understanding the failings of the current state and which drive priorities for improvement.
The second value is teamwork. Lean health care enterprises understand the different value which the broad range of workers in health care bring to the processes of health care but do not let this create a hierarchy of power. It is this hierarchy of power which inhibits freedom by all to work together in a fear free environment and which then diminishes the product for the customer. These organizations recognize the interdependency of all members of the organization and the importance of minimizing traditional power relationships.
The third value is continuous improvement. Lean health care enterprises are never satisfied with the current state. They believe that things can and must improve all the time. They believe in teaching and learning and becoming excellent at every position in the organization. They invest significant resources in training and giving time to their workers to improve processes. They insist on each worker participating in improvement and at least monthly improvement suggestions implemented by each worker for their own processes.
The final value of lean health care enterprises is integrity. These kinds of organizations conduct themselves with the highest level of integrity, which is modeled by the leadership. This principle starts with always doing things that are right from the customer’s perspective and is linked to a commitment to requiring the unvarnished truth about the current state to be publicly stated within the organization and with the organization’s customers. This truth telling is the key to enabling improvement. Without it, the real story is never surfaced, customers are harmed and the workers are burdened with truths that cannot be told. Organizations, which hold integrity as a foundational value, have no fear of public disclosure since they see such things as the truth about the current state and a driver of even more rapid improvement. Truly enlightened lean enterprises willingly “put their defects at the front door” for customers and workers to see to drive improvement and trust.
Principal, Rona Consulting Group
Mercer Island, Washington
This is the second in a series of posts about 9 Points that define the lean heatlh care enterprise:
1. A Compelling Vision
2. Enlightened and Fearless Leadership
3. Values Driven
4. Respect for the Customer and Customer Driven
5. Quality Driven
6. Obsessed with Safety
7. Respect for Staff
8. Continuous Improvement
9. Generate Higher Margins or Create Greater Capability
These nine points help characterize a lean health care organization. When implemented and fully engrained, the organization is transformed. Then it lives the principles of the Toyota Management System and produces perfect products, one at a time, in flow synchronized to the demand of the customer. This is what a lean health care organization looks like and how it behaves.
In the first post in this series, I covered Points 1 and 2. In this post, I cover Point 3 and discuss the value that drive the lean healthcare enterprise.
3. Values Driven
The lean health care enterprise is guided by its values. They are living foundational beliefs, which drive all behavior and become the yardsticks by which the day-to-day conduct of the organization is measured. The primary value is service to the customer. If service to the customer is flagging, then nothing else matters. It is this priority which is essential in understanding the failings of the current state and which drive priorities for improvement.
The second value is teamwork. Lean health care enterprises understand the different value which the broad range of workers in health care bring to the processes of health care but do not let this create a hierarchy of power. It is this hierarchy of power which inhibits freedom by all to work together in a fear free environment and which then diminishes the product for the customer. These organizations recognize the interdependency of all members of the organization and the importance of minimizing traditional power relationships.
The third value is continuous improvement. Lean health care enterprises are never satisfied with the current state. They believe that things can and must improve all the time. They believe in teaching and learning and becoming excellent at every position in the organization. They invest significant resources in training and giving time to their workers to improve processes. They insist on each worker participating in improvement and at least monthly improvement suggestions implemented by each worker for their own processes.
The final value of lean health care enterprises is integrity. These kinds of organizations conduct themselves with the highest level of integrity, which is modeled by the leadership. This principle starts with always doing things that are right from the customer’s perspective and is linked to a commitment to requiring the unvarnished truth about the current state to be publicly stated within the organization and with the organization’s customers. This truth telling is the key to enabling improvement. Without it, the real story is never surfaced, customers are harmed and the workers are burdened with truths that cannot be told. Organizations, which hold integrity as a foundational value, have no fear of public disclosure since they see such things as the truth about the current state and a driver of even more rapid improvement. Truly enlightened lean enterprises willingly “put their defects at the front door” for customers and workers to see to drive improvement and trust.
Monday, September 28, 2009
9 Points
J. Michael Rona
Principal, Rona Consulting Group
Mercer Island, Washington U.S.A.
The definition of a lean health care enterprise would be a health care system, which had in every manner patterned its management philosophy and system after the Toyota Management System. It would have the following characteristics upon close examination:
1. A Compelling Vision
2. Enlightened and Fearless Leadership
3. Values Driven
4. Respect for the Customer and Customer Driven
5. Quality Driven
6. Obsessed with Safety
7. Respect for Staff
8. Continuous Improvement
9. Generate Higher Margins or Create Greater Capability
These nine points help characterize a lean health care organization. When implemented and fully engrained, the organization is transformed. Then it lives the principles of the Toyota Management System and produces perfect products, one at a time, in flow synchronized to the demand of the customer. This is what a lean health care organization looks like and how it behaves.
Below I describe each of the 9 Points in detail:
1. A Compelling Vision
A clear and compelling vision is the critical starting point for any organization, but in particular for an organization that is pursuing a transformation. The question is transformation to what and why? The vision is a short and concise statement of what it is that the organization strives to be. By definition it declares a gap between the current state of the organization and its desired future state. The vision must be inspirational and a statement of aspiration. It must be a long view that would be welcomed by its customers and embraced by its people. It is a statement of quantum change and one that when achieved creates a major point of differentiation in the marketplace and pride for the organization’s workers.
2. Enlightened and Fearless Leadership
The lean healthcare enterprise is led by leaders who think very differently from the mainstream of health care leaders. They think first of the vision and have a clear sense of the future state. They understand that the key to transformation is a change in the management philosophy of the organization. They are unafraid of abandoning the current management paradigm and are comfortable with the uncertainty and ambiguity that exists in the transition from the current ways to the future way. They change themselves first and demonstrate the new way and are absolutely understanding but rigorously intolerant of individual managers defaulting to old ways. These leaders understand the changing of the mind of management that is occurring and help the transition by connecting the turmoil of change to the possibilities of the new way.
These leaders are passionate for the customers and constantly bring the voice and mind of the customer into the daily management of the organization. They are impatient with the traditional pace of management and relentlessly push for improvement. They are constant on the themes of change and what the new paradigm will bring. They have a deep knowledge and understanding of the new management process and philosophy. They have a constant view on the long term. They are unyielding in their belief in zero defects and the elimination of waste. They leave their offices and go to the “shop floor” to see with their own eyes the state of processes that are burdening their workers. And, they change things quickly.
I will describe Points 3 through 9 in posts to follow....
Principal, Rona Consulting Group
Mercer Island, Washington U.S.A.
The definition of a lean health care enterprise would be a health care system, which had in every manner patterned its management philosophy and system after the Toyota Management System. It would have the following characteristics upon close examination:
1. A Compelling Vision
2. Enlightened and Fearless Leadership
3. Values Driven
4. Respect for the Customer and Customer Driven
5. Quality Driven
6. Obsessed with Safety
7. Respect for Staff
8. Continuous Improvement
9. Generate Higher Margins or Create Greater Capability
These nine points help characterize a lean health care organization. When implemented and fully engrained, the organization is transformed. Then it lives the principles of the Toyota Management System and produces perfect products, one at a time, in flow synchronized to the demand of the customer. This is what a lean health care organization looks like and how it behaves.
Below I describe each of the 9 Points in detail:
1. A Compelling Vision
A clear and compelling vision is the critical starting point for any organization, but in particular for an organization that is pursuing a transformation. The question is transformation to what and why? The vision is a short and concise statement of what it is that the organization strives to be. By definition it declares a gap between the current state of the organization and its desired future state. The vision must be inspirational and a statement of aspiration. It must be a long view that would be welcomed by its customers and embraced by its people. It is a statement of quantum change and one that when achieved creates a major point of differentiation in the marketplace and pride for the organization’s workers.
2. Enlightened and Fearless Leadership
The lean healthcare enterprise is led by leaders who think very differently from the mainstream of health care leaders. They think first of the vision and have a clear sense of the future state. They understand that the key to transformation is a change in the management philosophy of the organization. They are unafraid of abandoning the current management paradigm and are comfortable with the uncertainty and ambiguity that exists in the transition from the current ways to the future way. They change themselves first and demonstrate the new way and are absolutely understanding but rigorously intolerant of individual managers defaulting to old ways. These leaders understand the changing of the mind of management that is occurring and help the transition by connecting the turmoil of change to the possibilities of the new way.
These leaders are passionate for the customers and constantly bring the voice and mind of the customer into the daily management of the organization. They are impatient with the traditional pace of management and relentlessly push for improvement. They are constant on the themes of change and what the new paradigm will bring. They have a deep knowledge and understanding of the new management process and philosophy. They have a constant view on the long term. They are unyielding in their belief in zero defects and the elimination of waste. They leave their offices and go to the “shop floor” to see with their own eyes the state of processes that are burdening their workers. And, they change things quickly.
I will describe Points 3 through 9 in posts to follow....
Wednesday, September 23, 2009
A Natural Match
By Deborah Dolezal
Senior Director, Kaizen Promotion Office
Park Nicollet Health Services
Minneapolis, Minnesota
As a healthcare worker and an implementer of lean, I am often struck by the similarity of the human body and the lean methodologies. They are both systems, each unique part doing a necessary function –
Circulatory, digestive, endocrine, immune, lymphatic, muscular, nervous, reproductive, respiratory, skeletal, urinary
Standard work, JIT, pull, one piece flow, mistake proofing, set up reduction, level loading, 5S.
Each function independently is unique in nature but cannot be successful without all parts working together. Each has a strong emphasis on flow and waste removal. When something is not operating properly, no one solution is right for everyone.
If chronic disease strikes, we instruct our patients to apply counter measures – usually involving a new form of standard work and are often surprised when these recommended changes are not immediately embraced, reminding us that change is hard and people need to be part of the solution, using their own creativity to fully define their best outcomes.
Current data from the Centers for Disease Control and Prevention:
• Percent of adults age 20 years and over with high serum cholesterol: 16% (2003-2006)
• Percent of noninstitutionalized adults 20 years and older with diabetes (diagnosed or undiagnosed): 10% (2003-2006)
• Number of noninstitutionalized adults with diagnosed heart disease: 25.1 million
• Percent of non-institutionalized adults ages 20 and over with hypertension: 32% (2003-2006)
• Percent of noninstitutionalized adults age 20 years and over who are overweight or obese: 67% (2005-2006)
The CDC also tells us that the medical care costs of people with chronic diseases account for more than 75% of the nation’s $2 trillion medical care costs. Experts who have recently testified to Congress say that 30 to 50% of these costs do not add value to patients.
Both the healthcare provider and the lean implementer have similar goals:
• Do no harm
• Add value
Healthcare and Lean - seems like a natural match.
Senior Director, Kaizen Promotion Office
Park Nicollet Health Services
Minneapolis, Minnesota
As a healthcare worker and an implementer of lean, I am often struck by the similarity of the human body and the lean methodologies. They are both systems, each unique part doing a necessary function –
Circulatory, digestive, endocrine, immune, lymphatic, muscular, nervous, reproductive, respiratory, skeletal, urinary
Standard work, JIT, pull, one piece flow, mistake proofing, set up reduction, level loading, 5S.
Each function independently is unique in nature but cannot be successful without all parts working together. Each has a strong emphasis on flow and waste removal. When something is not operating properly, no one solution is right for everyone.
If chronic disease strikes, we instruct our patients to apply counter measures – usually involving a new form of standard work and are often surprised when these recommended changes are not immediately embraced, reminding us that change is hard and people need to be part of the solution, using their own creativity to fully define their best outcomes.
Current data from the Centers for Disease Control and Prevention:
• Percent of adults age 20 years and over with high serum cholesterol: 16% (2003-2006)
• Percent of noninstitutionalized adults 20 years and older with diabetes (diagnosed or undiagnosed): 10% (2003-2006)
• Number of noninstitutionalized adults with diagnosed heart disease: 25.1 million
• Percent of non-institutionalized adults ages 20 and over with hypertension: 32% (2003-2006)
• Percent of noninstitutionalized adults age 20 years and over who are overweight or obese: 67% (2005-2006)
The CDC also tells us that the medical care costs of people with chronic diseases account for more than 75% of the nation’s $2 trillion medical care costs. Experts who have recently testified to Congress say that 30 to 50% of these costs do not add value to patients.
Both the healthcare provider and the lean implementer have similar goals:
• Do no harm
• Add value
Healthcare and Lean - seems like a natural match.
Sunday, September 20, 2009
Making Sense of Alphabet Soup
By:
Patti Crome, RN, MA, CNA, FACMPE
Principal, Rona Consulting Group
CQI/TQM, Six Sigma, TPS…how does one deal with the alphabet soup and decide which quality method being used in health care today is right for their organization? Some of us remember our introduction to what was known as Continuous Quality Improvement (CQI), others may be familiar with Total Quality Management (TQM). Together with our clinical colleagues we were relieved there was finally a shift from a cost only focus to quality, actually stemming from Deming’s PDCA (Plan-Do-Check-Act) cycle of improvement.
TQM has a very clear focus on quality consciousness. It emphasizes that every organization has a direct customer and needs to understand what the customer needs and how to achieve quality with zero defects. This philosophy is engrained in a quality initiative referred to as the Toyota Way. This method was developed in the 1960’s when automobile manufacturer, Toyota, set a goal to win the prestigious Deming Prize, which rewards companies’ major advances in quality improvement. Toyota won the prize twice. TQM is powerful and became one very central piece of the Toyota Way (Liker and Hoseus, 2008).
A little later Six Sigma came on the health care scene. Based on TQM, Six Sigma boasts bottom line results that can be measured in dollars and cents. At its best, this method teaches problem solving throughout the organization but at its worst, it reverts back to the cost-only philosophy of organizational improvement. Lean Six Sigma is a compilation of tools and training focused on isolated projects to drive down unit costs… it tends to be results oriented and top down (Liker and Hoseus, 2008).
Another quality initiative known as the Toyota Production System (TPS), commonly known as “Lean—the ‘Toyota Way,’” is based on two pillars: continuous improvement and respect for people. Respect for people includes not only having a relentless focus on what is important to the patient (eliminating wait time, waste or non-value added work and emphasizing the services they are willing to pay for), but also, respect for the employees, recognizing they have the understanding and knowledge of the work being performed. In this method, the front line employees work with the patients and know the opportunities for improvement and more importantly, they are given the authority to design necessary changes and implement them as standard work. This system becomes both a “bottom up” and “top down” improvement method. Toyota Way “Leaders,” as opposed to the “Black Belts” in Six Sigma, must establish the vision, support the improvements and hold people accountable for the standard work designed in the improvement processes.
Standard work and accountability are both key to creating a quality patient environment, yet many times in health care, one or both are lacking. As Taiichi Ohno, one of the founders of the Toyota Management System says, “Without standards there can be no improvement (Womack and Jones, 1996).”
Lean methods adopted from the Toyota Management System are very powerful in supporting the pursuit of perfection that is desperately needed to transform health care today. Using the scientific method and focusing on the customer—our patients—will result in significant gains in patient quality when the role of the employee is kept central to that improvement work. The transformation will not be easy, but our patients and our staff deserve no less.
Patti Crome, RN, MA, CNA, FACMPE
Principal, Rona Consulting Group
CQI/TQM, Six Sigma, TPS…how does one deal with the alphabet soup and decide which quality method being used in health care today is right for their organization? Some of us remember our introduction to what was known as Continuous Quality Improvement (CQI), others may be familiar with Total Quality Management (TQM). Together with our clinical colleagues we were relieved there was finally a shift from a cost only focus to quality, actually stemming from Deming’s PDCA (Plan-Do-Check-Act) cycle of improvement.
TQM has a very clear focus on quality consciousness. It emphasizes that every organization has a direct customer and needs to understand what the customer needs and how to achieve quality with zero defects. This philosophy is engrained in a quality initiative referred to as the Toyota Way. This method was developed in the 1960’s when automobile manufacturer, Toyota, set a goal to win the prestigious Deming Prize, which rewards companies’ major advances in quality improvement. Toyota won the prize twice. TQM is powerful and became one very central piece of the Toyota Way (Liker and Hoseus, 2008).
A little later Six Sigma came on the health care scene. Based on TQM, Six Sigma boasts bottom line results that can be measured in dollars and cents. At its best, this method teaches problem solving throughout the organization but at its worst, it reverts back to the cost-only philosophy of organizational improvement. Lean Six Sigma is a compilation of tools and training focused on isolated projects to drive down unit costs… it tends to be results oriented and top down (Liker and Hoseus, 2008).
Another quality initiative known as the Toyota Production System (TPS), commonly known as “Lean—the ‘Toyota Way,’” is based on two pillars: continuous improvement and respect for people. Respect for people includes not only having a relentless focus on what is important to the patient (eliminating wait time, waste or non-value added work and emphasizing the services they are willing to pay for), but also, respect for the employees, recognizing they have the understanding and knowledge of the work being performed. In this method, the front line employees work with the patients and know the opportunities for improvement and more importantly, they are given the authority to design necessary changes and implement them as standard work. This system becomes both a “bottom up” and “top down” improvement method. Toyota Way “Leaders,” as opposed to the “Black Belts” in Six Sigma, must establish the vision, support the improvements and hold people accountable for the standard work designed in the improvement processes.
Standard work and accountability are both key to creating a quality patient environment, yet many times in health care, one or both are lacking. As Taiichi Ohno, one of the founders of the Toyota Management System says, “Without standards there can be no improvement (Womack and Jones, 1996).”
Lean methods adopted from the Toyota Management System are very powerful in supporting the pursuit of perfection that is desperately needed to transform health care today. Using the scientific method and focusing on the customer—our patients—will result in significant gains in patient quality when the role of the employee is kept central to that improvement work. The transformation will not be easy, but our patients and our staff deserve no less.
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