john e. billi, m.d. assoc. dean, assoc vp med affairs university of michigan jbilli@umich.edu...

John E. Billi, M.D.Assoc. Dean, Assoc VP Med AffairsUniversity of Michiganjbilli@umich.edu

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 CareWhy?

• “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 CareThe 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 CareWhere 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 CareStandardization 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 CareWho 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: www.med.umich.edu/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 learnings S. 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 StartedJ 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

Kai

zen

Su

pp

ort

Kai

zen

Su

pp

ort

Coo

rdin

ate

d W

orks

hops

Lea

n E

duca

tion

L

EI S

up

po

rtL

EI S

up

po

rt

JW,

JS,

DJL

Gui

da

nce

, D

epl

oym

en

t,G

emb

a, R

oun

dta

ble

s

• Value-Add

• Implementation

• Kaizen

“Do-Ers”

DJL 3-16-06

• Results

• Deployment

“Managers”

Diagnosis of Diagnosis of Business NeedBusiness NeedQ.V.C.O.S. InstallationResource DeploymentReduce Lead TimeMura, Muri

VP, Chief Engineer, Plant ManagerVP, Chief Engineer, Plant ManagerPolicy DeploymentPDCAHuman DevelopmentResultsSupplier, Customer Connection

• Responsible

• Policy, Strategy

“Leaders”

EvaluationEvaluation• Process• People• Support Elements

SR Change Agent, Guide

CEO/COO/President CEO/COO/President Exec. VPExec. VP

R.O.I.Market ConnectionLink Business ProcessesPDCA

“Personal Trainer” Influence

Setting PolicySetting PolicyPrinciplesSponsorshipStabilityMuri, Mura

Teller, Nurse, Engineer, WorkerTeller, Nurse, Engineer, Worker Standard WorkJidokaJIT/BTO• Tools, e.g. 55, SMED, Eliminate MudaPrerequisites for O.S. (direct connection in value stream)

Kai

zen

Su

pp

ort

Kai

zen

Su

pp

ort

Coo

rdin

ate

d W

orks

hops

Lea

n E

duca

tion

L

EI S

up

po

rtL

EI S

up

po

rt

JW,

JS,

DJL

Gui

da

nce

, D

epl

oym

en

t,G

emb

a, R

oun

dta

ble

s

• Value-Add

• Implementation

• Kaizen

“Do-Ers”

DJL JS 3-16-06

• Results

• Deployment

“Managers”

Diagnosis of Diagnosis of Business NeedBusiness NeedQ.V.C.O.S. InstallationResource DeploymentReduce Lead TimeMura, Muri

VP, Chief Engineer, Plant ManagerVP, Chief Engineer, Plant ManagerPolicy DeploymentPDCAHuman DevelopmentResultsSupplier, Customer Connection

• Responsible

• Policy, Strategy

“Leaders”

EvaluationEvaluation• Process• People• Support Elements

SR Change Agent, Guide

CEO/COO/President CEO/COO/President Exec. VPExec. VP

R.O.I.Market ConnectionLink Business ProcessesPDCA

“Personal Trainer” Influence

Setting PolicySetting PolicyPrinciplesSponsorshipStabilityMuri, Mura

Teller, Nurse, Engineer, WorkerTeller, Nurse, Engineer, Worker Standard WorkJidokaJIT/BTO• Tools, e.g. 55, SMED, Eliminate MudaPrerequisites 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 recurrenceC – disseminate local learningsD – 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 abnormalities2. Fix it now3. 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

BodyBody Interior Chassis Elect. Proto. Interior Chassis Elect. Proto. Eng.Eng.

John Shook

UMHS Chief Engineer System

MedMed Surg Anes Surg Anes Nursing PharmNursing 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 CareWork 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?