Lean Management & The Lean In Daily Work Model Foundations for Successful Leadership Lean Management & The Lean In Daily Work Model

Learning Objectives Gain a foundational understanding of Lean Thinking & Concepts Understand the difference between Traditional Management and Lean Management Become familiar with the Lean In Daily Work Model – including the important role of the supervisor within the model Learn how to support your staff in surfacing waste and addressing problems on a daily basis Recognize the true value managers can provide to their teams through the application of leadership standard work

What is Lean Thinking? “The endless transformation of waste into value from the customer’s perspective”. ---Womack and Jones, Lean Thinking

The Objective of Our Lean Work To increase Value Added Work and reduce Waste to Increase Throughput, Lower Cost and Improve Quality Lead Time

Waste only adds cost & time to a process What Is Waste? Any element of the process that adds no value to the final product or service Waste only adds cost & time to a process Waste can be found: In areas with lots of rework Areas experiencing long wait times Process steps requiring multiple reviews and revisions Areas where multiple handoffs occur within & across depts. Explain to group, that is section (while redundant to the lean tool day, is intended to act as a refresher for them)…Include a comment around how different consultants, hospitals, usually end up with 7 or possibly 8 wastes and the terms they use to describe them may differ. That is okay, as the definitions around waste is always the same…

How Does Waste Affect Me? Causes physical fatigue Causes emotional fatigue Increases frustrations Increases stress Causes you to blame others Steals your time

Built-in Quality Just-in-Time Safe – Effective – Patient Centered – Timely – Efficient - Equitable Built-in Quality Just-in-Time Error Proof Surface Problems Stop and Respond to Abnormalities Solve Problems at Root Cause Pacing by Demand Continuous Flow Pull Systems Customer Defines Value Foundational Stability Leveled Workload Mutual Trust Continuous Improvement (P-D-C-A) and Learning Visual Mgmt Standard Work Make Value Flow by Eliminating Errors and Waste Health Care House – Sources: J. Shook, J. Billi, J. Liker, S. Hoeft, J. Womack, Park-Nicollet. Revised 5/09 W. Walters

Lean is a system... Visual Mgmt Standardized Work Andon System 5S Flow & Pull Systems Problem Solving & Value Stream Mapping Load Leveling Error Proofing Quick Changeover These all tools that we use to implement…but in order to use them effectively we need to have the right culture in place, with appropriate lean management Notes:

The Flip Side Of Lean Management

Traditional vs. Lean Structure Traditional Team Structure In a traditional team structure, Leadership is often looked at as the ultimate customer and employees primary duties are to carry out the wants and needs of management. There is usually very little input from the employees on how business operations can be improved. Leaders Team Members Lean Thinking Team Members The Lean Leadership model is often described as an inverted triangle with team members as the largest base on top all the way down to Leadership supporting the team members on the bottom. It is a true servant leadership approach where Leaders develop the capacity to support team members in improving what needs to be done. Leader

Create a Fear-Free Environment Makes people defensive Keeps issues submerged for years Creates a crisis orientation Use information to drive improvement NOT pass judgment

How can we create (liberate) “20,000 problem solvers”? Help each worker take initiative to find and fix causes of problems he/she faces daily This means each of us has two jobs: Do the work Improve the work Leaders’ role: Support improvement work (time, mentoring) Align improvements so value flows to the customer Modified from John Shook

Value Creating Work of Management Gain agreement on what is important. (which must be to solve customer problems) Engage and mentor workers to be problem solvers (through performing the above work in dialogue) Create brilliant process to achieve what is important Create stable process and continuously improve Adapted from Womack on Lean Management Presented by LEI

The Lean In Daily Work Model: Standard Work for Daily Problem Solving Key Metrics: Define, Measure, & Display Routine Interactions to Identify Problems Assessment of Problem Complexity Problem Solving Approaches Transfer Knowledge for Shared Learning *Links to strategic deployment *Part of daily standard work *Takes place in the gemba *Design and run experiments *Share across organization Daily team huddles at visual board “Just Do It” no written plan needed Hourly / daily key operational metrics and targets Problems Low Daily leadership walks in the gemba (also wkly/mthly) Problems Triage based on problem complexity Med. Share learning from experiments across UMHS “Everyday Lean Ideas” structured form (8.5”x11”) Problems High Daily / weekly cumulative counts of complex problems Monthly review & problem prioritization by team leads “A3 Problem Solving” structured form (11”x17”)

Baseline Lean Culture Survey This survey is taken prior to implementing the Lean In Daily Work Model and again, a few months or so after the team has built the model into their daily work Employees Management Employees We talked about how important the lean culture is to support lean transformation…here is where we build that in… Mgmt

Value Metrics To be successful, we must base all of our improvement efforts on what our customers value most By clearly defining this value (as a metric), it will serve as the compass to tell us when we are on course & when we need to improve Value Metrics Need To Be… High-level enough to represent the over-arching Value we deliver Allow us to surface many different problems related to the Value Metric (vs. focusing on a specific problem) Without clearly defined Value Metrics, it would be impossible for us to continuously improve

Value Metric Traits Traits of Value Metrics: High level enough to represent the over-arching Value we deliver Are best measured in small increments – by hour, by day, etc. Do not require intense, pain-staking review in order to measure Connect directly to what our customers tell us they value Connect directly to departmental and institutional priorities

Value Metric Examples What do all of these examples have in common? Patient Relations - Customer: Patients and Patient’s Families (External) Customer’s Value: Timely & successful resolution of grievances Value Metric: “Successfully resolve 80% of all patient grievances within 10 days” Cardiac Procedures Unit – Customer: Patients (External), Ordering Physicians & Clinical Units (Internal) Customer’s Value: Timely & accurate completion & interpretation of ordered Surface ECHOs Value Metric: “Complete, Read & Accurately Interpret 100% of all inpatient Surface ECHOs ordered before 10 am – before the end of the business day” Urology Taubman Clinic– Customer: Patients (External), Physician (Internal) Customer’s Value: Having the right records available during the clinic visit Value Metric: “100% of outside New Patient records received, reviewed, and imaged prior to clinic visit” Pro Fee Payment Posting – Customer: Patients (External) & Clinical Departments (Internal) Customer’s Value: Timely posting of payments Value Metric(s): Post 100% of payments within 3 days of receipt Orthopaedics Surgery Clinic – Customer: Orthopaedic Patients (External) Customer’s Value: Expeditious clinic visit (while still meeting needs) Value Metric(s): 80% of patient visits to be completed within 1 hour

Brainstorm Possible Team Value Metrics - Team Activity 2 Teams – Team Lead Scribes – We Facilitate….30 minutes Process Check At 20 Minutes

Visual Management Attributes of visual management tools: Create “status at a glance” – enabling quick and simple detection of normal vs. abnormal operating conditions Provide clear information actionable at the point of communication Be maintained by those carrying out the work Those performing the work are the first to detect abnormalities Provide a clear and common understanding of goals & measures Allows employees to align their actions and decisions with the overall strategic direction of the department

Visual Management - Example Baseball Scoreboard The scoreboard provides real-time information about important game parameters to be monitored What is the score of the game? What is the batting avg. of the hitter – should we pitch differently to him based on it? What inning is it? What is the count? Was that a ball or strike? How many hits, errors? How are the other teams in the league performing today? The scoreboard answers important questions about the status of the game – it tells us how our team is doing in relation to the Goal…Namely to win the game!!!

Developing LIT’s Level 1 - Visual Management System Questions to be answered: What will the visual display look like? How will it display the Value Metric and the current status? How will problems be captured? Where will the visual board be located? Who will maintain it? How often will the Value Metrics be updated? Identify how the team might respond (Andon) to surfaced problems? Develop action plan for implementation of the visual display Who, What, By When 2 Teams – One working on institutional board, other the patient…Report out – get feedback with changes – agree on what they want to do…

Urology Adult Clinic Visual Board Ongoing Visual Monitoring Of Value Metrics

Value Creating Work of Management Gain agreement on what is important . (which must be to solve customer problems) Engage and mentor workers to be problem solvers (through performing the above work in dialogue) Create brilliant process to achieve what is important Create stable process and continuously improve Adapted from Womack on Lean Management Presented by LEI

Why Huddle? Make Our Customers The Focus Of Our Improvement (Through Our Value Metrics) Builds Stronger Staff Morale Improves Communication Gives Everyone On The Team The Ability to Surface “Waste” & Solve Daily Problems As A Team

Team Huddles The team meets at the visual board at a regular frequency (ideally on a daily basis) The board is reviewed to determine the status of the value metrics The team documents the waste / problems standing in the way of improving the value metric An Everyday Lean Idea (E.L.I.) form is initiated for identified wastes / problems the team has influence over and can be easily solved (process description to follow) A volunteer is identified to take ownership of each E.L.I. with responsibility to report back on progress at the next huddle The process repeats during the next huddle

Everyday Lean Idea (E.L.I.) Process ELI’s Should Be Initiated Any Time You Have An Idea, Whether In Between Or During A Huddle

Break-out Activity Initiate a few Everyday Lean Idea (ELI) on a common everyday problem Familiarize yourself with the form in order to better facilitate your team’s use back in your home area Practice completing the form, thinking through the waste and potential solution Be prepared to report out on one of your Everyday Lean Ideas

Leadership Gemba Rounding “Gemba” is a Japanese term meaning “the place where the truth can be found” – for us this means the actual place where the work is being done

Leadership Gemba Rounding Leadership reviews monthly calendar of standing meetings – seeks to identify up to 3 hours of meeting time per week to be replaced with Gemba time Leaders create their visual management board (Which Includes): Leadership Gemba Walk Route & Instructions Calendar for Leaders to initial upon Walk completion Leaders’ Open Issues Tracker Or equivalent form Everyday Lean Idea Visual Status (ELVIS) Summary of “What the Patients Are Telling Us” Direct Feedback During Walk Survey completed at end of visit Other input mechanisms Summary of Key Success Measures

Orthopaedic Taubman Visual Leadership Board Leadership Gemba Walk Standard Work & Layout Visual evidence of Leadership Gemba Walks Open Issues Tracker ELI Feedback Success Measures Patient Feedback

“Your ears will lie to you, but your eyes never will” Why Go To The Gemba? “Your ears will lie to you, but your eyes never will” Supports Continuous Improvement By Allowing Us To: Observe the process first hand rather than making assumptions See the entire value stream Identify & observe problems & waste Observe process changes Monitor sustaining of gains, compliance with standard work, and the determination of root cause for problems that surface References on Gemba Benefits: Baptist Health Care Leadership Institute

“Your ears will lie to you, but your eyes never will” Why Go To The Gemba? “Your ears will lie to you, but your eyes never will” There are many benefits when a Leader adopts regular Gemba Activity as a part of their Leadership Standard Work; Leader Benefits: Helps you to better know your staff Builds relationships / Solicits feedback Gives you opportunities to teach, train and share information Engages and empowers your staff Reveals areas where improvement is needed Establishes who should be rewarded and recognized Ensures quality and safety of services provided

“Your ears will lie to you, but your eyes never will” Why Go To The Gemba? “Your ears will lie to you, but your eyes never will” There are many benefits when a Leader Includes Regular Gemba Activity Into Their Leadership Standard Work Staff Benefits: Emphasizes that the environment is one of open communication Gives employees increased access to leaders Enables staff to be recognized for service excellence Builds trust between staff and leadership Allows staff to communicate the biggest barriers & challenges Ensures quality and safety of services provided

“Your ears will lie to you, but your eyes never will” Why Go To The Gemba? “Your ears will lie to you, but your eyes never will” There are many benefits when a Leader Includes Regular Gemba Activity Into Their Leadership Standard Work Patient Benefits: Observes caring behavior on the part of leadership Perception of service improves Feels valued through being given the opportunity to share information Inspired to loyalty More likely to recommend the organization to others

Leadership Behavior during Gemba Visits

Key Questions for Lean Leaders to ASK OFTEN! What problem are you working on now? What was the last experiment you tried? What happened? What did you learn? What do you plan to try next?

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http://youtu.be/IKPIYjyxi3Q

Practice “Asking Effective Questions” Reflection on Exercise Use Mentoring / Coaching Handout as a guide - Get in groups of three - Identify a Problem Owner, a Lean Leader, and an Observer - Problem Owner: briefly describe the problem - Lean Leader: practice “asking effective questions” that are framed around “pure inquiry” (use handout as a guide) - Observer: provide feedback on how the Lean Leader did (both positive things and opportunities for improvement) - Switch roles (repeat until everyone has a chance to play each role) Reflection on Exercise

The Lean In Daily Work Model is a System Visual Metrics in the Absence of Team Huddles & Leadership Gemba Walks Quickly Becomes Wallpaper… Team Huddles & Leadership Gemba Walks in the Absence of Visual Metrics Quickly Becomes a Social Event…

Value Creating Work of Management Gain agreement on what is important . (which must be to solve customer problems) Engage and mentor workers to be problem solvers (through performing the above work in dialogue) Create brilliant process to achieve what is important Create stable process and continuously improve Adapted from Womack on Lean Management Presented by LEI

Over 500 Implemented Ideas To Date Solving Problems Allowing Rapid Knowledge Spread Lean Implementation Teams L.I.T. S.P.A.R.K.S. Over 500 Implemented Ideas To Date

Key Measures of Success UMHS Strategic Alignment Key Measures of Success / Strategic Alignment Primary Goals Key Measures of Success UMHS Strategic Alignment Lean In Daily Work Process Sustained Monthly audits taking place in each Pilot area, surfacing necessary corrective actions Sustaining Gains Continuous Problem Solving on Relevant Issues 500+ Everyday Lean Ideas Implemented as of 7/2011 (Many more in queue!!!) People Development, Process Improvement, Service Excellence & Lateral Spread Improvement & Sustaining of Value Metrics In excess of 80% Improvement to team’s Value Metrics Strategic Deployment, Process Improvement & Service Excellence Improvement in Lean Culture Survey Score 51% Improvement In Overall Score 115% Improvement In “Willingness to Recommend” People Development & Service Excellence Evidence of Model Spread / Mentoring Relationships Proactive Mentoring from Established LIT Teams to New LIT Teams Lateral Spread

Lean Leadership Articles We will be following up with these two articles After reading, list specific behaviors that you can practice and that can be observed by others. Commit to practicing before, during, and after Leadership Walks Can you think of a way to measure your own personal progress?

Focus of Master’s Course (addressing more complex problem) Creating a Visual Prioritization System for these more complex problems Building Structured A3 Problem Solving into existing meetings

Lean In Daily Work Train the Trainer Sessions Offered Learning Objectives Gain a foundational understanding of Lean Thinking & Concepts Understand the difference between Traditional Management and Lean Management Become familiar with the elements of the Lean In Daily Work Model – including the important role of the supervisor within the model Learn how to support your staff in surfacing waste and addressing problems on a daily basis Recognize the true value managers can provide to their teams through the application of leadership standard work Lean In Daily Work Train the Trainer Sessions Offered

The Virtual Lean Resource Center The Virtual Lean Resource Center *Many additional resources available, below is a sample of the most utilized resources http://www.med.umich.edu/i/quality/tools/lean_assist.html Requests for Lean Assistance https://umichumhs.qualtrics.com/SE/?SID=SV_0MmahvI58YJgukQ Lean Coach Office Hours https://wiki.umms.med.umich.edu/x/QZNSBw (unique ID and level 1 Kerberos password) Specific websites dedicated to… Lean in Daily Work (https://wiki.umms.med.umich.edu/x/HgCwAw (unique id and level 1 Kerberos password) A3 Structured Problem Solving (https://wiki.umms.med.umich.edu/x/HgCwAw (unique id and level 1 Kerberos password) Value Stream Mapping (https://wiki.umms.med.umich.edu/x/rIIyBw (unique id and level 1 Kerberos password) In the Planning Phase… Lean Networking Groups to share improvement work & address common challenges

http://www.med.umich.edu/i/quality/about/mqs.html Click on this to directly link to the MQS Homepage Click on the Virtual Lean Resource Center

Michigan Quality System & Lean References Books: Womack J, Jones D. Lean Thinking. Liker J. The Toyota Way; Liker J, Meier D. The Toyota Way Fieldbook. Shook J. Managing to Learn. Dennis P. Getting the Right Things Done. Rother M, Shook J. Learning to See. Womack J, Jones D, Roos D. The Machine That Changed The World. Sobek D, Smalley A. Understanding A3 Thinking. Marchwinski C, Shook J, eds. Lean Lexicon. Bahri, S. Follow The Learner: The Role Of A Leader In Creating A Lean Culture Articles: Kim CS, Spahlinger DA, Kin JM, Billi JE. Lean health care: what can hospitals learn from a world-class automaker? J Hosp Med. 2006;1:191. Bush R. Reducing Waste in the US Healthcare System. JAMA 2007;297:871. Spear S. Fixing Health Care from the Inside, Today. HBR. 9/05. Spear S. Learning to Lead at Toyota. HBR 4/04 Spear S. Decoding the DNA of Toyota Production System. HBR 9/99 IHI Whitepaper: “Going Lean in Health Care” www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare.htm Web: Michigan Quality System at UMHS: med.umich.edu/mqs Lean Enterprise Institute: www.lean.org webinars, books, meetings… Ideal Patient Care Experience at UMHS www.med.umich.edu/i/acs/ipe.htm Crossing the Quality Chasm (IOM): newton.nap.edu/catalog/10027.html Lean Enterprise Academy (UK): www.leanuk.org National Health Service (UK): www.networks.nhs.uk/networks.php?pid=211

Questions / Comments? Contact Information: Brendon Weil Lean Coach, University of Michigan Health System 734-615-0175 bweil@umich.edu Kevin DeHority 734-615-0176 dehority@umich.edu