I've been collecting many of the learning experienced in our organizational transformation and creating models of what we have been observing. This model is something not only we have seen but something that is described by many going through their own transformations. I've recently been reading an excellent book recommended to me by a great friend, Beyond Heroes: A Lean Management System for Healthcare by Emily Adams and Kim Barna. In this book, they describe the transformation at ThedaCare and I've found a lot of the same learning that we have gone through in this past year. They describe the interactions between management, physicians, and staff trying to see problems in their processes and improving the system for the betterment of the whole patient experience. As the healthcare system itself transforms from a fee for service to a value-based payment system, Thedacare has been at the forefront of improving their entire system to add value for their patients. In this post I will describe the basic system we use as management to see and learn, and you will find parallels with many books describing their transformations. This basic is the foundation leader standard work that enables the cultural transformation.
The image above describes the high level system that enables the organization to See & Learn. Previously I described the Gemba Learning Model, that is, how we learn during Gemba Walks. In this I take a quick step back to get a better understanding about how the entire management system must change to one where we can See & Learn. Following these basic 4 elements, we have created a new way of managing, Huddles to listen and communicate, Gemba Walks to see and learn the process and struggles, Reflection for personal and team learning, and Improve to take what we have learned and identify opportunities to make things better.
Huddles
At the top of the model we find Huddles. This has been described in different forms and you may recognize this as a "morning meeting" or something similar. The essence remains the same - we must create the environment for open communication to establish a mutual trust between all employees that we are listening and working together as a team for the better of ourselves, our processes, and our customers. This step can be difficult for people who have not been taught the leadership skills of communication and transparency. We have found that initially this step starts as an "airing of grievances" at the start. If we have not been openly communicating with our staff in quite some time, this step will be seen as a frustration for management. Listening to what management may see as "complaining" in actuality we are seeing the release of frustrations from our employees. This is a necessary step in the Huddle, but we must quickly grow from this stage. The following stages may happen out of order and in different amounts of time. Typically though, you will see the following things happen.
Discussion of Issues
Discussion of Potential Solutions to Issues
Visualization of Issues and Problem Solving Process
Discussion of Safety, Quality, Performance
We have seen the Discussion of Issues happen generally first in every huddle we have seen evolve. We provide just basic training on how to huddle at first, building the leadership skills of communication and listening as the primary method to allow the work unit to create a huddle structure that works best for them. As upper leadership, the focus is to be there to develop the team in their huddles and challenge them to keep growing. This step allows the entire leadership/management team to listen to the issues experienced where the work is being done.
Gemba Walks
I have previously described the Gemba Learning Model in a previous post. Generally though, the Gemba Walks directly connect with the Huddles. At the Huddles we listen to the issues described by all the people. As part of our Gemba Walks, we try to take what we have heard and try to see what this means in the actual work. This allows the entire leadership/management team to get a clear understanding about the system's issues, especially where the people may be struggling within the system. It is important here to be able to walk with another person, but is not a requirement. Walking alone, you will find only what you can see based on your own knowledge. You will need to be vigilant to ask questions and get a better understanding of the process, trying constantly to see things outside your own blind spots. Walking with another person (preferably from a different function) allows you all to see from each other's perspectives, expanding the entire team's learning of the process at large.
A great example I have of this is walking a particular process for one of our product lines. In this product line there are 3 major processing steps with logic-based conveyance between them. As an operations manager, we saw the process running slowly and our people standing around. We would begin to blame the breakdowns in the conveyance for the issues we are seeing. As a maintenance manager, we will look at the breakdowns in the conveyance and look more deeply at why it is occurring - temporary O-Rings used on our mechanized rollers are wearing down more quickly than expected. As an industrial engineer we may look to the process and see 3 staff members that are manually inducting product into the process to mask the problems we are having with downtime of the conveyance. These 3 perspectives can now be discussed as a team and each person will get a deeper understanding of the process. In this scenario, the operations manager learned what to look for on the conveyance and how to communicate this with maintenance. The maintenance manager could see more clearly how these temporary fixes impacted the operational goals and could make more strategic purchases for certain parts of the system. The industrial engineer would be able to understand the needs of operations to use those 3 employees due to the pressure to get the product processed, and can help solve the root cause maintenance issues that may be causing this.
Reflections
Third, we have reflections. Reflections can be done individually or as a team. We have typically done these immediately following our Gemba Walks. The information we gathered from the walks are fresh in our minds, and we can now discuss together all of what we have learned. This step includes finding space either on the floor or (if there is no area to easily communicate) just off the floor to gather and communicate with each other. We ask 3 simple questions.
What was going well?
What can we do better?
What have I/We learned?
These are basic questions we ask, and in a short time we will be able to share our knowledge with each other. This step is what solidifies our learning from the listening and seeing portions of the system. We ask what was going well to get a better grasp of the idea of respect for people. We want to see the efforts people put into the process each and every day. By asking what we can do better, we see things as process problems and allow ourselves to initiate discussions as a team to make some improvement to the process. Since huddles have been established we can see some of those opportunities on the huddle boards, and most of the time these are the things we will use to start improvement projects. Finally by asking what we have learned we allow each other to be vulnerable and build trust among our own leadership/management team. This also allows us to understand where each other's needs are in development, and as a team we can help each other develop.
Improve
Finally we try to improve something. At the start of the journey we ask our teams to improve one simple thing each day. This is just to break down the idea that we must wait on others to improve, and begins to give authority to the teams to make improvements. This expands quickly to work units creating improvements on their own, but starts with us as the leadership/management teams to enable that to occur. There are many methods to improvement, but we follow the basics of either the A3, PDSA, DMAIC, or even a Just Do It method. Some teams spend more time with the Just Do It mentality, but this is where leadership can help develop the teams to establish a more scientific method with the teams. As an organization we have been using A3s more as a reporting sheet rather than a problem solving sheet, but using this basic system, we can introduce the A3 more easily as the way to solve problems with each other. The A3 for our organization follows the Define Measure Analyze Improve Control (DMAIC) problem solving method, but all have roots in the Plan Do Study (or Check) Adjust (or Act) process. Either way, the drive here is to improve the process. We are going to make things easier and safer for the employees, increase quality for the customer, or make the process more efficient (ultimately reducing cycle times). The improvements have a direction as well, using strategies and initiatives to drive discussions toward some overarching organizational goal for our customers.
Following this basic 4 element system, we can transform how we manage daily. Lean transformations talk about the turning point being a shift toward a daily management system of improvement, but this is not easy to understand especially if you have always used the traditional way of management. It requires a lot more involvement of our management and leadership at the place of work (Gemba), and focuses more on the learning process than the constant firefighting mode. It can take quite some time to learn and implement this system allowing people to learn from each other and work through some of the underlying trust issues we may have between workers and management. These steps are simple but not easy - they can be difficult but are absolutely necessary. Learning how to do this well, we can then create our own Leader Standard Work around this, and add in more learning on stability (using control charts). The remaining of our Lean Tools can be more easily introduced and learned after using this model. In fact, we have found a failing of our previous efforts as trying to deploy the tools without the management system behind it. Deploying tools alone leads to issues with sustaining improvements, and creates frustration of all employees (management and workforce).
We will continue teaching this system as we expand out more in our organization and I'm sure we will refine things as we go. I encourage everyone going through their own Lean Transformations to look at their own management systems and address the things that are keeping us from communicating, building mutual trust, learning, and improving. This model can be used as a start for nearly any organization, and is something I have observed in our organization and many others described in books and seen at their sites.
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