Tuesday, July 21, 2009

Lean: Tortoise not Hare

Here's an update for those of you interested in our process improvement efforts at BIDMC and our preliminary thinking about the next stages. Back in March 2008, we rolled out our BIDMC SPIRIT program, our first formal experiment with staff-based call-outs based loosely on the Totoya Production System, aka "Lean." It has accomplished some good stuff, and we have learned from it. (Search "BIDMC SPIRIT"and "Caller-Outer" on this blog to see a collection of those items.)

From the very beginning, we said that BIDMC SPIRIT would itself evolve, and now we are at the latter stages of thinking through how to do it. This process included some in-depth training of several of our senior clinical and administrative leaders, a cadre of the next organizational level of directors, and several of our medical trainees. Beyond training us, those sessions served as test beds for the specific curricula developed by our staff, in cooperation with and building on materials from the Greater Boston Manufacturing Partnership. Meanwhile, too, Steve Spear invited several of our folks to audit his process improvement class at MIT, where they have had more advanced exposure to Steve's work but also healthy interactions with people from other industries.

As the graphic above displays, we view ourselves at the very beginning of a long journey to full implementation of Lean principles in our hospital. Others, exemplified by Gary Kaplan and his colleagues at Virginia Mason Medical Center in Seattle, and John Tuissaint at Thedacare, started earlier and are further along.

As I was discussing with Jim Womack the other day, it is an interesting paradox that while an important part of the Lean philosophy is the concept of standardizing work (to avoid waste and unnecessary variation), when it comes to implementation of Lean, each organization is essentially sui generis. That is, the plan for diffusing the concepts of Lean in an institution like ours has to be cognizant of the people and the culture of the place, an environment that has evolved over decades.

The idea here is to be slow and steady -- "Tortoise not Hare" -- in both planning for implementation and executing the plan. I present, for your viewing, a simplified chart of the roll-out proposal we are currently thinking about and will be sharing with our leadership groups and staff. You can click on that chart and expand it. You might not get all the points, but you can see the major themes: Lots of training; application by the trainees of what they have learned; focus on broad system work across the hospital, but also specific project work in high priority areas; and a small, nimble governance structure to keep track of things and make mid-course corrections.

I hope, by presenting these materials here, to encourage others of you who have been through this kind of transformation to submit comments to share your experiences, and to encourage those who are thinking about doing this to reach out to others who are in mid-stream. As the US considers its options with regard to health care reform, the real action will remain in each hospital and physician group. Public policy instruments are blunt and imprecise. Unless we take charge of the manner in which we do our work, the broad general policies being considered in Washington, DC will make very little difference in the quality of care and the efficiency with which it is delivered.


Mark Graban said...

Great stuff Paul, it's wonderful that you would share this online.

Lots of progress being made in healthcare organizations - including BIDMC.

I heard another hospital CEO say last week, "The only real healthcare reform is eliminating waste". Lean certainly gives a method for eliminating waste and providing better value to patients, and I applaud your work (and Alice's and your team's) in this area.

Mark Graban said...

Oh and one other thought... I've also learned the "tortoise and hare" analogy from Toyota and have shared it with many hospitals. The idea of "go slow to go fast" is very counterintuitive.

I had a nurse at a hospital ask once, "isn't there an animal we can use that's sort of medium fast????" :-)

pburrell254 said...

Completley right, slow and steady wins the race.

Paul Levy said...

After some thought, I've removed several comments that arrived after these. They were making me uncomfortable, in terms of tone, and in my judgment were not consistent with the usual standards of people who read and write on this blog. Sorry to have to do that, but it also felt like that had little to do with the subject at hand.

Kelvin Cross said...

There’s a time for the tortoise and a time for the hare.

For the tortoise - When major rapid changes take place outside the organization (such as shifts in the marketplace or advances by competitors, regulatory changes, and technological innovations), incremental improvement efforts in some existing processes are simply insufficient (not transformational enough and too slow). A more fundamental and rapid redesign of how work gets done is required.

For the hare – no process should be allowed to slip backwards, but especially a newly redesigned process. Incremental improvements are essential to help reach and sustain the full benefits and potential of any process, and especially after being redesigned and newly implemented.

The relationship between radical or discontinuous improvement and incremental improvement is complementary … and the use of both is essential.

Steven Montague said...

As an airline captain, whenever my flight is late I always tell my crew that "we're going to hurry slowly." This is my way of saying let's not rush anything, but simply not waste any time.

People seem to get it when I use this expression when I'm teaching a teamwork class at a healthcare organization too.

Great stuff Mr. Levy. Thank you.

Steve Spear said...

Let me offer an alternative framing for 'standardization' or 'specification' in advance of doing work.

(1) Creating a script, choreography, 'play,' recipe maximizes the chance that you'll succeed by bringing to bear the best of what you already know.

(2) Missed in the blog's explanation is that making explicit what you'll do with what intended outcome makes problems jump out. Then, you discover what you don't know, so you know where to target your kaizen.

The previous formulation, on the blog, misses the role of standardization in prompting the improvement and innovation dynamic on which Toyota and other 'high velocity organizations' depend.

Anonymous said...

Sorry, my concrete brain doesn't understand Steve Spear's comment, specifically #2 and the last paragraph. Can you give a specific example based on a hospital process?
Of interest, the WSJ recently had an article in which the new CEO of Toyota North America said that Toyota NA had "lost its way" and needed to return to Toyota's original principles. Just goes to show how hard it is to sustain these initiatives.

Sorry for the comment blizzard; gotta take a sleeping pill.... (:


Paul Levy said...

I've asked Steve to reply.

Steve Spear said...

Thanks for the ping.

When I first started studying Toyota in 1995, I asked a simple question: ten years into the lean manufacturing movement, why was Toyota still outrunning its rivals? I expected to a missing production control tool--a variation on value stream maps, an extra version of kanban cards.

I was completely wrong in those expectations. It wasn't another standard work chart or shikumi diagram.

What I did discover that Toyota was designing all its work--from the repeatable work of individuals to the one off project work of large teams, so as the work was being done, it was obvious when and where problems were occurring. In short, for all the attention standardization had gotten as a way to create stability where chaos previously existed, I saw a second purpose.

Yes, by developing clear recipes, scripts, protocols, plays, whatever, Toyota was ensuring that when work was performed, it was being done with the best known methods brought to bear.

Also, and critical, as work was being done, the work itself was saying where its design was inadequate and where additional effort had to be applied to create deeper understanding.

That triggered incredibly rapid, highly disciplined problem solving that quickly and relentless created new useful knowledge that could be brought to bear.

The result? An ability to be ever more effective and ever more efficient.

The gist of my comment was a reaction to the incessant repeating that "lean" is about removing waste. No. That's a negative.

The key is to create value and to discover when creating value is being impeded so you can learn to create more value more effortlessly. That's a positive framing, and much much more consistent with what Toyota actually practices and preaches than how many in the lean manufacturing movement have distilled and distorted the message.

For more, please visit my blog: http://chasingtherabbitbook.com

Steve Spear

Wierz said...

Mr. Levy,

I have been following your blog since my time in graduate school and it has only become more helpful as I've moved into the 'real world'. As an individual who has been trained as a Lean leader in a large, academic medical center, I've been especially interested in your posts on performance improvement. I'm glad to see the "Tortoise, not Hare" analogy being used, as I struggled at first with the pace of a performance improvement culture change. While individual efforts may reap immediate rewards, the establishment of a culture that truly understands and leverages the tools of Lean and Six Sigma takes years of executive sponsorship and communication. I've shared your work with many of my colleagues and I look forward to seeing progress at both institutions.

Thanks for the sharing the great work at BI.