The Transformation Process

The process of transforming to a structured culture of continuous quality improvement is a defined one in Toyota. It begins with training of top management, agreement and definition of the quality mission and goals, team leader training in process improvement, identification of quality targets, then learning by doing at the 'shop floor' level in a model line area. In this scheme it is the Team Leader who is responsible for immediate patch fixes on the shop floor and more sustained process redesign through data-based PDCA change. The team member, who is on the automated line, is responsible for calling attention to the defects encountered or stopping the line so they can be fixed.

In healthcare, we don’t have a shop floor or an automated model line producing cars. But we do have analogous opportunities for highly educated and trained workers themselves, not just Team Leaders, to become engaged in the process of improvement at the level of the work, wherever that may be-- at the bedside, the clinic, the laboratory bench, the radiology suite, the emergency room, the ICU, the OR, the kitchen, etc.

The figure below depicts our Henry Ford Production System (HFPS) model for cultural transformation in healthcare. First the leaders train as a cohesive group, then the team members are trained and are empowered to work together in a defined structure before 'learning by doing.'  We find it is far more effective to train the team rather than the individual. We also include the requirement for workplace metrics of performance expectation and variability that Team Leaders and Team Members own.  This serves to frame the ongoing identification of quality target goals for teams to achieve. A defined structure with Team Leaders and Customer-Supplier meetings fosters the ability of teams to improve processes horizontally as the work flows, across existing silos of control. Structure also enables us to more effectively succeed with key Deming management principles #6-#9 that foster managers and team members to behave differently when encountering problems that they can now resolve in a blameless manner.

6. Institute modern methods of training on the job

7. Institute modern methods of supervision & leadership

8. Drive out fear

9. Break down barriers between departments

Structure and Teams That Promote a Culture of Continuous Improvement

"Start as soon as possible to construct with deliberate speed 

an organization to guide continual improvement of quality."            

- W. Edwards Deming

Lean success is sustained only when leaders and managers develop the environment, structures and aligned incentives to foster an educated and trained workforce that is empowered to work horizontally along the path of workflow. This is the key to obtaining the hundreds of small, granular process improvements done at the level of the work that the employees truly own.  A Lean culture is successful when workers are informed by metrics of work variation and empowered to make change, in concert with their leader, using the scientific method, e.g., data-driven PDCA.  Transformation to this culture of work and the structures designed to foster this manner of continuous process improvement by the workers are the responsibility of the leader. To begin a Lean journey without thinking through this structural element is toying with failure. Don’t do it.

In a true Lean management culture you don't have to have all the answers anymore. Your people do. The answers you provide are the organizational structure, reporting relationships, accountability, pace, recognition and reward and incentive to work in the new order. This approach to work allows you to tap the creativity from the workforce, continuously.

Without a structure though there will be potential chaos with so many anxious to use their newfound empowerment. Its one thing to tell someone they are empowered but quite something else to provide structure to ensure they behave in an empowered manner, respecting the existing order. This empowerment may range from serving as a leader of a defined work team, representing team members of customer-supplier meeting, or serving as a team member who consistently signals defective work and its causes through workplace whiteboards.

Toyota's production management system, the basis of Lean, is structured to thoroughly eliminate waste in pursuit of maximum cost reductions. That structure is defined by leadership and underscores the behavioral expectations that result in Toyota's culture. However, there is no direct translation from manufacturing and the structure and principles successful for Toyota's culture must be adapted from manufacturing to our own healthcare environments. Therefore, initial structural work is required of healthcare leaders in order to obtain success with the Lean management system.