The White Board in Identifying Opportunities for Change

"Even a mistake may turn out to be the one thing necessary to a worthwhile achievement."

-Henry Ford

The primary role of team members is to reveal in real-time, to each other, and to their managers what is not working as expected, that is, to identify in-process defects and waste.

To this end, we place white boards in the workplace so that defects can be made visible by the workers themselves, in a blameless fashion. A white board is a work communication tool for the worker and manager so that “no problem doesn't become a problem.”

Why write it down publicly?  Simply, to collect factual information about less than optimal work and because lack of effective communication begets poor quality. Should you walk into a workplace and see white boards, describing defects encountered, you will understand this tool to be a visual reminder that in a true Lean culture employees are empowered to work differently, invested in and accountable for the quality of the work they receive or produce.

White boards are a simple tool to help the individual worker and the team communicate within and between work stations, connect work stations horizontally across the path of work flow (or value stream) and make the workplace visual for both those doing the work and those managing the reliability, consistency and stability of the work. White boards are only fully functional as visual workplace tools when leaders have created the enlightened culture that encourages blameless identification of mistakes, provides an organizational structure and reporting relationships that incentivize empowered workers to contribute to daily defect resolution. This is the essence of Lean- a continual improvement loop with a 'shop floor' focus by employees who know the nature of their work best.

The elements that may be captured on white boards to clarify the defects that arise in your workstation and facilitate your team's subsequent resolution are the following:

•                Date

•                Problem

•                Who identified

•                Action- short term (our rapid fixes)

•                Action- long term (our A3 based improvements)

•                Responder/Comments

•                Estimate % complete  (visual using a circle with quadrants filled in)

See if this Issues List described above from a White Board adapted from the manufacturing world helps you think about how to best to use your own white boards.

Standardized White Board

Although we have been using white boards for some years now, we have only recently standardized our own approach in the laboratories.  Below is our current iteration of a white board. The header is meant to inform and educate the workforce. It contains regularly used references to the defect resolution process of the Henry Ford Production System:

• The 7 Types of Waste
• The 5 Why's of Root Cause Analysis using an Ishikawa Fishbone diagram of common causes
• The 4 Rules of Work from the Toyota Production System that are often in violation when a defect is encountered
• The process improvement procedure methodology of the Henry Ford Production System
• The leader's quality messages, here, the Wednesday's Words of Quality that I write weekly

The board is segmented to capture detail about:

• Daily defects encountered
• The defects immediately resolved on the spot or those queued for further development as an A3 based process improvement that often requires a 'Go and See' or a customer-supplier meeting
• Communications for and between shifts and ongoing quality education topics and learnings

So, should you as the manager on a "gemba walk" through the workplace see a blank white board, you now have a visual of either a perfect workday (doubtful) or a workforce disengaged from their responsibility of contributing to continuous improvement. The simple white board functions for all levels of work engagement. 
 
References:

Ford H. Today and Tomorrow. New York, NY: Doubleday; 1926

Ohno T. Toyota Production System: Beyond Large-Scale Production. Portland, OR: Productivity Press; 1988

Rother M. Toyota Kata. Managing People for Improvement, Adaptiveness and Superior Results. New York: McGraw-Hill, 2010.

Spear SJ, Bowen HK. Decoding the DNA of the Toyota Production System. Harvard Bus Rev. September 1, 1999:96-106.

Go and See

Go and See

The Deming approach to quality and the PDCA cycle attributed to him were appreciated by the Japanese in the early 1950s as a "way of thinking and managing rather than simply as techniques."

In this strategic basis for improvement (the Improvement Kata described by Mike Rother), "Toyota later added the words "Go and See" to the middle of the PDCA wheel."

This act of 'going and seeing' is critical to observe actual conditions for yourself and not to fall into the manager’s trap of jumping to conclusions. This must be the beginning of understanding a situation before suggestions for change can be made effectively.

The 4 key points of the Improvement Kata, founded in PDCA, deal with scientific experimentation, discovery and learning. This is how the culture changes for people from one of hiding and blame to one of openness and learning.  At its core, this approach to problem solving relies on development of people with insight and process repair closest to the level of the actual work. The 4 points of this problem solving routine defined by Rother are:


1. "Adaptive and evolutionary systems by their very nature involve experimentation." 


There is no one right answer, no one fix to a problem, just many tweaks on the way to a target condition whose path is largely unknown. Just try something. Let the data tell you if it is with accepting as a change in process. Given the right leadership and organizational structure, the workplace is your experimental playground to figure out how to do the work better. In the Henry Ford Production System, this is the basis of your empowerment.


2.  "Hypotheses can only be tested by experiment, not by intellectual discussion, opinion, or human judgement." 


Don't talk, test! What you believe or think is less important than what you try, usually on a small scale.


3. "In order for an experiment to be scientific it must be possible that the hypothesis will be refuted." 


Never assume that the change implemented will work as intended and should be accepted as originally designed. That assumption will stop improvement and adaptation in its tracks. The fluid nature of continuous improvement is an adjustment for most who adopt this approach to work and problem solving.


4. "When a hypothesis is refuted this is in particular when we can gain new insight and further develop our capability."

Dr. Rother elaborates further on these concepts:

"We learn from failures because they reveal boundaries in our current capability and horizons in our minds. This is why Toyota states that 'problems are jewels.' They show us the way forward to a target condition. You need to miss the target periodically (again, preferably on a small scale that does not affect the customer) in order to see the appropriate next step. 

...This is a fascinating point when you consider how much we as leaders, managers, and executives try to make it look like everything is going right as planned. The main reason for conducting an experiment is not to test if something will work, but to learn what will not work as expected, and thus what we need to do to keep moving forward."

"No Problem" = A Problem

Rother also observes that "If there is no problem, or it is made to seem that way, then our company would, in a sense, be standing still... The idea is to not stigmatize failures, but to learn from them."

"We hear about Toyota's success, but not about its thousands of small failures that occur daily, which provide a basis for that success. Toyota makes hay of problems every day, where we tend to hide little problems until they grow into big and complex problems that are then difficult to dissect. Toyota has mastered the art of recognizing problems as they occur, analyzing their nature, and using what it learns to adapt and keep moving toward its target condition."

To some, the writings of Mike Rother quoted above may be just an academic construct that cannot be realized. However, the philosophy and reality of this manner of working is supported by what we have accomplished in the laboratories of the Henry Ford Health System through the management structures and culture of an empowered workforce we have created and the principles, rules and tools we have adapted from manufacturing to our own healthcare environment. Our own Henry Ford said it better yet-

“There are no big problems, just a lot of little ones.”    -Henry Ford

This is a different way of thinking. Find the little problems proactively at the level of the work and empower the workforce to resolve them, continually.


But do encourage those you have empowered to "Go and See".  This is an important early step of problem solving in order to move from assumption or accusation to an understanding of root cause. 

References

Rother M. Toyota Kata. Managing People for Improvement, Adaptiveness and Superior Results. New York: McGraw-Hill, 2010.

Problem Solving that Leverages Worker Empowerment

In a Lean management system, continuous problem resolution is dependent on a worker-driven 'bottom up' approach rather than the conventional management driven 'top down' approach to problem solving.

This principle is at the core of Demingism but can only be effective if leaders create a blameless culture for workers to identify defective work and a structure that enables and incentivizes their participation and collaboration in continuous improvement. The irony here is that to empower workers to be accountable in solving their own problems through PDCA requires more work for leaders, not less.

In other words, the main role of leaders and managers is to ever improve the system of work itself. We do this by leveraging the quality improvement organizational structure illustrated below in this Henry Ford Production System adaptation of Toyota.

This quality reporting structure aligns team members with their team leader by work stations into small teams that foster worker identification of the nature and scope of daily defects, and stimulate and guide the discussion of possible solutions that can be tested. This cooperative approach is predicated on a 'no blame but all accountable' sense of process ownership by teams.

Workers more readily assimilate the mantra- "never pass a defect" through this empowering structure that continually informs the workforce about the quality of their work product and charges them with improving it. 

Roles of Leadership

The roles of leadership are to establish the shift in work expectations, structures and realignment of incentives so that workers can relate to and interact with each other horizontally across the path of workflow and contribute collaboratively toward work process redesign across historical silos of control. To be effective in fostering change from the bottom-up, so to speak, the people-focused strengths of Toyota's culture must be reproduced- namely:

·         Employees in charge of their own jobs

·         Employees designing standardized work

·   Employees working to continually improve the work, changes made and effectiveness assessed by the customer focused PDCA cycle

Roles of Team Members

In this new Lean culture of work, the consistently engaged, learning, communicating and contributing team member is expected to fulfill the following empowered roles so that effective process improvements can be continually designed and tested by scientific method (PDCA) in the workplace:

·         Understand the work rules, principles and tools of process improvement

·         Identify defects, daily, on whiteboards

·         Meet in teams regularly to share and brainstorm problems in the workplace

·         Join teams charged with addressing interventions

·         Assist in design of measurement tools

·         Collect data

·         Assist in root cause analysis

·         Communicate to other teams, customers-suppliers

·         Communicate to managers/leaders

·         Keep track of process improvements

·         Continually seek better ways of performing the work

·         Present results of successes

·         Learn from previously proposed interventions that did not work (the failures)

Teamwork is the Cure

Teamwork is the foundation of Lean process improvement, and it has been proven that individuals will extend themselves to make the company successful if they are engaged early on in the decision-making process. In Toyota’s culture, learning often is by experience in which an early ongoing effort is demonstrated to teach teams how to work together to reach common goals. The problem-solving approach is “Go and See” in which subject matter experts observe the problem to deeply understand the current condition before suggesting process improvements. This includes analysis of workflow, standardized work procedures, and further evaluation to analyze and detect the root cause of defects. In comparison, other quality improvement methods often are limited to the review of data from reports created by individuals external to the work itself. This has limited value and changes made without participation of those invested in the work seldom sustain.

Transforming the culture of work, or more correctly the employees' incentives to relate to each other and work differently, must occur to obtain success in a Lean enterprise.  

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

Creating, Structuring and Sustaining a Culture of Continuous Improvement in Healthcare

These words are meant for those who are tired of the status quo and intend to create, lead and manage a Lean enterprise based on a Deming-style management system.  I am not talking about accomplishing leader-prioritized Lean projects with selected tools but rather creating a culture of a healthcare workforce engaged, structured and incentivized to participate in the work of improvement at all levels. That is to say, a Lean enterprise, defined as a culture of continuous improvements made by empowered workers. 

As of this writing, we have had the pleasure these past 6 years to lecture, train and share the story of our journey of continuous improvement all over the world. Most audiences see the results we describe, the standardization, and the visual artifacts of our way of working throughout the laboratories as the success. Initially, we described in the peer reviewed literature our plan to transform to a functional culture that allowed for continuous improvement (Transforming to a Quality Culture: The Henry Ford Production System, AJCP 2006;126(Suppl 1):S21-S29). We have learned much since that early plan. But it is that culture change and what we have learned in that quest that is the true success.

As a product of the culture that we created, we have been transformed, leaders and workers alike. We have learned many lessons by doing, succeeding, failing, adjusting, reinventing, innovating and doing again. In reflection, we have performed continual and successive PDCA cycles in that transformation to a quality culture.  In this next series of blog entries, I will review our lessons in the implementation 'how to' create, structure and sustain a culture of continuous improvement in healthcare with parallels borrowed from Henry Ford, W. Edwards Deming, and the successful Toyota Motor manufacturing management system.

We don't make cars in healthcare. We make people well and we work differently in a very complex environment of hand-offs with much variability. We don't have a 'shop floor' but we do have work as seen by those closest to it at the level of the 'bench' and at the level of the 'bed pan.'  Lessons from Lean must therefore be extrapolated to very different work conditions and professional relationships. This is hard work and requires understanding the best from others' work systems and innovating and adapting approaches that mine those successes to achieve our goal of transforming our healthcare culture.

What will follow in subsequent blog entries are our lessons learned from first hand experience in creating an effective PDCA-based culture of continuous process improvement that aren't typically taught in Lean training courses. This is from the 'school of hard knocks.' I was intent on writing a book but I feel this is the most efficient way of sharing these lessons so others may adapt and implement successfully in their own environments as well. We don't have time to waste in American healthcare.

I call this series that follows THE LEAN LEADERS GUERRILLA HANDBOOK.

I hope it helps you.

Let me hear from you so we can all learn something.

On Leadership

This editorial is reproduced from the  American Journal of Clinical Pathology (September 2010; 134:361-365) and outlines a call to arms, a manifesto, as in “a public declaration of principles, policies, or intentions, especially of a political nature." We who are trusted with the higher calling of healthcare must see that the people who are passionate in selflessly dedicating their lives to the well being of others can work in effective and safe systems. After all, "it's not systems that produce quality, its people who do." But systems are designed and lead by leaders and that is where one must start if anything will change from the status quo. Here are my observations and call for leaders to lead change in this most important human endeavor. After all, what will be said of our generation, what did we do with our time here? Maintain the status quo?  Not!

Leaders Wanted: A Call to Change the Status Quo in Approaching Health Care, Once Again

Richard J. Zarbo, MD, DMD

(editorial from the American Journal of Clinical Pathology, September 2010)

It has been more than 20 years since Don Berwick, MD, newly appointed administrator of the Centers for Medicare & Medicaid Services and well known as the CEO of the Institute for Healthcare Improvement, called for a change in American health care to a systems-based culture of continuous quality improvement (CQI). His seminal 1989 article, “Continuous Improvement as an Ideal in Health Care,” highlighted the then “new” (to us) Japanese concept of total quality control or total quality management (TQM) that has been idealized as a model of culture, management, and efficiency since the early 1990s.(1)

The world’s most successful implementation of CQI is the Toyota Production System, now popularly referred to as LEAN or LEAN management. What we know of LEAN are professors’ descriptions during the past 20 years of Toyota’s culture, production system principles, work rules, and process improvement tools.(2-5) The LEAN philosophy at its heart is a culture underlying a core business strategy founded in the ideal of continuous improvement (kaizen) that is based on the knowledge of process variation. It is founded in the management system proposed by W. Edwards Deming, a management guru to the Japanese since the early 1950s, who was discovered late by Western businesses.(6) Looking at the recent decline of American automotive manufacturing, some would say too late.

LEAN is a scientifically based approach to quality improvement predicated on the data-driven Plan-Do-Check- Act (PDCA) analytic, also known as the Shewhart or Deming Cycle, that was fairly ineffective 20 years ago in this country when practiced as TQM (Figure 1). 

Application of PDCA problem solving seems to be in resurgence, but successful application for change is highly variable, especially in health care. Toyota’s success during the past 50 years, rarely reproduced, derives from a leadership-driven management culture of continuous improvement that over many decades perfected the principles of Deming and innovated aspects of efficient production design with worker empowerment to produce thousands of process improvements, many at the level of the worker, year in and year out.(7) Toyota’s organizational structure and cultural expectations empower organized teams of employees to drive a daily examination of continuous improvement opportunities and learnings, thereby allowing them to be accountable, in charge of their own jobs, and allowed to design their standardized work. The result is CQI bread into the DNA of Toyota’s culture. This cultural transformation of work is what will be required in health care for the true power of LEAN to be leveraged. We failed to change our culture when attempting TQM 20 years ago, and the fate of LEAN will be no different. Transforming the culture of work or, more correctly, the employees’ incentives to relate to each other and work differently is a requirement to obtain success in a LEAN enterprise that is continuously learning and improving. This requires leadership, as only leaders can make this kind of significant change and support realignment of incentives so that workers in connected workstations are encouraged to work collaboratively and horizontally along the path of workflow. This is the only way to obtain the strengths of Toyota’s culture, namely: (1) employees in charge of their own jobs; (2) employees designing standardized work; and (3) employees working to continually improve the work at their own level, with changes made and effectiveness assessed by the customer-focused PDCA cycle.

(Figure 1)

The never-ending cycle of continuous improvement. The Shewhart or Deming cycle.

At the core of continuous process improvement is a leader’s understanding of the consistency and reliability of the work product or service produced and the extension of that knowledge to empowered work teams. In other words, the leader’s focus should be on having real-time insight or metrics about in-process variation of work product or service that direct continuous process improvements. As the saying goes, If you can’t measure it, you can’t fix it! This is our challenge in medicine, how to understand what is occurring “in the shop” in real-time, at the level of each piece of work. Ironically, managers of the produce we purchase at the local grocery store are supported by more computerized information to make informed decisions in real time at the level of the individual head of cabbage than we have in most hospitals and laboratories. More often than not, because of paper-based or crude information systems that cannot communicate with each other, this requires manual collection of data, at the level of the worker, where the defects are encountered, to gain a deeper understanding of indicators that are “critical to quality.”

Defects and waste in process are measures of variation. These are the twin enemies of quality. They are also the enemies of productivity and profit, for no one pays for second time rework and we are often not well paid for first-time work. Often not much is known about in-process variation leading to waste and poor quality. In the laboratory environment, we define a defect as a deviation from a predetermined outcome of a process, which is a flaw, an imperfection, or a deficiency in specimen processing requiring delaying or stopping work or returning work to the sender. These defects are noninterpretive defects critical to quality and trigger a series of reworks to satisfy set standards.

Waste can be defined as an amount of time, resources, and human skills that were consumed but did not contribute to value addition in a product or service as it moved across a value-addition process. Waste can take the form of idle time between steps, duplication and rework for each step of a process, and nonutilization of human, organizational, and physical resources. In pursuit of a “zero-defects” performance goal in our quality culture, the Henry Ford Production System, we have designed novel and simple data collection tools to assess current conditions and sources of defects in the workplace to get a handle on these forms of waste and variation.(8,9) This method is applicable to any work environment where automated data are not available or sufficiently granular to lend insight into the detailed root causes of defective work.

In their 1999 Harvard Business Review article, Decoding the DNA of the Toyota Production System, Spear and Bowen(3) described 4 work rules of LEAN. The first 3 rules deal with the extremely important reduction of variation through standardization of work activities, connections, and pathways. Measurement is the basis of the fourth rule dealing with how improvements are to be made. In this approach to work, problem solving is done by the workers to improve their own work, at the level where the work is done, guided by a teacher, using data, to move incrementally toward an ideal condition through continuous cycles of improvement. This is the scientific approach to problem solving and change based on the Deming Cycle, or PDCA (Plan, Do, Check, Act). Therefore, the fourth rule of LEAN work is founded in measurement that reveals to the manager and worker what is not going right or, in other words, insight into work variation. Notably, the fourth rule also calls for employee engagement, the basis of the team approach to quality improvement.

So, how do the manager and the worker gain insight into the workplace variation that they own and they can change?

For a manager to ensure a system’s consistency and reliability, it is vital to understand the level of variation (defects) in operations on a daily basis in order to focus efforts to bring work quality within predictable limits. This requires continually “feeling the pulse of the machine” so to speak, from assessment of daily metrics. This is the manager’s role in LEAN.

There are essentially 3 types of metrics of value that indicate variation in an operation and that should be used as a basis of PDCA-based “scientifically” designed process improvements. The specific metrics, per se, are best determined by the need for leaders and empowered work teams to understand in real time the quality of work, namely the sources of defects and types of waste associated with the work for which they are accountable.

What are these metrics?

1. Defects that are handed to you by your “supplier”
2. In-process defects that you make
3. Defects that you hand off to your “customer.”

The definition of the terms customer and supplier used here, although borrowed from manufacturing, are translatable to our own complex processes along the path of workflow in health care. Who passes work to you? (Your supplier.) You rely on your supplier for information, data, parts, tools, tasks, patients, etc. Who requests or gets work from you? (Your customer.) Are customers inside your section, division, or department (internal customers) or outside your sphere (external customers)?

The use of daily metrics in feedback loops to guide quality initiatives that improve processes is illustrated in Figure2. For laboratories, these are the opportunities to understand preanalytic, intra-analytic, and postanalytic variation along the path of workflow.

(Figure 2) 

Customer feedback informing improvements.

This systematic approach to work improvement is not new. In 1926, Henry Ford,(10) reflecting on the extremely efficient auto manufacturing business he created and that was an inspiration for Toyota, reflected that: “Our system of management is not a system at all; it consists of planning the methods of doing the work as well as the work.” The old way of doing business is to manage outcomes such as labeling defects and misidentifications by detecting defects after the fact. Inspection is a countermeasure when you cannot trust what you just produced, ordered, or received to be defect-free. Inspection itself is rework. It is far better to eliminate the need for inspection on a mass basis by building quality into the product (or service) in the first place. How do we do this? By constantly monitoring in-process feedback and customer feedback to understand variation. It is this “scientific” understanding of the workplace that allows work to be redesigned by educated managers and trained, empowered work teams who use LEAN work rules focused on standard work, workflow principles, and process improvement tools.

Successful change of the status quo is highly dependent on effective leadership and follows from Deming’s call for managers and leaders to adopt the new philosophy of management. That philosophy is nicely summarized by Gabor(11) in The Man Who Discovered Quality: How W. Edwards Deming Brought the Quality Revolution to America.

“In companies that have embraced Deming’s vision, management’s job is to ‘work on the system’ to achieve continual product and process improvement. The Deming-style manager must: 

• Ensure a system’s consistency and reliability, by bringing
• Level of variation in its operations within predictable limits, then by
• Identifying opportunities for improvement, by
• Enlisting the participation of every employee, and by
• Giving subordinates the practical benefit of his experience and the help they need to chart improvement strategies.”

By leveraging our investment in the creation of a LEAN managed culture and empowered employees, we have had much success in the large, integrated laboratory operations of the Henry Ford Health System, Detroit, MI. For example, in the surgical pathology division, within 1 year of roughly 100 process improvements, the number of cases with defects was reduced by 55% (including specimen receipt, specimen accessioning, grossing, histology slides, and slide recuts).(12) This number was further reduced by 91% after 2 years of LEAN management in the Henry Ford Production System. Patient safety also wins when there is a focus on waste and defect reduction and work simplification. Through the implementation of process redesign and bar code–specified work processes, laboratory misidentification defects were reduced by approximately 62% overall (95% reduction in slide misidentification defects while increasing technical throughput at the microtome stations by 125%).(13) 

And we are never done, and we should never be satisfied with the status quo. In this quality culture, we have become our own benchmark for what is possible. All quality is local. What we do well today we can do better tomorrow. We need only ask: “What would you, as the patient (or customer), expect?” to guide our continuous improvement efforts.

This brings us back to why TQM failed 20 years ago and why LEAN should not fail today. In fact, in personal conversations with Jeffrey Liker, MD, author of The Toyota Way(4) and Toyota Culture,(5) I am informed that 90% of organizations that try to adopt LEAN management fail. Why?

Quite simply, it is very difficult to create and sustain a “Japanese-style” management culture within a “Western” management culture. People with more span of control will have more opportunity for significant change, but that does not mean that you should not try. It does mean that as a leader you must invest your time and efforts differently to change the status quo. As observed in the description of our own quality initiative, “Transforming to a Quality Culture: the Henry Ford Production System”(8): “Toyota’s success is the result of leadership and employee involvement. To be functional leaders, senior staff at Toyota must believe, drive, understand, and live the same training philosophy and employee empowerment that in turn reinforces the culture established by the original company founders.”

It is no stretch to look to the most successful business of manufacturing for health care solutions. Toyota’s culture that foremost values respect for people equally with continuous improvement most closely melds with the culture of health care that is invested heavily in well-trained but often uncoordinated care teams. According to Liker and Hoseus(5) in Toyota Culture: The Heart and Soul of the Toyota Way, “LEAN systems and structure is buried 2 levels down in Toyota’s model and not the focus.” Without the creation by leadership of an organizational structure and value system to encourage and support a bottom-up, worker-empowered culture of continual improvement, significant and sustained change à la the Toyota Production System with hundreds of process improvements is not possible; only sporadic leader directed projects, often prompted by crisis, and application of disconnected quality tools or focused but limited kaizen events will be seen.

From my personal learnings during 5 years in promoting a LEAN culture in the laboratories of the Henry Ford Health System, this is how I see the required steps for leaders to transform to an effective PDCA-based culture of continuous process improvement in an existing non-LEAN culture, with my apologies to Deming and his 14 principles of management. Upper leadership and midlevel management must agree on and drive the following elements:

1. There must  be one culture, one incentivized way of doing things. If there are too many models, silos are perpetuated and workers doubt sincerity of the change. Confusion results, and workers, unsure of what is expected, continually seek clarity about the direction. This lack of cultural coherence results in the conclusion that they are being subjected to another management fad of the month that can be dodged or outlasted. This is leadership failure. Welcome to Liker’s 90% of places that tried LEAN and failed!
2. Leaders and managers must adopt the basic principles of management that allow the process- improvement model to work effectively across work units and business units in a horizontal manner as the work flows. A spirit of selfless collaboration enables the breakdown of the silos to achieve true horizontal management. Again, incentives must be realigned for the new behavior to become reality, and this must come from top management.
3. Leaders must adopt their new role to continually work on the “system of work,” push the change with their “direct reports” and workers, and, by doing this, live by the new culture. Absent elements 1, 2, and 3, the remaining points are not sustainable. Stop now. You’re into lip service.
4. Structure must be established to teach and adopt standard work rules that promote standardization of activities, connections, and pathways and allow empowered workers to implement PDCA-based process improvements with their established teams.
5. Structure must be established to teach and adopt process improvement tools aimed at the chief enemies of quality, namely, variation, defects, and waste. Eventually, sufficient efficiencies will be achieved in workflow smoothing, work simplification, and just-in-time approaches to work, resulting in increased productivity, throughput, timeliness, and customer satisfaction with decreased rework and cost.
6. Organizational structures must be created to sustain the preceding and recognize the value of engaged workers, their effective, collaborative teams, and their leaders.

LEAN success does not result from merely training in the process-improvement tools; it is founded in culture and the empowered worker! We need more than a handful of foot soldiers trained in “boot camps.” Success will require effective battalions and brigades supported by impassioned generals. Success starts and ends with leadership. The current challenge for businesses of any type, and especially health care, is how to adopt the Deming style of management rather than merely how to apply the principles and use the tools of Toyota’s efficient production system. I have related my approach above.

The key lesson from the TQM history in health care is that what is really required for success is a change in culture, that is, the behavioral incentives that derive from the norms, values, belief systems, decision-making processes, and political power bases that make an organization function. Anything less comes up short when the goal is to effect continuous process improvement. Are you ready to lead?

From the Department of Pathology and Laboratory Medicine, Henry Ford Health System, Detroit, MI.

References

1. Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med. 1989;320:53-56.
2. Womack JP, Jones DT, Roos D. The Machine That Changed the World: The Story of Lean Production: How Japan’s Secret Weapon in the Global Auto Wars Will Revolutionize Western Industry. New York, NY: Rawson Associates; 1990.
3. Spear SJ, Bowen HK. Decoding the DNA of the Toyota Production System. Harvard Bus Rev. September 1, 1999:96-106.
4. Liker JK. The Toyota Way: 14 Management Principles From the World’s Greatest Manufacturer.New York, NY: McGraw-Hill; 2004.
5. Liker JK, Hoseus M. Toyota Culture. The Heart and Soul of the Toyota Way. New York, NY: McGraw Hill; 2008.
6. Deming WE. Out of the Crisis. Cambridge, MA: Massachusetts Institute of Technology; 1986.
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