Defining Work Stations and Teams

The role of leaders is to talk with those who actually do the work and diagram just what these 'work stations' are and what they do. Our definition of 'work stations' in healthcare are semi-autonomous and multi-skilled work teams along the path of workflow that contribute to a task, service or product that is used by or serves another group in the workplace. You are now creating a Work Process Flow Map, understanding what is done so you can create reporting structure for change. The next steps will allow you to understand what is done that adds value, doesn’t add value but is required or what is done that is of no value and can be changed. With more detail about each process in that work station, you are creating a Value Stream Map. The level of detail required to understand wasteful and inefficient processes may include cycle time, set up time, the number people/staff/shifts, the volume/batch size, the defect rate, measures of reliability, and identifiable defects and bottlenecks.

The structure should define work as it is done or contributed to or passed to numerous contributors. How do you get to this point?  Here's a suggestion. Tape a long piece of butcher paper to the wall and begin diagramming the flow of your product or service to follow the patient, or the specimen or the invoice, etc, sequentially, until you are finished with all you can do. That is your workstation. Align and connect these workstations horizontally and identify team leaders and members for each workstation. You may identify inefficiencies of work looping back to the same workstation or forking to two different workstations for no good reason. These are opportunities for workflow redesign.

The identification of a Team Leader, if none already exists, may be accomplished in a number of ways. This includes appointment by ability, by passion or by vote of the work station members. The option to bypass a non-effective Lean team leader with the appointment of a co-leader should be noted as a dysfunctional team is a significant barrier and the role of the team leader is often key to success. For areas with multiple shifts, it is important to have a team leader for the workstation on each shift so that the input and voice of all workers can be channeled for continuous improvements.

Defining Reporting Relationships for Accountability

In the Henry Ford Production System, we have adapted to our healthcare environment the best of several structures (see figure below): 1) Toyota's line-level organizational structure for quality improvement using Group Leaders, Team Leaders and their respective Team Members aligned with 'work stations'; 2) Team Members empowered to represent their team in Customer-Supplier meetings in the interface as work is passed across work stations, units, departments and hospitals; and 3) Process improvements lead not by the Team Leader as in Toyota but by the empowered healthcare Team Members themselves. This requires leaders to adopt the Deming-style of management rather than merely applying the principles and using the tools of Toyota's efficient production system in focused projects. 

That organizational structure is depicted in the cartoon below for continuous improvement linking numerous multidisciplinary workstations and teams at the level of the worker. It is expanded for the work designated "Initial Patient Evaluation" into further sequential Teams along that path of workflow contributing to "Initial Evaluation." If there is no designated Team Leaders, for these 'work stations,' make sure that there are. The designation of a Team Leader for process improvement is an HR-free one, that is, it requires no Human Resources Department permission. I view this role as an expansion of the job description duty usually listed as - "other duties as assigned". In an effective Lean culture that "other" box can and should become very large. This person is key and is tasked with driving and facilitating the team-based approach to process improvements at the level of the actual work. 

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. 

Changing the Way People Work

Further Practical Tips in Producing Change in the Way People Work

The structures we create and the support we provide to sustain worker-involved change is critical to its success. Dr. Jeffrey Liker has nicely framed the key issues for leaders intent on truly changing culture that will result in "a business transformation that puts customers first and does this through developing people. People who do the work have to improve the work."

"As we are progressing on the 'Lean journey', companies are maturing from process-improvement toolkits to lean value-stream management, to employee engagement in problem solving, to aligned culture focused by self-aware leadership on the right business problems. The companies I teach are begging for guidance on leadership. They have had enough discussion of tools. They understand that path is a dead end. It is the right time for this discussion, but how do you have the discussion?

...There are tools, but they are not tools for 'improving the process.' They are tools for making problems visible and for helping people think about how to solve those problems. Whether it is a kanban or standardized work or 5S, these are tools to set a standard and make the deviation from the standard visible to the work group. Then the work group must develop problem-solving skills to identify the root cause and solve the real problem.

...Any solution is an experiment that is 'right half the time.' If the tools do not change the way people who do the work think about their own processes, the tools are a failure. If leaders do not understand how to use the tools to unleash the creativity and motivation of people, they are not leaders-they are just administering a bureaucratic process."

The Bottom Line

"You get what you accept and what you accept sets the standard."  -Joseph Bujak, MD

It is common to for leaders to speak of change in the same sentence with changing culture. But our own experience with culture change these past 6 years in the Henry Ford Production System across all laboratories of nearly 800 workers in Henry Ford Health System has taught us repeatedly that culture is a desirable but secondary outcome to changing structure and process that enables and expects employees to work differently.

It is the investment of time in training our people to work collaboratively in the structures that we create that enables a continuous push for incremental improvement. This is how leaders incentivize people to behave and ultimately defines our culture. 


Dr. Liker has shared with us that

"People development takes 10 times longer than process improvement."

So don't expect miracles from a Lean culture overnight. It takes time to train and form functional problem-solving teams. It's one small step after another that takes you toward the goal. Just never stop striving. 




References

Jeffrey K. Liker: Personal communication and book review at Lean Enterprise Institute of The Lean Manager: A Novel of Lean Transformation (2009, Balle and Balle)

Leader's Role in Leading Change

You Must Lead the Change

What is your role in leading change and assuring successful transformation to a Lean working culture? What is expected of you? What is the difference between leadership and management?

John Kotter, a voice of the Western management style, would say,

"Leadership is the development of vision and strategies, the alignment of relevant people behind those strategies, and the empowerment of individuals to make the vision happen, despite obstacles. This stands in contrast with management, which involves keeping the current system operating through planning, budgeting, organizing, staffing, controlling, and problem solving."

Both roles are very important to business success and we often wear both hats.

But Deming would call us to a different understanding for business success in the LEAN culture, notably his Principle #7- Adopt and Institute Leadership.  By leadership he means, 

"The job of management is not supervision, but leadership.  Management must work on sources of improvement, the intent of quality of product and of service, and on the translation of the intent into design and actual product."

In other words, your primary focus is overseeing the continuous development of a better system of work in which employees can be more effective in achieving the goals that you have assigned them. Otherwise, you're not doing the job. And they can’t be expected to do their jobs to your level of expectation in a flawed system of work.

To quote Deming again,  "The required transformation of Western style of management requires that managers be leaders."

Kotter's 8 Steps of Change

Change, especially significant change of the status quo is not easy. Everyone loves the idea of change for the better, until it’s his or her time to change. Kotter describes a number of managerial behaviors that are critical to succeed in producing change. When managers produce successful change of any significance in organizations, the effort is usually a time-consuming and highly complex 8-step process, never a 1-2-3, hit-and-run affair.  According to Kotter, managers who opportunistically skip steps or proceed in the wrong order rarely achieve their aspirations.

In the most successful change efforts, leaders must move through 8 complicated stages in which they (1) create a sense of urgency, (2) put together a strong enough team to direct the process, (3) create an appropriate vision, (4) communicate that new vision broadly, (5) empower employees to act on the vision, (6) produce sufficient short-term results to give their efforts credibility and to disempower the cynics, (7) build momentum and use that momentum to tackle the tougher change problems, and (8) anchor the new behavior in organizational culture.

References

W. Edwards Deming: Out of the Crisis. MIT Press 2000.

John P. Kotter: On What Leaders Really Do. Harvard Business School Press, 1999.

Constancy of Purpose

The Leader's Focus on Constancy of Purpose

Creating constancy of purpose towards improving work product and service levels is the basis of continual improvement.  This enables us to be competitive and to grow in a very tough healthcare market where patients and reimbursements are declining. Ultimately, this allows us to stay in business and to provide jobs.

This constancy of purpose is focused on the customer. Who are your customers?  Internal as well as external?  Who are your passing your work product to? What do they want?  What specifically are their needs and expectations?   How well are you serving them?  Are you just meeting minimum expectations and someone else's benchmarks or are you thrilling them? How do you know?

Constancy of purpose requires leaders to address:

• philosophy and policy
• core values
• long term strategic course

In the previous blog entry, I discussed the philosophy at the core of people development, supported by an appropriate management system that empowers the workforce to effectively employ technical tools of work efficiency and process improvement.  It is our role as leaders to reinforce this cultural transformation in the workers perception of their work roles, to create structures for empowered workers to be accountable and successful, to communicate, support, reward and model this culture of engaged workers, helping to identify and resolve defects and eliminate waste. Leaders must be engaged and lead from "the shop floor" to use the manufacturing analogy. It is from this perspective that opportunities for improvement become evident daily, at a very granular level. This leader engagement is more than just taking a walk-around to ask how things are going. 

What To Do

"Doing your best is not good enough. You have to know what to do. Then do your best."

-W. Edwards Deming

As a leader, knowing what to do is the part each of you and your workers own in your area of expertise. That requires constant attention to refining what you do to be better, continually. For that you need a structure that provides accountability by defined teams for continual identification and correction of defective work and work processes in the workplace and at individual workstations where this occurs with on-going measures of how well you are performing. I will address the specifics of these topics with "how to" examples subsequently in this Lean Leaders Guerrilla Handbook series.

References

W. Edwards Deming: Out of the Crisis. MIT Press 2000.