Holiday Greetings from the Kaizen Curmudgeon and Jaded Julie

“Julie, don’t you think it’s time for us to take a break from all this Lean and leadership and problem-solving stuff and wish our readers a Merry Christmas?”

“Merry Christmas doesn’t sound very politically correct, Curmudge. We should say ‘Happy Holidays’.”

“Politically correct, Julie; what’s that?”

“The dictionary says it means ‘marked by or adhering to a typically progressive orthodoxy involving race, gender, sexual affinity, or ecology’.”

“Does it say anything about age? If it did, I wouldn’t be old; I’d be ‘generationally challenged’.”

“Sorry, Curmudge, but age isn’t mentioned.”

“Well then, I can’t be politically correct. Besides, did you ever hear of a politically correct curmudgeon? That sounds like an oxymoron.”

“An oxy what, Curmudge? Oh, never mind.”

“Despite saying we weren’t going to, let’s think for a moment about Lean. The main principles of Lean are continuous improvement and respect for people. If we have respect for all people, we don’t have much need for political correctness. To me, respect is genuine, but political correctness sounds like something dreamed up by a correct politician. And that really is an oxymoron.”

“I looked it up, Curmudge. An oxymoron is ‘conjoining contradictory terms’. Your example really helped me to understand it. But we still haven’t decided how we’re going to express our best wishes to everyone.”

“The fact that we don’t work in a secular hospital makes it simple, Julie. We can say, without reservation, ‘Merry Christmas’. And to those for whom Christmas isn’t meaningful but have December holidays we’ll wish a heartfelt ‘Happy Hanukkah, Eid al-Adha, Kwanzaa, and Boxing Day’.”

“Happy Holidays, Curmudge.”

“Merry Christmas, Julie.”

Affinity’s Kaizen Curmudgeon

Jaded Julie Learns about Dr. Deming

"Julie, when we met last time you convinced me that the training of nurses prepares them to be excellent problem-solvers. All you need is to learn the language of Lean problem solving, and you’ll be off and running.”

“That’s a good choice of words, Curmudge, since nurses are either running or walking fast most of the time. By the way, I hope that the ‘language of Lean problem solving’ doesn’t mean that I have to learn a bunch of new Japanese words.”

“Not a problem, Julie. Lean problem solving is based on the Deming Cycle: Plan, Do, Check, Act. It’s named for an American, Dr. W. Edwards Deming, and the cycle is also used for process improvement. Of course, before you can implement the Deming Cycle, you have to understand the nature of the problem you are working on. So of necessity, the cycle is preceded by a fifth element, Grasp the Situation. Here it is shown as a diagram.”
“That ‘Grasp Situation’ sure looks a lot like Assessment and Diagnosis in the Nursing Process. I’m beginning to see what you are driving at.”

“Grasping the situation is a universal starting point for any investigation. In industry we used to call it penetrating the problem. It’s logical that one must know where he is before planning how he’s going to get to where he wants to go. Getting to the true source of a problem—the so-called root cause—will be the topic of a separate discussion. However from your experience as a nurse, Julie, I’m confident that you can understand the concept. Plan and Do in the Deming Cycle correspond to Planning and Implementation in nursing, and Check—sometimes called Study—is the same as your Evaluation.”

“What about Act, Curmudge? To me, that sounds a lot like Do.”

“You’re right, Julie. The difference is simply its location in the cycle. It’s what you do following evaluation. Actions might include accepting at this point the problem solution you have achieved or the process improvement you have developed. If the process meets the targets established in the Plan, accept it as a standard. Otherwise one could plan ways that might yield a better solution or process and go around the cycle again.”

“I understand, Curmudge. If this is typical, Lean tools should be easy for a nurse to use.”

“Lean tools are straightforward. The real challenge of Lean is learning, accepting, and implementing its culture. The basic Lean culture originated in Japan, and those of us in the older generation grew up not thinking very highly of those guys.”

“Nevertheless, I bet if you and I put our heads together, we can resolve some of those cultural differences. Don’t forget, Curmudge, yours is a much, much older generation.”

“Watch that much, much older stuff, Julie. These are my fingers on the keys.”

“Sayonara, Curmudge.”

Affinity’s Kaizen Curmudgeon

This Time, Jaded Julie is the Teacher

“I confess, Curmudge. I’ve been looking ahead and can see that sometime you are going to teach me about problem solving.”

“That’s right, Julie. We’ll talk about problem-solving techniques used by groups. Things like root cause analysis and brainstorming.”

“Did you know that health care professionals do a lot of individual problem solving?”

“Of course I do. I’ve learned a lot since I began studying at Google University. I sense, however, that you are poised to teach me about problem solving in nursing, so I’ll sit back and let you be the teacher. But remember, Julie, the hands-on aspects of nursing are not my thing.”

“Okay, we’ll start with a placement test of your nursing knowledge. What are the two kinds of diagnoses?”

“That’s simple. Right and wrong.”

“No, no, Ancient One. The two kinds of diagnoses are medical and nursing. It looks as if we’ll have to start your nursing education at square one. Medical diagnosis is the act of distinguishing one disease from another, and a nursing diagnosis captures an individual patient’s reactions to actual or potential health-related problems. Nursing diagnosis is part of the Nursing Process, which includes Assessment, Diagnosis, Planning, Implementation, and Evaluation.”

“So when do you do this Nursing Process?”

“We do it virtually all the time. It should be second nature to an RN. If a patient experiences problems that would be expected from their diagnosis, our planning, implementation, and evaluation are relatively straightforward.”

“But what if your assessment reveals that the patient is experiencing unanticipated difficulties? That’s when your diagnostic and problem-solving talents kick in, right? I didn’t see anything in the nurses’ station labeled ‘Panic Button’.”

“No, but we have to determine right away if we should have pressed the button if we had one. Differentiation of criticality is one of our most important skills. That requires immediate recall of a lot of knowledge plus judgment and critical thinking. That’s why we assess and fulfill the training needs of new hires.”

“You’re not alone up there, Julie. I presume that in a critical situation you can get help from other nurses, the charge nurse, a hospitalist, or the rapid response team.”

“And if the problem is in an instrument, I can call BioMed or read the policy and procedure or the instrument manual. Remember ‘RTM’?”

“I seem to recall a slightly different abbreviation, but I definitely approve of the one you just used. But Julie, I suspect there are needs for a nurse’s critical thinking skills beyond just knowing when to call for help.”

“There sure are. A nurse’s knowledge and judgment are among the first lines of defense against medication errors and other threats to patient safety. Here are a few examples:
· In calls to physicians and hand-offs to the nurse on the next shift, practice SBAR (Situation, Background, Assessment, Recommendation).
· Know what physician orders to expect so you are not fooled by poor handwriting and can question an order that might contain an error.
· Be acquainted with a medication’s contraindications so you can discern when to have your dosage calculations checked by a colleague.”

“You could probably fill several pages with additional examples. Perhaps one of our future discussions should be devoted to patient safety. We wrote about this topic in our pre-Kaizen Curmudgeon days, and we ought to revisit it.”

“So, Curmudge, do you now appreciate the importance of problem solving in nursing?”

“I certainly do. Next time I’ll share with you how your training as a nurse has prepared you for Lean problem solving.”

“Curmudge, I can hardly wait.”

Affinity’s Kaizen Curmudgeon

Jaded Julie Learns about Leaders and Managers

“In our last session, Curmudge, you said we would talk about my becoming a leader. Can you teach me what I need to know?”

“Julie, I can’t teach you how to become a leader, because you already are one. Perhaps that will become evident after we describe the characteristics of leaders and managers.”

“As usual, I’m going to get a ten-dollar answer to a ten-cent question. Okay, Curmudge, proceed.”

“When I was a manager, we didn’t make a distinction between leadership and management. We led and coached, but back then most everything was somewhat hierarchical.”

“Hey, Curmudge, that’s one big word that I know. Hierarchical is like in grade school when the nun had a ruler in her hand.”

“I think your definition is incomplete, Julie, but it certainly captures the spirit of the word.”

“So what is the distinction between leadership and management?”

“It depends upon whose book you read. According to John Kotter—remember him from last time—‘Leadership defines what the future should look like, aligns people with that vision, and inspires them to make it happen.’ ‘Management is a set of processes that can keep a complicated system of people and technology running smoothly.’ Kotter feels that too much management and too little leadership can produce a strong bureaucracy and inhibit a cultural transformation. That could be a big problem for an organization undergoing change, like Affinity.”

“It seems to me that Professor Kotter is focused on executives and those in upper levels of management. But what about me? You said I could be a leader. There must be more to the story.”

“There certainly is, Julie. Mitch McCrimmon (http://www.leadersdirect.com) has a narrower view of leadership and gives management a broader scope. He says that leadership—which he calls ‘thought leadership’—is an impact on a group that causes them to change their thinking, values, beliefs, or attitudes. Once the new idea is accepted, its propagation and implementation are the function of management. The Toyota Production System, the foundation for Lean, encourages everyone to generate new ideas; the ideas gain acceptance when their originators exhibit leadership laterally and even upwards. So that, Julie, is how you can be a leader.”

“Which of these definitions of leadership and management is best, Curmudge?”

“It’s not a one-or-the-other issue, Julie. Differentiating between leadership and management within the top executive ranks is not critical as long as their efforts are taking the organization in the right direction. In our present case, that means toward a Lean culture. Of course, the executives should be aware of McCrimmon so they don’t stifle thought leadership coming from below. However, this differentiation is important in gemba, where all workers are encouraged to lead in increasing efficiency and reducing waste. The workers may not be managers, but they most certainly can be leaders.”

“What else did McCrimmon say about leaders, Curmudge?”

“He said that there are only two positions, leadership and followership. At any point in time one must occupy one position or the other, and you can shift from leader to follower in an instant.”

“I presume that you are going to give me an example.”

“Of course—a down-home drama. As dinner time approaches I sometimes try to provide diplomatic leadership by suggesting to Mrs. Curmudgeon, ‘What are you going to fix for dinner?’ Then she takes the lead by replying, ‘Look in the freezer and fix whatever you’d like.’, and I immediately become a follower.”

“And the moral of your story is…”

“It’s preferable to be a follower than to starve.”

“See you next time, Curmudge.”

Affinity’s Kaizen Curmudgeon

A Funny Thing Happened on the Way to the Transformation

“Actually it wasn’t funny at all, Jaded Julie. It was very sad. The Lean transformation got bogged down and didn’t occur. This happens elsewhere all too frequently, but we mustn’t allow it to occur at Affinity. So let’s look ahead at problems that we might face. Forewarned is forearmed.”

“Why tell me, Curmudge? It’s a long way from a nurses’ station to a corner office.”

“Health care desperately needs leaders who are dedicated, informed, change agents. You are already dedicated, you are learning about a Lean transformation, and we’ll talk later about how you can play a leadership role.”

“I appreciate your confidence. Please proceed to forewarn and forearm me.”

“In our last conversation on Hoshin Kanri, I pointed out that a Lean transformation is a major cultural change that must have the unwavering support of top management. So all one has to do is read and apply the principles described in John Kotter’s book, Leading Change.”

“Curmudge, you know that I don’t have time to read a whole book.”

“Of course. That’s why we do this blog. It provides an easy-reading page or two for people who are too busy to read a book cover-to-cover, no matter how good it is. If you’d like more detail, read Charles Hagood’s column at www.leanhealthcareexchange.com.”

“I prefer your version, Curmudge, but that’s because I’m part of the story.”

“There’s not much more we can say about the importance of the CEO, Julie, except to quote the advice to leaders given by Father Hesburgh of Notre Dame: ‘The very essence of leadership is that you have to have a vision. It’s got to be a vision you articulate clearly and forcefully on every occasion. You cannot blow an uncertain trumpet’.”

“I really like that ‘uncertain trumpet’ part, Curmudge. It’s the sort of statement that will stick in one’s mind.”

“It’s only a figure of speech, but all CEO’s must know that their message has to be consistent. Additionally Julie, through the Affinity Executive Team, we already have the top management support required for our becoming a world-class Lean organization. Professor Kotter would call them our ‘guiding coalition’. Without a powerful guiding coalition, a Lean transformation is likely to founder.”

“What about middle management, Curmudge? Can they sink a Lean culture?”

“If they don’t ‘get with it’, they certainly can. Middle managers must change from being the boss to being leaders and facilitators. It’s up to them to see that top management’s message cascades down to the workers.”

“Everything about Lean sounds good for the workers in gemba. How can we be a part of making sure the Lean transformation is successful?”

“First Julie, keep an open mind to the benefits of Lean. Workers won’t even listen to management’s message if they distrust management or bear too many wounds from earlier failed programs. Corporate leadership, especially the CEO and their own manager, must convey the principle of respect for people in a manner that the workers will believe. If too many workers persist in believing that Lean is just another ‘program-of-the-month’, we will not have a Lean transformation.”

“I’m convinced, Curmudge. You taught me that a Lean culture is good for nurses and techs and others in the workplace. Now I understand that Lean is fragile and requires everyone’s buy-in to make it succeed. But if Lean is a culture, does that mean that it will be an ongoing way of life? Will we ever reach the end of our efforts to remove more and more waste?”

“It’s going to be a never-ending quest. Toyota’s been at it for 50 years, and they’re not there yet. Say, Julie, with your sagacity maybe you should write this blog.”

“My what? Well anyway, see you next time.”

“Bye, Julie.”

Affinity’s Kaizen Curmudgeon

A Hoshin Kanri/Gemba Kaizen Transformation?

“Just to show you that I have been listening, Curmudge, may I start this session with a question?”

“You’ve got the floor, Jaded Julie.”

“Is Hoshin Kanri a part of Lean? The workplace, gemba, is the focus of Lean, but Hoshin Kanri is an initiative that goes from the top down.”

“Good observation, Julie. I see them as complementary, and here at Affinity Hoshin Kanri is an extremely important adjunct to Lean. A Lean cultural transformation is a major change, and change must have the vocal, enthusiastic, and unwavering support of the organization’s leadership. Without their involvement, the people farther down in the organization will ignore the change.”

“Curmudge, this sounds just like in medieval times when the knights would sound the charge and lead their followers from in front. If the leaders were not always there, the troops would lose heart and go home. They would probably say that this was just another conquest of the month.”

“Great analogy! At Affinity, Hoshin Kanri is the means by which top management provides their support for the Lean transformation. With Lean as a corporate strategy and Lean tools needed for many of the hoshins, Hoshin Kanri cascades the Lean transformation all the way down to gemba. So to answer your question, Julie, Lean and Hoshin Kanri go together like love and marriage.”

“You sound old fashioned, Curmudge, but what would I expect? So maybe we should call this whole thing the Hoshin Kanri/Gemba Kaizen Transformation.”

“That’s good Japanese, Julie, but it sounds like the name of the solution to a problem in advanced mathematics.”

“Well, can we just give it a home-grown name, like the Affinity Performance Excellence System?”

“That name has already been taken. But perhaps we can consider it to have been kaizened and subjected to continuous improvement. Then we’ll call it Jaded Julie’s Affinity Performance Excellence System.”

“Wow! Does that mean that you regard me as somebody special?”

“As a nurse, Julie, you always were.”

Affinity’s Kaizen Curmudgeon

Hoshin Kanri is More than Diagrams

“Jaded Julie, now that you have learned what PD and PM matrices look like, should we learn how they are used to guide our actions?”

“Well, Curmudge, what else can a captive audience say but ‘yes’?”

“I appreciate your enthusiasm. Did you know that in the world of Hoshin Kanri there are two kinds of time, Discretionary Time and Ready-to-Serve (RTS) Time?”

“At least I understand discretionary time. That’s the five minutes left in the day after I get home from work, feed the family, and put the kids to bed. Does ready-to-serve time apply to me? I’m a nurse, not a waitress.”

“It’s only a term, Julie. Remember that tackling isn’t the job of an offensive tackle. Actually, most of your shift would be considered ready-to-serve time. It’s the time you devote to your daily required processes like patient care and compliance-required recordkeeping. Duties performed during RTS time are those required for the hospital to stay in business; they can’t be put aside in favor of another activity. Two- or three-day process-improvement events that don’t require resources from outside your department would also be RTS.”

“So what does RTS time have to do with Hoshin Kanri?”

“RTS and discretionary time are complementary. They add up to one’s whole working day. People with significant discretionary time are managers, directors, and members of corporate departments like Information Systems, Marketing, and the Kaizen Promotion Office (KPO).”

“I presume, Curmudge, that those folks shouldn’t use their discretionary time standing around talking about the Badgers and the Packers.”

“They would do so at their peril, Julie. Their discretionary time, also called ‘deployable time,’ should be used to work on the projects shown on Hoshin Kanri PM and PD2 matrices. Ideally, everyone should try to make their RTS activities more efficient—perhaps using Lean tools—so that their RTS time decreases and their discretionary time expands.”

“These days, IS and KPO staff members must be in great demand for Hoshin Kanri projects. Seems as if they might need to have 20 hours per day of discretionary time.”

“Fortunately, prioritization and allocation of resources are central features of Hoshin Kanri. Corporate hoshins and the projects supporting them have highest priority; then business unit hoshins and finally department hoshins at the low end of the priority list. If a given person’s discretionary time is fully committed to a project supporting a corporate hoshin, he/she is not available to work on business unit or department projects.”

“But what if that person is absolutely essential for the lower-priority project?”

“In that case, Julie, the project—and possibly the hoshin if the project is essential to the hoshin’s success—is put in the ‘parking lot.’ In Hoshin Kanri language, the project is said to have been ‘deselected.’ It can be recovered from the parking lot and worked on after the higher priority project is completed.”

“And what if the staff person’s discretionary time is needed in two projects at the same priority level?”

“Then the appropriate directors negotiate the relative priorities of their projects. The Japanese call this process ‘playing catch ball’.”

“The words are English, Curmudge, but I bet they are pronounced with a Japanese accent.”

“That’s okay. Hoshin Kanri is their game; perhaps they anticipated that we would be using it. Now, Julie, I believe that we have covered most of the organizational elements of Hoshin Kanri, but we need to spend a moment discussing Hoshin Kanri management.”

“If you say so, Curmudge. This part is going to be easier, right?”

“Right. The PM’s and PD2’s that we have learned about are Hoshin Kanri’s visual management tools. They are posted in each team area and reviewed weekly by the hoshin leader. Problems are marked in red and are addressed immediately. This process will soon be possible electronically using QuickBase®”

“It seems that there are no hiding places in Hoshin Kanri.”

“There sure aren’t. Hoshin Kanri provides transparency, which is an essential feature of good modern management. Then every month or every other week the business unit leadership does a walk-around review of the status of local and corporate hoshins. Finally, every quarter the top management devotes a meeting to hoshin reporting and coordination. This provides company-wide accountability for all initiatives and how they drive strategies leading to achievement of organizational goals.”

“What happens if a hoshin leader’s planning matrix shows a lot of red? I understand that hoshins are described as ‘must-do, can’t-fail’ initiatives.”

“That’s true, Julie, but that means that the organization can’t fail to accomplish the hoshin. Red in the PM simply signals the need for assistance as soon as the need is apparent. That’s the beauty of Hoshin Kanri’s real-time visual management.”

“Curmudge, it also signals the need to take a break from filling my brain with Hoshin Kanri.”

“See you soon, Julie.”

Affinity’s Kaizen Curmudgeon

Jaded Julie Learns about Policy Deployment Matrices

“Okay, Julie, sometimes one has to grab the bull by the tail and look the problem right in the eye. So here’s the policy deployment (PD1) matrix for the Curmudgeon Company.”


“Wow, Curmudge! That’s an information-filled matrix. Where do I start?”

“First, let’s read it like a map, with north at the top. Start at the west with Goals, then Strategies in the north, and Hoshins in the east. Strategies are linked to goals by the big dots, called ‘meatballs’, in the northwest; Hoshins are linked to Strategies by the meatballs in the northeast. The Team Support and the meatballs in the southeast show the organizations that are going to accomplish the hoshins.”

“If I look at the PD1 matrix long enough—maybe for a week—it will all soak in. I fear, however, that you already have another type matrix to dump on me.”

“I do have another one, Julie, but its concept is a lot simpler than its sticker shock. It’s just a PD1 rolled onto its side, that is, rotated a quarter turn counterclockwise. Here it is.”

“Hey, the goals went away!”

“No, they’re still there, Julie, but they are hidden from view and hopefully imbedded in your mind. Unless, of course, you want us to make this thing three-dimensional.”

“No thanks. I see now that the Strategies are in the west, and the Hoshins in the north. But you’ve added Projects in the east. I remember those from the planning matrix (PM). At least the projects supporting the ‘Improve yard’ hoshin were on the planning matrix we looked at.”

“That’s right, Julie. The ‘Remodel bathroom’ hoshin would have its own PM. If the Curmudgeon Company were bigger, like Affinity, each department would have a PD2 showing its projects; and individual people assigned to the projects would be shown under Support on the south side of the matrix.”

“These matrices are informative, Curmudge; they do require concentration. My head is spinning, but it has only gone a quarter turn counterclockwise. Is there more to Hoshin Kanri than diagrams that have to be read sideways?”

“There certainly is, Julie, and we’ll talk about that next time.”

“Bye, Curmudge.”

Affinity’s Kaizen Curmudgeon

Jaded Julie Learns the Language of Hoshin Kanri

"Time for a vocabulary lesson, Julie. Then we’ll learn how the words are used.”

“Okay, Curmudge, but I sure hope that when a new word goes into my brain, an old word doesn’t come popping out.”

“Don’t worry, Julie. That only happens to senior citizens. Let’s start by talking about matrices, which is the plural of matrix.”

“So what is a matrix?”

“I don’t think you want me to say that a matrix is a rectangular array of numbers, so why don’t we just use an example. A calendar is a simple matrix; it shows days of the week across the top and weeks of the month down the side. If you go out for fish every Friday, you’ll be doing it on October 5, 12, 19, and 26 in 2007. That’s pretty important information, don’t you agree?”

“I’m getting hungry already. Go on, Curmudge.”

“In Hoshin Kanri Planning there are several types of matrices. Each one has a name, and each name has an abbreviation.”

“I sense that this conversation is going down hill, but I haven’t bailed out yet.”

“Good! These are the names and abbreviations of the two main types of matrices: Policy Deployment (PD), and Planning Matrix (PM). Note that when ‘P’ is followed by ‘D’ it stands for Policy, and when ‘P’ is followed by ‘M’ it stands for Planning.”

“That sounds a bit inconsiderate of students, but at least it’s in English.”

“Don’t complain. There are similar idiosyncrasies in Arabic, and they have been learned by millions of children. Let’s gain an understanding of these terms by devising a simple scenario. Call the company the Curmudgeon Company with my wife and me the co-CEO’s.”

“I presume that you each make some of the important corporate decisions.”

“Right. She decides where we live and how the house is furnished, and I decide what color shirt to wear to work every day. Anyway, back to the scenario. We have developed two long-term goals, Move to a Warmer Climate and Sell the House. Our strategies for selling the house include Remodel the Interior and Upgrade the Exterior to Improve Curb Appeal. One of our hoshins (short-term essential achievements) to further the ‘Upgrade the Exterior’ strategy is to Improve the Appearance of the Yard. Although this is all hypothetical, I hope it helps clarify the terms we introduced last time, Goals, Strategies, and Hoshins.”

“It’s not bad, Curmudge. Whenever I get discouraged, I think of little children trying to learn Arabic.”

“Remember, Julie, the reason for the scenario is to help us understand the two main types of matrices used in hoshin kanri planning, the Policy Deployment Matrix (PD), and the Planning Matrix (PM). The Planning Matrix is simpler, so we’ll start with that one. Every hoshin has a planning matrix that shows the hoshin’s measure of success, the individual projects undertaken to support the hoshin, and the progress of those projects. Shown below is the planning matrix (PM) for our ‘Improve the Appearance of the Yard’ hoshin.”

"Well, Julie, I hope our example makes the Hoshin Planning Matrix appear straightforward. Next time we’ll tackle Policy Deployment Matrices.”

“I agree, Curmudge. Sometimes you do make complex topics easier to learn.”

“When do you want to hear my lectures on thermodynamics, Julie?”

“How about in ten years?”

“Bye, Julie.”

Affinity’s Kaizen Curmudgeon

Jaded Julie Begins to Learn about Hoshin Kanri Planning

“I’m sorry, Jaded Julie, but we’re going to have to deviate from our Lean transformation theme. The new topic is Hoshin Kanri Planning.”

“That’s okay, Curmudge. As Yogi Berra said, ‘If you come to a fork in the road, take it.’ But it sounds as if I’m going to have to learn two new Japanese words. You know that I’m not very good at foreign languages.”

“There’s nothing to fear, Julie. There are only two Japanese words that we’ll be learning; everything else is in English. Besides, every trade and profession has its own language. You have already learned the language of nursing. If someone says ‘Foley catheter’ to you, you immediately know what they mean. Those words mean nothing to the average person on the street, and those folks who recognize them simply shudder.”

“So you’re saying that learning Hoshin Kanri is essentially the same as learning a foreign language or the specialized English vocabulary of a profession?”

“Exactly. Learn the most essential words and the rules for their usage; then practice, practice, practice. Soon you’ll be thinking in Hoshin Kanri.”

“I’m shivering with anticipation. By the way, Curmudge, why are we doing this?”

“Every corporation needs to plan how it will improve its performance. Affinity has determined that Hoshin Kanri is the best planning process. It can be translated as policy deployment, goal deployment, or policy management, but Affinity has adopted the Japanese terms. In this process, the leadership team identifies goals for the corporation, develops strategies for achieving the goals, and then specifies essential achievements needed to further the strategies. In this context, the essential achievements are called ‘hoshins’. Sorry about the additional Japanese, but it’s just a rule of the game—sort of like learning to roll your ‘r’s to be understood in a foreign country.”

“It seems reasonable so far, but it sounds as if it involves only management. So why do I have to learn this?”

“You’re right in that the folks most directly involved with Hoshin Kanri are those from top management on down to directors and managers. But you might be called on to help. As I’ll point out later, Hoshin Kanri will permeate all of Affinity; and you will want to understand what is going on around you. Furthermore, achieving a Lean transformation is one of our corporate strategies. Hoshin Kanri is the means by which the Lean transformation that you have been studying will be accomplished.”

“So it will relate to me. I was about to lose interest. Proceed, Curmudge, but go slowly.”

“Let’s wrap up this session by mentioning that the business units—each hospital, Affinity Medical Group, etc.—commit to hoshins (remember—essential achievements) that further the corporate strategies that are within their purview. They also develop their own business unit strategies and hoshins. The result of this is that everyone is focused long term on achieving the corporate goals.”

“Whew! Are we finished for the day?”

“Yes. We’ll tackle more Hoshin Kanri Planning next time. Meanwhile, think how easy it was to learn the special terminology of sports, like ’first down’ and ‘offside’ in football…”

“…and throwing a ‘Hail Mary’ pass from your own 10-yard line.”

“You’ve got the idea, Julie. And I’ll make sure that learning Hoshin Kanri is not ‘unnecessary roughness’.”

Affinity’s Kaizen Curmudgeon

Jaded Julie Learns More about a Lean Transformation

“Hey, Jaded Julie, my shadowing you for a day last month certainly convinced me of the potential value of Lean for nursing.”

“No problem, Curmudge. You were not in the way, and you seemed to have a lot in common with the older patients.”

“But remember the critical difference, Julie. I was standing up.”

“I’d like to learn more about Lean, Curmudge, especially the Lean tools that you mentioned.”

“Let’s not get ahead of ourselves. The tools and techniques used in Lean are only half the story. We first need to learn the basics of a Lean transformation. Using Lean tools without knowing the basic philosophy would be like putting you to work on Four South without first learning physiology.”

“Go ahead and teach, Curmudge, as long as it’s not biochemistry.”

“Lean has two basic principles. We have already learned about the first one, Continuous Improvement or Kaizen. The second principle is Respect for People.”

“That’s easy. We already show respect for our patients in our caring for them.”

“There’s more to it than that, Julie. In a Lean transformation the organization respects all of its people, including everyone in gemba. I’m sure you recall that gemba is everywhere in the hospital where services are performed for our customers, the patients. Remember the upside-down organizational pyramid. A major focus of Lean is to help workers realize their full potential. This is very different from traditional management systems.”

“I hesitate to ask, Curmudge, but is there more to Respect for People than professional fulfillment?”

“I’m glad you did ask. An essential part of a Lean transformation is a ‘no lay-off’ policy as a result of process improvement and standardization. That means if your unit becomes so efficient due to application of Lean that not everyone is needed, the extra person will have opportunities elsewhere with Affinity.”

“Wow! That sounds great. Is there anything else?”

“Eventually there will be. When there are gains to share, a ‘gainsharing’ program will be started. Gainsharing means that when the hospital exceeds predetermined performance levels, the monetary gains will be shared with everyone.”

“Curmudge, all of this Lean stuff sounds super, but I know there is no free lunch. What can go wrong?”

“As usual, Jaded Julie, you have keen perception. When we get together next time, we’ll chat about potential pitfalls. See you then, Julie.”

“Ciao, Curmudge.”

Affinity’s Kaizen Curmudgeon

The Curmudgeon Shadows Jaded Julie

“Thank you, Jaded Julie, for allowing me to shadow you last week. I learned a lot.”

“Well, you weren’t much trouble. You didn’t get in my way, and only a few patients asked, ‘Who is the old guy?’ Why did you need to shadow a nurse, anyway?”

“Remember last month’s saying from Gemba Kaizen about going to where the action is—‘Go to Gemba.’ If I hope to teach you anything useful, I need to know what a nurse does. So I took my own advice and went to gemba.”

“So what did you learn in my gemba?”

“Good things first. You do a great job of caring for your patients. Despite having a lot to do, you were always compassionate and responsive to the patients’ needs.”

“Thanks for the kind words. Did you see anything that we should improve?”

“I didn’t see, but I heard…a very noisy TV set in a patient room. In my opinion, that’s not a healing environment. If I were a patient, I’d want to get well quickly just to get away from the noise.”

“To live up to your name, Curmudge, I suppose you found other things to complain about.”

“Let’s call them opportunities, Julie, not complaints. Nurses spend too much time writing, and you do it by hand. And you are seemingly in constant motion. It might be good exercise, but I’ll bet that a lot of it isn’t value added.”

“Okay, Curmudge, but what can we do about all this writing and running?”

“Our need for better technology is dire, but you can’t do much about that personally. Ultimately, you’ll be able to use Lean tools to make your processes more efficient.”

“Lean tools? Is that like a skinny monkey wrench?”

“No, they are techniques you can use to remove waste from your processes. We’ll talk about them later. Meanwhile, keep up the good work. Perhaps I’ll even return for another visit.”

“If you do, I’ll warn everyone that ‘The Kaizen Curmudgeon Is Coming’.”

“At least the patients won’t wonder who the old guy is.”

Affinity’s Kaizen Curmudgeon

Jaded Julie Learns About "Gemba"

“Hi, Jaded Julie. I see you decided not to wear your kimono at work.”

“The kimono might have been okay, but I couldn’t see myself clop-clopping down the hall responding to a ‘code’ wearing those wooden shoes with blocks on the bottom.”

“Those are ‘geta,’ Julie. I agree with your good judgment.”

“You said last time that we’d learn a new word today—something like ‘gumbo’.”

“Not gumbo, Julie, ‘gemba.’ We’re doing Japanese, not ‘Cajun. Gemba means ‘the real place.’ It’s your workplace.”

“But I thought my workplace was called Four South.”

“Julie, in a hospital gemba is any place where services are performed for our customers, the patients. The OR, ED, lab, radiology, examination rooms, patient care units, and lots of other places are all gemba. But not executive offices or the gift shop.”

“I get it. Gemba is where the action is no matter where it’s at.”

“I couldn’t have said it better. Without all of these gembas Affinity couldn’t fulfill its mission of providing services that promote the health and well being of the communities we serve. In Gemba Kaizen®, an older brother of Lean, the organizational pyramid is inverted with gemba at the top. The role of all of the managers and directors is to support the workers in gemba. To help with solving problems or making improvements, managers are told to ‘go to gemba’.”

“That sounds great to me, Curmudge. I always wanted to be at the top of the pyramid even if it’s really the bottom.”

“You’re the top, Julie. You and the rest of the folks in gemba. Masaaki Imai said, ‘If we call the customer king, we should call the gemba people Buddha’.”

“I’m for that, Curmudge, as long as I don’t have to sit cross-legged on the floor.”

“’Bye, Julie.”

“’Bye, Curmudge.”

Affinity’s Kaizen Curmudgeon

Profile Change

The Curmudgeon and Jaded Julie Talk About Names

“Hey, Jaded Julie, I have a new name. It’s The Kaizen Curmudgeon.”

“I liked your old name, Affinity’s Quality Curmudgeon. And the columns you wrote on patient safety, standards, and Lean were easy to find in Quality Management’s home page on the Affinity intranet. Why the change?”

“I’ve got a new home, in Affinity’s Kaizen Promotion Office, and I’m going to write a blog instead of intranet columns. So it’s new geography, a new communication medium, and of course, a new name.”

“But with your old name, I at least understood one of the words.”

“My last name wasn’t so bad. Although the dictionary says that a curmudgeon is a nasty old person, I prefer to think of him as a grouch possessing a significant amount of perspicacity.”

“Thanks for the help. At least I know what a grouch is. But what’s that Kaizen stuff?”

“Kaizen is a Japanese word meaning ‘change for the better’ or ‘continuous improvement.’ It's one of the principles of the Lean transformation that we are initiating at Affinity Health System."

“So why use Japanese words? They are all Greek to me.”

“Lean was first used in Japan. It's their game, so we use their words. It’s sort of like the way they use our words for our game, baseball, or besuboru in Japanese. Other baseball terms that the Japanese have adopted (sort of) are pinchi hitta (pinch hitter), rukii (rookie), and senta (center fielder).”

“Hey, that Japanese stuff is a great idea. Maybe I can wear a kimono at work instead of my blue scrubs.”

“We’ll see. Julie, next time we get together I’ll introduce another Japanese word, gemba (the workplace), and we’ll talk more about what is involved in a Lean transformation.”

“I can’t wait, Curmudge."

"Sayonara."

Affinity's Kaizen Curmudgeon