Friday, October 28, 2011

Lean Leadership 3

“Continuing with our music analogy, Jaded Julie, what is the first thing that happens after you have arrived at a concert venue?”

“I go to the ladies’ room and ‘powder my nose,’ as my mother would say.”

“But right after that you would receive a program for tonight’s orchestra concert.”

“Right, Curmudge. I’ll need that to learn what’s going to be played and who will play it. Say, that reminds me of the visual controls—the dashboard or process status board—that we are developing for the unit back at the hospital. That makes our organization, efforts, and accomplishments transparent to our team as well as to passers-by.”

“I’m delighted that you are thinking about work, Julie, but you must not be enjoying the concert. So what goes on the board? I presume that it is updated at the beginning of each shift.”

“These are my thoughts, Curmudge. I will need to collect input from above and below me in the organization. Presumably this would include hospital-wide and unit measures of performance. Unit data would include census, patients (room numbers) of concern or likely to need special care, and anticipated discharges. Safety issues and the status of process improvement efforts should be included. Of course, it shouldn’t become so crowded that one can’t see the forest for the trees.”

“Good, Julie. Now that the dashboard is designed, let’s think about standard work for you, a front-line leader in a nursing unit. You might not have thought about it, but you closely resemble front-line leaders at Toyota. They have developed hands-on proficiency at all of the operations performed by their team. With all of your experience, you have developed comparable proficiency in nursing. Congratulations, you are a supernurse.”

“I won’t be a supernurse in this position very long if I don’t develop some leadership standard work. Each day (or shift) will start with a report from my predecessor and a tour of the unit to collect data to update the dashboard. This will be followed by a brief stand-up huddle in front of the dashboard with the nurses in the unit; of course, this can’t occur until they have taken report from their counterparts on the preceding shift. We’ll welcome any ‘float’ nurses and assure that they will be brought up to speed on our standard work. The focus of this short meeting will be the current data on the dashboard, especially that pertaining to current improvement projects.”

“At that point, I’d be ready for a coffee break, but I know that you don’t have time. It’s time to get out in gemba and see that the agreed-upon standard work is being followed. If the work had not been standardized, you wouldn’t be able to detect deviations. When you see a deviation, ask ‘why?’; it might represent a new idea to improve the process. Be alert for ‘workarounds’ and ‘treasure hunts;’ they are clear signals of problems to be addressed and corrected. As a supernurse, you will be the unit’s fount of knowledge and master of techniques. If a patient is a ‘hard stick,’ you’ll be able to insert an IV catheter on the first try. And even when special talents are not required, you can provide an extra pair of hands to fill in where needed.”

“Thus far, except for the dashboard much of my job doesn’t sound too different from what it was before Lean.”

“But now your front-line leader’s job has become standard work. Your tasks are very similar (standardized) to those of other leaders in other comparable units. Through your joint efforts, you have learned what works best and adopted it as standard work. All of you are coaching your teams in standard work, continuous improvement, problem solving, and respect for one another. This requires that you possess personal discipline and can impart—through coaching—discipline to each of your direct reports.”

“Before we leave Lean at my level of leadership, we must not forget my daily or weekly meetings with my supervisor or manager. Her standard work is to assess my accountability for providing the Lean leadership that we have been discussing. She fully understands the value of gemba walks and agrees that ‘the currency of leadership is presence.’ If I appear unenthusiastic about Lean, she will remind me that, ‘it is easier to act your way into a new way of thinking than to think your way into a new way of acting.’ That translates into, ‘just do it,’ or ‘try it and you’ll like it.’ “

“Our readings (1,2) have suggested that regular daily or weekly meetings of leaders and their staffs going at least three levels up the chain of leadership are essential in maintaining the momentum of a Lean transition. Remember Masaaki Imai’s admonition, ‘Kaizen is everyday improvement, everybody improvement, everywhere improvement.’ Remember also that Lean, like the flywheel we discussed back on March 26, 2008, resembles a bearing with lots of friction; it requires constant pushing. That puts a lot of responsibility for Lean’s success on the shoulders of middle managers who must adopt Lean leadership.”

“There’s a bundle of stuff that we front-line and middle managers have to know and do on a daily basis, Curmudge. Can you summarize from our reading?”

“From Kenney (1):
• ‘Know the status of daily work.
• Know if planned work is completed on time.
• Understand both upstream and downstream impact.
• Know that standard work is being followed.
• Know when to take action and what action to take.’

From Mann (2):
• ‘Assessment based on data captured on visual controls.
• Assignment for corrective action and/or improvement.
• Accountability for having completed the previous day’s assignments.’ "

“All of that sounds pretty intuitive, Curmudge. As I’ve said before, ‘Lean is just organized common sense.’ Lean leadership is powerful because it enforces daily accountability. And if people do this every day for months or years, they will forget what they would slide back into if they had any inclination to back-slide.”

“By the way, Julie, whatever happened to that concert that you were attending?”

“I got so wrapped up in thinking and talking about Lean that I was asked to leave.”

Affinity’s Kaizen Curmudgeon

(1) Kenney, Charles Transforming Health Care (CRC Press, 2011)
(2) Mann, David Creating a Lean Culture (CRC Press, 2010)

Thursday, October 20, 2011

Lean Leadership 2

“I suspect that all of us start each workday with standard work. I turn off the alarm clock and jump out of bed. Shave, do stretching exercises, and bring in the Wall Street Journal from the driveway. Eat breakfast, get dressed, and drive to work. Except for weekends, every day is essentially the same.”

“That was when you were working, Curmudge. Now that you are retired, you get out of bed more slowly and take time to read the front and editorial pages of the Journal. Everything else is pretty much the same as before.”

“My point, Jaded Julie, is that everyone knows about standard work, but each person has his/her own routine. That’s okay at home but not at work. Correcting this problem—facilitating the development of a unit’s standard work—is one of the most important tasks of a front-line supervisor. That’s the role I’d like you to play, Julie—a charge nurse or coordinator in a nursing unit of a generic hospital.”

“At least it’s better than my last role—a terminal patient in an ICU. If the nurses and techs haven’t taken a Lean Overview course, there’s a lot that I’ll have to teach. Kaizen events, value-stream mapping, A3 problem solving, 5S, PDCA, and more.”

“What the team members learn should stick with them, because they’ll be putting it to use right away. Remember that the standard processes will be developed by and owned by the team. A standard won’t fly if it is imposed from above.”

“Can you give me some ideas of things the team might achieve, Curmudge?”

“For inspiration, read about what other Lean hospitals have accomplished (1). Note that in every case their focus has been on enhancing the patient experience. Here are some of the things done at Virginia Mason Medical Center: made ‘taking report’ at shift change more efficient, reduced nurses’ time required for paperwork, instituted medical emergency teams, changed hourly rounding so that nurses would anticipate patient needs, and involved other departments in studies of systems to reduce the hospital’s ‘silo’ culture.”

“Those all sound good to me. They are excellent examples of Lean as it should be practiced in gemba. If I, as a front-line supervisor, could lead my team to accomplishments like those, you’d deem me an unqualified success.”

“You’ve made good progress, Julie, but there’s more. At this point in your fictional Lean leadership journey you are not doing what is needed to make those process changes endure. The problem is that some people in management—I hope not you—tend to leave standard work at the breakfast table. They arrive at work, check the day’s schedule for meetings, sometimes say a brief ‘good morning’ to the team members, and begin to fight the day’s most serious fire. They are attempting to manage a Lean team, but they aren’t practicing Lean themselves.”

“I’ve got it, Curmudge. Without Lean leadership, members of the team start drifting away from standard work and return to doing things ‘the way I’ve always done it.’ As we learned last week at Granddad’s farm, entropy is at work.”

“It’s also like a choir, where everyone might be singing a solo if it weren’t for each member reading from the same score…”

“…and an orchestra where we hear a bunch of toots and bleeps until the conductor taps his music stand with his baton.”

“Please note, Julie, that in both organizations the conductor can’t stop directing, walk away, and expect that the good music will continue. So next week we’ll return and play the next movement of the Lean Leadership Symphony.”

“I hope it won’t turn out to be a dirge. Bravo, Curmudge!”

“Brava, Julie.”

Affinity’s Kaizen Curmudgeon

(1) Kenney, Charles Transforming Health Care. (CRC Press, 2011)

Thursday, October 13, 2011

The Need for Lean Leadership--Entropy

“Curmudge, did I understand you to say that many organizations are stymied in their Lean journey because they haven’t developed a Lean management system to go along with Lean implemented in their workplace?”

“That’s what the literature says, Jaded Julie. People in gemba have learned to use Lean tools, like standard work; but without ongoing reinforcement by Lean leadership, they tend to slip back into their old, nonstandard ways of doing things. Then the Lean journey sputters to a halt.”

“That’s a sad commentary on human nature. But you have said that this tendency toward disorganization is quite natural, applies to everything—not just people—and that it is described by a thermodynamic term called entropy. Without an external input of energy, disorganization—entropy—tends to increase.”

“You’ve got it, Julie, and I can assure you that the objects in my example never studied thermodynamics. When I was a child back in the early 1940’s I used to visit my grandfather’s farm in the hills of southwestern Virginia. Granddad’s sons, my uncles, were away in the war, so he was running the farm with the help of my step-grandmother and their dog, Shep. When it was time to milk the cows, Granddad would send Shep up the ‘holler’ (hollow, a narrow valley) to collect the widely scattered cows and herd them back to the barn. Because Shep was part Border Collie, this was a very natural task.”

“I’m listening, Curmudge. This will undoubtedly turn out to be one of your homespun tales ending with a lesson.”

“So we’ll continue, Jaded Julie. The cows went into the barn and into their familiar stalls (in those days we didn’t have stanchions). Grandfather milked each cow by hand. I tried to help but got little milk; I did get a solid whack on the head by the cow’s tail. Upon finishing, we opened the barn door and the gate to the pasture, and the cows filed out and up into the hills.”

“I suspect that we are just about to learn something about entropy, the topic of today’s conversation.”

“The cows might have stood shoulder-to-shoulder and marched in rank up the holler like a cavalry charge consuming the grass in a wide swath. They didn’t, of course. Each cow went its own way—some on one hill and some on another—so they were scattered all over the place for Shep to find them when milking time came around again.”

“I’ve got it, Curmudge. The cows’ random distribution demonstrated entropy, the natural tendency toward increased randomness. That’s similar to the story you told once before about your grandson. Although his toys were put away neatly in the toy box each evening, they were scattered all over the house by the end of the next day.”

“When winter came to Granddad’s farm, he kept the cows in the barn. It was a lot of work carrying in feed and hauling out manure, but he didn’t want a cow breaking a leg slipping on an icy rock on a steep hill. However, if the barn door and the pasture gate had been left open and if Shep had been busy trying futilely to herd the chickens, the cows would have wandered out of the barn, up the holler, and again become scattered randomly up in the hills.”

“I’ve got it again, Curmudge. When the cows were not being carefully managed, they backslid into their old habit of wandering randomly. Their actions again demonstrate the tendency of entropy—randomness—to increase.”

“Here’s another example of increasing randomness. If one puts a cube of ice—a well-ordered structure—into a glass of Scotch, the ice will spontaneously melt into less-ordered liquid water. Of course, the full explanation is rather complicated.”

“Good example, Curmudge, but not if you like to drink your Scotch neat. So are we going to carry this lesson over to Lean, where we’ll discuss workers and managers instead of cows and Border Collies?”

“Nurse Julie, you can bet your white cap (if you have one) on that.”

Affinity’s Kaizen Curmudgeon

Thursday, October 6, 2011

How Things Happen

The Medicare Summary Notice and Provider Reimbursement

“Curmudge, don’t you think a better title would be How Things Work?”

“Not really, Jaded Julie. Saying that something works implies a favorable judgment regarding the performance of the subject, and I don’t think that we are qualified to do that.”

“But doesn‘t a ‘happening’ suggest a natural occurrence, like a tornado or a snowstorm? Isn’t provider reimbursement completely anthropogenic?”

“It is indeed man-made, Julie, but instead of semantics, let’s tackle our subject.”

“How did you get onto this topic, anyway?”

“A friend asked me to explain some of the numbers on her Medicare Summary Notice, which is sort of like an insurance company’s Explanation of Benefits. If you wonder why we are limiting this discussion to Medicare, it’s because most of my friends are my contemporaries and all of my contemporaries are either on Medicare or deceased.”

“Let’s get with it, Curmudge. I believe we must start by learning some abbreviations.”

“RVUs (Relative Value Units) are used to determine how much medical providers should be paid. Components of RVUs include physician work (time, skill, training), practice expense, and malpractice insurance expense. They are adjusted by a factor that reflects the different costs of practicing medicine across the country and are then multiplied by a dollars-per-RVU conversion factor.”

“I know the next one; that’s the CPT (Current Procedure Terminology) code. There is a CPT code for each medical, surgical, and diagnostic service, and each CPT has an associated RVU. That’s the origin of the ‘Medicare-Approved’ values next to each CPT code on your Medicare Summary Notice. The RVUs have a lot of bearing on provider compensation, Curmudge. Are they handed down on stone tablets?”

“They might as well be. They are determined in meetings of a committee representing all medical specialties. I have read of these meetings described as the proverbial ‘smoke-filled room’ but without smoke.”

“And finally we have ICD (International Classification of Diseases), a system of diagnosis codes. This is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases, as maintained by the World Health Organization (WHO). We are now using Revision 9 (ICD-9), but Revision 10 (ICD-10) must be employed by October 1, 2013. The new code set contains more codes than ICD-9, including many for very specific occurrences.”

“Do you suppose that they have one for getting crushed in a buffalo stampede in Buffalo, New York?”

“It’s interesting, Curmudge, that Medicare will reject a provider’s claim if the procedure code is not appropriate for the diagnosis code. For example, an x-ray of the wrist will be rejected if the patient is diagnosed with glaucoma. It is certainly critical for a provider to have proficient back-office support.”

“So back to the Medicare Summary Notice, the most common one (Part B) showing claims from individual providers. You may note that the ‘Medicare-Approved’ amount may be a lot less than the ‘Amount Charged’ (by the provider). Don’t worry; you’re usually not responsible for the difference. The next column is ‘Medicare Paid Provider’. It is typically 80% of the ‘Medicare-Approved’ amount. The remaining 20%, in the ‘You May Be Billed’ column, is the total that you plus your secondary (medi-gap) insurance are expected to pay. On occasion, my final out-of-pocket cost has been around 1% of the amount charged. Mrs. Curmudgeon’s hospital bill was $4,000, but I ended up paying only $40. Actually, I thought she was worth more than that.”

“Curmudge, despite all of the RVUs, codes, and correction factors, it just sounds as if providers are paid on a piecework basis. Did you ever have a job in which you were paid for piecework?”

“I did that back in the 1940’s when I was a child. It was called berry pickin’. We kids would stand on a designated corner, and a farmer would come by to pick us up and take us to his berry field. I would select a row that appeared to have lots of berries (I think they were strawberries), grab a basket, and fill it as fast as I could. Then another basket and then another. It was hard stoop-labor, and we were paid only a few pennies per basket. To this day, whenever I buy berries my back hurts.”

“Do you see any parallels between your experience and provider compensation?”

“Well, I suppose choosing a medical specialty might relate to selecting a row with lots of berries. (Some day we’ll cogitate a bit on why docs select specialties.) And my filling lots of boxes of berries might correlate with a provider’s racking up a lot of RVUs.”

“Pretty interesting, Curmudge. I hope your friend who inspired this topic wasn’t looking for a short answer.”

Affinity’s Kaizen Curmudgeon