Habits, Cultures, and the Shingo Prize

“It would appear from the title, Curmudge, that we are going to brew up a mixture from the topics that we’ve discussed for the past several weeks.”

“That’s the plan, Julie.  Remember Generic General Hospital that we used as a model several years ago?  Well, that’s where we are going this week.”

“Will we be guiding the hospital in their quest for a Shingo Prize?”

“No way.  That’s not a job for fictional characters, even in a fictional hospital.  You and I will be like the Greek chorus in ancient Greek drama; our task will be to observe and comment on the action.”

“What, Ancient Scholar, will you think of next?  Oh well, raise the curtain…oops, they didn’t have theater curtains back then.”

“Generic General had begun its Lean journey a few years ago, but its progress had seemingly reached a plateau.  Perhaps having a new goal, the Shingo Prize, would inspire everyone.”

“Golly Curmudge, we’ve already discussed how demanding the Shingo requirements are.  The whole hospital will have to become oriented toward a Shingo culture, and everyone will need to think about Shingo all the time.”

“Obviously, Julie, they can’t do that while caring for patients.  Shingo will have to permeate everyone’s habits.  Recall that culture is the product of one’s habits, and habits are those actions that we do automatically without thinking in response to a cue.  As we said last week, the habit loop is cue-routine-reward.”

“Everyone in the hospital has one big habit.  The cue is the alarm clock waking us in the morning (or before our shift), and the routine action is practicing our profession.  For those caring for patients, it’s meeting the standard of care.  Then the reward at the end of the day or shift is going home to our family, if we have one.”

“The ‘family’ part does make a difference.  The reward in this example is almost universal.  Getting home on time is valued by everyone from housekeepers to physicians.  This may be a key to encourage people to continuously improve the efficiency of their work.”

“Now Curmudge, let’s consider the role of habits in patient-care gemba.  Most of the procedures that we nurses do become habits.  We learned them in training and perfected our techniques under the guidance of our prefector during orientation.  Improvements might occur due to technology or changes in professional standards, but individual improvements are likely to be minor.”

“In a long-ago posting we defined procedures as involving one person, and said that processes are linked procedures often requiring more than one.  Although processes may seem habitual, they may present more opportunities than procedures for participants to think critically about improvements.  Higher on the complexity scale are the hospital’s value streams.  They would commonly be the subjects of continuous improvement efforts.”

“What about Lean and Shingo training, Curmudge?  I suspect that it would become more intense as one moves up the professional and management scale.”

“I agree.  Continuously scanning for the eight wastes of health care should be habitual for all RNs and above.  Lean leadership, as we discussed in our posting on 10/28/11 and the two preceding postings, should become an imperative habit for all in management.  And holding middle managers accountable must become a habit of those at higher levels.”

“And how will middle managers learn their role in the world of Shingo?”

“Think about our own education, Julie.  Although we went to class to get difficult concepts clarified, we always had to sit down with the textbook and grind the material into our brain.  In the quest for a Shingo Prize, our supervisors will be our teacher/coaches, and the textbook will be the parts of the Shingo booklet that are pertinent to our work.  Because Shingo is essentially a testing regimen for an organization’s Lean transformation, one might also need to study parts of the currently available Lean textbooks and attend workshops on Lean management systems.  People will find time to study, and they’ll build upon what they already learned in Lean training.”

“From reading the Shingo booklet I learned that the Shingo examiners will demand that the hospital select and maintain at least three years’ worth of meaningful metrics that demonstrate their progress.  Length of stay (LOS) would be commonly used, but more metrics will be needed.  It’s hard to forecast what those metrics will be, but people might follow the old laboratory guidance, ’say what you do, do what you say, and prove (with data) that you have done it.’ ”

“Every major program in any organization needs an overarching goal.  In a hospital, ‘Winning a Shingo Prize‘ won’t be meaningful to most people, especially patients.  The folks in top management and Marketing will have to concoct a ‘keystone’ goal that is patient focused.  In a faith-based hospital, it might be based on the organization’s mission and values.”

“Hey Curmudge, I hope there’s more to be said about the reward part of the habit loop.  Going home at the end of the day is generally assumed and not given much thought.  Perhaps we need a sort-of perverse reward that will shake people out of their lethargy, like your turning on your headlights whenever you start your car.  Your reward is to not get run down by a bigger car.”

“It’s alarming, Julie, that some writers predict hard times for some hospitals in the near future (1).  If that should come to pass, the ultimate personal reward would be to become a surviving person in a surviving hospital, i.e., to not be let go.  The very thought of the writers’ forecast should gain everyone’s attention.  It should be the cue that fires up habits needed to win a Shingo Prize.“

“I shudder at the gloomy forecast.  If it really happens, it will trash all efforts at achieving a Lean transformation.”

“It would be an absolute last resort.  But remember, Julie, if fictional characters like us can be sacked, it could happen to real people.”

“Enough of this conjecture.  Let’s return to your carpeted gulag.  The granite blocks in this ancient Greek amphitheater are hard on the feet and the seat.” 

Kaizen Curmudgeon 

(1) Becker’s Hospital Review, September 26, 2012.  PPACA Could Directly Eliminate 400K Hospital Jobs in 2013, Average Hospital Would Shed Over 100 Positions.                

Habits

“Curmudge, in our conversation a couple of weeks ago we noted that the Shingo Prize people felt that organizations whose Lean transformation efforts failed had focused too much on tools (how) and not enough on culture (why).  Do you agree with their assertion?”

“Not entirely, Julie.”

“What!  When you see all the world-renown Lean leaders listed as members of the Shingo Academy, how dare you not agree fully?  You are just an old geezer working in his gulag…er…bedroom.”

“Pardon the disrespect, m’lady, but I think that many of those organizations whose Lean journeys got lost in the woods just didn‘t work hard enough.  Specifically, too few people hardwired the Shingo guiding principles, supporting concepts, systems, and tools, i.e., they didn’t become habits.”

“Well, it’s not because you and I didn’t talk enough about hardwiring. Five years

ago we listed some ways a Lean program could fail, and we tackled hardwiring on 8/12/11 and 8/18/11.  People either don’t read our postings, or they are as forgetful as you are.”

“That being the case, Julie, we’d better return to the fundamentals.  When something is hardwired, it becomes a habit.  A habit is something that we do automatically, without thinking, in response to a cue.  Following the cue is the routine followed by a reward.  There are good habits like brushing your teeth after breakfast and bad habits like smoking.  With smoking, the cue might be second-hand smoke, the routine is smoking the cigarette, and the reward is the effect of the nicotine and its metabolic products in one’s nervous system.”

“It seems to me, Curmudge, that someone whose organization aspires to win a Shingo Prize or achieve a Lean transformation would want to learn about habits.  Charles Duhigg’s The Power of Habit (1) would be a good place to start.”

“I agree.  Here are a few quotations (exact or paraphrased) from the book:

‘When a habit emerges, the brain stops fully participating in decision making.’

‘To change an old habit, you must keep the old cue and deliver the old reward, and insert a new routine.’

‘New habits are created by putting together a cue, a routine, and a reward, and then cultivating a craving that drives the loop.’

‘Keystone habits are those that when they change, other habits also change.’  Continuous improvement is an example of a keystone habit.

‘Keystone habits encourage widespread change by creating cultures where new values become ingrained.’

‘During turmoil, organizational habits become malleable.’

‘Peer pressure promotes social habits that encourage people to conform to group expectations.’ “

“It’s evident that habits are essential in our everyday lives, including one’s work in health care.  Although you don’t know diddly about health care, Old Guy, perhaps together we might conjure up some examples.”

“I promise that next week we’ll talk about habits, health care, and the Shingo Prize.  But before we wrap things up today, I’d like to share a personal observation.”

“Although most habits develop over time, I understand, Curmudge, that a significant emotional event, which you experienced, can create a habit instantaneously.”

“A young woman driving a big piece of ‘Detroit iron’ made a left turn and hit my Mazda head-on.  I would have been killed if I had not been wearing my seat belt.  Although it was mid-afternoon, she could have seen me more easily if my headlights had been on.  Now, day or night, as soon as I turn the key in the ignition, I turn on the headlights.  The memory of that single, traumatic event triggers my habit.”

“So what does your personal anecdote have to do with the world of commerce and health care?”

“It suggests, Julie, that if someone has sufficient authority and can issue a command forcefully enough, he can instill a habit in a direct report in an instant.”

Kaizen Curmudgeon

(1) Duhigg, Charles.  The Power of Habit.  (2012, Random House)

The Shingo Prize 2

"Julie, in our last posting we laid the foundation for the Shingo House.  Now let’s go inside and learn more.” 

“The TPS has a triangle and Shingo has a house.  The Japanese seem to be big on figures.  Maybe that’s because their written language is based on little figures called kanji.”

“The Shingo house has four levels or Dimensions; they are, from bottom to top, Cultural Enablers, Continuous Process Improvement, Enterprise Alignment, and Results.  Also, the house is divided vertically down the middle with Guiding Principles on one side and Supporting Concepts on the other.”

“Hey Curmudge, I was once in a church like that, with one side for men and the other side for women.  In that church, I’ll bet that the Principles were the men and the Supporting Concepts were the women, but that would have never occurred to the developers of the Shingo Prize.”

“Then on the Principles side of the house, ten Principles are distributed among the four Dimensions.  Some of the more familiar ones are Respect Every Individual, Focus on Process, and Think Systemically.  Familiar exhortations are also on the Supporting Concepts side, such as Identify and Eliminate Waste, and Standardize Processes.  Following the Supporting Concepts are lists of systems and tools that relate to each of the four Dimensions.  Finally there are typical open-ended questions that might be asked by an examiner. ”

“I doubt that there’s room in the blog to talk about the systems and tools.”

“You’ll have to read the Shingo booklet to find the details, Julie.  As we’ve said before, a blog isn’t a textbook; we can only provide a taste of the subject.  Unfortunately, if a person can’t set aside five minutes per week to read a blog posting, they are unlikely to tackle the whole booklet.”

“Okay, so what did you find in the booklet that is really new?”

“In two words, not much.  The Dimensions, Guiding Principles, Supporting Concepts, Systems, and Tools seem to be a collection of everything I’ve ever read about Lean, Six Sigma, Gemba Kaizen, and Total Quality Management.  It’s all there, and it would make very good sense to one who is interested in improving processes.  The sample reviewer questions are the kind that I would ask if I were an examiner.”

“Well, Mr. Inspector, where in the booklet does it help the person in gemba to understand why he is doing what he is doing?”

“I didn’t see it spelled out.  I believe that a person learns the why of what he is doing by doing it under the guidance of a good coach.  In fact that’s the essence of the Shingo Prize…dedicated management leading the people in gemba in doing the right things.”

“In a single sentence, what’s the lesson from all this that I can take home to the kids?”

“Not to disparage the Shingo principles, Julie, but success might result from the sheer magnitude of effort required for an organization to be a serious contender for the Shingo Prize.”

“I guess, Curmudge, that you are saying that many programs have comparable administrative sticks, but Shingo has a bigger carrot.”

“You’ve got it right again, Julie.”

Kaizen Curmudgeon