• Cali and Jody » Blog Archive » Lean Six Sigma and ROWE – Lean and Six Sigma have arrived in places where Cali and Jody talk about ROWE. . These things (some of them) are catching on, correctly or not. This is a good thing, a bad thing, and an opportunity

• detnews.com | Webvideo | Ford’s most advanced assembly plant operates in rural Brazil – A profile of Ford's plant – "among the LEANest in the world." It's in Brazil, not in the U.S.

Studer Q. Results That Last: Hardwiring Behaviors That Will Take Your Company to the Top. 1st ed. Wiley; 2007

I decided to read this book because I have been a fan of Quint Studer’s philosophy ever since reading some of his blog writings (here’s a great example, and note the power of blogs to bring in a new audience).
Results That Last is written from the perspective of a seasoned health care executive. I love stories, and Quint puts some very good ones in here. I appreciate that (a) he’s an optimist (”I believe that life rewards action more than inaction”) and that he shares his successes and his mistakes.
I think this book is especially good reading for a person starting a new position (that would be me) in that discussion on good leadership behaviors and creating a transparent plan are a great foundation for integration into an organization with a lot going on (aka every organization).
I agree with the commentary on striving for breakthrough performance – I especially like this quote that we should all remember:

Great companies must have at least 70 percent in the 5s

There are few things I didn’t like/agree with, and these could be chalked up to “controversial ideas” because I have heard them in mainstream health care. A lot. And we should rethink them:

Controversial idea #1: “I had to keep two groups of customers happy: patients and physicians.” On this one I worry that duality of customership creates confusion and doesn’t distinguish the best health care organizations, in my opinion. i understand that physicians refer patients to hospitals and need to tools to deliver great care for them. This is different than saying that they are a customer group like patients are. I prefer the approach that organizations like Park Nicollet use: “The patient is our only customer.”

Controversial idea #2: Making employees happy results in making customers happy. I’ve done a little research on this which I need to dig up (but, please help me here if you know of some) and I think the two are more comingled than people think. It’s possible that when an organization works hard to keep it’s customers happy, this results in employees being happy because ultimately they come to work to deliver for customers. The converse is also true, that an organization can keep employees very happy and have unhappy customers.

Controversial Idea #3: Focus on low vs high performers as opposed to functional vs dysfunctional processes. I think the book excels in demonstrating some baseline leadership behaviors like honesty and standard work like rounding, but I worry that there’s excessive attention paid (right up front, in the first chapter no less) on dealing with “low performers.” This is a bit antithetical to what people like me do in applying Toyota Management strategies – I suggest asking “why?” five times to see if a person is performing poorly or whether their environment is performing poorly for them.

There are two really great things mentioned in this book as well:

Impact of pre-visit and post-visit calls: Great data about the value of these, and in a system that has a personal health record, we just do “pre-visit and post-visit e-mail”. Wonderful.

Key Words at Key Times: Loved this as well. I used to do it in clinical practice – start every visit with “Welcome to our medical office” and end every visit with “Thank you for coming in to see us.” (It is interesting to me that some doctors/nurses don’t think to say “welcome” to a patient when the patient comes to see them!)

Overall, I think the book is actually a very good baseline/starter for more discovery about leadership approaches. Since I tend to be ahead-of-my-time-guy/person/citizen I’d probably recommend following this with something on LEAN or Toyota Management.

• Novice to Expert: Use Collaborative Leadership to Go Further – Very nice piece on collaborative leadership – told from the perspective of the Navy. LEAN-like.

I just updated this sample “Medical Education 2.0″ curriculum, based on the Yale Medical School curriculum, by adding a subject called “Process Improvement in Ambulatory Care / Inpatient Care.” I then realized that I don’t know of a resource to link to that would help people who haven’t done this do it in undergraduate medical education. Anyone have ideas?

The skills I am thinking of are ones around looking at the entire process of care, figuring out how to serve the patient best utilizing all of the tools available (technology, people, business), along with some work on improving service. This would include something on teaching students how to write to patients (no medical school teaches this – they only teach verbal communication, am I wrong about this?)

Thanks to Bertalan Mesko for getting this ball rolling. Take a look at the Google Docs document – what do you think the medical students of tomorrow should be learning?

Medical Education 2.0 concept: – Google Docs

Kolodner RM, Cohn SP, Friedman CP. Health Information Technology: Strategic Initiatives, Real Progress [Internet]. Health Aff. 2008 Aug 19;hlthaff.27.5.w391.

Kibbe DC, McLaughlin CP. The Alternative Route: Hanging Out The Unmentionables For Better Decision Making In Health Information Technology [Internet]. Health Aff. 2008 Aug 19;hlthaff.27.5.w396

Diamond CC, Shirky C. Health Information Technology: A Few Years Of Magical Thinking? [Internet]. Health Aff. 2008 Aug 19;hlthaff.27.5.w383

When I read these I thought about what my opinion was about them, and what I might write in a blog post about them. I didn’t really want to critique their opinion or lay mine on top, because I think the pieces stand up well on their own, and I am no more connected to the facts than these authors are.

So I thought I’d just end up writing a post that said that I read these articles (I know, uncharacteristic of me).

Then, I stepped on the Washington, DC Metro, and this advertisement, for a local hospital stared me in the face:

I looked at it several different ways – on the one hand, the implication is that if your child has a serious spine problem, they will take care of it. However, if you do not have a child with a serious spine problem, should you go elsewhere for primary care, or are they good at that, too?

Is 3-D imaging today’s marker for quality health care? That’s what brought me back to the point of these three pieces.

In my travels, I don’t often see advertising for health care organizations that say, “Come to us for your primary care, your child is more likely to be immunized by us.” Or, “Come to us for all of your care – we’ve been rated the best listeners in DC.”

Here’s another example from my Twitterfeed. How did health care come to this?

What these pieces do for me is support the work to move to a system where the customer is the patient. The care experience should be as good as any a person can get from any other industry, online or offline, and one that is accountable to it for the things patients care about. It’s not how many personal health records there are, but how often patients and families make meaningful decisions to stay healthy because of them.

For me, this is where the energy comes from around patient access, patient and family involvement in care, and in the design and improvement of the health system.

Finally, I just re-acquainted myself with this quote yesterday, from my reading of A Fortunate Man, by John Berger about a country doctor in 1967. Here’s what the author said about computers in medicine back then.

It may be that computers will soon diagnose better than doctors. But the facts fed to computers will still have to be the result of intimate, individual recognition of the patient.

Was he right? (rhetorical question)

“Why Work Sucks and How to Fix It: No Schedules, No Meetings, No Joke–the Simple Change That Can Make Your Job Terrific” (Cali Ressler, Jody Thompson)

As a leader in an organization, imagine reading this description of an employee’s workday:

A typical day for me includes waking up when my room is too bright from the sun and I can no longer sleep. I check my e-mail to make sure there are no pressing issues and respond to anyone who needs my input. I will typically watch an episode of South Park on the Internet, then walk to my local grocery store and buy some breakfast, even though it’s closer to lunch at this point. After eating I will work in front of my television with ESPN on in the background. At this point I will choose to go into the office or continue to work from home, or maybe not even work at all and go for a bike ride or jog. If there is still work to do later that night, I’ll do it then and it’s no big deal.

I’ll admit it – it kind of made me gulp when I read it.

At the same time, though, I have been in a lot of conversations with a lot of personal and professional colleagues over the past 3-4 years or so, where the question we’re asking ourselves is, “Is this how work life is supposed to be?” Spoken or unspoken, the answer is “we don’t think so.” Various companies’ data also show a trend toward less vacancy in their physical locations.

In the middle of that self-discovery, I read about BestBuy, Inc., (see “Smashing the Clock“). This is the book about their journey.

It’s time to let go and see what our employees can really do – BestBuy Manager

A Results Only Work Environment (ROWE) is as it says – one where results are measured, not time spent. There are no timeclocks, no discussion of time, and no “Sludge” as the authors refer to it. “Sludge” are the comments people make to each other about time, whether it’s about being late to a meeting, or working late at night. Simply put, the authors state, an employer is trading work for money. Why not give them what they pay for?

Reading beyond the BusinessWeek article was very useful – this is not flextime, it’s not “working from home,” it’s a different philosophy altogether. That includes the vignette above. Totally allowed, if you have the results to show for it. The concept can appear challenging; however, it makes sense, in the context of strong leadership committed to respecting employees and customers. That’s where I found similarities to the work I have done.

About respect

When I first read about this work, I asked about how this was similar or different from the LEAN transformation I participated in, in the area of health information technology. Some of the things were consistent, some seemed less so, like having technology teams physically present alongside doctors and nurses, guiding care and feeding of an electronic health record system.

My reconciliation of all of this rests with not comparing individual tools/approaches between ROWE and LEAN. What they both have in common is respect for the customer and staff, and strong leaders. It’s impressive that at the heart of the ROWE movement was (at the time) a 24 year old employee of BestBuy (Cali Ressler), who was dissatisfied with the status quo. The authors also explicitly reject war analogies in business as I have. In my own situation, there was not just a desire to change the way we worked, it was clear that not changing would be unsafe. Healthcare organizations across the country are now learning this, thankfully, but it’s a slow transformation, and the transformations that are happening are nowhere near as radical as ROWE, which is why I am interested in the movement (not because I want to be radical, but because the threats to our patients and their families’ health are so significant).

Just because you can no longer be late doesn’t mean you can be lame

Preliminary data from the University of Minnesota’s Flexible Work and Well-Being Center are showing that voluntary terminations are down, involuntary terminations are up.

Mea culpa and, as usual, I see analogies to health care

I liked the concepts in the book a lot, and have done a self-inventory of my own sludge and the sludge that’s been directed my way. The kind of sludge I get nowadays is really from people who want to understand better how technology can be used to help patients stay healthy. I welcome it as an opportunity to teach and learn. As the authors discussed, people can learn to live sludge-free, and they really want to live sludge-free. It starts with us.

I could see myself promoting ROWE in health care settings, and I think physicians, primary care ones especially, would benefit. The work I do to change health care is completely connected to the idea that health is a means, not an end, and people who go into health care want to support our patients where support is needed, mostly where they live, work, and play. I don’t believe people in health care are any more attached to time than Cali and Jody’s (former?) colleagues at BestBuy are. When I read the stories of BestBuy employees before and after, I reflected on some of the conversations I have had with health professionals (at all levels) who have really been challenged to juggle their passion for helping people and their ability to provide for themselves and their families, physically and emotionally. What would it be like for a family medicine or internal medicine specialist to provide their cognitive services to patients and families using a combination of virtual tools and office (or even home presence) when the situation called for it? Look at what HelloHealth is doing. It’s possible.

A Results Only Patient Experience (ROPE)?

A came upon this table in the book, and curiously, I found it extensible to our health care system. I hope I won’t get in trouble for using it to think about what our health care system were like if our patients experienced it the way a BestBuy employee experienced their work life. The edits are mine.

I admit, that maybe, once or twice in my past, I may have used convening and convener in less than flattering terms, much like I used to use “process” in unflattering terms. I learned through LEAN, though, that process isn’t bad, bad process is bad. And so I have learned the same thing about convening, now that I have done it a couple times this summer, with the California Healthcare Foundation.

The most recent time was yesterday, when Veenu Aulakh, MPH, and I brought together Safety Net health care organizations, and national experts in patient online access and social impact of the Internet to talk about (you can guess…) “Patient Online Access in the Safety Net.”

These being the first convenings I have co-led, rather than participated in, I have learned a ton, and have gotten a good understanding of doing this for a purpose, which both situations have had. In the event we hosted yesterday, in Oakland, I put together an A3 document before we invited anyone, which included the background, the goals, and most importantly, the “why?” we were doing this in the first place. It was really helpful to have created agreement around the “why?” – I referred to this many times in the planning.

At the event itself, I got a new perspective that I had not had as a participant previously. It was one of listener/observer – even when I was doing the talking, I was interested to see reactions and learn what people and organizations are capable of. It made me think that when I have been a participant in convenings in the past, this is what my hosts were doing – learning what myself or my organization was capable of doing to solve a problem, as much as they might have tapped me as an expert. Interesting to have this happening in my brain.

Sharing information happened, too, courtesy of some of the most innovative organizations in the U.S., including Cambridge Health Alliance, University of California, San Francisco’s Positive Health Program , New York’s Primary Care Information Project, Institute for Family Health, and Kaiser Permanente.

In addition to all of this, there were a few nice moments of recognition for people’s work, such as when Jim Kahn, MD, thanked Kate Christensen, MD, and her team at Kaiser Permanente for their support and assistance in the launch of the myHERO patient portal for HIV patients cared for at San Francisco General Hospital.

…and a little something for me, a follow-up conversation with Hilary Worthen, MD, from Cambridge Health Alliance, about his study and pathway to discover and implement LEAN in primary care at CHA. He told me that for him, this is a transition from thinking about exam rooms and staff to “work that you need to get done, defined by doctor and patient.” I love hearing about how people apply their creativity and copy the thinking of LEAN to do exceptional things for their patients.

This being the second time I have done this, I don’t know if it was perfect. We tried a lot of things I’ve not done in meetings before, and I am still working to integrate social media before, during, and after. I am definitely sold on my philosophy of supporting any and all technology use (”if you need or want to use your device, use it”) - I have not, in my conveningness, come around to the “turn your devices off” philosophy, as I have written about previously.

Oh, and I learned that a 60″ table seats 8 people.

Here are a few images from yesterday. I’ll follow up with my slides in a separate post. Click on any to see larger size.

• Strategy Execution and the Balanced Scorecard (HBS Working Knowledge) – Excellent article with another reminder that strategy deserves its own bandwidth, and should be tied to operations, back and forth, in other words, always checking that what we're doing every day matters. Nice nod to leadership: "There are two key issues. First is leadership. Without strong visionary leadership, no strategy will be executed effectively." This can be challenging in healthcare. Luckily, our patients and their families want to help.

I looked online for a definition of the phrase “Ford-Talk,” so maybe it was a term that was coined internally within the last organization I worked for, or the broader Toyota Management System community.

It refers to a culture where managers who are called into a room by their boss give positive assessments of how their areas are doing. This was ascribed to an American carmaker, but I think it could apply to many American companies, relative to their Japanese analogues, where it is expected that failures are pointed out, so they can be fixed. As it is said, an assembly line that is reported as being 100% functional is one that is not functional because it is not finding mistakes and fixing them.

I thought of Ford-Talk when I read This article, which talks about the failure of managers to tell the CEO that things weren't ready. and this article, which dissects the CEO’s memo about the failures to staff and does a nice job of bringing Steve Jobs’ talents in working with the public to light.

However, if articles like this one alluding to the inner workings of the company (“The Economist: Jobs’s Job”) are to be believed I think there may be a different perspective than, “the managers did not report that there were problems and luckily Steve owned the problem publicly so the company could regroup and succeed.”

What I have learned is even the most innovative environments may operate with a command-and-control approach, not by purpose, but by neglect. When that happens, the failure may be not to listen, rather than not to speak.

Did that happen here? I don’t know. The comment about managers failing to tell the boss something caught my eye as a Toyota Management System/LEAN aficionado and made me wonder if there was more to learn.

I am interested in stories like this because I’ve been working in healthcare to improve the listening. When we go from telling people, “You won’t hear anything from us if everything is normal (the ultimate Ford-Talk),” to listening to the question, “I just got my lab report and I have a question about this specific number” we’re more likely to pick up mistakes. It’s better to be embarrassed and change course quickly than wait in these individual cases, and when there is a bigger problem to ask “why?” the problem happened, five times. There may be more than a simple answer…..